essay about health and social care

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

13.1 Sociological Perspectives on Health and Health Care

Learning objective.

• List the assumptions of the functionalist, conflict, and symbolic interactionist perspectives on health and medicine.

Before discussing these perspectives, we must first define three key concepts—health, medicine, and health care—that lie at the heart of their explanations and of this chapter’s discussion. Health refers to the extent of a person’s physical, mental, and social well-being. As this definition suggests, health is a multidimensional concept. Although the three dimensions of health just listed often affect each other, it is possible for someone to be in good physical health and poor mental health, or vice versa. Medicine refers to the social institution that seeks to prevent, diagnose, and treat illness and to promote health in its various dimensions. This social institution in the United States is vast, to put it mildly, and involves more than 11 million people (physicians, nurses, dentists, therapists, medical records technicians, and many other occupations). Finally, health care refers to the provision of medical services to prevent, diagnose, and treat health problems.

With these definitions in mind, we now turn to sociological explanations of health and health care. As usual, the major sociological perspectives that we have discussed throughout this book offer different types of explanations, but together they provide us with a more comprehensive understanding than any one approach can do by itself. Table 13.1 “Theory Snapshot” summarizes what they say.

Table 13.1 Theory Snapshot

The Functionalist Approach

As conceived by Talcott Parsons (1951), the functionalist perspective emphasizes that good health and effective medical care are essential for a society’s ability to function. Ill health impairs our ability to perform our roles in society, and if too many people are unhealthy, society’s functioning and stability suffer. This was especially true for premature death, said Parsons, because it prevents individuals from fully carrying out all their social roles and thus represents a “poor return” to society for the various costs of pregnancy, birth, child care, and socialization of the individual who ends up dying early. Poor medical care is likewise dysfunctional for society, as people who are ill face greater difficulty in becoming healthy and people who are healthy are more likely to become ill.

For a person to be considered legitimately sick, said Parsons, several expectations must be met. He referred to these expectations as the sick role . First, sick people should not be perceived as having caused their own health problem. If we eat high-fat food, become obese, and have a heart attack, we evoke less sympathy than if we had practiced good nutrition and maintained a proper weight. If someone is driving drunk and smashes into a tree, there is much less sympathy than if the driver had been sober and skidded off the road in icy weather.

Second, sick people must want to get well. If they do not want to get well or, worse yet, are perceived as faking their illness or malingering after becoming healthier, they are no longer considered legitimately ill by the people who know them or, more generally, by society itself.

Third, sick people are expected to have their illness confirmed by a physician or other health-care professional and to follow the professional’s instructions in order to become well. If a sick person fails to do so, she or he again loses the right to perform the sick role.

Talcott Parsons wrote that for a person to be perceived as legitimately ill, several expectations, called the sick role, must be met. These expectations include the perception that the person did not cause her or his own health problem.

Nathalie Babineau-Griffith – grand-maman’s blanket – CC BY-NC-ND 2.0.

If all these expectations are met, said Parsons, sick people are treated as sick by their family, their friends, and other people they know, and they become exempt from their normal obligations to all these people. Sometimes they are even told to stay in bed when they want to remain active.

Physicians also have a role to perform, said Parsons. First and foremost, they have to diagnose the person’s illness, decide how to treat it, and help the person become well. To do so, they need the cooperation of the patient, who must answer the physician’s questions accurately and follow the physician’s instructions. Parsons thus viewed the physician-patient relationship as hierarchical: the physician gives the orders (or, more accurately, provides advice and instructions), and the patient follows them.

Parsons was certainly right in emphasizing the importance of individuals’ good health for society’s health, but his perspective has been criticized for several reasons. First, his idea of the sick role applies more to acute (short-term) illness than to chronic (long-term) illness. Although much of his discussion implies a person temporarily enters a sick role and leaves it soon after following adequate medical care, people with chronic illnesses can be locked into a sick role for a very long time or even permanently. Second, Parsons’s discussion ignores the fact, mentioned earlier, that our social backgrounds affect the likelihood of becoming ill and the quality of medical care we receive. Third, Parsons wrote approvingly of the hierarchy implicit in the physician-patient relationship. Many experts say today that patients need to reduce this hierarchy by asking more questions of their physicians and by taking a more active role in maintaining their health. To the extent that physicians do not always provide the best medical care, the hierarchy that Parsons favored is at least partly to blame.

The Conflict Approach

The conflict approach emphasizes inequality in the quality of health and of health-care delivery (Weitz, 2013). As noted earlier, the quality of health and health care differs greatly around the world and within the United States. Society’s inequities along social class, race and ethnicity, and gender lines are reproduced in our health and health care. People from disadvantaged social backgrounds are more likely to become ill, and once they do become ill, inadequate health care makes it more difficult for them to become well. As we will see, the evidence of disparities in health and health care is vast and dramatic.

The conflict approach also critiques efforts by physicians over the decades to control the practice of medicine and to define various social problems as medical ones. Physicians’ motivation for doing so has been both good and bad. On the good side, they have believed they are the most qualified professionals to diagnose problems and to treat people who have these problems. On the negative side, they have also recognized that their financial status will improve if they succeed in characterizing social problems as medical problems and in monopolizing the treatment of these problems. Once these problems become “medicalized,” their possible social roots and thus potential solutions are neglected.

Several examples illustrate conflict theory’s criticism. Alternative medicine is becoming increasingly popular, but so has criticism of it by the medical establishment. Physicians may honestly feel that medical alternatives are inadequate, ineffective, or even dangerous, but they also recognize that the use of these alternatives is financially harmful to their own practices. Eating disorders also illustrate conflict theory’s criticism. Many of the women and girls who have eating disorders receive help from a physician, a psychiatrist, a psychologist, or another health-care professional. Although this care is often very helpful, the definition of eating disorders as a medical problem nonetheless provides a good source of income for the professionals who treat it and obscures its cultural roots in society’s standard of beauty for women (Whitehead & Kurz, 2008).

Obstetrical care provides another example. In most of human history, midwives or their equivalent were the people who helped pregnant women deliver their babies. In the nineteenth century, physicians claimed they were better trained than midwives and won legislation giving them authority to deliver babies. They may have honestly felt that midwives were inadequately trained, but they also fully recognized that obstetrical care would be quite lucrative (Ehrenreich & English, 2005).

According to conflict theory, physicians have often sought to define various social problems as medical problems. An example is the development of the diagnosis of ADHD, or attention deficit/hyperactivity disorder.

birgerking – What I Really Do… ADD/ADHD – CC BY 2.0.

In a final example, many hyperactive children are now diagnosed with ADHD, or attention deficit/hyperactivity disorder. A generation or more ago, they would have been considered merely as overly active. After Ritalin, a drug that reduces hyperactivity, was developed, their behavior came to be considered a medical problem and the ADHD diagnosis was increasingly applied, and tens of thousands of children went to physicians’ offices and were given Ritalin or similar drugs. The definition of their behavior as a medical problem was very lucrative for physicians and for the company that developed Ritalin, and it also obscured the possible roots of their behavior in inadequate parenting, stultifying schools, or even gender socialization, as most hyperactive kids are boys (Conrad, 2008; Rao & Seaton, 2010).

Critics say the conflict approach’s assessment of health and medicine is overly harsh and its criticism of physicians’ motivation far too cynical. Scientific medicine has greatly improved the health of people around the world. Although physicians are certainly motivated, as many people are, by economic considerations, their efforts to extend their scope into previously nonmedical areas also stem from honest beliefs that people’s health and lives will improve if these efforts succeed. Certainly there is some truth in this criticism of the conflict approach, but the evidence of inequality in health and medicine and of the negative aspects of the medical establishment’s motivation for extending its reach remains compelling.

The Symbolic Interactionist Approach

The symbolic interactionist approach emphasizes that health and illness are social constructions . This means that various physical and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are defined as such by a society and its members (Buckser, 2009; Lorber & Moore, 2002). The ADHD example just discussed also illustrates symbolic interactionist theory’s concerns, as a behavior that was not previously considered an illness came to be defined as one after the development of Ritalin. In another example first discussed in Chapter 7 “Alcohol and Other Drugs” , in the late 1800s opium use was quite common in the United States, as opium derivatives were included in all sorts of over-the-counter products. Opium use was considered neither a major health nor legal problem. That changed by the end of the century, as prejudice against Chinese Americans led to the banning of the opium dens (similar to today’s bars) they frequented, and calls for the banning of opium led to federal legislation early in the twentieth century that banned most opium products except by prescription (Musto, 2002).

In a more current example, an attempt to redefine obesity is now under way in the United States. Obesity is a known health risk, but a “fat pride” or “fat acceptance” movement composed mainly of heavy individuals is arguing that obesity’s health risks are exaggerated and calling attention to society’s discrimination against overweight people. Although such discrimination is certainly unfortunate, critics say the movement is going too far in trying to minimize obesity’s risks (Diamond, 2011).

The symbolic interactionist approach has also provided important studies of the interaction between patients and health-care professionals. Consciously or not, physicians “manage the situation” to display their authority and medical knowledge. Patients usually have to wait a long time for the physician to show up, and the physician is often in a white lab coat; the physician is also often addressed as “Doctor,” while patients are often called by their first name. Physicians typically use complex medical terms to describe a patient’s illness instead of the more simple terms used by laypeople and the patients themselves.

Management of the situation is perhaps especially important during a gynecological exam, as first discussed in Chapter 12 “Work and the Economy” . When the physician is a man, this situation is fraught with potential embarrassment and uneasiness because a man is examining and touching a woman’s genital area. Under these circumstances, the physician must act in a purely professional manner. He must indicate no personal interest in the woman’s body and must instead treat the exam no differently from any other type of exam. To further “desex” the situation and reduce any potential uneasiness, a female nurse is often present during the exam.

Critics fault the symbolic interactionist approach for implying that no illnesses have objective reality. Many serious health conditions do exist and put people at risk for their health regardless of what they or their society thinks. Critics also say the approach neglects the effects of social inequality for health and illness. Despite these possible faults, the symbolic interactionist approach reminds us that health and illness do have a subjective as well as an objective reality.

Key Takeaways

• A sociological understanding emphasizes the influence of people’s social backgrounds on the quality of their health and health care. A society’s culture and social structure also affect health and health care.
• The functionalist approach emphasizes that good health and effective health care are essential for a society’s ability to function, and it views the physician-patient relationship as hierarchical.
• The conflict approach emphasizes inequality in the quality of health and in the quality of health care.
• The interactionist approach emphasizes that health and illness are social constructions; physical and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are defined as such by a society and its members.

For Your Review

• Which approach—functionalist, conflict, or symbolic interactionist—do you most favor regarding how you understand health and health care? Explain your answer.
• Think of the last time you visited a physician or another health-care professional. In what ways did this person come across as an authority figure possessing medical knowledge? In formulating your answer, think about the person’s clothing, body position and body language, and other aspects of nonverbal communication.

Buckser, A. (2009). Institutions, agency, and illness in the making of Tourette syndrome. Human Organization, 68 (3), 293–306.

Conrad, P. (2008). The medicalization of society: On the transformation of human conditions into treatable disorders . Baltimore, MD: Johns Hopkins University Press.

Diamond, A. (2011). Acceptance of fat as the norm is a cause for concern. Nursing Standard, 25 (38), 28–28.

Lorber, J., & Moore, L. J. (2002). Gender and the social construction of illness (2nd ed.). Lanham, MD: Rowman & Littlefield.

Musto, D. F. (Ed.). (2002). Drugs in America: A documentary history . New York, NY: New York University Press.

Parsons, T. (1951). The social system . New York, NY: Free Press.

Rao, A., & Seaton, M. (2010). The way of boys: Promoting the social and emotional development of young boys . New York, NY: Harper Paperbacks.

Weitz, R. (2013). The sociology of health, illness, and health care: A critical approach (6th ed.). Thousand Oaks, CA: Wadsworth.

Whitehead, K., & Kurz, T. (2008). Saints, sinners and standards of femininity: Discursive constructions of anorexia nervosa and obesity in women’s magazines. Journal of Gender Studies, 17 , 345–358.

Social Problems Copyright © 2015 by University of Minnesota is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.15(1); 2023 Jan

The Role of Social Determinants of Health in Promoting Health Equality: A Narrative Review

Khushbu chelak.

1 Public Health and Epidemiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND

Swarupa Chakole

2 Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND

Significant health disparities exist locally and even throughout the nation. Dipping health inequalities necessitates a focus on the inadequate spread of power, money, and resources, as well as the situations of daily living, which may be addressed through social determinants of health. This study aimed to review the role of health-related social factors in overcoming health disparities. We conducted a search of English-language literature, including studies published on health and health equalities or inequalities. Most reports show that social determinants of health have a higher effect on health. The elimination process of these health inequities occurs through well-designed economic and social policies. Every aspect of social determinants influences the health aspects of people; hence, some areas to focus on include employment, education, socioeconomic status, social support networks, health policies, and healthcare access. Launching interventions to reduce health disparities can help improve the community’s health and health equality.

Introduction and background

According to the World Health Organization (WHO), social determinants of health (SDH) are defined as the circumstances in which humans are born, develop, live, earn, and age. At the international, regional, and state or local levels, the distribution of money, power, and resources shapes these circumstances [ 1 ]. The WHO Commission on Social determinants of Health (CSDH) has stated that progress on SDH is the most successful means of enhancing all people’s well-being and raising disparities [ 2 ]. The WHO established the CSDH based on SDH intervention, which is the most effective strategy to improve well-being and reduce inequality [ 2 ]. Important aspects include governmental, financial, and traditional organizations, based on factors such as manageable healthcare and learning organizations; safe ecological conditions; aesthetically pleasant neighborhoods; and the availability of nutritious food [ 3 ]. Nowadays, health challenges such as being overweight, cardiovascular diseases, diabetes, and depression are prominent, wreaking havoc upon people because of the increasing demands of a high lifestyle. This leads to people suffering from non-communicable diseases. These socioeconomic variables contribute to societal stratification and health disparities among persons of different social and economic classes, genders, and ethnicity.

History of social determinants of health inequality

In the 19th century, people started becoming aware of the factors that had an impact on the health of the population [ 4 ]. Rudolf Virchow, a pioneer in this field, testified on the role of poverty in generating a disease that led to a plague outbreak in Prussia [ 4 ]. Friedrich Engels also studied to find out about the increased mortality. After that, Salvador Allende tried in Chile to demonstrate the importance of political and social variables in people’s health inequities [ 4 ]. All of them tried to frame how factors influence health and what role they play. Marmot emphasized that the workplace may be an important location for addressing disparities. Similarly, changing housing might have an impact on physical and mental health [ 5 ]. Cutting across the structural inequalities, health inequality is a more contemporary challenge and possibly a consequence of the imbalances in development planning and economic design [ 6 ]. Interventions on health and its disparities help overcome further problems [ 7 ]. There is a long history of housing evidence from several reviews [ 8 ]. People suffering from the financial crisis and economic disparities were also among the many who were deeply affected by the growing socioeconomic demands in the early days.

Methodology

This article presents a narrative review of SDH in promoting health equality. PubMed and Google Scholar were used to find all original and review articles with original reports. A set of keywords and Medical Subject Headings (MeSH) terms related to health inequalities and SDH were used. Keywords used were social inequalities, social inequities, poverty, health determinants, behavior, economic status, and social movement. The following MeSH terms were used interchangeably and in combination to find all relevant articles: social determinants, health inequities, and social movement. All free full-text PubMed Central articles were searched using Pubmed and Google Scholar. Studies that discussed the relationship between health inequities, the importance of social determinants, health inequities, health policies, social factors, health equality, and social movement were included. Articles that reviewed SDH in a more general way and whose main focus was not health inequalities and equalities were excluded (Figure ​ (Figure1 1 ).

Social determinants of health

A subcategory of health factors is SDH, as shown in Figure ​ Figure2 2 .

Source: Open access journal under a CC-BY license contributed by social determinants of health. Available at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 [ 9 ].

The most significant health factors include government policy, medical availability, individual behavioral choices, and biological and genetic features [ 3 ]. Examples of SDH include occupation, job status, workplace safety, level of income, opportunities for education, job and place of work protection, inequity between men and women, and segregation based on race. The various health aspects of SDH include food poverty and limitations of access to nutritious food options, housing, and helpful facilities available; early childhood growth and experiences; inclusion in the community and social assistance; the prevalence of crime and exposure to violent behavior; neighborhood circumstances and physical environment; and possibilities for recreation and leisure, as shown in Table ​ Table1 1 .

Source: Open access journal under a CC-BY license contributed by social determinants of health (2018). Available at: https://www.christenseninstitute.org/wp-content/uploads/2018/10/Social-Determinants-of-Health-Table.png [ 10 ].

Social determinants of health indicators

Social determinants determine how health is affected, how they play a significant role in influencing health, and how we can improve health for all. Some of the effects of social determinants affect health in the long term. For example, a less educated person might have less knowledge about how to utilize resources which may affect their ability to use resources to the fullest. Thus, social determinants play a role which must be recognized and improved.

Socioeconomic Status

Financial stress and socioeconomic status are a combination of a family’s or ordinary citizen’s profession, academic performance, wealth, and economic standing. Wealth and power are characteristics that influence a person’s socioeconomic status. The total amount earned in earnings or compensation over a year is income. Income limits a family’s overall lifestyle and influences their consumption habits [ 11 ]. Discrimination based on caste, creed, and gender makes a person vulnerable, enabling them to stop asking for more. They are subjugated to extreme pressure, which only worsens their mental status and health. Health education and programs must be used to educate people about how beneficial it is to count everyone as a whole. The promotion of health equality and equity remains the most significant goal of balancing financial stress.

Equality Education

Education is a means of improving one’s socioeconomic standing. A wealthy family’s socioeconomic status suggests a higher chance of enrolling and graduating from college. Family background, rather than other factors, such as supplemental educational services, significantly influence how much and what kind of education people get and what kind of employment they obtain [ 11 ]. The goal of improving income equality and eradicating poverty through education has not been met. Higher wages and social policies that support low-income families are needed to enhance students’ social and economic conditions [ 11 ]. Educational perspectives allow us to take a comprehensive and clearer view of the causes of health and disease in a population and must be paid attention to [ 4 ].

Gender Inequality and Age Inequality

Women earn less and are more likely to be poor. Institutional discrimination in a patriarchal society, where women were supposed to be mothers and spouses rather than part of the formal workforce, is to blame for gender inequality [ 11 ]. Poverty is more prevalent among the youngest and oldest population groups. Children are more likely to be poor than other age groups. School attainment, high school graduation rates, and reading skills are all impacted by poverty [ 11 ]. Health inequality does not mean just some kind of health difference but the differences in health like that of a pregnant woman who has fewer resources and is deficient and the newborn child who might be underweight leading to problems such as stunting and growth retardation. This adversely affects the opportunities and performances of those afflicted by it and can be corrected by successfully evaluating the determinants affecting health [ 6 ].

Economic Inequality

The United States has the least poverty rates and the most restrictive social policies regarding escaping poverty. Except for Mexico and Turkey, all other developed countries have more significant income disparity than the United States. Young people, full-time workers in low-status jobs, people of color, illiterate people, and women are most likely to be poor [ 11 ]. In influenced market knowledge and customer needs individualized society, incomes or wealth are alternate socioeconomic indicators [ 3 ].

Economic Power

Economic power is the ability to improve the standard of living of a country or business. Economic power represents the status of people with higher socioeconomic status wielding more power than those with lower socioeconomic status. For example, employment provides income that shapes choices about housing, child care, education, medical care, and food, among others. Influence is a factor of being able to produce, buy, and sell. Power is the primary force in today’s era. Because the curriculum is governed by teachers, school board members, and national standards, teachers and students have power connections [ 11 ].

Implications of a System Approach

In a systems approach, the current state of affairs and its factors are both causes and outcomes. Rather than a linear path of socioeconomic variables leading to various health outcomes, they are interconnected in a causal web. The feedback loops result in outcomes that influence the causes. Low income and deprivation, for example, lead to inferior health outcomes, exacerbating the group’s poor and worsening health. A more advanced model, such as the system dynamic model, is necessary to operationalize [ 12 ]. Early events and life cycle, occupational considerations, social ties (social networks and support, discrimination, neighborhood characteristics), and healthcare are all identified as social risk factors [ 13 ]. Eliminating these health inequities indicates that well-designed economic and social policies can promote health and health equity. It outlines 10 guidelines to keep in mind while launching interventions to reduce health disparities [ 14 ]. The circumstances increase their impact on life [ 15 ]. The physical atmosphere, opportunities for learning, suitable housing, occupation, and wealth are examples of these circumstances, known as SDH [ 16 ]. Recommendations such as improving living conditions and inequalities among people are justified in their own right but the way these are linked to health is problematic [ 17 ]. The magnitude of inequalities should be viewed with caution because the study does not take caste into account, potentially exaggerating socioeconomic inequalities [ 18 ].

Policies for Improving Health Equality

While numerous public policies contribute to public health and equality, enhancing public health is not the society’s or the government’s only goal. Although these initiatives have been effective at commencing actions addressing SDH, continuing inequities, and diverse social, economic, and cultural differences across India, more cooperation is required across the current programs of different ministries [ 18 ], resulting in policy incoherence may develop. Due to a lack of policy coherence throughout the government, one branch of the government may ensure the introduction of a national development plan of action, for example, TB free response to the change of the WHO [ 19 ]. At the same time, other parts promote exports, industrialization, and proposals that are dangerous to human life. The single cause for these discrepancies is a lack of knowledge among areas of the connections between health and quality of life, on the one hand, and more significant health determinants, such as productivity expansion, on the other. Another cause is that unrelated initiatives may have unexpected consequences that are not monitored or addressed. In its preamble, the Indian Constitution provides core values for establishing a social order in the country. An orderly society is built on these core values. Equality, various freedoms, socioeconomic justice, and individual dignity are fundamental principles for governing a democratic country like India. The policy approach will protect the social rights of people [ 20 ].

The healthcare system must comprehend the obligations of other parts and establish mutual consideration of health, its consequences, and great social welfare or life characteristics to contribute to policy coherence across government. It needs novel solutions and institutions that create avenues for debate and decision-making that cut across typical policy silos in government. In practice, this entails taking a variety of acts, such as facilitating seminars of government policymakers, program leaders, and healthcare provider organizations, to promote policy, service, and program coherence in response to the needs of disadvantaged groups, such as via conferences conducted at numerous organizational stages and with private and government providers. For evaluation of policy progress and pitfalls, from a theoretical perspective, several policy-making frameworks can be used to describe how programs are developed and executed [ 21 ].

The policy windows model by Kingdom (1995) is crucial as it illustrates how and why issues become part of the policy agenda before implementation [ 22 ]. Three streams are coupled or decoupled problem, policy, and politics; according to Kingdom, open and close strategy opportunities. The gathering of proof regarding health inequality is essential but not enough for policy change. Problems must be viewed or identified as problems that can be addressed by legislation. Complicated by the fact that general populace initiatives in largely unrelated domains may have population health implications [ 23 ]. The collection of facts, particularly the Acheson Report, has aided in the designation of health disparities as a political issue. Similar inquiries have formed the issue in other places [ 24 ].

Socioeconomic Determinants and Health Inequities

SDH must all be incorporated into public health services to reduce health disparities. Health services must be adapted to the demands of distinct population groups. Due to the build-up of difficulty through several areas and over the life course, different social groups in the population differ in their empowerment to participate in health interventions. Many public health programs have not met or are not meeting their health equity targets due to a lack of healthcare-specific interventions and a failure to reach out to vulnerable people and address significant social variables that affect public health. Disparities exist between public and private health systems [ 25 ]. Policy efforts at the health system level are required to monitor and improve these disparities [ 25 ]. The coronavirus disease 2019 (COVID-19) pandemic has had the greatest impact on groups that have faced discrimination and historical injustices [ 26 ]. Poor living conditions and exploitative labor have become more prevalent, allowing for inequitable income distribution and health risks [ 26 ]. Governments have exploited the pandemic to further erode civil and human rights and promote extractives [ 26 ]. A post-COVID-19 world must ensure equity, social justice, solidarity, and a shift in the balance of power and resources for poor and marginalized people [ 26 ].

Lower-income societies with lower smoking rates have a lower incidence of lung cancer [ 27 ]. Individual smoking patterns or different rates of illness prevalence and incidence among social groups, i.e., inequalities, are caused by balances or imbalances in community norms and social structures. Sick people are diametrically opposed to the overall healthy population [ 27 ]. The term health inequalities in SDH (SDHI) has recently been taken to refer to settings, social structures, social norms, and some determinants. Three primary paths have been proposed to describe how the social environment causes fitness inequities [ 28 ]. Social choice, or mobility of community, suggests that health, relatively more than the other way around, determines socioeconomic status. As a result, healthier people will be happier. They move toward a higher socioeconomic status than others who were less beneficial, resulting in inequities. Social causation claims that discrepancies in health outcomes are caused by a variety of unequally distributed material, psychosocial, and behavioral factors [ 29 , 30 ].

A life path viewpoint indicates various features throughout life (e.g., malnutrition in the maternal prenatal period, low learning services in infancy, physically hazardous employment, influence, and manifest illness trends across time). The eco-social method tries to assimilate these organic, communal, and natural variables in illness through a vigorous process of incorporation which means we accurately integrate natural effects from the substantial and the social world [ 7 , 31 ]. Over the last 40 years, research on health inequalities and growth has shed light on the income well-being trend [ 32 ]. Measuring the disparity between subgroups requires using different health data based on the relevant dimension of inequality (i.e., demographic, socioeconomic, or geographic factors) [ 33 ]. Monitoring health inequality at the national level assists in assessing the impact of policies, programs, and practices on the disadvantaged subgroup [ 33 ]. This priority will be given to the proposed Sustainable Development Goals. which ask countries to increase the income, gender, geographical location, race, age, ethnicity, disability, migrant status, and other relevant characteristics at the national level [ 34 ].

Conceptual Limitations of Inequalities

SDHI covertly and overtly embraces substantial parts of a Newtonian view of reality (i.e., reductionism, linearity, and hierarchy), as do most notions connected to health outcomes [ 35 ]. This reductive approach is represented by a factor influencing health outcomes, for example, socioeconomic stratification of mortality due to asthma and the selection of interventions that focus on a single determinant, for example, improving thermal comfort in homes with insufficient heat [ 36 ]. Another common assumption in this debate is linearity, which argues that determinants of inequalities can be used in a variety of situations [ 30 ]. Differential access to healthcare or education is presumed to be health disparities in results [ 37 ], essentially in a linear pattern, whether overtly or implicitly [ 38 ]. In the case of what works in terms of tackling health inequalities, disappointingly very less relevant reviews have been conducted [ 39 ].

Conclusions

After reviewing the current literature on SDH and health inequalities, we conclude that economic and social factors such as poverty, social exclusion, and others are usually regarded as SDH. Interventions are the most effective strategies to improve everyone’s well-being and reduce inequalities. The severity of employment, geography, and education imply that better healthcare management and expanded education and work prospects are required. Additional efforts in this area will likely help overcome social health inequalities in communities and achieve health equality. Policies that reduce social disadvantage can reduce health inequalities. The current state of the health sector, for which the union and state governments are equally responsible, and the right to health is not equally distributed can only be corrected if the union and state governments start practicing and introducing more efforts to achieve health equality. Health rights should be given to all people, encouraging them to use more services. Hence, making them healthier, more productive, and fit.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

How to build a better health system: 8 expert essays

We need to focus on keeping people healthy, not just treating them when they're sick Image:  REUTERS/Rupak De Chowdhuri

.chakra .wef-1c7l3mo{-webkit-transition:all 0.15s ease-out;transition:all 0.15s ease-out;cursor:pointer;-webkit-text-decoration:none;text-decoration:none;outline:none;color:inherit;}.chakra .wef-1c7l3mo:hover,.chakra .wef-1c7l3mo[data-hover]{-webkit-text-decoration:underline;text-decoration:underline;}.chakra .wef-1c7l3mo:focus,.chakra .wef-1c7l3mo[data-focus]{box-shadow:0 0 0 3px rgba(168,203,251,0.5);} Global Future Council on Health and Healthcare

Introduction

By Francesca Colombo , Head, Health Division, Organisation for Economic Co-operation and Development (OECD) and Helen E. Clark , Prime Minister of New Zealand (1999-2008), The Helen Clark Foundation

Our healthy future cannot be achieved without putting the health and wellbeing of populations at the centre of public policy.

Ill health worsens an individual’s economic prospects throughout the lifecycle. For young infants and children, ill health affects their capacity to acumulate human capital; for adults, ill health lowers quality of life and labour market outcomes, and disadvantage compounds over the course of a lifetime.

And, yet, with all the robust evidence available that good health is beneficial to economies and societies, it is striking to see how health systems across the globe struggled to maximise the health of populations even before the COVID-19 pandemic – a crisis that has further exposed the stresses and weaknesses of our health systems. These must be addressed to make populations healthier and more resilient to future shocks.

Each one of us, at least once in our lives, is likely to have been frustrated with care that was inflexible, impersonal and bureaucratic. At the system level, these individual experiences add up to poor safety, poor care coordination and inefficiencies – costing millions of lives and enormous expense to societies.

This state of affairs contributes to slowing down the progress towards achieving the sustainable development goals to which all societies, regardless of their level of economic development, have committed.

Many of the conditions that can make change possible are in place. For example, ample evidence exists that investing in public health and primary prevention delivers significant health and economic dividends. Likewise, digital technology has made many services and products across different sectors safe, fast and seamless. There is no reason why, with the right policies, this should not happen in health systems as well. Think, for example, of the opportunities to bring high quality and specialised care to previously underserved populations. COVID-19 has accelerated the development and use of digital health technologies. There are opportunities to further nurture their use to improve public health and disease surveillance, clinical care, research and innovation.

To encourage reform towards health systems that are more resilient, better centred around what people need and sustainable over time, the Global Future Council on Health and Health Care has developed a series of stories illustrating why change must happen, and why this is eminently possible today. While the COVID-19 crisis is severally challenging health systems today, our healthy future is – with the right investments – within reach.

1. Five changes for sustainable health systems that put people first

The COVID-19 crisis has affected more than 188 countries and regions worldwide, causing large-scale loss of life and severe human suffering. The crisis poses a major threat to the global economy, with drops in activity, employment, and consumption worse than those seen during the 2008 financial crisis . COVID-19 has also exposed weaknesses in our health systems that must be addressed. How?

For a start, greater investment in population health would make people, particularly vulnerable population groups, more resilient to health risks. The health and socio-economic consequences of the virus are felt more acutely among disadvantaged populations, stretching a social fabric already challenged by high levels of inequalities. The crisis demonstrates the consequences of poor investment in addressing wider social determinants of health, including poverty, low education and unhealthy lifestyles. Despite much talk of the importance of health promotion, even across the richer OECD countries barely 3% of total health spending is devoted to prevention . Building resilience for populations also requires a greater focus on solidarity and redistribution in social protection systems to address underlying structural inequalities and poverty.

Beyond creating greater resilience in populations, health systems must be strengthened.

High-quality universal health coverage (UHC) is paramount. High levels of household out-of-pocket payments for health goods and services deter people from seeking early diagnosis and treatment at the very moment they need it most. Facing the COVID-19 crisis, many countries have strengthened access to health care, including coverage for diagnostic testing. Yet others do not have strong UHC arrangements. The pandemic reinforced the importance of commitments made in international fora, such as the 2019 High-Level Meeting on Universal Health Coverage , that well-functioning health systems require a deliberate focus on high-quality UHC. Such systems protect people from health threats, impoverishing health spending, and unexpected surges in demand for care.

Second, primary and elder care must be reinforced. COVID-19 presents a double threat for people with chronic conditions. Not only are they at greater risk of severe complications and death due to COVID-19; but also the crisis creates unintended health harm if they forgo usual care, whether because of disruption in services, fear of infections, or worries about burdening the health system. Strong primary health care maintains care continuity for these groups. With some 94% of deaths caused by COVID-19 among people aged over 60 in high-income countries, the elder care sector is also particularly vulnerable, calling for efforts to enhance control of infections, support and protect care workers and better coordinate medical and social care for frail elderly.

Third, the crisis demonstrates the importance of equipping health systems with both reserve capacity and agility. There is an historic underinvestment in the health workforce, with estimated global shortages of 18 million health professionals worldwide , mostly in low- and middle-income countries. Beyond sheer numbers, rigid health labour markets make it difficult to respond rapidly to demand and supply shocks. One way to address this is by creating a “reserve army” of health professionals that can be quickly mobilised. Some countries have allowed medical students in their last year of training to start working immediately, fast-tracked licenses and provided exceptional training. Others have mobilised pharmacists and care assistants. Storing a reserve capacity of supplies such as personal protection equipment, and maintaining care beds that can be quickly transformed into critical care beds, is similarly important.

Fourth, stronger health data systems are needed. The crisis has accelerated innovative digital solutions and uses of digital data, smartphone applications to monitor quarantine, robotic devices, and artificial intelligence to track the virus and predict where it may appear next. Access to telemedicine has been made easier. Yet more can be done to leverage standardised national electronic health records to extract routine data for real-time disease surveillance, clinical trials, and health system management. Barriers to full deployment of telemedicine, the lack of real-time data, of interoperable clinical record data, of data linkage capability and sharing within health and with other sectors remain to be addressed.

Fifth, an effective vaccine and successful vaccination of populations around the globe will provide the only real exit strategy. Success is not guaranteed and there are many policy issues yet to be resolved. International cooperation is vital. Multilateral commitments to pay for successful candidates would give manufacturers certainty so that they can scale production and have vaccine doses ready as quickly as possible following marketing authorisation, but could also help ensure that vaccines go first to where they are most effective in ending the pandemic. Whilst leaders face political pressure to put the health of their citizens first, it is more effective to allocate vaccines based on need. More support is needed for multilateral access mechanisms that contain licensing commitments and ensure that intellectual property is no barrier to access, commitments to technology transfer for local production, and allocation of scarce doses based on need.

The pandemic offers huge opportunities to learn lessons for health system preparedness and resilience. Greater focus on anticipating responses, solidarity within and across countries, agility in managing responses, and renewed efforts for collaborative actions will be a better normal for the future.

OECD Economic Outlook 2020 , Volume 2020 Issue 1, No. 107, OECD Publishing, Paris

OECD Employment Outlook 2020 : Worker Security and the COVID-19 Crisis, OECD Publishing, Paris

OECD Health at a Glance 2019, OECD Publishing, Paris

https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf

OECD (2020), Who Cares? Attracting and Retaining Care Workers for the Elderly, OECD Health Policy Studies, OECD Publishing, Paris

Working for Health and Growth: investing in the health workforce . Report of the High-Level Commission on Health Employment and Economic Growth, Geneva.

Colombo F., Oderkirk J., Slawomirski L. (2020) Health Information Systems, Electronic Medical Records, and Big Data in Global Healthcare: Progress and Challenges in OECD Countries . In: Haring R., Kickbusch I., Ganten D., Moeti M. (eds) Handbook of Global Health. Springer, Cham.

2. Improving population health and building healthy societies in times of COVID-19

By Helena Legido-Quigley , Associate Professor, London School of Hygiene and Tropical Medicine

The COVID-19 pandemic has been a stark reminder of the fragility of population health worldwide; at time of writing, more than 1 million people have died from the disease. The pandemic has already made evident that those suffering most from COVID-19 belong to disadvantaged populations and marginalised communities. Deep-rooted inequalities have contributed adversely to the health status of different populations within and between countries. Besides the direct and indirect health impacts of COVID-19 and the decimation of health systems, restrictions on population movement and lockdowns introduced to combat the pandemic are expected to have economic and social consequences on an unprecedented scale .

Population health – and addressing the consequences of COVID-19 – is about improving the physical and mental health outcomes and wellbeing of populations locally, regionally and nationally, while reducing health inequalities.¹ Moreover, there is an increasing recognition that societal and environmental factors, such as climate change and food insecurity, can also influence population health outcomes.

The experiences of Maria, David, and Ruben – as told by Spanish public broadcaster RTVE – exemplify the real challenges that people living in densely populated urban areas have faced when being exposed to COVID-19.¹

Maria is a Mexican migrant who has just returned from Connecticut to the Bronx. Her partner Jorge died in Connecticut from COVID-19. She now has no income and is looking for an apartment for herself and her three children. When Jorge became ill, she took him to the hospital, but they would not admit him and he was sent away to be cared for by Maria at home with their children. When an ambulance eventually took him to hospital, it was too late. He died that same night, alone in hospital. She thinks he had diabetes, but he was never diagnosed. They only had enough income to pay the basic bills. Maria is depressed, she is alone, but she knows she must carry on for her children. Her 10-year old child says that if he could help her, he would work. After three months, she finds an apartment.

David works as a hairdresser and takes an overcrowded train every day from Leganés to Chamberi in the centre of Madrid. He lives in a small flat in San Nicasio, one of the poorest working-class areas of Madrid with one of the largest ageing populations in Spain. The apartments are very small, making it difficult to be in confinement, and all of David’s neighbours know somebody who has been a victim of COVID-19. His father was also a hairdresser. David's father was not feeling well; he was taken to hospital by ambulance, and he died three days later. David was not able to say goodbye to his father. Unemployment has increased in that area; small local shops are losing their customers, and many more people are expecting to lose their jobs.

Ruben lives in Iztapalapa in Mexico City with three children, a daughter-in-law and five grandchildren. Their small apartment has few amenities, and no running water during the evening. At three o’clock every morning, he walks 45 minutes with his mobile stall to sell fruit juices near the hospital. His daily earnings keep the family. He goes to the central market to buy fruit, taking a packed dirty bus. He thinks the city's central market was contaminated at the beginning of the pandemic, but it could not be closed as it is the main source of food in the country. He has no health insurance, and he knows that as a diabetic he is at risk, but medication for his condition is too expensive. He has no alternative but to go to work every day: "We die of hunger or we die of COVID."

These real stories highlight the issues that must be addressed to reduce persistent health inequalities and achieve health outcomes focusing on population health. The examples of Maria, David and Ruben show the terrible outcomes COVID-19 has had for people living in poverty and social deprivation, older people, and those with co-morbidities and/or pre-existing health conditions. All three live in densely populated urban areas with poor housing, and have to travel long distances in overcrowded transport. Maria’s loss of income has had consequences for her housing security and access to healthcare and health insurance, which will most likely lead to worse health conditions for her and her children. Furthermore, all three experienced high levels of stress, which is magnified in the cases of Maria and David who were unable to be present when their loved ones died.

The COVID-19 pandemic has made it evident that to improve the health of the population and build healthy societies, there is a need to shift the focus from illness to health and wellness in order to address the social, political and commercial determinants of health; to promote healthy behaviours and lifestyles; and to foster universal health coverage.² Citizens all over the world are demanding that health systems be strengthened and for governments to protect the most vulnerable. A better future could be possible with leadership that is able to carefully consider the long-term health, economic and social policies that are needed.

In order to design and implement population health-friendly policies, there are three prerequisites. First, there is a need to improve understanding of the factors that influence health inequalities and the interconnections between the economic, social and health impacts. Second, broader policies should be considered not only within the health sector, but also in other sectors such as education, employment, transport and infrastructure, agriculture, water and sanitation. Third, the proposed policies need to be designed through involving the community, addressing the health of vulnerable groups, and fostering inter-sectoral action and partnerships.

Finally, within the UN's Agenda 2030 , Sustainable Development Goal (SDG) 3 sets out a forward-looking strategy for health whose main goal is to attain healthier lives and wellbeing. The 17 interdependent SDGs offer an opportunity to contribute to healthier, fairer and more equitable societies from which both communities and the environment can benefit.

The stories of Maria, David and Ruben are real stories featured in the Documentary: The impact of COVID19 in urban outskirts, Directed by Jose A Guardiola. Available here. Permission has been granted to narrate these stories.

Buck, D., Baylis, A., Dougall, D. and Robertson, R. (2018). A vision for population health: Towards a healthier future . [online] London: The King's Fund. [Accessed 20 Sept. 2020]

Wilton Park. (2020). Healthy societies, healthy populations (WP1734). Wiston House, Steyning. Retrieved from https://www.wiltonpark.org.uk/event/wp1734/ Cohen B. E. (2006). Population health as a framework for public health practice: a Canadian perspective. American journal of public health , 96 (9), 1574–1576.

3. Imagine a 'well-care' system that invests in keeping people healthy

By Maliha Hashmi , Executive Director, Health and Well-Being and Biotech, NEOM, and Jan Kimpen , Global Chief Medical Officer, Philips

Imagine a patient named Emily. Emily is aged 32 and I’m her doctor.

Emily was 65lb (29kg) above her ideal body weight, pre-diabetic and had high cholesterol. My initial visit with Emily was taken up with counselling on lifestyle changes, mainly diet and exercise; typical advice from one’s doctor in a time-pressured 15-minute visit. I had no other additional resources, incentives or systems to support me or Emily to help her turn her lifestyle around.

I saw Emily eight months later, not in my office, but in the hospital emergency room. Her husband accompanied her – she was vomiting, very weak and confused. She was admitted to the intensive care unit, connected to an insulin drip to lower her blood sugar, and diagnosed with type 2 diabetes. I talked to Emily then, emphasizing that the new medications for diabetes would only control the sugars, but she still had time to reverse things if she changed her lifestyle. She received further counselling from a nutritionist.

Over the years, Emily continued to gain weight, necessitating higher doses of her diabetes medication. More emergency room visits for high blood sugars ensued, she developed infections of her skin and feet, and ultimately, she developed kidney disease because of the uncontrolled diabetes. Ten years after I met Emily, she is 78lb (35kg) above her ideal body weight; she is blind and cannot feel her feet due to nerve damage from the high blood sugars; and she will soon need dialysis for her failing kidneys. Emily’s deteriorating health has carried a high financial cost both for herself and the healthcare system. We have prevented her from dying and extended her life with our interventions, but each interaction with the medical system has come at significant cost – and those costs will only rise. But we have also failed Emily by allowing her diabetes to progress. We know how to prevent this, but neither the right investments nor incentives are in place.

Emily could have been a real patient of mine. Her sad story will be familiar to all doctors caring for chronically ill patients. Unfortunately, patients like Emily are neglected by health systems across the world today. The burden of chronic disease is increasing at alarming rates. Across the OECD nearly 33% of those over 15 years live with one or more chronic condition, rising to 60% for over-65s. Approximately 50% of chronic disease deaths are attributed to cardiovascular disease (CVD). In the coming decades, obesity, will claim 92 million lives in the OECD while obesity-related diseases will cut life expectancy by three years by 2050.

These diseases can be largely prevented by primary prevention, an approach that emphasizes vaccinations, lifestyle behaviour modification and the regulation of unhealthy substances. Preventative interventions have been efficacious. For obesity, countries have effectively employed public awareness campaigns, health professionals training, and encouragement of dietary change (for example, limits on unhealthy foods, taxes and nutrition labelling).⁴,⁵ Other interventions, such as workplace health-promotion programmes, while showing some promise, still need to demonstrate their efficacy.

The COVID-19 crisis provides the ultimate incentive to double down on the prevention of chronic disease. Most people dying from COVID-19 have one or more chronic disease, including obesity, CVD, diabetes or respiratory problems – diseases that are preventable with a healthy lifestyle. COVID-19 has highlighted structural weaknesses in our health systems such as the neglect of prevention and primary care.

While the utility of primary prevention is understood and supported by a growing evidence base, its implementation has been thwarted by chronic underinvestment, indicating a lack of societal and governmental prioritization. On average, OECD countries only invest 2.8% of health spending on public health and prevention. The underlying drivers include decreased allocation to prevention research, lack of awareness in populations, the belief that long-run prevention may be more costly than treatment, and a lack of commitment by and incentives for healthcare professionals. Furthermore, public health is often viewed in a silo separate from the overall health system rather than a foundational component.

Health benefits aside, increasing investment in primary prevention presents a strong economic imperative. For example, obesity contributes to the treatment costs of many other diseases: 70% of diabetes costs, 23% for CVD and 9% for cancers. Economic losses further extend to absenteeism and decreased productivity.

Fee-for-service models that remunerate physicians based on the number of sick patients they see, regardless the quality and outcome, dominate healthcare systems worldwide. Primary prevention mandates a payment system that reimburses healthcare professionals and patients for preventive actions. Ministries of health and governmental leaders need to challenge skepticism around preventive interventions, realign incentives towards preventive actions and those that promote healthy choices by people. Primary prevention will eventually reduce the burden of chronic diseases on the healthcare system.

As I reflect back on Emily and her life, I wonder what our healthcare system could have done differently. What if our healthcare system was a well-care system instead of a sick-care system? Imagine a different scenario: Emily, a 32 year old pre-diabetic, had access to a nutritionist, an exercise coach or health coach and nurse who followed her closely at the time of her first visit with me. Imagine if Emily joined group exercise classes, learned where to find healthy foods and how to cook them, and had access to spaces in which to exercise and be active. Imagine Emily being better educated about her diabetes and empowered in her healthcare and staying healthy. In reality, it is much more complicated than this, but if our healthcare systems began to incentivize and invest in prevention and even rewarded Emily for weight loss and healthy behavioural changes, the outcome might have been different. Imagine Emily losing weight and continuing to be an active and contributing member of society. Imagine if we invested in keeping people healthy rather than waiting for people to get sick, and then treating them. Imagine a well-care system.

Anderson, G. (2011). Responding to the growing cost and prevalence of people with multiple chronic conditions . Retrieved from OECD.

Institute for Health Metrics and Evaluation. GBD Data Visualizations. Retrieved here.

OECD (2019), The Heavy Burden of Obesity: The Economics of Prevention, OECD Health Policy Studies, OECD Publishing, Paris.

OECD. (2017). Obesity Update . Retrieved here.

Malik, V. S., Willett, W. C., & Hu, F. B. (2013). Global obesity: trends, risk factors and policy implications. Nature Reviews Endocrinology , 9 (1), 13-27.

Lang, J., Cluff, L., Payne, J., Matson-Koffman, D., & Hampton, J. (2017). The centers for disease control and prevention: findings from the national healthy worksite program. Journal of occupational and environmental medicine , 59 (7), 631.

Gmeinder, M., Morgan, D., & Mueller, M. (2017). How much do OECD countries spend on prevention? Retrieved from OECD.

Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ. 2020;368:m1198.

Richardson, A. K. (2012). Investing in public health: barriers and possible solutions. Journal of Public Health , 34 (3), 322-327.

Yong, P. L., Saunders, R. S., & Olsen, L. (2010). Missed Prevention Opportunities The healthcare imperative: lowering costs and improving outcomes: workshop series summary (Vol. 852): National Academies Press Washington, DC.

OECD. (2019). The Heavy Burden of Obesity: The Economics of Prevention. Retrieved here .

McDaid, D., F. Sassi and S. Merkur (Eds.) (2015a), “Promoting Health, Preventing Disease: The Economic Case ”, Open University Press, New York.

OECD. (2019). The Heavy Burden of Obesity: The Economics of Prevention. Retrieved from OECD.

4. Why e arly detection and diagnosis is critical

By Paul Murray , Head of Life and Health Products, Swiss Re, and André Goy , Chairman and Executive Director & Chief of Lymphoma, John Theurer Cancer Center, Hackensack University Medical Center

Although healthcare systems around the world follow a common and simple principle and goal – that is, access to affordable high-quality healthcare – they vary significantly, and it is becoming increasingly costly to provide this access, due to ageing populations, the increasing burden of chronic diseases and the price of new innovations.

Governments are challenged by how best to provide care to their populations and make their systems sustainable. Neither universal health, single payer systems, hybrid systems, nor the variety of systems used throughout the US have yet provided a solution. However, systems that are ranked higher in numerous studies, such as a 2017 report by the Commonwealth Fund , typically include strong prevention care and early-detection programmes. This alone does not guarantee a good outcome as measured by either high or healthy life expectancy. But there should be no doubt that prevention and early detection can contribute to a more sustainable system by reducing the risk of serious diseases or disorders, and that investing in and operationalizing earlier detection and diagnosis of key conditions can lead to better patient outcomes and lower long-term costs.

To discuss early detection in a constructive manner it makes sense to describe its activities and scope. Early detection includes pre-symptomatic screening and treatment immediately or shortly after first symptoms are diagnosed. Programmes may include searching for a specific disease (for example, HIV/AIDS or breast cancer), or be more ubiquitous. Prevention, which is not the focus of this blog, can be interpreted as any activities undertaken to avoid diseases, such as information programmes, education, immunization or health monitoring.

Expenditures for prevention and early detection vary by country and typically range between 1-5% of total health expenditures.¹ During the 2008 global financial crisis, many countries reduced preventive spending. In the past few years, however, a number of countries have introduced reforms to strengthen and promote prevention and early detection. Possibly the most prominent example in recent years was the introduction of the Affordable Care Act in the US, which placed a special focus on providing a wide range of preventive and screening services. It lists 63 distinct services that must be covered without any copayment, co-insurance or having to pay a deductible.

Whilst logic dictates that investment in early detection should be encouraged, there are a few hurdles and challenges that need to be overcome and considered. We set out a few key criteria and requirements for an efficient early detection program:

1. Accessibility The healthcare system needs to provide access to a balanced distribution of physicians, both geographically (such as accessibility in rural areas), and by specialty. Patients should be able to access the system promptly without excessive waiting times for diagnoses or elective treatments. This helps mitigate conditions or diseases that are already quite advanced or have been incubating for months or even years before a clinical diagnosis. Access to physicians varies significantly across the globe from below one to more than 60 physicians per 10,000 people.² One important innovation for mitigating access deficiencies is telehealth. This should give individuals easier access to health-related services, not only in cases of sickness but also to supplement primary care.

2. Early symptoms and initial diagnosis Inaccurate or delayed initial diagnoses present a risk to the health of patients, can lead to inappropriate or unnecessary testing and treatment, and represents a significant share of total health expenditures. A medical second opinion service, especially for serious medical diagnoses, which can occur remotely, can help improve healthcare outcomes. Moreover, studies show that early and correct diagnosis opens up a greater range of curative treatment options and can reduce costs (e.g. for colon cancer, stage-four treatment costs are a multiple of stage-one treatment costs).³

3. New technology New early detection technologies can improve the ability to identify symptoms and diseases early: i. Advances in medical monitoring devices and wearable health technology, such as ECG and blood pressure monitors and biosensors, enable patients to take control of their own health and physical condition. This is an important trend that is expected to positively contribute to early detection, for example in atrial fibrillation and Alzheimers’ disease. ii. Diagnostic tools, using new biomarkers such as liquid biopsies or volatile organic compounds, together with the implementation of machine learning, can play an increasing role in areas such as oncology or infectious diseases.⁴

4. Regulation and Intervention Government regulation and intervention will be necessary to set ranges of normality, to prohibit or discourage overdiagnosis and to reduce incentives for providers to overtreat patients or to follow patients' inappropriate requests. In some countries, such as the US, there has been some success through capitation models and value-based care. Governments might also need to intervene to de-risk the innovation paradigm, such that private providers of capital feel able to invest more in the development of new detection technologies, in addition to proven business models in novel therapeutics.

OECD Health Working Papers No. 101 "How much do OECD countries spend on prevention" , 2017

World Health Organization; Global Health Observatory (GHO) data; https://www.who.int/gho/health_workforce/physicians_density/en/

Saving lives, averting costs; A report for Cancer Research UK, by Incisive Health, September 2014

Liquid Biopsy: Market Drivers And Obstacles; by Divyaa Ravishankar, Frost & Sullivan, January 21, 2019

Liquid Biopsies Become Cheap and Easy with New Microfluidic Device; February 26, 2019

How America’s 5 Top Hospitals are Using Machine Learning Today; by Kumba Sennaar, February 19, 2019

5. The business case for private investment in healthcare for all

Pascal Fröhlicher, Primary Care Innovation Scholar, Harvard Medical School, and Ian Wijaya, Managing Director in Lazard’s Global Healthcare Group

Faith, a mother of two, has just lost another customer. Some households where she is employed to clean, in a small town in South Africa, have little understanding of her medical needs. As a type 2 diabetes patient, this Zimbabwean woman visits the public clinic regularly, sometimes on short notice. At her last visit, after spending hours in a queue, she was finally told that the doctor could not see her. To avoid losing another day of work, she went to the local general practitioner to get her script, paying more than three daily wages for consultation and medication. Sadly, this fictional person reflects a reality for many people in middle-income countries.

Achieving universal health coverage by 2030, a key UN Sustainable Development Goal (SDG), is at risk. The World Bank has identified a $176 billion funding gap , increasing every year due to the growing needs of an ageing population, with the health burden shifting towards non-communicable diseases (NCDs), now the major cause of death in emerging markets . Traditional sources of healthcare funding struggle to increase budgets sufficiently to cover this gap and only about 4% of private health care investments focus on diseases that primarily affect low- and middle-income countries.

In middle-income countries, private investors often focus on extending established businesses, including developing private hospital capacity, targeting consumers already benefiting from quality healthcare. As a result, an insufficient amount of private capital is invested in strengthening healthcare systems for everyone.

Why is this the case? We discussed with senior health executives investing in Lower and Middle Income Countries (LMIC) and the following reasons emerged:

• Small market size . Scaling innovations in healthcare requires dealing with country-specific regulatory frameworks and competing interest groups, resulting in high market entry cost.
• Talent . Several LMICs are losing nurses and doctors but also business and finance professionals to European and North American markets due to the lack of local opportunities and a significant difference in salaries.
• Untested business models with relatively low gross margins. Providing healthcare requires innovative business models where consumers’ willingness to pay often needs to be demonstrated over a significant period of time. Additionally, relatively low gross margins drive the need for scale to leverage administrative costs, which increases risk.
• Government Relations. The main buyer of health-related products and services is government; yet the relationship between public and private sectors often lacks trust, creating barriers to successful collaboration. Add to that significant political risk, as contracts can be cancelled by incoming administrations after elections. Many countries also lack comprehensive technology strategies to successfully manage technological innovation.
• Complexity of donor funding. A significant portion of healthcare is funded by private donors, whose priorities might not always be congruent with the health priorities of the government.

Notwithstanding these barriers, healthcare, specifically in middle-income settings, could present an attractive value proposition for private investors:

• Economic growth rates . A growing middle class is expanding the potential market for healthcare products and services.
• Alignment of incentives . A high ratio of out-of-pocket payments for healthcare services is often associated with low quality. However, innovative business models can turn out of pocket payments into the basis for a customer-centric value proposition, as the provider is required to compete for a share of disposable income.
• Emergence of National Health Insurance Schemes . South Africa, Ghana, Nigeria and others are building national health insurance schemes, increasing a population’s ability to fund healthcare services and products .
• Increased prevalence of NCDs. Given the increasing incidence of chronic diseases and the potential of using technology to address these diseases, new business opportunities for private investment exist.

Based on the context above, several areas in healthcare delivery can present compelling opportunities for private companies.

• Aggregation of existing players.
• Leveraging primary care infrastructure. Retail companies can leverage their real estate, infrastructure and supply chains to deploy primary care services at greater scale than is currently the case.
• Telemedicine . Telecommunications providers can leverage their existing infrastructure and customer base to provide payment mechanisms and telehealth services at scale. As seen during the COVID-19 pandemic, investment in telemedicine can ensure that patients receive timely and continuous care in spite of restrictions and lockdowns.
• Cost effective diagnostics . Diagnostic tools operated by frontline workers and combined with the expertise of specialists can provide timely and efficient care.

To fully realize these opportunities, government must incentivise innovation, provide clear regulatory frameworks and, most importantly, ensure that health priorities are adequately addressed.

Venture capital and private equity firms as well as large international corporations can identify the most commercially viable solutions and scale them into new markets. The ubiquity of NCDs and the requirement to reduce costs globally provides innovators with the opportunity to scale their tested solutions from LMICs to higher income environments.

Successful investment exits in LMICs and other private sector success stories will attract more private capital. Governments that enable and support private investment in their healthcare systems would, with appropriate governance and guidance, generate benefits to their populations and economies. The economic value of healthy populations has been proven repeatedly , and in the face of COVID-19, private sector investment can promote innovation and the development of responsible, sustainable solutions.

Faith – the diabetic mother we introduced at the beginning of this article - could keep her client. As a stable patient, she could measure her glucose level at home and enter the results in an app on her phone, part of her monthly diabetes programme with the company that runs the health centre. She visits the nurse-led facility at the local taxi stand on her way to work when her app suggests it. The nurse in charge of the centre treats Faith efficiently, and, if necessary, communicates with a primary care physician or even a specialist through the telemedicine functionality of her electronic health system.

Improving LMIC health systems is not only a business opportunity, but a moral imperative for public and private leaders. With the appropriate technology and political will, this can become a reality.

6. How could COVID-19 change the way we pay for health services?

John E. Ataguba, Associate Professor and Director, University of Cape Town and Matthew Guilford, Co-Founder and Chief Executive Officer, Common Health

The emergence of the new severe acute respiratory syndrome coronavirus (SARS-Cov-2), causing the coronavirus disease 2019 (COVID-19), has challenged both developing and developed countries.

Countries have approached the management of infections differently. Many people are curious to understand their health system’s performance on COVID-19, both at the national level and compared to international peers. Alongside limited resources for health, many developing countries may have weak health systems that can make it challenging to respond adequately to the pandemic.

Even before COVID-19, high rates of out-of-pocket spending on health meant that every year, 800 million people faced catastrophic healthcare costs ,100 million families were pushed into poverty, and millions more simply avoided care for critical conditions because they could not afford to pay for it.

The pandemic and its economic fallout have caused household incomes to decline at the same time as healthcare risks are rising. In some countries with insurance schemes, and especially for private health insurance, the following questions have arisen: How large is the co-payment for a COVID-19 test? If my doctor’s office is closed, will the telemedicine consultation be covered by my insurance? Will my coronavirus care be paid for regardless of how I contracted the virus? These and other doubts can prevent people from seeking medical care in some countries.

In Nigeria, like many other countries in Africa, the government bears the costs associated with testing and treating COVID-19 irrespective of the individual’s insurance status. In the public health sector, where COVID-19 cases are treated, health workers are paid monthly salaries while budgets are allocated to health facilities for other services. Hospitals continue to receive budget allocations to finance all health services including the management and treatment of COVID-19. That implies that funds allocated to address other health needs are reduced and that in turn could affect the availability and quality of health services.

Although health workers providing care for COVID-19 patients in isolation and treatment centres in Nigeria are paid salaries that are augmented with a special incentive package, the degree of impact on the quality improvement of services remains unclear. The traditional and historical allocation of budgets does not always address the needs of the whole population and could result in poor health services and under-provision of health services for COVID-19 patients.

In some countries, the reliance on out-of-pocket funding is hardly better for private providers, who encounter brand risks, operational difficulties, and – in extreme cases – the risk of creating “debtor prisons” as they seek to collect payment from patients. Ironically, despite the huge demand for medical services to diagnose and treat COVID-19, large healthcare institutions and individual healthcare practitioners alike are facing financial distress.

Dependence on a steady stream of fee-for-service payments for outpatient consultations and elective procedures is leading to pay cuts for doctors in India , forfeited Eid bonuses for nurses in Indonesia , and hospital bankruptcies in the United States . In a recent McKinsey & Company survey, 77% of physicians reported that their business would suffer in 2020 , and 46% were concerned about their practice surviving the coronavirus pandemic.

COVID-19 is exposing how fee-for-service, historical budget allocation and out-of-pocket financing methods can hinder the performance of the health system. Some providers and health systems that deployed “value-based” models prior to the pandemic have reported that these approaches have improved financial resilience during COVID-19 and may support better results for patients. Nevertheless, these types of innovations do not represent the dominant payment model in any country.

How health service providers are paid has implications for whether service users can get needed health services in a timely fashion, and at an appropriate quality and an affordable cost. By shifting from fee-for-service reimbursements to fixed "capitation" and performance-based payments, these models incentivize providers to improve quality and coordination while also guaranteeing a baseline income level, even during times of disruption.

Health service providers could be paid either in the form of salaries, a fee for services they provide, by capitation (whether adjusted or straightforward), through global budgets, or by using a case-based payment system (for example, the diagnostics-related groups), among others. Because there are different incentives to consider when adopting any of the methods, they could be combined to achieve a specific goal. For example, in some countries, health workers are paid salaries , and some specific services are paid on a fee-for-service basis.

Ideally, health services could be purchased strategically , incorporating aspects of provider performance in transferring funds to providers and accounting for the health needs of the population they serve.

In this regard, strategic purchasing for health has been advocated and should be highlighted as crucial with the emergence of the COVID-19 pandemic. There is a need to ensure value in the way health providers are paid, inter alia to increase efficiency, ensure equity, and improve access to needed health services. Value-based payment methods, although not new in many countries, provide an avenue to encourage long-term value for money, better quality, and strategic purchasing for health, helping to build a healthier, more resilient world.

7. L essons in integrated care from the COVID-19 pandemic

Sarah Ziegler, Postdoctoral Researcher, Department of Epidemiology and Biostatistics, University of Zurich, and Ninie Wang, Founder & CEO, Pinetree Care Group.

Since the start of the COVID-19 pandemic, people suffering non-communicable diseases (NCDs) have been at higher risk of becoming severely ill or dying. In Italy, 96.2% of people who died of COVID-19 lived with two or more chronic conditions.

Beyond the pandemic, cardiovascular disease, cancer, respiratory disease and diabetes are the leading burden of disease, with 41 million annual deaths. People with multimorbidity - a number of different conditions - often experience difficulties in accessing timely and coordinated healthcare, made worse when health systems are busy fighting against the pandemic.

Here is what happened in China with Lee, aged 62, who has been living with Chronic Obstructive Pulmonary Disease (COPD) for the past five years.

Before the pandemic, Lee’s care manager coordinated a multi-disciplinary team of physicians, nurses, pulmonary rehabilitation therapists, psychologists and social workers to put together a personalized care plan for her. Following the care plan, Lee stopped smoking and paid special attention to her diet, sleep and physical exercises, as well as sticking to her medication and follow-up visits. She participated in a weekly community-based physical activity program to meet other COPD patients, including short walks and exchange experiences. A mobile care team supported her with weekly cleaning and grocery shopping.

Together with her family, Lee had follow-up visits to ensure her care plan reflected her recovery and to modify the plan if needed. These integrated care services brought pieces of care together, centered around Lee’s needs, and provided a continuum of care that helped keep Lee in the community with a good quality of life for as long as possible.

Since the COVID-19 outbreak, such NCD services have been disrupted by lockdowns, the cancellation of elective care and the fear of visiting care service . These factors particularly affected people living with NCDs like Lee. As such, Lee was not able to follow her care plan anymore. The mobile care team was unable to visit her weekly as they were deployed to provide COVID-19 relief. Lee couldn’t participate in her community-based program, follow up on her daily activities, or see her family or psychologists. This negatively affected Lee’s COPD management and led to poor management of her physical activity and healthy diet.

The pandemic highlights the need for a flexible and reliable integrated care system to enable healthcare delivery to all people no matter where they live, uzilizing approaches such as telemedicine and effective triaging to overcome care disruptions.

Lee’s care manager created short videos to assist her family through each step of her care and called daily to check in on the implementation of the plan and answer questions. Lee received tele-consultations, and was invited to the weekly webcast series that supported COPD patient communities. When her uncle passed away because of pneumonia complications from COVID-19 in early April, Lee’s care manager arranged a palliative care provider to support the family through the difficult time of bereavement and provided food and supplies during quarantine. Lee could even continue with her physical activity program with an online training coach. There were a total of 38 exercise videos for strengthening and stretching arms, legs and trunk, which she could complete at different levels of difficulty and with different numbers of repetitions.

Lee’s case demonstrates that early detection, prevention, and management of NCDs play a crucial role in a global pandemic response. It shows how we need to shift away from health systems designed around single diseases towards health systems designed for the multidimensional needs of individuals. As part of the pandemic responses, addressing and managing risks related to NCDs and prevention of their complications are critical to improve outcomes for vulnerable people like Lee.

How to design and deliver successful integrated care

The challenge for the successful transformation of healthcare is to tailor care system-wide to population needs. A 2016 WHO Framework on integrated people-centered health services developed a set of five general strategies for countries to progress towards people-centered and sustainable health systems, calling for a fundamental transformation not only in the way health services are delivered, but also in the way they are financed and managed . These strategies call for countries to:

• Engage and empower people / communities: an integrated care system must mobilize everyone to work together using all available resources, especially when continuity of essential health and community services for NCDs are at risk of being undermined.
• Strengthen governance and accountability, so that integration emphasizes rather than weakens leadership in every part of the system, and ensure that NCDs are included in national COVID-19 plans and future essential health services.
• Reorient the model of care to put the needs and perspectives of each person / family at the center of care planning and outcome measurement, rather than institutions.
• Coordinate services within and across sectors, for example, integrate inter-disciplinary medical care with social care, addressing wider socio-economic, environmental and behavioral determinants of health.
• Create an enabling environment, with clear objectives, supportive financing, regulations and insurance coverage for integrated care, including the development and use of systemic digital health care solutions.

Whether due to an unexpected pandemic or a gradual increase in the burden of NCDs, each person could face many health threats across the life-course.

Only systems that dynamically assess each person’s complex health needs and address them through a timely, well-coordinated and tailored mix of health and social care services will be able to deliver desired health outcomes over the longer term, ensuring an uninterrupted good quality of life for Lee and many others like her.

• Wang B, Li R, Lu Z, Huang Y. Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis. Aging (Albany NY) 2020;12: 6049–57.
• WHO. Noncommunicable diseases in emergencies. Geneva: World Health Organization, 2016.
• WHO. COVID-19 significantly impacts health services for noncommunicable diseases. June 2020.
• Kluge HHP, Wickramasinghe K, Rippin HL, et al. Prevention and control of non-communicalbe diseases in the COVID-19 response. The Lancet. 2020. 395:1678-1680
• WHO. Framework on integrated people-centred health services. Geneva: World Health Organization, 2016.

8 . Why access to healthcare alone will not save lives

Donald Berwick, President Emeritus and Senior Fellow, Institute for Healthcare Improvement; Nicola Bedlington, Special Adviser, European Patient Forum; and David Duong, Director, Program in Global Primary Care and Social Change, Harvard Medical School.

Joyce lies next to 10 other women in bare single beds in the post-partum recovery room at a rural hospital in Uganda. Just an hour ago, Joyce gave birth to a healthy baby boy. She is now struggling with abdominal pain. A nurse walks by, and Joyce tries to call out, but the nurse was too busy to attend to her; she was the only nurse looking after 20 patients.

Another hour passes, and Joyce is shaking and sweating profusely. Joyce’s husband runs into the corridor to find a nurse to come and evaluate her. The nurse notices Joyce’s critical condition - a high fever and a low blood pressure - and she quickly calls the doctor. The medical team rushes Joyce to the intensive care unit. Joyce has a very severe blood stream infection. It takes another hour before antibiotics are started - too late. Joyce dies, leaving behind a newborn son and a husband. Joyce, like many before her, falls victim to a pervasive global threat: poor quality of care.

Adopted by United Nations (UN) in 2015, the Sustainable Development Goals (SDG) are a universal call to action to end poverty, protect the planet and ensure that all enjoy peace and prosperity by 2030. SDG 3 aims to ensure healthy lives and promote wellbeing for all. The 2019 UN General Assembly High Level Meeting on Universal Health Coverage (UHC) reaffirmed the need for the highest level of political commitment to health care for all.

However, progress towards UHC, often measured in terms of access, not outcomes, does not guarantee better health, as we can see from Joyce’s tragedy. This is also evident with the COVID-19 response. The rapidly evolving nature of the COVID-19 pandemic has highlighted long-term structural inefficiencies and inequities in health systems and societies trying to mitigate the contagion and loss of life.

Systems are straining under significant pressure to ensure standards of care for both COVID-19 patients and other patients that run the risk of not receiving timely and appropriate care. Although poor quality of care has been a long-standing issue, it is imperative now more than ever that systems implement high-quality services as part of their efforts toward UHC.

Poor quality healthcare remains a challenge for countries at all levels of economic development: 10% of hospitalized patients acquire an infection during their hospitalization in low-and-middle income countries (LMIC), whereas 7% do in high-income countries. Poor quality healthcare disproportionally affects the poor and those in LMICs. Of the approximately 8.6 million deaths per year in 137 LMICs, 3.6 million are people who did not access the health system, whereas 5 million are people who sought and had access to services but received poor-quality care.

Joyce’s story is all too familiar; poor quality of care results in deaths from treatable diseases and conditions. Although the causes of death are often multifactorial, deaths and increased morbidity from treatable conditions are often a reflection of defects in the quality of care.

The large number of deaths and avoidable complications are also accompanied by substantial economic costs. In 2015 alone, 130 LMICs faced US $6 trillion in economic losses. Although there is concern that implementing quality measures may be a costly endeavor, it is clear that the economic toll associated with a lack of quality of care is far more troublesome and further stunts the socio-economic development of LMICs, made apparent with the COVID-19 pandemic.

Poor-quality care not only leads to adverse outcomes in terms of high morbidity and mortality, but it also impacts patient experience and patient confidence in health systems. Less than one-quarter of people in LMICs and approximately half of people in high-income countries believe that their health systems work well.

A lack of application and availability of evidenced-based guidelines is one key driver of poor-quality care. The rapidly changing landscape of medical knowledge and guidelines requires healthcare workers to have immediate access to current clinical resources. Despite our "information age", health providers are not accessing clinical guidelines or do not have access to the latest practical, lifesaving information.

Getting information to health workers in the places where it is most needed is a delivery challenge. Indeed, adherence to clinical practice guidelines in eight LMICs was below 50%, and in OECD countries, despite being a part of national guidelines, 19-53% of women aged 50-69 years did not receive mammography screening.4 The evidence in LMICs and HICs suggest that application of evidence-based guidelines lead to reduction in mortality and improved health outcomes.

Equally, the failure to change and continually improve the processes in health systems that support the workforce takes a high toll on quality of care. During the initial wave of the COVID-19 pandemic, countries such as Taiwan, Hong Kong, Singapore and Vietnam, which adapted and improved their health systems after the SARS and H1N1 outbreaks, were able to rapidly mobilize a large-scale quarantine and contact tracing strategy, supported with effective and coordinated mass communication.

These countries not only mitigated the economic and mortality damage, but also prevented their health systems and workforce from enduring extreme burden and inability to maintain critical medical supplies. In all nations, investing in healthcare organizations to enable them to become true “learning health care systems,” aiming at continual quality improvement, would yield major population health and health system gains.

The COVID-19 pandemic underscores the importance for health systems to be learning systems. Once the dust settles, we need to focus, collectively, on learning from this experience and adapting our health systems to be more resilient for the next one. This implies a need for commitment to and investment in global health cooperation, improvement in health care leadership, and change management.

With strong political and financial commitment to UHC, and its demonstrable effect in addressing crises such as COVID-19, for the first time, the world has a viable chance of UHC becoming a reality. However, without an equally strong political, managerial, and financial commitment to continually improving, high-quality health services, UHC will remain an empty promise.

1. United Nations General Assembly. Political declaration of the high-level meeting on universal health coverage. New York, NY2019.

2. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10 years on. Institute of Health Equity;2020.

3. National Academies of Sciences, Engineering, and Medicine: Committee on Improving the Quality of Health Care Globally. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: National Academies Press;2018.

4. World Health Organization, Organization for Economic Co-operation and Development, World Bank Group. Delivering quality health services: a global imperative for universal health coverage. World Health Organization; 2018.

5. Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 2018;6(11):e1196-e1252.

6. Ricci-Cabello I, Violán C, Foguet-Boreu Q, Mounce LT, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review. European Journal of General Practice. 2015;21(3):192-202.

7. Valtis YK, Rosenberg J, Bhandari S, et al. Evidence-based medicine for all: what we can learn from a programme providing free access to an online clinical resource to health workers in resource-limited settings. BMJ global health. 2016;1(1).

8. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America . Washington, DC: National Academies Press 2012.

• Search Menu
• Browse content in Arts and Humanities
• Browse content in Archaeology
• Anglo-Saxon and Medieval Archaeology
• Archaeological Methodology and Techniques
• Archaeology by Region
• Archaeology of Religion
• Archaeology of Trade and Exchange
• Biblical Archaeology
• Contemporary and Public Archaeology
• Environmental Archaeology
• Historical Archaeology
• History and Theory of Archaeology
• Industrial Archaeology
• Landscape Archaeology
• Mortuary Archaeology
• Prehistoric Archaeology
• Underwater Archaeology
• Urban Archaeology
• Zooarchaeology
• Browse content in Architecture
• Architectural Structure and Design
• History of Architecture
• Residential and Domestic Buildings
• Theory of Architecture
• Browse content in Art
• Art Subjects and Themes
• History of Art
• Industrial and Commercial Art
• Theory of Art
• Biographical Studies
• Byzantine Studies
• Browse content in Classical Studies
• Classical History
• Classical Philosophy
• Classical Mythology
• Classical Literature
• Classical Reception
• Classical Art and Architecture
• Classical Oratory and Rhetoric
• Greek and Roman Epigraphy
• Greek and Roman Law
• Greek and Roman Archaeology
• Greek and Roman Papyrology
• Late Antiquity
• Religion in the Ancient World
• Digital Humanities
• Browse content in History
• Colonialism and Imperialism
• Diplomatic History
• Environmental History
• Genealogy, Heraldry, Names, and Honours
• Genocide and Ethnic Cleansing
• Historical Geography
• History by Period
• History of Agriculture
• History of Education
• History of Emotions
• History of Gender and Sexuality
• Industrial History
• Intellectual History
• International History
• Labour History
• Legal and Constitutional History
• Local and Family History
• Maritime History
• Military History
• National Liberation and Post-Colonialism
• Oral History
• Political History
• Public History
• Regional and National History
• Revolutions and Rebellions
• Slavery and Abolition of Slavery
• Social and Cultural History
• Theory, Methods, and Historiography
• Urban History
• World History
• Browse content in Language Teaching and Learning
• Language Learning (Specific Skills)
• Language Teaching Theory and Methods
• Browse content in Linguistics
• Applied Linguistics
• Cognitive Linguistics
• Computational Linguistics
• Forensic Linguistics
• Grammar, Syntax and Morphology
• Historical and Diachronic Linguistics
• History of English
• Language Acquisition
• Language Variation
• Language Families
• Language Evolution
• Language Reference
• Lexicography
• Linguistic Theories
• Linguistic Typology
• Linguistic Anthropology
• Phonetics and Phonology
• Psycholinguistics
• Sociolinguistics
• Translation and Interpretation
• Writing Systems
• Browse content in Literature
• Bibliography
• Children's Literature Studies
• Literary Studies (Asian)
• Literary Studies (European)
• Literary Studies (Eco-criticism)
• Literary Studies (Modernism)
• Literary Studies (Romanticism)
• Literary Studies (American)
• Literary Studies - World
• Literary Studies (1500 to 1800)
• Literary Studies (19th Century)
• Literary Studies (20th Century onwards)
• Literary Studies (African American Literature)
• Literary Studies (British and Irish)
• Literary Studies (Early and Medieval)
• Literary Studies (Fiction, Novelists, and Prose Writers)
• Literary Studies (Gender Studies)
• Literary Studies (Graphic Novels)
• Literary Studies (History of the Book)
• Literary Studies (Plays and Playwrights)
• Literary Studies (Poetry and Poets)
• Literary Studies (Postcolonial Literature)
• Literary Studies (Queer Studies)
• Literary Studies (Science Fiction)
• Literary Studies (Travel Literature)
• Literary Studies (War Literature)
• Literary Studies (Women's Writing)
• Literary Theory and Cultural Studies
• Mythology and Folklore
• Shakespeare Studies and Criticism
• Browse content in Media Studies
• Browse content in Music
• Applied Music
• Dance and Music
• Ethics in Music
• Ethnomusicology
• Gender and Sexuality in Music
• Medicine and Music
• Music Cultures
• Music and Religion
• Music and Culture
• Music and Media
• Music Education and Pedagogy
• Music Theory and Analysis
• Musical Scores, Lyrics, and Libretti
• Musical Structures, Styles, and Techniques
• Musicology and Music History
• Performance Practice and Studies
• Race and Ethnicity in Music
• Sound Studies
• Browse content in Performing Arts
• Browse content in Philosophy
• Aesthetics and Philosophy of Art
• Epistemology
• Feminist Philosophy
• History of Western Philosophy
• Metaphysics
• Moral Philosophy
• Non-Western Philosophy
• Philosophy of Science
• Philosophy of Action
• Philosophy of Law
• Philosophy of Religion
• Philosophy of Language
• Philosophy of Mind
• Philosophy of Perception
• Philosophy of Mathematics and Logic
• Practical Ethics
• Social and Political Philosophy
• Browse content in Religion
• Biblical Studies
• Christianity
• East Asian Religions
• History of Religion
• Judaism and Jewish Studies
• Qumran Studies
• Religion and Education
• Religion and Health
• Religion and Politics
• Religion and Science
• Religion and Law
• Religion and Art, Literature, and Music
• Religious Studies
• Browse content in Society and Culture
• Cookery, Food, and Drink
• Cultural Studies
• Customs and Traditions
• Ethical Issues and Debates
• Hobbies, Games, Arts and Crafts
• Lifestyle, Home, and Garden
• Natural world, Country Life, and Pets
• Popular Beliefs and Controversial Knowledge
• Sports and Outdoor Recreation
• Technology and Society
• Travel and Holiday
• Visual Culture
• Browse content in Law
• Arbitration
• Browse content in Company and Commercial Law
• Commercial Law
• Company Law
• Browse content in Comparative Law
• Systems of Law
• Competition Law
• Browse content in Constitutional and Administrative Law
• Government Powers
• Judicial Review
• Local Government Law
• Military and Defence Law
• Parliamentary and Legislative Practice
• Construction Law
• Contract Law
• Browse content in Criminal Law
• Criminal Procedure
• Criminal Evidence Law
• Sentencing and Punishment
• Employment and Labour Law
• Environment and Energy Law
• Browse content in Financial Law
• Banking Law
• Insolvency Law
• History of Law
• Human Rights and Immigration
• Intellectual Property Law
• Browse content in International Law
• Private International Law and Conflict of Laws
• Public International Law
• IT and Communications Law
• Jurisprudence and Philosophy of Law
• Law and Politics
• Law and Society
• Browse content in Legal System and Practice
• Courts and Procedure
• Legal Skills and Practice
• Primary Sources of Law
• Regulation of Legal Profession
• Medical and Healthcare Law
• Browse content in Policing
• Criminal Investigation and Detection
• Police and Security Services
• Police Procedure and Law
• Police Regional Planning
• Browse content in Property Law
• Personal Property Law
• Study and Revision
• Terrorism and National Security Law
• Browse content in Trusts Law
• Wills and Probate or Succession
• Browse content in Medicine and Health
• Browse content in Allied Health Professions
• Arts Therapies
• Clinical Science
• Dietetics and Nutrition
• Occupational Therapy
• Operating Department Practice
• Physiotherapy
• Radiography
• Speech and Language Therapy
• Browse content in Anaesthetics
• General Anaesthesia
• Neuroanaesthesia
• Browse content in Clinical Medicine
• Acute Medicine
• Cardiovascular Medicine
• Clinical Genetics
• Clinical Pharmacology and Therapeutics
• Dermatology
• Endocrinology and Diabetes
• Gastroenterology
• Genito-urinary Medicine
• Geriatric Medicine
• Infectious Diseases
• Medical Oncology
• Medical Toxicology
• Pain Medicine
• Palliative Medicine
• Rehabilitation Medicine
• Respiratory Medicine and Pulmonology
• Rheumatology
• Sleep Medicine
• Sports and Exercise Medicine
• Clinical Neuroscience
• Community Medical Services
• Critical Care
• Emergency Medicine
• Forensic Medicine
• Haematology
• History of Medicine
• Browse content in Medical Dentistry
• Oral and Maxillofacial Surgery
• Paediatric Dentistry
• Restorative Dentistry and Orthodontics
• Surgical Dentistry
• Medical Ethics
• Browse content in Medical Skills
• Clinical Skills
• Communication Skills
• Nursing Skills
• Surgical Skills
• Medical Statistics and Methodology
• Browse content in Neurology
• Clinical Neurophysiology
• Neuropathology
• Nursing Studies
• Browse content in Obstetrics and Gynaecology
• Gynaecology
• Occupational Medicine
• Ophthalmology
• Otolaryngology (ENT)
• Browse content in Paediatrics
• Neonatology
• Browse content in Pathology
• Chemical Pathology
• Clinical Cytogenetics and Molecular Genetics
• Histopathology
• Medical Microbiology and Virology
• Patient Education and Information
• Browse content in Pharmacology
• Psychopharmacology
• Browse content in Popular Health
• Caring for Others
• Complementary and Alternative Medicine
• Self-help and Personal Development
• Browse content in Preclinical Medicine
• Cell Biology
• Molecular Biology and Genetics
• Reproduction, Growth and Development
• Primary Care
• Professional Development in Medicine
• Browse content in Psychiatry
• Addiction Medicine
• Child and Adolescent Psychiatry
• Forensic Psychiatry
• Learning Disabilities
• Old Age Psychiatry
• Psychotherapy
• Browse content in Public Health and Epidemiology
• Epidemiology
• Public Health
• Browse content in Radiology
• Clinical Radiology
• Interventional Radiology
• Nuclear Medicine
• Radiation Oncology
• Reproductive Medicine
• Browse content in Surgery
• Cardiothoracic Surgery
• Gastro-intestinal and Colorectal Surgery
• General Surgery
• Neurosurgery
• Paediatric Surgery
• Peri-operative Care
• Plastic and Reconstructive Surgery
• Surgical Oncology
• Transplant Surgery
• Trauma and Orthopaedic Surgery
• Vascular Surgery
• Browse content in Science and Mathematics
• Browse content in Biological Sciences
• Aquatic Biology
• Biochemistry
• Bioinformatics and Computational Biology
• Developmental Biology
• Ecology and Conservation
• Evolutionary Biology
• Genetics and Genomics
• Microbiology
• Molecular and Cell Biology
• Natural History
• Plant Sciences and Forestry
• Research Methods in Life Sciences
• Structural Biology
• Systems Biology
• Zoology and Animal Sciences
• Browse content in Chemistry
• Analytical Chemistry
• Computational Chemistry
• Crystallography
• Environmental Chemistry
• Industrial Chemistry
• Inorganic Chemistry
• Materials Chemistry
• Medicinal Chemistry
• Mineralogy and Gems
• Organic Chemistry
• Physical Chemistry
• Polymer Chemistry
• Study and Communication Skills in Chemistry
• Theoretical Chemistry
• Browse content in Computer Science
• Artificial Intelligence
• Computer Architecture and Logic Design
• Game Studies
• Human-Computer Interaction
• Mathematical Theory of Computation
• Programming Languages
• Software Engineering
• Systems Analysis and Design
• Virtual Reality
• Browse content in Computing
• Business Applications
• Computer Security
• Computer Games
• Computer Networking and Communications
• Digital Lifestyle
• Graphical and Digital Media Applications
• Operating Systems
• Browse content in Earth Sciences and Geography
• Atmospheric Sciences
• Environmental Geography
• Geology and the Lithosphere
• Maps and Map-making
• Meteorology and Climatology
• Oceanography and Hydrology
• Palaeontology
• Physical Geography and Topography
• Regional Geography
• Soil Science
• Urban Geography
• Browse content in Engineering and Technology
• Agriculture and Farming
• Biological Engineering
• Civil Engineering, Surveying, and Building
• Electronics and Communications Engineering
• Energy Technology
• Engineering (General)
• Environmental Science, Engineering, and Technology
• History of Engineering and Technology
• Mechanical Engineering and Materials
• Technology of Industrial Chemistry
• Transport Technology and Trades
• Browse content in Environmental Science
• Applied Ecology (Environmental Science)
• Conservation of the Environment (Environmental Science)
• Environmental Sustainability
• Environmentalist Thought and Ideology (Environmental Science)
• Management of Land and Natural Resources (Environmental Science)
• Natural Disasters (Environmental Science)
• Nuclear Issues (Environmental Science)
• Pollution and Threats to the Environment (Environmental Science)
• Social Impact of Environmental Issues (Environmental Science)
• History of Science and Technology
• Browse content in Materials Science
• Ceramics and Glasses
• Composite Materials
• Metals, Alloying, and Corrosion
• Nanotechnology
• Browse content in Mathematics
• Applied Mathematics
• Biomathematics and Statistics
• History of Mathematics
• Mathematical Education
• Mathematical Finance
• Mathematical Analysis
• Numerical and Computational Mathematics
• Probability and Statistics
• Pure Mathematics
• Browse content in Neuroscience
• Cognition and Behavioural Neuroscience
• Development of the Nervous System
• Disorders of the Nervous System
• History of Neuroscience
• Invertebrate Neurobiology
• Molecular and Cellular Systems
• Neuroendocrinology and Autonomic Nervous System
• Neuroscientific Techniques
• Sensory and Motor Systems
• Browse content in Physics
• Astronomy and Astrophysics
• Atomic, Molecular, and Optical Physics
• Biological and Medical Physics
• Classical Mechanics
• Computational Physics
• Condensed Matter Physics
• Electromagnetism, Optics, and Acoustics
• History of Physics
• Mathematical and Statistical Physics
• Measurement Science
• Nuclear Physics
• Particles and Fields
• Plasma Physics
• Quantum Physics
• Relativity and Gravitation
• Semiconductor and Mesoscopic Physics
• Browse content in Psychology
• Affective Sciences
• Clinical Psychology
• Cognitive Neuroscience
• Cognitive Psychology
• Criminal and Forensic Psychology
• Developmental Psychology
• Educational Psychology
• Evolutionary Psychology
• Health Psychology
• History and Systems in Psychology
• Music Psychology
• Neuropsychology
• Organizational Psychology
• Psychological Assessment and Testing
• Psychology of Human-Technology Interaction
• Psychology Professional Development and Training
• Research Methods in Psychology
• Social Psychology
• Browse content in Social Sciences
• Browse content in Anthropology
• Anthropology of Religion
• Human Evolution
• Medical Anthropology
• Physical Anthropology
• Regional Anthropology
• Social and Cultural Anthropology
• Theory and Practice of Anthropology
• Browse content in Business and Management
• Business Strategy
• Business History
• Business Ethics
• Business and Government
• Business and Technology
• Business and the Environment
• Comparative Management
• Corporate Governance
• Corporate Social Responsibility
• Entrepreneurship
• Health Management
• Human Resource Management
• Industrial and Employment Relations
• Industry Studies
• Information and Communication Technologies
• International Business
• Knowledge Management
• Management and Management Techniques
• Operations Management
• Organizational Theory and Behaviour
• Pensions and Pension Management
• Public and Nonprofit Management
• Strategic Management
• Supply Chain Management
• Browse content in Criminology and Criminal Justice
• Criminal Justice
• Criminology
• Forms of Crime
• International and Comparative Criminology
• Youth Violence and Juvenile Justice
• Development Studies
• Browse content in Economics
• Agricultural, Environmental, and Natural Resource Economics
• Asian Economics
• Behavioural Finance
• Behavioural Economics and Neuroeconomics
• Econometrics and Mathematical Economics
• Economic Systems
• Economic Methodology
• Economic History
• Economic Development and Growth
• Financial Markets
• Financial Institutions and Services
• General Economics and Teaching
• Health, Education, and Welfare
• History of Economic Thought
• International Economics
• Labour and Demographic Economics
• Law and Economics
• Macroeconomics and Monetary Economics
• Microeconomics
• Public Economics
• Urban, Rural, and Regional Economics
• Welfare Economics
• Browse content in Education
• Adult Education and Continuous Learning
• Care and Counselling of Students
• Early Childhood and Elementary Education
• Educational Equipment and Technology
• Educational Strategies and Policy
• Higher and Further Education
• Organization and Management of Education
• Philosophy and Theory of Education
• Schools Studies
• Secondary Education
• Teaching of a Specific Subject
• Teaching of Specific Groups and Special Educational Needs
• Teaching Skills and Techniques
• Browse content in Environment
• Applied Ecology (Social Science)
• Climate Change
• Conservation of the Environment (Social Science)
• Environmentalist Thought and Ideology (Social Science)
• Natural Disasters (Environment)
• Social Impact of Environmental Issues (Social Science)
• Browse content in Human Geography
• Cultural Geography
• Economic Geography
• Political Geography
• Browse content in Interdisciplinary Studies
• Communication Studies
• Museums, Libraries, and Information Sciences
• Browse content in Politics
• African Politics
• Asian Politics
• Chinese Politics
• Comparative Politics
• Conflict Politics
• Elections and Electoral Studies
• Environmental Politics
• European Union
• Foreign Policy
• Gender and Politics
• Human Rights and Politics
• Indian Politics
• International Relations
• International Organization (Politics)
• International Political Economy
• Irish Politics
• Latin American Politics
• Middle Eastern Politics
• Political Methodology
• Political Communication
• Political Philosophy
• Political Sociology
• Political Theory
• Political Behaviour
• Political Economy
• Political Institutions
• Politics and Law
• Public Administration
• Public Policy
• Quantitative Political Methodology
• Regional Political Studies
• Russian Politics
• Security Studies
• State and Local Government
• UK Politics
• US Politics
• Browse content in Regional and Area Studies
• African Studies
• Asian Studies
• East Asian Studies
• Japanese Studies
• Latin American Studies
• Middle Eastern Studies
• Native American Studies
• Scottish Studies
• Browse content in Research and Information
• Research Methods
• Browse content in Social Work
• Addictions and Substance Misuse
• Adoption and Fostering
• Care of the Elderly
• Child and Adolescent Social Work
• Couple and Family Social Work
• Developmental and Physical Disabilities Social Work
• Direct Practice and Clinical Social Work
• Emergency Services
• Human Behaviour and the Social Environment
• International and Global Issues in Social Work
• Mental and Behavioural Health
• Social Justice and Human Rights
• Social Policy and Advocacy
• Social Work and Crime and Justice
• Social Work Macro Practice
• Social Work Practice Settings
• Social Work Research and Evidence-based Practice
• Welfare and Benefit Systems
• Browse content in Sociology
• Childhood Studies
• Community Development
• Comparative and Historical Sociology
• Economic Sociology
• Gender and Sexuality
• Gerontology and Ageing
• Health, Illness, and Medicine
• Marriage and the Family
• Migration Studies
• Occupations, Professions, and Work
• Organizations
• Population and Demography
• Race and Ethnicity
• Social Theory
• Social Movements and Social Change
• Social Research and Statistics
• Social Stratification, Inequality, and Mobility
• Sociology of Religion
• Sociology of Education
• Sport and Leisure
• Urban and Rural Studies
• Browse content in Warfare and Defence
• Defence Strategy, Planning, and Research
• Land Forces and Warfare
• Military Administration
• Military Life and Institutions
• Naval Forces and Warfare
• Other Warfare and Defence Issues
• Peace Studies and Conflict Resolution
• Weapons and Equipment

Medicine and Social Justice: Essays on the Distribution of Health Care (2nd edn)

• Cite Icon Cite
• Permissions Icon Permissions

Because medicine can preserve life, restore health and maintain the body’s functions, it is widely acknowledged as a basic good that just societies should provide for their members. Yet, there is wide disagreement over the scope and content of what to provide, to whom, how, when, and why. In this book, some of the best-known philosophers, physicians, legal scholars, political scientists, and economists writing on the subject discuss what social justice in medicine should be. The forty-two chapters in this second edition update and expand upon the thirty-four chapters of the first edition. Eighteen chapters from the original volume are revised to address policy changes and challenging issues that have emerged in the intervening decade. Twenty-two chapters are entirely new. The treatment of foundational theory and conceptual issues related to access to health care and rationing medical resources have been expanded to provide a more comprehensive and nuanced discussion of the background concepts that underlie distributive justice debates, with global perspectives on health and well-being added. New additions to the section on health care justice for specific populations include chapters on health care for the chronically ill, soldiers, prisoners, the severely cognitively disabled, and the LGBT population. New chapters address questions of justice related to genetics, medical malpractice, research on human subjects, pandemic and disaster planning, newborn screening, and justice for the brain dead and those with profound neurological injury.

Signed in as

Institutional accounts.

• Google Scholar Indexing
• GoogleCrawler [DO NOT DELETE]

Personal account

• Sign in with email/username & password
• Get email alerts
• Save searches
• Purchase content
• Activate your purchase/trial code
• Add your ORCID iD

Institutional access

Sign in with a library card.

• Sign in with username/password
• Recommend to your librarian
• Institutional account management
• Get help with access

Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:

IP based access

Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account.

Sign in through your institution

Choose this option to get remote access when outside your institution. Shibboleth/Open Athens technology is used to provide single sign-on between your institution’s website and Oxford Academic.

• Click Sign in through your institution.
• Select your institution from the list provided, which will take you to your institution's website to sign in.
• When on the institution site, please use the credentials provided by your institution. Do not use an Oxford Academic personal account.
• Following successful sign in, you will be returned to Oxford Academic.

If your institution is not listed or you cannot sign in to your institution’s website, please contact your librarian or administrator.

Enter your library card number to sign in. If you cannot sign in, please contact your librarian.

Society Members

Society member access to a journal is achieved in one of the following ways:

Sign in through society site

Many societies offer single sign-on between the society website and Oxford Academic. If you see ‘Sign in through society site’ in the sign in pane within a journal:

• Click Sign in through society site.
• When on the society site, please use the credentials provided by that society. Do not use an Oxford Academic personal account.

If you do not have a society account or have forgotten your username or password, please contact your society.

Sign in using a personal account

Some societies use Oxford Academic personal accounts to provide access to their members. See below.

A personal account can be used to get email alerts, save searches, purchase content, and activate subscriptions.

Some societies use Oxford Academic personal accounts to provide access to their members.

Viewing your signed in accounts

Click the account icon in the top right to:

• View your signed in personal account and access account management features.
• View the institutional accounts that are providing access.

Signed in but can't access content

Oxford Academic is home to a wide variety of products. The institutional subscription may not cover the content that you are trying to access. If you believe you should have access to that content, please contact your librarian.

For librarians and administrators, your personal account also provides access to institutional account management. Here you will find options to view and activate subscriptions, manage institutional settings and access options, access usage statistics, and more.

Our books are available by subscription or purchase to libraries and institutions.

• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Rights and permissions
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Home — Essay Samples — Nursing & Health — Social Care — Health And Social Care

Health and Social Care

• Categories: Medicare Social Care Universal Health Care

About this sample

Words: 1547 |

Published: Jan 8, 2020

Words: 1547 | Pages: 3 | 8 min read

Table of contents

Own role and expectations, to work in a person centred way, to give/gain consent, complaints policy and procedures, health and safety at work act 1974, manual handling operations regulations, safeguarding from abuse.

Cite this Essay

Let us write you an essay from scratch

• 450+ experts on 30 subjects ready to help
• Custom essay delivered in as few as 3 hours

Get high-quality help

Dr. Heisenberg

Verified writer

• Expert in: Nursing & Health

+ 120 experts online

By clicking “Check Writers’ Offers”, you agree to our terms of service and privacy policy . We’ll occasionally send you promo and account related email

No need to pay just yet!

Related Essays

3 pages / 1486 words

5 pages / 2332 words

4 pages / 2018 words

1 pages / 536 words

Remember! This is just a sample.

You can get your custom paper by one of our expert writers.

121 writers online

Still can’t find what you need?

Browse our vast selection of original essay samples, each expertly formatted and styled

Related Essays on Social Care

In the field of health and social care, referrals play a crucial role in ensuring that individuals receive the appropriate and timely support they need. Referrals are the process by which individuals are directed to a specialist [...]

Autonomy The definition of Autonomy is the ability of an individual to make a rational, un-influenced decision. Therefore, it can be said that autonomy is a general indicator of health. The progression of many terminal diseases [...]

In this assignment I will explain the principal psychological perspectives and assessing the different psychological approaches to study. The main psychological perspective An approach is a perspective that involves specific [...]

The United States is one of the highest birth rate for teens. If more teens were to take Birth control we would have less abortion rates and less teen pregnancies in the United States. There are many types and the [...]

Obesity is a growing concern in both personal and public health that has been identified as a lifestyle condition accelerated by poor living and eating habits. Obesity has been identified as a predisposing factor diabetes, [...]

In 2013, Venka Child aged 16 from Bristol worked with Fixers to create a short video about challenges teen mothers go through. In some part of the video, a teen mother is shown opening a fridge which is almost empty. The teen [...]

Related Topics

By clicking “Send”, you agree to our Terms of service and Privacy statement . We will occasionally send you account related emails.

Where do you want us to send this sample?

By clicking “Continue”, you agree to our terms of service and privacy policy.

Be careful. This essay is not unique

This essay was donated by a student and is likely to have been used and submitted before

Download this Sample

Free samples may contain mistakes and not unique parts

Sorry, we could not paraphrase this essay. Our professional writers can rewrite it and get you a unique paper.

Please check your inbox.

We can write you a custom essay that will follow your exact instructions and meet the deadlines. Let's fix your grades together!

Get Your Personalized Essay in 3 Hours or Less!

We use cookies to personalyze your web-site experience. By continuing we’ll assume you board with our cookie policy .

• Instructions Followed To The Letter
• Deadlines Met At Every Stage
• Unique And Plagiarism Free

Impact of Foundation Degree in Health and Social Care Essay

Introduction, description, action plan.

This reflective essay is based on my progression in the past two months, where I have been undertaking a Foundation Degree in Health and Social Care. In this essay, I intend to cover many issues relating to this course. The discussion includes frequent assessments, the importance of coming together in groups, and talking about what I need to work on to improve my personal growth and development professionally. The reflection will also enable me to be a better practitioner by learning from my previous mistakes and bettering myself as a person. I will implement a consistent act in developing and growing efficiency and effectiveness within the context of what is considered a desirable practice. The concepts I have grasped will make me easily use the abilities I learned and implement the skills effectively related to my learning and training.

Gibb’s Reflective Cycle has enabled me to break down the reflection with ease because of its systematic flow, which is easy to understand. The model is effective because it ensures every detail in the reflective essay is covered effectively (Adeani, Febriani, and yafryadin, 2020). Some of the areas I will reflect on include time management, assignment writing, referencing, critical thinking presentation, and module evaluation. More details on my development in specific areas are elaborated on in the sections below, as per Gibb’s Reflective Cycle throughout the paper.

When the semester started, and I had my first module, I was buzzing and ready for the course. The introductory part was interesting, as everything seemed to be easy and encouraged me to set my mind ready for completing the next semester. This part was a great introduction to the course, as I learned that I would be handling more topics than I had expected. The professor was brilliant in all aspects. It was easy to note that he had simplified the work to enable everyone to understand the course concepts and ways of handling various topics. At some point, the professor taught about literature management, and that is when I learned the value of taking short notes as the lecture continued. I discovered that short notes are easy to go through and remember during any revisions. The lecturers/tutors provided various assignments during the course, including group work, which were very insightful. The different learning styles that the tutors have introduced are helpful, and I find them useful. Based on this knowledge, I can now choose the best approaches to studying per my learning style. Having specific learning styles is that it assists with proper time management. It is necessary to involve proper timing as I participate in group discussions and project management, and it will be proper to save time for the other aspects of my studies.

The individual assignment was a bit easier than what I did to do for the group work; however, I enjoyed the group tasks even more. The group assignment made me ha acquire good presentation skills. Once one has enough knowledge on a topic, presenting it becomes easy. The first major group project enabled me to learn and get to know some of my classmates better; though most were younger than me, they were extremely brilliant in their assignment input. We divided the workload so that everyone would be able to handle a specific topic and present it effectively. However, there was confusion whereby three people picked e same topic, so we had to quickly gather and do the pending work in the shortest period possible. That was when I realized how smart my group mates were and could critically think and analyze a question to give the best assignment’s answers. I have to admit that the first group assignment that was theoretical made me better in every aspect. Most significantly, it honed my critical and analytical skills in various assignments. When the results came for the written group assignment, we had passed. Nevertheless, the sections we scored even more highly are the areas we handled together as a group; one of the benefits of group work.

As one of the older students in the class, the entire period’s experience has enabled me to uplift my confidence. Engaging with younger learners in the class brings out some level of confidence (Ford et al., 2015). However, as Edwards and Best (2020) observe, personal growth and improvement build on awareness. Of late am always alert and updated on a variety of issues with regards to what I learn and how I do it. Close association with my tutor outside and inside the class has been essential to understanding specific topics and having diverse opinions n certain topics. That is among the reasons until today, my results have been top-notch, always striving to do more and become a better learner. The entire faculty is very friendly, so it is easy to seek assistance in any matter. I have acquired more knowledge and skill in Health and Social Care in the past two months than I ever had anticipated.

At the beginning of the module, I did not know what to make of some situations while in class. I was a bit nervous and silent and did not participate much. In the past month, I was able to illustrate a different presentation by myself brilliantly. The attitude has grown from then, and I feel more rejuvenated and ready to work on any assignment or presentation. People often overlook the importance of professors and tutors (Veine et al., 2018). The way I can break down information now shows pure growth and development, all thanks to my professors (Dhaliwal, Singh, and Singh, 2017).

During the first major group work, where we had assigned portions for everyone to handle, I was a bit mad and frustrated when some group members had not done part of their assignment and instead did what was assigned to others. Everything was in shambles and the fact that I could not previously work well under pressure. The three who had messed up were also nervous and full of guilt. What made me change my view on my group members’ is the unity and work rate they put in to ensure that the project was done efficiently using the least possible time. That group project created a bond that made us closer even when out of school.

This module has been beneficial to my growth, and I am already buzzing about what awaits in the next module. The good and bad things about a situation always create ripple effects depending on the circumstances. As I evaluated the results with my group members today, I realized that we made a mistake in assigning different projects to the group members. We could have done the best thing to join our minds and do all the assignments from start to finish together. However, the upside of the situation is that even though the deadline was approaching fast, we managed to work on the assignments effectively. There was a revelation that the people in that group had an intense work rate. On realizing that everyone was focused and intended to work hard, it was clear that we would pass the project and beat the deadline.

I believe everything is currently on the right track for me because of the work rate and dedication that I am putting in so that I can be among the best in the field. It is not easy to be ranked as one of the best in a field without major dedication. That is what I have my eyes focused on, being the best in my field so that I may be able to work with other greats. The reason why things were hard for me, in the beginning, was my naivety. But now, with all the confidence in me, I can achieve anything. Even with the group, things did not previously go well as planned because there was no common ground at first. Since everyone was new, everyone opted to handle their work section, which caused significant confusion. What drove the group members in producing their best is the joint effort that brought out the work rate and discipline from everyone.

There was also no groupthink element, whereby the most dominant answer was not contested (Bassot, 2020). This never happened in our group, and a matter of fact is that everyone fairly gave their ideas, and if it was convincing enough, then it is what we used.

On reflection, I believe that I have overachieved what was initially in my work schedule. Knowing clinical practices is a breakthrough as I ready myself for my career. It is essential to have basic knowledge of all career requirements. (Husebø, O’Regan and Nestel, 2015). I have surpassed the expected standards that I had initially planned. This is a hallmark, and it shows just how much dedication I have put in working on my major. The progress I have in just the two months has enabled me to acquire various health-related skills, get more knowledge on clinical practices, and acquire new insights and ideas regarding my major. Frequent reflection of what I have accomplished is essential as it will necessitate professional and personal development, as Wain (2017) emphasizes. When I look back at the group assignments and workshop, I smile a bit because they are not only exciting but there are lots of new information that I get to know during the workshops.

The two months have been very fruitful, and I have gained valuable skills and knowledge from the modules. By reflecting, we develop reflective skills such as self-awareness, ability to describe, critically analyze, synthesize, and evaluate (Béres and Fook, 2020). This reflection is important for any scholar as it helps identify strengths and areas which need improvement.

I want to do more in order to keep growing in the field of health and social care practice. All this is achievable if I continue with the work ethic I am currently putting in. Slowing down will make me lose focus on the end goal. By following my professors’ advice, frequently practising through placements, and implementing all that I have learned and keep learning, I will undoubtedly reach my targets. Through my evaluation and analysis, it is evident that my learning curve is on a steady rise. Because I am still in my learning process, I must acquire substantial knowledge to fit my professional portfolio and assist during job hunting in the future. The referencing skills acquired will push me to be a better researcher.

In all honesty, despite everything going on well currently, if I had an opportunity to change anything, the only thing I would change is how I first present myself as a timid person. I now believe that there was nothing to be nervous about, and all that counted was me being able to express myself. Thankfully to those involved with the school, right from the faculty, the professors, and fellow learners, who have made me more confident and courageous when undertaking an array of activities. The next time I am in the same situation, I will act accordingly and make my presence felt right from the beginning. Regarding the group situation, with the little experience from my first group rodeo, I will be able to take charge and assist the group member in making appropriate decisions regarding the different projects we are handling. I will also ensure that every member is awarded the appropriate time to express themselves without any form of prejudice. By following my action plan, I believe I will supersede all my set goals and be an excellent example to everyone out there.

• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2022, February 23). Impact of Foundation Degree in Health and Social Care. https://ivypanda.com/essays/impact-of-foundation-degree-in-health-and-social-care/

"Impact of Foundation Degree in Health and Social Care." IvyPanda , 23 Feb. 2022, ivypanda.com/essays/impact-of-foundation-degree-in-health-and-social-care/.

IvyPanda . (2022) 'Impact of Foundation Degree in Health and Social Care'. 23 February.

IvyPanda . 2022. "Impact of Foundation Degree in Health and Social Care." February 23, 2022. https://ivypanda.com/essays/impact-of-foundation-degree-in-health-and-social-care/.

1. IvyPanda . "Impact of Foundation Degree in Health and Social Care." February 23, 2022. https://ivypanda.com/essays/impact-of-foundation-degree-in-health-and-social-care/.

Bibliography

IvyPanda . "Impact of Foundation Degree in Health and Social Care." February 23, 2022. https://ivypanda.com/essays/impact-of-foundation-degree-in-health-and-social-care/.

• Gibb's Reflective Cycle: Analysis
• Importance of Modules as the Behavior and Culture Category
• Reflective Practice in Health Care
• The Quality Indicators Used by Managers in Different Health Facilities
• Mercy Medical Center Overview
• Modern Medical Institutions Introducing Electronic Medical Records
• Partners in Health Company and Its Mission
• Escape Fire Documentary on US Healthcare System

• Open access
• Published: 13 May 2024

What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review

• Olivia R. Phillips 1 , 2   na1 ,
• Cerian Harries 2 , 3   na1 ,
• Jo Leonardi-Bee 1 , 2 , 4   na1 ,
• Holly Knight 1 , 2 ,
• Lauren B. Sherar 2 , 3 ,
• Veronica Varela-Mato 2 , 3 &
• Joanne R. Morling 1 , 2 , 5  

Research Involvement and Engagement volume  10 , Article number:  48 ( 2024 ) Cite this article

15 Accesses

2 Altmetric

Metrics details

There is increasing interest in using patient and public involvement (PPI) in research to improve the quality of healthcare. Ordinarily, traditional methods have been used such as interviews or focus groups. However, these methods tend to engage a similar demographic of people. Thus, creative methods are being developed to involve patients for whom traditional methods are inaccessible or non-engaging.

To determine the strengths and limitations to using creative PPI methods in health and social care research.

Electronic searches were conducted over five databases on 14th April 2023 (Web of Science, PubMed, ASSIA, CINAHL, Cochrane Library). Studies that involved traditional, non-creative PPI methods were excluded. Creative PPI methods were used to engage with people as research advisors, rather than study participants. Only primary data published in English from 2009 were accepted. Title, abstract and full text screening was undertaken by two independent reviewers before inductive thematic analysis was used to generate themes.

Twelve papers met the inclusion criteria. The creative methods used included songs, poems, drawings, photograph elicitation, drama performance, visualisations, social media, photography, prototype development, cultural animation, card sorting and persona development. Analysis identified four limitations and five strengths to the creative approaches. Limitations included the time and resource intensive nature of creative PPI, the lack of generalisation to wider populations and ethical issues. External factors, such as the lack of infrastructure to support creative PPI, also affected their implementation. Strengths included the disruption of power hierarchies and the creation of a safe space for people to express mundane or “taboo” topics. Creative methods are also engaging, inclusive of people who struggle to participate in traditional PPI and can also be cost and time efficient.

‘Creative PPI’ is an umbrella term encapsulating many different methods of engagement and there are strengths and limitations to each. The choice of which should be determined by the aims and requirements of the research, as well as the characteristics of the PPI group and practical limitations. Creative PPI can be advantageous over more traditional methods, however a hybrid approach could be considered to reap the benefits of both. Creative PPI methods are not widely used; however, this could change over time as PPI becomes embedded even more into research.

Plain English Summary

It is important that patients and public are included in the research process from initial brainstorming, through design to delivery. This is known as public and patient involvement (PPI). Their input means that research closely aligns with their wants and needs. Traditionally to get this input, interviews and group discussions are held, but this can exclude people who find these activities non-engaging or inaccessible, for example those with language challenges, learning disabilities or memory issues. Creative methods of PPI can overcome this. This is a broad term describing different (non-traditional) ways of engaging patients and public in research, such as through the use or art, animation or performance. This review investigated the reasons why creative approaches to PPI could be difficult (limitations) or helpful (strengths) in health and social care research. After searching 5 online databases, 12 studies were included in the review. PPI groups included adults, children and people with language and memory impairments. Creative methods included songs, poems, drawings, the use of photos and drama, visualisations, Facebook, creating prototypes, personas and card sorting. Limitations included the time, cost and effort associated with creative methods, the lack of application to other populations, ethical issues and buy-in from the wider research community. Strengths included the feeling of equality between academics and the public, creation of a safe space for people to express themselves, inclusivity, and that creative PPI can be cost and time efficient. Overall, this review suggests that creative PPI is worthwhile, however each method has its own strengths and limitations and the choice of which will depend on the research project, PPI group characteristics and other practical limitations, such as time and financial constraints.

Peer Review reports

Introduction

Patient and public involvement (PPI) is the term used to describe the partnership between patients (including caregivers, potential patients, healthcare users etc.) or the public (a community member with no known interest in the topic) with researchers. It describes research that is done “‘with’ or ‘by’ the public, rather than ‘to,’ ‘about’ or ‘for’ them” [ 1 ]. In 2009, it became a legislative requirement for certain health and social care organisations to include patients, families, carers and communities in not only the planning of health and social care services, but the commissioning, delivery and evaluation of them too [ 2 ]. For example, funding applications for the National Institute of Health and Care Research (NIHR), a UK funding body, mandates a demonstration of how researchers plan to include patients/service users, the public and carers at each stage of the project [ 3 ]. However, this should not simply be a tokenistic, tick-box exercise. PPI should help formulate initial ideas and should be an instrumental, continuous part of the research process. Input from PPI can provide unique insights not yet considered and can ensure that research and health services are closely aligned to the needs and requirements of service users PPI also generally makes research more relevant with clearer outcomes and impacts [ 4 ]. Although this review refers to both patients and the public using the umbrella term ‘PPI’, it is important to acknowledge that these are two different groups with different motivations, needs and interests when it comes to health research and service delivery [ 5 ].

Despite continuing recognition of the need of PPI to improve quality of healthcare, researchers have also recognised that there is no ‘one size fits all’ method for involving patients [ 4 ]. Traditionally, PPI methods invite people to take part in interviews or focus groups to facilitate discussion, or surveys and questionnaires. However, these can sometimes be inaccessible or non-engaging for certain populations. For example, someone with communication difficulties may find it difficult to engage in focus groups or interviews. If individuals lack the appropriate skills to interact in these types of scenarios, they cannot take advantage of the participation opportunities it can provide [ 6 ]. Creative methods, however, aim to resolve these issues. These are a relatively new concept whereby researchers use creative methods (e.g., artwork, animations, Lego), to make PPI more accessible and engaging for those whose voices would otherwise go unheard. They ensure that all populations can engage in research, regardless of their background or skills. Seminal work has previously been conducted in this area, which brought to light the use of creative methodologies in research. Leavy (2008) [ 7 ] discussed how traditional interviews had limits on what could be expressed due to their sterile, jargon-filled and formulaic structure, read by only a few specialised academics. It was this that called for more creative approaches, which included narrative enquiry, fiction-based research, poetry, music, dance, art, theatre, film and visual art. These practices, which can be used in any stage of the research cycle, supported greater empathy, self-reflection and longer-lasting learning experiences compared to interviews [ 7 ]. They also pushed traditional academic boundaries, which made the research accessible not only to researchers, but the public too. Leavy explains that there are similarities between arts-based approaches and scientific approaches: both attempts to investigate what it means to be human through exploration, and used together, these complimentary approaches can progress our understanding of the human experience [ 7 ]. Further, it is important to acknowledge the parallels and nuances between creative and inclusive methods of PPI. Although creative methods aim to be inclusive (this should underlie any PPI activity, whether creative or not), they do not incorporate all types of accessible, inclusive methodologies e.g., using sign language for people with hearing impairments or audio recordings for people who cannot read. Given that there was not enough scope to include an evaluation of all possible inclusive methodologies, this review will focus on creative methods of PPI only.

We aimed to conduct a qualitative systematic review to highlight the strengths of creative PPI in health and social care research, as well as the limitations, which might act as a barrier to their implementation. A qualitative systematic review “brings together research on a topic, systematically searching for research evidence from primary qualitative studies and drawing the findings together” [ 8 ]. This review can then advise researchers of the best practices when designing PPI.

Public involvement

The PHIRST-LIGHT Public Advisory Group (PAG) consists of a team of experienced public contributors with a diverse range of characteristics from across the UK. The PAG was involved in the initial question setting and study design for this review.

Search strategy

For the purpose of this review, the JBI approach for conducting qualitative systematic reviews was followed [ 9 ]. The search terms were (“creativ*” OR “innovat*” OR “authentic” OR “original” OR “inclu*”) AND (“public and patient involvement” OR “patient and public involvement” OR “public and patient involvement and engagement” OR “patient and public involvement and engagement” OR “PPI” OR “PPIE” OR “co-produc*” OR “co-creat*” OR “co-design*” OR “cooperat*” OR “co-operat*”). This search string was modified according to the requirements of each database. Papers were filtered by title, abstract and keywords (see Additional file 1 for search strings). The databases searched included Web of Science (WoS), PubMed, ASSIA and CINAHL. The Cochrane Library was also searched to identify relevant reviews which could lead to the identification of primary research. The search was conducted on 14/04/23. As our aim was to report on the use of creative PPI in research, rather than more generic public engagement, we used electronic databases of scholarly peer-reviewed literature, which represent a wide range of recognised databases. These identified studies published in general international journals (WoS, PubMed), those in social sciences journals (ASSIA), those in nursing and allied health journals (CINAHL), and trials of interventions (Cochrane Library).

Inclusion criteria

Only full-text, English language, primary research papers from 2009 to 2023 were included. This was the chosen timeframe as in 2009 the Health and Social Reform Act made it mandatory for certain Health and Social Care organisations to involve the public and patients in planning, delivering, and evaluating services [ 2 ]. Only creative methods of PPI were accepted, rather than traditional methods, such as interviews or focus groups. For the purposes of this paper, creative PPI included creative art or arts-based approaches (e.g., e.g. stories, songs, drama, drawing, painting, poetry, photography) to enhance engagement. Titles were related to health and social care and the creative PPI was used to engage with people as research advisors, not as study participants. Meta-analyses, conference abstracts, book chapters, commentaries and reviews were excluded. There were no limits concerning study location or the demographic characteristics of the PPI groups. Only qualitative data were accepted.

Quality appraisal

Quality appraisal using the Critical Appraisal Skills Programme (CASP) checklist [ 10 ] was conducted by the primary authors (ORP and CH). This was done independently, and discrepancies were discussed and resolved. If a consensus could not be reached, a third independent reviewer was consulted (JRM). The full list of quality appraisal questions can be found in Additional file 2 .

Data extraction

ORP extracted the study characteristics and a subset of these were checked by CH. Discrepancies were discussed and amendments made. Extracted data included author, title, location, year of publication, year study was carried out, research question/aim, creative methods used, number of participants, mean age, gender, ethnicity of participants, setting, limitations and strengths of creative PPI and main findings.

Data analysis

The included studies were analysed using inductive thematic analysis [ 11 ], where themes were determined by the data. The familiarisation stage took place during full-text reading of the included articles. Anything identified as a strength or limitation to creative PPI methods was extracted verbatim as an initial code and inputted into the data extraction Excel sheet. Similar codes were sorted into broader themes, either under ‘strengths’ or ‘limitations’ and reviewed. Themes were then assigned a name according to the codes.

The search yielded 9978 titles across the 5 databases: Web of Science (1480 results), PubMed (94 results), ASSIA (2454 results), CINAHL (5948 results) and Cochrane Library (2 results), resulting in 8553 different studies after deduplication. ORP and CH independently screened their titles and abstracts, excluding those that did not meet the criteria. After assessment, 12 studies were included (see Fig.  1 ).

PRISMA flowchart of the study selection process

Study characteristics

The included studies were published between 2018 and 2022. Seven were conducted in the UK [ 12 , 14 , 15 , 17 , 18 , 19 , 23 ], two in Canada [ 21 , 22 ], one in Australia [ 13 ], one in Norway [ 16 ] and one in Ireland [ 20 ]. The PPI activities occurred across various settings, including a school [ 12 ], social club [ 12 ], hospital [ 17 ], university [ 22 ], theatre [ 19 ], hotel [ 20 ], or online [ 15 , 21 ], however this information was omitted in 5 studies [ 13 , 14 , 16 , 18 , 23 ]. The number of people attending the PPI sessions varied, ranging from 6 to 289, however the majority (ten studies) had less than 70 participants [ 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Seven studies did not provide information on the age or gender of the PPI groups. Of those that did, ages ranged from 8 to 76 and were mostly female. The ethnicities of the PPI group members were also rarely recorded (see Additional file 3 for data extraction table).

Types of creative methods

The type of creative methods used to engage the PPI groups were varied. These included songs, poems, drawings, photograph elicitation, drama performance, visualisations, Facebook, photography, prototype development, cultural animation, card sorting and creating personas (see Table  1 ). These were sometimes accompanied by traditional methods of PPI such as interviews and focus group discussions.

The 12 included studies were all deemed to be of good methodological quality, with scores ranging from 6/10 to 10/10 with the CASP critical appraisal tool [ 10 ] (Table  2 ).

Thematic analysis

Analysis identified four limitations and five strengths to creative PPI (see Fig.  2 ). Limitations included the time and resource intensity of creative PPI methods, its lack of generalisation, ethical issues and external factors. Strengths included the disruption of power hierarchies, the engaging and inclusive nature of the methods and their long-term cost and time efficiency. Creative PPI methods also allowed mundane and “taboo” topics to be discussed within a safe space.

Theme map of strengths and limitations

Limitations of creative PPI

Creative ppi methods are time and resource intensive.

The time and resource intensive nature of creative PPI methods is a limitation, most notably for the persona-scenario methodology. Valaitis et al. [ 22 ] used 14 persona-scenario workshops with 70 participants to co-design a healthcare intervention, which aimed to promote optimal aging in Canada. Using the persona method, pairs composed of patients, healthcare providers, community service providers and volunteers developed a fictional character which they believed represented an ‘end-user’ of the healthcare intervention. Due to the depth and richness of the data produced the authors reported that it was time consuming to analyse. Further, they commented that the amount of information was difficult to disseminate to scientific leads and present at team meetings. Additionally, to ensure the production of high-quality data, to probe for details and lead group discussion there was a need for highly skilled facilitators. The resource intensive nature of the creative co-production was also noted in a study using the persona scenario and creative worksheets to develop a prototype decision support tool for individuals with malignant pleural effusion [ 17 ]. With approximately 50 people, this was also likely to yield a high volume of data to consider.

To prepare materials for populations who cannot engage in traditional methods of PPI was also timely. Kearns et al. [ 18 ] developed a feedback questionnaire for people with aphasia to evaluate ICT-delivered rehabilitation. To ensure people could participate effectively, the resources used during the workshops, such as PowerPoints, online images and photographs, had to be aphasia-accessible, which was labour and time intensive. The author warned that this time commitment should not be underestimated.

There are further practical limitations to implementing creative PPI, such as the costs of materials for activities as well as hiring a space for workshops. For example, the included studies in this review utilised pens, paper, worksheets, laptops, arts and craft supplies and magazines and took place in venues such as universities, a social club, and a hotel. Further, although not limited to creative PPI methods exclusively but rather most studies involving the public, a financial incentive was often offered for participation, as well as food, parking, transport and accommodation [ 21 , 22 ].

Creative PPI lacks generalisation

Another barrier to the use of creative PPI methods in health and social care research was the individual nature of its output. Those who participate, usually small in number, produce unique creative outputs specific to their own experiences, opinions and location. Craven et al. [ 13 ], used arts-based visualisations to develop a toolbox for adults with mental health difficulties. They commented, “such an approach might still not be worthwhile”, as the visualisations were individualised and highly personal. This indicates that the output may fail to meet the needs of its end-users. Further, these creative PPI groups were based in certain geographical regions such as Stoke-on-Trent [ 19 ] Sheffield [ 23 ], South Wales [ 12 ] or Ireland [ 20 ], which limits the extent the findings can be applied to wider populations, even within the same area due to individual nuances. Further, the study by Galler et al. [ 16 ], is specific to the Norwegian context and even then, maybe only a sub-group of the Norwegian population as the sample used was of higher socioeconomic status.

However, Grindell et al. [ 17 ], who used persona scenarios, creative worksheets and prototype development, pointed out that the purpose of this type of research is to improve a certain place, rather than apply findings across other populations and locations. Individualised output may, therefore, only be a limitation to research wanting to conduct PPI on a large scale.

If, however, greater generalisation within PPI is deemed necessary, then social media may offer a resolution. Fedorowicz et al. [ 15 ], used Facebook to gain feedback from the public on the use of video-recording methodology for an upcoming project. This had the benefit of including a more diverse range of people (289 people joined the closed group), who were spread geographically around the UK, as well as seven people from overseas.

Creative PPI has ethical issues

As with other research, ethical issues must be taken into consideration. Due to the nature of creative approaches, as well as the personal effort put into them, people often want to be recognised for their work. However, this compromises principles so heavily instilled in research such as anonymity and confidentiality. With the aim of exploring issues related to health and well-being in a town in South Wales, Byrne et al. [ 12 ], asked year 4/5 and year 10 pupils to create poems, songs, drawings and photographs. Community members also created a performance, mainly of monologues, to explore how poverty and inequalities are dealt with. Byrne noted the risks of these arts-based approaches, that being the possibility of over-disclosure and consequent emotional distress, as well as people’s desire to be named for their work. On one hand, the anonymity reduces the sense of ownership of the output as it does not portray a particular individual’s lived experience anymore. On the other hand, however, it could promote a more honest account of lived experience. Supporting this, Webber et al. [ 23 ], who used the persona method to co-design a back pain educational resource prototype, claimed that the anonymity provided by this creative technique allowed individuals to externalise and anonymise their own personal experience, thus creating a more authentic and genuine resource for future users. This implies that anonymity can be both a limitation and strength here.

The use of creative PPI methods is impeded by external factors

Despite the above limitations influencing the implementation of creative PPI techniques, perhaps the most influential is that creative methodologies are simply not mainstream [ 19 ]. This could be linked to the issues above, like time and resource intensity, generalisation and ethical issues but it is also likely to involve more systemic factors within the research community. Micsinszki et al. [ 21 ], who co-designed a hub for the health and well-being of vulnerable populations, commented that there is insufficient infrastructure to conduct meaningful co-design as well as a dominant medical model. Through a more holistic lens, there are “sociopolitical environments that privilege individualism over collectivism, self-sufficiency over collaboration, and scientific expertise over other ways of knowing based on lived experience” [ 21 ]. This, it could be suggested, renders creative co-design methodologies, which are based on the foundations of collectivism, collaboration and imagination an invalid technique in the research field, which is heavily dominated by more scientific methods offering reproducibility, objectivity and reliability.

Although we acknowledge that creative PPI techniques are not always appropriate, it may be that their main limitation is the lack of awareness of these methods or lack of willingness to use them. Further, there is always the risk that PPI, despite being a mandatory part of research, is used in a tokenistic or tick-box fashion [ 20 ], without considering the contribution that meaningful PPI could make to enhancing the research. It may be that PPI, let alone creative PPI, is not at the forefront of researchers’ minds when planning research.

Strengths of creative PPI

Creative ppi disrupts power hierarchies.

One of the main strengths of creative PPI techniques, cited most frequently in the included literature, was that they disrupt traditional power hierarchies [ 12 , 13 , 17 , 19 , 23 ]. For example, the use of theatre performance blurred the lines between professional and lay roles between the community and policy makers [ 12 ]. Individuals created a monologue to portray how poverty and inequality impact daily life and presented this to representatives of the National Assembly of Wales, Welsh Government, the Local Authority, Arts Council and Westminster. Byrne et al. [ 12 ], states how this medium allowed the community to engage with the people who make decisions about their lives in an environment of respect and understanding, where the hierarchies are not as visible as in other settings, e.g., political surgeries. Creative PPI methods have also removed traditional power hierarchies between researchers and adolescents. Cook et al. [ 13 ], used arts-based approaches to explore adolescents’ ideas about the “perfect” condom. They utilised the “Life Happens” resource, where adolescents drew and then decorated a person with their thoughts about sexual relationships, not too dissimilar from the persona-scenario method. This was then combined with hypothetical scenarios about sexuality. A condom-mapping exercise was then implemented, where groups shared the characteristics that make a condom “perfect” on large pieces of paper. Cook et al. [ 13 ], noted that usually power imbalances make it difficult to elicit information from adolescents, however these power imbalances were reduced due to the use of creative co-design techniques.

The same reduction in power hierarchies was noted by Grindell et al. [ 17 ], who used the person-scenario method and creative worksheets with individuals with malignant pleural effusion. This was with the aim of developing a prototype of a decision support tool for patients to help with treatment options. Although this process involved a variety of stakeholders, such as patients, carers and healthcare professionals, creative co-design was cited as a mechanism that worked to reduce power imbalances – a limitation of more traditional methods of research. Creative co-design blurred boundaries between end-users and clinical staff and enabled the sharing of ideas from multiple, valuable perspectives, meaning the prototype was able to suit user needs whilst addressing clinical problems.

Similarly, a specific creative method named cultural animation was also cited to dissolve hierarchies and encourage equal contributions from participants. Within this arts-based approach, Keleman et al. [ 19 ], explored the concept of “good health” with individuals from Stoke-on Trent. Members of the group created art installations using ribbons, buttons, cardboard and straws to depict their idea of a “healthy community”, which was accompanied by a poem. They also created a 3D Facebook page and produced another poem or song addressing the government to communicate their version of a “picture of health”. Public participants said that they found the process empowering, honest, democratic, valuable and practical.

This dissolving of hierarchies and levelling of power is beneficial as it increases the sense of ownership experienced by the creators/producers of the output [ 12 , 17 , 23 ]. This is advantageous as it has been suggested to improve its quality [ 23 ].

Creative PPI allows the unsayable to be said

Creative PPI fosters a safe space for mundane or taboo topics to be shared, which may be difficult to communicate using traditional methods of PPI. For example, the hypothetical nature of condom mapping and persona-scenarios meant that adolescents could discuss a personal topic without fear of discrimination, judgement or personal disclosure [ 13 ]. The safe space allowed a greater volume of ideas to be generated amongst peers where they might not have otherwise. Similarly, Webber et al. [ 23 ], , who used the persona method to co-design the prototype back pain educational resource, also noted how this method creates anonymity whilst allowing people the opportunity to externalise personal experiences, thoughts and feelings. Other creative methods were also used, such as drawing, collaging, role play and creating mood boards. A cardboard cube (labelled a “magic box”) was used to symbolise a physical representation of their final prototype. These creative methods levelled the playing field and made personal experiences accessible in a safe, open environment that fostered trust, as well as understanding from the researchers.

It is not only sensitive subjects that were made easier to articulate through creative PPI. The communication of mundane everyday experiences were also facilitated, which were deemed typically ‘unsayable’. This was specifically given in the context of describing intangible aspects of everyday health and wellbeing [ 11 ]. Graphic designers can also be used to visually represent the outputs of creative PPI. These captured the movement and fluidity of people and well as the relationships between them - things that cannot be spoken but can be depicted [ 21 ].

Creative PPI methods are inclusive

Another strength of creative PPI was that it is inclusive and accessible [ 17 , 19 , 21 ]. The safe space it fosters, as well as the dismantling of hierarchies, welcomed people from a diverse range of backgrounds and provided equal opportunities [ 21 ], especially for those with communication and memory difficulties who might be otherwise excluded from PPI. Kelemen et al. [ 19 ], who used creative methods to explore health and well-being in Stoke-on-Trent, discussed how people from different backgrounds came together and connected, discussed and reached a consensus over a topic which evoked strong emotions, that they all have in common. Individuals said that the techniques used “sets people to open up as they are not overwhelmed by words”. Similarly, creative activities, such as the persona method, have been stated to allow people to express themselves in an inclusive environment using a common language. Kearns et al. [ 18 ], who used aphasia-accessible material to develop a questionnaire with aphasic individuals, described how they felt comfortable in contributing to workshops (although this material was time-consuming to make, see ‘Limitations of creative PPI’ ).

Despite the general inclusivity of creative PPI, it can also be exclusive, particularly if online mediums are used. Fedorowicz et al. [ 15 ], used Facebook to create a PPI group, and although this may rectify previous drawbacks about lack of generalisation of creative methods (as Facebook can reach a greater number of people, globally), it excluded those who are not digitally active or have limited internet access or knowledge of technology. Online methods have other issues too. Maintaining the online group was cited as challenging and the volume of responses required researchers to interact outside of their working hours. Despite this, online methods like Facebook are very accessible for people who are physically disabled.

Creative PPI methods are engaging

The process of creative PPI is typically more engaging and produces more colourful data than traditional methods [ 13 ]. Individuals are permitted and encouraged to explore a creative self [ 19 ], which can lead to the exploration of new ideas and an overall increased enjoyment of the process. This increased engagement is particularly beneficial for younger PPI groups. For example, to involve children in the development of health food products, Galler et al. [ 16 ] asked 9-12-year-olds to take photos of their food and present it to other children in a “show and tell” fashion. They then created a newspaper article describing a new healthy snack. In this creative focus group, children were given lab coats to further their identity as inventors. Galler et al. [ 16 ], notes that the methods were highly engaging and facilitated teamwork and group learning. This collaborative nature of problem-solving was also observed in adults who used personas and creative worksheets to develop the resource for lower back pain [ 23 ]. Dementia patients too have been reported to enjoy the creative and informal approach to idea generation [ 20 ].

The use of cultural animation allowed people to connect with each other in a way that traditional methods do not [ 19 , 21 ]. These connections were held in place by boundary objects, such as ribbons, buttons, fabric and picture frames, which symbolised a shared meaning between people and an exchange of knowledge and emotion. Asking groups to create an art installation using these objects further fostered teamwork and collaboration, both at an individual and collective level. The exploration of a creative self increased energy levels and encouraged productive discussions and problem-solving [ 19 ]. Objects also encouraged a solution-focused approach and permitted people to think beyond their usual everyday scope [ 17 ]. They also allowed facilitators to probe deeper about the greater meanings carried by the object, which acted as a metaphor [ 21 ].

From the researcher’s point of view, co-creative methods gave rise to ideas they might not have initially considered. Valaitis et al. [ 22 ], found that over 40% of the creative outputs were novel ideas brought to light by patients, healthcare providers/community care providers, community service providers and volunteers. One researcher commented, “It [the creative methods] took me on a journey, in a way that when we do other pieces of research it can feel disconnected” [ 23 ]. Another researcher also stated they could not return to the way they used to do research, as they have learnt so much about their own health and community and how they are perceived [ 19 ]. This demonstrates that creative processes not only benefit the project outcomes and the PPI group, but also facilitators and researchers. However, although engaging, creative methods have been criticised for not demonstrating academic rigour [ 17 ]. Moreover, creative PPI may also be exclusive to people who do not like or enjoy creative activities.

Creative PPI methods are cost and time efficient

Creative PPI workshops can often produce output that is visible and tangible. This can save time and money in the long run as the output is either ready to be implemented in a healthcare setting or a first iteration has already been developed. This may also offset the time and costs it takes to implement creative PPI. For example, the prototype of the decision support tool for people with malignant pleural effusion was developed using personas and creative worksheets. The end result was two tangible prototypes to drive the initial idea forward as something to be used in practice [ 17 ]. The use of creative co-design in this case saved clinician time as well as the time it would take to develop this product without the help of its end-users. In the development of this particular prototype, analysis was iterative and informed the next stage of development, which again saved time. The same applies for the feedback questionnaire for the assessment of ICT delivered aphasia rehabilitation. The co-created questionnaire, designed with people with aphasia, was ready to be used in practice [ 18 ]. This suggests that to overcome time and resource barriers to creative PPI, researchers should aim for it to be engaging whilst also producing output.

That useable products are generated during creative workshops signals to participating patients and public members that they have been listened to and their thoughts and opinions acted upon [ 23 ]. For example, the development of the back pain resource based on patient experiences implies that their suggestions were valid and valuable. Further, those who participated in the cultural animation workshop reported that the process visualises change, and that it already feels as though the process of change has started [ 19 ].

The most cost and time efficient method of creative PPI in this review is most likely the use of Facebook to gather feedback on project methodology [ 15 ]. Although there were drawbacks to this, researchers could involve more people from a range of geographical areas at little to no cost. Feedback was instantaneous and no training was required. From the perspective of the PPI group, they could interact however much or little they wish with no time commitment.

This systematic review identified four limitations and five strengths to the use of creative PPI in health and social care research. Creative PPI is time and resource intensive, can raise ethical issues and lacks generalisability. It is also not accepted by the mainstream. These factors may act as barriers to the implementation of creative PPI. However, creative PPI disrupts traditional power hierarchies and creates a safe space for taboo or mundane topics. It is also engaging, inclusive and can be time and cost efficient in the long term.

Something that became apparent during data analysis was that these are not blanket strengths and limitations of creative PPI as a whole. The umbrella term ‘creative PPI’ is broad and encapsulates a wide range of activities, ranging from music and poems to prototype development and persona-scenarios, to more simplistic things like the use of sticky notes and ordering cards. Many different activities can be deemed ‘creative’ and the strengths and limitations of one does not necessarily apply to another. For example, cultural animation takes greater effort to prepare than the use of sticky notes and sorting cards, and the use of Facebook is cheaper and wider reaching than persona development. Researchers should use their discretion and weigh up the benefits and drawbacks of each method to decide on a technique which suits the project. What might be a limitation to creative PPI in one project may not be in another. In some cases, creative PPI may not be suitable at all.

Furthermore, the choice of creative PPI method also depends on the needs and characteristics of the PPI group. Children, adults and people living with dementia or language difficulties all have different engagement needs and capabilities. This indicates that creative PPI is not one size fits all and that the most appropriate method will change depending on the composition of the group. The choice of method will also be determined by the constraints of the research project, namely time, money and the research aim. For example, if there are time constraints, then a method which yields a lot of data and requires a lot of preparation may not be appropriate. If generalisation is important, then an online method is more suitable. Together this indicates that the choice of creative PPI method is highly individualised and dependent on multiple factors.

Although the limitations discussed in this review apply to creative PPI, they are not exclusive to creative PPI. Ethical issues are a consideration within general PPI research, especially when working with more vulnerable populations, such as children or adults living with a disability. It can also be the case that traditional PPI methods lack generalisability, as people who volunteer to be part of such a group are more likely be older, middle class and retired [ 24 ]. Most research is vulnerable to this type of bias, however, it is worth noting that generalisation is not always a goal and research remains valid and meaningful in its absence. Although online methods may somewhat combat issues related to generalisability, these methods still exclude people who do not have access to the internet/technology or who choose not to use it, implying that online PPI methods may not be wholly representative of the general population. Saying this, however, the accessibility of creative PPI techniques differs from person to person, and for some, online mediums may be more accessible (for example for those with a physical disability), and for others, this might be face-to-face. To combat this, a range of methods should be implemented. Planning multiple focus group and interviews for traditional PPI is also time and resource intensive, however the extra resources required to make this creative may be even greater. Although, the rich data provided may be worth the preparation and analysis time, which is also likely to depend on the number of participants and workshop sessions required. PPI, not just creative PPI, often requires the provision of a financial incentive, refreshments, parking and accommodation, which increase costs. These, however, are imperative and non-negotiable, as they increase the accessibility of research, especially to minority and lower-income groups less likely to participate. Adequate funding is also important for co-design studies where repeated engagement is required. One barrier to implementation, which appears to be exclusive to creative methods, however, is that creative methods are not mainstream. This cannot be said for traditional PPI as this is often a mandatory part of research applications.

Regarding the strengths of creative PPI, it could be argued that most appear to be exclusive to creative methodologies. These are inclusive by nature as multiple approaches can be taken to evoke ideas from different populations - approaches that do not necessarily rely on verbal or written communication like interviews and focus groups do. Given the anonymity provided by some creative methods, such as personas, people may be more likely to discuss their personal experiences under the guise of a general end-user, which might be more difficult to maintain when an interviewer is asking an individual questions directly. Additionally, creative methods are by nature more engaging and interactive than traditional methods, although this is a blanket statement and there may be people who find the question-and-answer/group discussion format more engaging. Creative methods have also been cited to eliminate power imbalances which exist in traditional research [ 12 , 13 , 17 , 19 , 23 ]. These imbalances exist between researchers and policy makers and adolescents, adults and the community. Lastly, although this may occur to a greater extent in creative methods like prototype development, it could be suggested that PPI in general – regardless of whether it is creative - is more time and cost efficient in the long-term than not using any PPI to guide or refine the research process. It must be noted that these are observations based on the literature. To be certain these differences exist between creative and traditional methods of PPI, direct empirical evaluation of both should be conducted.

To the best of our knowledge, this is the first review to identify the strengths and limitations to creative PPI, however, similar literature has identified barriers and facilitators to PPI in general. In the context of clinical trials, recruitment difficulties were cited as a barrier, as well as finding public contributors who were free during work/school hours. Trial managers reported finding group dynamics difficult to manage and the academic environment also made some public contributors feel nervous and lacking confidence to speak. Facilitators, however, included the shared ownership of the research – something that has been identified in the current review too. In addition, planning and the provision of knowledge, information and communication were also identified as facilitators [ 25 ]. Other research on the barriers to meaningful PPI in trial oversight committees included trialist confusion or scepticism over the PPI role and the difficulties in finding PPI members who had a basic understanding of research [ 26 ]. However, it could be argued that this is not representative of the average patient or public member. The formality of oversight meetings and the technical language used also acted as a barrier, which may imply that the informal nature of creative methods and its lack of dependency on literacy skills could overcome this. Further, a review of 42 reviews on PPI in health and social care identified financial compensation, resources, training and general support as necessary to conduct PPI, much like in the current review where the resource intensiveness of creative PPI was identified as a limitation. However, others were identified too, such as recruitment and representativeness of public contributors [ 27 ]. Like in the current review, power imbalances were also noted, however this was included as both a barrier and facilitator. Collaboration seemed to diminish hierarchies but not always, as sometimes these imbalances remained between public contributors and healthcare staff, described as a ‘them and us’ culture [ 27 ]. Although these studies compliment the findings of the current review, a direct comparison cannot be made as they do not concern creative methods. However, it does suggest that some strengths and weaknesses are shared between creative and traditional methods of PPI.

Strengths and limitations of this review

Although a general definition of creative PPI exists, it was up to our discretion to decide exactly which activities were deemed as such for this review. For example, we included sorting cards, the use of interactive whiteboards and sticky notes. Other researchers may have a more or less stringent criteria. However, two reviewers were involved in this decision which aids the reliability of the included articles. Further, it may be that some of the strengths and limitations cannot fully be attributed to the creative nature of the PPI process, but rather their co-created nature, however this is hard to disentangle as the included papers involved both these aspects.

During screening, it was difficult to decide whether the article was utilising creative qualitative methodology or creative PPI , as it was often not explicitly labelled as such. Regardless, both approaches involved the public/patients refining a healthcare product/service. This implies that if this review were to be replicated, others may do it differently. This may call for greater standardisation in the reporting of the public’s involvement in research. For example, the NIHR outlines different approaches to PPI, namely “consultation”, “collaboration”, “co-production” and “user-controlled”, which each signify an increased level of public power and influence [ 28 ]. Papers with elements of PPI could use these labels to clarify the extent of public involvement, or even explicitly state that there was no PPI. Further, given our decision to include only scholarly peer-reviewed literature, it is possible that data were missed within the grey literature. Similarly, the literature search will not have identified all papers relating to different types of accessible inclusion. However, the intent of the review was to focus solely on those within the definition of creative.

This review fills a gap in the literature and helps circulate and promote the concept of creative PPI. Each stage of this review, namely screening and quality appraisal, was conducted by two independent reviewers. However, four full texts could not be accessed during the full text reading stage, meaning there are missing data that could have altered or contributed to the findings of this review.

Research recommendations

Given that creative PPI can require effort to prepare, perform and analyse, sufficient time and funding should be allocated in the research protocol to enable meaningful and continuous PPI. This is worthwhile as PPI can significantly change the research output so that it aligns closely with the needs of the group it is to benefit. Researchers should also consider prototype development as a creative PPI activity as this might reduce future time/resource constraints. Shifting from a top-down approach within research to a bottom-up can be advantageous to all stakeholders and can help move creative PPI towards the mainstream. This, however, is the collective responsibility of funding bodies, universities and researchers, as well as committees who approve research bids.

A few of the included studies used creative techniques alongside traditional methods, such as interviews, which could also be used as a hybrid method of PPI, perhaps by researchers who are unfamiliar with creative techniques or to those who wish to reap the benefits of both. Often the characteristics of the PPI group were not included, including age, gender and ethnicity. It would be useful to include such information to assess how representative the PPI group is of the population of interest.

Creative PPI is a relatively novel approach of engaging the public and patients in research and it has both advantages and disadvantages compared to more traditional methods. There are many approaches to implementing creative PPI and the choice of technique will be unique to each piece of research and is reliant on several factors. These include the age and ability of the PPI group as well as the resource limitations of the project. Each method has benefits and drawbacks, which should be considered at the protocol-writing stage. However, given adequate funding, time and planning, creative PPI is a worthwhile and engaging method of generating ideas with end-users of research – ideas which may not be otherwise generated using traditional methods.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Critical Appraisal Skills Programme

The Joanna Briggs Institute

National Institute of Health and Care Research

Public Advisory Group

Public and Patient Involvement

Web of Science

National Institute for Health and Care Research. What Is Patient and Public Involvement and Public Engagement? https://www.spcr.nihr.ac.uk/PPI/what-is-patient-and-public-involvement-and-engagement Accessed 01 Sept 2023.

Department of Health. Personal and Public Involvement (PPI) https://www.health-ni.gov.uk/topics/safety-and-quality-standards/personal-and-public-involvement-ppi#:~:text=The Health and Social Care Reform Act (NI) 2009 placed,delivery and evaluation of services . Accessed 01 Sept 2023.

National Institute for Health and Care Research. Policy Research Programme – Guidance for Stage 1 Applications https://www.nihr.ac.uk/documents/policy-research-programme-guidance-for-stage-1-applications-updated/26398 Accessed 01 Sept 2023.

Greenhalgh T, Hinton L, Finlay T, Macfarlane A, Fahy N, Clyde B, Chant A. Frameworks for supporting patient and public involvement in research: systematic review and co-design pilot. Health Expect. 2019. https://doi.org/10.1111/hex.12888

Article   PubMed   PubMed Central   Google Scholar  

Street JM, Stafinski T, Lopes E, Menon D. Defining the role of the public in health technology assessment (HTA) and HTA-informed decision-making processes. Int J Technol Assess Health Care. 2020. https://doi.org/10.1017/S0266462320000094

Article   PubMed   Google Scholar  

Morrison C, Dearden A. Beyond tokenistic participation: using representational artefacts to enable meaningful public participation in health service design. Health Policy. 2013. https://doi.org/10.1016/j.healthpol.2013.05.008

Leavy P. Method meets art: arts-Based Research Practice. New York: Guilford; 2020.

Google Scholar  

Seers K. Qualitative systematic reviews: their importance for our understanding of research relevant to pain. Br J Pain. 2015. https://doi.org/10.1177/2049463714549777

Lockwood C, Porritt K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M, Loveday H, Carrier J, Stannard D. Chapter 2: Systematic reviews of qualitative evidence. Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis JBI. 2020. https://synthesismanual.jbi.global . https://doi.org/10.46658/JBIMES-20-03

CASP. CASP Checklists https://casp-uk.net/images/checklist/documents/CASP-Qualitative-Studies-Checklist/CASP-Qualitative-Checklist-2018_fillable_form.pdf (2022).

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006. https://doi.org/10.1191/1478088706qp063oa

Article   Google Scholar  

Byrne E, Elliott E, Saltus R, Angharad J. The creative turn in evidence for public health: community and arts-based methodologies. J Public Health. 2018. https://doi.org/10.1093/pubmed/fdx151

Cook S, Grozdanovski L, Renda G, Santoso D, Gorkin R, Senior K. Can you design the perfect condom? Engaging young people to inform safe sexual health practice and innovation. Sex Educ. 2022. https://doi.org/10.1080/14681811.2021.1891040

Craven MP, Goodwin R, Rawsthorne M, Butler D, Waddingham P, Brown S, Jamieson M. Try to see it my way: exploring the co-design of visual presentations of wellbeing through a workshop process. Perspect Public Health. 2019. https://doi.org/10.1177/1757913919835231

Fedorowicz S, Riley V, Cowap L, Ellis NJ, Chambers R, Grogan S, Crone D, Cottrell E, Clark-Carter D, Roberts L, Gidlow CJ. Using social media for patient and public involvement and engagement in health research: the process and impact of a closed Facebook group. Health Expect. 2022. https://doi.org/10.1111/hex.13515

Galler M, Myhrer K, Ares G, Varela P. Listening to children voices in early stages of new product development through co-creation – creative focus group and online platform. Food Res Int. 2022. https://doi.org/10.1016/j.foodres.2022.111000

Grindell C, Tod A, Bec R, Wolstenholme D, Bhatnagar R, Sivakumar P, Morley A, Holme J, Lyons J, Ahmed M, Jackson S, Wallace D, Noorzad F, Kamalanathan M, Ahmed L, Evison M. Using creative co-design to develop a decision support tool for people with malignant pleural effusion. BMC Med Inf Decis Mak. 2020. https://doi.org/10.1186/s12911-020-01200-3

Kearns Á, Kelly H, Pitt I. Rating experience of ICT-delivered aphasia rehabilitation: co-design of a feedback questionnaire. Aphasiology. 2020. https://doi.org/10.1080/02687038.2019.1649913

Kelemen M, Surman E, Dikomitis L. Cultural animation in health research: an innovative methodology for patient and public involvement and engagement. Health Expect. 2018. https://doi.org/10.1111/hex.12677

Keogh F, Carney P, O’Shea E. Innovative methods for involving people with dementia and carers in the policymaking process. Health Expect. 2021. https://doi.org/10.1111/hex.13213

Micsinszki SK, Buettgen A, Mulvale G, Moll S, Wyndham-West M, Bruce E, Rogerson K, Murray-Leung L, Fleisig R, Park S, Phoenix M. Creative processes in co-designing a co-design hub: towards system change in health and social services in collaboration with structurally vulnerable populations. Evid Policy. 2022. https://doi.org/10.1332/174426421X16366319768599

Valaitis R, Longaphy J, Ploeg J, Agarwal G, Oliver D, Nair K, Kastner M, Avilla E, Dolovich L. Health TAPESTRY: co-designing interprofessional primary care programs for older adults using the persona-scenario method. BMC Fam Pract. 2019. https://doi.org/10.1186/s12875-019-1013-9

Webber R, Partridge R, Grindell C. The creative co-design of low back pain education resources. Evid Policy. 2022. https://doi.org/10.1332/174426421X16437342906266

National Institute for Health and Care Research. A Researcher’s Guide to Patient and Public Involvement. https://oxfordbrc.nihr.ac.uk/wp-content/uploads/2017/03/A-Researchers-Guide-to-PPI.pdf Accessed 01 Nov 2023.

Selman L, Clement C, Douglas M, Douglas K, Taylor J, Metcalfe C, Lane J, Horwood J. Patient and public involvement in randomised clinical trials: a mixed-methods study of a clinical trials unit to identify good practice, barriers and facilitators. Trials. 2021 https://doi.org/10.1186/s13063-021-05701-y

Coulman K, Nicholson A, Shaw A, Daykin A, Selman L, Macefield R, Shorter G, Cramer H, Sydes M, Gamble C, Pick M, Taylor G, Lane J. Understanding and optimising patient and public involvement in trial oversight: an ethnographic study of eight clinical trials. Trials. 2020. https://doi.org/10.1186/s13063-020-04495-9

Ocloo J, Garfield S, Franklin B, Dawson S. Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: a systematic review of reviews. Health Res Policy Sys. 2021. https://doi.org/10.1186/s12961-020-00644-3

National Institute for Health and Care Research. Briefing notes for researchers - public involvement in NHS, health and social care research. https://www.nihr.ac.uk/documents/briefing-notes-for-researchers-public-involvement-in-nhs-health-and-social-care-research/27371 Accessed 01 Nov 2023.

Download references

Acknowledgements

With thanks to the PHIRST-LIGHT public advisory group and consortium for their thoughts and contributions to the design of this work.

The research team is supported by a National Institute for Health and Care Research grant (PHIRST-LIGHT Reference NIHR 135190).

Author information

Olivia R. Phillips and Cerian Harries share joint first authorship.

Authors and Affiliations

Nottingham Centre for Public Health and Epidemiology, Lifespan and Population Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK

Olivia R. Phillips, Jo Leonardi-Bee, Holly Knight & Joanne R. Morling

National Institute for Health and Care Research (NIHR) PHIRST-LIGHT, Nottingham, UK

Olivia R. Phillips, Cerian Harries, Jo Leonardi-Bee, Holly Knight, Lauren B. Sherar, Veronica Varela-Mato & Joanne R. Morling

School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK

Cerian Harries, Lauren B. Sherar & Veronica Varela-Mato

Nottingham Centre for Evidence Based Healthcare, School of Medicine, University of Nottingham, Nottingham, UK

Jo Leonardi-Bee

NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, NG7 2UH, UK

Joanne R. Morling

You can also search for this author in PubMed   Google Scholar

Contributions

Author contributions: study design: ORP, CH, JRM, JLB, HK, LBS, VVM, literature searching and screening: ORP, CH, JRM, data curation: ORP, CH, analysis: ORP, CH, JRM, manuscript draft: ORP, CH, JRM, Plain English Summary: ORP, manuscript critical review and editing: ORP, CH, JRM, JLB, HK, LBS, VVM.

Corresponding author

Correspondence to Olivia R. Phillips .

Ethics declarations

Ethics approval and consent to participate.

The Ethics Committee of the Faculty of Medicine and Health Sciences, University of Nottingham advised that approval from the ethics committee and consent to participate was not required for systematic review studies.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

40900_2024_580_MOESM1_ESM.docx

Additional file 1: Search strings: Description of data: the search strings and filters used in each of the 5 databases in this review

Additional file 2: Quality appraisal questions: Description of data: CASP quality appraisal questions

40900_2024_580_moesm3_esm.docx.

Additional file 3: Table 1: Description of data: elements of the data extraction table that are not in the main manuscript

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Phillips, O.R., Harries, C., Leonardi-Bee, J. et al. What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review. Res Involv Engagem 10 , 48 (2024). https://doi.org/10.1186/s40900-024-00580-4

Download citation

Received : 28 November 2023

Accepted : 25 April 2024

Published : 13 May 2024

DOI : https://doi.org/10.1186/s40900-024-00580-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Public and patient involvement
• Creative PPI
• Qualitative systematic review

Research Involvement and Engagement

ISSN: 2056-7529

• General enquiries: [email protected]

• Our Process

Expert Health & Social Care Writers In The UK

Essays.uk offers professional assistance in your academic endeavours. If you are a health and social care student, you know how hard it can get to complete your essays and assignments along with practising. This is where our health and social care writers are your solution. They have years of practical and theoretical experience and are adept in writing. Hire our top health and social care writers to succeed in your academics now.

Brandon Skinner

Demi Walton

Jessica White

Laura Winter

Jonathan Davidson

Joe McKenzie

Research Fields Of Our Health And Social Care Writers

• Public Health focuses on promoting and protecting the health of communities through disease prevention, health education, policy development, and research aimed at improving population health outcomes.
• Nursing encompasses the provision of healthcare, patient advocacy, and promoting wellness through patient care, treatment, education, and collaboration with interdisciplinary healthcare teams.
• Gerontology is the study of ageing and older adults, focusing on the physical, mental, and social aspects of ageing and providing care, support, and enhancing the quality of life for older individuals.
• Mental Health involves assessing, diagnosing, treating, and supporting individuals experiencing mental health disorders, promoting mental well-being, and reducing stigma surrounding mental health.
• Social Work addresses social issues and promotes social change, empowering individuals, families, and communities and enhancing their well-being through advocacy, counselling, and connecting people with necessary resources.
• Healthcare Administration involves managing and overseeing healthcare organisations and systems, including operations, financial management, policy implementation, and ensuring patient care delivery.

What Is Health and Social Care Studies?

Health and Social Care Studies is an interdisciplinary field that focuses on understanding and addressing the health and social needs of individuals, communities, and populations. It combines elements of healthcare, social work, psychology, sociology, and public health to examine the delivery and management of health services, social support systems, and the impact of social factors on health outcomes.

The field encompasses healthcare policy, health promotion, patient care, social welfare, mental health, ageing, disability, and the social determinants of health, aiming to improve individuals’ and communities’ overall well-being and quality of life.

How Can Our Health and Social Care Writers Help You?

Our academic Health and Social Care writers can conduct in-depth research on specific topics within the field, helping you understand complex concepts, theories, and current practices. They can assist in structuring and writing your essays, assignments, or research papers, ensuring clarity, coherence, and adherence to academic standards.

Our writers have expertise in Health and Social Care, offering insights into healthcare policies, social welfare systems, patient care approaches, and evidence-based practices. They can guide ethical considerations, research methodologies, data analysis, and the application of theories to real-world scenarios. Their assistance is tailored to your specific needs in Health and Social Care.

Our expert health and social care writers can help you with the following:

• Health and Social Care Dissertations
• Health and Social Care Essays
• Health and Social Care Reports
• Health and Social Care Case Studies
• Health and Social Care Research Papers
• Health and Social Care Assignments

Academic Subjects Covered by EssaysUK

Ready to Place an Order?

USEFUL LINKS

LEARNING RESOURCES

COMPANY DETAILS

• How It Works

• Open access
• Published: 09 May 2024

A systematic review of telemedicine for neuromuscular diseases: components and determinants of practice

• Deniz Senyel 1 , 2 ,
• Katja Senn 1 ,
• James Boyd 2 &
• Klaus Nagels 1  

BMC Digital Health volume  2 , Article number:  17 ( 2024 ) Cite this article

100 Accesses

Metrics details

Introduction

Neuromuscular diseases (NMDs) entail a group of mostly inherited genetic disorders with heterogeneous phenotypes impacting muscles, the central or peripheral nervous system. They can lead to severe disabilities and shortened lifespans. Despite their severity, NMDs often lack in public awareness and appropriate medical and social support. Telemedicine can improve patients’ and caregivers’ lives by enhancing continuity of and access to care. The first aim of this systematic review was to summarise the status quo of telemedicine services for patients with NMDs. Secondly, barriers and facilitators of the respective implementation processes should be analysed.

The databases PubMed, Web of Science and CENTRAL by Cochrane were searched in May 2022. To be truly explorative, any original evidence from any setting was included. Two independent researchers completed the screening process. Data was extracted and analysed using the taxonomy of Bashshur et al. (2011) and the Consolidated Framework for Implementation Research (CFIR).

Fifty-seven original papers were included in the systematic review. The results showed a high representation of teleconsultations and remote monitoring studies. Teleconsultations replaced in person appointments and telemonitoring mostly focused on ventilation. Physical therapy, pulmonology, neurology, and psychology were the most represented medical specialties. We found barriers and facilitators relating to implementation mainly referred to the intervention and the individuals involved. Technical errors and inaccessibility due to a lack of technical devices or the patient’s disability were stated as hindrances. A positive mindset of users as well as patient empowerment were necessary for the adoption of new technology. Technophobia or uncertainty around technology negatively impacted the implementation process.

This systematic review provides an overview of the current use of telemedicine in patients with NMDs. The distribution of telemedicine interventions between the defined domains was very heterogenous. Previous research has neglected to fully describe the implementation process of telemedicine for NMDs.

The evidence shows that telemedicine can benefit patients with NMDs in a multitude of ways. Therefore, health policies should endorse and incentivise the uptake of telemedicine by institutions and health care workers. Further research needs to be conducted to confirm the current evidence and close existing research gaps.

Peer Review reports

Neuromuscular diseases (NMDs) are a heterogeneous group of disorders, that affect the nerves controlling muscles, leading to muscle weakness, wasting, and other related symptoms [ 1 ]. NMDs are often hereditary and have been linked to 500 different affected genes [ 2 , 3 ]. Most NMDs are classified as rare diseases. The prevalence of NMDs can vary widely and, even for common diagnostic groups, the prevalence ranges between 0.1 to 60 per 100,000 [ 4 ]. The onset, cause, and course of the disease vary widely between disorders [ 5 ]. While each individual's experience is unique, there are common disability-related challenges faced by patients with NMDs. Acknowledging these commonalities and addressing the unique needs of each person are essential for providing comprehensive care and support to individuals and their families living with NMDs. NMDs are highly complex diseases defined by a degenerative course and progressive muscle weakness as the main symptom. Their impact extends beyond the musculoskeletal system, affecting various organs and systems throughout the body, such as eyes, lungs or the brain [ 1 , 2 ]. As a result, patients suffer from a reduced quality of life and a significant disease burden [ 2 , 6 ]. Multidisciplinary care is often considered the optimal approach for providing holistic treatment and symptomatic management for individuals with NMDs [ 7 , 8 , 9 , 10 , 11 ]. The needs of patients during disease progression are ever changing based on disease stage, symptom burden, and personal priorities. General practitioners, specialists, and allied health professionals each bring unique expertise to the care team, allowing for comprehensive, patient-centred care that adapts to changing needs and priorities throughout the course of the disease and ensures continuity and quality of care [ 1 , 12 , 13 ]. Recognising and supporting caregivers is crucial in the care of NMD patients. Most NMD patients receive informal care, often provided by their partner or family members. The caregiver burden increases with the progression of the patient’s disease. In severe cases, it can lead to psychological distress and burnout, a state of physical and emotional exhaustion [ 14 , 15 , 16 , 17 ].

Mobile health apps, teleconsultation and telemonitoring have been proven to be useful tools in the management and treatment of chronic diseases such as diabetes, heart failure, asthma, chronic obstructive pulmonary disease, and cancer. They have the potential to increase treatment adherence, support self-management, and promote continuity of care [ 18 , 19 , 20 ]. They have the potential to reduce hospital admissions, decrease mortality rates, and lessen health services usage [ 21 , 22 , 23 , 24 ]. The research focus in telemedicine for NMDs varies between disorders. A recent systematic review by Helleman et al. showed telemedicine for ALS patients to be a useful option for remote monitoring, consultations, and follow-ups [ 25 ]. From a patient’s perspective it can be time- and cost-saving while reducing stress and fatigue. While telemedicine has demonstrated its value in certain NMDs like ALS, its usage in the care of other NMDs have not been as extensively studied or described.

This systematic review aims to identify telemedicine interventions for patients with NMDs and analyse the barriers and facilitators of the implementation process associated with telemedicine for NMD patients. The taxonomy by Bashshur et al. will be used to standardise terminology and make it easier to categorise and study the various telehealth interventions and services [ 26 ]. The term “Telemedicine” will be used as an umbrella term to encompass a broad range of remote healthcare services and technologies. This is done to avoid the potential ambiguities and unclarities that can arise from newer terms like "e-health" or "telehealth". This review will provide an overview of the status quo and will offer recommendations for future innovations.

This systematic review followed the PRISMA [ 27 ] checklist. The study protocol was registered on PROSPERO (ID: CRD42022325481).

Databases and search strategy

For the literature search PubMed, Web of Science, and the Cochrane database CENTRAL were used as sources. If full text could not be found, the authors were contacted. The final search was conducted in May of 2022.

The search strategy consisted of two major themes: Firstly, synonyms for NMDs and secondly, synonyms and subcategories for telemedicine. The full search strings can be found in the supplementary file 1 .

Study selection

The study selection was conducted by two reviewers KS and DS. The following inclusion criteria were applied: Studies from any country with any healthcare and insurance system were eligible to maximise the diversity and inclusivity of the evidence base. No restrictions regarding cultural or socio-economic context were made to be truly explorative. Articles were eligible for inclusion if their study population consisted of patients with one or more types of NMDs. Since a single comprehensive list of all NMDs could not be found, the list of NMDs by the Muscular Dystrophy Association (MDA) was used as a reference [ 28 ]. If a disease could not be found under the listed disorders, the International Classification of Diseases (ICD) was consulted [ 29 ]. No limitations regarding sex, age, race, or nationality were made. All types of telemedicine were eligible for inclusion. The taxonomy by Bashshur et al. was used as a guiding definition [ 26 ]. Bashshur uses telemedicine in his paper as the original term for ICT in healthcare. The domains include the following components:

Telehealth : Health behavior & education; Health & disease epidemiology; Environmental/Industrial health; Health management & policy.

E-health : Electronic health record; Health information; Clinical decision support system; Physician order entry.

M-health : Clinical support; Health worker support; Remote data collection; Helplines.

Interventions could be implemented on a national, communal, or institutional level. The users could include patients, caregivers, and healthcare workers. Only primary research was included. Due to the explorative nature of the systematic review, no major restrictions regarding study types were made. Only articles written in English or German were included. Due to the rapid pace of technological progress, only studies from the last ten years were considered. This ensured that the telemedicine interventions were not out-of-date or obsolete.

Studies were excluded if no specific diagnostic group was mentioned. Further reviews, study protocols and commentaries were excluded.

Data extraction and analysis

The data extraction and analysis were done by DS. From the included studies the following data points were extracted: authors, year of publication, country, included NMDs, intervention type and analysed outcomes. Additionally, barriers and facilitators of the implementation process were collected. The Consolidated Framework for Implementation Research (CFIR) was used to guide the extraction process [ 30 ]. The CFIR is an established framework for the analysis of implementation processes. Based on this structure, a detailed coding manual with operationalised definitions for each construct was created. This manual served as a reference guide to ensure that the extraction and coding process was systematic and reproducible.

The data synthesis was done narratively. Since no effect measures were used, a quantitative analysis was not applicable. Firstly, the types of telemedicine interventions were clustered according to the domains described by Bashshur et al., to gain a comprehensive understanding of the current landscape of telemedicine applications [ 26 ]. Secondly, the CFIR was used to label quotes on implementation barriers and facilitators [ 30 ].

No meta-analysis was conducted as there are no quantitative outcomes to analyse. Further, the heterogeneity of the studies was not assessed. Due to the broad inclusion criteria, a high heterogeneity could be expected. Since the focus of this systematic review lies on the intervention types, rather than on their effectiveness, subgroup analyses were not performed. Equally no sensitivity analyses were conducted. The focus of the systematic review was not to summarise evidence regarding a specific intervention, it was an exploration of the current telemedicine options for patients with NMDs.

Risk of bias

The study protocol stated a risk of bias assessment using the RoB 2 and ROBINS-I tools [ 31 , 32 ]. This was later changed to the JBI’s critical appraisal tools as they offered a wider selection of checklists [ 33 ]. No meta-bias was analyzed since the outcomes of the studies were not a point of interest.

Included studies

Figure  1 depicts the study selection process for the systematic review, including a total of 57 reports. These included four report pairs with interlinked content. Ando et al. published two papers on the Intervention Careportal in 2019 and 2021 [ 34 , 35 ]. Hobson et al. conducted one study with results disseminated across two publications [ 36 , 37 ]. Martinet et al. conducted two studies utilising the same intervention but with distinct comparison groups and study populations [ 38 , 39 ]. Lastly, Sobierajska-Rek et al. and Wasilewska et al. published two articles addressing different subsections of one main study [ 40 , 41 ]. Studies excluded during the full text screening process can be found in supplementary file 2 .

Flow diagram of the identified studies (Source: own depiction)

Study characteristics

Table 1 presents an overview of the study characteristics. A total of 25 studies were carried out using a cross-sectional design [ 34 , 35 , 40 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 ]. Additionally, the review included two case series [ 64 , 65 ] and one case–control study [ 66 ]. Among the studies, 16 adopted a cohort study design [ 41 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 ], while ten employed an experimental design [ 36 , 37 , 38 , 39 , 82 , 83 , 84 , 85 , 86 , 87 ]. The remaining three reports were method papers [ 88 , 89 , 90 ]. Geographically, the majority of the studies took place in Europe [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 47 , 48 , 49 , 53 , 58 , 59 , 60 , 62 , 65 , 66 , 68 , 69 , 72 , 73 , 74 , 76 , 80 , 81 , 82 , 84 , 87 , 88 , 89 , 90 ] and the USA [ 44 , 45 , 46 , 51 , 52 , 54 , 56 , 57 , 63 , 67 , 71 , 77 , 78 , 79 , 85 , 86 ]. Two studies were conducted in Canada [ 50 , 64 ] and one in each of the following countries: Japan [ 70 ], India [ 75 ], Brazil [ 83 ], and Australia [ 55 ]. One study included participants from around the globe [ 61 ].

A total of twenty-nine studies exclusively focussed on ALS patients [ 34 , 35 , 36 , 37 , 42 , 46 , 48 , 51 , 52 , 55 , 56 , 57 , 62 , 69 , 70 , 71 , 72 , 73 , 76 , 77 , 78 , 79 , 80 , 81 , 85 , 86 , 87 , 88 , 89 , 90 ], while another four studies included ALS patients alongside other NMD diagnostic groups [ 53 , 54 , 58 , 60 ]. The study outcomes assessed in these studies varied widely. Clinical outcomes, such as physical and cognitive function, as well as mental health, were often used. Further, user satisfaction and utilisation measurements were applied to evaluate interventions. For patient registry studies, epidemiological statistics, including prevalence, were commonly employed as outcome measures.

While the primary focus has been on exploring the availability of telemedicine interventions for patients with NMDS, it is crucial not to overlook the evaluation of individual study quality and the potential impact of bias. In summary, most studies demonstrated a low risk of bias and employed sound methods and procedures. However, certain limitations, such as the lack of comparison groups, insufficient follow up time, and some inadequate reporting, should be noted. Visual depictions and the complete analysis can be found in supplementary material 3 . Three reports were not assessed as they only presented a method paper without empirical results [ 88 , 89 , 90 ].

Telemedicine domains of included interventions

In the following sections the telemedicine interventions included in the analysis will be examined, guided by the taxonomy by Bashshur et al [ 26 ]. According to their definition, telemedicine comprises of three major domains: telehealth, e-health, and m-health . Eight studies were categorised under the telehealth domain, encompassing all traditional public health areas. E-health, mainly describing the online storage of information and supporting tools for physicians, was represented by ten studies. The majority of studies fell within the m-health domain, a rapidly growing field that leverages mobile devices like smartphones and tablets to deliver healthcare services, monitor patients remotely, and support self-management. Given that interventions could encompass elements from different domains, multiple mentions or references to different domains is possible. As stated, there were instances where multiple reports featured identical telemedicine interventions [ 34 , 35 , 36 , 37 , 38 , 39 ]. In order not to bias the results, identical interventions were counted as one during the analysis of the telemedicine domains and components. The distribution of telemedicine domains is illustrated in Fig.  2 a.

Distribution of the telemedicine ( a ) and telehealth domains ( b ) (Source: own depiction)

The studies within the telehealth domain were mostly epidemiological studies. Six studies described online patient registries for one or more NMDs [ 43 , 44 , 47 , 56 , 58 , 72 ]. The remaining two studies were categorised under health education. One study introduced a blended curriculum focusing on physical examinations for patients with NMDs [ 45 ] while another detailed a virtual neuromuscular ultrasound course [ 61 ]. The distribution of the telehealth domain can be seen in Fig.  2 b.

The second smallest domain was e-health (Fig.  3 ). Within this domain, three studies incorporated electronic health records [ 69 , 89 , 90 ]. Health information was the subject of five studies, with two of these not providing an intervention but instead investigating patients’ computer use and information seeking behaviour [ 42 , 50 ]. Only two interventions described clinical decision support systems, one supporting physicians during the diagnostic phase [ 53 ] and another supporting patients with advanced care planning [ 71 ]. A singular app used a function for physician order entries, specifically for nutrition plan entries [ 86 ].

Distribution of the e-Health ( a ) and m-health domains ( b ) (Source: own depiction)

Most included studies contained m-health components (Fig.  3 ). Among the various m-health interventions analysed, helplines represented the smallest category. Specifically, four interventions provided emergency telephone support, and one included useful helpline numbers in their app [ 35 , 60 , 81 , 89 , 90 ].

The predominant categories within the m-health domain were clinical support and remote data collection. Nine studies reported interventions with synchronous consultations and data collection [ 40 , 51 , 57 , 62 , 65 , 73 , 75 , 81 , 85 ]. To illustrate, Christodoulou et al. conducted telephone-based cognitive-behavioural screening in ALS patients [ 85 ], demonstrating how telemedicine can seamlessly combine remote data collection processes with distance consultations. Another example was the remote application of the ALS Functioning Rating Scale during teleconsultations [ 62 ]. An alternative approach identified involving clinical support and remote data collection occurring asynchronously, utilising specially designed devices or mobile applications for data collection [ 35 , 66 , 68 , 69 , 70 , 88 , 90 ]. In this approach, clinical consultation was offered either on demand or automatically triggered based on the collected data.

Fourteen studies used clinical support without remote data collection, including home exercise programs [ 40 , 82 , 83 , 84 ], psychological interventions [ 39 , 87 ] and pure teleconsultation [ 52 , 54 , 55 , 60 , 77 , 78 , 79 ]. In contrast, 12 studies focussed on pure remote data collection without clinical support. This included, accelerometers [ 74 , 80 ], physical assessments [ 63 , 64 , 67 , 76 ] or the assessment of the patient’s nutritional status [ 86 ] or disease-related health [ 37 , 46 , 89 ]. Additionally, Cesareo et al. as well as Wasilewska et al. examined remote pulmonary monitoring devices [ 41 , 49 ].

Barriers and facilitators for the implementation of telemedicine

CFIR was used to assess factors that may facilitate or hinder the implementation of telemedicine. This framework consists of five domains: the inner setting, the outer setting, the implementation process, the intervention characteristics, and the characteristics of the individuals. Relevant information was found in 22 studies, with a predominant focus on patient and carer perspectives [ 34 , 36 , 37 , 41 , 42 , 48 , 49 , 50 , 51 , 52 , 55 , 62 , 63 , 66 , 69 , 73 , 74 , 75 , 76 , 77 , 78 , 83 ]. As a result, no information regarding the inner/outer setting or the implementation process was gathered. All statements focused on the intervention characteristics or the characteristics of the individuals. Thus, the following section is structured according to the two domains and their constructs.

Intervention characteristics

A summary of mentioned barriers and facilitators can be seen in Table  2 .

General characteristics

This category summarises all barriers and facilitators directly linked to the intervention that could not be categorised elsewhere. The most common barrier encountered during the implementation of telemedicine interventions were malfunctions related to internet connectivity or end devices. Examples included software errors [ 51 ], faulty data transmission [ 34 ] or a poor internet connection [ 83 ]. Additionally, it was reported, that the internet and necessary end devices, such as smartphones, tablets, or computers, were often not available [ 48 , 50 , 63 ].

Relative advantage

A major factor for patients was the reduced time and travel burden [ 34 , 51 , 52 , 62 , 76 , 78 ]. In more advanced stages of the diseases travelling with medical equipment became almost impossible, making telemedicine vital for house-bound patients [ 78 ].

Telemonitoring and the remote data collection provided multiple advantages, with patients and caregivers highlighting the timeliness of actions in case of alerts [ 34 , 73 ]. Continuous monitoring also proved beneficial for in-person visits, as medical staff stated that appointments could be used more efficiently with data being analysed beforehand [ 69 ]. Some disadvantages regarding telemedicine were acknowledged. Caregivers and physicians noted the lack of physical evaluation as problematic [ 51 , 52 ]. Additionally, an emotional distance and a lack of informal encounters between patients and healthcare workers was reported [ 52 , 55 ].

Adaptability

Patients appreciated the flexibility of online exercise programs, which were easier to integrate into their daily routines [ 83 ]. It was seen as important to be able to choose the main form of communication [ 55 , 62 ]. For example, patients with speech difficulties communicating via E-Mail was preferred.

Interventions were easier implemented if participants were thoroughly informed about the telemedicine service and if a computer-literate person was on-site [ 78 ]. The duration and frequency of sessions was another major point. Overall, more frequent, and shorter sessions were perceived as less fatiguing [ 78 ].

Design and quality

Critical considerations included the presentation, design, and quality of telemedicine products, emphasizing features like accessible closing mechanisms for wearable devices and age-appropriate designs [ 49 , 74 ].

From a patient’s perspective telemedicine was cost-saving due to reduced travel [ 34 , 48 ]. Nevertheless, acquisition costs could be a barrier for some. Institutional perspectives indicated potential savings, ranging from 20 to 89%, depending on the approach, making costs a crucial factor [ 50 , 77 ].

Characteristics of individuals

The second domain related to the characteristics of individuals. This includes all stakeholders such as patients, caregivers, and healthcare workers. Table 3 depicts the barriers and facilitators relating to the characteristics of individuals.

Knowledge and Beliefs about the Intervention

The CFIR highlights the importance of an individual’s pre-existing knowledge and beliefs about the intervention [ 30 ]. Trust in the intervention was vital for patients using telemonitoring [ 34 , 36 , 52 , 69 , 78 ]. This includes being confident that the transmitted data was monitored and that providers would act in the case of abnormalities.

Self-efficacy

Easy to use technology was seen as an enabler for telemedicine implementation, as it reassured the user in their abilities. Accordingly, barriers arose if patients could not or did not feel confident in using technological devices [ 50 , 51 , 69 ]. Lack of confidence led patients to use technology on rare occasions and only if deemed necessary [ 36 ].

Other personal attributes

Lastly, this category summarises all personal traits of stakeholders that might impact the implementation of the intervention [ 30 ]. Younger, higher-educated patients embraced technology more readily [ 42 , 75 ]. Another enabler was telemonitoring improving patient empowerment, symptom awareness, and communication [ 34 , 36 , 51 , 69 ]. However, some found constant disease confrontation challenging [ 69 ]. Lastly, a personal connection with medical staff enabled telemedicine use [ 36 ].

This systematic review presents a comprehensive overview of the current status of telemedicine applications for patients with NMDs. The primary objective was to classify the identified interventions according to the dimensions of telemedicine. While some studies within this review explored the epidemiology of NMDs, and two interventions provided education for clinical staff, it's clear that certain aspects of telemedicine in public health remain under-studied.

E-health, encompassing health information, an electronic health record or physician order entries/treatment instructions, was comparatively underutilised, with only a subset of interventions included. Moreover, decision support systems were rarely investigated. The predominant focus of most interventions was on clinical support and remote data collection.

The second phase of the analysis concentrated on the implementation process, with a specific focus on identifying barriers and facilitators associated with both the intervention itself and the individuals involved. In comparison to traditional care, telemedicine often demonstrated a relative advantage. The high motivation demonstrated by NMD patients and their caregivers in integrating telemedicine into their care plan is a testament to the potential of telemedicine as a transformative force in healthcare.

Telemedicine was often perceived as a resource-saving, less fatiguing alternative, particularly offering increased accessibility for homebound patients. The lack of physical touch and reduced personal connections emerged as significant barriers. Additionally, the accessibility of technology played a pivotal role, as inadequate design hindered some patients from using telemedicine services. The acceptance and uptake of telemedicine services often depended on the readiness of patients and their caregivers to embrace and adapt to new digital solutions. Recognising the importance of patient empowerment, fostering the development of essential skills and confidence in utilising technology is crucial for enabling patients to actively engage in their healthcare.

Clinical and policy implications

The COVID-19 pandemic created an unprecedented opportunity for the development and implementation of telehealth. Disruptions in healthcare access, caused by social distancing and hygiene guidelines, led healthcare practitioners to expand telemedicine services to ensure the continuity of care [ 91 , 92 ]. This trend extended to the field of neuromuscular disease care as well [ 48 , 62 , 91 , 93 , 94 ]. The American Academy of Neurology's "Telehealth Position Statement" endorsed telemedicine, citing benefits such as improved access, reduced costs, and enhanced comfort, aligning with findings in this review [ 95 ].

Our findings further highlighted important considerations for the successful implementation of telemedicine. Firstly, it is essential to recognise that not all geographic locations are equally suited for telehealth. Remote areas with insufficient internet or cell phone coverage, as well as low-income households with a lack of digital technologies, may encounter difficulties in participating in telemedicine interventions [ 96 ]. Secondly, careful selection of the target population is vital, as the attitude and willingness of users significantly impact technology uptake [ 34 , 36 , 52 , 69 , 78 ]. The acceptance and efficacy of telemedicine interventions are inherently intertwined with diverse cultural attitudes towards healthcare and technology.

Therefore, understanding cultural factors is critical to discern how these variables may influence the successful integration of telehealth programs across diverse patient populations. A systematic analysis of cultural competence would provide valuable insights to refine and customise approaches, meeting the distinctive needs of diverse communities. Such considerations not only enhance the inclusivity of telemedicine but also contribute to its overall effectiveness and acceptance among a broad spectrum of individuals.

As the results have shown, it is vital to adapt telemedicine to the specific and evolving needs of patients with NMDs. These needs not only vary from patient to patient but also change over time as the disease progresses [ 5 ]. Therefore, when designing telemedicine technology for patients with NMDs, emphasis should be placed on adaptability, flexibility and accessibility [ 49 , 55 , 62 , 74 , 83 ].

Designing telemedicine technology that caters for the unique challenges faced by patients with physical disabilities and cognitive impairments is crucial for fostering inclusive healthcare [ 49 , 74 ]. User interfaces need to incorporate accessibility features, such as voice commands, large fonts, and intuitive navigation, to accommodate individuals with motor challenges or cognitive limitations. Additionally, instructions and information must be presented in various accessible formats, accommodating diverse learning needs [ 97 ].

Prioritising plain language and ensuring readability at lower literacy levels is essential. This approach not only makes instructions universally accessible but also empowers all patients to effectively participate in telemedicine interactions. By incorporating these considerations into the design, telemedicine can better serve the needs of patients with NMDs, promoting inclusivity and enhancing the overall effectiveness of healthcare delivery [ 97 ].

Health policies and regulatory frameworks play a significant role in influencing the development and adoption of telehealth practices. A nuanced understanding of these regulations, encompassing aspects such as licensure, reimbursement, and liability, is essential for gaining comprehensive insights into the complex landscape that shapes and governs telemedicine [ 96 ]. The intricate web of reimbursement policies directly influences the economic viability of telemedicine services, impacting both healthcare providers and patients. By navigating and understanding these policy and regulatory intricacies, stakeholders in the telemedicine ecosystem can strategically address and potentially overcome barriers, facilitating a more widespread and effective implementation of telehealth services [ 96 ].

This review reveals that telemedicine interventions for patients with NMDs exist but have yet to realise their full protentional. Firstly, the heavy focus on ALS care should be expanded to encompass all diagnostic groups within the NMD spectrum. Especially the high availability of mHealth applications, which could be seamlessly integrated into care plans. This integration has the potential to enhance continuity of care, simultaneously easing the burden on the healthcare system and reducing appointment frequency for patients [ 69 ].

The incorporation of long-term patient data through remote monitoring holds numerous advantages [ 98 , 99 ]. Continuous data collection could offer enhanced insights into disease progression, thereby improving disease management. Given the degenerative nature of most NMDs, there is a speculation that long-term data could help in detecting early signs of deterioration, facilitating quicker adaption of treatments. Furthermore, detailed information about disease progression could contribute to health prognosis, empowering both patients and healthcare professionals to better plan and coordinate care [ 98 , 99 ]. It is evident that the full benefits of telemonitoring remain undiscovered, making it an important and interesting area for future research. The exploration of these untapped potentials could significantly advance the effectiveness and scope of telemedicine in the context of NMDs.

Research and evaluation opportunities

The current telemedicine landscape yields promising results, particularly in its role in supporting rare disease research through the establishment of disease registries. These registries systematically collect patient data related to disease progression and treatment, forming the foundation for observational studies [ 100 , 101 ]. These studies offer critical insights into the management and progression of rare disease, contributing to evidence-based clinical decisions and facilitating the recruitment of participants for clinical trial.

National and international patient registries are pivotal for studying prevalence and incidence, enhancing our understanding of rare diseases like neuromuscular disorders [ 100 , 101 ]. The establishment of global patient registries becomes especially important for pooling data on rare diseases. International collaborations can help bridge the gap in research for understudied NMDs. By fostering collaboration and sharing data on a global scale, telemedicine-supported registries contribute significantly to advancing our understanding and management of rare diseases.

The results of our systematic review highlight a gap in the research on telemedicine for NMDs. Except for ALS, most NMDs are underrepresented in the current body of literature. Future research should include a more diverse range of diagnostic groups and undertake a comparative analysis of challenges and solutions. This would lead to a higher external validity and faster adaption of telemedicine solutions.

While teleconsultation and remote monitoring for NMDs are well described, other critical domains within telemedicine have received comparatively limited attention. These research gaps should be addressed in the future. Most importantly, implementation science has a critical role in the successful deployment of telemedicine interventions for NMDs. As seen in this systematic review studies, the focus needs to be on patients, caregivers, and health care practitioners, as well as the intervention itself.

It is noteworthy that there is underreporting of crucial aspects, such as the inner and outer settings, as well as the implementation process, in telemedicine interventions for NMDs. Additionally, there is need for research examining the impact of health policies and clinical guidelines on the adoption and implementation of telemedicine. The lack of implementation research has been described in the systematic review by Helleman et al., who analysed telemedicine for ALS patients [ 25 ]. Implementation science is needed to improve the efficiency and uptake of future telemedicine interventions for NMDs [ 102 ].

While our systematic review focused on highlighting the barriers and facilitators of telemedicine, we fully recognise the importance of addressing the validation challenges associated with digital health data. Future research and healthcare policies should emphasise the need for robust validation processes to ensure the reliability and clinical relevance of digital outcomes in telemedicine interventions.

Limitations

Despite an extensive search string, additional search terms might have yielded more results, especially considering synonyms for neuromuscular diseases. A more specific search for individual diagnostic groups would have been more inclusive, but the sheer number of NMDs made this unfeasible.

The literature databases used represent common sources of clinical evidence, but they may not comprehensively cover health policies, management, and health education related to NMDs, which might be found in other types of databases.

The absence of experimental study designs in the individual studies was notable, with most included studies being cross-sectional or observational. However, as this review aims to provide an overview of interventions, this description suffices.

The majority of included studies are from high-income countries, and the extent of telemedicine utilisation in low- and middle-income countries remains unclear. The variation in target population size and time horizon in NMD research reflects the complexity and rarity of these conditions, suggesting a need for longer follow-up times in future studies to better describe long-term outcomes.

This systematic review offers a comprehensive view of the telemedicine landscape in the context of NMDs. While domains like teleconsultation and telemonitoring have received extensive attention and reporting in the literature, other critical domains, such as decision support tools and informational support, are notably lacking in research and documentation. To further understand, develop and implement telemedicine solutions and to close existing gaps in NMD-specific healthcare provision, policies and guidelines are needed. By actively integrating telemedicine into existing healthcare plans and maintaining a commitment to ongoing updates and improvements, healthcare systems can optimise care delivery, enhance patient outcomes, and ensure that individuals with NMDs receive the high-quality care they deserve. In addition, more high-quality studies are needed to close research gaps concerning the implementation process of telemedicine and prove the respective efficiency and effectiveness in the long run.

Availability of data and materials

Due to the nature of the paper, no primary data was generated. All data analysed during this study are included in this published article and its supplementary information files.

Abbreviations

Amyotrophic lateral sclerosis

Anti-synthetase syndrome

Becker muscular dystrophy

Consolidated framework for implementation research

Congenital myopathy

Congenital muscular dystrophy

Charcot-Marie-tooth disease

Dermatomyositis

Duchenne muscular dystrophy

Emery-Dreifuss muscular dystrophy

Facioscapulohumeral muscular dystrophy

Hereditary spastic paraparesis

International classification of diseases

Juvenile dermatomyositis

Lambert-Eaton-myasthenic-syndrome

Limb-Girdle muscular dystrophy

Myotonic dystrophy

Muscular dystrophy

Muscular dystrophy association

Myofibrillar myopathies

Myasthenia gravis

Muscle glycogenosis

Necrotizing myositis

Neuromuscular disease

Overlap myositis

Pompe disease

Polymyositis

Post-Polio syndrome

Randomized controlled trial

Spinal and bulbar muscular atrophy

Spinal muscular atrophy

Transthyretin familial amyloid polyneuropathy

Mary P, Servais L, Vialle R. Neuromuscular diseases: diagnosis and management. Orthopaed Traumatol: Surg Res. 2018;104(1, Supplement):89-S95. Available from: https://www.sciencedirect.com/science/article/pii/S187705681730333X .

Google Scholar  

Aitken M, Mercer EJ, Mckemey A. Understanding neuromuscular disease care: current state and future prospects. IQVIA Institute; 2018.

Bonne G, Rivier F, Hamroun D. The 2018 version of the gene table of monogenic neuromuscular disorders (nuclear genome). Neuromusc Disord: NMD 2017; 27(12). Available from: https://pubmed.ncbi.nlm.nih.gov/29961566/ .

Deenen JC, Horlings CG, Verschuuren JJ, Verbeek AL, van Engelen BG. The epidemiology of neuromuscular disorders: a comprehensive overview of the literature. J Neuromuscul Dis. 2015;2(1):73–85.

Article   PubMed   Google Scholar  

Feldman EL, Russell JW, Löscher WN, Grisold W, Meng S. Atlas of Neuromuscular diseases: a practical guideline. 3rd ed. Cham: Springer International Publishing; Imprint Springer; 2021. Springer eBook Collection.

Book   Google Scholar  

Craig BM, Hartman JD, Owens MA, Brown DS. Prevalence and losses in quality-adjusted life years of child health conditions: a burden of disease analysis. Matern Child Health J. 2016;20(4):862–9.

Article   PubMed   PubMed Central   Google Scholar  

Birnkrant DJ, Bushby K, Bann CM, Alman BA, Apkon SD, Blackwell A, et al. Diagnosis and management of Duchenne muscular dystrophy, part 2: respiratory, cardiac, bone health, and orthopaedic management. Lancet Neurol. 2018;17(4):347–61. Available from: https://pubmed.ncbi.nlm.nih.gov/29395990/ .

Birnkrant DJ, Bushby K, Bann CM, Apkon SD, Blackwell A, Brumbaugh D, et al. Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and neuromuscular, rehabilitation, endocrine, and gastrointestinal and nutritional management. Lancet Neurol. 2018;17(3):251–67. Available from: https://pubmed.ncbi.nlm.nih.gov/29395989/ .

Hulisz D. Amyotrophic lateral sclerosis: disease state overview. The American journal of managed care. 2018;24(15 Suppl):S320–6. Available from: https://pubmed.ncbi.nlm.nih.gov/30207670/ .

PubMed   Google Scholar  

Khan F, Ng L, Amatya B, Brand C, Turner-Stokes L. Multidisciplinary care for Guillain-Barré syndrome. Europ J Phys Rehabil Med. 2011;47(4):607–12. Available from: https://pubmed.ncbi.nlm.nih.gov/21912364/ .

CAS   Google Scholar  

Mercuri E, Sumner CJ, Muntoni F, Darras BT, Finkel RS. Spinal muscular atrophy. Nat Rev Dis Prim. 2022;8(1):52. Available from: https://pubmed.ncbi.nlm.nih.gov/35927425/ .

Birnkrant DJ, Bushby K, Bann CM, Apkon SD, Blackwell A, Colvin MK, et al. Diagnosis and management of Duchenne muscular dystrophy, part 3: primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Lancet Neurol. 2018;17(5):445–55.

Johnson NE. Myotonic muscular dystrophies. Continuum (Minneap Minn). 2019;25(6):1682–95.

Brandt M, Johannsen L, Inhestern L, Bergelt C. Parents as informal caregivers of children and adolescents with spinal muscular atrophy: a systematic review of quantitative and qualitative data on the psychosocial situation, caregiver burden, and family needs. Orphanet J Rare Dis. 2022;17(1):274. Available from: https://pubmed.ncbi.nlm.nih.gov/35854387/ .

Landfeldt E, Edström J, Buccella F, Kirschner J, Lochmüller H. Duchenne muscular dystrophy and caregiver burden: a systematic review. Dev Med Child Neurol. 2018;60(10):987–96.

Tramonti F, Bonfiglio L, Bongioanni P, Belviso C, Fanciullacci C, Rossi B, et al. Caregiver burden and family functioning in different neurological diseases. Psychol Health Med. 2019;24(1):27–34.

de Wit J, Bakker LA, van Groenestijn AC, van den Berg LH, SchrÖder CD, Visser-Meily JMA, et al. Caregiver burden in amyotrophic lateral sclerosis: a systematic review. Palliat Med. 2018;32(1):231–45. Available from: https://pubmed.ncbi.nlm.nih.gov/28671483/ .

Hamine S, Gerth-Guyette E, Faulx D, Green BB, Ginsburg AS. Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review. J Med Internet Res. 2015;17(2):e52. Available from: https://pubmed.ncbi.nlm.nih.gov/25803266/ .

Hanlon P, Daines L, Campbell C, McKinstry B, Weller D, Pinnock H. Telehealth interventions to support self-management of long-term conditions: a systematic metareview of diabetes, heart failure, asthma, chronic obstructive pulmonary disease, and cancer. J Med Internet Res. 2017;19(5):e172.

Whitehead L, Seaton P. The effectiveness of self-management mobile phone and tablet apps in long-term condition management: a systematic review. J Med Internet Res. 2016;18(5):e97.

Bashshur RL, Shannon GW, Smith BR, Alverson DC, Antoniotti N, Barsan WG, et al. The empirical foundations of telemedicine interventions for chronic disease management. Telemed J e-health. 2014;20(9):769–800.

Eze ND, Mateus C, Cravo Oliveira Hashiguchi T. Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLos One. 2020;15(8):0237585.

Article   Google Scholar  

León-Salas B, González-Hernández Y, Infante-Ventura D, de Armas-Castellano A, García-García J, García-Hernández M, et al. Telemedicine for neurological diseases: a systematic review and meta-analysis. Eur J Neurol. 2023;30(1):241–54.

Wang H, Yuan X, Wang J, Sun C, Wang G. Telemedicine maybe an effective solution for management of chronic disease during the COVID-19 epidemic. Prim Health Care Res Dev. 2021;22:e48.

Helleman J, Kruitwagen ET, van den Berg LH, Visser-Meily JMA, Beelen A. The current use of telehealth in ALS care and the barriers to and facilitators of implementation: a systematic review. Amyotroph Lateral Scler Frontotemporal Degener. 2020;21(3–4):167–82.

Article   CAS   PubMed   Google Scholar  

Bashshur R, Shannon G, Krupinski E, Grigsby J. The taxonomy of telemedicine. Telemed J E-health 2011;17(6). Available from: https://pubmed.ncbi.nlm.nih.gov/21718114/ .

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

Muscular Dystrophy Association. Find a neuromuscular disease | Muscular Dystrophy Association; 2018 [cited 2022 Mar 28.526Z]. Available from: https://www.mda.org/disease/list .

ICD-11 for Mortality and Morbidity Statistics; 2022 [cited 2022 Mar 31.331Z]. Available from: https://icd.who.int/browse11/l-m/en .

Damschroder LJ, Aron DC, Keith RE, Kirsh, SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4. Available from: https://pubmed.ncbi.nlm.nih.gov/19664226/ .

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.

Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.

Critical Appraisal Tools | JBI; 2022 [cited 2022 Sep 8]. Available from: https://jbi.global/critical-appraisal-tools .

Ando H, Ashcroft-Kelso H, Halhead R, Chakrabarti B, Young CA, Cousins R, et al. Experience of telehealth in people with motor neurone disease using noninvasive ventilation. Disabil Rehabil Assist Technol. 2021;16(5):490–6.

Ando H, Ashcroft-Kelso H, Halhead R, Young CA, Chakrabarti B, Levene P, et al. Incorporating self-reported questions for telemonitoring to optimize care of patients with MND on noninvasive ventilation (MND OptNIVent). Amyotroph Lateral Scler Frontotemporal Degener. 2019;20(5–6):336–47.

Hobson E, Baird W, Bradburn M, Cooper C, Mawson S, Quinn A, et al. Process evaluation and exploration of telehealth in motor neuron disease in a UK specialist centre. BMJ Open. 2019;9(10):e028526. Available from: https://pubmed.ncbi.nlm.nih.gov/31640994/ .

Hobson EV, Baird WO, Bradburn M, Cooper C, Mawson S, Quinn A, et al. Using telehealth in motor neuron disease to increase access to specialist multidisciplinary care: a UK-based pilot and feasibility study. BMJ Open. 2019;9(10):e028525. Available from: https://bmjopen.bmj.com/content/9/10/e028525 .

Martínez O, Amayra I, López-Paz JF, Lázaro E, Caballero P, García I, et al. Effects of teleassistance on the quality of life of people with rare neuromuscular diseases according to their degree of disability. Front Psychol. 2021;12:637413.

Martínez O, Jometón A, Pérez M, Lázaro E, Amayra I, López-Paz JF et al. Effectiveness of teleassistance at improving quality of life in people with neuromuscular diseases. Spanish J Psychol 2014;17. Available from: https://pubmed.ncbi.nlm.nih.gov/26055393/ .

Sobierajska-Rek A, Mański Ł, Jabłońska-Brudło J, Śledzińska K, Ucińska A, Wierzba J. Establishing a telerehabilitation program for patients with Duchenne muscular dystrophy in the COVID-19 pandemic. Wien Klin Wochenschr. 2020;133(7–8):344–50. Available from: https://link.springer.com/article/10.1007/s00508-020-01786-8 .

PubMed   PubMed Central   Google Scholar  

Wasilewska E, Sobierajska-Rek A, Małgorzewicz S, Soliński M, Szalewska D, Jassem E. Is it possible to have home e-monitoring of pulmonary function in our patients with duchenne muscular dystrophy in the covid-19 pandemic?-A one center pilot study. Int J Environ Res Public Health 2021;18(17).

Abdulla S, Vielhaber S, Machts J, Heinze H-J, Dengler R, Petri S. Information needs and information-seeking preferences of ALS patients and their carers. Amyotroph Lateral Scler Frontotemporal Degener. 2014;15(7–8):505–12.

Ambrosini A, Calabrese D, Avato FM, Catania F, Cavaletti G, Pera MC, et al. The Italian neuromuscular registry: a coordinated platform where patient organizations and clinicians collaborate for data collection and multiple usage. Orphanet J Rare Dis. 2018;13(1):176.

Anil R, Kumar A, Alaparthi S, Sharma A, Nye JL, Roy B, et al. Exploring outcomes and characteristics of myasthenia gravis: Rationale, aims and design of registry - The EXPLORE-MG registry. J Neurol Sci. 2020;414:116830.

Benjamin JC, Groner J, Walton J, Noritz G, Gascon GM, Mahan JD. A blended curriculum to improve resident physical exam skills for patients with neuromuscular disability. MedEdPORTAL. 2019;15:10792.

Berry JD, Paganoni S, Carlson K, Burke K, Weber H, Staples P, et al. Design and results of a smartphone-based digital phenotyping study to quantify ALS progression. Ann Clin Transl Neurol. 2019;6(5):873–81.

Bettio C, Salsi V, Orsini M, Calanchi E, Magnotta L, Gagliardelli L, et al. The Italian National Registry for FSHD: an enhanced data integration and an analytics framework towards smart health care and precision medicine for a rare disease. Orphanet J Rare Dis. 2021;16(1):470.

Capozzo R, Zoccolella S, Musio M, Barone R, Accogli M, Logroscino G. Telemedicine is a useful tool to deliver care to patients with Amyotrophic Lateral Sclerosis during COVID-19 pandemic: results from Southern Italy. Amyotroph Lateral Scler Frontotemporal Degener. 2020;21(7–8):542–8.

Cesareo A, Nido SA, Biffi E, Gandossini S, D’Angelo MG, Aliverti A. A Wearable device for breathing frequency monitoring: a pilot study on patients with muscular dystrophy. Sensors (Basel) 2020;20(18).

Climans SA, Piechowicz C, Koopman WJ, Venance SL. Survey of Canadian myotonic dystrophy patients’ access to computer technology. Can J Neurol Sci. 2017;44(5):567–71.

Geronimo A, Simmons Z. Evaluation of remote pulmonary function testing in motor neuron disease. Amyotroph Lateral Scler Frontotemporal Degener. 2019;20(5–6):348–55.

Geronimo A, Wright C, Morris A, Walsh S, Snyder B, Simmons Z. Incorporation of telehealth into a multidisciplinary ALS Clinic: feasibility and acceptability. Amyotroph Lateral Scler Frontotemporal Degener. 2017;18(7–8):555–61.

Grigull L, Lechner W, Petri S, Kollewe K, Dengler R, Mehmecke S, et al. Diagnostic support for selected neuromuscular diseases using answer-pattern recognition and data mining techniques: a proof of concept multicenter prospective trial. BMC Med Inform Decis Mak. 2016;16:31.

Hooshmand S, Cho J, Singh S, Govindarajan R. Satisfaction of telehealth in patients with established neuromuscular disorders. Front Neurol. 2021;12:667813.

James N, Power E, Hogden A, Vucic S. Patients’ perspectives of multidisciplinary home-based e-Health service delivery for motor neurone disease. Disabil Rehabil Assist Technol. 2019;14(7):737–43.

Malek AM, Stickler DE, Antao VC, Horton DK. The National ALS Registry: a recruitment tool for research. Muscle Nerve. 2014;50(5):830–4.

Pulley MT, Brittain R, Hodges W, Frazier C, Miller L, Matyjasik-Liggett M, et al. Multidisciplinary amyotrophic lateral sclerosis telemedicine care: The store and forward method. Muscle Nerve. 2019;59(1):34–9.

Roy AJ, van den Bergh P, van Damme P, Doggen K, van Casteren V. Early stages of building a rare disease registry, methods and 2010 data from the Belgian Neuromuscular Disease Registry (BNMDR). Acta Neurol Belg. 2015;115(2):97–104.

Sobierajska-Rek A, Mański Ł, Jabłońska-Brudło J, Śledzińska K, Wasilewska E, Szalewska D. Respiratory telerehabilitation of boys and young men with Duchenne muscular dystrophy in the COVID-19 Pandemic. Int J Environ Res Public Health 2021;18(12).

Spiliopoulos KC, Kasdaglis N, Veltsista D, Lykouras D, Lagadinou M, Chroni E. Teleneurology in a center for neuromuscular diseases during the COVID-19 pandemic. Acta Neurol Belg. 2022;122(3):721–4.

Tawfik EA, van Alfen N, Cartwright MS, Inkpen P, Kerasnoudis A, Lieba-Samal D, et al. Virtual neuromuscular ultrasound courses during COVID-19 pandemic: Leveraging technology to enhance learning opportunities. Muscle Nerve. 2021;65(1):29–33.

Vasta R, Moglia C, D’Ovidio F, Di Pede F, de Mattei F, Cabras S, et al. Telemedicine for patients with amyotrophic lateral sclerosis during COVID-19 pandemic: an Italian ALS referral center experience. Amyotroph Lateral Scler Frontotemporal Degener. 2021;22(3–4):308–11.

White MK, Leffler M, Rychlec K, Jones C, McSherry C, Walker L, et al. Adapting traditional content validation methods to fit purpose: an example with a novel video assessment and training materials in Duchenne muscular dystrophy (DMD). Qual Life Res. 2019;28(11):2979–88.

Menon D, Alnajjar S, Barnett C, Vijayan J, Katzberg H, Fathi D, et al. Telephone consultation for myasthenia gravis care during the COVID-19 pandemic: Assessment of a novel virtual myasthenia gravis index. Muscle Nerve. 2021;63(6):831–6.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Portaro S, Calabrò RS, Bramanti P, Silvestri G, Torrisi M, Conti-Nibali V, et al. Telemedicine for Facio-Scapulo-Humeral Muscular Dystrophy: A multidisciplinary approach to improve quality of life and reduce hospitalization rate? Disabil Health J. 2017;11(2):306–9.

Trucco F, Pedemonte M, Racca F, Falsaperla R, Romano C, Wenzel A, et al. Tele-monitoring in paediatric and young home-ventilated neuromuscular patients: A multicentre case-control trial. J Telemed Telecare. 2019;25(7):414–24.

Contesse MG, Sapp ATL, Apkon SD, Lowes LP, Dalle Pazze L, Leffler MG. Reliability and construct validity of the Duchenne Video Assessment. Muscle Nerve. 2021;64(2):180–9.

Garuti G, Bagatti S, Verucchi E, Massobrio M, Spagnolatti L, Vezzani G, et al. Pulmonary rehabilitation at home guided by telemonitoring and access to healthcare facilities for respiratory complications in patients with neuromuscular disease. Eur J Phys Rehabil Med. 2013;49(1):51–7. Available from: https://pubmed.ncbi.nlm.nih.gov/22820817/ .

CAS   PubMed   Google Scholar  

Helleman J, van Eenennaam R, Kruitwagen ET, Kruithof WJ, Slappendel MJ, van den Berg LH, et al. Telehealth as part of specialized ALS care: feasibility and user experiences with “ALS home-monitoring and coaching.” Amyotroph Lateral Scler Frontotemporal Degener. 2020;21(3–4):183–92.

Kamei T, Yamamoto Y, Kanamori T, Nakayama Y, Porter SE. Detection of early-stage changes in people with chronic diseases: A telehome monitoring-based telenursing feasibility study. Nurs Health Sci. 2018;20(3):313–22.

Levi BH, Simmons Z, Hanna C, Brothers A, Lehman E, Farace E, et al. Advance care planning for patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener. 2017;18(5–6):388–96.

Longinetti E, Regodón Wallin A, Samuelsson K, Press R, Zachau A, Ronnevi L-O, et al. The Swedish motor neuron disease quality registry. Amyotroph Lateral Scler Frontotemporal Degener. 2018;19(7–8):528–37.

de Marchi F, Sarnelli MF, Serioli M, de Marchi I, Zani E, Bottone N, et al. Telehealth approach for amyotrophic lateral sclerosis patients: the experience during COVID-19 pandemic. Acta Neurol Scand. 2021;143(5):489–96.

McErlane F, Davies EH, Ollivier C, Mayhew A, Anyanwu O, Harbottle V, et al. Wearable technologies for children with chronic illnesses: an exploratory approach. Ther Innov Regul Sci. 2021;55(4):799–806.

Naveen R, Sundaram TG, Agarwal V, Gupta L. Teleconsultation experience with the idiopathic inflammatory myopathies: a prospective observational cohort study during the COVID-19 pandemic. Rheumatol Int. 2020;41(1):67–76.

Newton J, Jayaprakash K, Glasmacher SA, McEleney A, Bethell A, Fraser E, et al. Excellent reliability of the ALSFRS-R administered via videoconferencing: a study of people with motor neuron disease in Scotland. J Neurol Sci. 2020;416:116991.

Paganoni S, van de Rijn M, Drake K, Burke K, Doyle M, Ellrodt AS, et al. Adjusted cost analysis of video televisits for the care of people with amyotrophic lateral sclerosis. Muscle Nerve. 2019;60(2):147–54.

Roman A, Baylor C, Johnson L, Barton M. Expanding Availability of Speech-Generating Device Evaluation and Treatment to People With Amyotrophic Lateral Sclerosis (pALS) Through Telepractice: Perspectives of pALS and Communication Partners. Am J Speech Lang Pathol. 2021;30(5):2098–114.

Selkirk SM, Washington MO, McClellan F, Flynn B, Seton JM, Strozewski R. Delivering tertiary centre specialty care to ALS patients via telemedicine: a retrospective cohort analysis. Amyotroph Lateral Scler Frontotemporal Degener. 2017;18(5–6):324–32.

van Eijk RPA, Bakers JNE, Bunte TM, de Fockert AJ, Eijkemans MJC, van den Berg LH. Accelerometry for remote monitoring of physical activity in amyotrophic lateral sclerosis: a longitudinal cohort study. J Neurol. 2019;266(10):2387–95.

Vitacca M, Comini L, Assoni G, Fiorenza D, Gilè S, Bernocchi P, et al. Tele-assistance in patients with amyotrophic lateral sclerosis: long term activity and costs. Disabil Rehabil Assist Technol. 2012;7(6):494–500.

Alexanderson H, Munters LA, Dastmalchi M, Loell I, Heimbürger M, Opava CH, et al. Resistive home exercise in patients with recent-onset polymyositis and dermatomyositis—a randomized controlled single-blinded study with a 2-year followup. J Rheumatol. 2014;41(6):1124–32.

Astley C, Sieczkowska SM, Marques IG, Ihara BP, Lindoso L, Lavorato SSM, et al. Home-based exercise program for adolescents with juvenile dermatomyositis quarantined during COVID-19 pandemic: a mixed methods study. Pediatr Rheumatol Online J. 2021;19(1):159.

Bankolé L-C, Millet GY, Temesi J, Bachasson D, Ravelojaona M, Wuyam B, et al. Safety and efficacy of a 6-month home-based exercise program in patients with facioscapulohumeral muscular dystrophy: A randomized controlled trial. Medicine (Baltimore). 2016;95(31): e4497.

Christodoulou G, Gennings C, Hupf J, Factor-Litvak P, Murphy J, Goetz RR, et al. Telephone based cognitive-behavioral screening for frontotemporal changes in patients with amyotrophic lateral sclerosis (ALS). Amyotroph Lateral Scler Frontotemporal Degener. 2016;17(7–8):482–8.

Wills AM, Garry J, Hubbard J, Mezoian T, Breen CT, Ortiz-Miller C et al. Nutritional counseling with or without mobile health technology: a randomized open-label standard-of-care-controlled trial in ALS. BMC Neurol 2019; 19.

de Wit J, Beelen A, Drossaert CHC, Kolijn R, van den Berg LH, SchrÖder CD, et al. Blended psychosocial support for partners of patients with ALS and PMA: results of a randomized controlled trial. Amyotroph Lateral Scler Frontotemporal Degener. 2020;21(5–6):344–54.

Palumbo A, Ielpo N, Calabrese B, Corchiola D, Garropoli R, Gramigna V et al. SIMpLE: A mobile cloud-based system for health monitoring of people with ALS. Sensors (Basel) 2021; 21(21).

Ricci G, Baldanzi S, Seidita F, Proietti C, Carlini F, Peviani S, et al. A mobile app for patients with Pompe disease and its possible clinical applications. Neuromusc Disord: NMD. 2018;28(6):471–5.

Scalvini S, Bernocchi P, Zanelli E, Comini L, Vitacca M. Maugeri centre for telehealth and telecare: a real-life integrated experience in chronic patients. J Telemed Telecare. 2018;24(7):500–7.

El-Hassar L, Amara A, Sanson B, Lacatus O, Amir Belhouchet A, Kroneman M, et al. Telemedicine in neuromuscular diseases during covid-19 pandemic: ERN-NMD European survey. J Neuromuscul Dis. 2022;Preprint(Preprint):1–12.

Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020;20(1):1193.

Bombaci A, Abbadessa G, Trojsi F, Leocani L, Bonavita S, Lavorgna L. Telemedicine for management of patients with amyotrophic lateral sclerosis through COVID-19 tail. Neurol Sci. 2021;42(1):9–13.

Giannotta M, Petrelli C, Pini A. Telemedicine applied to neuromuscular disorders: focus on the COVID-19 pandemic era. Acta myologica: myopathies and cardiomyopathies. 2022;41(1):30–6. Available from: https://pubmed.ncbi.nlm.nih.gov/35465343/ .

Hatcher-Martin JM, Busis NA, Cohen BH, Wolf RA, Jones EC, Anderson ER, et al. American academy of neurology telehealth position statement. Neurology. 2021;97(7):334–9. Available from: https://n.neurology.org/content/97/7/334 .

Kruse CS, Williams K, Bohls J, Shamsi W. Telemedicine and health policy: a systematic review. Health Policy Technol. 2021;10(1):209–29.

Phuong J, Ordóñez P, Cao J, Moukheiber M, Moukheiber L, Caspi A, et al. Telehealth and digital health innovations: a mixed landscape of access. PLOS Digit Health. 2023;2(12):e0000401.

Beswick E, Fawcett T, Hassan Z, et al. A systematic review of digital technology to evaluate motor function and disease progression in motor neuron disease. J Neurol. 2022;269:6254–68.

Serrano LP, Maita KC, Avila FR, Torres-Guzman RA, Garcia JP, Eldaly AS, Haider CR, Felton CL, Paulson MR, Maniaci MJ, Forte AJ. Benefits and challenges of remote patient monitoring as perceived by health care practitioners: a systematic review. Permanente J. 2023;27(4):100.

Lacaze P, Millis N, Fookes M, Zurynski Y, Jaffe A, Bellgard M, Winship I, McNeil J, Bittles AH. Rare disease registries: a call to action. Intern Med J. 2017;47(9):1075–9.

Kölker S, Gleich F, Mütze U, Opladen T. Rare disease registries are key to evidence-based personalized medicine: highlighting the European experience. Front Endocrinol. 2022;4(13):832063.

Peters DH, Adam T, Alonge O, Akua Agyepong I, Tran N. Implementation research: what it is and how to do it. BMJ 2013;347. Available from: https://www.bmj.com/content/347/bmj.f6753.full

Download references

Acknowledgements

Not applicable.

The authors did not receive any funding for this paper.

Author information

Authors and affiliations.

Chair of Healthcare Management and Health Services Research, University of Bayreuth, Bayreuth, Germany

Deniz Senyel, Katja Senn & Klaus Nagels

Chair of Digital Health and Innovation, Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, Australia

Deniz Senyel & James Boyd

You can also search for this author in PubMed   Google Scholar

Contributions

DS and KS prepared the study protocol as well as performed the literature search and study selection. DS conducted the data extraction and analysis. The report was written by DS with contributions by KS. JB and KN supervised the complete process. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Deniz Senyel .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1., supplementary material 2., supplementary material 3., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Senyel, D., Senn, K., Boyd, J. et al. A systematic review of telemedicine for neuromuscular diseases: components and determinants of practice. BMC Digit Health 2 , 17 (2024). https://doi.org/10.1186/s44247-024-00078-9

Download citation

Received : 05 June 2023

Accepted : 22 February 2024

Published : 09 May 2024

DOI : https://doi.org/10.1186/s44247-024-00078-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Telemedicine
• Neuromuscular diseases
• Digitalization

BMC Digital Health

ISSN: 2731-684X

• Submission enquiries: [email protected]
• General enquiries: [email protected]

How Daily Stress Affects your Heart Health

This essay about the impact of stress on heart health explores how chronic stress triggers hormonal changes that adversely affect cardiovascular function. It highlights the direct consequences of prolonged stress, such as increased blood pressure and atherosclerosis, which elevate the risk of heart disease. Additionally, the essay discusses how stress influences lifestyle choices that can further harm heart health, like poor diet, smoking, and lack of exercise. It also touches on the role of chronic inflammation under stress, which contributes to the deterioration of arterial health. Solutions for managing stress, such as regular exercise, mindfulness practices, and maintaining strong social connections, are outlined as effective strategies to mitigate these risks. Overall, the essay emphasizes the importance of managing stress to protect heart health, suggesting practical ways to alleviate stress and its harmful impacts on the cardiovascular system.

How it works

It’s no secret that the fast pace of modern life often brings a fair share of stress. Whether it’s the hustle of meeting tight deadlines, managing household responsibilities, or navigating complex social relationships, stress seems to shadow much of our daily routines. What might not be so apparent, however, is the profound impact this stress can have on our heart health.

When we’re stressed, our body reacts by releasing hormones like adrenaline and cortisol. These hormones kick-start the body’s ‘fight or flight’ response, gearing us up for immediate action.

This natural survival mechanism can be lifesaving in acute situations, but when triggered too often—thanks to chronic stress—it can wear down our body, particularly our cardiovascular system.

Chronic stress leads to continuous high levels of cortisol and adrenaline, which are tough on the heart and arteries. Consistently high blood pressure from prolonged stress can damage the arterial walls, which may lead to heart disease. As these walls thicken and harden, conditions like atherosclerosis decrease arterial flexibility, dramatically increasing the risk of heart attacks and strokes.

Stress doesn’t just wreak havoc on our bodies directly. It also influences our lifestyle choices. For many, stress is a gateway to picking up or continuing unhealthy habits—smoking, reaching for a drink, or indulging in junk food. While these may offer temporary relief, they come with a host of health issues, including weight gain, higher cholesterol levels, and increased blood sugar levels, all of which stress the heart even more.

Furthermore, chronic stress affects the way our body handles inflammation, a leading player in heart disease. Under stress, inflammatory responses can go into overdrive, accelerating the buildup of plaque in our arteries. Moreover, the constant rush of stress hormones can make the heart pump faster and harder, which over time can change the heart muscle itself.

Thankfully, there are effective ways to mitigate the impact of stress on our heart. Exercise, for example, is a fantastic stress reliever. It not only helps control weight and reduce blood pressure but also triggers the release of endorphins, chemicals in the brain that act as mood lifters and painkillers.

Mindfulness practices like yoga, meditation, and deep-breathing exercises can also help calm the mind and reduce stress. These activities help shift the body from stress responses to relaxation responses, lowering heart rate and blood pressure, and promoting overall heart health.

Social connections also play a crucial role in stress management. A robust social network can offer emotional support, reduce loneliness, and help manage stress more effectively. Keeping in touch with friends and family, participating in community activities, or even getting professional counseling can provide the support needed to manage stress.

To wrap it up, while stress is a natural part of life, managing it effectively is key to maintaining a healthy heart. By understanding how stress affects heart health and adopting strategies to cope, we can protect ourselves from the serious risks associated with heart disease. Taking active steps to reduce stress is not merely about feeling better—it’s about fostering a healthier, stronger heart.

Cite this page

How Daily Stress Affects Your Heart Health. (2024, May 12). Retrieved from https://papersowl.com/examples/how-daily-stress-affects-your-heart-health/

"How Daily Stress Affects Your Heart Health." PapersOwl.com , 12 May 2024, https://papersowl.com/examples/how-daily-stress-affects-your-heart-health/

PapersOwl.com. (2024). How Daily Stress Affects Your Heart Health . [Online]. Available at: https://papersowl.com/examples/how-daily-stress-affects-your-heart-health/ [Accessed: 16 May. 2024]

"How Daily Stress Affects Your Heart Health." PapersOwl.com, May 12, 2024. Accessed May 16, 2024. https://papersowl.com/examples/how-daily-stress-affects-your-heart-health/

"How Daily Stress Affects Your Heart Health," PapersOwl.com , 12-May-2024. [Online]. Available: https://papersowl.com/examples/how-daily-stress-affects-your-heart-health/. [Accessed: 16-May-2024]

PapersOwl.com. (2024). How Daily Stress Affects Your Heart Health . [Online]. Available at: https://papersowl.com/examples/how-daily-stress-affects-your-heart-health/ [Accessed: 16-May-2024]

Don't let plagiarism ruin your grade

Hire a writer to get a unique paper crafted to your needs.

Our writers will help you fix any mistakes and get an A+!

Please check your inbox.

You can order an original essay written according to your instructions.

Trusted by over 1 million students worldwide

1. Tell Us Your Requirements

2. Pick your perfect writer

3. Get Your Paper and Pay

Hi! I'm Amy, your personal assistant!

Don't know where to start? Give me your paper requirements and I connect you to an academic expert.

short deadlines

100% Plagiarism-Free

Certified writers

Purdue Online Writing Lab Purdue OWL® College of Liberal Arts

Welcome to the Purdue Online Writing Lab

Welcome to the Purdue OWL

This page is brought to you by the OWL at Purdue University. When printing this page, you must include the entire legal notice.

Copyright ©1995-2018 by The Writing Lab & The OWL at Purdue and Purdue University. All rights reserved. This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission. Use of this site constitutes acceptance of our terms and conditions of fair use.

The Online Writing Lab at Purdue University houses writing resources and instructional material, and we provide these as a free service of the Writing Lab at Purdue. Students, members of the community, and users worldwide will find information to assist with many writing projects. Teachers and trainers may use this material for in-class and out-of-class instruction.

The Purdue On-Campus Writing Lab and Purdue Online Writing Lab assist clients in their development as writers—no matter what their skill level—with on-campus consultations, online participation, and community engagement. The Purdue Writing Lab serves the Purdue, West Lafayette, campus and coordinates with local literacy initiatives. The Purdue OWL offers global support through online reference materials and services.

A Message From the Assistant Director of Content Development 

The Purdue OWL® is committed to supporting  students, instructors, and writers by offering a wide range of resources that are developed and revised with them in mind. To do this, the OWL team is always exploring possibilties for a better design, allowing accessibility and user experience to guide our process. As the OWL undergoes some changes, we welcome your feedback and suggestions by email at any time.

Please don't hesitate to contact us via our contact page  if you have any questions or comments.

All the best,

Social Media

Facebook twitter.