Practical logics: the shapes and lessons of popular medical knowledge and practice--examples from Vietnam and Indigenous Australia

Popular medical knowledge and practice exist in forms that people are able to remember, and that they use to manage their daily lives. This knowledge is fundamentally practical and relates to the patterns of everyday life and the rhythms of the body. The broad "polythetic" concepts of this knowledge system are typically drawn from both dominant and other medical knowledges, and combined in pragmatic, mnemonic ways that constitute a hybrid system. Such popular medical knowledge is attuned to local, family and cultural patterns of medical and other authority, and to the personal dispositions and environmental contexts of its users. Health promoters and educators who understand these formal, embodied and familiar dimensions of popular knowledge can potentially mimic this knowledge system, making their interventions a sustainable part of everyday family life.     

Communicatively Making Sense of Doulas within the U.S. Master Birth Narrative: Doulas as Liminal Characters

Doulas—or designated women experienced in childbirth who provide support to a birthing mother—have been shown to improve mothers’ medical outcomes, but they are relatively underused in U.S. births. We assert that doulas are rarely used, in part, because it is difficult to situate them within the contemporary U.S. master birth narrative that places family and medical staff as expected characters in the birth story. This qualitative study uses narrative theorizing to describe the communicatively situated position of doulas in light of the dominant U.S. master birth narrative. Through an analysis of interviews and focus groups with mothers, expectant parents, doulas, and medical staff (n = 52) at a community hospital, we explain how individuals communicatively located the doula as a character who occupied a liminal space that is (a) between borders, (b) crossing borders, and (c) outside borders. Although doulas’ liminal location enables individuals to creatively explain and promote doulas to important publics, doulas’ conceptual ambiguity in the birth narrative can also be constraining. We conclude with theoretical and practical implications.     

Patients‐in‐waiting or chronically healthy individuals? People with elevated cholesterol talk about risk

Risk adopts an ambiguous position between health and illness/disease and is culturally salient in various health‐related everyday practices. Previous research on risk experience has mostly focused on the illness/disease side of this risk ambiguity. Persons at risk have typically been defined as patients (of some kind) and their condition as a form of proto‐illness. To allow for the cultural proliferation of health risk and to account for the health side of risk ambiguity, I chose to focus on elevated cholesterol, a condition both intensely medicalised and connected to the everyday practice of eating, among participants (n = 14) recruited from a consumer panel and approached not as patients, but as individuals concerned about their cholesterol. Utilising the biographical disruption framework developed by Bury, I show how the risk experience of my participants differed from the chronic illness experience. Instead of patients‐in‐waiting suffering from a proto‐illness, they presented themselves as ‘chronically healthy individuals’ (Varul 2010), actively trying to avoid becoming patients through a responsible regimen of personal health care. The results call for a more nuanced approach to the risk experience, which accounts for both sides of the risk ambiguity.     

Doing everyday life—experiences of the oldest old

The purpose of this article is to explore how a group of elderly people, living and managing on their own, describe and experience their everyday doings. Interviews and observations were conducted with 18 community-living people aged 85 and above. The experiences of ‘Doing everyday life’ are described in five overarching themes: ‘Experiencing being old’, ‘Doings in everyday life’, ‘Patterns of the day’, ‘Altered doings’, and ‘The importance of time’. What is done during an ordinary day does not differ much from earlier in life, but how the doings are performed has changed. Being occupied and staying healthy and sound in mind was stressed as important in old age and even if reduced energy and functional constraints limited the doings, a strong volition to manage independently was expressed. The participants perceived society as regarding the elderly as useless and worthless. Knowledge emanating from the very old themselves is vital to diversify the image of elderly people and to offer interventions and support adapted to their needs and desires.     

How children and young people construct and negotiate living with medical technology

Increasing numbers of children need the support of medical technology for their survival and wellbeing, yet little is known about their experiences of living technology-assisted lives. This study aimed to explore how this group of children experience and construct medical technology and its influence on their identity and social relationships. Using a Grounded Theory approach, 28 children/young people aged between 8 and 19 years old and using different types of medical devices were recruited via nursing services in England. Data were collected by in-depth interviews conducted in children's homes. The medical technology occupied an ambivalent position in children's lives being seen as having both an enabling and disabling presence. Children actively engaged in work to incorporate the technology into their lives and bodies by developing strategies to manage their condition, the technology and their identities. This body work appeared to be driven by a desire to 'normalise' their bodies and their lives. Technologies were shaped to integrate them into everyday life and children managed their self-presentation and controlled information about their condition. This work was ongoing, responding to changing social contexts and relationships. For these children the process of 'growing up' involves incorporating disability, illness and technology. This study contributes to knowledge by examining how medical technology is constructed by children whose lives are dependent on it and illuminating the resources and strategies they use to manage their identity and negotiate peer culture interactions and norms.     

Researching illness and injury: methodological considerations

Circumstances surrounding the physical condition of the critically ill, the injured, and the dying make the conduct of qualitative research particularly difficult. Assumptions embedded in qualitative research are challenged or no longer apply: As sick people, participants are unfamiliar with their everyday worlds, and they are often incapable of describing their conditions and perceptions, so that researchers have difficulty obtaining data to comprehend, interpret, and generally conduct their research. Methodological problems extending from the participants' condition include the lack of everyday language to describe their experiences, the instability of the participants' reality, and the instability of the self. When researching participants who are sick, these methodological problems result in decisions about the timing of data collection, challenges to validity and reliability, and debates about who should be conducting this research.     

Doing everyday life--experiences of the oldest old

The purpose of this article is to explore how a group of elderly people, living and managing on their own, describe and experience their everyday doings. Interviews and observations were conducted with 18 community-living people aged 85 and above. The experiences of 'Doing everyday life' are described in five overarching themes: 'Experiencing being old', 'Doings in everyday life', 'Patterns of the day', 'Altered doings', and 'The importance of time'. What is done during an ordinary day does not differ much from earlier in life, but how the doings are performed has changed. Being occupied and staying healthy and sound in mind was stressed as important in old age and even if reduced energy and functional constraints limited the doings, a strong volition to manage independently was expressed. The participants perceived society as regarding the elderly as useless and worthless. Knowledge emanating from the very old themselves is vital to diversify the image of elderly people and to offer interventions and support adapted to their needs and desires.     

The meaning of medications: another look at compliance

Most research on compliance with medical regimens takes a doctor-centered perspective and proceeds from certain assumptions. This paper presents an alternative, patient-centered approach to managing medications, using data from 80 in-depth interviews of people with epilepsy. This approach focuses on the meanings of medication in people's everyday lives and looks at why people take their medications as well as why they do not. I argue that from a patient's perspective the issue is more one of self-regulation than compliance. When we examine 'noncompliance' beyond difficulties with 'side effects' and drug efficacy, the meanings of self-regulation include testing, controlling dependence, destigmatization and creating a practical practice. What appears to be noncompliance from a medical perspective may actually be a form of asserting control over one's disorder.     

Effecting change through dialogue: Habermas’ theory of communicative action as a tool in medical lifestyle interventions

Adjustments of everyday life in order to prevent disease or treat illness afflict partly unconscious preferences and cultural expectations that are often difficult to change. How should one, in medical contexts, talk with patients about everyday life in ways that might penetrate this blurred complexity, and help people find goals and make decisions that are both compatible with a good life and possible to accomplish? In this article we pursue the question by discussing how Habermas’ theory of communicative action can be implemented in decision-making processes in general practice. The theory of deliberative decision-making offers practical guidelines for what to talk about and how to do it. For a decision to be rooted in patients’ everyday life it has to take into consideration the patient’s practical circumstances, emotions and preferences, and what he or she perceives as ethically right behaviour towards other people. The aim is a balanced conversation, demonstrating respect, consistency and sincerity, as well as offering information and clarifying reasons. Verbalising reasons for one’s preferences may increase awareness of values and norms, which can then be reflected upon, producing decisions rooted in what the patient perceives as good and right behaviour. The asymmetry of medical encounters is both a resource and a challenge, demanding patient-centred medical leadership, characterised by empathy and ability to take the patient’s perspective. The implementation and adjustments of Habermas’ theory in general practice is illustrated by a case story. Finally, applications of the theory are discussed.     

Repositioning the patient: the implications of being 'at risk'

In the modern era of biomedical practice, genetic knowledge has redefined the idea of 'the patient' to include those who are 'at risk' of disease alongside those who are already sick. For such individuals, it is risk itself that constitutes the raison d'être of medical intervention. Using data from interviews with 58 users of a UK cancer genetics service together with data derived from clinical consultations, we consider the way such patients or clients make sense of a cancer genetic risk estimate and how they integrate genetic risk information into their lifeworld. In particular, we note that patient-clients who are 'at risk' tend to see themselves in a liminal position betwixt the healthy and the sick, and that such individuals consequently seek recourse to systems of medical surveillance that can continuously monitor their state of health. Our analysis also revealed the fact that many of those deemed by professionals to be at low risk of inheriting cancer-related mutations subsequently strove to be re-categorised as being at moderate or high risk of an adverse outcome. A number of explanations concerning lay health beliefs, lay 'representations' of health and the nature of the patient-client's lifeworld are examined and assessed in order to account for this apparent paradox.     

Liminality and breastfeeding: women negotiating space and two bodies

It is almost universally accepted that breastfeeding infants is nutritionally superior to bottle-feeding. However, despite this medical advice, in many countries breastfeeding rates remain low and in the UK, rates are relatively static. The literature on breastfeeding has discussed international rates and the broad socio-economic factors influencing these rates. Through an observational study of a group of breastfeeding and non-breastfeeding women in the United Kingdom, this research utilises contemporary theoretical perspectives on the body, space and rites of passage, and investigates the reasons why some breastfeeding mothers may be in a liminal period, and the breastfeeding event itself, at times, a liminal and marginalised act. The paper argues that, for the group studied, breastfeeding is sometimes discouraged by its medicalisation, and that breastmilk and breastfeeding are often considered by mothers to be embarrassing. Many of the women studied regarded certain public and private places to be unacceptable places to breastfeed and claimed to modify their behaviour accordingly. The paper demonstrates the value of conducting locally based qualitative research into breastfeeding experiences, and of using theoretical perspectives from post-medical geography to interpret women's experiences.     

'Filling one's days': managing sick leave legitimacy in an online forum

An inherent part of the general understanding of illness is that it is incapacitating, making those who are ill unable to do things that they would normally do. Staying at home from work is a common consequence, and what `ill' people do while at home then becomes accountable. This article explores online discourse about the kinds of activities people engage in when on sick leave. It employs a discursive psychological framework for analysis, drawing heavily on conversation analysis. A Swedish internet forum thread on sick leave is examined, focusing on how the participants describe and account for the things they do when staying home from work due to illness. The analysis suggests that the participants' accounts of their activities delicately manage the legitimacy of their sick leave. In examining how this is done in practice, the analysis makes visible the balancing act between being ill enough to stay home from work and well enough for other activities. In the context of recent debates in Sweden and elsewhere about the legitimacy of sick leave in different situations, the analysis of how legitimacy is actually negotiated is an important concern, making visible the moral work of being on sick leave.     

A new life with aphasia: everyday activities and social support

People who develop aphasia must adjust their lifestyles and learn to cope with the activity limitations that may follow from their disability. The purpose of this study was to describe aphasic individuals' experiences of everyday activities and social support in daily life. Interviews were conducted with 20 people with aphasia, and analysed with qualitative content analysis. The results show that everyday activities changed considerably with the onset of aphasia, and the participants were hindered from participating in activities by communication problems or physical disabilities. Aphasia led to the loss of friends and colleagues, and the interviewees often felt lonely. They generally received a lot of social support from close relatives, but support from the healthcare system was lacking. They need different kinds of social support to help them manage their aphasia and everyday activities and to improve their participation in society. Further studies are needed to improve our knowledge of everyday activity and social support for people with aphasia, and what it means to live with aphasia.     

The meaning of complementary and alternative medicine practices among people with HIV in the United States: strategies for managing everyday life

The meanings of complementary and alternative medicine (CAM) practices in the everyday lives of people with HIV in the United States were investigated. Interviews of people with HIV revealed that two out of three interviewees (N = 62) used some form of CAM over the course of their ongoing HIV infection. Management of their everyday lives as ill persons was improved to the extent that CAM meanings addressed self-regulation of treatment practices and strategies to cope with uncertainty. Four main strategies are dealt with: managing symptoms, medications and emotions; self experimenting to evaluate disease progression; gaining freedom from medical regimens; and managing AIDS stigma. It was shown that CAM practices are one way people with HIV can increase control over their illness and attempt to normalise health status. CAM practices were discussed in the context of self-regulation in relation to other illnesses.     

The moral orders of work and health: a case of sick leave due to burnout

Being on sick leave due to burnout entails a high level of accountability. Persons suffering from burnout do not automatically play a legitimate sick role because of the fuzziness of the burnout concept. In addition, while being on sick leave, they are in a non‐working position, which is against the ideals of work‐centred society. Therefore, they are required to explain their ‘deviant’ situation. Drawing on the interview data, the article explores how sick leave is explained and justified in narrative accounts by Finnish burnout sufferers. Results show that sick leave makes the moral orders of work, health and illness visible. Sick leave as a process involves negotiation of one's status and worth in the categories of ‘respectable employee’ and ‘credible patient’. A transition to sick leave requires causal explanations of burnout, which aim to legitimate ill‐being. Being on sick leave creates an obligation for activity and productivity that is ‘work‐like’ management of health. The study shows the fundamental level at which work structures everyday life, routines, and habits in the work‐centred society. In this context, burnout sufferers struggle to legitimise their work‐related distress and absence from work and restore their morally worthy identities.     

'I deal with the small things': The doctor-patient relationship and professional identity in GPs' stories of cancer care

An important part of GPs' work consists of attending to the everyday and existential conditions of human being. In these life world aspects, biomedicine is often not the relevant theory to guide the GP; nevertheless they are a part of GPs' professional domain. In cancer care, previous studies have shown that GPs with a biomedical perspective on medicine could feel subordinate to specialists, and that doctors with a curative focus could see disease progression as a personal failure. The aim of this study was to explore in depth the experiences of being a GP for people with advanced cancer. Fourteen Norwegian GPs were interviewed about accompanying patients through a cancer illness. Their stories were analysed using a narrative approach. The GPs expressed a strong commitment to these patients, a loyalty which in some cases could be weakened due to judgements of distant specialists. In view of the GPs' close knowledge of their patients' background and history this subordination was a paradox, mirroring a hierarchy of medical knowledge. The GPs had an ideal of honesty and openness about death, which they sometimes failed. To reach the ideal of honesty, clinicians would have to abandon the biomedical ideal of mastering human nature through interventions and acknowledge the fundamental uncertainty and finiteness of human life. GPs may learn from being with their patients that bodily and existential suffering are connected, and thus learn implicitly to overlook the body-mind dualism. This practical wisdom lacks a theoretical anchoring, which is a problem not only for general practice.     

Arts and health as a practice of liminality: Managing the spaces of transformation for social and emotional wellbeing with primary school children

Intervention to enhance wellbeing through participation in the creative arts has a transformative potential, but the spatialities to this are poorly theorised. The paper examines arts-based interventions in two primary schools in which small groups of children are taken out of their everyday classrooms to participate in weekly sessions. The paper argues that such intervention is usefully seen as a practice of liminality, a distinct time and space that needs careful management to realise a transformative potential. Such management involves negotiating multiple sources of tension to balance different modes of power, forms of art practices and permeability of the liminal time-space.     

Liminal space and the negotiation of care work in extra-care housing

This is a qualitative case study of care work in a liminal space, specifically the case of an extra-care housing residence, which is an innovative housing alternative for elderly people in need of care in Sweden. The study is an exploration of social care workers' perceptions about their workplaces and their understandings of themselves, which are shaped by their embeddedness in architectural space. The extra-care housing residence appeared as a liminal space in which two dominant spaces – home care services and residential care – underpinned the staff's perceptions of an unclear workplace and their identity work.     

Negotiating Occupational Identities while Living with Chronic Rheumatic Disease

The purpose of this study was to explore everyday occupation for five persons living with chronic rheumatic disease. Data were collected through qualitative interviews, followed by participant observations in the subjects’ homes. The data were analysed using a qualitative comparative approach, followed by an interpretation of the results based on narrative theory. Four themes were identified from the analyses: (a) the continuing challenges of everyday occupational life, (b) activities anchored to personal occupational history, (c) everyday occupations mediating personal meaning, and (d) activities involving suspense or unpredictability. The results showed that everyday occupation was a challenge for the participants, as their illness caused considerable variation in pain and functional abilities. This influenced the subjects’ ability to perform occupations of everyday life. Their individual occupational history was closely interwoven with their everyday life and served as the foundation for their way of managing the situation. The everyday occupations of the subjects also served as mediators of their personal values and interests, and they made changes following these issues, not as anticipated due to their changing functional condition. The narrative structure of occupation was found to provide the subjects with opportunities to manage issues concerning their identity and created high-level negotiating skills. Processes of negotiating occupational identities in the subjects’ everyday life are presented and discussed, and may add new knowledge to occupational therapy and occupational science, as well as generating further research questions.     

Reconciling incompatibilities: a grounded theory of HIV medication adherence and symptom management

The purpose of this grounded theory study was to explain how ethnically diverse men and women living with HIV manage their interacting illness symptoms, medication side effects, and treatment adherence choices. The authors used the constant comparative method to analyze textual data from in-depth interviews with 66 HIV-infected people representing the changing HIV demographic profile in the San Francisco Bay area and generate a theory of Reconciling Incompatibilities. Adherence options of complying, not complying, or self-tailoring occurred in a context of attributional uncertainty as to whether distress was illness- or treatment-related, a sometimes silent virus, and perceived fickle medical markers. Conditions, including self-identity, illness ideology, concurrent treatment regimens, the meaning of time, medication burden and side effects, and lifestyle, coalesced to produce a state of mind that shaped adherence choices on a dose-by-dose basis. This theory offers a basis for interventions designed to promote optimal adherence choices concerning HIV therapies.