Advancing the communication of genetic risk for cardiometabolic diseases: a critical interpretive synthesis.

BACKGROUND: Genetics play an important role in risk for cardiometabolic diseases-including type 2 diabetes, cardiovascular disease and obesity. Existing research has explored the clinical utility of genetic risk tools such as polygenic risk scores-and whether interventions communicating genetic risk information using these tools can impact on individuals' cognitive appraisals of disease risk and/or preventative health behaviours. Previous systematic reviews suggest mixed results. To expand current understanding and address knowledge gaps, we undertook an interpretive, reflexive method of evidence synthesis-questioning the theoretical basis behind current interventions that communicate genetic risk information and exploring how the effects of genetic risk tools can be fully harnessed for cardiometabolic diseases. METHODS: We obtained 189 records from a combination of database, website and grey literature searches-supplemented with reference chaining and expert subject knowledge within the review team. Using pre-defined critical interpretive synthesis methods, quantitative and qualitative evidence was synthesised and critiqued alongside theoretical understanding from surrounding fields of behavioural and social sciences. FINDINGS: Existing interventions communicating genetic risk information focus predominantly on the "self", targeting individual-level cognitive appraisals, such as perceived risk and perceived behavioural control. This approach risks neglecting the role of contextual factors and upstream determinants that can reinforce individuals' interpretations of risk. It also assumes target populations to embody an "ascetic subject of compliance"-the idea of a patient who strives to comply diligently with professional medical advice, logically and rationally adopting any recommended lifestyle changes. We developed a synthesising argument-"beyond the ascetic subject of compliance"-grounded in three major limitations of this perspective: (1) difficulty applying existing theories/models to diverse populations, (2) the role of familial variables and (3) the need for a life course perspective. CONCLUSIONS: Interventions communicating genetic risk information should account for wider influences that can affect individuals' responses to risk at different levels-including through interactions with their family systems, socio-cultural environments and wider health provision. PROTOCOL REGISTRATION: PROSPERO CRD42021289269.

Living with polypharmacy: a narrative interview study with older Pakistanis in East London.

BACKGROUND: Polypharmacy is a growing and major public health issue. It can be burdensome and risky for patients and costly to healthcare systems. Older adults and those from ethnic minority backgrounds are disproportionately affected by polypharmacy. This study focuses on medication practices among Urdu-speaking Pakistani patients, a significant ethnic group in the UK. Most existing research on medication practices within South-Asian communities centres on adherence, leaving the social and moral dimensions of polypharmacy unpacked. Understanding how British Pakistani patients understand and manage polypharmacy in the context of their daily lives is crucial to avoiding harmful polypharmacy. METHODS: In-depth narrative interviews were conducted with 15 first-generation Pakistani patients using the Biographical Narrative Interview Method. Participants were recruited from GP practices in East London. All participants were prescribed ten or more regular medications (a pragmatic marker of 'higher risk' polypharmacy) and were aged over 50. Interviews were conducted with a bilingual researcher at home and were designed to elicit narratives of patients' experiences of polypharmacy in the context of their biographies and daily lives. RESULTS: Polypharmacy is enacted through networks of interpersonal and socio-material relationships. The doctor-patient relationship and the family network held particular significance to study participants. In addition, participants described emotional bonds between themselves and their medicines, identifying them as 'forces for good'-substances which allowed them to maintain their health through the intercession of God. Meanings attributed to medicines and enacted through these social, emotional, and spiritual relationships contributed to emerging and sustaining polypharmacy. CONCLUSIONS: Patients make sense of and manage treatments in culturally specific ways. Developing an understanding of how medication practices in different communities are enacted is important for informing meaningful and effective conversations with patients about their medicines. Our findings contribute to enabling the integration of culturally sensitive approaches to prescribing.

Self-Management in Older Pakistanis Living With Multimorbidity in East London.

In this article, we explore how older British Pakistani people experience multimorbidity (defined as the coexistence of two or more medical conditions) and engage with self-management within the context of their life histories and relationships. We conducted biographical narrative interviews in Urdu and/or English with 15 first-generation Pakistani migrants living with multimorbidity, at their homes in East London. Our analysis showed that the triadic construct of family, faith, and health was central to how participants made sense of their lives, constituting notions of "managing" in the context of multimorbidity. For Pakistani patients, the lived experience of health was inseparable from a situated context of family and faith. Our findings have implications for existing public health strategies of self-management, underpinned by neoliberal discourses that focus on individual responsibility and agency. Health care provision needs to better integrate the importance of relationships between family, faith, and health when developing services for these patients.

Diet in pregnancy, 1930-1960: a shifting social, political and scientific concern.

The diet of expectant mothers was a significant issue of social, political and scientific concern between 1930 and 1960. However, while histories of maternity services and nutritional science are independently available, no existing study addresses the nutrition of expectant mothers in this period. Between 1900 and 1930, maternal mortality rates were rising despite improving clinical antenatal provisions. Breakthroughs in nutritional science resulted in the identification of key dietary components, while changing social attitudes meant hunger was increasingly being seen as a humanitarian issue requiring a modern solution. As a result, the diet of expectant mothers first began to be addressed as a social concern in the 1930s. It subsequently made a transition into official policy as part of wartime rationing. The government entirely changed its attitude to maternal nutrition in a beneficial and successful way during the war; conferring to modern historians another example of war being a generator of change. Diet in pregnancy finally became the concern of the scientific community post-war, as illustrated by the work of the Royal College of Obstetrics and Gynaecology Nutrition Committee for Pregnancy, whose papers are considered for the first time here. This paper charts the rise of diet in pregnancy as a concern and considers the contributions of different communities involved between 1930 and 1960. It also notes that the actual recommended diet stayed the same. Thus while diet is the subject here, discussion focuses on why there were such distinct rearrangements of social, political and scientific forces around an issue that itself remained unchanged.