Moving between ideologies in self‐management support—A qualitative study

Abstract Background Reforms in current health policy explicitly endorse health promotion through group‐based self‐management support for people with long‐term conditions. Health promotion and traditional medicine are based on different logics. Accordingly, health professionals in health‐promoting settings demand the adoption of new practices and ways of thinking. Objectives The objective of our study was to investigate how health professionals perceive the health‐promoting group‐based self‐management support that is politically initiated for people with long‐term conditions. Design This study had a qualitative research design that included focus group interviews and was guided by a social constructivist paradigm in which group‐based self‐management was viewed as a social construction. Different logics at play were analysed through the theoretical lens of institutional logic. Discussions among participants show frames of references seen as logics. Setting and participants We recruited health professionals from group‐based health‐promoting measures for people with type 2 diabetes in Norway. Two focus groups comprising four and six participants each were invited to discuss the practices and value of health promotion through group‐based self‐management support. Results The analysis resulted in three themes of discussion among participants that contained reflections of logics in movement. Health professionals’ discussions moved between different logics based on the importance of expert‐based knowledge on compliance and on individual lifestyle choices. Discussion and conclusion The study indicates that health promotion through self‐management support is still a field “in the making” and that professionals strive to establish new logics and practices that are not considered difficult to manage or do not contain incompatible understandings.


| INTRODUC TI ON
This study focuses on the experiences of health professionals working with self-management support for people with type 2 diabetes and how they understand health-promoting practices. The objective of the study is primarily health professionals' perceptions of group-based self-management support. Self-management support represents an example of a recently initiated, widely endorsed health-promoting measure in health care. 1,2 Group-based self-management support is a developing field in which health professionals in interprofessional settings create and negotiate new practices. 3 The growing prevalence of long-term conditions has been described in the literature as a burden on public health care, represented by its costs to society and its impact on the quality of life of individuals diagnosed with one or more long-term conditions. 4 Hence, changes in contemporary health policy are directed at improving self-management and reducing the costs of services, 5 which involve a reorganization of chronic disease care delivery taking place in several European countries. [6][7][8][9] The new health policy affects services to people with long-term conditions, and type 2 diabetes is a condition that affects particularly vulnerable groups in society. [10][11][12] Health professionals are expected to find new ways of meeting patients within the framework of groups to support self-management, which is different from traditional one-on-one consultations.
Research shows that health professionals influence the uptake and contagion of self-management strategies for people with type 2 diabetes. [13][14][15] However, some studies show that in group-based selfmanagement support settings, health professionals tend to dichotomize participants into "good" or "bad" patients, such that those who do not achieve any behaviour change are viewed as difficult and noncompliant. [16][17][18] Investigating what "meets" patients when they enrol in group-based self-management support is important. Awareness of how health professionals operate in these settings is important for conclusions that may form the basis for quality improvement and the design of measures well suited to meet the preferences and needs of different groups of patients attending group-based selfmanagement support.
Part of policy development involves decentralizing healthpromoting services from specialist care to primary care. 2,19 It has previously been shown that it is difficult for primary care practitioners to focus on health promotion. 20 One study suggests that health professionals strive to integrate the ideals of promotion, such as well-being, but instead tend to focus on adherence to and compliance with medical advice. 20,21 By focusing strictly on risk and disease prevention, health professionals often fail to broaden their aim towards more holistically inclusive and general health promotion. 21,22 A relevant question is whether and how the alteration of frames changes the rationale of actors in the health-promoting setting, which is why we are interested in how health professionals perceive group-based self-management support. Additionally, further investigation is sought regarding the notion of coproduction in the context of group-based self-management support between both participants and health professionals, 16 which requires knowledge of the pervasive logics that drive practices in self-management support settings. Investigating both patients' and health professionals' perspectives simultaneously is a demanding exercise, and for the sake of being able to investigate one group at a time, our group of interest in this study is health professionals.

| The medical perspective vs the perspective of health promotion through group-based self-management support
To grasp the perceptions of health professionals, it seems reasonable to highlight some overall differences between traditional perspectives of medicine and a health-promoting approach. The way we understand the medical perspective in our study presupposes a form of practice that aligns with expectations that patients follow and comply with medical directions in a manner that heeds professional power and legitimacy. 23,24 The modus operandi of the medical perspective emphasizes treatment guided by an expert and depicts the individual as someone who "must be helped" and health professionals as legitimate experts in ensuring that this takes place. 3 In contrast to the medical perspective, health promotion may be said to encapsulate both person-oriented and group-oriented dimensions, 25 which makes it reasonable to say that health promotion sees the individual as part of his/her social context. The World Health Organization (WHO) states that health promotion is aimed at empowering individuals to take control of their health, which is depicted as a process of enabling people to take increased responsibility for their own health and well-being. 26,27 In line with this goal, health promotion is described as aiming to direct health professionals to help people through addressing the nonmedical factors of their health. 28 Nonmedical factors in our study reflect strategies that do not follow the medical perspective (for instance, providing support beyond medical guidelines and treatment), preferably acknowledging patients' knowledge of their own health. Group-based self-management support is based on an ideology of empowering participants to become active agents in their health. 29 The groupbased approaches vary in content and may include a mix of the following group pedagogic measures: expert-patient tutoring; discussions between leaders and participants; educational components; and content such as nutrition advice and physical activities, the latter of which could be described as a lifestyle-oriented approach. 3 The Norwegian structure of group-based support ranges from public, professionally led groups to private nonprofit layperson-driven groups, and local physical activity and nutrition programmes may be both professionally and layperson-driven. 30 In other countries, selfmanagement support is primarily based on initiatives from volunteer and patient organizations. 31 Health professionals must adopt changes in their ways of thinking and frames of reference when meeting patients with type 2 diabetes in groups rather than in one-on-one consultations and in focusing on patients' well-being rather than their disease.
With regard to health professionals' understanding of health promotion, research has shown that health promotion is akin to health education. 32,33 As health promotion and health education often become intermingled, it seems apt to clarify the distinction between a medical-centred approach to health education and a health-promoting approach. In Table 1, we have highlighted theoretical differences based on the distinction between patientcentred and medico-centred views on health education. 34 In line with the information presented in Table 1, studies have shown that the medical perspective has been identified as a paternalistic and individualistic "behaviour-changing approach" when applied in health-promoting contexts. [35][36][37] The main focus in patientprovider communication seems to be disease and treatment, despite the advocacy for a health-promoting focus. 38 Our study conceptualizes ideologies associated with health promotion as expressions of logics, and in this study, we use the theoretical framework of institutional logic.

| Institutional logic
At the core of the theory of institutional logic is the premise that practices and perceptions are socially constructed. Our study thus adopts a social constructivist stance, viewing logics as practices created through constantly ongoing interactions. Institutional logics refer to a set of cultural beliefs, rules and practices that shape the thoughts and behaviours of actors in settings where individuals regularly interact. 39 Actors may challenge or maintain and produce and reproduce logics through patterns of practices and assumptions. 40 The logics signify certain frames of reference that guide actors' understandings and, hence, intentions with regard to the kind of practices being developed. Practices involved in chronic disease management settings may illustrate different sets of logics that may be coinciding or incompatible. Knowledge on how different practices in the health-promoting field are incompatible or compatible is essential when countries are undergoing a change in orientation towards health promotion. 20,41 Our aim is to investigate how health professionals perceive group-based self-management support and what logics they are drawing upon, within the context of focus group interviews.

| DE S I G N AND ME THODS
As the institutional logic perspective is characterized by socially constructed understandings through shared knowledge, we needed a methodological approach that enabled us to observe the construction and upholding of shared common understandings among health professionals. The focus group interview method is seen as a useful way to elicit the coconstruction of meaning in action, 42 in which both interaction and content are available for analysis. Listening to and observing how a focus group interview evolves in context make it possible to elicit different understandings and assumptions being described by the group. 43 We understand interaction as the underlying context of the statements expressed. 44,45

| Recruitment
The authors established contact with the leaders of several groupbased self-management support measures who contacted their colleagues for group interviews. The recruitment lasted for several rounds, as health professionals represent a busy informant group.
Many invitations to join the group interview were refused due to heavy workloads. Two of the participants withdrew from the interview only minutes before it started, due to other assignments in their work schedule. The focus group data were gathered and analysed in 2016.

| Participants
Our data were derived from two focus groups that included a total of 10 health professionals (additional information on group participants is given in Table 2).
The health professionals in our study have diverse experiences with group-based self-management support, most of them working with type 2 diabetes. Hence, the strength of our data set is that it represents a wide range of professions that comprise relevant occupations in group-based support measures, such as GPs, physiotherapists, specialized diabetes nurses and nutritionists.
The literature on focus groups suggests that more information may be obtained by conducting two focus groups of four participants instead of one group of eight participants. 46,47 When the interaction and discussion are the objects of study interest, the sample size is subordinate; however, the relational context and the context of statements 48 are important. The two focus groups differed with respect to their relational context. Group 1 consisted of four participants who knew each other (most of the participants worked together), while group 2 consisted of a larger group (six participants), several of whom did not know each other at all. We

Medical perspective Health-promoting perspective
Health education Health education is a means to instigate controlled behaviour, encouraging health gains by persuasion Health education focuses on actively inviting patients to dialogue with health professionals

Eminence of knowledge
The health professional is viewed as the legitimate holder of valued, medical information that is conveyed to the patient, who absorbs the information uncritically The boundaries between professional-as-teacher and patient-as-learner are blurred. The patient's lay health beliefs are considered of equal value as the professional's knowledge recognized many of the same discussion themes in the two group interviews, and it is reasonable to believe that our questions would have triggered the same discussions in additional interviews with health professionals.

| Group interviews
Two moderators led the interviews, which were conducted in Norwegian. We invited the participants to discuss the practice and value of group-based self-management support for people with longterm conditions and to share their thoughts on health-promoting policy, focusing on people with type 2 diabetes. For an overview of the research questions relevant to our analysis, see Figure 1.

| Data analysis
Both focus group interviews were recorded and transcribed verbatim.
We searched for the logics that comprised the assumptions, practices and values that participants expressed. In accordance with seeing logics as constructed through interaction, we also looked for agreements and disagreements. We found themes of discussion among participants in which we claim to identify the logics at play. The objective of our focus was to search for what the participants said, how they said it and how these different ways of saying it contributed to discussions. 43,49 The analysis process did not explicitly deal with subthemes, as we interpreted 50 statements in the context of discussions to identify logics that make up the frame of reference behind the statements expressed. The main statements illustrating patterns of shared knowledge and disagreement were the basis of the overall themes.
We circulated the analysis drafts among all the coauthors and discussed them at seminars with fellow colleagues. During the analysis process, all knowledge shared in the focus group setting was seen as socially constructed 51 and as expressions of shared logics.

| FIND ING S AND INTERPRE TATI ON S
Both of the focus groups in our study provided rich data concerning health promotion and group-based self-management support. In the following sections, we start with describing the shift of frames upon TA B L E 2 Group participants which all health professionals agree, which we call "logics in movement." Furthermore, we present how health professionals express the logic of the medical perspective through statements revealing the dominance of expert knowledge and the focus on individual responsibility. The driving force of negotiation in discussions among health professionals is seen to be lifestyle orientation.
We use numbers to categorize the individual participants. In the presentation of the findings, we connect the statements to the number that represents the participant.

| Logics in movement
Health professionals in our focus groups acknowledged quite early in the interviews that the health-promoting arena represents a new setting operating outside the "traditional" medical frame. This distinction is illuminated through the emphasis on the lack of hospital uniforms, which distinguishes a medical context from other contexts and enables the freedom to act and think differently, which is associated with an open setting and civil society. An example of such statement is the following: It is a bit like that, I am dressed as a civilian, right.
Perhaps that has something to do with it; it's not that hospital-like. We also think it is very good that they

F I G U R E 1 Interview guide
How do you perceive the group-based self-management support and its value for people with long-term conditions?

What health-promoting practices and values do you think make people with long-term conditions want to participate (or not) in group-based self-management support? How do you view group-based self-management support as a cost-effective measure? Has the attitude towards people with type 2 diabetes in the society in general changed due to a stronger focus on group-based self-management support?
then we can put the disease under the activity, but it is important not to talk about the disease too much.
The phrase "putting the disease under the activity" illustrates the strength of the medical perspective, even though the participant is trying to search for new ways of approaching patients.

| Priority of expert-based knowledge
In this statement, the act of conveying medical guidelines to the patient and the commensurate degree of "compliance" seem to govern the logic. The statements lean towards an understanding in which the health professional is viewed as the legitimate holder of valued information, which is supposed to be conveyed to the patient, who should then absorb the information uncritically. 34 We may also see the above statement as imbued with a paternalistic approach, such that the patient seems to be under the guardianship of the professional while the professional wonders (similarly to a parent) if he/she is "too harsh or too nice." The priority of expert-based knowledge, in line with a medical perspective and, hence, a medical logic, is also visible in the way group participants evaluate health-promoting measures: What is supposed to be quality and quality assurance, you get that in the health service, while in the voluntary group-based support, it may be more random if you get a quality-assured measure or not. I know that the Norwegian Diabetes Association is schooling their group leaders, and that, of course, is a way to ensure quality, but this will certainly vary between different group-based support activities.
The statement is situated in a context where health professionals express a concern that health-promoting measures driven by voluntary organizations may not be "good" enough as an arena for ensuring lifestyle change. The political incentive to offer group-based selfmanagement support, understood by health professionals in the focus groups as health education, is seen as a challenge in terms of limited time and space to support people in the demanding dietary regimens and lifestyle changes they are supposed to make. Health professionals expressed worry that health-promoting initiatives that do not involve guidelines associated with expert knowledge may not facilitate health improvement. Even though the health professionals in our study express a high degree of critical reflection regarding the medical perspective, the quotation above indicates that the dominant logic or rationale is still occupied by the need for quality assurance and assurance that medical guidelines for compliance may be given to people with longterm conditions.
When asking questions in the focus groups, we mentioned measures driven by private nonprofit organizations, such as the Norwegian Diabetes Association, in order to give the participants a broad perspective on health promotion. In line with earlier research, the health professionals in our study struggle with grasping that health promotion may encapsulate other frameworks for good living than that of medico-centred health education. 32 Even though volunteer organizations are mentioned in passing, the discussions in our focus groups are still centred on disease prevention. Organizations that have existed for decades in the Norwegian community that are important for well-being and health in the population, such as the Norwegian Confederation of Sport or the Norwegian Trekking Association, are not discussed as health-promoting arenas facilitating support. The health professionals in our study thereby show how they remain rooted in a medical perspective, striving to widen their approach to involve, for example, other community organizations.

| Individual-or group-oriented lifestyle change
In the following section, we try to illustrate how the logic of fellowship takes priority over the medical perspective approach, as health professionals imply that people with type 2 diabetes may help one another within the sphere of a group-based health-promoting setting. At the same time, while pointing out the benefit of the groupbased approach, health professionals appear to focus discussion of the group-based measure on individual lifestyle choices.
Well, then, they have something in common, right?
It is in a way the same thing: when I think about it, if they struggle with obesity, then they have at least that in common. Then, it is not a composition of different diseases. What is important especially with regard to patients with type 2 diabetes is that they are actually a stigmatized group. It may not be that easy to get support from others because the disease is like this: 'You may have caused it yourself.' So I think it is even more important for this patient group to meet others who understand what it is like.
The statement suggests that the common features of the patient group are perceived to be obesity and stigma and that this commonality carries the potential to elicit support among the participants. However, the statement lacks a component of reflexivity, such that the composition is seen as categorizing a group of people based on negative features. 53 The statement may also suggest that the health-promoting set- The above statement reflects, once again, the strength of the medical perspective, here illustrated as a focus on the disease, stating that in order to benefit from group-based self-management support, people with type 2 diabetes should base their participation on having a diagnosis.
There are seemingly positive statements regarding the group composition, as long as it will enhance individual lifestyle changes: The exercise groups, I believe, may have the potential to help participants motivate each other. Members may feel that they can't let the group down. As long as you are more than just one individual, then it gives you motivation to actually perform better than if you were alone. It is a positive push.
This statement highlights the potential of group-based support to compel patients to participate in healthy activities via feelings of commitment to the other group members. Nevertheless, the point of "healthy activities" (exemplified here by physical exercise) becomes apparent, along with the "push" to "perform better at being healthy." The moral imperative of performing better and the benefit of a guiltless conscience lead to the individual, person-oriented lifestyle change that is sought to be accomplished by the group method. We thus understand that it is not the group setting per se that seems important, but rather the potential of the group to drive individual lifestyle change.

| D ISCUSS I ON
The health professionals' discussions in the focus groups of our study suggest a high degree of self-reflection when the value of health-promoting measures was discussed. We use the term "selfreflection" to describe those instances where group participants critically assess practices that we see as based on a medical perspective. Overall, the discussions in the focus groups revealed a picture of logics based on values that seem to be in opposition. There are instances where focus group participants seemed "stuck" in a medical Previous literature concerned with type 2 diabetes patients and health professionals highlights the distinction of "illness vs life," where the main conflict between health professionals and diabetes patients is termed "keeping life and disease apart." 55,56 In our study, we find that it is lifestyle vs life that has become the apparent category; that is, the notion of "life" is reduced to "lifestyle" based on health profes-

| LIMITATI ON S , S TRENG TH S AND IMPLI C ATI ON S FOR FURTHER RE S E ARCH
Our study participants represent unique cases, as there are not yet many health professionals who work in group-based selfmanagement support measures in the community setting in Norway (at the time of data analysis, 2016). We recruited a variety of professionals who represent a wide range of health fields. Knowledge on how health professionals perceive health promotion and groupbased self-management support is important for the adjustment of actors in the health-promoting field in a way that benefits patients.
Hughes et al 16 address the importance of the coproduction of meaning. Through the review on facilitators' and participants' experiences of group-based self-management support, the authors highlight that by focusing on medical aspects of self-management, the groups constrain opportunities to provide support, and facilitators appear to lack the confidence necessary to support participants beyond a medical paradigm. By exploring further the notion of the coproduction of meaning beyond the professional-patient interaction, Hughes et al direct attention to the broader set of ties with others, represented by each of the patient's relationships that may contribute to self-management support. However, in our study, this approach may be relevant for directing attention to the importance of a social constructivist perspective in the health-promoting field.
The findings in our study are based on few informants, and any generalizations should be made with caution. However, health professionals represent a network of other health professionals, and it is reasonable to believe that the dominance of a medical perspective in the health-promoting setting is worth addressing for the benefit of people who take part in group-based selfmanagement support.

ACK N OWLED G EM ENTS
We are grateful to all the health professionals who took their time to participate in the group discussions, including those who were helpful in the recruitment process.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest regarding this research.

AUTH O R S' CO NTR I B UTI O N S
The first author has made substantial contribution to conception and design and also contributed to the acquisition of data.