A Qualitative, Systems Thinking Approach to Study Self-Management in Women with Migraine
Deanna Befus, PhD, RN1, Kristen Hassmiller Lich, PhD, MHSA2, Shawn M. Kneipp, PhD, RN, APHN-BC3, Janet Bettger, ScD4, Remy R. Coeytaux, MD, PhD1, and Janice Humphreys, PhD,
RN5
Supplemental material:
System Support Map steps (detailed prompts) Strengths-based Problem Solving steps Strengths-based Problem Solving worksheets
System Support Map steps:
Step 1: Participants identified the most meaningful aspects of life that having migraine prevented them from experiencing by completing this sentence and noting their responses on sticky notes along the outsides of their papers: “If it weren’t for my migraines, I would be able to___.” Using one yellow sticky note for each response, participants placed their notes along the perimeter of their sheets of poster paper.
Step 2: Each participant positioned herself in the center of her own map by placing one green sticky note in the center circle. All of the women wrote “me” on this sticky note, and were encouraged to add any other descriptors they liked.
Step 3: Using pink sticky notes, participants identified up to five of their most important migraine triggers and placed these notes in the second circle from the center. We encouraged participants to define ‘important’ for themselves and try to be as specific as possible, including thinking about those things or situations that they may subconsciously avoid, and why (e.g., crowded spaces due to the likelihood of encountering perfumes, or outdoor activities during the
summer because of the bright light and heat). Participants then identified up to five of their most troublesome migraine features, defined as those aspects of their headache episode that were maximally disabling, that ‘stopped you in your tracks.’ We referred to these as ‘deal breakers.’
After placing all their pink trigger/feature sticky notes, participants used markers to draw arrows from these sticky notes back to the green “me” sticky note in the center, indicating that these triggers and features had important impact on them.
Step 4: Using orange sticky notes, participants identified “the ways [they] take care of
themselves,” to prevent migraine episodes, manage the episode while it was happening, and cope with the most disabling features identified in the previous ring. This was an unstructured process, allowing participants to think through behaviors that they ‘did on autopilot.’ We encouraged participants to include those behaviors and actions that may not, on the surface, seem like self- management activities but, in reality, were management choices, such as pre-emptive actions based on prodromal symptoms (e.g., social isolation before the episode begins) and other behaviors to avoid triggers or symptom escalation (Lorig & Holman, 2003). Participants used markers to draw arrows connecting each self-management activity to its corresponding trigger.
Step 5: In the fourth ring and using gold sticky notes, participants identified their “critical needs”
for each self-management activity. For each self-management activity listed on an orange sticky note in the third ring, participants created a list of the facilitators or conditions required for them to engage in the specific self-management activity. We encouraged participants to consider concepts or qualities as well as concrete objects. Using markers, participants drew arrows from each self-management activity to its respective list of needs.
Step 6: Using blue sticky notes, each participant considered each of her identified self-
management activities and listed her personal outcomes and trade-offs for each. This process was
designed to both identify the actual (versus desired) outcome of a specific self-management action and identify the opportunity costs for each action, of which participants may not be consciously aware. Outcomes of self-management activities were distinguished using “+,” and trade-offs with “–“ signs. Using markers, participants drew arrows from each self-management activity to its associated outcomes.
Step 7: Participants turned their attention back to the ideal outcomes they identified at the beginning of the session. If any of those initial goals were attained by using any of the self- management activities listed, women would move the yellow sticky note from the periphery onto the SSM, place it near the blue outcomes/trade-offs sticky note, and connect it with an arrow to its corresponding self-management activity.
Strengths-Based Problem Solving steps:
Step 1: Participants thought about personal strengths and created a list. If a woman got stuck, the facilitator encouraged her to think of a time when she succeeded at something and felt good about her actions, and then share that story with the group. Others in the group described the strengths that they thought the woman exemplified in her story.
Step 2: After creating lists of strengths, participants reflected on their SSMs. Each woman identified one ‘story’ into which she wanted to dive more deeply. We defined a ‘story’ as one path, from trigger/feature to outcome, on a participant’s map. Each woman recreated that story on a separate blank piece of paper, writing down each variable and connecting them with arrows.
Step 3: Next, we discussed which aspects of this story were complicated and why. During this period, each participant easily identified a key point in the story where the complexity began,
that is, a sort of breaking point wherein factors or situations intervened that prevented her from attaining a more desirable outcome. We identified this as our main ‘problem’ for the exercise.
Step 4: We worked through a problem-solving exercise worksheet (see below), pausing at each step to experiment with integrating various strengths. We suggested the women think of
strengths on their lists as ‘not-so-secret weapons’ that could be used creatively to think about an existing pattern differently. In this way, we could unpack a self-management heuristic and examine it with new eyes. While the new approach did not as fully illuminate interconnections between self-management approaches and important outcomes as CCs, by encouraging
participants to think broadly (into other “stories”) as they brainstormed pros and cons of possible solutions, they did begin to appreciate how to plan their actions in the bigger context of their full story.
