Illness identity as an important component of candidacy: Contrasting experiences of help-seeking and access to care in cancer and heart disease

University students' access to mental health services: A qualitative study of the experiences of health service professionals through the lens of candidacy in England

OBJECTIVES

In order to develop a better understanding of students' access to mental health services, we explored the experiences of health care professionals interacting with university students with mental health problems.

METHODS

We interviewed 23 professionals working across university advice and counselling services, NHS general practice, crisis, and psychological services in North and East London between June 2022 and January 2023. Our approach drew on reflexive thematic analysis and the principles of abductive analysis. The notion of candidacy - that is, how different needs are deemed deserving of health service attention - was particularly helpful to our understanding of the ongoing phenomenon of interest in the data.

RESULTS

Each student's access to mental health support was highly contingent on the student's dynamic social context and the pressures and organisation of the local health system. Professionals described how different students viewed different needs as deserving of health service attention. Which students reached the professional's service depended on the resources and relationships a student could draw upon, and the service's relative permeability. Once there, what action professionals took was strongly influenced by the professional's service expertise, resource constraints, the relationships the professional's service had with other organisations, the students' wishes, and whether students regarded treatment offers as acceptable.

CONCLUSIONS

Candidacy offers a useful lens to view university students' access to mental health support. Access appears to be an increasingly intricate task for students, given the fragmented service landscape, surging demand for mental health care and challenges of emerging adulthood. Our findings suggest that policy goals to increase use of mental health services are unlikely to improve outcomes for students without policy makers and health systems giving holistic consideration of inter-service relationships and available resources.

Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis

BACKGROUND

Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them.

SETTING AND SAMPLE

UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023.

METHODS

Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts.

RESULTS

Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions.

CONCLUSION

While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.

Seeking help for atrial fibrillation: the role of the body in distributed decision making

We adopt Rapley's (2008) concept of distributed decision making to explore the role of the body in people's decisions to seek medical care. We conducted in-depth interviews with patients diagnosed with atrial fibrillation (AF) who were taking long-term anticoagulants to prevent stroke. We interviewed seventeen patients recruited from English anticoagulant clinics using the biographic-narrative-interpretive method, and conducted thematic, structural and metaphorical analyses. This pluralistic analysis focused on how distributed decision-making was enacted through a range of socio-material, relational and embodied practices. Participants told how they experienced AF-related sensations that fluctuated in intensity and form. Some had no symptoms at all; others experienced sudden incapacitation - these experiences shaped different journeys towards seeking medical help. We draw on work by Mol (2002) to show how the body was differently observed, experienced and done across contexts as the narratives unfolded. We show that as part of a relational assemblage, involving social, material and technological actors over time, a new body-in-need-of-help was enacted and medical help sought. This body-in-need-of-help was collectively discussed, interpreted and experienced through distribution of body parts, fluids and technological representations to shape decisions. RAPLEY T., 2008. Distributed decision making: the anatomy of decisions-in-action. Sociology of Health & Illness, 30, 429-444. MOL A., 2002. The body multiple: ontology in medical practice. Duke University Press: Durham.

Poverty proofing healthcare: A qualitative study of barriers to accessing healthcare for low-income families with children in northern England

Poverty impacts negatively on children's health and future life chances. Access to the UK's National Health Service (NHS) is based on clinical need rather than the ability to pay but horizontal inequities in access exist. Children North East, a charity supporting children experiencing poverty, are working with partners to reduce the impacts of poverty on NHS access. This collaborative study aimed to understand barriers to healthcare access faced by families living on low incomes to validate and support further development of a Poverty Proofing© healthcare tool. Twenty-four parents and eight Voluntary Community Social Enterprise sector staff participated in qualitative interviews or focus groups. Data were analysed thematically, and three main themes were identified as impacting access to healthcare: hidden costs, securing appointments and developing relationships with healthcare providers. We conclude that low-income families experience both financial and other barriers to accessing NHS healthcare and that these barriers are exacerbated for low-income families living in remote/rural areas.

Tailored to a Woman's Heart: Gender Cardio-Oncology Across the Lifespan

PURPOSE OF REVIEW

Females outnumber males among long-term cancer survivors, primarily as a result of the prevalence of breast cancer. Late cardiovascular effects of cancer develop over several decades, which for many women, may overlap with reproductive and lifecycle events. Thus, women require longitudinal cardio-oncology care that anticipates and responds to their evolving cardiovascular risk.

RECENT FINDINGS

Women may experience greater cardiotoxicity from cancer treatments compared to men and a range of treatment-associated hormonal changes that increase cardiometabolic risk. Biological changes at critical life stages, including menarche, pregnancy, and menopause, put female cancer patients and survivors at a unique risk of cardiovascular disease. Women also face distinct psychosocial and physical barriers to accessing cardiovascular care. We describe the need for a lifespan-based approach to cardio-oncology for women. Cardio-oncology care tailored to women should rigorously consider cancer treatment/outcomes and concurrent reproductive/hormonal changes, which collectively shape quality of life and cardiovascular outcomes.

Exploring access to community care and emergency department use among people with dementia: A qualitative interview study with people with dementia, and current and bereaved caregivers

OBJECTIVES

Emergency department (ED) attendance is common among people with dementia and associated with poor health outcomes. Literature suggests a link between access to community care and the ED, but we know little about the mechanisms behind this link. This study aimed to explore experiences of accessing community and emergency care among people affected by dementia.

METHODS

Informed by critical realism, semi-structured online and telephone interviews were conducted with people with dementia and family caregivers, with and without experience of using the ED. Participants were recruited from across the United Kingdom using purposive sampling with maximum variation. A mostly experiential reflexive thematic analysis approach was used, applying the candidacy model of access to deepen interpretation.

RESULTS

Two dyad and 33 individual interviews were conducted with 10 people with dementia, 11 current caregivers and 16 bereaved caregivers (men = 11, 70-89 years = 18, white ethnicity = 32). Three themes are reported: (1) Navigating a 'push system', (2) ED as the 'last resort', and (3) Taking dementia 'seriously'. Themes describe a discrepancy between the configuration of services and the needs of people affected by dementia, who resort to the ED in the absence of accessible alternatives. Underlying this discrepancy is a lack of systemic prioritisation of dementia and wider societal stigma.

CONCLUSION

Although a last resort, ED attendance is frequently the path of least resistance for people with dementia who encounter multiple barriers for timely, responsive access to community health and social care. Greater systemic prioritisation of dementia as a life-limiting condition may help to reduce reliance on the ED through essential development of post-diagnostic care, from diagnosis to the end of life.

Negotiation of collective and individual candidacy for long Covid healthcare in the early phases of the Covid-19 pandemic: Validated, diverted and rejected candidacy

This analysis of people's accounts of establishing their need and experiences of healthcare for long Covid (LC) symptoms draws on interview data from five countries (UK, US, Netherlands, Canada, Australia) during the first ∼18 months of the Covid-19 pandemic when LC was an emerging, sometimes contested, condition with scant scientific or lay knowledge to guide patients and professionals in their sense-making of often bewildering constellations of symptoms. We extend the construct of candidacy to explore positive and (more often) negative experiences that patients reported in their quest to understand their symptoms and seek appropriate care. Candidacy usually considers how individuals negotiate healthcare access. We argue a crucial step preceding individual claims to candidacy is recognition of their condition through generation of collective candidacy. "Vanguard patients" collectively identified, named and fought for recognition of long Covid in the context of limited scientific knowledge and no established treatment pathways. This process was technologically accelerated via social media use. Patients commonly experienced "rejected" candidacy (feeling disbelieved, discounted/uncounted and abandoned, and that their suffering was invisible to the medical gaze and society). Patients who felt their candidacy was "validated" had more positive experiences; they appreciated being believed and recognition of their changed lives/bodies and uncertain futures. More positive healthcare encounters were described as a process of "co-experting" through which patient and healthcare professional collaborated in a joint quest towards a pathway to recovery. The findings underpin the importance of believing and learning from patient experience, particularly vanguard patients with new and emerging illnesses.

Barriers and facilitators to accessing and utilising post-treatment psychosocial support by Black men treated for prostate cancer-a systematic review and qualitative synthesis

PURPOSE

To synthesise findings from published studies on barriers and facilitators to Black men accessing and utilising post-treatment psychosocial support after prostate cancer (CaP) treatment.

METHODS

Searches of Medline, Embase, PsycInfo, Cochrane Database of Systematic Reviews and Central, CINAHL plus and Scopus were undertaken from inception to May 2021. English language studies involving Black men aged ≥18 and reporting experiences of, or suggestions for, psychosocial support after CaP treatment were included. Low or moderate quality studies were excluded. Searches identified 4,453 articles and following deduplication, 2,325 were screened for eligibility. Two independent reviewers carried out screening, quality appraisal and data extraction. Data were analysed using thematic synthesis.

RESULTS

Ten qualitative studies involving 139 Black men were included. Data analysis identified four analytical constructs: experience of psychosocial support for dealing with treatment side effects (including impact on self-esteem and fear of recurrence); barriers to use of psychosocial support (such as perceptions of masculinity and stigma around sexual dysfunction); facilitators to use of psychosocial support (including the influence of others and self-motivation); and practical solutions for designing and delivering post-treatment psychosocial support (the need for trusted healthcare and cultural channels).

CONCLUSIONS

Few intervention studies have focused on behaviours among Black CaP survivors, with existing research predominantly involving Caucasian men. There is a need for a collaborative approach to CaP care that recognises not only medical expertise but also the autonomy of Black men as experts of their illness experience, and the influence of cultural and social networks.

Qualitative study of candidacy and access to secondary mental health services during the COVID-19 pandemic

Candidacy, a construct describing how people's eligibility for care is negotiated between themselves and services, has received limited attention in the context of mental health care. In addition, candidacy research has only rarely studied the views of carers and health professionals. In this article, we use concepts relating to candidacy to enable a theoretically informed examination of experiences of access to secondary mental health services during the first wave of the COVID-19 pandemic in England. We report a qualitative study of the views and experiences of service users, carers, and healthcare professionals. Analysis of 65 in-depth interviews was based on the constant comparative method. We found that wide-ranging service changes designed to address the imperatives of the pandemic were highly consequential for people's candidacy. Macro-level changes, including increased emphasis on crisis and risk management and adapted risk assessment systems, produced effects that went far beyond restrictions in the availability of services: they profoundly re-structured service users' identification of their own candidacy, including perceptions of what counted as a problem worthy of attention and whether they as individuals needed, deserved, and were entitled to care. Services became less permeable, such that finding a point of entry to those services that remained open required more work of service users and carers. Healthcare professionals were routinely confronted by complex decisions and ethical dilemmas about provision of care, and their implicit judgements about access may have important implications for equity. Many of the challenges of access exposed by the pandemic related to pre-existing resource deficits and institutional weaknesses in care for people living with mental health difficulties. Overall, these findings affirm the value of the construct of candidacy for explaining access to mental healthcare, but also enable deepened understanding of the specific features of candidacy, offering enduring learning and implications for policy and practice.

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Candidacy is a framework for understanding influences on access to healthcare.

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We studied access to mental healthcare services during the COVID-19 pandemic.

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Candidacy was profoundly affected by service changes.

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Understandings of entitlement and thresholds for access were reconfigured.

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The value of the candidacy framework for mental health contexts is affirmed.

Service User and Service Provider Perceptions of Enablers and Barriers for Refugee and Asylum-Seeking Women Accessing and Engaging with Perinatal Mental Health Care Services in the WHO European Region: A Scoping Review Protocol

There is a need to understand the specific perinatal mental health care needs of migrant subgroups who often have differing health care needs and specific barriers to accessing and engaging with health care services. It is important to have evidence about the WHO European context given the rising numbers of refugees and asylum seekers in the region. The aim of this scoping review is to map the factors that enable and prevent access and engagement of refugee and asylum-seeking women with perinatal mental health care services in the WHO European Region, from the perspectives of service providers and service users. The database search will include PsycINFO, Cochrane, Web of Science, MEDLINE, EMBASE, CINAHL complete, Scopus, Academic Search Complete, and Maternity and Infant Care (OVID). Search results will be exported to an online tool that provides a platform to help manage the review process, including title, abstract, and full-text screening and voting by reviewers independently. Data concerning access and engagement with health care services will be mapped on to the candidacy framework. Systematically searching evidence within the WHO European region and examining this evidence through the candidacy lens will help develop a more comprehensive and a deeper conceptual understanding of the barriers and levers of access and engagement with perinatal mental health care services, whilst identifying gaps in existing evidence. Exploring factors that influence access and engagement for refugee and asylum-seeking women from the perspective of key stakeholders in the service provision and/or service utilisation of perinatal mental health care services will add a more comprehensive understanding of the recursive relationship between service provision and use.

Revisiting Candidacy: What Might It Offer Cancer Prevention?

The notion of candidacy emerged three decades ago through Davison and colleagues’ exploration of people’s understanding of the causes of coronary heart disease. Candidacy was a mechanism to estimate one’s own or others risk of disease informed by their lay epidemiology. It could predict who would develop illness or explain why someone succumbed to it. Candidacy’s predictive ability, however, was fallible, and it was from this perspective that the public’s reticence to adhere to prevention messages could be explained, as ultimately anybody could be ‘at-risk’. This work continues to resonate in health research, with over 700 citations of Davison’s Candidacy paper. Less explored however, is the candidacy framework in its entirety in other illness spheres, where prevention efforts could potentially impact health outcomes. This paper revisits the candidacy framework to reconsider it use within prevention. In doing so, candidacy within coronary heart disease, suicide prevention, diabetes, and cancer will be examined, and key components of candidacy and how people negotiate their candidacy within differing disease contexts will be uncovered. The applicability of candidacy to address modifiable breast cancer risk factors or cancer prevention more broadly will be considered, as will the implications for public health policy.

Digital mediation of candidacy in maternity care: Managing boundaries between physiology and pathology

This paper brings together scholarship across sociology, media and communication, and human computer interaction to explore the intersection of digital health and the maternity care system. We draw on data (including interviews, focus groups, observations, and analyses of digital media content) from 19 studies involving over 400 women to explore women's experiences of using different forms of digital support such as the Internet, mobile technologies (apps and text messaging), social media, and remote monitoring devices in their reproductive journeys. We use a best fit approach to analysis, mapping our findings to the candidacy framework and notions of trajectory work to understand how women engage in digital health practices to negotiate boundaries between physiology and pathology and to enter dialogue with maternity services during conception, pregnancy and the postnatal period. We propose an integrated revised conceptual framework which explicates intersections between digital and care practices, and micro-level negotiations between women and professionals in the maternal health context. Our revised framework retains the dimensions of candidacy, but it introduces a precursor to the identification of candidacy in the form of 'understanding normality'. It identifies distinct forms of digital work (e.g. information work, navigation work, machine work) which operate across the candidacy dimensions that women (and partners at times) engage in to negotiate legitimacy when entering into encounters with the maternity care system. Operating conditions (norms around expert motherhood; neoliberal discourses around health optimisation, risk and responsibilisation) provide a broader macro-level context, influencing the micro-level dialogic processes between women and healthcare professionals. Our synthesis highlights digital mediation as a useful filter to understand care systems, distribution of lay/professional responsibilities, relational practices and the (dis)enablement of candidacy.

Quality of life in breast cancer patients with cancer treatment-related cardiac dysfunction: a qualitative study

BACKGROUND

Although improved breast cancer (BC) treatment has decreased mortality, these anti-cancer regimens may have serious cardiovascular side effects that affect patients' long-term prognosis and quality of life (QoL). BC patients with cancer treatment-related cardiac dysfunction (CTRCD) can suffer from a variety of symptoms, such as dyspnoea and fatigue. The impact of CTRCD after BC treatment on patients' daily life has not been qualitatively explored yet.

AIMS

This study aims to explore the influence of CTRCD on QoL of women with BC, as defined by the concept of positive health. Second, we aim to evaluate the personal experience with cardiac surveillance during the BC trajectory.

METHODS AND RESULTS

A qualitative study with semi-structured interviews was conducted and thematically analysed to explore the QoL and healthcare experiences of BC patients with CTRCD. Twelve patients participated in this study. Five themes are selected in response to the study objective: (i) patients: overwhelming fatigue, (ii) patients: mental burden of anxiety, (iii) social setting: lack of understanding and acceptance, (iv) medical specialists: lack of knowledge and acknowledgement, and (v) patients: need for personalized care.

CONCLUSION

This study identified core components of the impact CTRCD has on the QoL of BC patients. Patients experienced an increased health-related burden due to CTRCD, affecting their physical, social, and psychosocial well-being. Healthcare experiences were largely affected by a lack of acknowledgement and professional communication. Patients underlined the need for personalized care during follow-up.

Using candidacy theory to explore unemployed over-50s perceptions of suitability of a welfare to work programme: A longitudinal qualitative study

Welfare to work interventions seek to move out-of-work individuals from claiming unemployment benefits towards paid work. However, previous research has highlighted that for over-50s, particularly those with chronic health conditions, participation in such activities are less likely to result in a return to work. Using longitudinal semi-structured interviews, we followed 26 over-50s during their experience of a mandated welfare to work intervention (the Work Programme) in the United Kingdom. Focusing on their perception of suitability, we utilise and adapt Candidacy Theory to explore how previous experiences of work, health, and interaction with staff (both in the intervention, and with healthcare practitioners) influence these perceptions. Despite many participants acknowledging the benefit of work, many described a pessimism regarding their own ability to return to work in the future, and therefore their lack of suitability for this intervention. This was particularly felt by those with chronic health conditions, who reflected on difficulties with managing their conditions (e.g., attending appointments, adhering to treatment regimens). By adapting Candidacy Theory, we highlighted the ways that mandatory intervention was navigated by all the participants, and how some discussed attempts to remove themselves from this intervention. We also discuss the role played by decision makers such as employment-support staff and healthcare practitioners in supporting or contesting these feelings. Findings suggest that greater effort is required by policy makers to understand the lived experience of chronic illness in terms of ability to RTW, and the importance of inter-agency work in shaping perceptions of those involved.

Healthcare access experiences of persons with MS explored through the Candidacy Framework

Canada has one of the highest rates of multiple sclerosis (MS) in the world, affecting 1 in every 385 individuals. This neurodegenerative condition is unpredictable and variable in symptom profile and disease course making it difficult to manage. Canadians with MS are high users of healthcare services; however, they report multiple unmet needs, high disease burden, and low satisfaction with healthcare. Access to healthcare is vital to health maintenance and may explain these poor experiences. Access is often measured using utilisation as a proxy, which may fail to capture the complexities of access experiences that this population faces. The Candidacy Framework offers an alternative to utilisation measures, by examining the process of accessing care, while considering the impact of social patterning and health system environments on this process. The aim of the current study is to align the experiences of persons with MS in accessing healthcare services with the stages of the Candidacy Framework. Forty-eight individuals with MS living across Ontario were recruited to participate in one of five focus groups or ten individual interviews. Analysis included a first inductive phase, using constant comparative methods, followed by a deductive phase, using content analysis. The Candidacy Framework was not able to capture all experiences shared by persons with MS, including patient-centred care, past experiences and outcome expectation, and care outcomes. We propose these concepts be included as refinements to the current Framework, providing a more thorough explanation of the experiences of persons with MS in accessing care to manage their condition.

Engaging the 'Missing Men' in the HIV Treatment Cascade: Creating a Tailored Intervention to Improve Men's Uptake of HIV Care Services in Rural South Africa: A Study Protocol

Men, especially young men, have been consistently missing from the HIV care cascade, leading to poor health outcomes in men and ongoing transmission of HIV in young women in South Africa. Although these men may not be missing for the same reasons across the cascade and may need different interventions, early work has shown similar trends in men’s low uptake of HIV care services and suggested that the social costs of testing and accessing care are extremely high for men, particularly in South Africa. Interventions and data collection have hitherto, by and large, focused on men in relation to HIV prevention in women and have not approached the problem through the male lens. Using the participatory method, the overall aim of this study is to improve health outcomes in men and women through formative work to co-create male-specific interventions in an HIV-hyper endemic setting in rural KwaZulu-Natal, South Africa.

Women at high risk of HIV-infection in Kampala, Uganda, and their candidacy for PrEP

Pre-exposure prophylaxis (PrEP), antiretroviral medication for prevention of HIV-acquisition, is part of biomedical HIV prevention strategies recommended for people at risk of HIV-infection. A decision to take PrEP depends on an assessment of 'being at risk' either by an individual, or healthcare provider. In this paper, we draw on the concept of 'candidacy' to examine the different ways in which women attending a dedicated clinic in Kampala, Uganda, for women at risk of HIV infection (including sex workers), assessed their suitability for PrEP. We conducted in-depth interviews with 30 HIV negative women up to four different times, to gather information on the motives for taking PrEP, and their life history and daily life. All the women described the relevance of PrEP to mitigate their risk of HIV infection. However, there were challenges to adherence because of alcohol use, irregular working hours and a fear of being seen taking pills that others might assume to be HIV treatment. The ways in which the different women used PrEP and interpreted the place of PrEP in their lives were not solely based on their assessment of protecting themselves during sex work. They also used PrEP to guard against infection from their regular partners, and as a tool to allow them to make more money safely, by having sex without a condom with clients. While eligibility to access PrEP was predicated on the women's being in an 'at risk' population group, an incentive to use PrEP was to protect themselves from HIV acquisition from a long-term partner and preserve the 'trust' in their intimate relationship by having condom-less sex. Applying a candidacy lens we highlight the complexity in how women experience and present as being 'at risk' and query the criteria on which categories of risk and PrEP eligibility are determined.

Organisational barriers to implementing the MAMAACT intervention to improve maternity care for non-Western immigrant women: A qualitative evaluation

BACKGROUND

In Europe, the number of children born by non-Western immigrant women is rising and these women have an increased risk of negative pregnancy and birth outcomes, compared to the host populations. Several individual and system barriers are associated with immigrant women's access to maternity care. Scientific evaluations of interventions to enhance the health of immigrant women in the maternity setting are lacking, and there is a need for further development of the evidence base on how health care system initiatives may mitigate ethnic inequities in reproductive health. In Denmark, the MAMAACT intervention was developed to improve midwives' as well as non-Western immigrant women's response to pregnancy complications and to promote midwives' intercultural communication and cultural competence. The intervention included a training course for midwives as well as a leaflet and a mobile application. This study focuses on the significance of the antenatal care context surrounding the implementation of the MAMAACT intervention (Id. No: SUND-2018-01).

OBJECTIVES

To explore the main organisational barriers, which impacted the intended mechanisms of the MAMAACT intervention in Danish antenatal care.

DESIGN

A qualitative study design was used for data collection and analysis.

SETTING

Midwifery visits at ten antenatal facilities affiliated to five Danish maternity wards formed the setting of the study.

PARTICIPANTS AND METHODS

Data consisted of nine focus group interviews with midwives (n = 27), twenty-one in-depth interviews with non-Western immigrant women, forty observations of midwifery visits, and informal conversations with midwives at antenatal care facilities (50 h). Data were initially analysed using systematic text condensation. The candidacy framework was applied for further interpretation of data.

RESULTS

Analysis of data revealed three main categories: 'Permeability of antenatal care services', 'The interpreter as an aid to candidacy´, and 'Local conditions influencing the production of candidacy'.

CONCLUSIONS

Several organisational barriers impacted the intended mechanisms of the MAMAACT intervention. Major barriers were incomplete antenatal records, insufficient referrals to specialist care, inadequate interpreter assistance, and lack of local time resources for initiating a needs-based dialogue with the women. Immigrant targeted interventions must be understood as events within complex systems, and training midwives in intercultural communication and cultural competence cannot alone improve system responses to pregnancy complications among immigrant women. Changes in the legal, social, and political context of the health care system are needed to support organisational readiness for the MAMAACT intervention.

A need-based, multi-level, cross-sectoral framework to explain variations in satisfaction of care needs among people living with dementia

BACKGROUND

Provision of care and support for people with dementia and family carers is complex, given variation in how dementia manifests, progresses and affects people, co-morbidities associated with ageing, as well as individual preferences, needs, and circumstances. The traditional service-led approach, where individual needs are assessed against current service provision, has been recognised as unfit to meet such complexity. As a result, people with dementia and family members often fail to receive adequate support, with needs remaining unmet. Current research lacks a conceptual framework for explaining variation in satisfaction of care needs. This work develops a conceptual framework mapped onto the care delivery process to explain variations in whether, when and why care needs of people with dementia are met and to expose individual-, service-, system-level factors that enable or hinder needs satisfaction.

METHODS

Data collected through 24 in-depth interviews and two focus groups (10 participants) with people with dementia and family carers living in the North East of England (UK) were analysed thematically to develop a typology of care needs. The need most frequently reported for people with dementia (i.e. for support to go out and about) was analysed using themes stemming from the conceptual framework which combined candidacy and discrepancy theories.

RESULTS

The operationalisation of the framework showed that satisfaction of the need to go out was first determined at the point of service access, affected by issues about navigation, adjudication, permeability, users' resistance to offers, users' appearance, and systems-level operating conditions, and, subsequently, at the point of service use, when factors related to service structure and care process determined (dis)satisfaction with service and, hence, further contributed to met or unmet need.

CONCLUSION

The conceptual framework pinpoints causes of variations in satisfaction of care needs which can be addressed when designing interventions and service improvements.

Exploring People's Candidacy for Mobile Health-Supported HIV Testing and Care Services in Rural KwaZulu-Natal, South Africa: Qualitative Study

BACKGROUND

The use of mobile communication technologies (mHealth: mobile health) in chronic disease management has grown significantly over the years. mHealth interventions have the potential to decentralize access to health care and make it convenient, particularly in resource-constrained settings. It is against this backdrop that we aimed to codevelop (with potential users) a new generation of mobile phone-connected HIV diagnostic tests and Web-based clinical care pathways needed for optimal delivery of decentralized HIV testing, prevention, and care in low- and middle-income countries.

OBJECTIVE

The aim of this study was to understand ways in which an mHealth intervention could be developed to overcome barriers to existing HIV testing and care services and promote HIV self-testing and linkage to prevention and care in a poor, HIV hyperendemic community in rural KwaZulu-Natal, South Africa.

METHODS

A total of 54 in-depth interviews and 9 focus group discussions were conducted with potential users (including health care providers) in 2 different communities. Theoretically informed by the candidacy framework, themes were identified from the interview transcripts, manually coded, and thematically analyzed.

RESULTS

Participants reported barriers, such as fear of HIV identity, stigma, long waiting hours, clinic space, and health care workers' attitudes, as major impediments to effective uptake of HIV testing and care services. People continued to reassess their candidacy for HIV testing and care services on the basis of their experiences and how they or others were treated within the health systems. Despite the few concerns raised about new technology, mobile phone-linked HIV testing was broadly acceptable to potential users (particularly men and young people) and providers because of its privacy (individual control of HIV testing over health provider-initiated testing), convenience (individual time and place of choice for HIV testing versus clinic-based testing), and time saving.

CONCLUSIONS

Mobile phone-connected HIV testing and Web-based clinical care and prevention pathways have the potential to support access to HIV prevention and care, particularly for young people and men. Although mHealth provides a way for individuals to test their candidacy for HIV services, the barriers that can make the service unattractive at the clinic level will also need to be addressed if potential demand is to turn into actual demand.

Exploring adolescents and young people's candidacy for utilising health services in a rural district, South Africa

BACKGROUND

We use the 'candidacy framework' to describe adolescents' and young people's (AYP) experiences of health services in a rural KwaZulu-Natal district, South Africa.

METHODS

A qualitative approach was used including group discussions, in-depth and key informant interviews with a purposive sample of AYP (n = 70), community leaders (n = 15), school health teams (n = 10), and health service providers (n = 6).

RESULTS

Findings indicate tacit understanding among AYP that they are candidates for general health services. However, HIV stigma, apprehensions and misconceptions about sexual and reproductive health, and socio-cultural views which disapprove of AYP pre-marital sex undermine their candidacy for sexual and reproductive services.

CONCLUSION

Consideration and understanding of the vulnerabilities and reasons AYP exclude themselves will inform interventions to address their health needs. AYP's participation in the design of health services will increase their acceptability and encourage uptake of services.

Patients and informal caregivers' experiences of burden of treatment in lung cancer and chronic obstructive pulmonary disease (COPD): a systematic review and synthesis of qualitative research

OBJECTIVE

To identify, characterise and explain common and specific features of the experience of treatment burden in relation to patients living with lung cancer or chronic obstructive pulmonary disease (COPD) and their informal caregivers.

DESIGN

Systematic review and interpretative synthesis of primary qualitative studies. Papers were analysed using constant comparison and directed qualitative content analysis.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science searched from January 2006 to December 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary qualitative studies in English where participants were patients with lung cancer or COPD and/or their informal caregivers, aged >18 years that contain descriptions of experiences of interacting with health or social care in Europe, North America and Australia.

RESULTS

We identified 127 articles with 1769 patients and 491 informal caregivers. Patients, informal caregivers and healthcare professionals (HCPs) acknowledged lung cancer's existential threat. Managing treatment workload was a priority in this condition, characterised by a short illness trajectory. Treatment workload was generally well supported by an immediacy of access to healthcare systems and a clear treatment pathway. Conversely, patients, informal caregivers and HCPs typically did not recognise or understand COPD. Treatment workload was balanced with the demands of everyday life throughout a characteristically long illness trajectory. Consequently, treatment workload was complicated by difficulties of access to, and navigation of, healthcare systems, and a fragmented treatment pathway. In both conditions, patients' capacity to manage workload was enhanced by the support of family and friends, peers and HCPs and diminished by illness/smoking-related stigma and social isolation.

CONCLUSION

This interpretative synthesis has affirmed significant differences in treatment workload between lung cancer and COPD. It has demonstrated the importance of the capacity patients have to manage their workload in both conditions. This suggests a workload which exceeds capacity may be a primary driver of treatment burden.

PROSPERO REGISTRATION NUMBER

CRD42016048191.

Using the candidacy framework to understand how doctor-patient interactions influence perceived eligibility to seek help for cancer alarm symptoms: a qualitative interview study

BACKGROUND

'Candidacy' is concerned with the way people consider their eligibility for accessing health services. We used the Candidacy Framework to explore how the doctor-patient relationship can influence perceived eligibility to visit their General Practitioner (GP) among people experiencing cancer alarm symptoms.

METHODS

We carried out a secondary analysis of qualitative interviews with 29 women and 33 men, aged ≥50 years experiencing cancer alarm symptoms, recruited through primary care. Interviews focused on symptom experience, help-seeking and primary care use. Framework analysis was used to analyse transcripts with a focus on GP-patient interactions.

RESULTS

Perceived (im)permeability of services acted as a barrier to help-seeking, due to limited availability of appointments, time-limited communication and difficulties asserting candidacy. There was also a focal role of communication in building a positive doctor-patient relationship, with some participants describing resisting offers of appointments as a result of previous negative GP adjudication. These factors not only influenced the current consultation but had longer-term consequences for future consultation.

CONCLUSIONS

Candidacy provides a valuable theoretical framework to understand the interactional factors of the doctor-patient relationship which influence perceived eligibility to seek help for possible cancer alarm symptoms. We have highlighted areas for targeted interventions to improve patient-centred care and improve earlier diagnosis.

Untimely illness: When diagnosis does not match age-related expectations

Background

We explore the concept of “untimely diagnosis,” where the onset of a long‐term condition occurs at a life stage which does not conform to traditional expectations, focusing on two conditions (asthma and arthritis) typically associated with a particular life stage (childhood and older adulthood, respectively). Previous literature has focused on the meaning of chronic illness in terms of life history, and the biographical lens has been used in various ways to make sense of the experience. Less attention has been paid to the condition onset when it seems dissonant with chronological age.

Methods

Secondary analysis of two qualitative data sets (total 58 interviews) exploring the experiences of people with adult‐onset asthma and young people diagnosed with arthritis. Data from the original interview transcripts relating to diagnosis and symptom recognition were re‐analysed using a “candidacy” framework to examine how age and diagnosis intersect.

Results

People did not always assert their candidacy for either condition because of pre‐conceived expectations around age. Similarly, health professionals sometimes failed to recognize patients’ candidacy, instead pursuing “age‐plausible” possibilities. In some cases, participants were proactive in suggesting a diagnosis to the health professional where diagnosis was delayed.

Conclusion

The diagnosis of adult‐onset asthma, and arthritis in young people, may be regarded as “untimely.” We suggest that being diagnosed with what is perceived to be a “childhood” condition in adulthood, or “an older person's” condition in childhood, may be viewed as a “biographical paradox” and an “untimely breach” to the expected order.