GPs' experience of managing chronic pain in a South Asian community--a qualitative study of the consultation process

How can healthcare organisations increase doctors' research engagement? A scoping review

PURPOSE

Clinician engagement in research has positive impacts for healthcare, but is often difficult for healthcare organisations to support in light of limited resources. This scoping review aimed to describe the literature on health service-administered strategies for increasing research engagement by medical practitioners.

DESIGN/METHODOLOGY/APPROACH

Medline, EMBASE and Web of Science databases were searched from 2000 to 2021 and two independent reviewers screened each record for inclusion. Inclusion criteria were that studies sampled medically qualified clinicians; reported empirical data; investigated effectiveness of an intervention in improving research engagement and addressed interventions implemented by an individual health service/hospital.

FINDINGS

Of the 11,084 unique records, 257 studies were included. Most (78.2%) studies were conducted in the USA, and were targeted at residents (63.0%). Outcomes were measured in a variety of ways, most commonly publication-related outcomes (77.4%), though many studies used more than one outcome measure (70.4%). Pre-post (38.8%) and post-only (28.7%) study designs were the most common, while those using a contemporaneous control group were uncommon (11.5%). The most commonly reported interventions included Resident Research Programs (RRPs), protected time, mentorship and education programs. Many articles did not report key information needed for data extraction (e.g. sample size).

ORIGINALITY/VALUE

This scoping review demonstrated that, despite a large volume of research, issues like poor reporting, infrequent use of robust study designs and heterogeneous outcome measures limited application. The most compelling available evidence pointed to RRPs, protected time and mentorship as effective interventions. Further high-quality evidence is needed to guide healthcare organisations on increasing medical research engagement.

Challenges and Barriers to Providing Primary Care to Children of South Asian Origin: Pediatricians' Perspectives

South Asian (SA) Americans have a high risk of metabolic and cardiovascular disease. Prevention efforts should start in childhood and should be culturally appropriate. We sought to understand the challenges and barriers that pediatricians face in providing care for SA children to inform professional education on culturally effective care. Qualitative interviews were conducted with a diverse sample (N = 17) of pediatricians. Challenges reported included feeding problems, inadequate physical activity, and mental health concerns. Communication barriers included parents' anxiety around feeding, influence of grandparents, stigma around mental health, and cultural communication gaps. Effective strategies included clear communication, a gradual approach, ensuring buy-in from grandparents, greater attention to family history, and improved cultural knowledge in pediatrician. Addressing feeding problems was the most mentioned challenge, which is especially concerning given the high chronic disease risk in SAs. Education on culturally appropriate strategies can equip pediatricians to effectively counsel SA families to address these risks.

A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care

Background

People with chronic pain do not always feel that they are being listened to or valued by health-care professionals (HCPs). We aimed to understand and improve this experience by finding out what HCPs feel about providing health care to people with chronic non-malignant pain. We did this by bringing together the published qualitative research.

Objectives

(1) To undertake a qualitative evidence synthesis (QES) to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain; (2) to make our findings easily available and accessible through a short film; and (3) to contribute to the development of methods for QESs.

Design

We used the methods of meta-ethnography, which involve identifying concepts and progressively abstracting these concepts into a line of argument.

Data sources

We searched five electronic bibliographic databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Allied and Complementary Medicine Database) from inception to November 2016. We included studies that explored HCPs’ experiences of providing health care to people with chronic non-malignant pain. We utilised the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework to rate our confidence in the findings.

Results

We screened 954 abstracts and 184 full texts and included 77 studies reporting the experiences of > 1551 HCPs. We identified six themes: (1) a sceptical cultural lens and the siren song of diagnosis; (2) navigating juxtaposed models of medicine; (3) navigating the patient–clinician borderland; (4) the challenge of dual advocacy; (5) personal costs; and (6) the craft of pain management. We produced a short film, ‘Struggling to support people to live a valued life with chronic pain’, which presents these themes (seeReport Supplementary Material 1; URL:www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation; accessed 24 July 2017). We rated our confidence in the review findings using the GRADE-CERQual domains. We developed a conceptual model to explain the complexity of providing health care to people with chronic non-malignant pain. The innovation of this model is to propose a series of tensions that are integral to the experience: a dualistic biomedical model compared with an embodied psychosocial model; professional distance compared with proximity; professional expertise compared with patient empowerment; the need to make concessions to maintain therapeutic relationships compared with the need for evidence-based utility; and patient advocacy compared with health-care system advocacy.

Limitations

There are no agreed methods for determining confidence in QESs.

Conclusions

We highlight areas that help us to understand why the experience of health care can be difficult for patients and HCPs. Importantly, HCPs can find it challenging if they are unable to find a diagnosis and at times this can make them feel sceptical. The findings suggest that HCPs find it difficult to balance their dual role of maintaining a good relationship with the patient and representing the health-care system. The ability to support patients to live a valued life with pain is described as a craft learnt through experience. Finally, like their patients, HCPs can experience a sense of loss because they cannot solve the problem of pain.

Future work

Future work to explore the usefulness of the conceptual model and film in clinical education would add value to this study. There is limited primary research that explores HCPs’ experiences with chronic non-malignant pain in diverse ethnic groups, in gender-specific contexts and in older people living in the community.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

General practitioners' strategies in consultations with immigrants in Norway-practice-based shared reflections among participants in focus groups

BACKGROUND

Immigrants comprise 16.8% of the population in Norway and meet General Practitioners (GPs) as their first point of contact with most health care services as do others in Norway. While Norwegian GPs are not trained in cultural competence, little is known about the extent to which they see good care for immigrants as relying on specific strategies.

OBJECTIVES

To explore the thoughts of GPs in Norway about strategies they might use with immigrant patients.

METHODS

We performed focus groups posing the question 'What strategies do you use when meeting immigrant patients?' to three groups of GPs working in Norway. Two groups comprised 10 trainee GPs each; the final group comprised eight certified GPs. Verbatim transcripts were analysed by systematic text condensation.

RESULTS

Strategies for consultations with immigrants emerged gradually throughout the focus groups, coalescing around (i) Respect and learn about immigrant culture. (ii) Particularize diagnosis and care, accommodating epidemiological and cultural knowledge for a given group, while keeping a keen eye on the individual. (iii) Inform about Norwegian health care. (iv) Organize resources such as time, translators and interdisciplinary teams. Other core elements of cultural competence, including reflections on the GP's own cultural background, were conspicuously absent, however.

CONCLUSION

Given the growing numbers of immigrants and the early transfer of refugees to general practice, our study points to the urgent need of supplementing teaching in patient-centred clinical method with cultural competence. Our study also highlights the potential of educational GP groups to develop strategies for cross-cultural consultations.

Cultural aspects of pain: A study of Indian Asian women in the UK

OBJECTIVES

Culture and ethnicity are acknowledged as important factors in the context of the biopsychosocial model. They may contribute to explaining the experience of pain, therapeutic encounters within healthcare, and the strategies that individuals use to cope with pain. The present study explored these issues in a sample of Indian Asian women in the UK.

METHODS

Based on a phenomenological approach, 17 women participated in five semi-structured group interviews. Data were analysed using qualitative content analysis, so as to identify core themes and subthemes inductively from the data.

RESULTS

Six themes were identified: meaning of pain; personal experience of pain; causes of pain; coping strategies; family and friends; experience of healthcare. Pain was conceptualized in both physical and mental terms, and its experience was explained largely in terms of functional consequences. The causes of pain offered suggested externalized beliefs, relating to events in participants' lives, rather than being expressed in biomedical terms. Alongside culture-specific therapies, the women spoke of coping strategies based on rest and activity. Although satisfaction with healthcare appeared to be high overall, problems due to communication - sometimes related to a language barrier - were voiced by some participants.

CONCLUSIONS

Greater attention to cultural aspects of the pain experience may assist health professionals in communicating with and managing patients with pain from ethnic minority backgrounds.

Meta-ethnography to understand healthcare professionals' experience of treating adults with chronic non-malignant pain

OBJECTIVES

We aimed to explore healthcare professionals' experience of treating chronic non-malignant pain by conducting a qualitative evidence synthesis. Understanding this experience from the perspective of healthcare professionals will contribute to improvements in the provision of care.

DESIGN

Qualitative evidence synthesis using meta-ethnography. We searched five electronic bibliographic databases from inception to November 2016. We included studies that explore healthcare professionals' experience of treating adults with chronic non-malignant pain. We used the GRADE-CERQual framework to rate confidence in review findings.

RESULTS

We screened the 954 abstracts and 184 full texts and included 77 published studies reporting the experiences of over 1551 international healthcare professionals including doctors, nurses and other health professionals. We abstracted six themes: (1) a sceptical cultural lens, (2) navigating juxtaposed models of medicine, (3) navigating the geography between patient and clinician, (4) challenge of dual advocacy, (5) personal costs and (6) the craft of pain management. We rated confidence in review findings as moderate to high.

CONCLUSIONS

This is the first qualitative evidence synthesis of healthcare professionals' experiences of treating people with chronic non-malignant pain. We have presented a model that we developed to help healthcare professionals to understand, think about and modify their experiences of treating patients with chronic pain. Our findings highlight scepticism about chronic pain that might explain why patients feel they are not believed. Findings also indicate a dualism in the biopsychosocial model and the complexity of navigating therapeutic relationships. Our model may be transferable to other patient groups or situations.

Barriers to self-management of chronic pain in primary care: a qualitative focus group study

BACKGROUND

Supported self-management is a recommended intervention for chronic pain. Effective self-management should enable an individual to reduce the impact of pain on their everyday life. Clinical guidelines suggest primary care services have a role to play in supporting self-management of chronic pain.

AIM

To examine the opinions of primary care healthcare professionals (HCPs) and people with chronic pain and their carers, in order to identify possible barriers to the facilitation and adoption of self-management.

DESIGN AND SETTING

A qualitative study using focus groups in locations throughout Scotland.

METHOD

Eighteen focus groups were held with patients and HCPs. Fifty-four patients, nine carers, and 38 HCPs attended the groups.

RESULTS

Four categories of barriers were found. 1) Patient-HCP consultation: some patients felt a discussion about self-management came too late or not at all. Communication and building positive relations were sometimes challenging. 2) Patient experience: the emotional impact of pain was difficult and patients often felt unsupported by HCPs. 3) Limited treatment options: some participants felt there was a tendency for overmedicalisation. 4) Organisational constraints: short appointment times, long waiting lists, and a compartmentalised NHS created challenges.

CONCLUSION

This study illustrates some of the barriers faced by HCPs and patients in the facilitation and adoption of self-management of chronic pain. If self-management is to be an important approach to chronic pain, primary care services need to be designed to address the barriers identified.

Perspectives of Health Care Providers on US South Asians' Attitudes Toward Pain Management at End of Life

A lack of research on pain management among seriously ill South Asians reveals a critical gap in the knowledge base regarding culturally responsive end-of-life care. This qualitative descriptive study investigated the perspectives of health care providers that have cared for seriously ill older South Asians, on the attitudes of US South Asians toward the management of pain experienced at end of life and the factors that influenced these attitudes. Thematic analysis of interviews and focus group discussions with 57 health care providers indicated that providers perceive South Asian patients and families to be generally reluctant to use medications to treat pain experienced at end of life. Detailed description of patient-related and culturally based reasons for this reluctance is provided along with implications for hospice and palliative care.

Improving communication between health-care professionals and patients with limited English proficiency in the general practice setting

Quality service provision and patient safety and satisfaction in encounters with health-care professionals relies on effective communication between the practitioner and patient. This study aimed to identify effective practices for improving communication between clinical staff in general practice and patients with limited English proficiency, and to promote their implementation in general practice. Effective interventions and strategies were identified from a review of international research. Experiences with their use in practice were explored via focus group discussions with general practitioners and practice nurses. The results suggest that, wherever possible, communication in the patient’s primary language is preferable; use of a qualified medical interpreter should be promoted, and practices should have a standardised and documented procedure for accessing interpreter services. General practice staff must increase their awareness about services that are available to facilitate communication with patients with limited English proficiency, and also develop attitudes, both individual and organisational, that will maximise the effectiveness of these strategies. These findings were used to develop brief, evidence-based practice guidelines that were disseminated to focus group participants for evaluation of utility and general feedback. This evidence-based guidance is now available to assist clinical and administrative general practice staff across regional and metropolitan South Australia.

Organ trafficking for live donor kidney transplantation in Indoasians resident in the west midlands: high activity and poor outcomes

INTRODUCTION

Some Indoasian (IA) patients with established renal failure travel abroad for commercial kidney transplantation. We compared the 1-year outcomes of IA patients from one UK region who received overseas transplants with IA patients receiving local living donor (LD) kidney transplantation, deceased donor (DD) transplantation, and dialysis.

METHODS

Between 1996 and 2006, 40 adults were transplanted overseas; 38 were IA, and follow-up data were available on 36 patients. Forty IA patients received LD transplants, and 156 patients received DD transplants locally. A cohort of 120 prospective dialysis patients was also used as a comparator group.

RESULTS

In the overseas cohort, 20 patients (56%) were not active in the UK transplant waiting list at the time of kidney transplantation overseas. One-year graft survival was 87%, and 1-year patient survival was 83%. Composite graft and patient survival was 69.5% at 1 year. In the local LD transplant recipients, patient survival was 97.5% (39 of 40; P=0.03), and graft survival was 97.5% (39 of 40; P=0.06). Composite graft and patient survival was 95% (P=0.003). In the overseas group, 42% had major infections compared with 15% in the local group (P=0.02). One-year graft survival for DD transplant was 84.6% (132 of 156), and 1-year patient survival was 93% (145 of 156; P=NS and P=0.06, respectively). In the dialysis group, 1-year patient survival was 96.7% (116 of 120; P=0.001).

CONCLUSION

IA patients who choose to travel overseas for kidney transplantation have poor clinical outcomes and should be counseled accordingly.

Ethnicity and Culture and Their Relationship to Health Care

This paper focuses on recognizing the concepts of ethnicity, culture and diversity and how care can be delivered with the principle of equality to diverse communities. The learning outcomes and contents are listed in Box 1 . Much of this paper is likely to refresh existing knowledge rather than be new information for health care providers. However, I hope the perspective given enables you to challenge yourself and reflect on your own practice.

GPs' perceptions of the service needs of South Asian people with chronic pain: a qualitative enquiry

This qualitative study describes GPs' experiences of and needs for management of people from a South Asian community who have chronic pain. Semi-structured interviews were conducted with 18 GPs from practices in two PCTs in Leicester. The data was analysed using grounded theory. The results indicate that managing patients from a South Asian community with chronic pain can be challenging due to differing pain expression and presentation. Emerging themes refer to shortages of services for these patients including the need for CBT, counselling, community support and GP education and training. Potential implications of the results for service provision are discussed.

Qualitative research on pain

PURPOSE OF REVIEW

This review brings together developments over the past year in pain research using qualitative methodologies. In line with the goals of the current biopsychosocial model of pain, such a research framework offers in-depth understanding of the experience of pain within its cultural, familial and socioeconomic environmental context.

RECENT FINDINGS

Using 'qualitative' and 'pain' as title and keyword Medline and CSA database searches, the pain literature revealed four main areas where qualitative studies have contributed significantly to knowledge development. These are: general chronic pain care: perspectives of patients and practitioners; pain experience across the lifespan; psychosocial aspects of back pain; and experience of underresearched conditions.

SUMMARY

The detailed insight into subjective experiences of the pain sufferer or healthcare provider offered by qualitative research can make important contributions to evaluating and improving practice and also in theory development.