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Footman K. The illusion of treatment choice in abortion care: A qualitative study of comparative care experiences in England and Wales. Soc Sci Med 2024; 348:116873. [PMID: 38615614 DOI: 10.1016/j.socscimed.2024.116873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/12/2024] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
Treatment choice is a key component of quality, person-centred care, but policies promoting choice often ignore how capacity to choose is unequally distributed and influenced by social structures. In abortion care, the choice of either medication or a procedure is limited in many countries, but the structuring of treatment choice from the perspective of people accessing abortion care is poorly understood. This qualitative study explored comparative experiences of abortion treatment choice in England and Wales, using in-depth interviews with 32 people who recently accessed abortion care and had one or more prior abortions. A codebook approach was used to analyse the data, informed by a multidisciplinary framework for understanding the relationship between choice and equity. Abortion treatment choice was structured by multiple intersecting mechanisms: limitations on the supply of abortion care, incomplete or unbalanced information from providers, and participants' socio-economic environments. Long waiting times or travel distances could reduce choice of both treatment options. In interactions with providers, participants described not being offered procedural abortions or receiving information that favoured medication abortion. Participants' socio-economic environments impacted the way they navigated decision-making and their ability to manage the experience of either treatment option. Individual preferences for care were shaped in part by the interplay between these structural barriers, creating an illusion of choice, as the health system bias towards medication abortion reinforced some participants' negative perceptions of procedural abortion. The erosion of choice, to the point it is rendered illusory, has unequal impacts on quality of care. People's needs for their abortion care are complex and diverse, and access to varied service models is required to meet these needs. Treatment choice could be expanded by integrating public and private non-profit sector provision, aligning time limits and workforce requirements for abortion care with international standards, addressing financial pressures on service delivery, and revising the language used to depict each treatment option.
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Affiliation(s)
- Katy Footman
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, WC2A 2AE, UK.
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Hinton L, Dakin FH, Kuberska K, Boydell N, Willars J, Draycott T, Winter C, McManus RJ, Chappell LC, Chakrabarti S, Howland E, George J, Leach B, Dixon-Woods M. Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders. BMJ Qual Saf 2024; 33:301-313. [PMID: 35552252 PMCID: PMC11041557 DOI: 10.1136/bmjqs-2021-014329] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 03/15/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it. METHODS This UK-wide study involved interviews and an online survey inviting free-text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system-level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers. FINDINGS Participants included 106 pregnant women and 105 healthcare professionals and managers/stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety. CONCLUSIONS This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research.
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Affiliation(s)
- Lisa Hinton
- THIS Institute (The Healthcare Improvement Studies), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francesca H Dakin
- Nuffield Department of Primary Health Care Sciences, Oxford University, Oxford, UK
| | - Karolina Kuberska
- THIS Institute (The Healthcare Improvement Studies), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Tim Draycott
- Royal College of Obstetricians and Gynaecologists, London, UK
| | | | - Richard J McManus
- Nuffield Department of Primary Health Care Sciences, Oxford University, Oxford, UK
| | - Lucy C Chappell
- Maternal and Fetal Research Unit Division of Women's Health, St Thomas' Hospital, London, UK
| | | | - Elizabeth Howland
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Kellett S, Bee C, Smithies J, Aadahl V, Simmonds-Buckley M, Power N, Dugen-Williams C, Fallon N, Delgadillo J. Cognitive-behavioural versus cognitive-analytic guided self-help for mild-to-moderate anxiety: a pragmatic, randomised patient preference trial. Br J Psychiatry 2023; 223:438-445. [PMID: 37395600 PMCID: PMC10895510 DOI: 10.1192/bjp.2023.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/04/2023] [Accepted: 05/16/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Guided self-help (GSH) for anxiety is widely implemented in primary care services because of service efficiency gains, but there is also evidence of poor acceptability, low effectiveness and relapse. AIMS The aim was to compare preferences for, acceptability and efficacy of cognitive-behavioural guided self-help (CBT-GSH) versus cognitive-analytic guided self-help (CAT-GSH). METHOD This was a pragmatic, randomised, patient preference trial (Clinical trials identifier: NCT03730532). The Beck Anxiety Inventory (BAI) was the primary outcome at 8- and 24-week follow-up. Interventions were delivered competently on the telephone via structured workbooks over 6-8 (30-35 min) sessions by trained practitioners. RESULTS A total of 271 eligible participants were included, of whom 19 (7%) accepted being randomised and 252 (93%) chose their treatment. In the preference cohort, 181 (72%) chose CAT-GSH and 71 (28%) preferred CBT-GSH. BAI outcomes in the preference and randomised cohorts did not differ at 8 weeks (-0.80, 95% confidence interval (CI) -4.52 to 2.92) or 24 weeks (0.85, 95% CI -2.87 to 4.57). After controlling for allocation method and baseline covariates, there were no differences between CAT-GSH and CBT-GSH at 8 weeks (F(1, 263) = 0.22, P = 0.639) or at 24 weeks (F(1, 263) = 0.22, P = 0.639). Mean BAI change from baseline was a reduction of 9.28 for CAT-GSH and 9.78 for CBT-GSH at 8 weeks and 12.90 for CAT-GSH and 12.43 for CBT-GSH at 24 weeks. CONCLUSIONS Patients accessing routine primary care talking treatments prefer to choose the intervention they receive. CAT-GSH expands the treatment offer in primary care for patients with anxiety seeking a brief but analytically informed GSH solution.
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Affiliation(s)
- Stephen Kellett
- Rotherham Doncaster and South Humber NHS Foundation Trust, UK; and University of Sheffield, UK
| | | | | | | | | | - Niall Power
- Derbyshire Community Health Services NHS Foundation Trust, UK
| | | | | | - Jaime Delgadillo
- Rotherham Doncaster and South Humber NHS Foundation Trust, UK; and University of Sheffield, UK
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Faija CL, Connell J, Gellatly J, Rushton K, Lovell K, Brooks H, Armitage C, Bower P, Bee P. Enhancing the quality of psychological interventions delivered by telephone in mental health services: increasing the likelihood of successful implementation using a theory of change. BMC Psychiatry 2023; 23:405. [PMID: 37280575 DOI: 10.1186/s12888-023-04829-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/29/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The implementation of new and complex interventions in mental health settings can be challenging. This paper explores the use of a Theory of Change (ToC) for intervention design and evaluation to increase the likelihood of complex interventions being effective, sustainable, and scalable. Our intervention was developed to enhance the quality of psychological interventions delivered by telephone in primary care mental health services. METHODS A ToC represents how our designed quality improvement intervention targeting changes at service, practitioner, and patient levels was expected to improve engagement in, and the quality of, telephone-delivered psychological therapies. The intervention was evaluated following implementation in a feasibility study within three NHS Talking Therapies services through a qualitative research design incorporating semi-structured interviews and a focus group with key stakeholders (patients, practitioners, and service leads) (N = 15). Data were analysed using the Consolidated Framework for Implementation Research (CFIR) and the ToC was examined and modified accordingly following the findings. RESULTS CFIR analysis highlighted a set of challenges encountered during the implementation of our service quality improvement telephone intervention that appeared to have weakened the contribution to the change mechanisms set out by the initial ToC. Findings informed changes to the intervention and refinement of the ToC and are expected to increase the likelihood of successful future implementation in a randomised controlled trial. CONCLUSIONS Four key recommendations that could help to optimise implementation of a complex intervention involving different key stakeholder groups in any setting were identified. These include: 1-developing a good understanding of the intervention and its value among those receiving the intervention; 2-maximising engagement from key stakeholders; 3-ensuring clear planning and communication of implementation goals; and 4-encouraging the use of strategies to monitor implementation progress.
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Affiliation(s)
- Cintia L Faija
- School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
| | - Janice Connell
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Judith Gellatly
- School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK
| | - Kelly Rushton
- School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK
| | - Karina Lovell
- School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Helen Brooks
- School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK
| | - Christopher Armitage
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Peter Bower
- Centre for Primary Care and Centre for Health Informatics, NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Penny Bee
- School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK
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Saxon D, Barkham M, Bee P, Gellatly J, Faija C, Bower P. Telephone treatments in Improving Access to Psychological Therapies services: an analysis of use and impact on treatment uptake. BMC Psychiatry 2023; 23:95. [PMID: 36750788 PMCID: PMC9903253 DOI: 10.1186/s12888-022-04404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/18/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND There is debate about how best to increase access to psychological therapy and deliver mental healthcare effectively and efficiently at a national level. One trend is the increased use of the telephone to deliver therapy. However, there is the potential to disadvantage certain patient groups and/or impact on uptake of help. This study aims to answer three questions: (i) Which factors are associated with being offered an assessment by telephone? (ii) Which factors are associated with attendance at assessment? and (iii) What is the impact of an assessment by telephone on subsequent treatment appointment? METHODS Routine outcome data was provided by seven UK Improving Access to Psychological Therapy services. The analysis sample comprised 49,923 patients who referred to 615 general practices in 2017. Multilevel modelling, including service and GP practice as random factors, was used to answer the three research questions. RESULTS The offer of an initial assessment by telephone was strongly associated with local service configuration. Patient self-referral, a shorter wait, greater age and lower deprivation were associated with attendance at assessment and subsequent treatment session. Telephone mode assessment had no impact on the uptake of the assessment but may influence the uptake of further treatment if this was also by telephone. The practitioner carrying out the assessment had a significant effect on subsequent treatment uptake. CONCLUSION Offering telephone assessments does not have a negative impact on uptake of assessment and services may benefit by facilitating and integrating telephone assessments into their systems. The COVID-19 pandemic has accelerated the use of telephone and other remote means of delivery, and results from this study can inform services to consider how best to re-configure post-pandemic.
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Affiliation(s)
- David Saxon
- Department of Psychology, Clinical and Applied Psychology Unit (CAPU), University of Sheffield, 1 Vicar Lane, S1 2LT, Sheffield, UK.
| | - Michael Barkham
- grid.11835.3e0000 0004 1936 9262Department of Psychology, Clinical and Applied Psychology Unit (CAPU), University of Sheffield, 1 Vicar Lane, S1 2LT Sheffield, UK
| | - Penny Bee
- grid.5379.80000000121662407School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Judith Gellatly
- grid.5379.80000000121662407School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Cintia Faija
- grid.5379.80000000121662407School of Health Sciences, Division of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Peter Bower
- grid.5379.80000000121662407NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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