1
|
Sohanpal R, Mammoliti KM, Barradell A, Kelly M, Newton S, Steed L, Wileman V, Rowland V, Dibao-Dina C, Moore A, Pinnock H, Taylor SJC. Patient perspectives on the Tailored intervention for Anxiety and Depression Management in COPD (TANDEM): a qualitative evaluation. BMC Health Serv Res 2024; 24:960. [PMID: 39169308 PMCID: PMC11337569 DOI: 10.1186/s12913-024-11370-9] [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: 04/15/2024] [Accepted: 07/29/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is commonly associated with anxiety/depression which can affect self-management and quality of life. The TANDEM trial evaluated a cognitive behavioural approach intervention targeting COPD-related symptoms of anxiety and/or depression, comprising up to eight one-to-one sessions delivered by respiratory healthcare professionals prior to pulmonary rehabilitation (PR). The intervention showed no improvement in anxiety/depression or uptake/completion of PR. We present patient perspectives of the intervention to help understand these results. METHOD Semi-structured individual interviews, using a semi-structured topic guide informed by Sekhon's Theoretical Framework of Acceptability, were conducted with 19 patients between September 2019 and April 2020. The interviews were audio-recorded, transcribed verbatim and analysed thematically. RESULTS The following could have limited the impact of the intervention: (1) The lives of patients were complex and commonly affected by competing comorbidities or other external stressors which they managed through previously adopted long-standing coping strategies. (2) Some patients were reluctant to talk about their mood despite the Facilitators' training and person centred-skills which aimed to enable patients to talk freely about mood. (3) The intervention handouts and 'home-practice' were perceived as helpful for some, but not suitable for all. (4) Many patients perceived improvements in their physical and mental health, but this was not sustained due to a mix of personal and external factors, and some did not perceive any benefits. (5) PR non-attendance/non-completion was a result of personal and PR service-related reasons. (6) Discussing COPD and mental health with the Facilitator was a novel experience. Many patients felt that TANDEM could be of benefit if it was offered earlier on/at different time points in the COPD illness journey. CONCLUSION We found the delivery of TANDEM prior to PR was not helpful for patients with advanced COPD often experiencing other comorbidities, and/or difficult personal/external events. These patients already utilised long-standing coping strategies to manage their COPD. Holistic interventions, that address the impact of COPD in relation to wider aspects of a patients' life, may be more beneficial. TRIAL REGISTRATION ISRCTN Registry 59,537,391. Registration date 20 March 2017.
Collapse
Affiliation(s)
| | | | - Amy Barradell
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | - Liz Steed
- Queen Mary University of London, London, UK
| | | | | | | | | | | | | |
Collapse
|
2
|
Dixon J, Morton B, Nkhata MJ, Silman A, Simiyu IG, Spencer SA, Van Pinxteren M, Bunn C, Calderwood C, Chandler CIR, Chikumbu E, Crampin AC, Hurst JR, Jobe M, Kengne AP, Levitt NS, Moshabela M, Owolabi M, Peer N, Phiri N, Singh SJ, Tamuhla T, Tembo M, Tiffin N, Worrall E, Yongolo NM, Banda GT, Bickton F, Bilungula AMM, Bosire E, Chawani MS, Chinoko B, Chisala M, Chiwanda J, Drew S, Farrant L, Ferrand RA, Gondwe M, Gregson CL, Harding R, Kajungu D, Kasenda S, Katagira W, Kwaitana D, Mendenhall E, Mensah ABB, Mnenula M, Mupaza L, Mwakasungula M, Nakanga W, Ndhlovu C, Nkhoma K, Nkoka O, Opare-Lokko EA, Phulusa J, Price A, Rylance J, Salima C, Salimu S, Sturmberg J, Vale E, Limbani F. Interdisciplinary perspectives on multimorbidity in Africa: Developing an expanded conceptual model. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003434. [PMID: 39078807 PMCID: PMC11288440 DOI: 10.1371/journal.pgph.0003434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 06/11/2024] [Indexed: 08/02/2024]
Abstract
Multimorbidity is an emerging challenge for health systems globally. It is commonly defined as the co-occurrence of two or more chronic conditions in one person, but its meaning remains a lively area of academic debate, and the utility of the concept beyond high-income settings is uncertain. This article presents the findings from an interdisciplinary research initiative that drew together 60 academic and applied partners working in 10 African countries to answer the questions: how useful is the concept of multimorbidity within Africa? Can the concept be adapted to context to optimise its transformative potentials? During a three-day concept-building workshop, we investigated how the definition of multimorbidity was understood across diverse disciplinary and regional perspectives, evaluated the utility and limitations of existing concepts and definitions, and considered how to build a more context-sensitive, cross-cutting description of multimorbidity. This iterative process was guided by the principles of grounded theory and involved focus- and whole-group discussions during the workshop, thematic coding of workshop discussions, and further post-workshop development and refinement. Three thematic domains emerged from workshop discussions: the current focus of multimorbidity on constituent diseases; the potential for revised concepts to centre the priorities, needs, and social context of people living with multimorbidity (PLWMM); and the need for revised concepts to respond to varied conceptual priorities amongst stakeholders. These themes fed into the development of an expanded conceptual model that centres the catastrophic impacts multimorbidity can have for PLWMM, families and support structures, service providers, and health systems.
Collapse
Affiliation(s)
- Justin Dixon
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ben Morton
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Misheck J. Nkhata
- SHLS Nursing and Midwifery, Teesside University, Middlesborough, United Kingdom
| | - Alan Silman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, United Kingdom
| | - Ibrahim G. Simiyu
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Stephen A. Spencer
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Myrna Van Pinxteren
- Faculty of Health Sciences, Department of Medicine and Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa
| | - Christopher Bunn
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- College of Social Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Claire Calderwood
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Clare I. R. Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Edith Chikumbu
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Amelia C. Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Modou Jobe
- MRC Unit The Gambia at LSHTM, Banjul, The Gambia
| | - Andre Pascal Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, Durban, South Africa
| | - Naomi S. Levitt
- Faculty of Health Sciences, Department of Medicine and Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Mayowa Owolabi
- Centre for Genomic and Precision Medicine, University of Ibadan, Ibadan, Nigeria
| | - Nasheeta Peer
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, Durban, South Africa
| | - Nozgechi Phiri
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Sally J. Singh
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Tsaone Tamuhla
- South African National Bioinformatics Institute, University of the Western Cape, Cape Town, South Africa
| | - Mandikudza Tembo
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nicki Tiffin
- South African National Bioinformatics Institute, University of the Western Cape, Cape Town, South Africa
| | - Eve Worrall
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nateiya M. Yongolo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Gift T. Banda
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Fanuel Bickton
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Department of Rehabilitation Sciences, The Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Edna Bosire
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- SAMRC Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Marlen S. Chawani
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Health Economics and Policy Unit, The Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Mphatso Chisala
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Jonathan Chiwanda
- Department of Non-communicable Diseases, Ministry of Health, Lilongwe, Malawi
| | - Sarah Drew
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Lindsay Farrant
- Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rashida A. Ferrand
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mtisunge Gondwe
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Celia L. Gregson
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Richard Harding
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, United Kingdom
| | - Dan Kajungu
- Makerere University Centre for Health and Population Research, Makerere University, Kampala, Uganda
| | - Stephen Kasenda
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | | | - Duncan Kwaitana
- Department of Family Medicine, The Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Emily Mendenhall
- Edmund A. Walsh School of Foreign Service, Georgetown University, Washington, DC, United States of America
| | - Adwoa Bemah Boamah Mensah
- Department of Nursing, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Modai Mnenula
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | - Wisdom Nakanga
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Deanery of Clinical Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Chiratidzo Ndhlovu
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Kennedy Nkhoma
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, United Kingdom
| | - Owen Nkoka
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- College of Social Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Edwina Addo Opare-Lokko
- Greater Accra Regional Hospital, Faculty of Family Medicine, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Jacob Phulusa
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Alison Price
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jamie Rylance
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Charity Salima
- Achikondi Women and Community Friendly Health Services, Lilongwe, Malawi
| | - Sangwani Salimu
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Joachim Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
- International Society of Systems and Complexity Sciences for Health, Waitsfield, VT, United States of America
| | - Elizabeth Vale
- University of the Witwatersrand, Johannesburg, South Africa
| | - Felix Limbani
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| |
Collapse
|
3
|
Milani A, Saiani L, Misurelli E, Lacapra S, Pravettoni G, Magon G, Mazzocco K. The relevance of the contribution of psychoneuroendocrinoimmunology and psychology of reasoning and decision making to nursing science: A discursive paper. J Adv Nurs 2024; 80:2943-2957. [PMID: 38318634 DOI: 10.1111/jan.16087] [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: 03/05/2023] [Revised: 11/20/2023] [Accepted: 01/21/2024] [Indexed: 02/07/2024]
Abstract
AIM Patients' death or adverse events appear to be associated with poor healthcare decision-making. This might be due to an inability to have an adequate representation of the problem or of the connections among problem-related elements. Changing how a problem is formulated can reduce biases in clinical reasoning. The purpose of this article is to explore the possible contributions of psychoneuroendocrinoimmunology (PNEI) and psychology of reasoning and decision-making (PRDM) to support a new nursing theoretical frame. DESIGN Discursive paper. METHOD This article discusses the main assumptions about nursing and nurses' ability to face patient's problems, suggesting a new approach that integrates knowledge from PNEI and PRDM. While PNEI explains the complexity of systems, highlighting the importance of systems connections in affecting health, PRDM underlines the importance of the informative context in creating a mental representation of the problem. Furthermore, PRDM suggests the need to pay attention to information that is not immediately explicit and its connections. CONCLUSION Nursing recognizes the patient-nurse relationship as the axiom that governs care. The integration of PNEI and PRDM in nursing theoretics allows the expansion of the axiom by providing essential elements to read a new type of relationship: the relationship among information. PNEI explains the relationships between biological systems and the psyche and between the whole individual and the environment; PRDM provides tools for the nurse's analytical thinking system to correctly process information and its connections. IMPACT ON NURSING PRACTICE A theoretical renewal is mandatory to improve nursing reasoning and nursing priority identification. Integrating PNEI and PRDM into nursing theoretics will modify the way professionals approach patients, reducing cognitive biases and medical errors. NO PATIENT OR PUBLIC CONTRIBUTION There was no patient or public involvement in the design or writing of this discursive article.
Collapse
Affiliation(s)
- Alessandra Milani
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
- PhD Student, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Eliana Misurelli
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Silvana Lacapra
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giorgio Magon
- Nursing Manager, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Ketti Mazzocco
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
| |
Collapse
|
4
|
Sohanpal R, Pinnock H, Steed L, Heslop-Marshall K, Kelly MJ, Chan C, Wileman V, Barradell A, Dibao-Dina C, Font Gilabert P, Healey A, Hooper R, Mammoliti KM, Priebe S, Roberts M, Rowland V, Waseem S, Singh S, Smuk M, Underwood M, White P, Yaziji N, Taylor SJ. A tailored psychological intervention for anxiety and depression management in people with chronic obstructive pulmonary disease: TANDEM RCT and process evaluation. Health Technol Assess 2024; 28:1-129. [PMID: 38229579 PMCID: PMC11017633 DOI: 10.3310/pawa7221] [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] [Indexed: 01/18/2024] Open
Abstract
Background People with chronic obstructive pulmonary disease have high levels of anxiety and depression, which is associated with increased morbidity and poor uptake of effective treatments, such as pulmonary rehabilitation. Cognitive-behavioural therapy improves mental health of people with long-term conditions and could potentially increase uptake of pulmonary rehabilitation, enabling synergies that could enhance the mental health of people with chronic obstructive pulmonary disease. Aim Our aim was to develop and evaluate the clinical effectiveness and cost effectiveness of a tailored cognitive-behavioural approach intervention, which links into, and optimises the benefits of, routine pulmonary rehabilitation. Design We carried out a pragmatic multicentre randomised controlled trial using a 1.25 : 1 ratio (intervention : control) with a parallel process evaluation, including assessment of fidelity. Setting Twelve NHS trusts and five Clinical Commissioning Groups in England were recruited into the study. The intervention was delivered in participant's own home or at a local NHS facility, and by telephone. Participants Between July 2017 and March 2020 we recruited adults with moderate/very severe chronic obstructive pulmonary disease and mild/moderate anxiety and/or depression, meeting eligibility criteria for assessment for pulmonary rehabilitation. Carers of participants were invited to participate. Intervention The cognitive-behavioural approach intervention (i.e. six to eight 40- to 60-minute sessions plus telephone support throughout pulmonary rehabilitation) was delivered by 31 trained respiratory healthcare professionals to participants prior to commencing pulmonary rehabilitation. Usual care included routine pulmonary rehabilitation referral. Main outcome measures Co-primary outcomes were Hospital Anxiety and Depression Scale - anxiety and Hospital Anxiety and Depression Scale - depression at 6 months post randomisation. Secondary outcomes at 6 and 12 months included health-related quality of life, smoking status, uptake of pulmonary rehabilitation and healthcare use. Results We analysed results from 423 randomised participants (intervention, n = 242; control, n = 181). Forty-three carers participated. Follow-up at 6 and 12 months was 93% and 82%, respectively. Despite good fidelity for intervention delivery, mean between-group differences in Hospital Anxiety and Depression Scale at 6 months ruled out clinically important effects (Hospital Anxiety and Depression Scale - anxiety mean difference -0.60, 95% confidence interval -1.40 to 0.21; Hospital Anxiety and Depression Scale - depression mean difference -0.66, 95% confidence interval -1.39 to 0.07), with similar results at 12 months. There were no between-group differences in any of the secondary outcomes. Sensitivity analyses did not alter these conclusions. More adverse events were reported for intervention participants than for control participants, but none related to the trial. The intervention did not generate quality-of-life improvements to justify the additional cost (adjusted mean difference £770.24, 95% confidence interval -£27.91 to £1568.39) to the NHS. The intervention was well received and many participants described positive affects on their quality of life. Facilitators highlighted the complexity of participants' lives and considered the intervention to be of potential valuable; however, the intervention would be difficult to integrate within routine clinical services. Our well-powered trial delivered a theoretically designed intervention with good fidelity. The respiratory-experienced facilitators were trained to deliver a low-intensity cognitive-behavioural approach intervention, but high-intensity cognitive-behavioural therapy might have been more effective. Our broad inclusion criteria specified objectively assessed anxiety and/or depression, but participants were likely to favour talking therapies. Randomisation was concealed and blinding of outcome assessment was breached in only 15 participants. Conclusions The tailored cognitive-behavioural approach intervention delivered with fidelity by trained respiratory healthcare professionals to people with chronic obstructive pulmonary disease was neither clinically effective nor cost-effective. Alternative approaches that are integrated with routine long-term condition care are needed to address the unmet, complex clinical and psychosocial needs of this group of patients. Trial registration This trial is registered as ISRCTN59537391. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/146/02) and is published in full in Health Technology Assessment; Vol. 28, No. 1. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Ratna Sohanpal
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Liz Steed
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Moira J Kelly
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Claire Chan
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Vari Wileman
- School of Mental Health and Psychological Sciences, Institute of Psychiatry, King's College London, London, UK
| | - Amy Barradell
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Paulino Font Gilabert
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | - Andy Healey
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | - Richard Hooper
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Kristie-Marie Mammoliti
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Priebe
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mike Roberts
- Safer Care Victoria, Melbourne, Melbourne, VIC, Australia
| | | | | | - Sally Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Melanie Smuk
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick White
- Department of Population Health, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Nahel Yaziji
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | - Stephanie Jc Taylor
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
5
|
Piotrowski A, Coenen J, Rupietta C, Basten J, Muth C, Söling S, Zimmer V, Karbach U, Kellermann-Mühlhoff P, Köberlein-Neu J. Factors facilitating the implementation of a clinical decision support system in primary care practices: a fuzzy set qualitative comparative analysis. BMC Health Serv Res 2023; 23:1161. [PMID: 37884934 PMCID: PMC10605331 DOI: 10.1186/s12913-023-10156-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Understanding how to implement innovations in primary care practices is key to improve primary health care. Aiming to contribute to this understanding, we investigate the implementation of a clinical decision support system (CDSS) as part of the innovation fund project AdAM (01NVF16006). Originating from complexity theory, the practice change and development model (PCD) proposes several interdependent factors that enable organizational-level change and thus accounts for the complex settings of primary care practices. Leveraging the PCD, we seek to answer the following research questions: Which combinations of internal and external factors based on the PCD contribute to successful implementation in primary care practices? Given these results, how can implementation in the primary care setting be improved? METHODS We analyzed the joint contributions of internal and external factors on implementation success using qualitative comparative analysis (QCA). QCA is a set-theoretic approach that allows to identify configurations of multiple factors that lead to one outcome (here: successful implementation of a CDSS in primary care practices). Using survey data, we conducted our analysis based on a sample of 224 primary care practices. RESULTS We identified two configurations of internal and external factors that likewise enable successful implementation. The first configuration enables implementation based on a combination of Strong Inside Motivation, High Capability for Development, and Strong Outside Motivation; the second configuration based on a combination of Strong Inside Motivators, Many Options for Development and the absence of High Capability for Development. CONCLUSION In line with the PCD, our results demonstrate the importance of the combination of internal and external factors for implementation outcomes. Moreover, the two identified configurations show that different ways exist to achieve successful implementation in primary care practices. TRIAL REGISTRATION AdAM was registered on ClinicalTrials.gov ( NCT03430336 ) on February 6, 2018.
Collapse
Affiliation(s)
- Alexandra Piotrowski
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany.
- Chair of General Practice II and Patient-Centeredness in Primary Care, Institute of General Practice and Primary Care, Faculty of Health, Witten/Herdecke University, Witten, Germany.
| | - Jana Coenen
- Jackstädt Center of Entrepreneurship and Innovation Research, University of Wuppertal, Wuppertal, Germany
| | - Christian Rupietta
- Jackstädt Center of Entrepreneurship and Innovation Research, University of Wuppertal, Wuppertal, Germany
- Queen's Business School, Queen's University Belfast, Belfast, UK
| | - Jale Basten
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | - Christiane Muth
- Department of General Practice and Family Medicine, Medical School OWL, Bielefeld University, Bielefeld, Germany
| | - Sara Söling
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Department of Rehabilitation and Special Education, Faculty of Human Sciences, University of Cologne, Cologne, Germany
| | - Viola Zimmer
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | - Ute Karbach
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Department of Rehabilitation and Special Education, Faculty of Human Sciences, University of Cologne, Cologne, Germany
| | | | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| |
Collapse
|
6
|
STANGE KURTC, MILLER WILLIAML, ETZ REBECCAS. The Role of Primary Care in Improving Population Health. Milbank Q 2023; 101:795-840. [PMID: 37096603 PMCID: PMC10126984 DOI: 10.1111/1468-0009.12638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 04/26/2023] Open
Abstract
Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.
Collapse
Affiliation(s)
- KURT C. STANGE
- Center for Community Health IntegrationCase Western Reserve University
| | - WILLIAM L. MILLER
- Lehigh Valley Health System and University of South Florida Morsani College of Medicine
| | | |
Collapse
|
7
|
Borghmans F, Laletas S. Complex adaptive phenomenology: A conceptual framework for healthcare research. J Eval Clin Pract 2023. [PMID: 36740901 DOI: 10.1111/jep.13811] [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: 05/09/2022] [Accepted: 01/16/2023] [Indexed: 02/07/2023]
Abstract
RATIONALE Healthcare research exploring the lived experiences of health care professionals from different disciplines, such as nursing, medicine, and allied health, has repeatedly highlighted many methodological challenges, especially in understanding the individual human experience within complex systems. In response, complexity theory and phenomenological approaches emerged and evolved in ways that potentially offered researchers frameworks to inform an understanding of the individual human experience. However, while these two theoretical approaches inform a method of inquiry, there is a gap in understanding the phenomenon of 'being' and how this is embodied within complex systems such as the healthcare system. THE AIMS AND OBJECTIVES The aim of this paper is to present an integrated theoretical framework, namely complex adaptive phenomenology (CAP). CAP aims to address this inquiry gap by offering a structured conceptual framework wherein complexity theory and phenomenology are complementary but multi-dimensional. The key objective of CAP was to synthesize and integrate two methods of inquiry that examine the relational aspects of 'being', that is the gestalt of perception, action, and context, The authors argue that CAP is well-suited to complex research contexts such as healthcare. The framework focuses on the reciprocal, co-constructive relationships extant between perception, meaning, context, and action that shape experiences of 'being' within complex systems. Complexity theory's connectionist orientation explains the relationships that are formative of the experience of being, while phenomenology explores the manifestations of these formative relationships by attending to the notion of 'being' itself. CONCLUSION The authors propose that an integrated framework, of phenomenology and complexity theory, can provide a platform for deeper understandings of the experiences of health professionals and contribute to healthcare scholarship.
Collapse
|
8
|
Meyer C, Dickins M, O’Keefe F, Hall K, Lowthian J. Risk Negotiation With People With Dementia: From Co-designed Paper Version to Implementation Preparation of an Electronic Conversation Tool. Gerontol Geriatr Med 2023; 9:23337214221149772. [PMID: 36726412 PMCID: PMC9885029 DOI: 10.1177/23337214221149772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 01/28/2023] Open
Abstract
The home care workforce provides essential support for older people with dementia to live a life of fulfillment. "Enabling Choices," an evidence-informed conversation tool, aims to negotiate risk around everyday activities between home care workers, people with dementia and their informal carers. This paper describes tool conversion into electronic format and preparation for implementation throughout a large Australian health and aged care service provider, utilizing the Implementation Framework for Aged Care (IFAC). Using codesign principles, the tool was converted from paper-based to electronic format involving frontline, operational and Information Management Services staff, and people with dementia/carers. Focus groups and interviews identified tool acceptability, feasibility, and appropriateness. For implementation preparation, the wider socio-cultural-political context was mapped, and key questions of the IFAC addressed. Environment, workflow, and training requirements were determined, and strategies for behavior change ascertained. Numerous opportunities and challenges exist for the widespread upscale of an evidence-informed tool into practice.
Collapse
Affiliation(s)
- Claudia Meyer
- Bolton Clarke Research Institute,
Forest Hill, VIC, Australia,La Trobe University, Bundoora, VIC,
Australia,Monash University, Frankston, VIC,
Australia,Flinders University, Adelaide, SA,
Australia,Claudia Meyer, Bolton Clarke Research
Institute, Level 1, 347 Burwood Highway, Forest Hill, VIC 3131, Australia.
| | - Marissa Dickins
- Bolton Clarke Research Institute,
Forest Hill, VIC, Australia,Monash University, Clayton, VIC,
Australia
| | - Fleur O’Keefe
- Bolton Clarke Research Institute,
Forest Hill, VIC, Australia
| | - Kylie Hall
- Bolton Clarke Research Institute,
Forest Hill, VIC, Australia
| | - Judy Lowthian
- Bolton Clarke Research Institute,
Forest Hill, VIC, Australia,Monash University, Clayton, VIC,
Australia,University of Queensland, St Lucia,
Australia
| |
Collapse
|
9
|
Dixon J, Mendenhall E, Bosire EN, Limbani F, Ferrand RA, Chandler CIR. Making morbidity multiple: History, legacies, and possibilities for global health. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2023; 13:26335565231164973. [PMID: 37008536 PMCID: PMC10052471 DOI: 10.1177/26335565231164973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/04/2023] [Indexed: 06/19/2023]
Abstract
Multimorbidity has been framed as a pressing global health challenge that exposes the limits of systems organised around single diseases. This article seeks to expand and strengthen current thinking around multimorbidity by analysing its construction within the field of global health. We suggest that the significance of multimorbidity lies not only in challenging divisions between disease categories but also in what it reveals about the culture and history of transnational biomedicine. Drawing on social research from sub-Saharan Africa to ground our arguments, we begin by describing the historical processes through which morbidity was made divisible in biomedicine and how the single disease became integral not only to disease control but to the extension of biopolitical power. Multimorbidity, we observe, is hoped to challenge single disease approaches but is assembled from the same problematic, historically-loaded categories that it exposes as breaking down. Next, we highlight the consequences of such classificatory legacies in everyday lives and suggest why frameworks and interventions to integrate care have tended to have limited traction in practice. Finally, we argue that efforts to align priorities and disciplines around a standardised biomedical definition of multimorbidity risks retracing the same steps. We call for transdisciplinary work across the field of global health around a more holistic, reflexive understanding of multimorbidity that foregrounds the culture and history of translocated biomedicine, the intractability of single disease thinking, and its often-adverse consequences in local worlds. We outline key domains within the architecture of global health where transformation is needed, including care delivery, medical training, the organisation of knowledge and expertise, global governance, and financing.
Collapse
Affiliation(s)
- Justin Dixon
- The Health Research Unit Zimbabwe (THRU ZIM), Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Emily Mendenhall
- Edmund A. Walsh School of Foreign Service, Georgetown University, Washington, DC, United States
- Faculty of Health Sciences, SAMRC Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Edna N Bosire
- Faculty of Health Sciences, SAMRC Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - Felix Limbani
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rashida A Ferrand
- The Health Research Unit Zimbabwe (THRU ZIM), Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
10
|
Telles Correia D, Stoyanov D, Rocha Neto HG. How to define today a medical disorder? Biological and psychosocial disadvantages as the paramount criteria. J Eval Clin Pract 2022; 28:1195-1204. [PMID: 34105223 DOI: 10.1111/jep.13592] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 04/13/2021] [Accepted: 05/22/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The 20th century has seen great developments in the concept of disease. Marked by the biopsychosocial paradigm, several strategies for disease definition were added to previous descriptive organic views, but a final concept is still out of reach. METHOD A critical review was carried out on thorough analysis of articles and textbooks to describe the main concepts and definitions of disease. RESULTS The concept 'disease' is a pragmatic construct, not a natural kind. Three main ways to define disease were identified, and characterized: Biological (disease as a lesion, disadvantage/deviation from normal and dysfunction), Psychosocial (distress and disability, existential potentials, descriptive prototype, and prototype typification), and values-based definition. CONCLUSION All the paradigms have advantages and flaws, but progressive use of all criteria in disease definition adds validity and reliability to diagnostic constructs. Such constructs must be, above all, useful for practice and research. Biological paradigm is relevant, but fails to cover all the complexity that involves human illness and the treatment process. An emphasis on distress, dysfunction, and carefully selected value-laden characteristics might be the right direction for useful diagnostic construct conceptions.
Collapse
Affiliation(s)
- Diogo Telles Correia
- Faculdade de Medicina, Clinica Universitária de Psiquiatria e Psicologia Médica, Universidade de Lisboa, Lisbon, Portugal
| | - Drozdstoy Stoyanov
- Division of Translational Neuroscience, Research Institute, Department of Psychiatry and Medical Psychology, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Helio G Rocha Neto
- Faculdade de Medicina, Clinica Universitária de Psiquiatria e Psicologia Médica, Universidade de Lisboa, Lisbon, Portugal.,Programa de Pós Graduação em Psiquiatria e Saúde Mental-PROPSAM, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro-UFRJ, Rio de Janeiro, Brazil
| |
Collapse
|
11
|
Lynch JM, van Driel M, Meredith P, Stange KC, Getz L, Reeve J, Miller WL, Dowrick C. The Craft of Generalism clinical skills and attitudes for whole person care. J Eval Clin Pract 2022; 28:1187-1194. [PMID: 34652051 DOI: 10.1111/jep.13624] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/16/2021] [Accepted: 09/12/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism. METHODS The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research. RESULTS The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent. CONCLUSIONS Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.
Collapse
Affiliation(s)
- Johanna M Lynch
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia.,Integrate Place at Zest Infusion, Birkdale, Queensland, Australia
| | - Mieke van Driel
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia
| | - Pamela Meredith
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | - Kurt C Stange
- Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio, USA
| | - Linn Getz
- Department of Public Health and Nursing, NTNU: Norwegian University of Science and Technology, Trondheim, Norway
| | - Joanne Reeve
- Primary Care Research, Hull York Medical School, Hull, UK
| | - William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA.,Department of Family Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Christopher Dowrick
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| |
Collapse
|
12
|
Sturmberg J. There is More to 'Making Connections to Improve Health Outcomes'. Glob Adv Health Med 2022; 11:2164957X221126675. [PMID: 36160085 PMCID: PMC9500305 DOI: 10.1177/2164957x221126675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022] Open
Abstract
Langevin1 rightly points to the reductionist mindset being the stumbling block for providing person-centered care. While considering the interconnections between the various domains underpinning health is a necessary first step towards more person-centered care, it ultimately is not sufficient. Person-centered care arises from the appreciation of the interdependencies and interactions between the various domains across its large-scale supersystems as much as its small-scale subsystems. Viewed with a complex-adaptive systems mindset health and disease are the phenotypical outcome categorisations of a person’s whole-of-systems dynamics across all scales of organisation.2,3
Collapse
Affiliation(s)
- Joachim Sturmberg
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,International Society for Systems and Complexity Sciences for Health
| |
Collapse
|
13
|
Johnsen TM, Norberg BL, Krogh FH, Vonen HD, Getz LO, Austad B. The impact of clinical experience on working tasks and job-related stress: a survey among 1032 Norwegian GPs. BMC PRIMARY CARE 2022; 23:216. [PMID: 36030207 PMCID: PMC9419378 DOI: 10.1186/s12875-022-01810-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND General practice is a generalist discipline fraught with complexity. For inexperienced physicians, it may be demanding to get to grips with the clinical challenges. The purpose of this article is to describe possible differences in the range of tasks between inexperienced and experienced general practitioners (GPs), and the extent to which clinical experience affects the way in which GPs perceive their daily work. METHODS An online questionnaire was sent to all regular GPs in Norway (N = 4784) in 2018. The study sought to document the tasks performed during a typical working day and how the GPs perceived their working situation. In this study, we compare the tasks, working situation and occurrence of potentially conflictual consultations among 'less experienced physicians' (≤ 5 years of experience in general practice) versus 'more experienced physicians' (> 5 years of experience). The findings are discussed in light of theories on development of expertise. RESULTS We received responses from 1032 GPs; 296 (29%) were less experienced and 735 (71%) more experienced. The two groups reported virtually the same number of consultations (19.2 vs. 20.5) and clinical problems handled (40.4 vs. 44.2) during the study day. The less experienced physicians reported a higher proportion of challenging and/or conflictual consultations, involving prescriptions for potentially addictive medication (5.7% vs. 3.1%), sickness certification (4.1% vs. 2.4%) and referral for medical investigations on weak clinical indication (8.1% vs. 5.6%). For other clinical issues there were minor or no differences. Both GP groups reported high levels of work-related stress with negative effect on self-perceived health (61.6% vs 64.6%). GPs who felt that high job demands harmed their health tended to handle a slightly higher number of medical issues per consultation and more consultations with elements of conflict. CONCLUSIONS AND IMPLICATIONS Inexperienced GPs in Norway handle a workload comparable to that of experienced GPs, but they perceive more conflictual consultations. These findings have relevance for training and guidance of future GP specialists. Irrespective of experience, the GPs report such high levels of negative work-related stress as to indicate an acute need for organisational changes that imply a reduced workload.
Collapse
Affiliation(s)
- Tor Magne Johnsen
- Norwegian Centre for E-Health Research (NSE), Tromsø, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), General Practice, Research Unit, Trondheim, Norway
- Midtbyen Medical Centre Trondheim, Trondheim, Norway
| | - Børge Lønnebakke Norberg
- Norwegian Centre for E-Health Research (NSE), Tromsø, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), General Practice, Research Unit, Trondheim, Norway
| | - Frode Helgetun Krogh
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), General Practice, Research Unit, Trondheim, Norway
| | - Hanne Dahl Vonen
- Medical Student Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Linn Okkenhaug Getz
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), General Practice, Research Unit, Trondheim, Norway
| | - Bjarne Austad
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), General Practice, Research Unit, Trondheim, Norway
- Øya Medical Centre, Trondheim General Practice Research Unit, Trondheim, Norway
| |
Collapse
|
14
|
Graham KD, Steel A, Wardle J. The converging paradigms of holism and complexity: An exploration of naturopathic clinical case management using complexity science principles. J Eval Clin Pract 2022; 29:662-681. [PMID: 35703447 DOI: 10.1111/jep.13721] [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: 01/24/2022] [Revised: 04/12/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE Traditional whole systems of medicine, such as naturopathy, are founded upon holism; a philosophical paradigm consistent with contemporary complexity science. Naturopathic case management is predicated upon the understanding of an intimately interconnected internal physiological and external context of the human organism-potentially indicating a worldview aligned with a complexity perspective. In this study we investigate naturopathic clinical reasoning using a complexity lens with the aim of ascertaining the extent of correspondence between the two. METHOD Mind maps depicting case presentations were sought from Australian degree qualified naturopaths. A network mapping was undertaken, which was then analysed in accordance with a complexity science framework using exploratory data analysis and network analysis processes and tools. RESULTS Naturopathic case schematics, in the form of mind maps (n = 70), were collected, network mapped, and analysed. A total of 739 unique elements and 2724 links were identified across the network. Integral elements across the network were: stress, fatigue, general anxiety, systemic inflammation, gut dysbiosis, and diet. A modularity algorithm detected 11 communities, the primary ones of these representing the nervous system and mood; the gastrointestinal tract, liver, and nutrition; immune function and the immune system; and diet and nutrients. CONCLUSIONS Naturopathic case management is holistic and based on a perspective of an integrated physiology and external context of the human organism. The traditional concept of holism, when subjected to a complexity lens, leads to the emergence of a contemporary holistic paradigm cognisant of the human organism being a complex system. The application of complexity science to investigate naturopathic case management as employed in this study, demonstrates that it is possible to investigate traditional philosophies and principles in a scientific and critical manner. A complexity science research approach may offer a suitable scientific paradigm to develop our understanding of traditional whole systems of medicine.
Collapse
Affiliation(s)
- Kim D Graham
- Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Amie Steel
- Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jon Wardle
- National Centre for Naturopathic Medicine, Southern Cross University, Lismore, New South Wales, Australia
| |
Collapse
|
15
|
Meyer C, Ogrin R, Golenko X, Cyarto E, Paine K, Walsh W, Hutchinson A, Lowthian J. A codesigned fit-for-purpose implementation framework for aged care. J Eval Clin Pract 2022; 28:421-435. [PMID: 35129259 PMCID: PMC9303944 DOI: 10.1111/jep.13660] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/06/2021] [Accepted: 12/14/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The field of implementation science is critical for embedding research evidence into healthcare practice, benefiting individuals, organizations, governments, and the broader community. Implementation science is messy and complex, underpinned by many theories and frameworks. Efficacious interventions for older people with multiple comorbidities exist, yet many lack effectiveness evaluation relevant to pragmatic implementation within aged care practice. This article outlines the conceptualization and development of an Implementation Framework for Aged Care (IFAC), fit-for-purpose for an aged care organization, Bolton Clarke, intent on embedding evidence into practice. METHOD A four-stage process was adopted to (1) explore context and relevant literature to conceptualize the IFAC; (2) identify key elements for a draft IFAC; (3) expand elements and refine the draft in consultation with experts and (4) apply the IFAC to three existing projects, identifying key learnings. A checklist to operationalize the IFAC was then developed. RESULTS The IFAC is grounded in codesign principles and encapsulated by the implementation context, from a social, cultural and political perspective. The IFAC addresses the questions of (1) why do we need to change?; (2) what do we know?; (3) who will benefit?; (4) who will make the change?; (5) what strategies will be used?; and (6) what difference are we making? Three pilot projects: early adoption of a Wellness and Reablement approach; a care worker and virtual physiotherapist-led program to prevent falls; and a therapeutic horticulture program for residential communities, highlight learnings of applying the IFAC in practice. CONCLUSION This fit-for-purpose IFAC was developed for a proactive and responsive aged care provider. The simplicity of the six-question IFAC is underpinned by substantial theoretical perspectives for its elements and their connections. This complexity is then consolidated into an 18-question checklist to operationalize the IFAC, necessary to advance the translation of evidence into clinical practice.
Collapse
Affiliation(s)
- Claudia Meyer
- Department of Bolton Clarke, Bolton Clarke Research Institute, Victoria, Australia.,Department is School of Psychology and Public Health, Centre for Health Communication and Participation, La Trobe University, Bundoora, Victoria, Australia.,Department is School of Primary and Allied Health Care, Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Frankston, Victoria, Australia
| | - Rajna Ogrin
- Department of Bolton Clarke, Bolton Clarke Research Institute, Victoria, Australia.,Department of Business Strategy and Innovation, Griffith University, Southport, Queensland, Australia
| | - Xanthe Golenko
- Department of Bolton Clarke, Bolton Clarke Research Institute, Victoria, Australia.,Department of Business Innovation and Strategy, Griffith Business School, Griffith University, Southport, Queensland, Australia
| | - Elizabeth Cyarto
- Department of Bolton Clarke, Bolton Clarke Research Institute, Victoria, Australia.,Faculty of Health and Behavioural Sciences, University of Queensland, St Lucia, Queensland, Australia.,Department of Psychiatry, University of Melbourne, Parkville, Victoria, Australia
| | - Kath Paine
- Department of Bolton Clarke, Bolton Clarke Research Institute, Victoria, Australia
| | - Willeke Walsh
- Department of Bolton Clarke, Bolton Clarke Research Institute, Victoria, Australia
| | - Alison Hutchinson
- Department is School of Psychology and Public Health, Centre for Health Communication and Participation, La Trobe University, Bundoora, Victoria, Australia.,School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation Deakin University, Geelong, Victoria, Australia
| | - Judy Lowthian
- Department of Bolton Clarke, Bolton Clarke Research Institute, Victoria, Australia.,Faculty of Health and Behavioural Sciences, University of Queensland, St Lucia, Queensland, Australia.,Faculty of Medicine, Nursing and Health Sciences, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
16
|
Graham KD, Steel A, Wardle J. Primary health care case management through the lens of complexity: an exploratory study of naturopathic practice using complexity science principles. BMC Complement Med Ther 2022; 22:107. [PMID: 35428262 PMCID: PMC9011958 DOI: 10.1186/s12906-022-03585-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/05/2022] [Indexed: 12/29/2022] Open
Abstract
Background Advances in systems science creates an opportunity to bring a complexity perspective to health care practices and research. While medical knowledge has greatly progressed using a reductionist and mechanistic philosophy, this approach may be limited in its capacity to manage chronic and complex illness. With its holistic foundation, naturopathy is a primary health profession with a purported alignment with a complexity perspective. As such this pilot study aimed to investigate the application of complexity science principles, strategies, and tools to primary health care using naturopathy as a case study. Methods A network mapping and analysis of the naturopathic case management process was conducted. Mind maps were created by naturopathic practitioners to reflect their clinical conceptualisation of a common paper clinical case. These mind maps were inputed into Gephi, a network mapping, exploration, and analysis software. Various layouts of the data were produced, and these were analysed using exploratory data analysis and computational network analysis. Results Seven naturopathic practitioners participated in the study. In the combined network mapping, 133 unique elements and 399 links were identified. Obesity, the presenting issue in the case, was centrally located. Along with obesity, other keystone elements included: systemic inflammation, dysbiosis, diet, the liver, and mood. Each element was connected on average to 3.05 other elements, with a degree variation between one and 36. Six communities within the dataset were identified, comprising: the nervous system and mood, gastroinstetinal and dietary factors, systemic inflammation and obesity, the endocrine system and metabolism. Conclusions This pilot study demonstrates that it is feasible to apply a complexity science perspective to investigating primary health care case management. This supports a shift to viewing the human organism as a complex adaptive system within primary health care settings, with implications for health care practices that are more cognisant with the treatment of chronic and complex conditions and research opportunities to capture the complex clinical reasoning processes of practitioners. Supplementary Information The online version contains supplementary material available at 10.1186/s12906-022-03585-2.
Collapse
|
17
|
de Oliveira CA, Weber B, dos Santos JLF, Zucoloto ML, de Camargo LL, Zanetti ACG, Rzewuska M, de Azevedo-Marques JM. Health complexity assessment in primary care: A validity and feasibility study of the INTERMED tool. PLoS One 2022; 17:e0263702. [PMID: 35180262 PMCID: PMC8856552 DOI: 10.1371/journal.pone.0263702] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background Health complexity includes biological, psychological, social, and health systems. Having complex health needs is associated with poorer clinical outcomes and higher healthcare costs. Care management for people with health complexity is increasingly recommended in primary health care (PHC). The INTERMED complexity assessment grid showed adequate psychometric properties in specialized settings. This study aimed to evaluate INTERMED’s validity and feasibility to assess health complexity in an adult PHC population. Method The biopsychosocial health care needs of 230 consecutive adult patients from three Brazilian PHC services were assessed using the INTERMED interview. Participants with a total score >20 were classified as “complex”. Quality of life was measured using the World Health Organization Quality of Life BREF (WHOQOL-BREF); symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS); social support using the Medical Outcomes Study—Social Support Survey (MOS-SSS); comorbidity levels using the Charlson Comorbidity Index (CCI). We developed two questionnaires to evaluate health services use, and patient perceived feasibility of INTERMED. Results 42 participants (18.3%) were classified as “complex”. A moderate correlation was found between the total INTERMED score and the total scores of WHOQOL-BREF (rho = - 0.59) and HADS (rho = 0.56), and between the social domains of INTERMED and MOS-SSS (rho = -0.44). After adjustment, the use of PHC (β = 2.12, t = 2.10, p < 0.05), any other health care services (β = 3.05, t = 3.97, p < 0.01), and any medication (β = 3.64, t = 4.16, p < 0.01) were associated with higher INTERMED scores. The INTERMED internal consistency was good (ω = 0.83), and the median application time was 7 min. Patients reported satisfaction with the questions, answers, and application time. Conclusion INTERMED displayed good psychometric values in a PHC population and proved promising for practical use in PHC.
Collapse
Affiliation(s)
- Camila Almeida de Oliveira
- Public Health Postgraduate Program, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- * E-mail:
| | - Bernardete Weber
- Registered Nurse, Hospital do Coração (HCor), São Paulo City, Brazil
| | | | - Miriane Lucindo Zucoloto
- Public Health Postgraduate Program, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Lisa Laredo de Camargo
- Postgraduate Program in Psychiatric Nursing, Ribeirão Preto College of Nursing, University of São Paulo, São Paulo, Brazil
| | - Ana Carolina Guidorizzi Zanetti
- Department of Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, São Paulo, Brazil
| | - Magdalena Rzewuska
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, United Kingdom
- Aberdeen Centre for Health Data Sciences, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | | |
Collapse
|
18
|
Tesser CD. Duas críticas às normativas dos Núcleos de Apoio à Saúde da Família. TRABALHO, EDUCAÇÃO E SAÚDE 2022. [DOI: 10.1590/1981-7746-ojs00118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Estudos empíricos identificaram insuficiências e precariedades na atuação de apoio matricial dos Núcleos de Apoio à Saúde da Família. Este artigo, baseado em experiências assistemáticas diversas e literatura selecionada, defende duas teses interligadas que criticam aspectos das normativas federais originais para atuação desses Núcleos: uma concepção − implícita nas normativas − de atenção primária à saúde como cenário de ações situadas apenas em campos de competência compartilháveis, por um lado; e a opção de inserção desses Núcleos relativamente fora do fluxo assistencial dos usuários, por outro. Argumenta-se que ambas, provavelmente, geraram efeitos adversos envolvidos nos problemas de atuação desses Núcleos: contribuíram para a superestimação dos seus resultados esperados, para o seu subaproveitamento e subdesenvolvimento institucional e para a precarização da sua legitimidade, dificultada com a Política Nacional de Atenção Básica de 2017 e atingida gravemente com o desfinanciamento federal em 2019. Defende-se o aperfeiçoamento dos Núcleos de Apoio à Saúde da Família e sugere-se sua inserção no fluxo assistencial entre a atenção primária à saúde e a atenção secundária, para reduzir o isolamento entre ambas e aperfeiçoar a coordenação personalizada do cuidado, facilitar a legitimidade dos ‘matriciadores’, o apoio matricial e a educação permanente dos profissionais.
Collapse
|
19
|
Sturmberg JP, Martin CM. How to cope with uncertainty? Start by looking for patterns and emergent knowledge. J Eval Clin Pract 2021; 27:1168-1171. [PMID: 34216085 DOI: 10.1111/jep.13596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 06/22/2021] [Indexed: 01/14/2023]
Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont, USA
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health Monash Health Clayton, Clayton, Australia
| |
Collapse
|
20
|
Hu XJ, Wang HHX, Li YT, Wu XY, Wang Y, Chen JH, Wang JJ, Wong SYS, Mercer SW. Healthcare needs, experiences and treatment burden in primary care patients with multimorbidity: An evaluation of process of care from patients' perspectives. Health Expect 2021; 25:203-213. [PMID: 34585465 PMCID: PMC8849236 DOI: 10.1111/hex.13363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/15/2021] [Accepted: 09/06/2021] [Indexed: 01/06/2023] Open
Abstract
Background Patients with multimorbidity often experience treatment burden as a result of fragmented, specialist‐driven healthcare. The ‘family doctor team' is an emerging service model in China to address the increasing need for high‐quality routine primary care. Objective This study aimed to explore the extent to which treatment burden was associated with healthcare needs and patients' experiences. Methods Multisite surveys were conducted in primary care facilities in Guangdong province, southern China. Interviewer‐administered questionnaires were used to collect data from patients (N = 2160) who had ≥2 clinically diagnosed long‐term conditions (multimorbidity) and had ≥1 clinical encounter in the past 12 months since enrolment registration with the family doctor team. Patients' experiences and treatment burden were measured using a previously validated Chinese version of the Primary Care Assessment Tool (PCAT) and the Treatment Burden Questionnaire, respectively. Results The mean age of the patients was 61.4 years, and slightly over half were females. Patients who had a family doctor team as the primary source of care reported significantly higher PCAT scores (mean difference 7.2 points, p < .001) and lower treatment burden scores (mean difference −6.4 points, p < .001) when compared to those who often bypassed primary care. Greater healthcare needs were significantly correlated with increased treatment burden (β‐coefficient 1.965, p < .001), whilst better patients' experiences were associated with lower treatment burden (β‐coefficient −0.252, p < .001) after adjusting for confounders. Conclusion The inverse association between patients' experiences and treatment burden supports the importance of primary care in managing patients with multimorbidity. Patient Contribution Primary care service users were involved in the instrument development and data collection.
Collapse
Affiliation(s)
- Xiu-Jing Hu
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Harry H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China.,JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Yu-Ting Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Ya Wu
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Yi Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Jia-Heng Chen
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Jia-Ji Wang
- Guangdong-provincial Primary Healthcare Association, Guangdong, China.,School of Public Health, Guangzhou Medical University, Guangzhou, China
| | - Samuel Y S Wong
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Stewart W Mercer
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Scotland, UK
| |
Collapse
|
21
|
Rzewuska M, Carolina Guidorizzi Zanetti A, Skea ZC, Moscovici L, Almeida de Oliveira C, Mazzoncini de Azevedo-Marques J. Mental-physical multimorbidity treatment adherence challenges in Brazilian primary care: A qualitative study with patients and their healthcare providers. PLoS One 2021; 16:e0251320. [PMID: 33983998 PMCID: PMC8118469 DOI: 10.1371/journal.pone.0251320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 04/26/2021] [Indexed: 11/26/2022] Open
Abstract
Improved understanding of multimorbidity (MM) treatment adherence in primary health care (PHC) in Brazil is needed to achieve better healthcare and service outcomes. This study explored experiences of healthcare providers (HCP) and primary care patients (PCP) with mental-physical MM treatment adherence. Adults PCP with mental-physical MM and their primary care and community mental health care providers were recruited through maximum variation sampling from nine cities in São Paulo State, Southeast of Brazil. Experiences across quality domains of the Primary Care Assessment Tool-Brazil were explored through semi-structured in-depth interviews with 19 PCP and 62 HCP, conducted between April 2016 and April 2017. Through thematic conent analysis ten meta-themes concerning treatment adherence were developed: 1) variability and accessibility of treatment options available through PHC; 2) importance of coming to terms with a disease for treatment initation; 3) importance of person-centred communication for treatment initiation and maintenance; 4) information sources about received medication; 5) monitoring medication adherence; 6) taking medication unsafely; 7) perceived reasons for medication non-adherence; 8) most challenging health behavior change goals; 9) main motives for initiation or maintenance of treatment; 10) methods deployed to improve treatment adherence. Our analysis has advanced the understanding of complexity inherent to treatment adherence in mental-physical MM and revealed opportunities for improvement and specific solutions to effect adherence in Brazil. Our findings can inform research efforts to transform MM care through optimization.
Collapse
Affiliation(s)
- Magdalena Rzewuska
- Health Services Research Unit, University of Aberdeen, Scotland, United Kingdom
- Public Health Postgraduate Program, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ana Carolina Guidorizzi Zanetti
- Department of Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, São Paulo, Brazil
| | - Zoë C. Skea
- Health Services Research Unit, University of Aberdeen, Scotland, United Kingdom
| | - Leonardo Moscovici
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Primary Health Care, Academic Health Services Complex at Ribeirão Preto Medical School of the São Paulo University, XIII Regional Health Department, Unified Health System, São Paulo State, Brazil
| | - Camila Almeida de Oliveira
- Public Health Postgraduate Program, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - João Mazzoncini de Azevedo-Marques
- Public Health Postgraduate Program, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Primary Health Care, Academic Health Services Complex at Ribeirão Preto Medical School of the São Paulo University, XIII Regional Health Department, Unified Health System, São Paulo State, Brazil
| |
Collapse
|