Constructing osteoarthritis through discourse--a qualitative analysis of six patient information leaflets on osteoarthritis

Participation in healthcare consultations: A qualitative study from the perspectives of persons diagnosed with hand osteoarthritis

INTRODUCTION

Scarce health resources and differing views between persons with hand osteoarthritis (OA) and health professionals concerning care preferences contribute to sustaining a gap between actual needs and existing clinical guidelines for hand OA. The aim of this study is to explore the experiences of persons diagnosed with hand OA in their encounters with health services and how those experiences influence negotiations and decision-making in hand OA care.

METHODS

Data from 21 qualitative interviews with persons diagnosed with hand OA were collected, transcribed verbatim and analysed using reflexive thematic analysis.

RESULTS

Three main themes were developed: symptoms are perceived as ordinary ageing in everyday life, consultations are shaped by trust in healthcare and the responsibilities of prioritisation and self-care govern interactions.

CONCLUSION

Ideas of ageing, professional knowledge and self-management dominate hand OA health encounters and contribute to shaping illness perceptions, preferences and opportunities to negotiate decisions in consultations.

PATIENT OR PUBLIC CONTRIBUTION

Two patient research partners with hand OA are members of the study project group. One of them is also a co-author of this manuscript.

Effect of Information Content and General Practitioner Recommendation to Exercise on Treatment Beliefs and Intentions for Knee Osteoarthritis: An Online Multi-Arm Randomized Controlled Trial

OBJECTIVE

To evaluate effects of general osteoarthritis (OA) information in addition to a treatment option grid and general practitioner (GP) recommendation to exercise on treatment beliefs and intentions.

METHODS

An online randomized trial of 735 people 45 years old or older without OA who were recruited from a consumer survey network. Participants read a hypothetical scenario about visiting their GP for knee problems and were randomized to the following: i) 'general information', ii) 'option grid' (general information plus option grid), or iii) 'option grid plus recommendation' (general information plus option grid plus GP exercise recommendation). The primary outcome was an agreement that exercise is the best management option (0-10 numeric rating scale; higher scores indicating higher agreement that exercise is best). The secondary outcomes were beliefs about other management options and management intentions. Linear regression models estimated the mean (95% confidence interval [CI]) between-group difference in postintervention scores, adjusted for baseline.

RESULTS

Option grid plus recommendation led to higher agreement that exercise is the best management by a mean of 0.4 units (95% CI: 0.1-0.6) compared with general information. There were no other between-group differences for the primary outcome. Option grid led to higher agreement that surgery was best, and x-rays were necessary, compared with general information (mean between-group differences: 0.7 [CI: 0.2-1.1] and 0.5 [CI: 0.1-1.0], respectively) and option grid plus recommendation (0.5 [CI: 0.1-0.9] and 0.9 [CI: 0.4-1.3]).

CONCLUSION

Addition of an option grid and GP exercise recommendation to general OA information led to more favorable views that exercise was best for the hypothetical knee problem. However, differences were small and of unclear clinical importance.

Are healthcare providers offering the proper education for people with low back pain? Content analysis of educational materials

BACKGROUND

Low back pain (LBP) is a prevalent disorder and leading cause of disability worldwide. In Saudi Arabia, patients with LBP are dispensed with educational materials to supposedly facilitate their recuperation.

OBJECTIVE

Appraise the suitability of educational materials provided for people with LBP in Saudi Arabia to determine whether they meet the needs of patients, inform self-management, and are consistent with clinical practice guidelines.

METHODS

A qualitative data collection method was used, and content analyses were conducted to analyse data based on manifest content. Educational items in English and Arabic were collected from relevant health providers in Saudi Arabia.

RESULTS

Seventeen educational materials were sourced from: Ministry of Health hospitals (n= 10), military hospitals (n= 4), private hospitals (n= 2), and a multidisciplinary healthcare association (n= 1). Six identified sub-themes comprise: epidemiological/anatomical data about LBP (n= 6); causes/risk factors (n= 10); exercise (n= 14) and physical activity-related (n= 3) recommendations; treatment-related recommendations (n= 2); general health and lifestyle-related recommendations (n= 8); and postural and ergonomics-related recommendations (n= 13). A common theme emerged, that 'the content of educational materials hindered reassurance and self-management for people with LBP.'

CONCLUSION

The reviewed educational materials fail to adequately report information that assure patients or inform their self-management among the Saudi population with LBP. Further, reviewed items are heavily influenced by the biomedical model of pain.

Comparative effect of two educational videos on self-efficacy and kinesiophobia in people with knee osteoarthritis: an online randomised controlled trial

OBJECTIVE

To compare change in self-efficacy for managing knee osteoarthritis (OA) pain and kinesiophobia after watching an educational video based on an empowerment and participatory discourse with a video based on a disease and impairment discourse.

DESIGN

Two-arm randomised controlled trial with participants aged ≥45 years with knee pain (n = 589). Participants completed both baseline and follow-up outcomes and watched one randomly-allocated video (12-minute duration) during one 30-45-minute session within a single online survey. The experimental video presented evidence-based knee OA information using design and language that aimed to empower people and focus on activity participation to manage OA, while the control video presented similar information but with a disease and impairment focus. Primary outcome measures were Arthritis Self-Efficacy Scale pain subscale (range 0-10) and Brief Fear of Movement Scale for OA (range 6-24). Secondary outcomes were expectations about prognosis and physical activity benefits, perceived importance and motivation to be physically active, knee OA knowledge, hopefulness for the future, level of concern and perceived need for surgery.

RESULTS

Compared to control (n = 293), the experimental group (n = 296) showed improved self-efficacy for managing OA pain (mean difference 0.4 [95%CI 0.2, 0.6] units) and reduced kinesiophobia (1.6 [1.1, 2.0] units). The experimental group also demonstrated greater improvements in all secondary outcomes apart from hopefulness, which was high in both groups.

CONCLUSION

An educational video based on an empowerment and participatory discourse improved pain self-efficacy and reduced kinesiophobia in people with knee OA more than a video based on a disease and impairment discourse.

CLINICALTRIALS

gov registration NCT05156216, Universal trial number U1111-1269-6143.

Improving uptake of Fracture Prevention drug treatments: a protocol for Development of a consultation intervention (iFraP-D)

INTRODUCTION

Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work.

METHODS AND ANALYSIS

The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial.

ETHICS AND DISSEMINATION

Ethical approval was obtained from North West-Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations.

TRIAL REGISTRATION NUMBER

researchregistry5041.

Evaluation of quality and readability of online patient information on osteoporosis and osteoporosis drug treatment and recommendations for improvement

Patient information is important to help patients fully participate in their healthcare. Commonly accessed osteoporosis patient information resources were identified and assessed for readability, quality, accuracy and consistency. Resources contained inconsistencies and scored low when assessed for quality and readability. We recommend optimal language and identify information gaps to address.

INTRODUCTION

The purpose of this paper is to identify commonly accessed patient information resources about osteoporosis and osteoporosis drug treatment, appraise the quality and make recommendations for improvement.

METHODS

Patient information resources were purposively sampled and text extracted. Data extracts underwent assessment of readability (Flesch Reading Ease and Flesch-Kincaid Grade Level) and quality (modified International Patient Decision Aid Standards (m-IPDAS)). A thematic analysis was conducted, and keywords and phrases were used to describe osteoporosis and its treatment identified. Findings were presented to a stakeholder group who identified inaccuracies and contradictions and discussed optimal language.

RESULTS

Nine patient information resources were selected, including webpages, a video and booklets (available online), from government, charity and private healthcare providers. No resource met acceptable readability scores for both measures of osteoporosis information and drug information. Quality scores from the modified IPDAS ranged from 21 to 64% (7-21/33). Thematic analysis was informed by Leventhal's Common-Sense Model of Disease. Thirteen subthemes relating to the identity, causes, timeline, consequences and controllability of osteoporosis were identified. Phrases and words from 9 subthemes were presented to the stakeholder group who identified a predominance of medical technical language, misleading terms about osteoporotic bone and treatment benefits, and contradictions about symptoms. They recommended key descriptors for providers to use to describe osteoporosis and treatment benefits.

CONCLUSIONS

This study found that commonly accessed patient information resources about osteoporosis have highly variable quality, scored poorly on readability assessments and contained inconsistencies and inaccuracies. We produced practical recommendations for information providers to support improvements in understanding, relevance, balance and bias, and to address information gaps.

A Critical Analysis of the Exercise Prescription and Return to Activity Advice That Is Provided in Patient Information Leaflets Following Lumbar Spine Surgery

Background and objectives: Lumbar spine surgery may be considered if pharmacologic, rehabilitation and interventional approaches cannot provide sufficient recovery from low back-related pain. Postoperative physiotherapy treatment in England is often accompanied by patient information leaflets, which contain important rehabilitation advice. However, in order to be an effective instrument for patients, the information provided in these leaflets must be up to date and based on the best available evidence and clinical practice. This study aims to critically analyse the current postoperative aspects of rehabilitation (exercise prescription and return to normal activity) that are provided in patient information leaflets in England as part of an evaluation of current practice following lumbar spine surgery. Materials and Methods: Patient information leaflets from English National Health Service (NHS) hospitals performing lumbar spine surgery were sourced online. A content analysis was conducted to collect data on postoperative exercise prescription and return to normal activities. Results: Thirty-two patient information leaflets on lumbar surgery were sourced (fusion, n = 11; decompression, n = 15; all lumbar procedures, n = 6). Many of the exercises prescribed within the leaflets were not based on evidence of clinical best practice and lacked a relationship to functional activity. Return to normal activity advice was also wide ranging, with considerable variation in the recommendations and definitions provided. Conclusions: This study highlights a clear variation in the recommendations of exercise prescription, dosage and returning to normal activities following lumbar spine surgery. Future work should focus on providing a consistent and patient-centred approach to recovery.

Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials

Background

Osteoarthritis (OA) is the most common long-term condition managed in UK general practice. However, care is suboptimal despite evidence that primary care and community-based interventions can reduce OA pain and disability.

Objectives

The overall aim was to improve primary care management of OA and the health of patients with OA. Four parallel linked workstreams aimed to (1) develop a health economic decision model for estimating the potential for cost-effective delivery of primary care OA interventions to improve population health, (2) develop and evaluate new health-care models for delivery of core treatments and support for self-management among primary care consulters with OA, and to investigate prioritisation and implementation of OA care among the public, patients, doctors, health-care professionals and NHS trusts, (3) determine the effectiveness of strategies to optimise specific components of core OA treatment using the example of exercise and (4) investigate the effect of interventions to tackle barriers to core OA treatment, using the example of comorbid anxiety and depression in persons with OA.

Data sources

The North Staffordshire Osteoarthritis Project database, held by Keele University, was the source of data for secondary analyses in workstream 1.

Methods

Workstream 1 used meta-analysis and synthesis of published evidence about effectiveness of primary care treatments, combined with secondary analysis of existing longitudinal population-based cohort data, to identify predictors of poor long-term outcome (prognostic factors) and design a health economic decision model to estimate cost-effectiveness of different hypothetical strategies for implementing optimal primary care for patients with OA. Workstream 2 used mixed methods to (1) develop and test a ‘model OA consultation’ for primary care health-care professionals (qualitative interviews, consensus, training and evaluation) and (2) evaluate the combined effect of a computerised ‘pop-up’ guideline for general practitioners (GPs) in the consultation and implementing the model OA consultation on practice and patient outcomes (parallel group intervention study). Workstream 3 developed and investigated in a randomised controlled trial (RCT) how to optimise the effect of exercise in persons with knee OA by tailoring it to the individual and improving adherence. Workstream 4 developed and investigated in a cluster RCT the extent to which screening patients for comorbid anxiety and depression can improve OA outcomes. Public and patient involvement included proposal development, project steering and analysis. An OA forum involved public, patient, health professional, social care and researcher representatives to debate the results and formulate proposals for wider implementation and dissemination.

Results

This programme provides evidence (1) that economic modelling can be used in OA to extrapolate findings of cost-effectiveness beyond the short-term outcomes of clinical trials, (2) about ways of implementing support for self-management and models of optimal primary care informed by National Institute for Health and Care Excellence recommendations, including the beneficial effects of training in a model OA consultation on GP behaviour and of pop-up screens in GP consultations on the quality of prescribing, (3) against adding enhanced interventions to current effective physiotherapy-led exercise for knee OA and (4) against screening for anxiety and depression in patients with musculoskeletal pain as an addition to current best practice for OA.

Conclusions

Implementation of evidence-based care for patients with OA is feasible in general practice and has an immediate impact on improving the quality of care delivered to patients. However, improved levels of quality of care, changes to current best practice physiotherapy and successful introduction of psychological screening, as achieved by this programme, did not substantially reduce patients’ pain and disability. This poses important challenges for clinical practice and OA research.

Limitations

The key limitation in this work is the lack of improvement in patient-reported pain and disability despite clear evidence of enhanced delivery of evidence-based care.

Future work recommendations

(1) New thinking and research is needed into the achievable and desirable long-term goals of care for people with OA, (2) continuing investigation into the resources needed to properly implement clinical guidelines for management of OA as a long-term condition, such as regular monitoring to maintain exercise and physical activity and (3) new research to identify subgroups of patients with OA as a basis for stratified primary care including (i) those with good prognosis who can self-manage with minimal investigation or specialist treatment, (ii) those who will respond to, and benefit from, specific interventions in primary care, such as physiotherapy-led exercise, and (iii) develop research into effective identification and treatment of clinically important anxiety and depression in patients with OA and into the effects of pain management on psychological outcomes in patients with OA.

Trial registration

Current Controlled Trials ISRCTN06984617, ISRCTN93634563 and ISRCTN40721988.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme and will be published in full inProgramme Grants for Applied Research Programme; Vol. 6, No. 4. See the NIHR Journals Library website for further project information.

Living with osteoarthritis is a balancing act: an exploration of patients' beliefs about knee pain

Background

This study aimed to explore the beliefs of people with knee osteoarthritis (OA) about the disease, and how these beliefs had formed and what impact these beliefs had on activity participation, health behaviour, and self-management.

Methods

Semi-structured interviews were conducted with 13 people with knee OA recruited from general practices, community physiotherapy clinics, and public advertisements in two provinces of New Zealand. Data were analysed using Interpretive Description.

Results

Two key themes emerged. 1) Knowledge: certainty and uncertainty described participants’ strong beliefs about anatomical changes in their knee. Participants’ beliefs in a biomechanical model of progressive joint degradation often appeared to originate within clinical encounters and from literal interpretation of the term ‘wear and tear’. These beliefs led to uncertainty regarding interpretation of daily symptoms and participants’ ability to influence the rate of decline and certainty that joint replacement surgery represented the only effective solution to fix the damaged knee. 2) Living with OA described broader perspectives of living with OA and the perceived need to balance competing values and risks when making decisions about activity participation, medication, attentional focus, accessing care, and making the most of today without sabotaging tomorrow. Misunderstandings about knee OA negatively impacted on activity participation, health behaviours, and self-management decisions.

Conclusion

Biomechanical models of OA reduced participant exploration of management options and underpinned a perceived need to balance competing values. Improved information provision to people with knee OA could help guide positive health behaviour and self-management decisions and ensure these decisions are grounded in current evidence.

Electronic supplementary material

The online version of this article (10.1186/s41927-018-0023-x) contains supplementary material, which is available to authorized users.

A qualitative study of Telehealth patient information leaflets (TILs): are we giving patients enough information?

BACKGROUND

The provision of patient information leaflets regarding telehealth has been perceived by potential consumers as a strategy to promote awareness and adoption of telehealth services. However, such leaflets need to be designed carefully if adoption and awareness among potential users is to be promoted. Therefore, the aims of this study were: first, to see how telehealth was portrayed in some of the existing telehealth leaflets (THLs). Second, to explore patients' perceptions of the existing THLs and their engagement with the concept and how THLs can be optimised.

METHODS

A two-step approach was employed to address the aims of this study. The first phase involved the use of discourse analysis to compare 12 electronically and publically available THLs, with the existing THL guidance "Involve Yorkshire and Humber". The second phase involved conducting 14 semi-structured interviews with potential telehealth users/patients to gauge their perception and engagement with the concept, using the two leaflets that were mostly matching with the guidance used. Six interviews were audio-recorded and eight had detailed jotted notes. The interviews were transcribed and thematically analysed to identify key themes.

RESULTS

The discourse analysis showed certain gaps and variations within the screened leaflets when addressing the following aspects: cost of the telehealth service, confidentiality, patients' choices in addition to equipment use and technical support. Analysis of the interviews revealed patients' need for having clear and sufficient information about the telehealth service within the THLs; in addition to, patients' preference for the use of simpler terminologies for telehealth description and the provision of clear simple texts with pictorial presentations. The interviews also revealed certain limitations against adoption of telehealth by the participants, such as: lack of privacy and confidentiality of information, fear of technology breakdown and equipment failure, loss of face-to-face contact with healthcare professionals and being too dependent on the telehealth service.

CONCLUSION

The current study showed a great variation among the screened THLs and highlighted certain gaps within the content and presentation of these leaflets. However, the study also highlighted certain key issues to be considered when designing THLs in the future to enhance telehealth uptake and use by patients.

Connectivity, contest and the ties of self-management support for type 2 diabetes: a meta-synthesis of qualitative literature

This paper presents a meta-synthesis of the literature on community-based self-management to support experiences of people diagnosed with type 2 diabetes. The aim was to synthesise findings on both formal and informal self-management support with particular reference to the relevance and influence of the social context operating at different levels. The review forms part of EU-WISE, a project financed through EU's 7th Framework Programme. The review was performed by systematically searching MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO and Web of Science for English language publications between 2005 and 2014 presenting research conducted in Europe on the experiences and perspectives of self-management concerns of patients diagnosed with type 2 diabetes. The search yielded 587 abstracts, which were reduced through search strategy refinement and eligibility and quality criteria to 29 papers that were included in the review. This review highlights the relevance of contextual factors operating at micro- and macro-levels. The synthesis yielded six second-order thematic constructs relating to self-management: sense of agency and identity, the significance and meaning of social networks, minimal disruption of everyday life, economic hardship, the problem of assigning patients' responsibility and structural influences of primary care. Using a line of argument synthesis, these themes were revisited, and a third-order construct, connectivity emerged which refers to how links in daily life are interwoven with peoples' social networks, local communities, economic and ideological conditions in society in a way which support self-management activities. This meta-synthesis indicates a need to heed the notion of connectivity as a means of mobilising and supporting the self-management strategies of people with type 2 diabetes in everyday life.

Acceptability of a 'guidebook' for the management of Osteoarthritis: a qualitative study of patient and clinician's perspectives

BACKGROUND

Written information can be of benefit to both practitioners and patients and the provision of quality information is emphasised as a core intervention by United Kingdom National Institute of Clinical Excellence (NICE) OA guidelines. Researchers, patients and HCPs developed an 'OA guidebook' to provide; a) a balanced source of information for patients; b) a resource to aid practitioners when discussing self-management. This study aimed to evaluate the acceptability and usefulness of the OA guidebook as part of complex intervention to deliver NICE OA guidelines in General Practice.

METHODS

The intervention comprises a series of consultations with GPs and practice nurses in which supported self-management is offered to patients. Eight practices in the West Midlands and North West of England were recruited to take part: four control practices and four intervention practices. Semi-structured interviews were undertaken with patients (n = 29), GPs (n = 9) and practice nurses (n = 4) from the intervention practices to explore experiences of the intervention and use of the guidebook. Data were analysed using thematic analysis and constant comparison of data within and across interviews.

RESULTS

GPs thought the guidebook helped provide patients with information about OA aetiology, prognosis and self-management. Thus, it backed up key messages they provided patients during consultations. GPs also found the guidebook helped them 'close off' consultations. Nurses also thought the guidebook helped them describe OA disease processes in consultations. Patients valued the explanations of disease onset, process and prognosis. The use of 'real' people and 'real life' situations contained within the guidebook made self-management strategies seem more tangible. A sense of inclusion and comfort was obtained from knowing other people encountered similar problems and feelings.

CONCLUSION

An OA specific written information guidebook was deemed acceptable and useful to practitioners and patients alike as part of the MOSAICS study. Findings reinforce the utility of this model of patient information as a resource to support patients living with chronic illnesses. An OA guidebook featuring a mixture of lay and professional information developed by professionals and lay people is useful and could effectively be used more widely in usual care.

Developing and evaluating a child-centred intervention for diabetes medicine management using mixed methods and a multicentre randomised controlled trial

Aim

To develop and evaluate an individually tailored age-appropriate diabetes diary and information pack for children and young people aged 6–18 years with type 1 diabetes to support decision-making and self-care with a specific focus on insulin management and blood glucose monitoring, compared with available resources in routine clinical practice.

Design

Four-stage study following the Medical Research Council framework for designing and evaluating complex interventions. Stage 1: context – brief review of reviews and mixed-method systematic review; updating of database of children’s diabetes information; children’s diabetes information quality assessment and diabetes guideline analysis; and critical discourse analysis. Stage 2: intervention development – working with expert clinical advisory group; contextual qualitative interviews and focus groups with children and young people to ascertain their information preferences and self-care practices; ongoing consultation with children; development of intervention programme theory. Stage 3: randomised controlled trial (RCT) to evaluate the diabetes diaries and information packs in routine practice. Stage 4: process evaluation.

Findings

The RCT achieved 100% recruitment, was adequately powered and showed that the Evidence into Practice Information Counts (EPIC) packs and diabetes diaries were no more effective than receiving diabetes information in an ad hoc way. The cost per unit of producing the EPIC packs and diabetes diaries was low. Compared with treatment as usual information, the EPIC packs fulfilled all NHS policy imperatives that children and young people should receive high-quality, accurate and age-appropriate information about their condition, self-management and wider lifestyle and well-being issues. Diabetes guidelines recommend the use of a daily diabetes diary and EPIC diaries fill a gap in current provision. Irrespective of allocation, children and young people had a range of recorded glycated haemoglobin (HbA1c) levels, which showed that as a group their diabetes self-management would generally need to improve to achieve the HbA1clevels recommended in National Institute for Health and Care Excellence guidance. The process evaluation showed that promotion of the EPIC packs and diaries by diabetes professionals at randomisation did not happen as intended; the dominant ‘normalisation’ theory underpinning children’s diabetes information may be counterproductive; risk and long-term complications did not feature highly in children’s diabetes information; and children and young people engaged in risky behaviour and appeared not to care, and most did not use a diabetes diary or did not use the information to titrate their insulin as intended.

Limitations

Recruitment of ‘hard to reach’ children and young people living away from their families was not successful. The findings are therefore more relevant to diabetes management within a family context.

Conclusions

The findings indicate a need to rethink context and the hierarchical relationships between children, young people, parents and diabetes professionals with regard to ‘partnership and participation’ in diabetes decision-making, self-care and self-management. Additional research, implementation strategies and service redesign are needed to translate available information into optimal self-management knowledge and subsequent optimal diabetes self-management action, including to better understand the disconnection between children’s diabetes texts and context; develop age-appropriate Apps/e-records for recording blood glucose measurements and insulin management; develop interventions to reduce risk-taking behaviour by children and young people in relation to their diabetes management; reconsider what could work to optimise children’s self-management of diabetes; understand how best to reorganise current diabetes services for children to optimise child-centred delivery of children’s diabetes information.

Study registration

Current Controlled Trials ISRCTN17551624.

Funding

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

Patients' perceptions of the treatment and management of hand osteoarthritis: a focus group enquiry

PURPOSE

 Osteoarthritis (OA) is the commonest reason for a musculoskeletal consultation in primary care in older adults. There is evidence that appropriate advice and management is sub-optimal. The aim of this study was to explore perceptions and experiences of the treatment and management of hand OA in older adults.

METHODS

 Four focus groups were conducted with primary (n = 15) and secondary (n = 14) care participants aged 50-84 years (mean age 64.9 years; 3 males, 14 females) with a clinical diagnosis of hand OA. Data were tape-recorded, transcribed and analysed using thematic analysis and constant comparison method.

RESULTS

 Participants described a lack of help and information with regards to management of their hand OA and also a perceived lack of understanding of the impact of hand OA on the individual. Some received contradictory advice about its management. Beliefs about treatment efficacy were balanced against perceived and actual side-effects and tolerance, and such perceptions appeared to influence the use of alternative therapies.

CONCLUSIONS

 The study identified a perceived unmet need in people with hand OA presenting in primary and secondary care. This may be due to the clinical uncertainty of treatment, lack of high-quality randomised controlled trials evaluating therapeutic options, and the limited written information available incorporating the patient experience. The study emphasised the need to understand patient illness and treatment beliefs. A better understanding of illness and treatment beliefs will facilitate the use of evidence-based approaches in the management of hand OA.

Developing written information on osteoarthritis for patients: facilitating user involvement by exposure to qualitative research

INTRODUCTION

In developing a guidebook on osteoarthritis (OA), we collaborated with people who have chronic joint pain (users). But to advise, users need to be aware of and sensitive about their own state of knowledge and educationalists argue that adults sometimes lack such awareness. This paper will report on our experience of providing users with findings from qualitative research to increase awareness of their level of knowledge.

METHOD

A summary of the results from qualitative research into people's experiences of living with chronic pain was sent to individual members of two groups of users. It was then used to structure group meetings held to help identify information needed for the guidebook.

FINDINGS

Some users found the summary difficult to read and suggested how to simplify it. Nevertheless, it helped most users to become aware of the experiences and views of others who have OA and thus become more sensitive to their own level of knowledge. It also helped them recall experiences that stimulated practical suggestions for managing joint pain in everyday life and provided a way of gently challenging the views of users when they appeared to assume that their views were widely held. The discussions brought to light gaps in the research literature.

CONCLUSION

We believe this way of involving users by exposing them to qualitative research findings about lay experiences of living with OA effectively facilitated the users' contributions to the needs of those who have to live with OA, and we believe it has wider applications.

Qualitative research: a review of methods with use of examples from the total knee replacement literature

Qualitative research is a useful approach to explore perplexing or complicated clinical situations. Since 1996, at least fifteen qualitative studies in the area of total knee replacement alone were found. Qualitative studies overcome the limits of quantitative work because they can explicate deeper meaning and complexity associated with questions such as why patients decline joint replacement surgery, why they do not adhere to pain medication and exercise regimens, how they manage in the postoperative period, and why providers do not always provide evidence-based care. In this paper, we review the role of qualitative methods in orthopaedic research, using knee osteoarthritis as an illustrative example. Qualitative research questions tend to be inductive, and the stance of the investigator is relevant and explicitly acknowledged. Qualitative methodologies include grounded theory, phenomenology, and ethnography and involve gathering opinions and text from individuals or focus groups. The methods are rigorous and take training and time to apply. Analysis of the textual data typically proceeds with the identification, coding, and categorization of patterns in the data for the purpose of generating concepts from within the data. With use of analytic techniques, researchers strive to explain the findings; questions are asked to tease out different levels of meaning, identify new concepts and themes, and permit a deeper interpretation and understanding. Orthopaedic practitioners should consider the use of qualitative research as a tool for exploring the meaning and complexities behind some of the perplexing phenomena that they observe in research findings and clinical practice.

Promoting patient engagement with self-management support information: a qualitative meta-synthesis of processes influencing uptake

Background

Patient information has been viewed as a key component of self-management. However, little attention has been given to methods of dissemination or implementation of effective information strategies. Previous problems identified with the use and implementation of patient information point to the need to explore the way in which patients engage with and use information to support self-management for chronic conditions.

Methods

Four published qualitative studies from a programme of research about self-management were analysed as a group; these included studies of the management of inflammatory bowel disease (IBD); self-help in anxiety and depression (SHADE); menorrhagia, treatment, information, and preference (MENTIP) study; and self-help for irritable bowel syndrome (IBS). For the analysis, we used an adapted meta-ethnographic approach to the synthesis of qualitative data in order to develop an evidence base.

Results

The ontological status and experience of the condition in everyday life was the most dominant theme to emerge from this synthesis. This, coupled with access to and experience of traditional health services responses, shaped the engagement with and use of information to support self-management. Five key elements were found which were likely to influence this: the perception and awareness of alternative self-management possibilities; the prior extent and nature of engagement with information; the extent of and ability to self-manage; opportunities for use of the information and the stage of the illness career; and congruence and synergy with the professional role.

Conclusion

People with chronic conditions need support from providers in both supply and engagement with information, in a way which gives legitimacy to the person's own self-management strategies and possible alternatives. Thus, a link could usefully be made between information offered, as well as patients' past experiences of self-management and engagement with services for their condition. The timeliness of the information should be considered, both in terms of the illness career and the type of condition (i.e., before depression gets too bad or time to reflect on existing knowledge about a condition and how it is to be managed) and in terms of the pre-existing relationship with services (i.e., options explored and tried).

More considered use of information (how it is provided, by whom, and at what point it should be introduced) is key to facilitating patients' engagement with and therefore use of information to support self-management.