Silos and rigid processes: Barriers to the successful implementation of the Older prisoner Health and Social Care Assessment and Plan

Older adults are the fastest growing sub-group in prisons. They have complex health, social care and custodial needs and often the support they receive is sub-optimal. The Older prisoner Health and Social Care Assessment and Plan (OHSCAP) aimed to better meet these inter-related needs. As part of a wider study, a randomised controlled trial was conducted to evaluate the OHSCAPs effectiveness in meeting older prisoners' health, social care and custodial needs in comparison to treatment as usual. This article describes the nested qualitative study which aimed to explore the barriers and facilitators to the effective implementation of the OHSCAP. Semi-structured interviews were conducted with older adults (n = 14) and staff members t (n = 12). Data was analysed using the framework method. Three overarching key themes were identified. These were: (1) balancing care and custodial requirements; (2) prison, health and social care silos; and (3) rigid prison processes. Prison is an important opportunity to engage residents and improve public health. Cultural and strategic change is required for health, social care and custodial interventions, such as the OHSCAP, to be successfully implemented into prison settings.

Transitional Care Interventions for Older Residents of Long-term Care Facilities: A Systematic Review and Meta-analysis

IMPORTANCE

Residents of long-term care facilities (LTCFs) experience high hospitalization rates, yet little is known about the effects of transitional care interventions for these residents.

OBJECTIVE

To assess the association of transitional care interventions with readmission rates and other outcomes for residents of LTCFs who are 65 years and older and LTCF staff and to explore factors that potentially mitigate the association.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were searched for English-language studies published until July 21, 2021. Associated qualitative studies were identified using aspects of the CLUSTER (citations, lead authors, unpublished materials, searched Google Scholar, tracked theories, ancestry search for early examples, and follow-up of related projects) methodology.

STUDY SELECTION

Controlled design studies evaluating transitional care interventions for residents of LTCFs 65 years and older were included. Records were independently screened by 2 reviewers; disagreements were resolved through discussion and involvement of a third reviewer. From 14 538 records identified, 15 quantitative and 4 qualitative studies met the eligibility criteria.

DATA EXTRACTION AND SYNTHESIS

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data were extracted by one reviewer and checked by a second reviewer. Fixed-effect and random-effects models were used according to the number of studies reporting the outcomes of interest.

MAIN OUTCOMES AND MEASURES

The primary outcome consisted of 30-, 60-, and 90-day readmission rates (hospital and emergency department [ED]). Other outcomes included length of stay, functional independence (Barthel score), and quality of life. The I2 statistic was used to quantify heterogeneity.

RESULTS

Of 14 538 records identified from searches, 15 quantitative studies (totaling 32 722 participants or records) and 4 qualitative studies were included. People allocated to transitional care interventions were 1.7 times less likely to be readmitted to the hospital or ED compared with those in control groups (14 studies; odds ratio, 1.66 [95% CI, 1.18-2.35]; I2 = 81% [95% CI, 70%-88%]). Length of stay in the ED was significantly decreased for intervention groups (3 studies; standardized mean difference, -3.00 [95% CI, -3.61 to -2.39]; I2 = 99% [95% CI, 98%-99%]). There were no significant differences for other outcomes. Factors associated with outcomes included communication and referral processes between health care professionals.

CONCLUSIONS AND RELEVANCE

Emerging evidence suggests that transitional care interventions are associated with lower readmissions for residents of LTCFs 65 years and older. Despite this and with aging populations, investment in such interventions has been remarkably low across most countries.

Effects of the first COVID-19 lockdown on quality and safety in mental healthcare transitions in England

BACKGROUND

The COVID-19 pandemic forced the rapid implementation of changes to practice in mental health services, in particular transitions of care. Care transitions pose a particular threat to patient safety.

AIMS

This study aimed to understand the perspectives of different stakeholders about the impact of temporary changes in practice and policy of mental health transitions as a result of coronavirus disease 2019 (COVID-19) on perceived healthcare quality and safety.

METHOD

Thirty-four participants were interviewed about quality and safety in mental health transitions during May and June 2020 (the end of the first UK national lockdown). Semi-structured remote interviews were conducted to generate in-depth information pertaining to various stakeholders (patients, carers, healthcare professionals and key informants). Results were analysed thematically.

RESULTS

The qualitative data highlighted six overarching themes in relation to practice changes: (a) technology-enabled communication; (b) discharge planning and readiness; (c) community support and follow-up; (d) admissions; (e) adapting to new policy and guidelines; (f) health worker safety and well-being. The COVID-19 pandemic exacerbated some quality and safety concerns such as tensions between teams, reduced support in the community and increased threshold for admissions. Also, several improvement interventions previously recommended in the literature, were implemented locally.

DISCUSSION

The practice of mental health transitions has transformed during the COVID-19 pandemic, affecting quality and safety. National policies concerning mental health transitions should concentrate on converting the mostly local and temporary positive changes into sustainable service quality improvements and applying systematic corrective policies to prevent exacerbations of previous quality and safety concerns.

Beyond the control of the care home: A meta-ethnography of qualitative studies of Infection Prevention and Control in residential and nursing homes for older people

Objective

This study aimed to develop interpretive insights concerning Infection Prevention and Control (IPC) in care homes for older people.

Design

This study had a meta‐ethnography design.

Data Sources

Six bibliographic databases were searched from inception to May 2020 to identify the relevant literature.

Review Methods

A meta‐ethnography was performed.

Results

Searches yielded 652 records; 15 were included. Findings were categorized into groups: The difficulties of enacting IPC measures in the care home environment; workload as an impediment to IPC practice; the tension between IPC and quality of life for care home residents; and problems dealing with medical services located outside the facility including diagnostics, general practice and pharmacy. Infection was revealed as something seen to lie ‘outside’ the control of the care home, whether according to origins or control measures. This could help explain the reported variability in IPC practice. Facilitators to IPC uptake involved repetitive training and professional development, although such opportunities can be constrained by the ways in which services are organized and delivered.

Conclusions

Significant challenges were revealed in implementing IPC in care homes including staffing skills, education, workloads and work routines. These challenges cannot be properly addressed without resolving the tension between the objectives of maintaining resident quality of life while enacting IPC practice. Repetitive staff training and professional development with parallel organisational improvements have prospects to enhance IPC uptake in residential and nursing homes.

Patient or Public Contribution

A carer of an older person joined study team meetings and was involved in writing a lay summary of the study findings.

Understanding barriers to the introduction of precision medicine in non-small cell lung cancer: a qualitative interview study

Background: While treatments targeting genetic mutations and alterations in non-small cell lung cancer (NSCLC) have been available since 2010, the adoption of such examples of precision medicine into clinical practice has historically been slow. This means that patients with NSCLC may not have received life improving and extending treatments which should have been available to them. The purpose of this qualitative interview study was to identify the barriers to the provision of examples of precision medicine for NSCLC. Methods: This study used semi-structured telephone interviews with clinicians, test providers and service commissioners to identify the perceived barriers to providing historical, current, and future examples of precision medicine in NSCLC. Participants were identified through mailing list advertisements and snowball sampling. The qualitative data was analysed using a framework analysis. Results: Interviews were conducted with 11 participants including: five oncologists; three pathologists; two clinical geneticists; and one service commissioner. A total of 17 barriers to the introduction of precision medicine for NSCLC were identified and these were grouped into five themes: the regulation of precision medicine and tests; the commissioning and reimbursement of tests and the testing process; the complexity of the logistics around providing tests; centralisation or localisation of test provision; and opinions about future developments in precision medicine for NSCLC. Conclusions: A number of barriers exist to the introduction of precision medicine in NSCLC. Addressing these barriers may improve access to novel life improving and extending treatments for patients.

A patient and public involvement workshop using visual art and priority setting to provide patients with a voice to describe quality and safety concerns: Vitamin B12 deficiency and pernicious anaemia

Background

Patient and public involvement and engagement (PPIE) is recognized as important for improved quality in health service provision and research. Vitamin B12 deficiency is one area where PPIE has potential to benefit patients, as patients often report sub‐optimal care due to diagnostic delay, insufficient treatment and poor relationships with health professionals.

Objective

In an effort to engage an understudied patient population in health‐care quality and safety discussions, and provide patients with an opportunity to have a voice, contribute to research priorities and express their current quality and safety concerns, we hosted a PPIE workshop.

Methods

One researcher (with lived experience) facilitated a one day workshop with 12 patients with varied demographics. The workshop had four components (a) one‐to‐one sessions with an artist, (b) quality and safety research/education priority setting, (c) comments on research proposals, and (d) development of a PPIE group for future research.

Results

All elements of the workshop elicited a number of quality and safety priorities for the group. Priority setting highlighted issues with interpretation of test results, symptom‐based treatment, self‐medication and relationship with primary care health‐care professionals. One of the major safety issues highlighted in the visual art element was feeling ignored, silenced or not listened too by health‐care professionals.

Discussion

Visual art methods to express experiences of health, and research priority setting tasks achieved the aim of providing patients with an opportunity to have a voice and express concerns about health‐care quality and safety issues. The addition of visual art allowed patients to articulate emotions and impacts on everyday life associated with quality and safety.

Patient or public contribution

A public contributor was involved in preparation of this manuscript. The event aimed to enable PPIE contribution in future research.

Digital methods to enhance the usefulness of patient experience data in services for long-term conditions: the DEPEND mixed-methods study

Background

Collecting NHS patient experience data is critical to ensure the delivery of high-quality services. Data are obtained from multiple sources, including service-specific surveys and widely used generic surveys. There are concerns about the timeliness of feedback, that some groups of patients and carers do not give feedback and that free-text feedback may be useful but is difficult to analyse.

Objective

To understand how to improve the collection and usefulness of patient experience data in services for people with long-term conditions using digital data capture and improved analysis of comments.

Design

The DEPEND study is a mixed-methods study with four parts: qualitative research to explore the perspectives of patients, carers and staff; use of computer science text-analytics methods to analyse comments; co-design of new tools to improve data collection and usefulness; and implementation and process evaluation to assess use of the tools and any impacts.

Setting

Services for people with severe mental illness and musculoskeletal conditions at four sites as exemplars to reflect both mental health and physical long-terms conditions: an acute trust (site A), a mental health trust (site B) and two general practices (sites C1 and C2).

Participants

A total of 100 staff members with diverse roles in patient experience management, clinical practice and information technology; 59 patients and 21 carers participated in the qualitative research components.

Interventions

The tools comprised a digital survey completed using a tablet device (kiosk) or a pen and paper/online version; guidance and information for patients, carers and staff; text-mining programs; reporting templates; and a process for eliciting and recording verbal feedback in community mental health services.

Results

We found a lack of understanding and experience of the process of giving feedback. People wanted more meaningful and informal feedback to suit local contexts. Text mining enabled systematic analysis, although challenges remained, and qualitative analysis provided additional insights. All sites managed to collect feedback digitally; however, there was a perceived need for additional resources, and engagement varied. Observation indicated that patients were apprehensive about using kiosks but often would participate with support. The process for collecting and recording verbal feedback in mental health services made sense to participants, but was not successfully adopted, with staff workload and technical problems often highlighted as barriers. Staff thought that new methods were insightful, but observation did not reveal changes in services during the testing period.

Conclusions

The use of digital methods can produce some improvements in the collection and usefulness of feedback. Context and flexibility are important, and digital methods need to be complemented with alternative methods. Text mining can provide useful analysis for reporting on large data sets within large organisations, but qualitative analysis may be more useful for small data sets and in small organisations.

Limitations

New practices need time and support to be adopted and this study had limited resources and a limited testing time.

Future work

Further research is needed to improve text-analysis methods for routine use in services and to evaluate the impact of methods (digital and non-digital) on service improvement in varied contexts and among diverse patients and carers.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 28. See the NIHR Journals Library website for further project information.

Patient safety in marginalised groups: a narrative scoping review

Background

Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising.

Methods

Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day.

Results

The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors.

Conclusions

This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks.

Trial registration

Not applicable for a scoping review.

Factors that influence rheumatologists' anti-tumor necrosis factor alpha prescribing decisions: a qualitative study

Background

Treatment decisions for any disease are usually informed by reference to published clinical guidelines or recommendations. These recommendations can be developed to improve the relative cost-effectiveness of health care and to reduce regional variation in clinical practice. Anti-tumor necrosis factor alpha (anti-TNF) treatments are prescribed for people with rheumatoid arthritis according to specific recommendations by the National Institute for Health and Care Excellence in England. Evidence of regional variation in clinical practice for rheumatoid arthritis may indicate that different factors have an influence on routine prescribing decisions. The aim of this study was to understand the factors that influence rheumatologists’ decisions when prescribing anti-TNF treatments for people with rheumatoid arthritis in England.

Methods

Semi-structured one-to-one telephone interviews were performed with senior rheumatologists in different regions across England. The interview schedule addressed recommendations by the National Institute for Health and Care Excellence, prescribing behavior, and perceptions of anti-TNF treatments. Interviews were recorded digitally, transcribed verbatim, and anonymized. Data were analyzed by thematic framework analysis that comprised six stages (familiarization; coding; developing the framework; applying the framework; generating the matrix; interpretation).

Results

Eleven rheumatologists (regional distribution - north 36%; midlands: 36%; south: 27%) participated (response rate: 24% of the sampling frame). The mean duration of the interviews was thirty minutes (range: 16 to 56 min). Thirteen factors that influenced anti-TNF prescribing decisions were categorized by three nested primary themes; specific influences were defined as subthemes: (i) External Environment Influences (National Institute for Health and Care Excellence Recommendations; Clinical Commissioning Groups; Cost Pressures; Published Clinical Evidence; Colleagues in Different Hospitals; Pharmaceutical Industry); (ii) Internal Hospital Influences (Systems to Promote Compliance with Clinical Recommendations; Internal Treatment Pathways; Hospital Culture); (iii) Individual-level Influences (Patient Influence; Clinical Autonomy; Consultant Experience; Perception of Disease Activity Score-28 (DAS28) Outcome).

Conclusions

Factors that influenced anti-TNF prescribing decisions were multifaceted, seemed to vary by region, and may facilitate divergence from published clinical recommendations. Strategic behavior appeared to illustrate a conflict between uniform treatment recommendations and clinical autonomy. These influences may contribute to understanding sources of regional variation in clinical practice for rheumatoid arthritis.

Beliefs and challenges held by medical staff about providing emergency care to migrants: an international systematic review and translation of findings to the UK context

OBJECTIVE

Migration has increased globally. Emergency departments (EDs) may be the first and only contact some migrants have with healthcare. Emergency care providers' (ECPs) views concerning migrant patients were examined to identify potential health disparities and enable recommendations for ED policy and practice.

DESIGN

Systematic review and meta-synthesis of published findings from qualitative studies.

DATA SOURCES

Electronic databases (Ovid Medline, Embase (via Ovid), PsycINFO (via OVID), CINAHL, Web of Science and PubMed), specialist websites and journals were searched.

ELIGIBILITY CRITERIA

Studies employing qualitative methods published in English.

SETTINGS

EDs in high-income countries.

PARTICIPANTS

ECPs included doctors, nurses and paramedics.

TOPIC OF ENQUIRY

Staff views on migrant care in ED settings.

DATA EXTRACTION AND SYNTHESIS

Data that fit the overarching themes of 'beliefs' and 'challenges' were extracted and coded into an evolving framework. Lines of argument were drawn from the main themes identified in order to infer implications for UK policy and practice.

RESULTS

Eleven qualitative studies from Europe and the USA were included. Three analytical themes were found: challenges in cultural competence; weak system organisation that did not sufficiently support emergency care delivery; and ethical dilemmas over decisions on the rationing of healthcare and reporting of undocumented migrants.

CONCLUSION

ECPs made cultural and organisational adjustments for migrant patients, however, willingness was dependent on the individual's clinical autonomy. ECPs did not allow legal status to obstruct delivery of emergency care to migrant patients. Reported decisions to inform the authorities were mixed; potentially leading to uncertainty of outcome for undocumented migrants and deterring those in need of healthcare from seeking treatment. If a charging policy for emergency care in the UK was introduced, it is possible that ECPs would resist this through fears of widening healthcare disparities. Further recommendations for service delivery involve training and organisational support.

'I have no love for such people, because they leave us to suffer': a qualitative study of health workers' responses and institutional adaptations to absenteeism in rural Uganda

BACKGROUND

Achieving positive treatment outcomes and patient safety are critical goals of the healthcare system. However, this is greatly undermined by near universal health workforce absenteeism, especially in public health facilities of rural Uganda. We investigated the coping adaptations and related consequences of health workforce absenteeism in public and private not-for-profit (PNFP) health facilities of rural Uganda.

METHODS

An empirical qualitative study involving case study methodology for sampling and principles of grounded theory for data collection and analysis. Focus groups and in-depth interviews were used to interview a total of 95 healthcare workers (11 supervisors and 84 frontline workers). The NVivo V.10 QSR software package was used for data management.

RESULTS

There was tolerance of absenteeism in both the public and PNFP sectors, more so for clinicians and managers. Coping strategies varied according to the type of health facility. A majority of the PNFP participants reported emotion-focused reactions. These included unplanned work overload, stress, resulting anger directed towards coworkers and patients, shortening of consultation times and retaliatory absence. On the other hand, various cadres of public health facility participants reported ineffective problem-solving adaptations. These included altering weekly schedules, differing patient appointments, impeding absence monitoring registers, offering unnecessary patient referrals and rampant unsupervised informal task shifting from clinicians to nurses.

CONCLUSION

High levels of absenteeism attributed to clinicians and health service managers result in work overload and stress for frontline health workers, and unsupervised informal task shifting of clinical workload to nurses, who are the less clinically skilled. In resource-limited settings, the underlying causes of absenteeism and low staff morale require attention, because when left unattended, the coping responses to absenteeism can be seen to compromise the well-being of the workforce, the quality of healthcare and patients' access to care.

Clinical Performance Feedback Intervention Theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research

BACKGROUND

Providing health professionals with quantitative summaries of their clinical performance when treating specific groups of patients ("feedback") is a widely used quality improvement strategy, yet systematic reviews show it has varying success. Theory could help explain what factors influence feedback success, and guide approaches to enhance effectiveness. However, existing theories lack comprehensiveness and specificity to health care. To address this problem, we conducted the first systematic review and synthesis of qualitative evaluations of feedback interventions, using findings to develop a comprehensive new health care-specific feedback theory.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar from inception until 2016 inclusive. Data were synthesised by coding individual papers, building on pre-existing theories to formulate hypotheses, iteratively testing and improving hypotheses, assessing confidence in hypotheses using the GRADE-CERQual method, and summarising high-confidence hypotheses into a set of propositions.

RESULTS

We synthesised 65 papers evaluating 73 feedback interventions from countries spanning five continents. From our synthesis we developed Clinical Performance Feedback Intervention Theory (CP-FIT), which builds on 30 pre-existing theories and has 42 high-confidence hypotheses. CP-FIT states that effective feedback works in a cycle of sequential processes; it becomes less effective if any individual process fails, thus halting progress round the cycle. Feedback's success is influenced by several factors operating via a set of common explanatory mechanisms: the feedback method used, health professional receiving feedback, and context in which feedback takes place. CP-FIT summarises these effects in three propositions: (1) health care professionals and organisations have a finite capacity to engage with feedback, (2) these parties have strong beliefs regarding how patient care should be provided that influence their interactions with feedback, and (3) feedback that directly supports clinical behaviours is most effective.

CONCLUSIONS

This is the first qualitative meta-synthesis of feedback interventions, and the first comprehensive theory of feedback designed specifically for health care. Our findings contribute new knowledge about how feedback works and factors that influence its effectiveness. Internationally, practitioners, researchers, and policy-makers can use CP-FIT to design, implement, and evaluate feedback. Doing so could improve care for large numbers of patients, reduce opportunity costs, and improve returns on financial investments.

TRIAL REGISTRATION

PROSPERO, CRD42015017541.

Safety work and risk management as burdens of treatment in primary care: insights from a focused ethnographic study of patients with multimorbidity

Background

In primary health care, patient safety failures can arise in service access, doctor-patient relationships, communication between care providers, relational and management continuity, or technical procedures. Through the lens of multimorbidty, and using qualitative ethnographic methods, our study aimed to illuminate safety issues in primary care.

Methods

Data were triangulated from electronic health records (EHRs); observation of primary care consultations; annual interviews with patients, (informal) care providers and GPs. A thematic analysis of observation, interview and field note material sought to describe the patient safety issues encountered and any associated factors or processes. A more detailed longitudinal description of 6 cases was used to contextualise safety issues identified in observation, interviews and EHRs.

Results

Twenty-six patients were recruited. Events which could lead to harm were found in all areas of a framework based on published literature. “Under” and “over” consultation as a precursor of safety failures emerged through thematic analysis of observation and interview material. Other findings concerned workload (for doctors and patients) and the limitations of short consultation times. There were differences in health data collected directly from the patients versus that found in EHRs. Examples included reference to a stroke history and diagnoses for CKD and hypertension. Case study analysis revealed specific issues which appeared contextual to safety concerns, mostly around the management of polypharmacy and patient medication adherence. Clinical imperatives appear around risk management, but the study findings point to a potential conflict with patient expectations around investigation, diagnosis and treatment.

Discussion

Patient safety work involves further burdens on top of existing workload for both clinicians and patients. In this conceptualisation, safety work seemingly forms part of a negative feedback loop with patient safety itself. A line of argument drawn from the triangulation of findings from different sources, points to a tension between the desirability of a minimally disruptive medicine versus safety risks possibly associated with ‘under’ or ‘over’ consultation. Multimorbidity acts as a magnifier of tensions in the delivery of health services and quality care in general practice. More attention should be put on system design than patient or professional behaviour.

Mental health service user and staff perspectives on tobacco addiction and smoking cessation: A meta-synthesis of published qualitative studies

WHAT IS KNOWN ON THE SUBJECT?: There are high rates of tobacco smoking in people living with mental illness, and rates are much higher than the general population. People living with mental illness experience high rates of cardiovascular disease and other physical health problems as a result of tobacco smoking. There is a lack of evidence on successful interventions for reducing the rates of smoking in people living with mental illness. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: A meta-synthesis of data from a number of studies to support mental health nurses to access data quickly and support the translation of findings into practice. Studies found staff working in mental health services expressed they did not have the confidence to adequately address smoking cessation for people living with mental illness. People living with mental illness would like support and encouragement support to help them achieve successful smoking cessation. People living with mental illness want support from mental health service staff to increase their confidence in smoking cessation rather than mainstream smoking cessation services. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Existing evidence-based interventions for smoking cessation has had limited impact on the smoking rates of people living with mental illness. Research is needed into innovative smoking cessation interventions and the service delivery of these interventions for people living with mental illness. Interventions to support people living with mental illness in smoking cessation could be part of mainstream mental health service delivery. Opportunities for smoking cessation training for mental health service staff could be provided.

ABSTRACT

Introduction People with mental illness are up to three times more likely to smoke and experience greater challenges and less success when trying to quit and therefore have higher risk of smoking-related morbidity and mortality. There is a lack of evidence on successful interventions to reduce the smoking rates in people living with serve mental illness. A meta-synthesis was undertaken to summarize the data from multiple studies to inform the development of future smoking cessation intervention studies. Methods MEDLINE, PsycINFO, Embase and CINAHL were searched in March 2017. A total of 965 titles and abstracts were screened for inclusion with 29 papers reviewed in full and 15 studies that met inclusion criteria. Included studies were assessed for quality using the Critical Appraisal Skills Programme tool. Key data across studies were examined and compared, and a thematic analysis was conducted. Results Analysis and synthesis developed five analytical themes: environmental and social context, living with a mental health illness, health awareness, financial awareness and provision of smoking cessation support. Themes generated the interpretive construct: "Whose role is it anyway?" which highlights tensions between staff perspectives on their role and responsibilities to providing smoking cessation support and support service users would like to receive. Relevance to mental health nursing Routine smoking cessation training for mental health professionals and research on innovative smoking cessation interventions to support people living with mental illness are needed. The Cochrane tobacco group has not found sufficient direct evidence of existing evidence-based interventions that have beneficial effect on smoking in people living with mental illness. With this in mind, mental health professionals should be encouraged to engage in future research into the development of new interventions and consider innovative harm reduction strategies for smoking into their practice, to reduce the morbidity and mortality many people living with mental illness experience from tobacco smoking.

Dementia in UK South Asians: a scoping review of the literature

OBJECTIVE

Over 850 000 people live with dementia in the UK. A proportion of these people are South Asians, who make up over 5% of the total UK population. Little is known about the prevalence, experience and treatment of dementia in the UK South Asian population. The aim of this scoping review is to identify dementia studies conducted in the UK South Asian population to highlight gaps in the literature which need to be addressed in future research.

METHOD

Databases were systematically searched using a comprehensive search strategy to identify studies. A methodological framework for conducting scoping reviews was followed. An extraction form was developed to chart data and collate study characteristics and findings. Studies were then grouped into six categories: prevalence and characteristics; diagnosis validation and screening; knowledge, understanding and attitudes; help-seeking; experience of dementia; service organisation and delivery.

RESULTS

A total of 6483 studies were identified, 27 studies were eligible for inclusion in the scoping review. We found that studies of prevalence, diagnosis and service organisation and delivery in UK South Asians are limited. We did not find any clinical trials of culturally appropriate interventions for South Asians with dementia in the UK. The existing evidence comes from small-scale service evaluations and case studies.

CONCLUSIONS

This is the first scoping review of the literature to identify priority areas for research to improve care for UK South Asians with dementia. Future research should first focus on developing and validating culturally appropriate diagnostic tools for the UK South Asians and then conducting high-quality epidemiological studies in order to accurately identify the prevalence of dementia in this group. The cultural adaptation of interventions for dementia and testing in randomised controlled trials is also vital to ensure that there are appropriate treatments available for the UK South Asians to access.

Understanding barriers to the introduction of precision medicines in non-small cell lung cancer: A qualitative interview protocol

Background: While precision medicines targeting genetic mutations and alterations in non-small cell lung cancer (NSCLC) have been available since 2010, their adoption into clinical practice has been slow. Evidence suggests that a number of barriers, such as insufficient clinician knowledge, a need for training of test providers, or a lack of specific clinical guidelines, may slow the implementation of precision in general. However, little attention has been given to the barriers to providing precision medicines in NSCLC. The purpose of this protocol is to outline the design for a qualitative interview study to identify the barriers and facilitators to the provision of precision medicines for NSCLC. Methods: This study will use semi-structured interviews with clinicians (n=10), test providers (n=10), and service commissioners (n=10) to identify the perceived barriers and facilitators to providing historical, current, and future precision medicines in NSCLC. Participants will be identified through mailing list advertisements and snowball sampling. Recruitment will continue until data saturation, indicated by no new themes arising from the data. Interviews will be conducted by telephone to facilitate geographical diversity. The qualitative data will be analysed using a framework analysis with themes anticipated to relate to; relevant barriers to providing precision medicines, the impact of different barriers on medicine provision, changes in the ability to provide precision medicines over time, and strategies to facilitate the provision of precision medicines. Ethics: This study has been approved by the University of Manchester Proportionate Review Research Ethics Committee (Reference number: 2017-1885-3619). Written consent will be obtained from all participants. Conclusion: This study is the first to explore the barriers and facilitators to providing precision medicines for NSCLC in the English NHS. The findings will inform strategies to improve the implementation of future precision medicines. These findings will be disseminated in peer-reviewed publications and national and international conferences.

'Nobody is after you; it is your initiative to start work': a qualitative study of health workforce absenteeism in rural Uganda

Background

Published evidence on the drivers of absenteeism among the health workforce is mainly limited to high-income countries. Uganda suffers the highest rate of health workforce absenteeism in Africa, attracting attention but lacking a definitive ameliorative strategy. This study aimed to explore the underlying reasons for absenteeism in the public and private 'not-for-profit' health sector in rural Uganda.

Methods

We undertook an empirical qualitative study, located within the critical realist paradigm. We used case study methodology as a sampling strategy, and principles of grounded theory for data collection and analysis. Ninety-five healthcare workers were recruited through focus groups and in-depth interviews. The NVivo V.10 software package was used for data management.

Results

Healthcare workers' absenteeism was explained by complex interrelated influences that could be seen to be both external to, and within, an individual's motivation. External influences dominated in the public sector, especially health system factors, such as delayed or omitted salaries, weak workforce leadership and low financial allocation for workers' accommodation. On the other hand, low staffing-particularly in the private sector-created work overload and stress. Also, socially constructed influences existed, such as the gendered nature of child and elderly care responsibilities, social class expectations and reported feigned sickness. Individually motivated absenteeism arose from perceptions of an inadequate salary, entitlement to absence, financial pressures heightening a desire to seek supplemental income, and educational opportunities, often without study leave.

Conclusion

Health workforce managers and policy makers need to improve governance efficiencies and to seek learning opportunities across different health providers.

Empowering people to help speak up about safety in primary care: Using codesign to involve patients and professionals in developing new interventions for patients with multimorbidity

Background

Multimorbidity, defined as the presence of two or more long‐term conditions, is increasingly common in primary care, and patients with multimorbidity may face particular barriers to quality of care and increased safety risks due to the complexity of managing multiple conditions. Consistent with calls to directly involve service users in improving care, we aimed to use design materials to codesign new interventions to improve safety in primary care.

Design

We drew on two established methods—accelerated experience‐based codesign and the future workshop approach. We synthesized design materials based on research into the patient experience of safety and multimorbidity in primary care to enable both patients, service users and carers, and primary health‐care professionals to propose interventions to improve care.

Results

Both patients and professionals prioritized polypharmacy as a threat to safety. Their recommendations for supportive interventions were consistent with Burden of Treatment theory, emphasizing the limited capacity of patients with multimorbidity and the need for services to proactively offer support to reduce the burden of managing complex treatment regimes.

Discussion & Conclusions

The process was feasible and acceptable to participants, who valued the opportunity to jointly propose new interventions. The iterative workshop approach enabled the research team to better explore and refine the suggestions of attendees. Final recommendations included the need for accessible reminders to support medication adherence and medication reviews for particularly vulnerable patients conducted with pharmacists within GP practices.

Threats to patient safety in primary care reported by older people with multimorbidity: baseline findings from a longitudinal qualitative study and implications for intervention

Background

In primary care, older patients with multimorbidity (two or more long-term conditions) are especially likely to experience patient safety incidents. Risks to safety in this setting arise as a result of patient, staff and system factors; particularly where these interact or fail to do so.

Recent research and policy highlight the important contribution patients can make to improving safety. Older patients with multimorbidity may have the most to gain from increasing their involvement but before interventions can be developed to support them to improve their patient safety, more needs to be known about how this is threatened and how patients respond to perceived threats.

We sought to identify and describe threats to patient safety in primary care among older people with multimorbidity, to provide a better understanding of how these are experienced and to inform the development of interventions to reduce risks to patient safety.

Methods

Twenty-six older people, aged 65 or over, with multimorbidity were recruited to a longitudinal qualitative study. At baseline, data on their health and healthcare were collected through semi-structured interviews. Data were analysed thematically, using a framework developed from a previous synthesis of qualitative studies of patient safety in primary care.

Results

Threats to patient safety were organised into six themes, across three domains of health and care. These encompassed all aspects of the patient journey, from access to everyday management. Across the journey, many issues arose due to poor communication, and uncoordinated care created extra burdens for patients and healthcare staff. Patients’ sense of safety and trust in their care providers were especially threatened when they felt their needs were ignored, or when they perceived responses from staff as inappropriate or insensitive.

Conclusions

For older patients with multimorbidity, patient safety is intrinsically linked to the challenges people face when managing health conditions, navigating the healthcare system, and negotiating care. We consider the implications of this for the development of interventions to reduce threats to patient safety. Potential patient-centred mechanisms include providing patients with more realistic expectations for primary care, and supporting them to communicate their needs and concerns more effectively.

Electronic supplementary material

The online version of this article (doi: 10.1186/s12913-017-2727-9) contains supplementary material, which is available to authorized users.

Barriers and facilitators in accessing dementia care by ethnic minority groups: a meta-synthesis of qualitative studies

BACKGROUND

It is estimated that there are about 25,000 people from UK ethnic minority groups with dementia. It is clear that there is an increasing need to improve access to dementia services for all ethnic groups to ensure that everyone has access to the same potential health benefits. The aim was to systematically review qualitative studies and to perform a meta-synthesis around barriers and facilitators to accessing care for dementia in ethnic minorities.

METHODS

Databases were searched to capture studies on barriers and facilitators to accessing care for dementia in ethnic minorities. Analysis followed the guidelines for meta-ethnography. All interpretations of data as presented by the authors of the included papers were extracted and grouped into new themes.

RESULTS

Six hundred and eighty four papers were identified and screened. Twenty eight studies were included in the meta-synthesis. The analysis developed a number of themes and these were incorporated into two overarching themes: 'inadequacies' and 'cultural habitus'.

CONCLUSIONS

The two overarching themes lend themselves to interventions at a service level and a community level which need to happen in synergy.

TRIAL REGISTRATION

The review was registered with PROSPERO: CRD42016049326 .

Findings and Predictors of Patient-Reported Experience of Primary Health Care in Nigeria

OBJECTIVE

The study reports findings and patients' characteristics that predict their experiences of primary health care (PHC) in Nigeria.

METHODS

A cross-sectional survey of 1680 patients attending 24 primary health centers in 6 states from the 6 geopolitical subdivisions in Nigeria. The patient evaluation scale was used for exit survey of patients' experiences with PHC. Categorical findings and mean ratings on experiences of PHC were analyzed using both descriptive and inferential statistics.

RESULTS

The mean response rate was 98%, and most respondents were female (73%) and married (72%). A higher proportion of patients gave positive feedback on their relationships with staff (84%) than they did available space in the waiting area (60%). Higher self-rated health status and nonpayment for care at the point of receipt were consistent predictors of positive patient experiences from the multilevel analysis.

CONCLUSION

Study reported findings and drivers of patient experiences with PHC. Aspects of PHC showing less positive patient experiences and some patients' factors associated with these are amenable to change and can form the focus of quality improvement actions.

Dementia care in England and the social model of disability

This article reviews the development of a social model of disability and considers whether or not it provides a helpful framework for dementia care. The social model has not yet fully included cognitive impairment, although considerable work has been carried out with regard to learning disability. By applying this model to dementia care, those who surround people with dementia can review the impact that they as 'non-demented' people have on others; can reconsider the value of hearing and responding to personal experiences; can reframe the focus to consider abilities instead of losses; and can better understand the impact of public policy. The article also considers the present shortcomings of a disability model in terms of how it relates to dementia care and concludes with some thoughts for future consideration. The article draws heavily on the findings of a research project conducted by Dementia Voice and the University of the West of England, Bristol, UK to consider the needs of two sub-groups of people with dementia – younger people (i.e. those under the age of 65) and those from minority ethnic groups.

Attitudes to participating in a birth cohort study, views from a multiethnic population: a qualitative study using focus groups

Background

Recruitment to birth cohort studies is a challenge. Few studies have addressed the attitudes of women about taking part in birth cohort studies particularly those from ethnic minority groups.

Objective

To seek the views of people from diverse ethnic backgrounds about participation in a proposed birth cohort examining the impact of infections.

Design and setting

Eight focus groups of pregnant women and mothers of young children took place in GP surgeries and community centres in an ethnically diverse area of east London. Purposeful sampling and language support ensured representation of people from ethnic minority groups. Audio recordings were taken and transcripts were analysed using the Framework approach.

Main outcome measures

The views of participants about taking part in the proposed birth cohort study, in particular concerning incentives to taking part, disincentives and attitudes to consenting children.

Results

There was more convergence of opinion than divergence across groups. Altruism, perceived health gains of participating and financial rewards were motivating factors for most women. Worries about causing harm to their child, inconvenience, time pressure and blood sample taking as well as a perceived lack of health gains were disincentives to most. Mistrust of researchers did not appear to be a significant barrier. The study indicates that ethnicity and other demographic factors influence attitudes to participation.

Conclusions

To recruit better, birth cohort studies should incorporate financial and health gains as rewards for participation, promote the altruistic goals of research, give assurances regarding the safety of the participating children and sensitive data, avoid discomfort and maximize convenience. Ethnicity influences attitudes to participation in many ways, and researchers should explore these factors in their target population.

Sensemaking and the co-production of safety: a qualitative study of primary medical care patients

This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings.

Systematic review of patients' views on the quality of primary health care in sub-Saharan Africa

This is the first systematic review of patient views on the quality of primary health care services in sub-Saharan Africa using studies identified from MEDLINE, CINAHL Plus, EMBASE and PsycINFO. In total, 20 studies (3 qualitative, 3 mixed method and 14 quantitative) were included. Meta-analysis was done using quantitative findings from facility- and community-based studies of patient evaluation of primary health care. There was low use of validated measures, and the most common scales assessed were humanness (70%) and access (70%). While 66% (standard deviation = 21%) of respondents gave favourable feedback, there were discrepancies between surveys in community and facility contexts. Findings suggest that patient views could vary with subject recruitment site. We recommend improvement in the methods used to examine patient views on quality of primary health care.

The care.data consensus? A qualitative analysis of opinions expressed on Twitter

BACKGROUND

Large, integrated datasets can be used to improve the identification and management of health conditions. However, big data initiatives are controversial because of risks to privacy. In 2014, NHS England launched a public awareness campaign about the care.data project, whereby data from patients' medical records would be regularly uploaded to a central database. Details of the project sparked intense debate across a number of platforms, including social media sites such as Twitter. Twitter is increasingly being used to educate and inform patients and care providers, and as a source of data for health services research. The aim of the study was to identify and describe the range of opinions expressed about care.data on Twitter for the period during which a delay to this project was announced, and provide insight into the strengths and flaws of the project.

METHODS

Tweets with the hashtag #caredata were collected using the NCapture tool for NVivo. Methods of qualitative data analysis were used to identify emerging themes. Tweets were coded and analysed in-depth within and across themes.

RESULTS

The dataset consisted of 9895 tweets, captured over 18 days during February and March 2014. Retweets (6118, 62%) and spam (240, 2%) were excluded. The remaining 3537 tweets were posted by 904 contributors, and coded into one or more of 50 sub-themes, which were organised into 9 key themes. These were: informed consent and the default 'opt-in', trust, privacy and data security, involvement of private companies, legal issues and GPs' concerns, communication failure and confusion about care.data, delayed implementation, patient-centeredness, and potential of care.data and the ideal model of implementation.

CONCLUSIONS

Various concerns were raised about care.data that appeared to be shared by those both for and against the project. Qualitatively analysing tweets enabled us to identify a range of concerns about care.data and how these might be overcome, for example, by increasing the involvement of stakeholders and those with expert knowledge. Our findings also highlight the risks of not considering public opinion, such as the potential for patient safety failures resulting from a lack of trust in the healthcare system. However, caution is advised if using Twitter as a stand-alone data source, as contributors may lie more heavily on one side of a debate than another. A mixed-methods approach would have enabled us to complement this data with a more representative overview.

Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

Objective

Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.

Method

Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.

Results

Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.

Conclusion

Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.

MAXimising Involvement in MUltiMorbidity (MAXIMUM) in primary care: protocol for an observation and interview study of patients, GPs and other care providers to identify ways of reducing patient safety failures

INTRODUCTION

Increasing numbers of older people are living with multiple long-term health conditions but global healthcare systems and clinical guidelines have traditionally focused on the management of single conditions. Having two or more long-term conditions, or 'multimorbidity', is associated with a range of adverse consequences and poor outcomes and could put patients at increased risk of safety failures. Traditionally, most research into patient safety failures has explored hospital or inpatient settings. Much less is known about patient safety failures in primary care. Our core aims are to understand the mechanisms by which multimorbidity leads to safety failures, to explore the different ways in which patients and services respond (or fail to respond), and to identify opportunities for intervention.

METHODS AND ANALYSIS

We plan to undertake an applied ethnographic study of patients with multimorbidity. Patients' interactions and environments, relevant to their healthcare, will be studied through observations, diary methods and semistructured interviews. A framework, based on previous studies, will be used to organise the collection and analysis of field notes, observations and other qualitative data. This framework includes the domains: access breakdowns, communication breakdowns, continuity of care errors, relationship breakdowns and technical errors.

ETHICS AND DISSEMINATION

Ethical approval was received from the National Health Service Research Ethics Committee for Wales. An individual case study approach is likely to be most fruitful for exploring the mechanisms by which multimorbidity leads to safety failures. A longitudinal and multiperspective approach will allow for the constant comparison of patient, carer and healthcare worker expectations and experiences related to the provision, integration and management of complex care. This data will be used to explore ways of engaging patients and carers more in their own care using shared decision-making, patient empowerment or other relevant models.

Developing cartoons for long-term condition self-management information

BACKGROUND

Advocating the need to adopt more self-management policies has brought with it an increasing demand for information about living with and making decisions about long-term conditions, with a significant potential for using cartoons. However, the purposeful use of cartoons is notably absent in many areas of health care as is evidence of their acceptability to patients and lay others. This paper outlines the process used to develop and evaluate cartoons and their acceptability for a series of self-management guidebooks for people with inflammatory bowel disease, irritable bowel syndrome, diabetes, chronic obstructive pulmonary disease and chronic kidney disease (CKD).

METHODS

Principles for a process to develop information and cartoons were developed. Cartoon topics were created using qualitative research methods to obtain lay views and experiences. The CKD guidebook was used to provide a detailed exemplar of the process. Focus group and trial participants were recruited from primary care CKD registers. The book was part of a trial intervention; selected participants evaluated the cartoons during in-depth interviews which incorporated think-aloud methods.

RESULTS

In general, the cartoons developed by this process depict patient experiences, common situations, daily management dilemmas, making decisions and choices and the uncertainties associated with conditions. CKD cartoons were developed following two focus groups around the themes of getting a diagnosis; understanding the problem; feeling that facts were being withheld; and setting priorities. Think-aloud interviews with 27 trial participants found the CKD cartoons invoked amusement, recognition and reflection but were sometimes difficult to interpret.

CONCLUSION

Humour is frequently utilised by people with long-term conditions to help adjustment and coping. Cartoons can help provide clarity and understanding and could address concerns related to health literacy. Using cartoons to engage and motivate people is a consideration untapped by conventional theories with the potential to improve information to support self-management.

What is the potential for social networks and support to enhance future telehealth interventions for people with a diagnosis of schizophrenia: a critical interpretive synthesis

BACKGROUND

Digital technologies are increasingly directed at improved monitoring, management and treatment of mental health. However, their potential contribution to social networks and self-management support for people diagnosed with a serious mental illness has rarely been considered. This review and meta-synthesis aimed to examine the processes of engagement and perceived relevance and appropriateness of telehealth interventions for people with a diagnosis of schizophrenia. The review addresses three key questions. How is the use of digital communications technologies framed in the professional psychiatric literature? How might the recognised benefits of telehealth translate to people with a diagnosis of schizophrenia? What is the user perspective concerning Internet information and communication technologies?

METHODS

A critical interpretive synthesis (CIS) of published findings from quantitative and qualitative studies of telehealth interventions for people with a diagnosis of schizophrenia.

RESULTS

Most studies were of an exploratory nature. The professional discourse about the use of different technologies was overlain by concerns with surveillance and control, focusing on the Internet as a potential site of risk and danger. The critical synthesis of findings showed that the key focus of the available studies was on the delivery of existing traditional approaches (e.g. improving medications adherence, provision of medical information about the condition, symptom monitoring and cognitive behavioural therapy). Even though it was clear that the Internet has considerable potential in terms of accessing and utilising lay support, the potential of communication technologies in mobilising of resources for personal self-management or peer support was a relatively absent or hidden a focus of the available studies.

CONCLUSIONS

Based on an interpretive synthesis of available studies, people with a diagnosis of schizophrenia or psychosis use the Internet primarily for the purposes of disclosure and information gathering. Empowerment, regulation and surveillance emerged as the key dimensions of engagement (or not) with telehealth interventions. The findings suggest that telehealth interventions are disproportionately used by particular patient groups (e.g.women, people who are employed). Further research needs to ascertain the mechanisms by which telehealth interventions may be potentially beneficial or harmful for engagement and management to people with a diagnosis of schizophrenia.

Trouble with ataxia: A longitudinal qualitative study of the diagnosis and medical management of a group of rare, progressive neurological conditions

OBJECTIVES

An exploratory investigation of diagnosis and management in progressive ataxias: rare neurological conditions usually affecting balance, mobility and speech.

METHODS

A longitudinal qualitative study into the experiences of people with ataxia and neurologists. Thematic analysis and follow-up interviews were used to determine diagnosis and management issues over time.

RESULTS

People with ataxia recruited via two hospital departments and Ataxia UK were interviewed at baseline (n = 38) and 12-month follow-up (n = 31). Eight consultant neurologists were interviewed once. Patient accounts were diverse, but many expressed frustration at having an incurable condition and dissatisfaction with service outcomes. At follow-up, there was variation in their contact and satisfaction with helping agencies. Service issues regarding continuity of care and the primary/secondary care interface were evident. Neurologists' accounts also varied. One-half reported that there is nothing that can be done, and one-half favoured specialist referral to increase the likelihood of finding an underlying aetiology within budget constraints.

CONCLUSIONS

Diagnostic uncertainties existing at baseline remained for patients at follow-up interviews, although some had learned to deal with the uncertainties brought by the diagnosis of a largely untreatable condition. Care pathways only seemed to operate in the case of defined conditions, such as Friedreich's Ataxia, the most commonly inherited cause. The findings point to a need to develop the evidence base to inform the relative utility of diagnostic procedures in the context of finite resources for patient care and support.

Redefined by illness: meta-ethnography of qualitative studies on the experience of rheumatoid arthritis

PURPOSE

To synthesize published qualitative studies concerning the lived experience of rheumatoid arthritis (RA). To compare the conceptual features of qualitative studies covering two different time periods.

METHODS

In 2002, 24 items published 1975-2001 were identified in comprehensive literature searches and assessed by multiple reviewers. In 2010, the first author found 28 articles published 2002-2009 in a simple search of the Medline database and synthesized them alone. Articles were synthesized using meta-ethnography.

RESULTS

Both syntheses found that the main symptoms of RA are variable and unpredictable. However, in the first synthesis a sociological model dominated where RA was seen as an assault on self-identity with devastating social consequences. The main concepts were biographical disruption, role incompetence and the dread of dependency on others. In the second synthesis, the findings produced a model for health care practitioners tied to perceptions of control and incorporating a career-adaptation model of the experience of RA.

CONCLUSIONS

We recommend that future synthesizers and primary qualitative health researchers focus more on non-hospital based populations and non-English language articles or study participants. The implications for rehabilitation follow from reflecting the findings of the synthesis against existing psychological models of coping and adaptation in RA. Implications for Rehabilitation Coping and adaptation are biographical processes, although the relative importance of active "disease mastery" versus more passive "getting used to it" is unclear. The uncertainty and fluctuating nature of symptoms and disease course presents existential challenges for people with RA in relation to maintaining physical functioning and social roles. Within a social model of disability, these findings point to potential intervention sites in society and relationships that would benefit people living with RA.

"Six sessions is a drop in the ocean": an exploratory study of neurological physiotherapy in idiopathic and inherited ataxias

OBJECTIVE

An exploratory study to examine specialist neurological physiotherapy service provision and utilisation for people with progressive ataxia.

DESIGN

Qualitative study involving thematic analysis of accounts in semi-structured interviews with physiotherapists and patients.

SETTING

People with ataxia and specialist neuro-rehabilitation physiotherapists in Greater Manchester, UK.

PARTICIPANTS

38 people with ataxia and 8 neurological-physiotherapists working in academic and hospital and community-based services in NHS and private settings. Recruiting physiotherapists experienced in working with the patient group was a challenge.

INTERVENTIONS

One hour cross-sectional semi-structured interview at physiotherapists' workplaces or in patients' own homes.

RESULTS

Neurological physiotherapy was experienced by 25 (66%) of the 38 people with ataxia. The overarching themes emerging from the analysis were 'making a difference,' engagement and service provision. A majority of both samples felt that services should be organised so as to provide longer term therapy and support that goes beyond short care packages followed by provision of home exercise programme. Engagement with services was linked to patient expectations, adherence and perception of outcomes. The most predominant codes in the data set were encapsulated by the theme 'making a difference,' which further included concerns about how to measure perceived clinical improvement (as experienced by patients) in the context of progressive decline.

CONCLUSIONS

The findings suggest a model of idealised service provision involving a holistic, open-access service including research efforts to improve the evidence base. Special attention needs to be paid to measuring improvements following therapy.

'You don't get told anything, they don't do anything and nothing changes'. Medicine as a resource and constraint in progressive ataxia

BACKGROUND

Progressive ataxias are neurological disorders affecting balance, co-ordination of movement and speech.

OBJECTIVE

A qualitative study was undertaken to discover patients' experiences of ataxia and its symptoms.

PARTICIPANTS

Thirty-eight people with ataxia recruited from patient support groups and two hospital outpatients departments.

DESIGN

Cross-sectional qualitative study with thematic analysis.

RESULTS

These accounts highlight the limits of medicine in the context of a rare, incurable and disabling disorder, and the embodied uncertainties brought by slowly progressive diseases that lie at the boundaries of mainstream medical knowledge. The existential crises faced by people with ataxia are seemingly magnified by sometimes idiopathic aetiologies and the limited number of inherited conditions identifiable by the available genetic tests. Interviewees were drawn into a medical system that was focused mainly on the diagnosis process, with widely varying results. However, when asked, most had rather valued the provision of disability aids and physical therapies. Only one informant reported overcoming the myriad uncertainties of progressive ataxia, and their account supported the notion of 'biographical repair' in chronic illness.

CONCLUSIONS

Clinical uncertainties in ataxia constrained people's attempts to deal with their condition. The construction of the proactive, informed, medical consumer who is assumed to be a partner in care is problematic in the context of a rare and difficult-to-diagnose disease for which there is usually no cure. Service providers should be mindful of the need to manage patient expectations in relation to diagnosis and cure. More focus might usefully be placed on the provision of physical therapies and disability aids.

Evaluating meta-ethnography: systematic analysis and synthesis of qualitative research

BACKGROUND

Methods for reviewing and synthesising findings from quantitative research studies in health care are well established. Although there is recognition of the need for qualitative research to be brought into the evidence base, there is no consensus about how this should be done and the methods for synthesising qualitative research are at a relatively early stage of development.

OBJECTIVE

To evaluate meta-ethnography as a method for synthesising qualitative research studies in health and health care.

METHODS

Two full syntheses of qualitative research studies were conducted between April 2002 and September 2004 using meta-ethnography: (1) studies of medicine-taking and (2) studies exploring patients' experiences of living with rheumatoid arthritis. Potentially relevant studies identified in multiple literature searches conducted in July and August 2002 (electronically and by hand) were appraised using a modified version of the Critical Appraisal Skills Programme questions for understanding qualitative research. Candidate papers were excluded on grounds of lack of relevance to the aims of the synthesis or because the work failed to employ qualitative methods of data collection and analysis.

RESULTS

Thirty-eight studies were entered into the medicine-taking synthesis, one of which did not contribute to the final synthesis. The synthesis revealed a general caution about taking medicine, and that the practice of lay testing of medicines was widespread. People were found to take their medicine passively or actively or to reject it outright. Some, in particular clinical areas, were coerced into taking it. Those who actively accepted their medicine often modified the regimen prescribed by a doctor, without the doctor's knowledge. The synthesis concluded that people often do not take their medicines as prescribed because of concern about the medicines themselves. 'Resistance' emerged from the synthesis as a concept that best encapsulated the lay response to prescribed medicines. It was suggested that a policy focus should be on the problems associated with the medicines themselves and on evaluating the effectiveness of alternative treatments that some people use in preference to prescribed medicines. The synthesis of studies of lay experiences of living with rheumatoid arthritis began with 29 papers. Four could not be synthesised, leaving 25 papers (describing 22 studies) contributing to the final synthesis. Most of the papers were concerned with the everyday experience of living with rheumatoid arthritis. This synthesis did not produce significant new insights, probably because the early papers in the area were substantial and theoretically rich, and later papers were mostly confirmatory. In both topic areas, only a minority of the studies included in the syntheses were found to have referenced each other, suggesting that unnecessary replication had occurred.

LIMITATIONS

We only evaluated meta-ethnography as a method for synthesising qualitative research, but there are other methods being employed. Further research is required to investigate how different methods of qualitative synthesis influence the outcome of the synthesis.

CONCLUSIONS

Meta-ethnography is an effective method for synthesising qualitative research. The process of reciprocally translating the findings from each individual study into those from all the other studies in the synthesis, if applied rigorously, ensures that qualitative data can be combined. Following this essential process, the synthesis can then be expressed as a 'line of argument' that can be presented as text and in summary tables and diagrams or models. Meta-ethnography can produce significant new insights, but not all meta-ethnographic syntheses do so. Instead, some will identify fields in which saturation has been reached and in which no theoretical development has taken place for some time. Both outcomes are helpful in either moving research forward or avoiding wasted resources. Meta-ethnography is a highly interpretative method requiring considerable immersion in the individual studies to achieve a synthesis. It places substantial demands upon the synthesiser and requires a high degree of qualitative research skill. Meta-ethnography has great potential as a method of synthesis in qualitative health technology assessment but it is still evolving and cannot, at present, be regarded as a standardised approach capable of application in a routinised way.

FUNDING

Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.

Getting a diagnosis v. learning to live with it? The case of the progressive ataxias

OBJECTIVES

To examine the perceptions and experiences of the diagnosis process in people with a progressive ataxia, a group of rare complex neurological conditions usually leading to disturbances in balance and speech.

METHODS

An explorative qualitative study involving analysis of public accounts posted to specialist Internet discussion forums by people with symptoms of ataxia. Internet data were utilized partly because ataxia is a rare condition.

RESULTS

The main themes that emerged were diagnosis as an arduous process, achieving diagnosis as a privilege, the importance of getting a medical label, being believed with regard to symptoms and 'idiopathic' diagnosis as a non-diagnosis. The accounts of people who were not able to secure a definitive diagnosis suggested that their priorities had changed from getting a diagnosis to managing and learning to live with their progressive disabilities.

CONCLUSIONS

The diagnosis of the progressive ataxias presents challenges for patients, clinicians and in terms of the extensive use of finite healthcare resources. Our findings suggest there are varied views on the importance of diagnosis to people with progressive ataxia. This warrants further in-depth research to understand how people rate the relative utility of diagnostics.

Population screening for Chlamydia trachomatis infection in the UK: a qualitative study of the experiences of those screened

BACKGROUND

Screening for Chlamydia trachomatis in selected health care settings is underway in the UK despite insufficient evidence about the personal impact of screening.

OBJECTIVES

To describe men and women's experiences of being screened for chlamydia as part of the Chlamydia Screening Studies (ClaSS) project, a population-based UK study of postal screening for chlamydia.

METHODS

We conducted in-depth interviews with 45 purposively sampled participants in the ClaSS project using a checklist of topics relating to their experiences of the screening process. Interviews were audio-tape recorded, transcribed verbatim and analysed using the constant comparison method.

RESULTS

Four main themes emerged: initial discomfort with screening arising from an unease with sexual health issues; anxiety, especially after receiving a positive test result, due to the fear of informing sexual partners, the risk of infertility and the possibility of having other undetected infections; women's concern about being stigmatised for having been infected with chlamydia, which affected how they felt about themselves and how they thought others would perceive them; and recognising the need to balance the harms of screening with the benefits. Despite some reported adverse effects, no one regretted their decision to be screened.

CONCLUSIONS

Public education and discussion of sexually transmitted infections should help to increase the acceptability of chlamydia screening and destigmatise a diagnosis of chlamydia. Those working in primary care settings are likely to become increasingly involved in chlamydia screening and so must be suitably trained to inform individuals of the potential adverse effects and to deal with their consequences.

Resisting medicines: a synthesis of qualitative studies of medicine taking

The study aimed to synthesise qualitative studies of lay experiences of medicine taking. Most studies focused on the experience of those not taking their medicine as prescribed, with few considering those who reject their medicines or accept them uncritically. Most were concerned with medicines for chronic illnesses. The synthesis revealed widespread caution about taking medicines and highlighted the lay practice of testing medicines, mainly for adverse effects. Some concerns about medicines cannot be resolved by lay evaluation, however, including worries about dependence, tolerance and addiction, the potential harm from taking medicines on a long-term basis and the possibility of medicines masking other symptoms. Additionally, in some cases medicines had a significant impact on identity, presenting problems of disclosure and stigma. People were found to accept their medicines either passively or actively, or to reject them. Some were coerced into taking medicines. Active accepters might modify their regimens by taking medicines symptomatically or strategically, or by adjusting doses to minimise unwanted consequences, or to make the regimen more acceptable. Many modifications appeared to reflect a desire to minimise the intake of medicines and this was echoed in some peoples' use of non-pharmacological treatments to either supplant or supplement their medicines. Few discussed regimen changes with their doctors. We conclude that the main reason why people do not take their medicines as prescribed is not because of failings in patients, doctors or systems, but because of concerns about the medicines themselves. On the whole, the findings point to considerable reluctance to take medicine and a preference to take as little as possible. We argue that peoples' resistance to medicine taking needs to be recognised and that the focus should be on developing ways of making medicines safe, as well as identifying and evaluating the treatments that people often choose in preference to medicines.

'How can they tell?' A qualitative study of the views of younger people about their dementia and dementia care services

There is growing interest in eliciting the views of younger people with dementia (i.e. those under 65 years of age) within health and social care research. The often erroneous view that these individuals are not capable of expressing their views and experiences has now been seriously challenged. The present paper draws on the findings from 14 qualitative in-depth interviews with younger people with dementia conducted in the South-west of England, and considers some of the issues involved in interviewing people with dementia. Purposive and snowballing techniques were used to recruit participants. Data were transcribed and subjected to comparative textual analysis to index, code and analyse the data for emergent themes. Four major themes emerged: (1) the general experience of having dementia; (2) dementia diagnosis; (3) the importance of age; and (4) risk and danger issues. The results indicate that the majority of participants were articulate and insightful about their experiences and needs. The present paper concludes by arguing that the challenge for health and social care professionals is to engage with and consult such individuals about their experiences and what they want from dementia care services, and the authors consider some of the issues involved in interviewing people with dementia.

Sexual function and quality of life in genitourinary medicine (GUM) outpatients and preliminary validation of a self-report questionnaire measure

A cross-sectional questionnaire survey of 216 men and 191 women attending a genitourinary medicine (GUM) clinic was undertaken to explore the relationship between sexual symptoms and quality of sexual life, and to test the psychometric validity of a pilot self-report measure of Sexual Function and Quality of Sexual Life (SFQoSL). Statistical comparisons were made with three reference groups: volunteers attending GUM for psychosexual counselling, outpatients at an Obstetrics and Gynaecology Department, and staff. Exploratory principal components analysis (with varimax rotation) of questionnaire item responses suggested an 11 (in women) and 13 (in men) factor solution, incorporating four multi-item scales. Internal consistency (Cronbach's alpha) of core items was 0.84 in 186 women (19 items) and 0.87 in 210 men (22 items). Construct validity was supported in comparisons with reference groups using one-way analysis of variance and post-hoc Scheffé testing. Overall, 116 (54%) male and 132 (69%) female GUM outpatients had scores indicating sexual dysfunction. Thirty-seven (17%) men reported erectile dysfunction; 54 (28%) women reported vaginal dryness affecting sex; 48 (25%) women reported genital changes affecting sex; 45 (21%) men and 64 (34%) women reported problems reaching orgasm.

Younger people in dementia care: a review of service needs, service provision and models of good practice

This paper reviews the literature on younger people (under 65 years of age) with dementia, in dementia care. Seventy-four relevant papers were identified by use of a search strategy derived from the methodology of systematic reviews, the majority of which originated in the UK (69, 93.2%). The need for specialist, flexible, age-appropriate, and dedicated services was a central theme in the literature. A person-centred approach was advocated within an individual or 'tailor made' model of care. However, the available evidence suggests that this model of good practice is not currently reflected in the majority of services provided in the United Kingdom. Overall, the literature argues that the needs of younger people with dementia are best served by inter-agency collaboration, early assessment, and an awareness of individual needs. Clearly, these proposals could usefully serve anybody with dementia, irrespective of age. However, aside from a few prevalence studies, and some exploratory work with small numbers of service users, little in the way of empirical work is available. The recommendations that have been made regarding dementia services for younger people are based largely on the practical experience of professionals and paid carers, rather than scientific evidence.

Minority ethnic groups in dementia care: a review of service needs, service provision and models of good practice

Sixty-seven English language articles were obtained for the review, the majority of which (44, 65.7%) had US origins. Broadly, the main issues covered in the literature were the under-utilization of services by minority ethnic groups; the prevalence of dementia in different ethnic groups; the experience of care giving in different racial groups and language as a factor in cognitive assessment. Although it has been argued that the instruments used to assess cognitive function are culturally biased, the available published evidence would seem to suggest that the fundamental issue is language ability, rather than minority group membership per se. Studies into the care giving experience amongst different ethnic or racial groups suffer from theoretical and methodological weaknesses. Studies of help-seeking among various ethnic groups in the US have found that many do not prioritize dementia as a health problem in the face of more pressing concerns. There was little consensus amongst the articles about whether services should be provided specifically for different ethnic groups, reflecting a lack of evidence concerning the efficacy of different models of service provision.

Reliable and valid self-report outcome measures in sexual (dys)function: a systematic review

This paper examines the published reliability and validity of non-disease specific, self-report measures of sexual function. Relevant papers were found in a search of the Embase electronic bibliographic database, for English language papers (published 1980-99) reporting on the psychometric testing of sexual function questionnaires. Existing published reviews or collections of such instruments were also searched, and the reference lists of all papers obtained were "back-searched" to identify other measures. Included measures were evaluated in a systematic manner using published standards concerning the validity, internal consistency, and reproducibility of health measurement scales and quality of life measures. Twenty-three self-report measures were identified for inclusion in this review. A further 2 measures were identified by reviewers of this paper after the main searches were undertaken. One measure was found not to be exclusively self-report. Eleven (46% of 24 included measures) did not meet minimum published standards for reliability, internal consistency, and validity. However one of these was reliable and valid in the female-version only. Of the 14 reliable and valid measures, or versions thereof (58% of 24), 2 (8% of 24) met "superior" psychometric standards. Many measures were developed for use with patients in sex or marital therapy, and are mainly suitable for administration to people with long-term sex partners. It is sensible to assume that instruments are only reliable and valid in the often specialized populations in which they were developed.

A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments

OBJECTIVE

To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments.

DESIGN

Randomised controlled trial.

SETTING

Orthopaedic outpatient departments in two hospitals.

SUBJECTS

481 patients with musculoskeletal problems referred for specialist orthopaedic opinion.

INTERVENTIONS

Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists).

MAIN OUTCOME MEASURES

Patient centred measures of pain, functional disability and perceived handicap.

RESULTS

A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238).

CONCLUSIONS

On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.

Assortative sexual mixing in a heterosexual clinic population--a limiting factor in HIV spread?

OBJECTIVE

To assess the degree of sexual mixing in a sexually transmitted disease clinic population stratified by country of birth.

DESIGN

Prospective linked HIV serosurvey incorporating demographic and sexual risk data gathered by a doctor-administered questionnaire.

SETTING

The Department of Genitourinary Medicine at St Thomas' Hospital, London, UK.

SUBJECTS

Fifteen thousand eight hundred and seventy-eight heterosexuals who attended between April 1992 and February 1995.

MAIN OUTCOME MEASURE

The degree of assortative (like-with-like) mixing, after stratification of the population by country of birth, of index patients, their parents and their sexual partners.

RESULTS

Sexual mixing in this population of sexually transmitted disease clinic attenders is highly assortative when the CoB of parents (family origin) of index patients is taken into account.

CONCLUSION

Our findings help to explain the low spread of heterosexual HIV infection in the UK to date, and may help future projections, and health targeting of those at risk. This model can be applied to other mixed population.

Gonorrhoea in inner London: results of a cross sectional study

OBJECTIVES

To estimate population based incidence rates of gonorrhoea in an inner London area and examine relations with age, ethnic group, and socioeconomic deprivation.

DESIGN

Cross sectional study.

SETTING

11 departments of genitourinary medicine in south and central London.

SUBJECTS

1978 first episodes of gonorrhoea diagnosed in 1994 and 1995 in residents of 73 electoral wards in the boroughs of Lambeth, Southwark, and Lewisham who attended any of the departments of genitourinary medicine.

MAIN OUTCOME MEASURES

Yearly age, sex, and ethnic group specific rates of gonorrhoea per 100,000 population aged 15-59 years; rate ratios for the effects of age and ethnic group on gonorrhoea rates in women and men before and after adjustment for confounding factors.

RESULTS

Overall incidence rates of gonorrhoea in residents of Lambeth, Southwark, and Lewisham were 138.3 cases yearly per 100,000 women and 291.9 cases yearly per 100,000 men aged 15-59 years. At all ages gonorrhoea rates were higher in non-white minority ethnic groups. Rate ratios for the effect of age adjusted for ethnic group and underprivilege were 15.2 (95% confidence interval 11.6 to 19.7) for women and 2.0 (1.7 to 2.5) for men aged 15-19 years compared with those over 30. After deprivation score and age were taken into account, women from black minority groups were 10.5 (8.6 to 12.8) times as likely and men 11.0 (9.7 to 12.6) times as likely as white people to experience gonorrhoea.

CONCLUSIONS

Gonorrhoea rates in Lambeth, Southwark, and Lewisham in 1994-5 were six to seven times higher than for England and Wales one year earlier. The presentation of national trends thus hides the disproportionate contribution of ongoing endemic transmission in the study area. Teenage women and young adult men, particularly those from black minority ethnic groups, are the most heavily affected, even when socioeconomic underprivilege is taken into account. There is urgent need for resources for culturally appropriate research and effective intervention to prevent gonococcal infections and their long term sequelae in this population.

Heterosexual gonorrhoea at St Thomas'--II: Sexual behaviour and sources of infection

This paper examines sexual behaviour in heterosexuals presenting to an inner-London genitourinary medicine (GUM) clinic with gonorrhoea. When comparing patients' documented sexual histories, there were notable differences between cases and a control group, especially in men. Male cases were more likely to have had both multiple sexual partners (chi 2 = 18.5, P < 0.001) and concurrent sexual relationships (chi 2 = 15.2, P < 0.001) in the 30 days preceding presentation. Unlike cases, male controls were more likely to have used a condom at last intercourse with a 'casual' partner (chi 2 = 17.5, P < 0.001). In an examination of the sources of infection in cases, women were far more likely to have been recipients of gonorrhoea than they were to transmit the infection. The source of their infection was most usually a regular sexual partner. In men, 'casual' and 'regular' partners and 'one night stands' were all important sources of infection. Our hypothesis that case patients would have met the sources of their infection in particular venues was not supported by the results of an original questionnaire survey.

Heterosexual gonorrhoea at St Thomas'--I: Patient characteristics and implications for targeted STD and HIV prevention strategies

This paper compares the socio-demographic characteristics of patients with gonorrhoea with a control group of other attendees to an inner-London genitourinary medicine (GUM) clinic. Between 16 May and 21 December 1994 inclusive there were 312 culture-confirmed heterosexually-acquired cases of Neisseria gonorrheae treated in our clinic: 192 (61.54%) men and 120 (38.46%) women. There were significant differences between the population of cases and controls. Both male (z = -5.36, P < 0.001) and female (z = -6.6, P < 0.001) cases were younger than controls. Cases were more likely to be black African-Caribbean than were controls and these differences were more marked in men (chi 2 = 47.85, P < 0.001). Cases were also more likely to reside in south London postal districts than were controls (chi 2 = 24.98, P < 0.001). The implications of these findings for targeted health interventions are discussed and we suggest avenues for further work.