"I think most people feel like healthcare professionals tell them to take their treatments and judge them for not taking them": reflexive thematic analysis of the views of adults with cystic fibrosis on how treatment adherence is discussed in healthcare

OBJECTIVE

Previous research exploring patient-practitioner communication in relation to adherence in cystic fibrosis (CF) is limited. This UK study explored the views of adults with CF on how treatment adherence (related to all CF treatments) is discussed in routine CF care.

METHODS

12 White British adults (ten females; aged 20-37 years; mean 30.1 years) with CF participated in semi-structured interviews.

RESULTS

Three overarching themes were developed through reflexive thematic analysis: (1) 'The power of language'; (2) 'Healthcare professionals do not recognise the importance of context'; and (3) '"Admitting" non-adherence is difficult'. The way in which adherence is discussed in adult CF care is viewed as paternalistic and infantilising. Participants reported that healthcare professionals do not always consider the desire to balance treatment-taking with living a normal life. Unwelcome responses from healthcare professionals, and the inability to accurately self-report the amount of treatment taken made it difficult to 'admit' non-adherence.

CONCLUSIONS

A culture change is needed in CF care such that people who struggle to take their treatments are not labelled as disobedient, wilfully disobeying orders from healthcare professionals in positions of authority. Instead, an open, honest, non-judgemental approach, as recommended by healthcare agencies for over a decade, should be adopted.

How do peer support interventions for the self-management of chronic pain, support basic psychological needs? A systematic review and framework synthesis using self-determination theory

OBJECTIVE

To identify how peer support interventions, for self-management of chronic pain, support basic psychological needs from a self-determination theory (SDT) perspective, using a systematic review.

METHODS

Ten databases were searched for studies reporting qualitative research about peer interactions in pain management interventions. 'Best fit' framework synthesis methodology was applied to identify strategies that support the satisfaction of competence, autonomy and motivation. These were matched to definitions of strategies provided by standardised taxonomies.

RESULTS

18 studies were selected for inclusion. The synthesis resulted in a conceptual model, identifying 12 peer strategies that support psychological needs for self-management of chronic pain; 10 overlapped with existing taxonomies.

CONCLUSION

This was the first known attempt to synthesise evidence about peer support strategies for people living with pain, using SDT as an a priori framework. The model demonstrates commonality between the motivation-promoting processes of peer support and those of other behaviour change interventions and identifies additional unique strategies provided by peers. This systematic classification of peer support strategies provides a means for future study of the efficacy and comprehensiveness of peer interventions.

PRACTICE IMPLICATIONS

The model could assist healthcare professionals and support groups to optimise the potential of peer processes.

Supporting and sustaining care at home: Experiences of adult daughters who support a parent with dementia to remain in their own home

Supporting a parent with dementia living in their own home is a challenging care issue which has potential for negative physical, emotional and psychosocial impacts. This research explores the experiences of adult daughters who sustain this arrangement as well as managing the competing demands of their lives. Using a qualitative approach, semistructured interviews were conducted between March and October 2017. Eight adult females in the United Kingdom who were supporting a parent with dementia to remain living in their home were interviewed. Photo-elicitation was used as an aid to data collection and complemented the use of Thematic Analysis (TA) to analyse verbatim transcripts. Four themes were identified: (a) Impact on identity: impact of the participants' experience on their sense of identity; (b) Continuity and change: relationship redefinition and duality of roles; (c) Stepping up to the challenge: adjustment to and coping with competing demands and ethical dilemmas; and (d) Finding help: 'It is just a minefield': experiences of help-seeking and service provision. This study highlights the experiences and challenges for adult daughters who support a parent with dementia. Ethical dilemmas regarding autonomy and safeguarding concerns figure large along with the competing demands of multiple roles. Service providers should aim to be more proactive in offering timely practical and psychosocial support and guidance to avoid compassion fatigue and acknowledge the valuable unpaid service provided by these 'women in the middle'.

The pain self-management paradox: why do we focus on the individual when life context plays such a major role?

Although there has been a drive toward pain self-management, self-management has not yet in my opinion been successfully defined or evaluated and neither has it been consistently translated from idea to practice. In this perspective article, I identify gaps in our approach to pain management and argue that even though we know life context plays a huge role in influencing our health, by and large we fail to take this into account. I argue for a shift in focus away from the 'self' and explore how we might be able to do this within the constraints of our tired and over-stretched health system.

Understanding the psychological and social influences on office workers taking breaks; a thematic analysis

Objective: There is a growing trend whereby office workers refrain from taking breaks at work. Previous research has not explored how employees understand the enablers and barriers to taking breaks. This study explored how office-based workers describe their behaviour in relation to, and perceive the notion of, taking breaks.Design: Five focus groups were held with 27 employees of differing levels of seniority at a local authority in the UK. Inductive thematic analysis was employed with the researchers maintaining a deliberate stance of curiosity towards the data, allowing for reflexivity and awareness of preconceptions towards the research.Results: The analysis identified 5 key themes: the non-binary nature of taking breaks at work, the influence of social and work relationships, the superordination of work over breaks and health, contradictory feelings of guilt and anxiety and being 'fair game' for work related matters if you remain at your desk at break times.Conclusion: This paper suggests that the complex relationships that people have with taking breaks, with others and with their physical environment should be taken into account when trying to understand break-taking behaviour. Based on these findings, suggestions for further research and potential health-related policy and organisational changes are made.

Understanding suicidal ideation and behaviour in individuals with chronic pain: a review of the role of novel transdiagnostic psychological factors

Individuals with chronic pain are at an elevated risk of suicide, yet psychosocial factors that might be involved in increasing or decreasing vulnerability for suicidal ideation and behaviour have received little attention. Extant literature on the topic of suicide in individuals with chronic pain incorporates only a few of the wide array of known vulnerability and protective factors. This Review focuses on transdiagnostic psychological processes, (ie, those of relevance for both chronic pain and suicide). We reviewed a selection of published literature on chronic pain and suicide, concentrating on previously unexplored and underexplored lines of research, including future orientation, mental imagery, and psychological flexibility. A greater degree of crosspollination between the fields of chronic pain and suicide research is required to progress our understanding of why some people with chronic pain become suicidal and others do not.

"Living in a foreign country": experiences of staff-patient communication in inpatient stroke settings for people with post-stroke aphasia and those supporting them

Purpose: Staff-patient communication in in-patient stroke settings is viewed as challenging for stroke survivors with aphasia and those supporting them. This study sought to explore these experiences from the perspectives of stroke survivors, their carers and healthcare professionals.Methods: A qualitative study where stroke survivors with aphasia, carers and healthcare professionals were interviewed (audio-recorded) one-to-one or via focus group. Stroke survivors were at least 6 months post-stroke and had a self-reported mild to moderate level of post-stroke aphasia. Transcripts for each group were analysed separately using inductive thematic analysis; followed by an integrative analysis.Results: Six stroke survivors with aphasia, 10 carers, and six healthcare professionals were recruited. Three overarching themes were identified: "being in a foreign country", "finding a voice", and "you're just a number". A dynamic model of communication is proposed offering a framework for understanding the relationships between "the context", "the people" and "the interactions".Conclusions: Communication was viewed as important but challenging by all three groups. To maximise staff-patient interactions in the future, attention needs to be paid to: the psychosocial needs of stroke survivors and their carers, ongoing staff training and support for the healthcare professionals supporting them, and the provision of an aphasia-friendly and a communicatively stimulating ward environment.Implications for RehabilitationEffective staff-patient communication is viewed as fundamental to stroke rehabilitation but challenging by patients with aphasia, their carers and the healthcare professionals supporting them.To maximise staff-patient communication three key areas must be considered and targeted: those involved/affected by staff-patient communication ("the people"), factors within the "hospital context", and "the interactions" between "the people".Tailoring and being consistent with communication and care is paramount to avoid repeated negative communication encounters which can result in disengagement from care.Stroke rehabilitation which currently focuses on the physical fails to address the psychological/emotional and social needs of the patients and those supporting them.

Parenting young people with complex regional pain syndrome: an analysis of the process of parental online communication

INTRODUCTION

Parenting a young person with complex regional pain syndrome (CRPS) is associated with high levels of parental distress and numerous emotional, informational, and practical challenges. To meet these challenges, parents seek others undergoing similar experiences, both in face to face and online forums.

OBJECTIVES

The objective of this study was to conduct a qualitative analysis of online forum data to explore the process of parental forum communication regarding parenting a young person with CRPS in online spaces.

METHODS

A total of 107 forum posts relating to parenting a young person with CRPS were collected from 39 users across 2 public forums. Data were analyzed using thematic analysis.

RESULTS

Findings identified 2 themes: "the informal rules of exchanging and receiving network support" and "parents positioning themselves as experts." The first theme highlighted the varied nature of support sought and provided by parents in addition to social rules associated with the negotiation of this support. The second theme represented an understanding of how parents presented themselves as experts in their young person's pain, both in relation to fellow parents and health care professionals.

CONCLUSION

This study provided a novel insight into support and communicational exchanges between parents of young people with CRPS on online public forums. Findings identified the perceived usefulness of online spaces in terms of parents of young people with CRPS seeking and providing support. Further research can helpfully investigate how we might implement online peer mentoring to improve support further for parents.

The Ethics of Using the Internet to Collect Qualitative Research Data

The practice of conducting research online is in its infancy. Consequently there is debate concerning the ethical implications of online data collection. We outline three approaches to online data collection and focus specifically on the issues of consent and anonymity of participants. We conclude that ethical issues raised when planning and implementing online data collection are no different to those raised by more traditional approaches to data collection.

‘You Can't Stop Undergraduates Asking Silly Questions’: Academics' Views on Submission of Undergraduate Student Projects for Ethical Review

Undergraduate projects may contribute new knowledge, but commonly their main purpose is an exercise in learning and applying simple research methods. They are usually short term and a first step into the research field. Support for undergraduate research experience is simple enough. However, integral to the research process is ethical scrutiny. A high standard of conduct of research is essential. The question of whether undergraduate student projects should be subject to full ethical review, to the same extent as that undertaken for full scale academic work, is a matter of debate. The purpose of this study was to explore the views of academics on the nature and extent of ethical review considered appropriate for undergraduate research projects. This was done in order to identify which side of the above debate was favoured.

Participants were undergraduate research project supervisors, drawn from a range of disciplines where research on human subjects is undertaken. A series of focus groups were undertaken, transcribed and subjected to thematic analysis.

There was general consensus that some consideration should be given to the ethical issues relating to student projects. However, participants were limited in their explicit identification of such issues, with only extreme examples being specifically described. Some favoured a ‘light touch’ proportional to the size of the project as appropriate, while others considered the level ethical scrutiny not related to the size, duration or outcome of the work. Opinions were divided on where responsibility ultimately lay. Some considered it to belong at departmental, faculty or institutional level, but others held the individual supervisor accountable. The degree of involvement of undergraduate research in ethical review and approval is clearly an issue amongst academics. This study helps raise awareness of these issues and promotes debate on the appropriate level and format of review needed for undergraduate research training.

Coping Strategies, Psychological Impact, and Support Preferences of Men With Rheumatoid Arthritis: A Multicenter Survey

Objective

To investigate the existence and distribution of 2 typologies (termed “factors”) of men with rheumatoid arthritis (RA) identified through our previous Q‐methodology study (n = 30) in a larger sample of men with RA, and whether differences in psychosocial impact or support preferences exist between the 2 factors, and between men and women with RA.

Methods

A postal survey was sent to 620 men with RA from 6 rheumatology units across England, and the support preferences section of the survey was given to 232 women with RA.

Results

A total of 295 male patients (47.6%) and 103 female patients (44.4%) responded; 15 male participants had missing data, and thus 280 were included in the analysis. Of these, 61 (22%) were assigned to factor A (“accept and adapt”), 120 (35%) were assigned to factor B (“struggling to match up”), and 99 (35%) were unassigned. The two factors differed significantly, with factor B reporting more severe disease, less effective coping strategies, and poorer psychological status. For support, men favored a question and answer session with a consultant (54%) or specialist nurse (50%), a website for information (69%), a talk by researchers (54%), or a symptom management session (54%). Overall, women reported more interest in support sessions than men, with ≥50% of women reporting interest in nearly every option provided.

Conclusion

Some men accept and adapt to their RA, but others (43%) report severe disease, less effective coping, and poor psychological status. Men's preferences for support are practical, with a focus on expanding their knowledge.

Bittersweet: a qualitative exploration of mothers' experiences of raising a single surviving twin

Loss of a child from a multiple birth pregnancy is not uncommon yet the idiographic experience of parents who have lost a single twin from a multiple birth pregnancy is underexplored. This novel study sought to explore the experiences of mothers bereaved after loss of a twin from a multiple birth pregnancy, focusing on the dual challenges of parenting and grieving. Eighteen mothers at least 12 months post loss were recruited from a private UK based Facebook page dedicated to supporting parents after loss from a multiple birth. Eligible mothers completed an independent qualitative open-ended survey to explore maternal experiences of loss. Data were analysed using Thematic Analysis. Findings represented a sense of duality for participants, with mothers experiencing conflict between roles and identities as well as the nature of their loss. Key themes identified include 'Narrating a story of family and loss', 'Finding a place for the twins within the family' and 'A changing sense of self'. Findings fit with theoretical conceptualisations of bereavement that acknowledge retaining relationships with the deceased. Practically, suggestions for supporting mothers to identify stock answers to often asked questions about family make up were suggested.

'Everyone assumes a man to be quite strong': Men, masculinity and rheumatoid arthritis: A case-study approach

Current literature has overlooked the impact of chronic illness on masculine identity. We therefore aimed to investigate the impact of rheumatoid arthritis (a long term condition, affecting more women than men) on masculine identity. Six focus groups with 22 men with rheumatoid arthritis (RA) (data reported elsewhere) followed by five one-to-one interviews with men (English, mean age: 59 years) sampled to reflect a heterogeneous experience of life with RA based on knowledge gained from the focus groups. Transcripts were analysed using thematic analysis and are presented as individual case studies. Whilst the case studies provide five distinct experiences, common themes can be drawn across them, such as the importance of paid work. The men needed to renegotiate their masculine identity to deal with their RA. Two dealt with this by pushing through pain to retain masculine activities, two replaced masculine roles they could no longer do with other roles, and one rejected masculinity completely. Men with long term conditions may need to re-write their masculinity scripts to enable them to accept and adapt to their condition. However, some men struggle with this, which should be taken into consideration when designing self-management services for men with long term conditions.

Exploring the Therapeutic Affordances of Self-Harm Online Support Communities: An Online Survey of Members

BACKGROUND

A growing number of online communities have been established to support those who self-harm. However, little is known about the therapeutic affordances arising from engagement with these communities and resulting outcomes.

OBJECTIVE

The aim of this study was to explore the presence of therapeutic affordances as reported by members of self-harm online support communities.

METHODS

In total, 94 respondents (aged 13-63 years, mean=23.5 years; 94% female) completed an online survey exploring their experiences of engaging with a self-harm online support community. Respondents varied in terms of how long they had been accessing an online community, with 22% (21/94) accessing less than 1 year, 39% (37/94) 1 to 2 years, 14% (13/94) 2 to 3 years, and 24.5% (23/94) more than 3 years. Responses were analyzed using deductive thematic analysis.

RESULTS

The results of our analysis describe each of the five therapeutic affordances that were present in the data, namely (1) connection, the ability to make contact with others who self-harm for the purposes of mutual support and in so doing reduce feelings of loneliness and isolation; (2) adaptation, that is, how use of online support varies in relation to the personal circumstances of the individual user; (3) exploration, that is, the ability to learn about self-harm and learn about strategies to reduce or stop self-harming behavior; (4) narration, that is, the ability to share experiences, as well as read about the experiences of others; and (5) self-presentation, that is, how and what users present about themselves to others in the online community.

CONCLUSIONS

Our findings suggest that engagement with self-harm online support communities may confer a range of therapeutic benefits for some users, which may serve to minimize the psychosocial burden of self-harm and promote positive coping strategies. In addition, the online nature of the support available may be helpful to those who are unable to access face-to-face support.

"You Obviously Just Have to Put on a Brave Face": A Qualitative Study of the Experiences and Coping Styles of Men With Rheumatoid Arthritis

Objective

To explore the experiences, coping styles, and support preferences of male rheumatoid arthritis (RA) patients.

Methods

Six focus groups comprised 22 men with RA. Transcripts were analyzed using inductive thematic analysis.

Results

Three overarching themes describe the experiences, coping styles, and support preferences of men with RA. In “challenges to masculinity,” the men described a “reduction in strength and abilities,” which can lead to loss of independence, “challenges to masculine identity and role,” and “loss of power and control.” Coping by “getting through life with RA” meant dealing with RA by “just getting on with it,” “information seeking,” engaging in “destructive behaviors,” and “withdrawing socially.” Preferred “sources of support” tended not to include friends, as they were perceived to lack understanding or support. For acceptable support the men reported a preference for information‐giving sessions rather than a discussion group, but there was no agreement on whether these should be mixed‐sex or men only, or who should run the sessions.

Conclusion

Male patients reported a range of coping styles and support preferences to address their experiences of living with RA, many of which may not be shared with women. Further research is needed to investigate whether these findings exist in a larger sample and whether the support preferences of men with RA are broadly different from those of women with RA to decide whether there is a clinical need to design a service for the potentially different needs of men.

Identifying different typologies of experiences and coping strategies in men with rheumatoid arthritis: a Q-methodology study

OBJECTIVE

To identify typologies of experiences and coping strategies of men with rheumatoid arthritis (RA).

DESIGN

Q-methodology (a qualitative and quantitative approach to grouping people according to their subjective opinion). Men with RA sorted 64 statements relating to their experience of living with RA according to level of agreement across a normal distribution grid. Data were examined using Q-factor analysis.

SETTING

Rheumatology outpatient departments in the UK.

PARTICIPANTS

30 of 65 invited men with RA participated in this study (46%).

RESULTS

All participants ranked highly the need to be well informed about their medication and the importance of keeping a positive attitude. 2 factors describing the experiences and coping strategies of male patients living with RA were identified: factor A: 'acknowledge, accept and adapt' (n=14) take a proactive approach to managing the impact of RA and find different ways of doing things; while factor B: 'trying to match up to a macho ideal' (n=8) are determined to continue with their pre-RA lives, and therefore push themselves to carry on even if this causes them pain. They are frustrated and angry due to the impact of RA but they internalise this rather than directing it at others.

CONCLUSIONS

While some men adapt to their RA by renegotiating their masculine identity, others struggle to relinquish their traditional masculine roles. Further research is needed to identify whether the finding that there are 2 distinct groups of men with RA can be generalised, and if so whether the differences can be explained by clinical, social or psychological factors, which may inform different therapeutic approaches.

Men, rheumatoid arthritis, psychosocial impact and self-management: A narrative review

Rheumatoid arthritis is a chronic disease affecting fewer men than women. We systematically reviewed the literature on impact and self-management of rheumatoid arthritis in men. A total of 28 papers were included and grouped into two categories: psychosocial impact of rheumatoid arthritis, and coping and self-management. This review finds gender differences relating to quality of life, work, distress, self-management, coping and support. We conclude that there is a dearth of literature focussing on rheumatoid arthritis in men only, and mixed gender studies include insufficient men to draw strong conclusions about men. Thus, further research is needed to understand the support needs of men with rheumatoid arthritis in depth.

Characteristics of good quality pharmaceutical services common to community pharmacies and dispensing general practices

Background

In the United Kingdom, pharmaceutical services can be delivered by both community pharmacies (CPs) and dispensing doctor practices (DPs). Both must adhere to minimum standards set out in NHS regulations; however, no common framework exists to guide quality improvement. Previous phases of this research had developed a set of characteristics indicative of good pharmaceutical service provision.

Objective

To ask key stakeholders to confirm, and rank the importance of, a set of characteristics of good pharmaceutical service provision.

Methods

A two-round Delphi-type survey was conducted in south-west England and was sent to participants representing three stakeholder groups: DPs, CPs and patients/lay members. Participants were asked to confirm, and rank, the importance of these characteristics as representing good quality pharmaceutical services.

Key Findings

Thirty people were sent the first round survey; 22 participants completed both rounds. Median ratings for the 23 characteristics showed that all were seen to represent important aspects of pharmaceutical service provision. Participants’ comments highlighted potential problems with the practicality of the characteristics. Characteristics relating to patient safety were deemed to be the most important and those relating to public health the least important.

Conclusions

A set of 23 characteristics for providing good pharmaceutical services in CPs and DPs was developed and attained approval from a sample of stakeholders. With further testing and wider discussion, it is hoped that the characteristics will form the basis of a quality improvement tool for CPs and DPs.

Insights into Pain: A Review of Qualitative Research

Qualitative research exposes and explores important aspects of the pain experience that are inaccessible to other approaches.Qualitative work adopts a different epistemological and ontological perspective to quantitative work.Qualitative research is not well established in the field of pain, but is growing.More interpretative engagement with qualitative data is required.

Emergency Department Staff Attitudes Toward People Presenting in Chronic Pain: A Qualitative Study

OBJECTIVE

Patients who experience their nonmalignant chronic pain as intolerable sometimes present at Emergency Departments (EDs). However, as emergency medical services are set up to provide rapid treatment for acute injury or illness; there is potential for misunderstanding and disappointment. Literature on the topic of ED staff attitudes toward chronic pain patients is minimal, USA-based and methodologically unsatisfying. We carried out an in-depth, qualitative study identifying the attitudes and narratives of ED staff around people in chronic pain.

DESIGN

Focus groups with ED staff; qualitative analysis of the group transcripts.

SETTING

Regional trauma centre in the UK.

SUBJECTS

Three focus groups, 20 ED clinicians, mean ED experience 8.1 years.

RESULTS

The clinical challenge of treating patients in the ED stemmed from a mismatch between patients' needs and what the setting can deliver. Participants reported frustration with the system and with chronic pain patients' perceived inconsistencies and requirements. However, they also highlighted good practice and acknowledged their frustration around not being able to help this group.

CONCLUSIONS

ED staff found people presenting at ED with chronic pain to be a challenging and frustrating population to treat. Staff was constrained by the fast-paced nature of their jobs as well as the need to prioritise emergency cases, and so were unable to spend the time needed by chronic pain patients. This was seen as being bad for staff, and for the patient experience. Staff suggested that care could be improved by appropriate information, signposting and with time invested in communication with the patient.

Co-creation of information leaflets to meet the support needs of people living with complex regional pain syndrome (CRPS) through innovative use of wiki technology

OBJECTIVE

People living with complex regional pain syndrome (CRPS) experience frustration with the lack of knowledge and understanding of CRPS as a pain condition. We report on our attempt to address this issue.

METHODS

People living with CRPS taking part in a larger study were invited to co-construct a CRPS wiki page that addressed the areas in which they had experienced the most difficulty. A blank wiki page was set up for participants to populate with issues they felt needed to be raised and addressed.

RESULTS

Participants failed to engage with the wiki technology. We modified our procedure and completed an inductive analysis of a sister-forum which participants were using as part of the larger study. Six issues of importance were identified. We used the discussion forum threads to populate the themes. Due to a continued lack of engagement with the wiki technology, the team decided to create a suite of leaflets which were piloted with delegates at a CRPS patient conference.

CONCLUSIONS

Future work should be mindful of the extent to which patients are able and willing to share their experiences through such technology. Striking the balance between patient-endorsed and researcher-driven co-creation of such material is imperative.

Meeting the support needs of patients with complex regional pain syndrome through innovative use of wiki technology: a mixed-methods study

Background

Using online discussion forums can have a positive impact on psychological well-being through development of shared group identity and validation of thoughts, feelings and experiences. This may be particularly beneficial to people with complex regional pain syndrome (CRPS), who often become socially isolated, lack mobility and face threats to their sense of identity. We set up a peer-support online forum to identify the nature of support provided and to explore its development over time. We then introduced a collaborative writing task to facilitate further the development of social processes implicated in psychological support.

Research questions

(1) What constitutes support in newly developed online interactions? (2) How does the process of giving and receiving support online evolve? (3) Can the combination of an online forum and a collaborative writing task increase support relative to an online forum alone?

Design

This is a three-phase mixed-methods research design. Phase 1: an online forum was launched. Phase 2: forum members were invited to cowrite a patient-centred CRPS information resource. Phase 3: the resource was shared and feedback was sought.

Participants

Posts from 26 members (seven males, 19 females) were analysed. The mean age of members was 35.6 years. The number of years since diagnosis was available for 14 members (ranging from 5 months to 10 years with a mean duration of 3.9 years).

Data analysis

In order to explore what constitutes support in newly developed online interactions, an inductive thematic analysis was conducted on all ‘introductory posts’ posted during phase 1. In order to explore how the process of giving and receiving support online evolved, a deductive content analysis using the Social Support Behavior Code was conducted on all forum posts posted during the first 12 months.

Results

Five themes were identified in members’ first posts. Three of these themes contributed to the development of a ‘common-identity’ community, while the remaining two established a positive tone, consistent with that of a ‘common-bond’ community. Content analysis revealed that support requests were present in 15.5% of posts: predominantly informational support (8.6%) with the remaining support categories ranging from 1.3% to 2.6%. Social support was present in 88.8% of posts; predominantly emotional support (72.8%) followed by informational (36.2%) and esteem (30.2%) support. For a variety of reasons, we were unable to address the third question fully; we gave all members the option of contributing to the collaborative writing task and anticipated comparing those who accepted the invitation with those who did not. However, either participants continued to take part in the forum and contributed to the writing task, or they ceased to interact with the forum altogether, thereby limiting our ability to compare across time and task.

Conclusions

Few members of the forum explicitly requested social support, but many offered it (emotional support was the most prevalent). There was evidence of both common-identity and common-bond community development from the outset. This continued to shape forum interactions throughout the 12 months of the study and set up a space that had an over-riding positive and supportive tone which enabled the members to reach out and offer support to similar others, in effect helping them to re-engage with the wider world. Future work that examines support across networked online communities is necessary.

Funding

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

Coping with chronic complex regional pain syndrome: advice from patients for patients

OBJECTIVE

To explore what advice people currently living with chronic complex regional pain syndrome would offer to another person coming to terms with a diagnosis of chronic complex regional pain syndrome.

METHODS

Semi-structured interviews with 21 adults (5 male) living with chronic complex regional pain syndrome who had completed a complex regional pain syndrome rehabilitation programme were conducted.

RESULTS

Effectively self-managing complex regional pain syndrome required individuals to play an active role. This could only be achieved if they felt they had sufficient control. Means of attaining control involved attaining a level of acceptance, becoming well-informed and accessing the right kind of support. The advice offered by patients for patients largely reflected that offered by healthcare professionals. One area where there was a conflict concerned sleep hygiene.

CONCLUSIONS

Our study provides support both for the argument put forward by Redman that without appropriate preparation and support, self-management is ineffective, and that by Skuladottir and Hallsdottir that the main challenge of the chronic pain trajectory is that of retaining a sense of control. The clinical implications of this are discussed.

An investigation of the motivations driving the online representation of self-injury: a thematic analysis

The objetive of the study was to identify a) the motivations for communicating about non-suicidal self-injury (NSSI) in a publicly accessible online forum, b) The significance (if any) of the "publicness" of the behavior. Using a Thematic Analysis of 423 text-based posts from an online NSSI forum, 5 motivations for using the site were identified: confessional, marking a turning point, acting as a deterrent, dispelling myths and offering or seeking support. Motivations for using the site differ markedly from motivations for engaging in NSSI and tend to be more outwardly focused. The publicness of the site therefore seems to be significant in terms of bearing witness, providing the opportunity to confront negative stereotypes, and the ability to seek and offer support to like-minded individuals.

An exploration of the support person's perceptions and experiences of complex regional pain syndrome and the rehabilitation process

We explored the perceptions and experiences of those who support a relative or friend with complex regional pain syndrome (CRPS), a chronic pain condition of unknown aetiology usually affecting a single limb. Semi-structured interviews were analysed using interpretative phenomenological analysis, and four superordinate themes are presented here. These themes describe the efforts of carers to make sense of CRPS and the rehabilitation process, to be sensitive to the discomfort of the person with CRPS and to respond in an attuned and helpful way. CRPS had become integrated into the carers' lives as they sought to monitor, protect and motivate the person they supported. The themes are discussed in relation to each other and to extant literature, including work on social support and adjustment to chronic illness, and the clinical implications are explored.

A qualitative exploration of carers' and 'patients' experiences of fibromyalgia: one illness, different perspectives

OBJECTIVES

Previous research has largely focused on the lived experience either of those who have fibromyalgia syndrome (FMS) or their spousal carers. This study aimed to explore the lived experiences of both those with FMS and their spousal carers.

METHODS

Participants were aged between 38 and 65 years and all came from the south-west of England. Semi-structured interviews were conducted with four women with FMS and their spousal carers, who were interviewed separately. The resultant transcripts were analysed using interpretative phenomenological analysis. An overriding theme running throughout was loss of identity, which fed into a sense of isolation. Participants reported feeling isolated from: healthcare professionals, whom they felt they had to convince that they had something 'real', and from friends and family because the unpredictability of their symptoms meant that they were less able to plan ahead and often had to pull out of arranged outings. They also felt isolated from their identity because they no longer recognized the person that they once were, and struggled to recognize the person that they had become. As a consequence, the people with FMS and their carers were both engaged in a process of reassessing who they were, now that FMS had become such a large part of their lives. This sense of isolation was evidenced for the carers as well as the people with FMS and is documented in three sub-themes described in the paper: 'others' attitudes', 'invisible illness' and 'role'.

CONCLUSION

This study has provided new information regarding the lifeworlds both of people living with FMS and their spousal carers. We identified a number of practical and attitudinal barriers that had led to the diminution of social networks for both members of the couple and have explored the related clinical and theoretical implications of this.

Seeking support: An interpretative phenomenological analysis of an Internet message board for people with Complex Regional Pain Syndrome

In this article, we report on the findings of a qualitative inquiry into how an online message board for people who have Complex Regional Pain Syndrome (CRPS) was used by its members. All messages (and responses) posted on the CRPS message board over a 4-month period were collected retrospectively. The data were analysed using the method of Interpretative Phenomenological Analysis. Members used the message board to seek (and provide) support to those with CRPS, and also to express their emotions, feelings and experiences linked to their condition. The message board provided an important source of support for a patient group that can otherwise become isolated as a result of their mobility problems. Furthermore, the analysis revealed the unrealistic hopes that patients can hold concerning the anticipated outcomes of their treatment. This is an important issue for healthcare professionals to explicitly address when interacting with the patient group.

Distinguishing between subgroups of adolescents who self-harm

The differences in factors associated with subgroups of adolescents in the continuum of deliberate self-harm (DSH) phenomena were investigated. In an anonymous self-report survey of 6,020 adolescents aged 15 and 16 years, 3.2% of adolescents (5.3% females, 1.3% males) reported DSH with intent to die, 2.8% (4.3% females; 1.5% males) reported DSH without intent to die, and 15% (22.4% females; 8.5% males) reported thoughts of DSH without acts. Regression analysis indicated considerable overlap in vulnerability factors along the spectrum of DSH thoughts and acts. A uniquely distinct relationship was found between DSH of a friend and DSH without intent to die on one hand and DSH of a family member with DSH with intent to die on the other. Results indicate that familial and nonfamilial social influences on DSH behavior may be important in designing prevention programs and that educational programs for the promotion of psychological well-being may be helpful for adolescents at any point along the spectrum of DSH that was examined.

The invisible reality of arthritis: a qualitative analysis of an online message board

BACKGROUND AND AIM

Living with a chronic illness, such as arthritis, creates many psychosocial stressors, which can be difficult to cope with. Exploring the interactions which take place on an online message board for people with arthritis may provide insight into both the social support offered, as well as highlighting the groups' needs that perhaps are not being met in a more formal 'offline' setting. The aim of this study was to investigate how and why an arthritis online message board was used.

METHODS

A retrospective three-month period of discussions posted on an online message board for people who have arthritis was downloaded into a word document. Collecting data in this manner ensured that completed discussions were captured. Eighty-seven initial messages and 981 replies were analysed. The discussions were analysed using interpretive phenomenological analysis.

RESULTS

Four master themes were identified. Firstly, the invisible reality of the condition; secondly, information exchange, whereby users of the message board were shown to be both seeking and providing information; thirdly, while users praised the support they received from family and friends, the support offered and received online was considered to provide additional benefits. Finally, the message board allowed users to share (primarily negative) emotions which they felt unable to express in their offline worlds.

CONCLUSION AND IMPLICATIONS

Patients do not always understand the information being offered by health care professionals, and they do not have the confidence to ask for clarification. Health care professionals need to ensure that they find a way of checking levels of patient understanding. Failure to do so means that patients may turn to alternative sources, which may not provide accurate information. The study also showed that people with arthritic conditions find it difficult to express how they are feeling in their offline world; furthermore, they find it difficult to ask for support from their significant others, preferring instead to 'suffer in silence' and seek support from the online community, potentially further isolating them from the support of those in their offline world. There is scope for such patients to be both empowered and educated, so that they are better able to ask for the help they need, which in turn will help to counteract the danger of isolation.

The presentation of "pro-anorexia" in online group interactions

Although pro-anorexia online support forums and the narratives that occur within them are increasingly the focus of research, none, to date, focuses closely on issues of identity within this online context. Our aim in conducting this study was to examine the presentation of pro-anorexia via an interpretive phenomenological analysis of postings to a pro-anorexia ("pro-ana") online discussion forum. Analysis indicates that pro-anorexic identities are normalized and strengthened through the normalization of participants' pro-ana thoughts and behaviors, and the group bond created through sharing a secret identity. This process renders participants less likely to reveal their pro-ana identity to friends and family in the real world. The implications of our findings are discussed in relation to the theory of identity demarginalization.

I hear, I listen and I care: a qualitative investigation into the function of a self-harm message board

This paper reports on the findings of a qualitative inquiry into the interactions on a nonprofessional self-harm message board. Individuals using the message board were very positive about the message board and appeared to feel that their needs for support, venting, and validation were being met. However, we found that negative harmful behaviors mentioned in messages posted on the board were either not acknowledged, or were legitimized and normalized by those who responded to the messages. We suggest that this process of minimizing the seriousness and/or normalizing the behaviors may actually be encouraging the maintenance of such behaviors and therefore conclude that caution should be exercised when using nonprofessional self-harm message boards.

Twelve years–experience with the Patient Generated Index (PGI) of quality of life: a graded structured review

The Patient Generated Index (PGI) is an individualised quality of life (QoL) measure that has been in use since 1994. Various adaptations have been made to suit a variety of client groups. The PGI's psychometric properties have been studied but their review is necessary to inform instrument choice. This article provides a structured review, using grading criteria adapted from those developed to aid outcome measure selection for use with older people. These criteria grade quality of evidence and strength of findings for psychometric validity, providing a useful model for future reviews. All published articles providing data addressing validity, reliability and/or responsiveness were included in the review. Eighteen relevant articles were identified and analysed using the grading criteria. Variable results and quality of investigation were seen. Generally the measure was found to be adequately reliable for group comparisons. The PGI appeared valid but evidence for responsiveness was unclear. Those versions of the measure using fewer points in their Likert scales may have higher reliability. Cognitions involved in QoL judgements remain little understood and investigations of psychometric properties may be enhanced by examination of appraisal processes.

Adolescents’ perception of risk and challenge: A qualitative study

Concern has been mounting about the increasing numbers of adolescents who engage in risky behaviours. This qualitative study aimed to identify adolescents' perception of risk and explored the factors that adolescents felt influenced their decisions about engaging in risky behaviours. The results indicated that adolescents perceived risk to be something where the outcome was uncontrollable. In contrast, challenges were thought of as having a known end point that was difficult to achieve. They considered themselves to be well-informed about health risks facing them, yet mentioned occasions when they lacked the ability to state that they did not want to engage in certain "risky" behaviours. The implications of the findings for future interventions are discussed.

Investigating the "self" in deliberate self-harm

In this study, the authors explored how a group of young people aged 16 to 26 years (who identified themselves as having engaged in deliberate self-harm) made sense of the self by conducting two online focus groups and four e-mail interviews. They analyzed data using interpretive phenomenological analysis. The concept of validation was the primary means of making sense of the self and concerned the desire to be considered legitimate and of worth. This desire was clearly evident across three realms of conflict: (a) the intrinsic or extrinsic self, which marked the distinction between objective fact and subjective opinion; (b) the accepted or denied self; and (c) the notion of normality. It is possible that having one's denied self validated online might lead to an exacerbation of an individual's self-harming behavior. Further work is needed to explore the effects of online discussion forums on such taboo forms of behavior.

In what ways are adolescents who engage in self-harm or experience thoughts of self-harm different in terms of help-seeking, communication and coping strategies?

The purpose of this study was to ascertain whether adolescents who deliberately harmed themselves or had thoughts of self-harm differed from other adolescents in terms of help-seeking, communication and coping strategies. The participants were 6020 15-16 year-old school pupils who were surveyed using an anonymous self-report questionnaire. Adolescents with one or more episodes of deliberate self-harm (DSH) in the previous year were more likely to identify themselves as having serious problems than other adolescents. However, a substantial proportion of adolescents with either DSH or thoughts of self-harm did not identify themselves as having serious problems. Adolescents with DSH were most likely to feel the need for help but not try to get any; they were less able to talk to family members and teachers and had fewer categories of people who they were able to talk to. Like other adolescents, those with DSH or thoughts of self-harm were more likely to seek and receive help from their friends than from other sources. They differed from other adolescents in terms of coping strategies they reported employing when faced with difficulties, showing less focus on problems and more avoidant behaviours. The findings have important implications for preventive strategies, including educational programmes on emotional health and coping, and for the clinical care of adolescents identified as at risk or having self-harmed.

The prevalence of suicidal phenomena in adolescents: a systematic review of population-based studies

The results of a systematic review of the international literature on the prevalence of suicidal phenomena in adolescents, including the influence of survey method, gender, and ethnicity are reported. The literature was searched using six electronic databases to identify all population-based studies of self-reported suicidal phenomena; 128 studies were included, comprising 513,188 adolescents. The mean proportion of adolescents reporting they had attempted suicide at some point in their lives was 9.7% (95% CI, 8.5-10.9), and 29.9% (95% CI, 26.1-33.8) of adolescents said they had thought about suicide at some point. Females were significantly more likely than males to report most suicidal phenomena. A lower prevalence of some suicidal phenomena was found for Asian populations. The prevalence of suicidal phenomena varied depending on the terminology used and tended to be higher in studies employing anonymous questionnaires than in studies employing non-anonymous methods (questionnaires or interviews), although most of these differences were not statistically significant.

Ethnic and gender differences in drinking, smoking and drug taking among adolescents in England: a self-report school-based survey of 15 and 16 year olds

Concern has been mounting about the increasing numbers of adolescents who (ab)use drugs, alcohol and cigarettes. The aim of this study was to establish the prevalence according to gender and ethnicity of drinking, smoking and drug-use in a representative sample of 15 and 16 year olds. The sample consisted of 6020 15- and 16-year-old pupils from 41 schools in England who completed an anonymous self-report survey. There were clear gender and ethnic differences in self-reported substance use. For example, more males than females reported drinking and drug taking. More females reported smoking, but males were more likely to be heavy smokers. Asian, Black and other boys and Black and Asian girls were less likely to report drinking during a typical week compared to White participants. Asian females were less likely to report smoking compared to White females. Cannabis was the most commonly used drug for both genders. Black males were more likely than White males to have used cannabis, opiates and other drugs. However, Asian females were more likely than their White counterparts to have used opiates, but were significantly less likely to have used cannabis. Asian males were more likely than White males to have used ecstasy. The results confirm gender differences in substance use and demonstrate that there are different patterns of substance use between ethnic groups. These findings have implications for targeting prevention campaigns through the media and educational initiatives.

Factors associated with suicidal phenomena in adolescents: a systematic review of population-based studies

Suicidal phenomena (suicide attempts, deliberate self-harm, and suicidal plans, threats and thoughts) are common in adolescents. Identification of factors associated with these phenomena could play an important role in the development of school or community-based prevention and intervention programs. In this article, we report the results of a systematic review of the international literature on population-based studies of factors associated with suicidal phenomena in adolescents. These factors encompass psychiatric, psychological, physical, personal, familial and social domains. The quantity of evidence in support of associations between suicidal phenomena and specific factors is compared with the quantity of evidence against such associations. We conclude with a summary of the findings, including identification of new or neglected areas, which require further investigation. Methodological considerations are highlighted and implications of the findings for clinicians and other professionals concerned with prevention of suicidal behavior by adolescents are discussed.

Suicidal phenomena and abuse in adolescents: a review of epidemiological studies

OBJECTIVE

To conduct a systematic review of the international literature to determine whether adolescents who had experienced abuse were more likely to also experience suicidal thoughts and behaviors than other adolescents, and to investigate the nature of this association.

METHOD

Reports of community- or school-based studies of adolescents on the association between the prevalence of suicidal phenomena and abuse were searched for via electronic databases, reviewing reference lists and contacting experts in the field.

RESULTS

Ten relevant studies were identified. Adolescents who had been physically or sexually abused were significantly more likely to experience suicidal thoughts and behaviors than other adolescents. This association appeared to be direct in most studies in which multivariate analyses were conducted. There is evidence that other factors (e.g., low self-esteem) may play a mediating role in the relationship between abuse and suicidal phenomena.

CONCLUSIONS

There is a clear link between abuse and suicidal phenomena occurring during childhood and adolescence.