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Bebbington E, Kakola M, Nagaraj S, Guruswamy S, McPhillips R, Majgi SM, Rajendra R, Krishna M, Poole R, Robinson C. Development of an electronic burns register: Digitisation of routinely collected hospital data for global burns surveillance. Burns 2024; 50:395-404. [PMID: 38172021 DOI: 10.1016/j.burns.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/05/2023] [Accepted: 08/10/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Burn registers provide important data that can track injury trends and evaluate services. Burn registers are concentrated in high-income countries, but most burn injuries occur in low- and middle-income countries where surveillance data are limited. Injury surveillance guidance recommends utilisation of existing routinely collected data where data quality is adequate, but there is a lack of guidance on how to achieve this. Our aim was to develop a rigorous and reproducible method to establish an electronic burn register from existing routinely collected data that can be implemented in low resource settings. METHODS Data quality of handwritten routinely collected records (register books) from a tertiary government hospital burn unit in Mysore, India was assessed prior to digitisation. Process mapping was conducted for burn patient presentations. Register and casualty records were compared to assess the case ascertainment rate. Register books from February 2016 to February 2022 were scanned and anonymised. Scans were quality checked and stored securely. An online data entry form was developed. All data underwent double verification. RESULTS Process mapping suggested data were reliable, and case ascertainment was 95%. 1930 presentations were recorded in the registers, representing 0.84% of hospital all-cause admissions. 388 pages were scanned with 4.4% requiring rescanning due to quality problems. Two-step verification estimated there to be errors remaining in 0.06% of fields following data entry. CONCLUSION We have described, using the example of a newly established electronic register in India, methods to assess the suitability and reliability of existing routinely collected data for surveillance purposes, to digitise handwritten data, and to quantify error during the digitisation process. The methods are likely to be of particular interest to burn units in countries with no active national burns register. We strongly recommend mobilisation of resources for digitisation of existing high quality routinely collected data as an important step towards developing burn surveillance systems in low resource settings.
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Affiliation(s)
- Emily Bebbington
- Centre for Mental Health and Society, School of Medical and Health Sciences, Bangor University, Wrexham, LL13 7YP, UK.
| | - Mohan Kakola
- Department of Plastic Surgery and Burns, Mysore Medical College and Research Institute, KR hospital, Irwin Road, Mysuru, Karnataka 570001, India
| | - Santhosh Nagaraj
- South Asia Self-harm Initiative, JSS Hospital, Mahatma Gandhi Road, Mysuru, Karnataka 570004, India
| | - Sathish Guruswamy
- South Asia Self-harm Initiative, JSS Hospital, Mahatma Gandhi Road, Mysuru, Karnataka 570004, India
| | - Rebecca McPhillips
- Social Care and Society, School of Health Sciences, Faculty of Biology, Medicine and Health, Ellen Wilkinson Building, Oxford Road, Manchester M13 9PL, UK
| | - Sumanth Mallikarjuna Majgi
- Department of Community Medicine, Mysore Medical College and Research Institute, Mysuru, Karnataka 570001, India
| | - Rajagopal Rajendra
- Department of Psychiatry, Mysore Medical College and Research Institute, Mysuru, Karnataka 570001, India
| | - Murali Krishna
- Centre for Mental Health and Society, School of Medical and Health Sciences, Bangor University, Wrexham, LL13 7YP, UK
| | - Rob Poole
- Centre for Mental Health and Society, School of Medical and Health Sciences, Bangor University, Wrexham, LL13 7YP, UK
| | - Catherine Robinson
- Social Care and Society, School of Health Sciences, Faculty of Biology, Medicine and Health, Ellen Wilkinson Building, Oxford Road, Manchester M13 9PL, UK
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Bebbington E, Ramesh P, McPhillips R, Bibi F, Khan M, Kakola M, Poole R, Robinson C. Terminology and methods used to differentiate injury intent of hospital burn patients in South Asia: Results from a systematic scoping review. Burns 2024; 50:302-314. [PMID: 37985272 DOI: 10.1016/j.burns.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/24/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION A key component in the classification of all injury types is to differentiate whether the injury was deliberately inflicted and by whom, commonly known as "intent" in the surveillance literature. These data guide patient care and inform surveillance strategies. South Asia is believed to have the greatest number of intentional burn injuries, but national surveillance data is not disaggregated by injury intent. Scientific literature can be used for injury surveillance where national data collection does not exist. In order to synthesise research findings, it is essential to assess the potential impact of misclassification bias. We therefore conducted a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia. METHODS We followed the methods in our registered protocol (https://doi.org/10.17605/OSF.IO/DCYNQ). Studies met defined population, concept, context, and study design criteria. The databases Embase, MEDLINE, CINAHL, PsycInfo, and PakMediNet were searched. Two reviewers independently screened results. Data were extracted in a standardised manner and verified. The rigour of the method used to differentiate injury intent was appraised. RESULTS 1435 articles were screened. Of these, 89 met our inclusion criteria. Most articles were from India and Pakistan, and used an observational study design. There were 14 stem terms used in the articles. The most common was "cause". There were 40 classifier terms. The most common were "accident", "suicide", and "homicide". Few articles defined these terms. The method used to differentiate injury intent was only described explicitly in 17% of articles and the rigour of the methods used were low. Where methods of differentiation were described, they appear to be based on patient or family report rather than multidisciplinary assessment. CONCLUSION The heterogeneity in terms, lack of definitions, and limited investigation of injury intent means this variable is likely to be prone to misclassification bias. We strongly recommend that the global burn community unites to develop a common data element, including definitions and methods of assessment, for the concept of burn injury intent to enable more reliable data collection practices and interstudy comparisons.
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Affiliation(s)
- Emily Bebbington
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, LL13 7YP, UK.
| | - Parvathy Ramesh
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Rebecca McPhillips
- Social Care and Society, School of Health Sciences, Faculty of Biology Medicine and Health, Jean McFarlane Building, University of Manchester, M13 9PY, UK
| | - Fatima Bibi
- Turning Point, 5 Greaves Street, Oldham OL1 1QN, UK
| | - Murad Khan
- Department of Psychiatry and Brain and Mind Institute, Aga Khan University, Karachi 74800, Pakistan
| | - Mohan Kakola
- Department of Plastic Surgery and Burns, Mysore Medical College and Research Institute, KR hospital, Irwin Road, Mysuru, Karnataka 570001, India
| | - Rob Poole
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, LL13 7YP, UK
| | - Catherine Robinson
- Social Care and Society, School of Health Sciences, Faculty of Biology Medicine and Health, Jean McFarlane Building, University of Manchester, M13 9PY, UK
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Bebbington E, Ramesh P, Kakola M, McPhillips R, Bibi F, Hanif A, Morris N, Khan M, Poole R, Robinson C. Terminology and methods used to differentiate injury intent of hospital burn patients in South Asia: a systematic scoping review protocol. Syst Rev 2023; 12:153. [PMID: 37653528 PMCID: PMC10468849 DOI: 10.1186/s13643-023-02317-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/11/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The greatest proportion of burn injuries globally occur in South Asia, where there are also high numbers of intentional burns. Burn injury prevention efforts are hampered by poor surveillance data on injury intent. There is a plethora of local routinely collected data in the research literature from South Asia that could be used for epidemiological purposes, but it is not known whether the definitions and methods of differentiation of injury intent are sufficiently homogenous to allow valid study comparisons. METHODS We will conduct a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia. The objectives of the study are to: determine the breadth of terminology and common terms used for burn injury intent; to determine if definitions are comparable across studies where the same term is used; and to appraise the rigour of methods used to differentiate burn injury intent and suitability for comparison across studies. The databases Embase, MEDLINE, CINAHL, PsycINFO, and PakMediNet will be searched. Screening and data extraction will be completed independently by two reviewers. To be included, the article must be as follows: peer reviewed, primary research, study cutaneous burns, based on hospital patients from a country in South Asia, and use intent terminology or discuss a method of differentiation of injury intent. Results will be restricted to English language studies. No date restrictions will be applied. A plain language summary and terminology section are included for non-specialist readers. DISCUSSION Results will be used to inform stakeholder work to develop standardised terminology and methods for burn injury intent in South Asia. They will be published open access in peer-reviewed journals wherever possible. SYSTEMATIC REVIEW REGISTRATION This review has been registered with the Open Science Framework ( https://doi.org/10.17605/OSF.IO/DCYNQ ).
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Affiliation(s)
- Emily Bebbington
- Centre for Mental Health and Society, School of Medical and Health Sciences, Bangor University, Bangor, LL13 7YP, UK.
| | - Parvathy Ramesh
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Mohan Kakola
- Department of Plastic Surgery and Burns, Mysore Medical College and Research Institute, Mysuru, India
| | - Rebecca McPhillips
- Social Care and Society, School of Health Sciences, University of Manchester, Manchester, UK
| | | | | | - Nia Morris
- John Spalding Library, Wrexham Maelor Hospital, Wrexham, UK
| | - Murad Khan
- Brain and Mind Institute, Aga Khan University, Karachi, Pakistan
| | - Rob Poole
- Centre for Mental Health and Society, School of Medical and Health Sciences, Bangor University, Bangor, LL13 7YP, UK
| | - Catherine Robinson
- Social Care and Society, School of Health Sciences, University of Manchester, Manchester, UK
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Capobianco L, Faija C, Cooper B, Brown L, McPhillips R, Shields G, Wells A. A framework for implementing Patient and Public Involvement in mental health research: The PATHWAY research programme benchmarked against NIHR standards. Health Expect 2023; 26:640-650. [PMID: 36625226 PMCID: PMC10010097 DOI: 10.1111/hex.13676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/05/2022] [Accepted: 11/02/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patient and Public Involvement (PPI) in research has become a key component recommended by research commissioners, grant award bodies and specified in government policies. Despite the increased call for PPI, few studies have demonstrated how to implement PPI within large-scale research studies. OBJECTIVE The aim of the current study was to provide a case example of the implementation of a patient advisory group in a large-scale mental health research programme (PATHWAY) and to benchmark this against UK standards. METHOD A PPI group was incorporated throughout the PATHWAY research programme, from grant development to dissemination. The group attended regular meetings and supported participant recruitment, evaluated patient-facing documents, supported the piloting of the research intervention and co-developed the dissemination and impact strategy. The implementation of PPI throughout the project was benchmarked against the UK standards for PPI. RESULTS The inclusion of PPI in the PATHWAY project provided tangible changes to the research project (i.e., improving study documents, co-developing dissemination materials) but also proved to be a beneficial experience to PPI members through the development of new skills and the opportunity to provide a patient voice in research. We show how PPI was involved across seven study phases and provide examples of implementation of the six UK standards. The study did not include PPI in data analysis but met all the UK standards for PPI. Challenges regarding practical components (i.e., meeting frequency, language use), increasing diversity and PPI members' knowledge of research were highlighted as areas for further improvement. CONCLUSIONS We provide a case example of how PPI can be implemented throughout a research lifecycle and we note the barriers faced and make suggestions for PPI in future implementation and research. PATIENT AND PUBLIC CONTRIBUTION PPI members were involved throughout the lifecycle of the research programme. The PPI lead was a co-author on the manuscript and contributed to report writing.
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Affiliation(s)
- Lora Capobianco
- Research & Innovation, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Cintia Faija
- School of Health Sciences, Division of Nursing, Midwifery & Social Work, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Bethany Cooper
- Research & Innovation, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Rebecca McPhillips
- School of Health Sciences, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Gemma Shields
- School of Health Sciences, Manchester Centre for Health Economics, Division of Population Health, Health Services Research, and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Adrian Wells
- Research & Innovation, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,School of Health Sciences, Center for New treatment and Understanding in Mental Health (CeNTrUM), Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Wood DP, Robinson CA, Nathan R, McPhillips R. A study of the implementation of patient safety policies in the NHS in England since 2000: what can we learn? J Health Organ Manag 2022; ahead-of-print. [PMID: 35298879 DOI: 10.1108/jhom-02-2021-0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Despite repeated policy initiatives, progress in improving patient safety in the National Health Service (NHS) in England over the past two decades has been slow. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019), which is being implemented currently, aims to address this problem. The purpose of this study is to identify learning from the implementation of past patient safety policies and thereby suggest means of supporting the NHS in delivering the current policy initiative successfully. DESIGN/METHODOLOGY/APPROACH The authors identified key health policies in the domain of patient safety, published since 2000, by searching the United Kingdom (UK) government website. Discussion papers from the research literature concerning these policies were collated and reviewed. The authors then used a thematic analysis approach to identify themes discussed within these papers. These themes represent factors that support the effective delivery of patient safety policy initiatives. FINDINGS Within the discussion papers the authors collated, concerning 11 patient safety policies implemented between 2000 and 2017, five inter-related core themes of capability, culture, systems, candour and leadership were identified. By evaluating these themes and identifying composite sub-themes, a conceptual framework is presented that can be used to support the delivery of patient safety policy initiatives to maximise their impact. ORIGINALITY/VALUE The conceptual framework the authors illustrate, arising from this new contribution to the body of knowledge, can be translated into a novel self-assessment for individual NHS trusts to understand organisational development areas in the domain of patient safety improvement.
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Affiliation(s)
- David Phillip Wood
- The University of Manchester, Manchester, UK.,Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
| | | | - Rajan Nathan
- Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
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Abstract
INTRODUCTION Much of the published literature on suicide comes from high income countries. In countries such as India, female suicide rates exceed the global suicide rate and suicide rates found in their male counterparts. Results from previous studies indicate that factors related to suicide among men and women in India are different from those seen in high-income countries. To date, no reviews have considered the relationship between gender and suicide in India. Therefore, the aim of this scoping review is to provide a comprehensive understanding of existing literature reporting gender differences in suicide rates, methods, risk factors and antecedent factors in India by reviewing published studies. METHOD A scoping review was conducted to map the existing literature on gender differences in suicide in India. To identify peer-reviewed publications, online databases PsycINFO and Embase were searched. The search terms were [suicid* AND India*]. The searches took place in November 2020 and May 2021, with no language restrictions. Articles published from 2014 onwards from India were included. Reference lists of selected studies were searched for studies that could meet the inclusion criteria. RESULTS This review identified 17 studies that met the inclusion criteria. The ratio between women and men who die by suicide in India is much lower than in high-income countries. Hanging was found to be a more commonly used method of suicide among both men and women, in comparison to high-income countries where hanging is more common among men. This review also identified several gaps in the literature. There were few studies that examined suicide among transgender Indians. There was limited literature on gender differences in risk and protective factors for suicide. Limitations such as the omission of a lack of gender-based analyses in several studies and under-reporting of suicide rates were identified. CONCLUSION Understanding suicide within the context of individual countries is essential in designing culture-appropriate suicide prevention strategies. This review identified an urgent need to establish and evaluate suicide surveillance systems in India. Furthermore, additional research is warranted to understand suicide among individuals who identify outside the gender binary, and gender-specific risk and protective factors.
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Affiliation(s)
- Parvathy Ramesh
- School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Peter J Taylor
- School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Rebecca McPhillips
- School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Rajesh Raman
- Department of Psychiatry, JSS Medical College, JSS University, Mysore, India
| | - Catherine Robinson
- School of Health Sciences, The University of Manchester, Manchester, United Kingdom
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McPhillips R, Capobianco L, Cooper BG, Husain Z, Wells A. Cardiac rehabilitation patients experiences and understanding of group metacognitive therapy: a qualitative study. Open Heart 2021; 8:openhrt-2021-001708. [PMID: 34261779 PMCID: PMC8281095 DOI: 10.1136/openhrt-2021-001708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/06/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Depression and anxiety are up to three times more prevalent in cardiac patients than the general population and are linked to increased risks of future cardiac events and mortality. Psychological interventions for cardiac patients vary in content and are often associated with weak outcomes. A recent treatment, metacognitive therapy (MCT) has been shown to be highly effective at treating psychological distress in mental health settings. This is the first study to explore qualitatively, cardiac rehabilitation (CR) patients' experiences and understanding of group MCT with the aim of examining aspects of treatment that patients experienced as helpful. METHODS In-depth qualitative interviews were conducted with 24 purposively sampled CR patients following group MCT. Data were analysed using thematic analysis. RESULTS Two main themes were identified: (1) general therapy factors that were seen largely as beneficial, where patients highlighted interaction with other CR patients and CR staff delivery of treatment and their knowledge of cardiology; (2) group MCT-specific factors that were seen as beneficial encompassed patients' understanding of the intervention and use of particular group MCT techniques. Most patients viewed MCT in a manner consistent with the metacognitive model. All the patients who completed group MCT were positive about it and described self-perceived changes in their thinking and well-being. A minority of patients gave specific reasons for not finding the treatment helpful. CONCLUSION CR patients with anxiety and depression symptoms valued specific group MCT techniques, the opportunity to learn about other patients, and the knowledge of CR staff. The data supports the transferability of treatment to a CR context and advantages that this might bring.
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Affiliation(s)
- Rebecca McPhillips
- Social Care and Society, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Lora Capobianco
- Research and Innovation, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Bethany Grace Cooper
- Research and Innovation, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Zara Husain
- Research and Innovation, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Adrian Wells
- Research and Innovation, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK.,School of Psychological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
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McPhillips R, Nafees S, Elahi A, Batool S, Krishna M, Krayer A, Huxley P, Chaudhry N, Robinson C. Knowledge, attitudes and experiences of self-harm and suicide in low-income and middle-income countries: protocol for a systematic review. BMJ Open 2021; 11:e041645. [PMID: 34158289 PMCID: PMC8220466 DOI: 10.1136/bmjopen-2020-041645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Over 800 000 people die due to suicide each year and suicide presents a huge psychological, economic and social burden for individuals, communities and countries as a whole. Low-income and middle-income countries (LMICs) are disproportionately affected by suicide. The strongest risk factor for suicide is a previous suicide attempt, and other types of self-harm have been found to be robust predictors of suicidal behaviour. An approach that brings together multiple sectors, including education, labour, business, law, politics and the media is crucial to tackling suicide and self-harm. The WHO highlights that evaluations of the knowledge and attitudes that priority groups, not only healthcare staff, have of mental health and suicidal behaviour are key to suicide prevention strategies. The aim of this systematic review is to examine the knowledge, attitudes and experiences different stakeholders in LMICs have of self-harm and suicide. METHODS AND ANALYSIS MEDLINE, Embase, PsycINFO, CINAHL, BNI, Social Sciences and Cochrane Library will be searched. Reviewers working independently of each other will screen search results, select studies for inclusion, extract and check extracted data, and rate the quality of the studies using the Strengthening the Reporting of Observational studies in Epidemiology and Critical Appraisals Skills Programme checklists. In anticipation of heterogeneity, a narrative synthesis of quantitative studies will be provided and metaethnography will be used to synthesise qualitative studies. ETHICS AND DISSEMINATION Ethical approval is not required. A report will be provided for the funding body, and the systematic review will be submitted for publication in a high-impact, peer-reviewed, open access journal. Results will also be disseminated at conferences, seminars, congresses and symposia, and to relevant stakeholders. PROSPERO REGISTRATION NUMBER CRD42019135323.
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Affiliation(s)
| | - Sadia Nafees
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Anam Elahi
- Social Care and Society, The University of Manchester, Manchester, UK
| | - Saqba Batool
- Social Care and Society, The University of Manchester, Manchester, UK
| | - Murali Krishna
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Anne Krayer
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Peter Huxley
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Nasim Chaudhry
- Research and Development, Pakistan Institute of Living and Learning, Karachi, Pakistan
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Abstract
Background Psychological distress is prevalent among patients with cardiovascular disease and is linked to increased risk of future cardiac events. Cardiac rehabilitation (CR) is widely recommended for treating psychological distress but has been of limited benefit. This study aims to understand how distressed cardiac patients describe their emotional needs and the response of CR. Methods and Results A qualitative descriptive study was conducted with 46 patients who screened positively for anxiety and/or depression. Semi‐structured interviews were held, and data were analyzed using a constant comparative approach. Patients described low mood and diverse concerns, including threat of another cardiac event, restrictions on their lives, and problems unrelated to their health. Patients described worrying constantly about these concerns, worrying about their worry, and feeling that worry was uncontrollable and harmful. Patients wanted to “get back to normal” but lacked any sense of how to achieve this and were reluctant to discuss their worries with CR staff. They hoped to recover over time, meanwhile seeking reassurance that they were responding “normally.” Patients were mostly dismissive of psychological techniques used in CR. Conclusions These findings expose a conundrum. Distressed CR patients have diverse worries but do not generally want to discuss them, so they invest hopes for feeling better in time passing and reassurance. An intervention acceptable to CR patients would allow them to address diverse worries but without having to share the content of worries, would have “face validity,” and would address patients’ worry about worry. Metacognitive therapy is an intervention that might be suitable. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02420431.
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Affiliation(s)
- Rebecca McPhillips
- School of Psychological Sciences Faculty of Biology, Medicine and Health Manchester Academic Health Science Centre University of Manchester United Kingdom.,Department of Research and Innovation Greater Manchester Mental Health Trust Manchester Academic Health Science Centre Manchester United Kingdom
| | - Peter Salmon
- Division of Clinical Psychology Psychological Sciences University of Liverpool United Kingdom
| | - Adrian Wells
- School of Psychological Sciences Faculty of Biology, Medicine and Health Manchester Academic Health Science Centre University of Manchester United Kingdom.,Department of Research and Innovation Greater Manchester Mental Health Trust Manchester Academic Health Science Centre Manchester United Kingdom
| | - Peter Fisher
- Division of Clinical Psychology Psychological Sciences University of Liverpool United Kingdom
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McPhillips R, Salmon P, Wells A, Fisher P. Qualitative Analysis of Emotional Distress in Cardiac Patients From the Perspectives of Cognitive Behavioral and Metacognitive Theories: Why Might Cognitive Behavioral Therapy Have Limited Benefit, and Might Metacognitive Therapy Be More Effective? Front Psychol 2019; 9:2288. [PMID: 30662413 PMCID: PMC6328488 DOI: 10.3389/fpsyg.2018.02288] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/02/2018] [Indexed: 02/03/2023] Open
Abstract
Introduction: Cognitive behavioral therapy (CBT) alleviates emotional distress in mental health settings, but has only modest effects in cardiac patients. Metacognitive therapy (MCT) also alleviates depression and anxiety in mental health settings and is in its initial stages of evaluation for cardiac patients. Aim: Our objective is to compare how CBT and MCT models conceptualize cardiac patients' distress, and to explore why CBT has had limited benefit for cardiac patients and whether MCT has the potential to be more efficacious. Method: Forty-nine cardiac rehabilitation patients, who screened positively for anxiety and/or depression, provided semi-structured interviews. We analyzed transcripts qualitatively to explore the “fit” of patients' accounts of their distress with the main elements of cognitive behavioral and metacognitive theories. Four illustrative cases, representative of the diverse presentations in the broader sample, were analyzed in detail and are presented here. Results: Conceptualizing patients' distress from the perspective of CBT involved applying many distinct categories to describe specific details of patients' talk, particularly the diversity of their concerns and the multiple types of cognitive distortion. It also required distinction between realistic and unrealistic thoughts, which was difficult when thoughts were associated with the risk or consequences of cardiac events. From the perspective of MCT a single category—perseverative negative thinking—was sufficient to understand all this talk, regardless of whether it indicated realistic or unrealistic thoughts, and could also be applied to some talk that did not seem relevant from a CBT perspective. Discussion: Conceptualizing distress from the perspective of CBT presents multiple, diverse therapeutic targets, not all of which a time-limited therapy would be able to address. Given the difficulty of identifying them as unrealistic or not, thoughts about disease, death or disability may not be amenable to classic CBT techniques such as reality testing. MCT proved more parsimonious and, because it did not distinguish between realistic and unrealistic thoughts, might prove a better fit to emotional distress in cardiac patients.
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Affiliation(s)
- Rebecca McPhillips
- Faculty of Biology, Medicine and Health, School of Psychological Sciences, Manchester Academic Health Science Center, University of Manchester, Manchester, United Kingdom.,Department of Research and Innovation, Greater Manchester Mental Health Trust, Manchester Academic Health Science Center, Manchester, United Kingdom
| | - Peter Salmon
- Division of Clinical Psychology, Psychological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Adrian Wells
- Faculty of Biology, Medicine and Health, School of Psychological Sciences, Manchester Academic Health Science Center, University of Manchester, Manchester, United Kingdom.,Department of Research and Innovation, Greater Manchester Mental Health Trust, Manchester Academic Health Science Center, Manchester, United Kingdom
| | - Peter Fisher
- Division of Clinical Psychology, Psychological Sciences, University of Liverpool, Liverpool, United Kingdom
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Wells A, McNicol K, Reeves D, Salmon P, Davies L, Heagerty A, Doherty P, McPhillips R, Anderson R, Faija C, Capobianco L, Morley H, Gaffney H, Heal C, Shields G, Fisher P. Metacognitive therapy home-based self-help for cardiac rehabilitation patients experiencing anxiety and depressive symptoms: study protocol for a feasibility randomised controlled trial (PATHWAY Home-MCT). Trials 2018; 19:444. [PMID: 30115112 PMCID: PMC6097432 DOI: 10.1186/s13063-018-2826-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 07/27/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anxiety and depression are common among patients attending cardiac rehabilitation services. Currently available pharmacological and psychological interventions have limited effectiveness in this population. There are presently no psychological interventions for anxiety and depression integrated into cardiac rehabilitation services despite emphasis in key UK National Health Service policy. A new treatment, metacognitive therapy, is highly effective at reducing anxiety and depression in mental health settings. The principal aims of the current study are (1) to evaluate the acceptability of delivering metacognitive therapy in a home-based self-help format (Home-MCT) to cardiac rehabilitation patients experiencing anxiety and depressive symptoms and conduct a feasibility trial of Home-MCT plus usual cardiac rehabilitation compared to usual cardiac rehabilitation; and (2) to inform the design and sample size for a full-scale trial. METHODS The PATHWAY Home-MCT trial is a single-blind feasibility randomised controlled trial comparing usual cardiac rehabilitation (control) versus usual cardiac rehabilitation plus home-based self-help metacognitive therapy (intervention). Economic and qualitative evaluations will be embedded within the trial. Participants will be assessed at baseline and followed-up at 4 and 12 months. Patients who have been referred to cardiac rehabilitation programmes and have a score of ≥ 8 on the anxiety and/or depression subscales of the Hospital Anxiety and Depression Scale will be invited to take part in the study and written informed consent will be obtained. Participants will be recruited from the National Health Service in the UK. A minimum of 108 participants will be randomised to the intervention and control arms in a 1:1 ratio. DISCUSSION The Home-MCT feasibility randomised controlled trial will provide evidence on the acceptability of delivering metacognitive therapy in a home-based self-help format for cardiac rehabilitation patients experiencing symptoms of anxiety and/or depression and on the feasibility and design of a full-scale trial. In addition, it will provide provisional point estimates, with appropriately wide measures of uncertainty, relating to the effectiveness and cost-effectiveness of the intervention. TRIAL REGISTRATION ClinicalTrials.gov, NCT03129282 , Submitted to Registry: 11 April 2017.
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Affiliation(s)
- Adrian Wells
- The University of Manchester, School of Psychological Sciences, Faculty of Biology, Medicine and Health, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Kirsten McNicol
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - David Reeves
- The University of Manchester, NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Williamson Building, Oxford Road, Manchester, M13 9PL UK
| | - Peter Salmon
- University of Liverpool, Institute of Psychology, Health and Society, Waterhouse Building, Block B, Brownlow Street, Liverpool, L69 3GL UK
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, L7 8XP UK
| | - Linda Davies
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Centre for Health Economics, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL UK
| | - Anthony Heagerty
- The University of Manchester, School of Medical Sciences, Core Technology Facility, Grafton Street, Manchester, M13 9NT UK
- Central Manchester Foundation Trust, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Patrick Doherty
- Department of Health Sciences, University of York, Seebohm Rowntree Building, York, YO10 5DD UK
| | - Rebecca McPhillips
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Rebecca Anderson
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Cintia Faija
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Lora Capobianco
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Helen Morley
- Division of Neuroscience and Experimental Psychology, The University of Manchester, School of Biological Sciences, Oxford Road, Manchester, M13 9PL UK
| | - Hannah Gaffney
- Division of Psychology and Mental Health, The University of Manchester, School of Health Sciences, Oxford Road, Manchester, M13 9PL UK
| | - Calvin Heal
- The University of Manchester, Centre for Biostatistics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, Manchester, M13 9PL UK
| | - Gemma Shields
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Centre for Health Economics, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL UK
| | - Peter Fisher
- University of Liverpool, Institute of Psychology, Health and Society, Waterhouse Building, Block B, Brownlow Street, Liverpool, L69 3GL UK
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, L7 8XP UK
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Speer SA, McPhillips R. Initiating discussions about weight in a non-weight-specific setting: What can we learn about the interactional consequences of different communication practices from an examination of clinical consultations? Br J Health Psychol 2018; 23:888-907. [PMID: 29947157 PMCID: PMC6174938 DOI: 10.1111/bjhp.12322] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/23/2018] [Indexed: 12/11/2022]
Abstract
Objectives Effective clinical communication is fundamental to tackling overweight and obesity. However, little is known about how weight is discussed in non‐weight‐specific settings where the primary purpose of the interaction concerns clinical matters apparently unrelated to weight. This study explores how mental health clinicians initiate discussions about a patient's possible weight problem in the non‐weight‐specific setting of a UK NHS Gender Identity Clinic (GIC), where weight is topicalized during discussions about the risks of treatment. Design A conversation analytic study. Methods A total of 194 recordings of routine clinician–patient consultations were collected from the GIC. Weight talk was initiated by four clinicians in 43 consultations. Twenty‐one instances contained reference to a possible weight problem. Transcripts were analysed using conversation analysis. Results Clinicians used three communication practices to initiate discussion of a possible weight problem with patients: (1) announcing that patients are overweight; (2) asking patients whether they are overweight; and (3) deducing that patients are overweight or obese via a body mass index (BMI) calculation. Announcing that patients are overweight is the least aligning practice that denies patient's agency and grammatically constrains them to agree with a negative label. Asking patients whether they are overweight treats them as having limited agency and generates comparatively aligning, but occasionally resistant, responses. Jointly deducing that patients are overweight or obese via a BMI calculation is the most aligning practice, which deflects responsibility for labelling the patient onto an objective instrument. Conclusions Small differences in the wording of turns that initiate discussions about a possible weight problem can have significant consequences for interactional alignment. Clinicians from different specialities may benefit from considering the interactional consequences of different practices for initiating discussions about weight during the kinds of real‐life discussions considered here. Statement of contribution What is already known on this subject? There is a correlation between clinical communication about weight and patient weight loss. Clinicians from all specialties are encouraged to discuss diet and exercise with patients, but communication about weight remains problematic. Health psychologists have identified an urgent need for communication training to raise sensitive topics like weight without damaging the doctor–patient relationship.
What does this study add? Clinicians in a non‐weight‐specific setting use three communication practices to introduce the possibility that a patient's weight may be a problem. These practices have varying consequences for the interaction and doctor–patient relationship. Conversation analytic findings may be useful in training clinicians how to initiate discussions about weight with patients.
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Affiliation(s)
- Susan A Speer
- Division of Psychology and Mental Health, School of Health Sciences, The University of Manchester, UK
| | - Rebecca McPhillips
- Division of Psychology and Mental Health, School of Health Sciences, The University of Manchester, UK
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Wells A, McNicol K, Reeves D, Salmon P, Davies L, Heagerty A, Doherty P, McPhillips R, Anderson R, Faija C, Capobianco L, Morley H, Gaffney H, Shields G, Fisher P. Improving the effectiveness of psychological interventions for depression and anxiety in the cardiac rehabilitation pathway using group-based metacognitive therapy (PATHWAY Group MCT): study protocol for a randomised controlled trial. Trials 2018; 19:215. [PMID: 29615092 PMCID: PMC5883514 DOI: 10.1186/s13063-018-2593-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/13/2018] [Indexed: 12/24/2022] Open
Abstract
Background Anxiety and depression are prevalent among cardiac rehabilitation patients but pharmacological and psychological treatments have limited effectiveness in this group. Furthermore, psychological interventions have not been systematically integrated into cardiac rehabilitation services despite being a strategic priority for the UK National Health Service. A promising new treatment, metacognitive therapy, may be well-suited to the needs of cardiac rehabilitation patients and has the potential to improve outcomes. It is based on the metacognitive model, which proposes that a thinking style dominated by rumination, worry and threat monitoring maintains emotional distress. Metacognitive therapy is highly effective at reducing this thinking style and alleviating anxiety and depression in mental health settings. This trial aims to evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy for cardiac rehabilitation patients with elevated anxiety and/or depressive symptoms. Methods/Design The PATHWAY Group-MCT trial is a multicentre, two-arm, single-blind, randomised controlled trial comparing the clinical- and cost-effectiveness of group-based metacognitive therapy plus usual cardiac rehabilitation to usual cardiac rehabilitation alone. Cardiac rehabilitation patients (target sample n = 332) with elevated anxiety and/or depressive symptoms will be recruited across five UK National Health Service Trusts. Participants randomised to the intervention arm will receive six weekly sessions of group-based metacognitive therapy delivered by either cardiac rehabilitation professionals or research nurses. The intervention and control groups will both be offered the usual cardiac rehabilitation programme within their Trust. The primary outcome is severity of anxiety and depressive symptoms at 4-month follow-up measured by the Hospital Anxiety and Depression Scale total score. Secondary outcomes are severity of anxiety/depression at 12-month follow-up, health-related quality of life, severity of post-traumatic stress symptoms and strength of metacognitive beliefs at 4- and 12-month follow-up. Qualitative interviews will help to develop an account of barriers and enablers to the effectiveness of the intervention. Discussion This trial will evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy in alleviating anxiety and depression in cardiac rehabilitation patients. The therapy, if effective, offers the potential to improve psychological wellbeing and quality of life in this large group of patients. Trial registration UK Clinical Trials Gateway, ISRCTN74643496, Registered on 8 April 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2593-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adrian Wells
- School of Psychological Sciences, Faculty of Biology, Medicine and Health, Rawnsley Building, Manchester Royal Infirmary, The University of Manchester, Oxford Road, Manchester, M13 9WL, UK. .,Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK.
| | - Kirsten McNicol
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - David Reeves
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Peter Salmon
- Institute of Psychology, Health and Society, University of Liverpool, Waterhouse Building, Block B, Brownlow Street, Liverpool, L69 3GL, UK.,The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - Linda Davies
- Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Anthony Heagerty
- School of Medical Sciences, Core Technology Facility, The University of Manchester, Grafton Street, Manchester, M13 9NT, UK.,Central Manchester Foundation Trust, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Patrick Doherty
- Department of Health Sciences, University of York, Seebohm Rowntree Building, York, YO10 5DD, UK
| | - Rebecca McPhillips
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Rebecca Anderson
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Cintia Faija
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Lora Capobianco
- Greater Manchester Mental Health NHS Foundation Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Helen Morley
- School of Biological Sciences, Division of Neuroscience and Experimental Psychology, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Hannah Gaffney
- School of Health Sciences, Division of Psychology and Mental Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Gemma Shields
- Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Peter Fisher
- Institute of Psychology, Health and Society, University of Liverpool, Waterhouse Building, Block B, Brownlow Street, Liverpool, L69 3GL, UK.,The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, L7 8XP, UK
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Speer SA, McPhillips R. Patients' perspectives on psychiatric consultations in the Gender Identity Clinic: implications for patient-centered communication. Patient Educ Couns 2013; 91:385-391. [PMID: 23369376 DOI: 10.1016/j.pec.2012.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 12/13/2012] [Accepted: 12/21/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To explore transsexual patients' perceptions of communication with psychiatrists in a Gender Identity Clinic and advance understanding of patient centered communication (PCC) in psychiatric, 'gatekeeping' settings. METHODS 21 qualitative interviews with a convenience sample of clinic patients. Interviews were coded at a semantic level and subject to an inductive thematic analysis. RESULTS Patients' perceptions clustered into three themes: (1) aspects of communication that patients described liking; (2) aspects of communication that patients described disliking; and (3) aspects of communication that patients deemed challenging but necessary or useful. CONCLUSION Patients described liking or disliking aspects of communication that reflect existing understandings of PCC. However, a striking feature of their accounts was how they were able to rationalize and reflect pragmatically on their negative communication experiences, welcoming doctors' challenges as an opportunity to consider their life-changing decision to transition from their natal gender. PRACTICE IMPLICATIONS In certain clinical settings, current operationalizations of PCC may not apply. Patients' perceptions of communication may be enhanced if an analysis of their experiences formed part of the professional training of doctors, who could be invited to consider the functional specificity of communication across settings and the consequences (both immediate and post hoc) of their communication practices.
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Affiliation(s)
- Susan A Speer
- School of Psychological Sciences, The University of Manchester, Manchester, UK.
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Abstract
Perhaps no group of Americans has a greater stake in the issues raised by the rapid growth in health care spending than the elderly. The elderly consume a share of the nation's health care that is disproportionate to their numbers. In 1984, per capita health care spending for the elderly was four times that for the rest of the population. Ophthalmic expenses form a significant portion of their health care spending. Increasing numbers of elderly and per capita spending have placed enormous pressure on Medicare. In recent years, changing patterns of ophthalmic care have influenced the size and direction of Medicare expenditures; for example, new technologies in cataract surgery have shifted services from inpatient to outpatient settings. Such shifting of costs and other program changes must be analyzed to determine the impact on future Medicare expenditures and beneficiaries.
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Affiliation(s)
- R McPhillips
- Bureau of Data Management and Strategy, Health Care Financing Administration, Baltimore, MD 21207
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McPhillips R. The health care delivery system. Information requirements and computer technology. Comput Nurs 1987; 5:89-93. [PMID: 3300904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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