Inequalities and mental health during the Coronavirus pandemic in the UK: a mixed-methods exploration.

BACKGROUND: The World Health Organisation declared the novel Coronavirus disease (COVID-19) a global pandemic on 11th March 2020. Since then, the world has been firmly in its grip. At the time of writing, there were more than 767,972,961 million confirmed cases and over 6,950,655 million deaths. While the main policy focus has been on controlling the virus and ensuring vaccine roll-out and uptake, the population mental health impacts of the pandemic are expected to be long-term, with certain population groups affected more than others. METHODS: The overall objectives of our 'Coronavirus: Mental Health and the Pandemic' study were to explore UK adults' experiences of the Coronavirus pandemic and to gain insights into the mental health impacts, population-level changes over time, current and future mental health needs, and how these can best be addressed. The wider mixed-methods study consisted of repeated cross-sectional surveys and embedded qualitative sub-studies including in-depth interviews and focus group discussions with the wider UK adult population. For this particular inequalities and mental health sub-study, we used mixed methods data from our cross-sectional surveys and we carried out three Focus Group Discussions with a maximum variation sample from across the UK adult population. The discussions covered the broader topic of 'Inequalities and mental health during the Coronavirus pandemic in the UK' and took place online between April and August 2020. Focus Groups transcripts were analysed using thematic analysis in NVIVO. Cross-sectional survey data were analysed using STATA for descriptive statistics. RESULTS: Three broad main themes emerged, each supporting a number of sub-themes: (1) Impacts of the pandemic; (2) Moving forward: needs and recommendations; (3) Coping mechanisms and resilience. Findings showed that participants described their experiences of the pandemic in relation to its impact on themselves and on different groups of people. Their experiences illustrated how the pandemic and subsequent measures had exacerbated existing inequalities and created new ones, and triggered various emotional responses. Participants also described their coping strategies and what worked and did not work for them, as well as support needs and recommendations for moving forward through, and out of, the pandemic; all of which are valuable learnings to be considered in policy making for improving mental health and for ensuring future preparedness. CONCLUSIONS: The pandemic is taking a long-term toll on the nations' mental health which will continue to have impacts for years to come. It is therefore crucial to learn the vital lessons learned from this pandemic. Specific as well as whole-government policies need to respond to this, address inequalities and the different needs across the life-course and across society, and take a holistic approach to mental health improvement across the UK.

The mental health experiences of ethnic minorities in the UK during the Coronavirus pandemic: A qualitative exploration.

Background: Worldwide, the Coronavirus pandemic has had a major impact on people's health, lives, and livelihoods. However, this impact has not been felt equally across various population groups. People from ethnic minority backgrounds in the UK have been more adversely affected by the pandemic, especially in terms of their physical health. Their mental health, on the other hand, has received less attention. This study aimed to explore the mental health experiences of UK adults from ethnic minorities during the Coronavirus pandemic. This work forms part of our wider long-term UK population study "Mental Health in the Pandemic." Methods: We conducted an exploratory qualitative study with people from ethnic minority communities across the UK. A series of in-depth interviews were conducted with 15 women, 14 men and 1 non-binary person from ethnic minority backgrounds, aged between 18 and 65 years old (mean age = 40). We utilized purposefully selected maximum variation sampling in order to capture as wide a variety of views, perceptions and experiences as possible. Inclusion criteria: adults (18+) from ethnic minorities across the UK; able to provide full consent to participate; able to participate in a video- or phone-call interview. All interviews took place via MS Teams or Zoom. The gathered data were transcribed verbatim and underwent thematic analysis following Braun and Clarke carried out using NVivo 12 software. Results: The qualitative data analysis yielded seven overarching themes: (1) pandemic-specific mental health and wellbeing experiences; (2) issues relating to the media; (3) coping mechanisms; (4) worries around and attitudes toward vaccination; (5) suggestions for support in moving forward; (6) best and worst experiences during pandemic and lockdowns; (7) biggest areas of change in personal life. Generally, participants' mental health experiences varied with some not being affected by the pandemic in a way related to their ethnicity, some sharing positive experiences and coping strategies (exercising more, spending more time with family, community cohesion), and some expressing negative experiences (eating or drinking more, feeling more isolated, or even racism and abuse, especially toward Asian communities). Concerns were raised around trust issues in relation to the media, the inadequate representation of ethnic minorities, and the spread of fake news especially on social media. Attitudes toward vaccinations varied too, with some people more willing to have the vaccine than others. Conclusion: This study's findings highlight the diversity in the pandemic mental health experiences of ethnic minorities in the UK and has implications for policy, practice and further research. To enable moving forward beyond the pandemic, our study surfaced the need for culturally appropriate mental health support, financial support (as a key mental health determinant), accurate media representation, and clear communication messaging from the Governments of the UK.

Promoting and Protecting Mental Health: A Delphi Consensus Study for Actionable Public Mental Health Messages.

PURPOSE: Public health campaigns are still relatively rare in mental health. This paper aims to find consensus on the preventive self-management actions (i.e. "healthy behaviors") for common mental health problems (e.g. depression and anxiety) that should be recommended in mental health campaigns directed at the general public. APPROACH: A 3-round Delphi study. PARTICIPANTS: 23 international experts in mental health and 1447 members of the public, most of whom had lived experience of mental health problems. METHOD: The modified Delphi study combined quantitative and qualitative data collection: 1) online qualitative survey data collection thematically analyzed, 2) recommendations rated for consensus, 3) consensus items rated by public panel on a Likert scale. RESULTS: Expert consensus was reached on 15 behaviors that individuals can engage in to sustain mental health. Eight were rated as appropriate by more than half (50%) of the public panel, including: avoiding illicit drugs (80%, n = 1154), reducing debt (72%, n = 1043), improving sleep (69%, n = 1000), regulating mood (65%, n = 941), having things to look forward to (60%, n = 869). CONCLUSIONS: A series of healthy behaviors for the promotion and protection of mental health received expert and public consensus. To our knowledge, this is the first study to offer a set of actions for public health messaging for the prevention of poor mental health. Future research should focus on evaluating effectiveness of these actions in a universal primary prevention context.

Mental health in the pandemic: a repeated cross-sectional mixed-method study protocol to investigate the mental health impacts of the coronavirus pandemic in the UK.

INTRODUCTION: The WHO declared a global pandemic on 11 March 2020. Since then, the world has been firmly in the grip of the COVID-19. To date, more than 211 730 035 million confirmed cases and more than 4 430 697 million people have died. While controlling the virus and implementing vaccines are the main priorities, the population mental health impacts of the pandemic are expected to be longer term and are less obvious than the physical health ones. Lockdown restrictions, physical distancing, social isolation, as well as the loss of a loved one, working in a frontline capacity and loss of economic security may have negative effects on and increase the mental health challenges in populations around the world. There is a major demand for long-term research examining the mental health experiences and needs of people in order to design adequate policies and interventions for sustained action to respond to individual and population mental health needs both during and after the pandemic. METHODS AND ANALYSIS: This repeated cross-sectional mixed-method study conducts regular self-administered representative surveys, and targeted focus groups and semi-structured interviews with adults in the UK, as well as validation of gathered evidence through citizens' juries for contextualisation (for the UK as a whole and for its four devolved nations) to ensure that emerging mental health problems are identified early on and are properly understood, and that appropriate policies and interventions are developed and implemented across the UK and within devolved contexts. STATA and NVIVO will be used to carry out quantitative and qualitative analysis, respectively. ETHICS AND DISSEMINATION: Ethics approval for this study has been granted by the Cambridge Psychology Research Ethics Committee of the University of Cambridge, UK (PRE 2020.050) and by the Health and Life Sciences Research Ethics Committee of De Montfort University, UK (REF 422991). While unlikely, participants completing the self-administered surveys or participating in the virtual focus groups, semi-structured interviews and citizens' juries might experience distress triggered by questions or conversations. However, appropriate mitigating measures have been adopted and signposting to services and helplines will be available at all times. Furthermore, a dedicated member of staff will also be at hand to debrief following participation in the research and personalised thank-you notes will be sent to everyone taking part in the qualitative research.Study findings will be disseminated in scientific journals, at research conferences, local research symposia and seminars. Evidence-based open access briefings, articles and reports will be available on our study website for everyone to access. Rapid policy briefings targeting issues emerging from the data will also be disseminated to inform policy and practice. These briefings will position the findings within UK public policy and devolved nations policy and socioeconomic contexts in order to develop specific, timely policy recommendations. Additional dissemination will be done through traditional and social media. Our data will be contextualised in view of existing policies, and changes over time as-and-when policies change.

Unlocking the potential for digital mental health technologies in the UK: a Delphi exercise.

BACKGROUND: Digitally enabled services can contribute to the support, treatment and prevention of mental health difficulties; however, questions remain regarding how we can most usefully harness such technology in primary and secondary mental healthcare settings. AIMS: To identify barriers and facilitators to enable the potential of digital mental health in England, Scotland, Wales and Northern Ireland. METHOD: A three-round Delphi exercise was carried out online with 16 participants from across the four nations of the UK representing the following stakeholder groups: service providers, health professionals, policymakers, lived experience, small and medium enterprises and academics. Qualitative data were collected in the first round (80 fragments) that were then coded to produce a 26-item round-two questionnaire for participant rating. Participants were given the opportunity to reconsider their scores in light of the group responses in round three. RESULTS: Eight statements under the following five themes reached consensus with median scores between 8 and 10 (i.e. important/very important): co-production; the human element; data security; funding; and regulation. CONCLUSIONS: The Delphi process allowed consensus to be achieved regarding the factors that experts consider important for harnessing technology in primary and secondary mental healthcare. Knowledge of these factors can help users and providers of mental health services negotiate how best to move forward with digitally enabled systems of care.

Perspectives on patients and carers in leading teaching roles in interprofessional education.

The involvement of patients and carers is central to the values of interprofessional education (IPE) which aims to improve the experience of care and care delivery. Partnership arrangements with service users and carers within Higher Education Institutions face the same barriers relating to status, power, and resources, as the implementation of IPE. The complexity of these alignments can be explained by Activity Theory (AT). Using a qualitative research methodology we set out to consider the stakeholder perspectives on whether patients should progress from telling their stories to taking on a leading teaching role, within a well-established IPE workshop. Following the principles of Participatory Action Research, data were collected cyclically, using consultation meetings, interviews (with tutors and patients) and focus groups (with students). The work was overseen by a steering group who reviewed and clarified the analysis, informed by AT. All stakeholders endorsed the validity of patients as teachers. Two new leadership roles were proposed; patients as Co-Tutors and as Mentors supporting the workshop. Service users and carers were realistic about the support required for progression. Students were more ambivalent, recognizing the right of patients to tell their stories but having concerns about their competence and potential bias when in leading roles. There is overall support for the development of a progressive route for patients to move beyond telling stories into leading teaching roles in IPE, but this brings added complexity and requires a supportive infrastructure, careful preparation of students and further research.

Students improve patient care and prepare for professional practice: an interprofessional community-based study.

BACKGROUND: We report on an education model that enables students to contribute to practice while experiencing the realities of complex team-working in the community. AIMS: The study considers how interprofessional learning impacts on patient care and service delivery. METHOD: A qualitative study using a realist approach. The views of practice-staff, patients and facilitators on how student team learning impacted on practice was obtained through focus groups, interviews and an e-questionnaire and compared to student analysis as feedback forms. RESULTS: Staff from six Primary Health Care Teams (n = 23) stated that the student teams had offered solutions to improve the quality of patient care and on organisational systems. The positive value of the student work was confirmed by the course facilitators (n = 8). In addition, practitioners were propelled to maintain high professional standards. Patients (n = 23) recalled benefits directly attributable to the student work confirmed by the 434 student feedback forms. CONCLUSION: Undergraduate interprofessional student teams in mid-training can support and help practice teams, and this subsequently benefits patient care. This practice-based interprofessional learning model offers learning, which is theory-based, and supports positive student contributions. This learning fits today's requirements for positive outcomes from education when mapped against the Kirkpatrick or the NHS (UK) education outcomes framework.

Using the lever of parity of esteem between mental and physical health to close the mental health gap - a call for action.

This paper provides a six-point definition of what parity of esteem for mental health means in practice. It highlights examples of the current disparity between mental and physical health and the importance of redressing this. The significance of securing a legislative basis for parity in England is discussed. The authors make a call for action, and pose six questions for international readers to consider and respond to.

Development of interprofessional education in mental health practice: adapting the Leicester Model.

Mental health provides a unique opportunity for health and social care students to experience interprofessional team working and collaborative practice. We tested whether we could introduce interprofessional learning into this area of collaborative practice by choosing to adapt and use a robust practice-based interprofessional education model. We outline the steps taken to adopt and adapt the model, which includes using action research principles. The research phase consisted of three cycles of teaching and evaluation. Both qualitative and quantitative data were collected from all stakeholders, patients (n = 6), students (n = 300) and facilitators (n = 6). Qualitative data (focus groups, interviews and free text questionnaires) were analyzed using principles from grounded theory Stages 1 and 2; quantitative data were analyzed using SPSS. Problems and difficulties which led to changes in the course structure and delivery were identified. In the final phase, all students significantly achieved their learning outcomes (p < 0.01 to p < 0.001). The action learning approach for implementation helped to modify the course content and develop shared ownership by students, patients, clinicians and educators. The model provided a guide for replication and the final course adhered to interprofessional principles because patients with complex mental health problems were central to the learning, it overcame the theory-practice gap, the students gained insights into the realities of everyday team working and the experience of clinical uncertainty and, in addition, the learning interfaced with uniprofessional knowledge concerning mental health. The research findings highlight that patients with mental health problems can contribute to interprofessional teaching in the community.

Interprofessional staff development: changing attitudes and winning hearts and minds.

As more educators are involved in interprofessional education (IPE) it is important to consider how participation affects those who are sceptical about IPE. We report a prospective study in which the attitudes of 13 educators, unfamiliar with IPE, were compared before and after facilitating their first IPE. Their views, obtained as personal stories, were analysed through cognitive dissonance theory. Prior to teaching, all novice educators had concerns about IPE. Post-facilitation all were more positive about the value and meaning of IPE.

GP Participation and Recruitment of Patients to RCTs: Lessons from Trials of Acupuncture and Exercise for Low Back Pain in Primary Care.

The objective of this study was to identify factors associated with general practitioner (GP) participation and the recruitment of people to trials in primary care, based on data from two trials of interventions for treating chronic low back pain. The study was based on data from two randomized controlled trials (RCTs), one involving exercise, the other acupuncture, and subsequent reporting by GPs in a postal questionnaire. The exercise trial achieved 62% recruitment whereas the acupuncture trial achieved 100% recruitment. In both trials GPs most efficient at referring patients were those with a special interest in the subject area, and those known personally to the research team. A follow-up GP questionnaire found that both trials had maintained a high profile with over 80% of GPs, and successful recruitment strategies included project reminder letters, updates and personal contacts. Achieving target recruitment of patients in the acupuncture trial was aided by the deliberate application of lessons learned in the exercise trial, in particular the need to keep initial study entry criteria broad, with subsequent filtering undertaken by the study researcher. In addition the use of effective methods of maintaining the trial profile, the involvement of a GP advisor, the decision to maximize the recruitment of GPs early in the trial and the direct recruitment of interested individual GPs. The successful recruitment of patients to trials in primary care requires careful planning and continuous monitoring from the outset. Prior to starting recruitment, it is useful to identify previous trials in a similar environment in order to learn from their experience and optimize patient recruitment.

Learning to listen: improving students' communication with disabled people.

BACKGROUND: This report outlines the action research used to develop a workshop for interprofessional student groups to enhance listening skills. AIM: The project aimed to enable students to reflect interprofessionally on the human factors central to effective communication using the power of storytelling by disabled people and their carers. METHODS: Qualitative data from students and participating service users were collected using focus groups and one-to-one interviews over three pilot cycles. RESULTS: The results from each pilot informed the cyclical development of the project so that each stage of data collection informed the next stage. During the pilots, 20 interviews with service users were completed and a total of 109 students participated. Transcribed data were analysed using principles from grounded theory. Quantitative scored questions on students' learning were analysed using statistical package for the social sciences. CONCLUSIONS: Both students (health and social care) and users benefitted from the education process which delivered highly relevant explicit learning opportunities, with analysis of how to improve communication for safe practice. Students benefitted from meaningful interactions with service users who shared their experiences and gave feedback on students' communication skills. The final workshop design resulted in a learning model which reflects the human side of healthcare delivery.

Learning together in practice: an interprofessional education programme to appreciate teamwork.

BACKGROUND: the paper reports on the first 100 students who completed ward-based interprofessional learning using the Leicester Model of Interprofessional Education. Pre-registration health and social care students were placed in small groups (n = 2-5) to learn together on a care of the elderly ward. The students cared for one in-patient to analyse the care package and the contributions of all members of the ward clinical team. At the end of the week the student team presented their patient case to the ward team offering solutions to problems in an interactive feedback session. METHOD: a multi-method evaluation aimed to assess the impact of the learning. Tutors completed a post-course questionnaire. RESULTS: the results confirmed that the learning was worthwhile. Students learned about related policy, patient involvement in discharge, the roles and responsibilities of team members in care delivery, the importance of effective communication, the complexity of teamworking and team decisions on discharge. They highlighted the added benefit of learning interprofessionally. All tutors saw the value of the interprofessional learning and welcomed student feedback which could be used to improve patient care. Clinicians had to balance clinical work and teaching. DISCUSSION: interprofessional learning in clinical areas requires effective models which engage students and ward teams. The Leicester Model can be applied in hospital settings to establish student team learning that is experiential, reflective and contributes to improving the quality of patient care.

Interprofessional educator ambassadors: An empirical study of motivation and added value.

BACKGROUND: Interprofessional education (IPE) is being led by a driving force of teaches who advocate for the importance of this learning within health and social care professional curriculum. Many of these leaders have additional uni professional teaching responsibilities. AIMS: This study aimed to explore the impact of leading an IPE curriculum on teachers, who were at the forefront of establishing a new IPE curriculum in the east midlands, UK. METHODS: The prospective study used the principles of grounded theory to analyse the educator's experiences. The study included teachers who work from academic university posts and those who teach from within practice. These IPE leaders were identified through their involvement in the design and delivery of the local IPE initiatives. They were invited to share their experiences at either a mixed-discipline focus group, a one-to-one interview or by completing a postal/e questionnaire. During analysis the views from each data set were triangulated. RESULTS: A total of 58 educators shared their experiences. All benefitted from being part of the planning and teaching teams. They were driven by a strong belief that IPE had the potential to improve patient care and that future healthcare practice would remain team based. Engagement had brought additional benefits to their teaching and career development in particular through forming new relationships with colleagues from other caring professions. They were concerned about educators teaching interprofessional student groups with little prior experience of IPE. CONCLUSION: The data suggest educators who take on a leading developmental role in designing and delivering an interprofessional curriculum benefit personally and professionally through working relationships with colleagues in other professions and through teaching wider networks of students. These new insights strengthen personal practice and research and in turn have the potential to influence and improve the quality of faculty teaching.

Medical students benefit from learning about patient safety in an interprofessional team.

CONTEXT: Safe clinical practice is inextricably linked to team-working. Delivering patient safety education interprofessionally heightens students' awareness of the importance of effective team-working for safe care and care delivery. METHODS: We conducted a comparative study using mixed-method analysis among medical students learning about patient safety, either uni- or interprofessionally, towards the end of their training. Emphasis is placed on the detailed analysis of qualitative data relating to student perceptions of the event before and afterwards. RESULTS: All medical students, whether working uni- or interprofessionally, increased their knowledge across all eight learning outcomes (P = 0.001). Although students said they felt more comfortable when learning alongside other medical students, those who learned with other disciplines gained added value from these interactions and were able to frame their thinking more clearly within the context of safe interprofessional team-working. CONCLUSIONS: Designing a team-based patient safety event to take place towards the end of medical education can enable students to assimilate all aspects of their curriculum relevant to safety. The link between team factors and the safety agenda is increased when students learn interprofessionally.

Beyond needling--therapeutic processes in acupuncture care: a qualitative study nested within a low-back pain trial.

BACKGROUND: In the medical and scientific literature, there is a dearth of reports about how acupuncturists work and deliver care in practice. An informed characterization of the treatment process is needed to support the appropriate design of evaluative studies in acupuncture. METHODS: The design was that of a nested qualitative study within a pragmatic clinical trial. Six acupuncturists who treated up to 25 patients each were interviewed after the treatment phase of the trial to obtain an account of their experiences of providing acupuncture care to patients with low back pain referred by their GP. Using semistructured interviews and a topic guide, data were collected and analyzed for both a priori and emergent themes. This paper focuses on practitioners' accounts of the goals and processes of care, and describes the strategies employed in addition to needling and other hands-on treatments. RESULTS: From the interview data, it is clear that a coherent body of theoretical knowledge informed clinical decisions and practice, and that the goals of treatment went beyond the alleviation of immediate pain-related symptoms. Acupuncturists in this study all described a pattern of patient-centered care based on a therapeutic partnership. Study participants confirmed the importance of three processes that characterized acupuncture care in this trial, each contributing to the goal of a positive long-term outcome; building a therapeutic relationship; individualizing care; and facilitating the active engagement of patients in their own recovery. Acupuncturists described elements of care that characterized these processes including establishing rapport, facilitating communication throughout the period of care, using an interactive diagnostic process, matching treatment to the individual patient, and the use of explanatory models from Chinese medicine to aid the development of a shared understanding of the patient's condition and to motivate lifestyle changes that reinforce the potential for a recovery of health. Acupuncturists did not view these therapeutic goals, processes, and strategies as a departure from their usual practice. CONCLUSIONS: This study suggests that acupuncture care for patients with chronic conditions such as low back pain is likely to be a complex intervention that utilizes a number of patient-centered strategies to elicit longterm therapeutic benefits. Research designed to evaluate the effectiveness of acupuncture as it is practiced in the UK needs to accommodate the full range of therapeutic goals and related treatment processes.

Acupuncture for low back pain: traditional diagnosis and treatment of 148 patients in a clinical trial.

AIMS: To assess patterns of diagnosis, including concordance, and treatment within a clinical trial of traditional acupuncture for low back pain. SETTING: In a pragmatic randomised controlled clinical trial, 148 patients with low back pain, of between 4 weeks and 12 months duration, were randomised to the offer of individualised acupuncture and received up to 10 treatments. METHODS: Standardised diagnosis and treatment records were completed by practitioners for 148 patients. The diagnosis was based on three pre-defined low back pain syndromes. For a subgroup of patients, one of the six practitioners then independently re-examined the patients, blind to the original diagnosis. The diagnostic inter-rater reliability was assessed in terms of percentage congruent classifications and Cohen's Kappa. Structured interviews of practitioners established further details about practice styles. RESULTS: The most commonly diagnosed syndrome associated with low back pain was Qi and Blood Stagnation (88% of patients), followed by Kidney Deficiency (53%) and Bi Syndrome (28%), with more than one syndrome being identified for 65% of patients. For the subgroup examined twice, practitioner concordance was reasonable: between 47 and 80% of classifications were congruent, while Kappa values lay between 0 ("the same as chance") and 0.67 ("good"). Practitioners provided 1269 treatments in total, using 177 different acupuncture points. Most commonly used channels were Bladder and Gall Bladder, and the commonest points were BL-23 and the two lowest Huatuojiaji points. Auxiliary treatments were utilised by all practitioners to varying degrees. CONCLUSIONS: Diagnostic concordance among practitioners was reasonable, and clear themes emerged for treatment. Further research is required to develop a flexible trial protocol with scope for individualised treatment.

Acupuncture for depression: first steps toward a clinical evaluation.

AIM OF STUDY: To explore issues that need to be addressed in the design of a clinical trial of acupuncture for people with depression. METHODS: In this study we conducted a focus group with 6 volunteer participants with experiences of depression, and a prospective case series of 10 patients who received acupuncture treatment for their depression. In the case series study, 10 patients were referred by their general practitioner, and received up to 10 individualized acupuncture treatments from one of two acupuncturists. Acupuncturists recorded traditional acupuncture diagnoses and details of the treatment provided. Measures of depression (Beck Depression Inventory and the Hospital Anxiety and Depression Scale) and health status (SF-36) were taken at baseline and 10 weeks later. Changes in mean before and after scores were analyzed using the Wilcoxon signed ranks test. Adverse events were also monitored. RESULTS: The focus group and the case series both identified considerable heterogeneity among people with depression. In the case series, only 6 patients both received treatment and completed 10-week questionnaires; however, significant improvements between before and after were found in their levels of depression (p < 0.05). Many factors, as well as the acupuncture, may have contributed to these improvements. No serious adverse events occurred. In the context of designing a clinical trial of acupuncture for depression, a series of methodological challenges is explored. CONCLUSION: This study highlighted the complexities of evaluating acupuncture for patients with depression. Successfully addressing the identified methodological challenges in the design of a trial will increase its relevance and impact.