Family wellbeing in general practice: a study protocol for a cluster-randomised trial of the web-based resilience programme on early child development.

BACKGROUND: Social, emotional and behavioural problems in early childhood are associated with increased risk for a wide range of poor outcomes associated with substantial cost and impact on society as a whole. Some of these problems are rooted in the early mother-infant relationship and might be prevented. In Denmark, primary health care has a central role in preventive care during pregnancy and the first years of the child's life and general practice provides opportunities to promote a healthy mother-infant relationship in early parenthood. OBJECTIVE: In the context of standardised antenatal and child development assessments focused on psychosocial wellbeing, we examine the impact of a complex intervention designed to improve maternal mentalisation skills, involving training of general practice clinicians and signposting towards a web-based resource. Joint main outcomes are child socio-emotional and language development at age 30 months measured by parentally reported questionnaires (Communicative Development Inventory and Strengths and Difficulties Questionnaire). METHODS: The study is a cluster-randomised controlled trial based in general practices in the Capital Region and the Zealand Region of Denmark. Seventy practices were included. Practices were randomised by a computer algorithm in a ratio of 1:1 to intervention or control groups. Each practice was asked to recruit up to 30 women consecutively at their first scheduled antenatal assessment. Clinicians in both groups received one day of training in preventive antenatal and child development consultations with added focus on parental psychosocial well-being, social support, and parent-child interaction. These preventive consultations delivered in both trial arms require enhanced data recording about psychosocial factors. In intervention clinics, clinicians were asked to signpost a web page at three scheduled antenatal consultations and at four scheduled consultations when the child is 5 weeks, 5 months, 1 and 2 years. DISCUSSION: We hypothesise that the intervention will increase mothers' ability to be sensitive to their child's mental state to an extent that improves the child's language and mental state at 30 months of age measured by parent-reported questionnaires. TRIAL REGISTRATION: ClinicalTrials.gov NCT04129359. Registered on Oct 16 2019.

Pregnant women's concerns and antenatal care during COVID-19 lock-down of the Danish society.

INTRODUCTION: Pandemics are known to cause stress and anxiety in pregnant women. During the coronavirus disease 2019 (COVID-19) lockdown of the Danish society, pregnant women were considered to be at increased risk, and access to antenatal care changed. METHODS: On 8 April 2020A, a questionnaire was sent to 332 pregnant women previously sampled by general practitioners in two Danish regions. The women were contacted via secured e-mail (e-Boks), and questionnaires were returned until 6 May. RESULTS: The questionnaire was returned by 257 women (77%). More than half believed that they were at a high risk of infection with COVID-19, and a third of the women were concerned about the risk of serious disease - especially for their unborn child. Almost 90% isolated at home most of the time. The majority were worried about possible consequences of the pandemic for antenatal care, but very few had actually missed a scheduled preventive consultation with their general practitioner, and only 15% had missed an appointment with their midwife. The majority of the women preferred normal consultations and found no added safety in shifting the consultation from the normal clinical setting. CONCLUSIONS: The COVID-19 pandemic and lockdown have had a major impact on Danish pregnant women. Even so, concerns were more focused on access to care than on the risk of COVID-19 infection. Contacts with the antenatal healthcare system have only been moderately affected. FUNDING: TRYG Foundation and KEU, Region Copenhagen. TRIAL REGISTRATION: not relevant.

Dealing with parental concerns: A study of GPs' practice.

OBJECTIVE: To investigate patterns of GPs' exploration and termination of dialogues about parental concerns in preventive child health assessments. METHODS: Interactional microanalysis of video recordings of 32 preventive child health assessments using conversation analysis. RESULTS: The GPs asked parents about concerns, but most concerns disclosed by parents were still left unexplored at the end of the consultation. Termination of dialogues about concerns could be achieved effectively by GPs through letting the biomedical agenda dominate or addressing the child directly. The parents generally cooperated with the various approaches to handling concerns. CONCLUSION: GPs displayed initial attentiveness towards emotional concerns but did not always follow through with subsequent exploration; many concerns raised were left unexplored. However, the same GP could employ both non-exploratory and exploratory practice within individual consultations. PRACTICE IMPLICATIONS: Preventive child heath assessments offer an opportunity for parents to raise concerns about their children's development. Improved understanding of the conversational mechanisms through which concerns are examined or sidelined could allow clinicians to maximise the effectiveness of their preventive consultations.

General practitioners' perspectives on chronic care consultations for patients with a history of cancer: a qualitative interview study.

BACKGROUND: General practitioners (GPs) are responsible for managing chronic care in the growing population of patients with comorbid chronic conditions and cancer. Studies have shown, however, that cancer patients are less likely to receive appropriate chronic care compared to patients without cancer. Patients say that how GPs engage in the care of comorbidities influences their own priority of these conditions. No studies have explored GPs' attitudes to and prioritization of chronic care in patients who have completed primary cancer treatment. This study aims to explore GPs' experiences, prioritization of, and perspectives on treatment and follow-up of patients with cancer and comorbidity. METHODS: Semi-structured interviews were conducted during 2016 with 13 GPs in Region Zealand in Denmark. We used Systematic Text Condensation in the analysis. RESULTS: All participating GPs said that chronic care in patients with a history of cancer was a high priority, and due to a clear structure in their practice, they experienced that few patients were lost to follow-up. Two different approaches to chronic care consultations were identified: one group of GPs described them as imitating outpatient clinics, where the GP sets the agenda and focuses on the chronic condition. The other group described an approach that was more attuned to the patient's agenda, which could mean that chronic care consultations served as an "alibi" for the patients to disclose other matters of concern. Both groups of GPs said that chronic care consultations for these patients supported normalcy, but in different ways. Some GPs said that offering future appointments in the chronic care process gave patients hope and a sense of normalcy. Other GPs strove for normalcy by focusing exclusively on the chronic condition and dealing with cancer as cured. CONCLUSIONS: The participating GPs gave a high priority to chronic care in patients with a history of cancer. Some GPs, however, followed a rigorous agenda. GPs should be aware that a very focused and biomedical approach to chronic care might increase fragmentation of care and collide with a holistic and patient-centered approach. It could also affect GPs' self-perception of their role and the core values of general practice.

How can the general practitioner support adolescent children of ill or substance-abusing parents? A qualitative study among adolescents.

OBJECTIVES: To explore significant experiences of adolescents as next of kin that the general practitioner (GP) should identify and recognize. DESIGN: Qualitative study with focus-group interviews. SUBJECTS AND SETTING: Three focus-group interviews were conducted with a total of 15 Norwegian adolescents each with an ill or substance-abusing parent. The participants were recruited from existing support groups. RESULTS: The adolescents' days were dominated by unpredictability in their family situation and their own exhausting efforts to keep up an ordinary youth life. Mostly, they consulted GPs for somatic complaints. In encounters with the GP, they wanted to be met both as a unique person and as a member of a family with burdens. Their expectations from the GP were partly negatively formed by their experiences. Some had experienced that both their own and their parent's health problems were not addressed properly. Others reported that the GP did not act when he or she should have been concerned about their adverse life situation. The GP may contribute to better long-term psychosocial outcomes by ensuring that the adolescents receive information about the parent's illness and have someone to talk to about their feelings and experiences. In addition, the GP may help by supporting their participation in relieving activities. CONCLUSION: Burdened adolescents seek a GP most often for somatic complaints. The GP has a potential to support them by taking the initiative to talk about their life situation, and by recognizing their special efforts. Key points Little is known about how a general practitioner can support adolescents with ill or substance-abusing parents. Adolescents experience unpredictability in life and strive to find balance between their own needs and the restrictions caused by parental illness. In encounters with adolescents having ill parents, the GP should take the initiative to talk about their family situation. The GP may help them by recognizing their experiences and struggles, give information, offer talks and support coping strategies.

Maternal pain influences her evaluation of recurrent pain in 6- to 11-year-old healthy children.

AIM: Children with recurrent pain rely on their parents to acknowledge it. We compared pain reported by healthy children and their mothers, to evaluate their agreement, and also looked at the effect of maternal health on children's pain. METHODS: This was a cross-sectional questionnaire-based survey in Danish public schools. The participants were 131 healthy children aged 6-11 years and their mothers. The main outcome measures were the prevalence of recurrent pain reported by the mother and child, agreements between their reports and any associations between the child's pain, socio-demographic characteristics and maternal health factors. RESULTS: Recurrent pain was reported by nearly one-third (31%) of the children and their mothers. A quarter (25%) of the mother-child pairs disagreed on the existence of pain in the child, and a third (33%) disagreed on the frequency and duration. When the data were adjusted for child characteristics and socio-demographic parameters, mothers who had chronic pain were five times more likely to report frequent pain in their children than mothers without pain. This is a new finding. CONCLUSION: Maternal health factors may influence her evaluation of her child's pain. Family health and pain behaviour should be considered when recurrent pain is suspected in a child.

Understanding medical symptoms: a conceptual review and analysis.

The aim of this article is to present a conceptual review and analysis of symptom understanding. Subjective bodily sensations occur abundantly in the normal population and dialogues about symptoms take place in a broad range of contexts, not only in the doctor's office. Our review of symptom understanding proceeds from an initial subliminal awareness by way of attribution of meaning and subsequent management, with and without professional involvement. We introduce theoretical perspectives from phenomenology, semiotics, social interactionism, and discourse analysis. Drew Leder's phenomenological perspectives deal with how symptom perception occurs when any kind of altered balance brings forward a bodily attention. Corporeality is brought to explicit awareness and perceived as sensations. Jesper Hoffmeyer's biosemiotic perspectives provide access to how signs are interpreted to attribute meaning to the bodily messages. Symptom management is then determined by the meaning of a symptom. Dorte E. Gannik's concept "situational disease" explains how situations can be reviewed not just in terms of their potential to produce signs or symptoms, but also in terms of their capacity to contain symptoms. Disease is a social and relational phenomenon of containment, and regulating the situation where the symptoms originate implies adjusting containment. Discourse analysis, as presented by Jonathan Potter and Margaret Wetherell, provides a tool to notice the subtle ways in which language orders perceptions and how language constructs social interaction. Symptoms are situated in culture and context, and trends in modern everyday life modify symptom understanding continuously. Our analysis suggests that a symptom can only be understood by attention to the social context in which the symptom emerges and the dialogue through which it is negotiated.

The Danish preventive child health examination should expand on mental health and the well-being of the family.

INTRODUCTION: In Denmark, around one in six children has significant somatic, psychological or social health problems, often in combination. The preventive child health examinations have a high participation rate; and they produce significant findings, predominantly concerning the child's physical health. The aim of this study was to explore how the child's physical, cognitive and psychosocial health are examined and assessed at the health examinations of children aged 0-5 years in general practice. METHODS: Our study employed observations of the consultations as well as individual interviews. A total of nine doctors from seven clinics participated. We included 21 cases in our study, each consisting of a consultation and subsequent interviews with the child's parents and with the doctor. RESULTS: The examination of the child's physical health and development is an important feature of the health examination. Motor, cognitive, social skills and mental health are assessed globally through observation and communication with the child, and, to a lesser degree, through conversation with the parents. The child health examination rarely has a family perspective, unless the doctor is already aware of problems in the family. CONCLUSION: The preventive child health examination is an important platform for examination and dialogue concerning a child's health. The physical aspect works well, but there is a need for development of the assessment of the child's mental health and the well-being of the family. FUNDING: Postdoctoral Fellowships in General Practice/Family Medicine - Denmark. TRIAL REGISTRATION: not relevant.

Meeting real patients: a qualitative study of medical students' experiences of early patient contact.

Teaching communication skills is an important task in the medical curriculum. It is widely agreed that the ability to communicate with the patient is just as important as biomedical knowledge and technical skills. We present data from an early patient contact (EPC) course with integrated theoretical and practical skills inspired by modifications of Kolb's learning cycle. Our objective was to examine first-term medical students' personal experiences and challenges with EPC. A qualitative design was adopted, with data from written logbooks and focus group interviews with medical students who had recently completed an EPC course. Data were analysed with a grounded theory approach. We found that meeting with a real patient--a person--was a central point of learning. Students' perceptions and reflections on their future profession and personal skills were broadened. Students became respectful of a patient's life and illness experiences, and their understanding of communication as central to a doctor's daily work increased. Our results deepen the current knowledge of students' benefit from EPC by taking it into first-term students' perspectives and focusing on the personal experiences and challenges that the students met during the course. Further integration of the patient in the learning processes is recommended.

Association of maternal self-medication and over-the-counter analgesics for children.

OBJECTIVE: Self-medication with over-the-counter (OTC) analgesics, such as paracetamol (PCM), among children and adolescents is increasing and constitutes an important public health issue internationally. Reasons for this development are unclear; parental influence is suggested. Our objective was to examine whether self-medication with OTC analgesics among school-aged children is influenced by maternal self-reported health and medicine use, taking the child's frequency of pain into account. METHODS: A quantitative cross-sectional survey was conducted on 131 children aged 6 to 11 years and their mothers in the framework of the Demonstration Of A Study To Coordinate And Perform Human Biomonitoring On A European Scale (DEMOCOPHES) European project. Participants were selected from 1 urban and 1 rural area of Denmark, and equally distributed in age and gender. Data were collected through structured interviews with all children and self-report questionnaires for mothers regarding health, pain, and medicine use. RESULTS: After adjusting for several sociodemographic and health parameters, maternal use of OTC analgesics was significantly associated with self-medication with OTC analgesics, particularly PCM, in our population of schoolchildren, even when the child's pain was adjusted for (odds ratio 3.00, P = .008). A clear association between child pain and OTC analgesic use was not found. Additionally, maternal health (self-rated health, chronic pain, chronic disease, daily medicine intake) did not significantly influence child use of OTC analgesics. CONCLUSIONS: Maternal self-medication with OTC analgesics is associated with self-medication of OTC analgesics, predominantly PCM, among school-aged children, perhaps more than the child's pain. Maternal health seems of less importance. Information to parents about pain self-management is important to promote appropriate PCM use among schoolchildren.

Becoming a client of the Danish social service system increases stress in parents of disabled infants.

INTRODUCTION: Parents of a young child with severe disabilities are facing a large range of new challenges; furthermore, most of these families have extended social needs regarding information, financial support, day care facilities, disability aids, etc. Many parents with disabled children have been found to be dissatisfied with social services. This study explores parents' experiences with Danish social services during their transition to a new daily life after the birth of a severely disabled child. MATERIAL AND METHODS: Repeated qualitative interviews were performed individually with 16 parents of a severely disabled young child during the first two years after the diagnosis of the child's disabilities. Data were analysed using grounded theory. RESULTS: We found that the encounter with the social services increased stress in the families. Parental expectations were not met, especially regarding information; parents felt clientized, and obtaining social support was very resource consuming. Parents' needs regarding practical support and empathic case-working were not met and they spent much time and effort due to lacking continuity between sectors. CONCLUSION: Parents have specific needs when becoming clients in the social service system whose organisation of social services needs improvement. Health care professionals are advised to identify problems and support cooperation between the parents and the social service system, as well as to report the health-related consequences of prolonged and inefficient case-working for the child and its parents. FUNDING: was received from Socialministeriet, Landsforeningen LEV, Ronald McDonalds Børnefond, Susie og Peter Robinsohns fond, Rosalie Petersens fond, PLU-fonden, Ville Heises fond, Sygesikringens forskningsfond, Helsefonden, Elsass fonden. TRIAL REGISTRATION: not relevant.

When resources get sparse: a longitudinal, qualitative study of emotions, coping and resource-creation when parenting a young child with severe disabilities.

Parents who realize that their newborn child is severely disabled often experience severe physical and emotional stress. Parental well-being is essential for the care-taking of the child. It is yet not known why some cope well and others do not. The aim of this study was to explore how parents coped with parenting a disabled child and how they maintained their energy and personal resources. We explored parents' experiences, coping and resources over a two-year period after their child was diagnosed with a severely disabling condition using a qualitative, longitudinal approach. Findings were interpreted in a theoretical framework of Lazarus and Folkman's studies on coping and Fredrickson's broaden-and-build theory of positive emotions, as well as theories of positive illusions and benefit finding during severe adversity. We found that parents continually created and sustained their personal resources through positive cognitive reappraisals of their circumstances, the consequences of those circumstances and their coping possibilities. Nine main coping strategies were identified constituting transformative pathways in resource-creation. A theory of resource-creation is proposed as an addition to the current understanding of coping and the role of positive emotions. Coping and resources were found to be closely interrelated and portals of intervention are discussed.