Improving treatment outcomes for leprosy in Pernambuco, Brazil: a qualitative study exploring the experiences and perceptions of retreatment patients and their carers.

BACKGROUND: Brazil has a high leprosy burden and poor treatment outcomes (TOs), manifesting in high relapse rates. Pernambuco, an impoverished Brazilian state suffering notable geographical health inequalities, has 'hyperendemic' leprosy. Although current literature identifies barriers and facilitators influencing leprosy treatment compliance, inadequate investigation exists on other factors influencing TOs, including carers' roles and psycho-dermatological impact. This qualitative study explores experiences and perceptions of leprosy patients and their carers in Pernambuco, Brazil; to identify location-specific factors influencing TOs, and consequently inform future management. METHODS: 27, semi-structured, in-depth interviews were conducted with 14 patients and 13 carers. Participants were recruited using maximum variation and snowball sampling from three clinics in Petrolina, Pernambuco. Transcripts and field notes from both participant groups were separately analysed using conventional thematic and deviant case analysis. The University of Birmingham Internal Research Ethics Committee and Instituto Lauro de Souza Lima provided ethical approval. RESULTS: Two homologous sets of four, primary, interdependent themes influencing leprosy TOs emerged: 'personal factors'; 'external factors'; 'clinical factors'; and 'the healthcare professional (HCP)-patient-carer relationship'. Poor participant knowledge and lack of symptomatic relief caused patients to distrust treatment. However, because participants thought HCP-led interventions were vital for optimal TOs, patients were effectively persuaded to adhere to pharmaceutical treatments. High standard patient and population education facilitated treatment engagement by encouraging evidence-based medicine belief, and dispelling health myths and stigma. Healthcare, on occasions, was perceived as disorganised, particularly in resource-scarce rural areas, and for those with mental health needs. Participants additionally experienced incorrect/delayed diagnoses and poor contact tracing. Leprosy's negative socio-economic impact on employment - together with stigma, dependency and changing relationships - caused altered senses of identity, negatively impacting TOs. Better dialogue between patients, HCPs and carers facilitated individualised patient support. CONCLUSION: This study highlights the importance of: effective evidence-based leprosy education; communication between HCPs, patients and carers; state-funded support; and healthcare resource distribution. These findings, if prioritised on governmental scales, provide the valuable insight needed to inform location-specific management strategies, and consequently improve TOs. Future research should evaluate the effectiveness of these implementations. Failure to address these findings will hinder regional elimination efforts.

Social networks, health and identity: exploring culturally embedded masculinity with the Pakistani community, West Midlands, UK.

BACKGROUND: Migrants from South Asia living in developed countries have an increased risk for developing cardiovascular disease (CVD), with limited research into underlying social causes. METHODS: We used social capital as an interpretive lens to undertake analysis of exploratory qualitative interviews with three generations of at-risk migrant Pakistani men from the West Midlands, UK. Perceptions of social networks, trust, and cultural norms associated with access to healthcare (support and information) were the primary area of exploration. RESULTS: Findings highlighted the role of social networks within religious or community spaces embedded as part of ethnic enclaves. Local Mosques and gyms remained key social spaces, where culturally specific gender differences played out within the context of a diaspora community, defined ways in which individuals navigated their social spheres and influenced members of their family and community on health and social behaviours. CONCLUSIONS: There are generational and age-based differences in how members use locations to access and develop social support for particular lifestyle choices. The pursuit of a healthier lifestyle varies across the diverse migrant community, determined by social hierarchies and socio-cultural factors. Living close to similar others can limit exposure to novel lifestyle choices and efforts need to be made to promote wider integration between communities and variety of locations catering to health and lifestyle.

'If there were doctors who could understand our problems, I would already be better': dissatisfactory health care and marginalisation in superdiverse neighbourhoods.

How people in community settings describe their experience of disappointing health care, and their responses to such dissatisfaction, sheds light on the role of marginalisation and underlines the need for radically responsive service provision. Making the case for studying unprompted accounts of dissatisfaction with healthcare provision, this is an original analysis of 71 semi-structured interviews with healthcare users in superdiverse neighbourhoods in four European cities. Healthcare users spontaneously express disappointment with services that dismiss their concerns and fail to attend to their priorities. Analysing characteristics of these healthcare users show that no single aspect of marginalisation shapes the expression of disappointment. In response to disappointing health care, users sought out alternative services and to persuade reluctant service providers, and they withdrew from services, in order to access more suitable health care and to achieve personal vindication. Promoting normative quality standards for diverse and diversifying populations that access care from a range of public and private service providers is in tension with prioritising services that are responsive to individual priorities. Without an effort towards radically responsive service provision, the ideal of universal access on the basis of need gives way to normative service provision.

A meta-ethnography of adult smokers' exploring the meanings of tobacco dependency medications adherence behaviours during smoking cessation.

AIMS: To synthesize the experiences and adherence of adult smokers' with tobacco dependence medications. DESIGN: Meta-ethnography. DATA SOURCES: Seven bibliographic databases were systematically searched until April 2016. REVIEW METHODS: A standardized appraisal tool evaluated the quality of the selected studies. RESULTS: Seven studies met the eligibility criteria. Three major themes described the experiences and adherence of adult smokers' with tobacco dependence medications; the psychosocial context, predilection for willpower and "natural" methods and a tendency to resist medications. CONCLUSION: The findings of this meta-ethnography are important to future clinical practice guideline development so health professionals contribute effectively to further reduction in smoking prevalence. Further research is needed to understand resistance to tobacco dependence medications and to inform the design of person-tailored interventions to improve tobacco dependence medication adherence that can be incorporated into smoking cessation interventions. IMPACT: Smoking causes more death and disability in the world than any other avoidable factor. Research on smoker perspectives on tobacco dependence medications is sparse. Tobacco dependency is a unique treatment context with specific adherence issues. Smokers are active decision-makers regarding tobacco dependence medications. Inconsistent adherence to tobacco dependency medication regimens was apparent. Implications for health professionals, healthcare policy and clinical practice guidelines regard the structure of consultations with smoking patients. It is critical for all health professionals to assess the person seeking to stop smoking and foresee the possible causes of non-adherence behaviour. Addressing non-adherence will to lead to more effective health communications and positively contribute to quality of smoking cessation care.

Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review.

BACKGROUND: Obstetric fistula is a debilitating childbearing injury that results from poorly managed obstructed labour, leading to the development of holes between the vagina and bladder and/or rectum. Effects of this injury are long-lasting, as women become incontinent and are often marginalised from their communities. Despite continuous occurrence of this injury in lower-income countries, it is preventable, as evidenced in high-income countries. This systematic review aims to identify and understand barriers and facilitators to interventions aimed at the prevention of obstetric fistulas in sub-Saharan African women. METHODS: Electronic databases and grey literature were searched. We included studies written in English that discussed interventions to prevent obstetric fistulas implemented in sub-Saharan Africa, and their associated barriers and facilitators. Quality of the studies was assessed, and data including: country of implementation, preventive interventions, and barriers and facilitators to the interventions were extracted. They were then categorised based on the Three Phase Delay Model. RESULTS: Our search yielded 537 studies, of which 18 were included from sub-Saharan countries including Ethiopia, Nigeria, and Zambia. The most noted barrier to prevention addressed the first phase of delay: the decision to seek care, particularly lack of awareness of the dangers of unsupervised labours. The most noted facilitator addressed the decision to seek care and the quality of care received at a facility, through partnerships between health facilities and governments, and other organisations that provided both financial and resource support. CONCLUSION: Despite being categorised by the three phases of the delay model, barriers and facilitators were found to play a role in multiple phases. The topic of obstetric fistula needs to be researched more extensively, particularly the effectiveness of preventive interventions.

A qualitative insight into informal childcare and childhood obesity in children aged 0-5 years in the UK.

BACKGROUND: Previous studies in various countries have found that informal childcare (provided by relatives, friends etc.) was associated with an increased risk of obesity in children aged 0-5 years. However, no qualitative research has been done to explore possible reasons for such a relationship and potential interventions to tackle it. We conducted a qualitative study with both parents and informal carers to explore their 1) experiences in receiving or giving informal childcare for British children aged 0-5 years; 2) perceived explanations of the relationship between informal childcare and childhood obesity and 3) preferred intervention ideas and delivery strategies for preventing obesity among those children under informal care. METHODS: Four in-depth focus groups with a total of 14 participants (7 parents, 7 informal caregivers) were conducted in Birmingham and Edinburgh (1 parent group and 1 informal caregiver group in each city). Data were audio recorded, transcribed verbatim and analysed using a thematic approach. RESULTS: The significance of informal care to parents, carers, and society was recognised (theme one). Informal carers were identified to have practical and emotional support roles for the parents (theme two). Informal care was perceived to contribute to childhood obesity in four ways (theme three): cross-generation conflict preventing adoption of healthy practices; the trade-off for parents between receiving childcare and maintaining control; reduced energy capacity of carers; and increased snacking. Potential intervention ideas and delivery strategies (theme four) were identified. Examples of identified ideas included providing carers with up-to-date weaning advice, and suggestions of healthy snacks and ways to increase physical activity level in informal care. The suggestion of utilising existing primary care platforms (e.g. health visitor check-ups) to reach and deliver low-cost information based interventions, to all children aged 0-5 years who receive informal care, was highlighted. CONCLUSIONS: This exploratory qualitative study provided novel insights into potential explanations for the evidenced link between informal care and childhood obesity in children aged 0-5 years, despite a small size and limited participants in each focus group. Our findings support the idea of and inform the development towards an information based and low-cost intervention delivered through existing primary care platforms.

What Predicts Online Health Information-Seeking Behavior Among Egyptian Adults? A Cross-Sectional Study.

BACKGROUND: Over the last decade, the Internet has become an important source of health-related information for a wide range of users worldwide. Yet, little is known about the personal characteristics of Egyptian Internet users who search for online health information (OHI). OBJECTIVE: The aim of the study was to identify the personal characteristics of Egyptian OHI seekers and to determine any associations between their personal characteristics and their health information-seeking behavior. METHODS: This cross-sectional questionnaire study was conducted from June to October 2015. A Web-based questionnaire was sent to Egyptian users aged 18 years and older (N=1400) of a popular Arabic-language health information website. The questionnaire included (1) demographic characteristics; (2) self-reported general health status; and (3) OHI-seeking behavior that included frequency of use, different topics sought, and self-reported impact of obtained OHI on health behaviors. Data were analyzed using descriptive statistics and multiple regression analysis. RESULTS: A total of 490 participants completed the electronic questionnaire with a response rate equivalent to 35.0% (490/1400). Regarding personal characteristics, 57.1% (280/490) of participants were females, 63.4% (311/490) had a university level qualification, and 37.1% (182/490) had a chronic health problem. The most commonly sought OHI by the participants was nutrition-related. Results of the multiple regression analysis showed that 31.0% of the variance in frequency of seeking OHI among Egyptian adults can be predicted by personal characteristics. Participants who sought OHI more frequently were likely to be female, of younger age, had higher education levels, and good self-reported general health. CONCLUSIONS: Our results provide insights into personal characteristics and OHI-seeking behaviors of Egyptian OHI users. This will contribute to better recognize their needs, highlight ways to increase the availability of appropriate OHI, and may lead to the provision of tools allowing Egyptian OHI users to navigate to the highest-quality health information.

How Do People With COPD Value Different Activities? An Adapted Meta-Ethnography of Qualitative Research.

Chronic Obstructive Pulmonary Disease (COPD) is a long-term condition where activities of daily living (ADLs) may be very restricted; people with COPD need to prioritize what is important to them. We conducted a meta-ethnography to understand which ADLs are valued and why, systematically searching for articles including experiences of ADLs and organizing themes from the articles into five linked concepts: (a) caring for the body, (b) caring for the personal environment, (c) moving between spaces, (d) interacting with others, and (e) selfhood across time. In addition, we identified three key aspects of personal integrity: effectiveness, connectedness, and control. We found that ADLs were valued if they increased integrity; however, this process was also informed by gendered roles and social values. People whose sense of control depended on effectiveness often found accepting help very difficult to bear; therefore, redefining control as situational and relational may help enjoyment of activities that are possible.

Appearance concerns and psychosocial adjustment following head and neck cancer: A cross-sectional study and nine-month follow-up.

Psychosocial difficulties have been reported in head and neck cancer (HNC) patients, yet only few studies have assessed the impact of altered appearance following HNC treatment using theoretically selected measures of appearance-related distress. This study investigated appearance-related adjustment following HNC, and demographic and socio-cognitive predictors of adjustment. HNC patients (n=49) completed baseline questionnaires and a nine-month postal follow-up (n=20). Participants showed considerable variation in appearance-related adjustment, with females reporting higher levels of appearance-related distress (derriford appearance scale [DAS-24]) than females in the general population and male HNC survivors. Depression scores on the hospital anxiety and depression scale were higher than UK norms whilst anxiety was similar to UK norms. There were no significant differences between baseline and follow-up data. Fear of negative evaluation (a central feature of social anxiety) was a significant predictor of appearance-related adjustment at baseline, whilst dispositional optimism was a significant predictor of appearance-related adjustment at baseline and follow-up. Qualitative responses showed themes of appearance and disability, and coping strategies. Findings suggest that appearance-related adjustment post-HNC varies considerably and psychosocial services working with HNC patients should consider this broad pattern of response. Future research to examine the role of socio-cognitive predictors of appearance-related adjustment could progress development of effective psychological interventions.

"Will anybody listen?" parents' views on childhood asthma care: a qualitative study.

BACKGROUND: Asthma is the most common chronic disease in children, resulting in considerable morbidity and health care utilisation, especially in geographical areas with high deprivation. Parents play a pivotal role in children's asthma management. AIM: To explore the views of parents whose children have asthma, regarding barriers and facilitators to receiving adequate asthma care. DESIGN & SETTING: A qualitative study conducted in an urban, multi-ethnic setting with high socioeconomic deprivation and paediatric asthma related hospital admissions. METHOD: The study used a pragmatic approach underpinned by a perspective of critical realism. Parents of children with asthma were recruited through purposive and convenience sampling and data collected through semi-structured interviews. Transcripts were analysed using thematic analysis, facilitated by NVivo software. RESULTS: 10 parents participated in nine interviews. Six themes were identified relating to: (1) the establishment of a new life dynamic following a diagnosis of asthma; (2) the turbulent and drawn-out process of asthma diagnosis; (3) the roles and expectations of the partnership established between parents and healthcare services; (4) the importance of schools in asthma management; (5) sources and access to relevant information; and (6) the importance of social support networks. Parents frequently felt unsupported and misunderstood, particularly during the diagnostic process. CONCLUSION: Unmet parental educational and emotional needs, particularly around the time of diagnosis were identified as a key barrier to adequate asthma management. Deeper understanding of gaps in support can instruct asthma care delivery and inform co-produced interventions, thus improving asthma outcomes in children.

A qualitative study exploring the lived experiences of patients living with mild, moderate and severe frailty, following hip fracture surgery and hospitalisation.

It is well recognised that hip fracture surgery is associated with a negative impact on short and long-term post-operative physical health and emotional well-being for patients. Furthermore, these patients are known to be frail with multiple co-morbidities. This study explores how frailty shapes the lived experiences of rehabilitation and recovery for patients who have undergone hip fracture surgery. Semi-structured interviews were conducted with sixteen participants, recently discharged from hospital following hip fracture surgery. Interpretative phenomenological analysis was applied to explore the lived experiences of frail patients and ascertain important themes. Patient experiences were captured in seven overarching themes: 1) the hospital as a place of "safety", 2) placing trust in others, 3) the slow recovery journey impeded by attitude and support, 4) maintaining autonomy and dignity whilst feeling vulnerable, 5) seeking a new normal, 6) loneliness and social isolation and 7) the ageing body. Based on our study findings, we have been able to suggest a number of opportunities to improve support for frailer patients in finding a new routine to their everyday lives, these include on-going physical and psychological support, information and education and a robust pathway for transition of care into the community. A conceptual thematic diagram is presented which helps to understand the experience and the complex needs of frail older people undergoing hip fracture surgery.

Concerns and expectations in women with polycystic ovary syndrome vary across age and ethnicity: findings from PCOS Pearls Study.

Objective: To understand and explore the perceptions and opinions of women with polycystic ovary syndrome (PCOS) and further delineate the variations across age and ethnicity. Design: Qualitative survey focussed on lived experiences of people with PCOS. Participants could share their views either as written text or as voice note audio recording(s) on WhatsApp. The data from the audio were transcribed verbatim. Responses were coded by two study members independently, using a thematic inductive method with NVivo 12. Two senior study members then reviewed these codes to identify common themes. Subjects: Women with PCOS aged 18-60 years. Results: 43 of 45 participants had a formal diagnosis of PCOS, the remaining two had suspected PCOS which was under investigation. Four participants opted to share their views as voice note recordings. Poor mental health was the most reported (83.3% of participants), followed by dermatological (81.0%) and menstrual issues (76.2%). Participants were generally dissatisfied with the care they received (88.1%). A lengthy diagnostic journey was reported in 35.7% of cases. 52.6% felt less feminine, particularly regarding weight gain and infertility. As part of the recommendations by participants, it was emphasised that others with the condition should educate themselves and be proactive in their management. 46.3% reported that being more enlightened regarding their condition improved their health outcomes and enabled them to advocate for their own care. Women in their 20s expressed distress due to poor mental health, needing a longer time to get the diagnosis, and having weight and eating concerns. While women with PCOS in their 30s discussed their menstrual irregularities and fertility issues, those in their 40s expressed their concerns about the societal expectations of women when diagnosed with PCOS. The concerns varied across ethnicities as well. Conclusion: PCOS has wide-ranging consequences for women living with the condition, with many dissatisfied with the clinical support they currently receive. The concerns and expectations vary across ages and ethnicities. Therefore, we propose involving women with PCOS to co-create clinical and educational resources informed by lived experiences to provide end-user-informed services.

Pharmacist management of atrial fibrillation in UK primary care: a qualitative study.

BACKGROUND: Atrial fibrillation (AF) affects up to 2% of the UK population. AF is a potentially long-term condition that needs management, and as such primary care pharmacists may have a substantial role in supporting the management of AF. OBJECTIVES: This study aims to explore the role of primary care pharmacists, working in community pharmacies and general practices (GPs), in supporting the management of AF. Furthermore, this study investigates pharmacists' confidence in their knowledge and their attitudes towards incorporating AF-associated mobile apps use into their current practice. METHODS: A qualitative study was conducted, using one-to-one semi-structured, audio-recorded interviews with primary care pharmacists. The topic guide was developed based on pharmacy visits and included the most relevant constructs from the 'consolidated framework for implementation research (CFIR)'. All interviews were audio-recorded, transcribed verbatim and thematically analysed until saturation was achieved, guided by Braun and Clarke's 6-step research method. This study was given a favourable opinion on 5 September 2019 by the University of Birmingham (UOB) Research Ethics Committee (Reference ERN_19-0908). RESULTS: Thematic saturation was achieved after 11 interviews with primary care pharmacists (seven community pharmacists, and four GP pharmacists). Three main themes emerged relating to (1) the clinical role of pharmacists in the management of AF; (2) knowledge and awareness; and (3) prioritisation of resources. The first highlighted that primary care pharmacists were an underutilised resource within AF management. The second demonstrated that pharmacists, especially those based in the community, felt a lack of confidence in their knowledge of AF and its management, mainly community pharmacists due to other roles taking precedence over clinical roles. Both community and GP pharmacists expressed the need to have further training in this therapeutic area to be able to effectively support patients with AF. The third shed light on the pharmacists' views relating to the technological revolution in healthcare. Pharmacists expressed an interest in using apps to support their current practice. CONCLUSIONS: Primary care pharmacists supported an extended care to AF management from screening to consultations, yet the provision of such services remains limited and inconsistent. Future research should focus on understanding the ways in which pharmacists' role can be adapted toward greater involvement in clinical care.

The Attitudes of Egyptian Web-Based Health Information Seekers Toward Health Information Provided Through the Internet: Qualitative Study.

BACKGROUND: The internet has become an established source of health information for many Egyptian internet users. Understanding users' attitudes toward the benefits and limitations of web-based health information will explain the influence of this information on users' health-related behavior and decisions. OBJECTIVE: This qualitative study aims to understand the attitude of Egyptian internet users toward internet health information and to explore the impact of obtained health information on users' behavior and on their physician-patient relationship. METHODS: For this qualitative study, semistructured interviews were conducted with a total of 49 participants (41/49, 84% Egyptian internet users and 8/49, 16% physicians) who participated in focus groups or individual interviews. We used a thematic analysis approach to explain and demonstrate participants' views, thoughts, and experiences in using web-based health information. RESULTS: The internet has become an important source of health information in comparison with other health information sources and is the central theme that has emerged across the thematic analysis. The attitude toward the use of internet health was classified into three main themes: feeling toward web-based health information (with subthemes: favoring, disliking, neutral, or having ambivalence feelings), motivators to seek internet health information, and behavioral changes using internet health information (subthemes: confidence, satisfaction, and improved knowledge). Themes that emerged from physicians' interviews included the accessibility of the internet health information, good communication, and coordination of care between patients and their physicians, and the active engagement of patients with their management plan. CONCLUSIONS: The internet has become an essential source of health information for Egyptian adults. Internet health information can improve the patient-physician relationship, especially when users discuss the obtained health information with their physician. Internet health information provided seekers with social support and self-confidence when making health decisions.

A systematic review of lived experiences of people with polycystic ovary syndrome highlights the need for holistic care and co-creation of educational resources.

Introduction: PCOS-related literature is mostly dominated by the medical perspective. However, the condition's lifelong, far reaching, and multifaceted impacts highlight the importance to gain the perspectives from those with PCOS. Therefore, we performed a systematic review to explore the current literatures and gaps around the experiences and perceptions of those living with PCOS. Method: A comprehensive search of seven electronic databases was conducted between July and October 2021. A total 34 from 1615 screened articles were included in this systematic review and subsequently coded using NVivo 12 software. The quality of individual studies was assessed by adaptation to the Critical Appraisal Skills Program (CASP) quality assessment tool. Results: Five domains were generated from the data: Signs/Symptoms, Diagnosis, Management, Perceptions, Resources and Improving Outcomes. Dissatisfaction surrounding the experience of diagnosis was common. Concerns surrounded perceived lack of knowledge from healthcare professionals and delays in diagnosis. Individual studies on adults and adolescents shared similar feelings. The consensus was found to be that current management was vague and generalised. Symptoms such as hirsutism, obesity, irregular menstruation challenge personal and societal expectations of femininity. Online PCOS resources are popular amongst those with PCOS but most of them lack evidence. A call for more culturally specific resources was found to be common ground amongst those with PCOS. Conclusion: Overall dissatisfaction amongst adults and adolescents regarding their diagnostic journey of PCOS. Tailored and culturally specific PCOS advice and management is necessary and can be achieved through co-creation of resources between healthcare professionals and those with PCOS. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42021272371.

"They're made in factories and not by witches on the allotment": a qualitative study of midlife women in the united kingdom, exploring their approaches to complementary and alternative medicines.

This article explores midlife women's experiences and approaches related to complementary and alternative therapies (CAMS). Ninety-six midlife women were asked about their use of CAMs as part of their overall approach to midlife health. Qualitative thematic analysis was combined with a case-based approach. Women set their experience of CAMs in the context of conventional medicine taking and discussed their safety and different uses. For treatments requiring direct contact with a practitioner, accessibility and quality of the relationship were crucial. Four overall approaches could be discerned (political-critical, pragmatic, careful and wellbeing-oriented) that dynamically interacted with women's experiences.

Oral and maxillofacial surgery and chronic painful temporomandibular disorders--a systematic review.

PURPOSE: To provide a systematic review of the best available research literature investigating the relation of oral and maxillofacial surgical procedures to the onset or relief of chronic painful temporomandibular disorder (TMD). MATERIALS AND METHODS: A comprehensive review of the databases CINAHL, Cochrane Library, Embase, Medline, NHS Evidence--Oral Health, PsycINFO, Web of Knowledge, and MetaLib was undertaken by 2 authors (P.S., M.H.) up to June 2009 using search terms appropriate to establishing a relation between orofacial surgical procedures and TMD. The search was restricted to English-language publications. RESULTS: Of the 1,777 titles reviewed, 35 articles were critically appraised but only 32 articles were considered eligible. These were observational studies that fell into 2 groups; 9 were seeking to establish a surgical cause for TMD. Of these, only 2 of a series of 3 claimed that there was a significant link, but this claim was based on weak data (health insurance records) and was abandoned in a subsequent report. Twenty-three studies were seeking to achieve relief by orthognathic surgical intervention. These were also negative overall, with 7 articles showing varying degrees of mostly nonsignificant improvement, whereas 16 showed no change or a worse outcome. No published report on the putative effect of implant insertion was found. CONCLUSION: These apparently contradictory approaches underline a belief that oral surgical trauma or gross malocclusion has a causative role in the onset of TMD. However, there was no overall evidence of a surgical causal etiology or orthognathic therapeutic value. This review emphasizes that it is in the patients' best interest to carry out prospective appropriately controlled randomized trials to clarify the situation.

Developing evidence for how to tailor medical interventions for the individual patient.

We aim to answer the question: How can we develop an evidence base that will assist tailoring health interventions to individual patients? Using social theory and interview data from people living with chronic illness, we developed a new approach to analysis. Individuals were considered as emergent complex systems, adjusting and adapting within their environment and sometimes transforming. The notion of illness trajectory brought our attention to data in the interviews about the "emergent present," the current period of time when all domains of life, from across time, have expression. We summarized patterns of adjustment and adaptation within the emergent present for people living with chronic back pain, depression, and diabetes. We considered the potential of this analysis approach to inform medical decision making. Our analysis approach is the first step in developing a categorization of individuals that might be useful in tailoring health care interventions to the individual.

Women's experiences of severe postnatal psychiatric illness: a systematic review protocol.

BACKGROUND: Super diversity has become a twenty-first-century phenomena in the UK. The Five Year Forward View Plan for Mental Health commits to improving access to Perinatal Mental Health services for all new mothers. Existing research indicates various postnatal mental illness aetiologies, traditional practices and beliefs, which are important to explore during medical consultation to achieve a collaborative relationship between the patient and clinician. The study of severe postnatal psychiatric illnesses is well established in the quantitative literature; however, the subjective experiences of mothers with severe psychiatric illnesses after childbirth have been given little attention. The aim of this systematic review is to synthesise the small body of qualitative findings, which will achieve a deeper understanding of mothers' experiences and understandings. This integration of qualitative data is invaluable in facilitating culturally competent strategies in Western settings and informing future research. METHODS/DESIGN: This protocol proposes a systematic review of qualitative literature of severe postnatal psychiatric illnesses, using a meta-ethnography approach following the PRISMA-P guidelines. A comprehensive search strategy will be developed to undertake a systematic search via online databases to identify eligible articles. Studies will be considered for eligibility if they include mothers aged 18 and over who have been diagnosed with a severe psychiatric illness during the postnatal period; present primary data on women's illness experiences; use qualitative methods. Titles and abstracts will be screened by the primary reviewer to identify potential papers. Two independent reviewers will access and read texts in full and agree on the final list of included studies. Discrepancies will be resolved via consultation with a third independent reviewer. The final list of included studies for review will be methodologically appraised by two independent reviewers using the Critical Appraisal Skills Programme. This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42018093674. DISCUSSION: To date, no systematic review following a meta-ethnographic approach on qualitative explorations of mothers worldwide diagnosed with severe postnatal psychiatric illnesses has been conducted. An amalgamation of this information enables a deeper understanding of how severe postnatal psychiatric illnesses manifests across cultures. This information is useful when devising culturally competent care. SYSTEMATIC REVIEW REGISTRATION: CRD42018093674.

Understanding the lived experiences of severe postnatal psychiatric illnesses in English speaking South Asian women, living in the UK: a qualitative study protocol.

INTRODUCTION: The South Asian population is the UK's largest and fastest growing minority ethnic group. There is evidence to suggest the lay understanding of postnatal psychiatric illnesses of this group may fall outside the purview of Western biomedical perspectives. Alternative explanations include psychosocial, cultural and spiritual factors. Approaching psychiatric illnesses through a social perspective includes gaining insight to the patient's subjective experiences and understandings via qualitative inquiry. The objectives of this qualitative study are to explore South Asian women's narrative of living with a severe postnatal psychiatric illness and experiences of Perinatal Mental Health Services, care and support. METHODS AND ANALYSIS: Data collection is ongoing and will continue until 31 December 2018. Participants will be identified and recruited from Perinatal Mental Health Services in Birmingham and London. Eligible participants will be English speaking South Asian females aged 18 years or above with the capacity to give written informed consent. Participants are clinically diagnosed with a severe postnatal psychiatric illness. This qualitative study uses individual in-depth face-to-face interviews that aim to last 1 hour. Interviews will be audio recorded with participants' permission. Interview audio recordings will be transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). The primary goal of IPA is for the researcher to closely study and interpret how individuals make sense of their life experiences in a particular context by drawing on the fundamental principles of phenomenology, hermeneutics and idiography. ETHICS AND DISSEMINATION: The University of Birmingham, the South Birmingham Research Ethics Committee and the Health Research Authority have approved this study (approvals date: 18-12-2017 ref: 17/WM/0350). Local capability and capacity have been confirmed from Trust Research and Development departments. The researchers plan to publish the results from this study in journals and present findings at academic conferences.