Evaluating the effects of a multicomponent support service for people recently diagnosed with dementia and their carers: A qualitative study.

INTRODUCTION: Although prior research has provided an understanding of the needs of people living with dementia (PLWD) and their carers, less is known about how tailored multicomponent interventions impact their lives. This study explored the effect of providing ongoing support to people who had been recently diagnosed with dementia and to their carers. METHODS: We conducted interviews with a convenience sample of key stakeholders: 11 interviews with people who had dementia and their familial carers (n = 14) and six interviews with staff and other practitioners involved with the service (n = 13). Inductive thematic analysis was performed on the data. RESULTS: Four themes were developed: the service as a source of respite, peer support, activities as facilitators of emotional wellbeing, and social support. The service was well-respected, credible, and trusted and was highly valued by practitioners, clients, and carers. It had a clear role in supporting PLWD and their carers. Peer support provided through the service contributed to greatly reducing self-reported carer burden. CONCLUSION: Recommendations arising from this study include offering holistic services to PLWD and their carers, developing activities for men, raising awareness of services among practitioners working with PLWD, and improving partnerships between services and agencies working with older people. PATIENT OR PUBLIC CONTRIBUTION: Service users were consulted on the themes generated from the data and were asked to provide feedback to help guide the interpretation of the data and ensure this reflected their views and experiences.

Talking about depression during interactions with GPs: a qualitative study exploring older people's accounts of their depression narratives.

BACKGROUND: Older people can struggle with revealing their depression to GPs and verbalising preferences regarding its management. This contributes to problems for GPs in both detecting and managing depression in primary care. The aim of this study was to explore older people's accounts of how they talk about depression and possible symptoms to improve communication about depression when seeing GPs. METHODS: Adopting a qualitative Interpretivist methodological approach, semi-structured interviews were conducted by IG based on the principles of grounded theory and situational analysis. GPs working in north east England recruited patients aged over 65 with depression. Data analysis was carried out with a process of constant comparison, and categories were developed via open and axial coding and situational maps. There were three levels of analysis; the first developed open codes which informed the second level of analysis where the typology was developed from axial codes. The typology derived from second level analysis only is presented here as older people's views are rarely reported in isolation. RESULTS: From the sixteen interviews with older people, it was evident that there were differences in how they understood and accepted their depression and that this influenced what they shared or withheld in their narratives. A typology showing three categories of older people was identified: those who appeared to talk about their depression freely yet struggled to accept aspects of it (Superficial Accepter), those who consolidated their ideas about depression aloud (Striving to Understand) and those who shared minimal detail about their depression and viewed it as part of them rather than a treatable condition (Unable to Articulate). The central finding was that older people's acceptance and understanding of their depression guided their depression narratives. CONCLUSIONS: This study identified differences between older people in ways they understand, accept and share their depression. Recognising that their depression narratives can change and listening for patterns in what older people share or withhold may help GPs in facilitating communication to better understand the patient when they need to implement alternative approaches to patient management.

Habitus of home and traditional drinking: a qualitative analysis of reported middle-class alcohol use.

There is evidence that alcohol consumption among those in middle-class occupations consistently exceeds safe levels, yet there has been little research into why this occurs. This article explores the meanings associated with alcohol use among professional, managerial and clerical workers. Qualitative data were collected from five focus groups of male and female employees aged 21-55 (N =49: 32 male, 17 female). Each focus group was conducted on the premises of a medium-scale or large-scale employer, four public sector and one private sector, in the north-east of England. Using Bourdieu's concepts of 'habitus', 'capitals' and 'fields' we found that, among these middle-class occupational groups, alcohol use was associated with two habitus: a 'home drinking' habitus and a 'traditional drinking' habitus. Those of the home drinking habitus particularly used wine as a source of cultural capital and a means of distinction, whereas those in the traditional habitus consumed lager, beer and spirits to have fun in social settings. A small minority appeared to belong to a third, omnivorous, habitus where a wide range of alcoholic drinks were consumed in a variety of contexts. Existing public health initiatives to reduce alcohol consumption may require modification to accommodate a range of drinking cultures.

The 'other' in patterns of drinking: a qualitative study of attitudes towards alcohol use among professional, managerial and clerical workers.

BACKGROUND: Recent evidence shows that workers in white collar roles consume more alcohol than other groups within the workforce, yet little is known about their views of drinking. METHODS: Focus groups were conducted in five workplaces to examine the views of white collar workers regarding the effect of alcohol use on personal and professional lives, drinking patterns and perceived norms. Analysis followed the method of constant comparison. RESULTS: Alcohol use was part of everyday routine. Acceptable consumption and 'excess' were framed around personal experience and ability to function rather than quantity of alcohol consumed. Public health messages or the risk of adverse health consequences had little impact on views of alcohol consumption or reported drinking. CONCLUSIONS: When developing public health alcohol interventions it is important to consider the views of differing groups within the population. Our sample considered public health messages to be of no relevance to them, rather they reinforced perceptions that their own alcohol use was controlled and acceptable. To develop effective public health alcohol interventions the views of this group should be examined in more detail.

Patient experience of infertility management in primary care: an in-depth interview study.

BACKGROUND: GPs do not have a full range of diagnostic resources to help manage infertile couples. Little is known about the patient experience of infertility management in primary care. OBJECTIVE: To explore the patient experience of infertility management from a primary care perspective. METHODS: This was a nested qualitative study with infertile couples in North-East England. In-depth interviews of infertile couples identified in the course of an observational study describing the incidence, prevalence, referral patterns and pregnancy outcomes for infertile couples. A grounded approach was used, with the interviews and analysis proceeding together using the method of constant comparison. Emergent themes and their links gave an overall explanation to the interview data. RESULTS: We interviewed 22 patients in 13 interviews. Factors that influenced a couple's experience of infertility management were personal and professional relationships, patient autonomy in decision making and access to services. CONCLUSIONS: This study provides insights into the experiences of infertile couples seeking assisted reproduction from their GP. A good experience was linked to a strong personal relationship, a patient-centred professional relationship fostering informed decision making by the couple, GPs using diagnostic resources, interpreting restrictive clinical and social criteria and referring appropriately.

Triggers for weight gain and loss among participants in a primary care-based intervention.

Numerous studies have sought to investigate the causes of obesity and the effectiveness of interventions for its treatment. However, there is little published evidence to describe patients' experiences of becoming and being obese. This paper reports on a qualitative study to explore the views and experiences of patients who had recently completed a primary care-based weight management intervention. Weight gain was often attributed to life events that caused changes in appetite and activity levels, rather than directly attributed to over-eating or inactivity. Triggers to help-seeking included health concerns, image factors and past experiences of stigmatization. Personalized messages and ongoing support from professionals and peers were identified as facilitators to successful weight management. This paper has implications for the role of primary and community care staff in the prevention, treatment and management o obesity, in terms of supporting patients through significant life events and encouraging them to access services.

General practitioners' perceptions and attitudes to infertility management in primary care: focus group study.

BACKGROUND: Infertility management in primary care is variable. National Institute of Clinical Excellence have recommended hysterosalpingography (HSG) as a first-line investigation for tubal assessment. Aim To explore general practitioners' (GPs) perceptions of, and attitudes to, the initial management of the infertile couple and their views on open access to HSG. DESIGN: Qualitative study using three focus groups. SETTING: Seven general practices in Newcastle upon Tyne and Northumberland. SUBJECTS: We purposively selected the three focus groups to provide a range of GPs' views. In total 13 practitioners participated: 11 GPs, one GP registrar and one nurse practitioner. RESULTS: The key themes to emerge were: (1) perceived professional responsibilities, (2) uncertainty and lack of knowledge, (3) consistency of approach to the initial management of infertility, and (4) access to infertility services. Some GPs felt that they should do all they possibly could, while others felt it was the responsibility of the infertility specialist. Uncertainty and lack of knowledge was linked to the relative infrequency of primary care infertility consultations and the difficulty 'keeping up to date' with rapidly advancing reproductive technologies in tertiary care. Some GPs subscribed to the notion of one suitably trained clinician delivering the service on behalf of a group of GPs. Some were unsure where HSG fitted into the overall management plan, but they were comfortable with following recommended guidelines. CONCLUSIONS: GPs recognize an advocacy role and many take on a significant degree of clinical responsibility welcoming the introduction of a new technology in primary care. Nevertheless, GPs feel that they lack proficiency and have little opportunity to rehearse the necessary skills. These findings contribute to an understanding of the management of infertility, an infrequently presenting problem in primary care.

Exploring the Role of Key Workers in Cancer Care: Patient and Staff Perspectives.

PURPOSE/AIMS: The key worker role in cancer services was established in England to improve the continuity of care for patients. We examined how the role has been implemented by clinical nurse specialists and how both cancer patients and nursing staff viewed its effectiveness to inform debate about the transfer of patients between clinical nurse specialists during cancer care. DESIGN: This study was questionnaire based, with separate surveys developed for patients and staff. METHOD: The questionnaires explored issues including implementation of the key worker role, modifications to it, and where the role was felt to have most impact. The questionnaires were completed by 101 staff members and 46 patients. The data were analyzed descriptively. RESULTS: Perspectives on the key worker role differed between nursing staff respondents and patient respondents. Overall, patient respondents were very positive, whereas staff respondents were less so. The following is a key difference related to patient handover: 71% of patient respondents wanted the same key worker throughout their treatment, but only 28% of staff respondents did. Staff respondents wanted more training to clarify the role. CONCLUSION: Continuity of care through an assigned key worker was highly valued by patients. Successful implementation could be better achieved through improved communication with both nursing staff and allied health professions. Where possible, cancer patients should be assigned a dedicated key worker at initial diagnosis.

A Qualitative Study of Service Provision for Alcohol Related Health Issues in Mid to Later Life.

AIMS: Epidemiological surveys over the last 20 years show a steady increase in the amount of alcohol consumed by older age groups. Physiological changes and an increased likelihood of health problems and medication use make older people more likely than younger age groups to suffer negative consequences of alcohol consumption, often at lower levels. However, health services targeting excessive drinking tend to be aimed at younger age groups. The aim of this study was to gain an in-depth understanding of experiences of, and attitudes towards, support for alcohol related health issues in people aged 50 and over. METHODS: Qualitative interviews (n = 24, 12 male/12 female, ages 51-90 years) and focus groups (n = 27, 6 male/21 female, ages 50-95 years) were carried out with a purposive sample of participants who consumed alcohol or had been dependent. FINDINGS: Participants' alcohol misuse was often covert, isolated and carefully regulated. Participants tended to look first to their General Practitioner for help with alcohol. Detoxification courses had been found effective for dependent participants but only in the short term; rehabilitation facilities were appreciated but seen as difficult to access. Activities, informal groups and drop-in centres were endorsed. It was seen as difficult to secure treatment for alcohol and mental health problems together. Barriers to seeking help included functioning at a high level, concern about losing positive aspects of drinking, perceived stigma, service orientation to younger people, and fatalistic attitudes to help-seeking. Facilitators included concern about risk of fatal illness or pressure from significant people. CONCLUSION: Primary care professionals need training on improving the detection and treatment of alcohol problems among older people. There is also a compelling need to ensure that aftercare is in place to prevent relapse. Strong preferences were expressed for support to be provided by those who had experienced alcohol problems themselves.

Alcohol service provision for older people in an area experiencing high alcohol use and health inequalities.

BACKGROUND: UK society is ageing. Older people who drink alcohol, drink more than those from previous generations, drink more frequently than other age groups and are more likely to drink at home and alone. Alcohol problems in later life however are often under-detected and under-reported meaning older people experiencing alcohol problems have high levels of unmet need. METHODS: This study sought to identify existing services within South of Tyne, North East England to capture the extent of service provision for older drinkers and identify any gaps. The Age UK definition of 'older people' (aged 50 and over) was used. Services were contacted by telephone, managers or their deputy took part in semi-structured interviews. FINDINGS: Forty six service providers were identified. Only one provided a specific intervention for older drinkers. Others typically provided services for age 18+. Among providers, there was no definitive definition of an older person. Data collection procedures within many organisations did not enable them to confirm whether older people were accessing services. Where alcohol was used alongside other drugs, alcohol use could remain unrecorded. CONCLUSION: To enable alcohol services to meet the needs of older people, greater understanding is needed of the patterns of drinking in later life, the experiences of older people, the scale and scope of the issue and guidance as to the most appropriate action to take. An awareness of the issues related to alcohol use in later life also needs to be integrated into commissioning of other services that impact upon older people.

Patterns of engagement between GPs and adolescents presenting with psychological difficulties: a qualitative study.

BACKGROUND: Psychological difficulties are common in adolescence with general practice attendees having higher rates than reported in community surveys. Yet GP identification of common mental health problems in this age group is limited. Anxiety and uncertainty around professional practice have been found among GPs and they vary in their degree of engagement with adolescents presenting with psychological difficulties. AIM: To explore which factors influence the degree of GP engagement. DESIGN AND SETTING: Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities. METHOD: Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis. RESULTS: In total 19 GPs were recruited: 10 were female, the age range was 29-59 years, with a modal range of 40-49 years. The participants collectively described a sense of their professional competence being challenged, yet reacted with varying degrees of engagement. Three themes appeared to shape a GP's response: performance in the clinical encounter; view of adolescents and their health needs; and the GP's own preferred epistemological framework. CONCLUSION: The findings suggest that better patterns of engagement between GPs and adolescents are supported by medical education which includes input and feedback from adolescents; education about the science and psychology of adolescence; more effective working across disciplinary boundaries; and recognition of the importance of addressing psychological difficulties early.

GPs' responses to adolescents presenting with psychological difficulties: a conceptual model of fixers, future planners, and collaborators.

BACKGROUND: Psychological difficulties are common in adolescents yet are not often addressed by GPs. Anxiety and uncertainty about professional practice, with a reluctance to medicalise distress, have been found among GPs. GP involvement in this clinical area has been shown to be influenced by how GPs respond to the challenges of the clinical consultation, how they view young people and their perception of their health needs, and a GP's knowledge framework. AIM: To explore the relationship between the above three influences to develop an overarching conceptual model. DESIGN AND SETTING: Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities. METHOD: Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis. RESULTS: In total 19 GPs were recruited: 10 were female, the age range was 29-59 years, with a modal range of 40-49 years. Three levels of analysis were undertaken. This study presents the final stage of analysis. GP 'enactment of role' was found to be the key to explaining the relationship between the three influencing factors. Three role archetypes were supported by the data: 'fixers', 'future planners', and 'collaborators'. CONCLUSION: The role of GPs in managing adolescent psychological difficulties is unclear. Policy advocates a direct role but this is unsupported by education and service delivery. GPs adopt their own position along a continuum, resulting in different educational needs. Better preparation for GPs is required with exploration of new, more collaborative models of care for troubled adolescents.

Intervention to reduce excessive alcohol consumption and improve comorbidity outcomes in hypertensive or depressed primary care patients: two parallel cluster randomized feasibility trials.

BACKGROUND: Many primary care patients with raised blood pressure or depression drink potentially hazardous levels of alcohol. Brief interventions (BI) to reduce alcohol consumption may improve comorbid conditions and reduce the risk of future alcohol problems. However, research has not established their effectiveness in this patient population. This study aimed to establish the feasibility of definitive trials of BI to reduce excessive drinking in primary care patients with hypertension or mild to moderate depression. METHODS: Thirteen general practices in North East England were randomized to the intervention or control arm of one of two parallel pilot trials. Adult patients drinking excessively and diagnosed with hypertension or mild-to-moderate depression received the Alcohol Use Disorders Identification Test (AUDIT) by postal survey. Consenting respondents scoring more than 7 on AUDIT (score range 0 to 40) received brief alcohol consumption advice plus an information leaflet (intervention) or an information leaflet alone (control) with follow-up at six months. Measurements included the numbers of patients eligible, recruited, and retained, and the AUDIT score and systolic/diastolic blood pressure of each patient or the nine-item Patient Health Questionnaire (PHQ-9) score. Acceptability was assessed via practitioner feedback and patient willingness to be screened, recruited, and retained at follow-up. RESULTS: In the hypertension trial, 1709 of 33,813 adult patients (5.1%) were eligible and were surveyed. Among the eligible patients, 468 (27.4%) returned questionnaires; 166 (9.6% of those surveyed) screened positively on AUDIT and 83 (4.8% of those surveyed) were recruited (50.0% of positive screens). Sixty-seven cases (80.7% of recruited patients) completed follow-up at six months. In the depression trial, 1,044 of 73,146 adult patients (1.4%) were eligible and surveyed. Among these eligible patients, 215 (20.6%) responded; 104 (10.0% of those surveyed) screened positively on AUDIT and 29 (2.8% of those surveyed) were recruited (27.9% of positive screens). Nineteen cases (65.5% of recruited patients) completed follow-up at six months. CONCLUSIONS: Recruitment and retention rates were higher in the hypertension trial than in the depression trial. A full brief intervention trial appears feasible for primary care patients with hypertension who drink excessively. High AUDIT scores in the depression trial suggest the importance of alcohol intervention in this group. However, future work may require alternative screening and measurement procedures. TRIAL REGISTRATION: Current Controlled Trials ISRCTN89156543; registered 21 October 2013.

"I think this is maybe our Achilles heel..." exploring GPs' responses to young people presenting with emotional distress in general practice: a qualitative study.

OBJECTIVE: An exploratory study to investigate general practitioners' (GPs') views and experiences of consulting with young people (aged 12-19 years) presenting with emotional distress in general practice. DESIGN: A qualitative study using grounded theory and situational analysis. Empirical data were generated through in-depth interviews based on a topic guide developed from the literature, and augmented with a series of situational maps. Continuous field notes and theoretical memos were recorded during data collection and analysis. The data were analysed using the constant comparative method of grounded theory. There were three levels of analysis. The first level developed the open codes and is presented here. SETTING: 18 general practices located in the north east of England. The practices recruited included rural, urban and mixed populations of patients who were predominantly living in socioeconomically disadvantaged communities. PARTICIPANTS: 19 GPs (10 women) aged between 29 and 59 years participated. The modal age range was 40-49 years. Theoretical sampling was used to guide recruitment and continued until theoretical saturation was reached. RESULTS: The overarching finding was that anxiety about practice dominated clinical consultations involving young people presenting with emotional distress. GPs responded differently to anxiety and to related uncertainties about professional practice, independent of GP age or gender. Anxiety occurred in the consultation, at an external level, across disciplinary boundaries, in relation to communication with young people and secondary to the complexity of presentations. CONCLUSIONS: Adolescent emotional distress presents professional challenges to GPs who feel ill-equipped and inadequately prepared to address early need. Medical education needs to prepare doctors better. More research is needed to look at what factors facilitate or prohibit greater GP engagement with emotionally distressed young people.

A qualitative study of alcohol, health and identities among UK adults in later life.

Increasing alcohol consumption among older individuals is a public health concern. Lay understandings of health risks and stigma around alcohol problems may explain why public health messages have not reduced rates of heavy drinking in this sector. A qualitative study aimed to elucidate older people's reasoning about drinking in later life and how this interacted with health concerns, in order to inform future, targeted, prevention in this group. In 2010 a diverse sample of older adults in North East England (ages 50-95) participated in interviews (n = 24, 12 male, 12 female) and three focus groups (participants n = 27, 6 male, 21 female). Data were analysed using grounded theory and discursive psychology methods. When talking about alcohol use older people oriented strongly towards opposed identities of normal or problematic drinker, defined by propriety rather than health considerations. Each of these identities could be applied in older people's accounts of either moderate or heavy drinking. Older adults portrayed drinking less alcohol as an appropriate response if one experienced impaired health. However continued heavy drinking was also presented as normal behaviour for someone experiencing relative wellbeing in later life, or if ill health was construed as unrelated to alcohol consumption. Older people displayed scepticism about health advice on alcohol when avoiding stigmatised identity as a drinker. Drinking patterns did not appear to be strongly defined by gender, although some gendered expectations of drinking were described. Identities offer a useful theoretical concept to explain the rises in heavy drinking among older populations, and can inform preventive approaches to tackle this. Interventions should engage and foster positive identities to sustain healthier drinking and encourage at the community level the identification of heavy drinking as neither healthy nor synonymous with dependence. Future research should test and assess such approaches.

Patients' views of antidepressants: from first experiences to becoming expert.

BACKGROUND: The majority of patients discontinue antidepressant treatment earlier than prescribed. The factors behind this and the influences on patients' choices about whether to take medication remain poorly understood. AIM: To explore factors that influence patients' decisions about taking antidepressant medication. DESIGN OF STUDY: Qualitative interview study. SETTING: Interviews were conducted across three sites: London, East Lancashire, and North East England. METHOD: Semi-structured interviews were conducted with a purposive sample of 65 primary care patients who were prescribed antidepressants in the past year for depression or mixed anxiety/depression. RESULTS: Participants described their first course of antidepressants as typically occurring when they had 'hit rock bottom', having exhausted all other possibilities; therefore, there was little sense of a positive choice at this stage. There would typically follow a period of experimentation where it was usual to stop and restart medication, often several times. Ultimately, these recurring cycles lead to participants becoming more expert about their condition and better able to make an informed decision about medication. For younger participants, recovery typically remained a goal, although for older people there was often an acceptance that their condition, and medication use, would be long term. CONCLUSION: Participants' accounts demonstrated how they could become expert at managing their condition through a process of trial and error.

Experience of fertility preservation among younger people diagnosed with cancer.

Of the 293,600 cancers diagnosed annually in the UK, 11% occur in the 15- to 49-year age group. Fertility preservation options exist for those faced with the loss of fertility as a consequence of radiotherapy or chemotherapy. The aim of this study was to explore experiences, attitudes and perceptions of fertility advice and treatment among cancer survivors, and the subsequent impact upon their lives. Eighteen people aged 19-42 years with a diagnosis of cancer made more than 5 years earlier and, registered with general practices in North East England, were interviewed using a grounded approach. Survival was the universal focus of patients at the point of diagnosis and they commonly failed to appreciate the effect of treatment upon future fertility. A positive experience was linked to the quality of information about fertility preservation or action offered, but this needed to be tailored to the patients' age, stage in their life course, relationships and fears. Possible loss of future fertility only becomes important beyond survival but patients wanted their potential future fertility addressed sensitively at the time of diagnosis and backed up by access to written or web-based patient information, or a fertility specialist.

Patient and professional views of open access hysterosalpingography for the initial management of infertility in primary care.

BACKGROUND: Hysterosalpingography (HSG) is recommended as a first-line investigation for tubal assessment of infertile women. This investigation is not routinely available to GPs. AIM: To explore the perceptions and attitudes of patients and health professionals to open access HSG for the initial management of infertile couples in general practice. DESIGN OF STUDY: A nested qualitative study using in-depth interviews with GPs, fertility specialists, and infertile couples. SETTING: Northumberland, Newcastle upon Tyne, North Tyneside, South Tyneside, and Gateshead. METHOD: Participants were 39 interviewees: 12 GPs, five fertility specialists, and 13 infertile couples (nine interviewed with their partner). RESULTS: Four themes emerged: personal factors; will it benefit patients, GPs, and fertility specialists?; professional factors; does it fit the role of a GP?; local context; do the skills exist in general practice?; and wider context; will it benefit the NHS? GPs who had used open access HSG, felt it was appropriate for general practice and would continue to use the service. All GPs, fertility specialists, and infertile couples who had experienced open access HSG wished the service to remain in place. The main barriers to its uptake were: infrequency with which infertility presents; lack of clarity on perceived responsibilities; difficulty keeping up to date, including assimilating guidelines; low clinical priority; and lack of support in authoritative guidance. CONCLUSION: Providing GPs with open access to HSG would allow a full initial assessment of the infertile couple and refer women with blocked tubes directly to tertiary care. While there is general support for the provision of such a facility, the majority of GPs perceive its use as being by a limited number of GPs who have a special interest in infertility. The study findings can inform future development of infertility services at the interface between primary and secondary/tertiary care.