Is there an association between socioeconomic status of General Practice population and postgraduate training practice accreditation? A cross-sectional analysis of Scottish General Practices.

BACKGROUND: Practice population socioeconomic status is associated with practice postgraduate training accreditation. General Practitioner recruitment to socioeconomically deprived areas is challenging, exposure during training may encourage recruitment. OBJECTIVES: To determine the association of practice population socioeconomic deprivation score and training status, and if this has changed over time. METHODS: Cross-sectional study looking at socioeconomic deprivation and training status for all General Practices in Scotland (n = 982). Data from Information Services Division, from 2015, were combined with the Scottish Index of Multiple Deprivation to calculate weighted socioeconomic deprivation scores for every practice in Scotland. Scottish training body database identified training practices (n = 330). Mean deprivation score for training and non-training practices was calculated. Logistic regression was used to quantify the odds ratio of training status based on deprivation score, adjusted for practice list size, and compared with a similar 2009 analysis. RESULTS: Socioeconomic deprivation score is associated with training status, but is not significant when adjusted for practice list size [OR (adjusted) 0.87, 95% CI: 0.74-1.04]. In contrast, in 2009, adjusted deprivation score remained significant. Mean deprivation score in training and non-training practices remained similar at both time points [2015: 2.98 (SD 0.88) versus 3.17 (SD 0.81); 2009: 2.95 versus 3.19), with a more deprived mean score in non-training practices. CONCLUSIONS: General practices in affluent areas remain more likely to train, although this association appears to be related to larger practice list sizes rather than socioeconomic factors. To ensure a variety of training environments training bodies should target, and support, smaller practices working in more socioeconomically deprived areas.

Digital Support Interventions for the Self-Management of Low Back Pain: A Systematic Review.

BACKGROUND: Low back pain (LBP) is a common cause of disability and is ranked as the most burdensome health condition globally. Self-management, including components on increased knowledge, monitoring of symptoms, and physical activity, are consistently recommended in clinical guidelines as cost-effective strategies for LBP management and there is increasing interest in the potential role of digital health. OBJECTIVE: The study aimed to synthesize and critically appraise published evidence concerning the use of interactive digital interventions to support self-management of LBP. The following specific questions were examined: (1) What are the key components of digital self-management interventions for LBP, including theoretical underpinnings? (2) What outcome measures have been used in randomized trials of digital self-management interventions in LBP and what effect, if any, did the intervention have on these? and (3) What specific characteristics or components, if any, of interventions appear to be associated with beneficial outcomes? METHODS: Bibliographic databases searched from 2000 to March 2016 included Medline, Embase, CINAHL, PsycINFO, Cochrane Library, DoPHER and TRoPHI, Social Science Citation Index, and Science Citation Index. Reference and citation searching was also undertaken. Search strategy combined the following concepts: (1) back pain, (2) digital intervention, and (3) self-management. Only randomized controlled trial (RCT) protocols or completed RCTs involving adults with LBP published in peer-reviewed journals were included. Two reviewers independently screened titles and abstracts, full-text articles, extracted data, and assessed risk of bias using Cochrane risk of bias tool. An independent third reviewer adjudicated on disagreements. Data were synthesized narratively. RESULTS: Of the total 7014 references identified, 11 were included, describing 9 studies: 6 completed RCTs and 3 protocols for future RCTs. The completed RCTs included a total of 2706 participants (range of 114-1343 participants per study) and varied considerably in the nature and delivery of the interventions, the duration/definition of LBP, the outcomes measured, and the effectiveness of the interventions. Participants were generally white, middle aged, and in 5 of 6 RCT reports, the majority were female and most reported educational level as time at college or higher. Only one study reported between-group differences in favor of the digital intervention. There was considerable variation in the extent of reporting the characteristics, components, and theories underpinning each intervention. None of the studies showed evidence of harm. CONCLUSIONS: The literature is extremely heterogeneous, making it difficult to understand what might work best, for whom, and in what circumstances. Participants were predominantly female, white, well educated, and middle aged, and thus the wider applicability of digital self-management interventions remains uncertain. No information on cost-effectiveness was reported. The evidence base for interactive digital interventions to support patient self-management of LBP remains weak.

Exploring GP work in areas of high socioeconomic deprivation: a secondary analysis.

BACKGROUND: There is a GP workforce crisis, particularly in areas of high socioeconomic deprivation where levels of multimorbidity and social complexity are higher than in areas of low socioeconomic deprivation. How this impacts GP work, and how GPs manage workload has not been fully explored. AIM: To explore GP work in areas of high socioeconomic deprivation and the strategies GPs employ, using Corbin and Strauss's framework on managing chronic illness as an analytical lens. DESIGN & SETTING: Secondary analysis of qualitative in-depth interviews with GPs working with populations experiencing high levels of socioeconomic deprivation. METHOD: Secondary analysis of in-depth interviews with GPs working in areas of high socioeconomic deprivation (n = 10). RESULTS: All three types of work defined by Corbin and Strauss (everyday, illness, and biographical) were described, and one additional type: emotional (work managing GPs' own emotions). The context of socioeconomic deprivation, increased multimorbidity plus social complexity ('multimorbidity plus'), influenced GP work. Healthcare systems and self-management strategies did not meet patients' needs, which meant the resulting gap created extra everyday work, often unrecognised (which was a source of frustration). GPs also described taking on 'illness work' for patients who were either overwhelmed or unable to do it. Some GPs described biographical work, asserting their professional role against demands from patients and other professionals. Work aligning with personal values was important in sustaining motivation; for example, being part of a strong team and having outside professional interests appeared to build resilience. CONCLUSION: GPs working in areas of high socioeconomic deprivation experience different types of work from those working in areas of low socioeconomic deprivation; much of which is unrecognised and not resourced. Current strategies to reduce burnout could be more effective if the complexity of different types of work was addressed. In addition, personal values, practice teams, and outside professional interests all need to be supported.

Exploring the utility of self-determination theory in complex interventions in multimorbidity: A qualitative analysis of patient experiences of the CARE Plus intervention.

OBJECTIVES: CARE Plus is a primary-care-based complex intervention for patients with multimorbidity living in areas of high socioeconomic deprivation. This study explores patients' experience of the intervention and whether self-determination theory is useful to understand reported impacts. METHOD: Thematic analysis of semistructured interviews of 14 participants conducted during a randomised controlled trial of CARE Plus. Improvement in wellbeing in daily lives following CARE Plus was estimated from participants' accounts of their experiences of the intervention. FINDINGS: Participants valued the CARE Plus consultations irrespective of perceived improvements. Six participants reported changes in wellbeing that improved daily life, three reported slight improvement (not impacting daily life) and five no improvement. Evidence of satisfaction of the three major self-determination theory psychological needs - relatedness, competence and autonomy - was prominent in the accounts of those experiencing improved wellbeing in daily life; this group also spoke in ways congruent with more self-determined motivational regulation. These changes were not evident in those with little or no improvement in wellbeing. DISCUSSION: This study suggests self-determination theory has utility in understanding the impact of CARE Plus on patients and may be a useful theory to inform development of future interventions to improve outcomes for patients with multimorbidity.

Child maltreatment and incident mental disorders in middle and older ages: a retrospective UK Biobank cohort study.

BACKGROUND: Understanding the mental health consequences of child maltreatment at different life stages is important in accurately quantifying the burden of maltreatment. This study investigated the association between child maltreatment and incident mental disorders in middle and older age as well as the potential mediators and moderators. METHODS: This is a retrospective cohort study of 56,082 participants from UK Biobank. Child maltreatment was recalled using the Childhood Trauma Screener. Incident mental disorders, including depressive, anxiety and affective disorders, behavioural syndromes, post-traumatic stress disorder (PTSD), schizophrenia, substance abuse, and dementia, after baseline assessment were ascertained through linkage to primary care records. FINDINGS: There was a dose-response relationship between child maltreatment and mental disorder. Those who experienced three or more maltreatment types had the highest risk of all mental disorders (HR 1.85, 95% CI: 1.67-2.06) followed by those who experienced two (HR 1.48, 95% CI: 1.35-1.63) and then one (HR 1.26, 95% CI: 1.19-2.35). Child maltreatment was most strongly associated with PTSD (HR 1.59, 95% CI: 1.20-2.10 P=0.001). The excess risk was largely unexplained by the included mediators. The association between child maltreatment and all mental disorders were stronger among participants who binge drank (Pinteraction=0.003) or had few social visits (Pinteraction=0.003). INTERPRETATION: The mental health consequence of child maltreatment could last decades, even among those who had no recorded mental disorders in early adulthood. In the absence of strong mediators, prevention of child maltreatment remains the priority. FUNDING: Wellcome Trust Institutional Strategic Support Fund.

Association between childhood maltreatment and the prevalence and complexity of multimorbidity: A cross-sectional analysis of 157,357 UK Biobank participants.

BACKGROUND: Child maltreatment is associated with long-term conditions (LTCs) in adulthood. Its relationship to multimorbidity (≥2 LTCs) is less clear. We explore the relationship between child maltreatment, multimorbidity and factors complicating management. METHODS: Cross-sectional analysis of 157,357 UK Biobank participants. Experience of four maltreatment types (physical/sexual/emotional/neglect) was identified. We explored the relationship between type, number and frequency of maltreatment and LTC count (0, 1, 2, 3, ≥4) using multinomial logistic regression. Binary logistic regression assessed the relationship between maltreatment and self-rated health, loneliness, social isolation, frailty and widespread pain in those with multimorbidity, adjusting for sociodemographics and lifestyle factors. RESULTS: 52,675 participants (33%) experienced ≥1 type of maltreatment; 983 (0.6%) experienced all four. Type, frequency and number of types of maltreatment were associated with higher LTC count. People experiencing four types of maltreatment were 5 times as likely to have a LTC count of ≥4 as those experiencing none (odds ratio (OR): 5.16; 99% confidence interval (CI): 3.77-7.07). Greater number of types of maltreatment was associated with higher prevalence of combined physical/mental health LTCs (OR: 2.99; 99% CI: 2.54-3.51 for four types of maltreatment). Compared to people who reported no maltreatment, people experiencing all four types of maltreatment were more likely to have poor self-rated health (OR: 3.56; 99% CI: 2.58-4.90), loneliness (OR: 3.16; 99% CI: 2.17-4.60), social isolation (OR: 1.45; 99% CI: 1.03-2.05), widespread pain (OR: 3.19; 99% CI: 1.87-5.44) and frailty (OR: 3.21; 99% CI: 2.04-5.05). CONCLUSION: Peoplewith a history of maltreatment have higher LTC counts and potentially more complicated management needs reinforcing calls for early intervention.

Using Always Events to derive patient-centred quality improvement priorities in a specialist primary care service providing care to a homeless population.

Background: 'Always Events' (AE) is a validated quality improvement (QI) method where patients, and/or carers, are asked what is so important that it should 'always' happen when they interact with healthcare services. Answers that meet defined criteria can be used to direct patient-centred QI activities. This method has never, to our knowledge, been applied in the care of a UK homeless population. We aimed to test the aspects of the acceptability and feasibility of the AE method to inform on its potential application to improve care for this vulnerable group of patients. Methods: All patients attending three consecutive drop-in clinics at a specialist homeless general practitioner service in Glasgow, who agreed to participate, were interviewed. Anonymised responses were transcribed and coded and a thematic analysis performed. Themes were summarised to generate candidate AE using the patient's own words. The authors then determined if they met the AE criteria. Results: Twenty out of 22 eligible patients were interviewed. Oral transcribing was found to be an acceptable way to gather data in this group. Nine candidate AEs were generated, of which five fitted the criteria to be used as metrics for future QI projects. This project generated AEs and QI targets, and highlighted issues of importance to patients that could be easily addressed. Conclusion: In the homeless context, obtaining high engagement and useful patient feedback, in a convenient way, is difficult. The AE method is an acceptable and feasible tool for generating QI targets that can lead to improvements in care for this vulnerable group.

GP speciality training in areas of deprivation: factors influencing engagement. A qualitative study.

BACKGROUND: GP training practices are less likely to be situated in areas of deprivation; little is known about GP views of postgraduate training in such areas. AIM: To explore the views of GPs working in deprived areas about GP speciality training (GPST). DESIGN & SETTING: Qualitative in-depth interviews with GPs working in practices in deprived areas in Scotland. METHOD: Ten in-depth interviews were conducted with GPs in training and non-training practices, to explore views on training. Interviews were audiotaped and transcribed verbatim, and inductive thematic analysis was undertaken. RESULTS: The importance of producing 'well-rounded' GPs who are able to work in a variety of environments was highlighted. Trainees need exposure to the specific challenges of deprived contexts (such as early multimorbidity, child protection, and addiction) and the benefit of this for trainees was thought to be invaluable. GPs identified many perceived barriers and benefits to training, some generic but some - such as inspiring the next generation (benefit) or overwhelming workload (barrier) - may be more relevant in areas of high deprivation. Overwhelming workload was the main reason for not becoming a training practice, though some would consider it if supported to develop a training culture. All the GPs, including non-trainers, were involved in optional activities which were felt to be important for resilience. CONCLUSION: GPs in areas of deprivation highlighted specific skills that could be gained by undertaking at least a part placement in deprived areas, with different skills likely to be gained from affluent areas. National education bodies should consider GP training rotations ensure a variety of training environments.