Experiences of support for people who access voluntary, community and social enterprise (VCSE) organisations for self-harm: a qualitative study with stakeholder feedback.

BACKGROUND: Prevalence of self-harm In England is rising, however contact with statutory services remains relatively low. There is growing recognition of the potential role voluntary, community and social enterprise sector (VCSE) organisations have in the provision of self-harm support. We aimed to explore individuals' experiences of using these services and the barriers and facilitators to accessing support. METHODS: Qualitative, online interviews with 23 adults (18+) who have accessed support from VCSE organisations for self-harm in the Yorkshire and the Humber region were undertaken. Interviews were audio recorded and transcribed verbatim. Thematic analysis was undertaken using NVivo software. RESULTS: Participants described how a lack of service flexibility and the perception that their individual needs were not being heard often made them less likely to engage with both statutory and VCSE organisations. The complexity of care pathways made it difficult for them to access appropriate support when required, as did a lack of awareness of the types of support available. Participants described how engagement was improved by services that fostered a sense of community. The delivery of peer support played a key role in creating this sense of belonging. Education and workplace settings were also viewed as key sources of support for individuals, with a lack of mental health literacy acting as a barrier to access in these environments. CONCLUSIONS: VCSE organisations can play a crucial role in the provision of support for self-harm, however, pathways into these services remain complex and links between statutory and non-statutory services need to be strengthened. The provision of peer support is viewed as a crucial component of effective support in VCSE organisations. Further supervision and training should be offered to those providing peer support to ensure that their own mental health is protected.

IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a cluster randomised controlled implementation trial.

BACKGROUND: Asthma is a common long-term condition and major public health problem. Supported self-management for asthma that includes a written personalised asthma action plan, supported by regular professional review, reduces unscheduled consultations and improves asthma outcomes and quality of life. However, despite unequivocal inter/national guideline recommendations, supported self-management is poorly implemented in practice. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) implementation strategy has been developed to address this challenge. The aim of this implementation trial is to determine whether facilitated delivery of the IMP2ART strategy increases the provision of asthma action plans and reduces unscheduled care in the context of routine UK primary care. METHODS: IMP2ART is a parallel group, cluster randomised controlled hybrid II implementation trial. One hundred forty-four general practices will be randomly assigned to either the IMP2ART implementation strategy or control group. Following a facilitation workshop, implementation group practices will receive organisational resources to help them prioritise supported self-management (including audit and feedback; an IMP2ART asthma review template), training for professionals and resources to support patients to self-manage their asthma. The control group will continue with usual asthma care. The primary clinical outcome is the between-group difference in unscheduled care in the second year after randomisation (i.e. between 12 and 24 months post-randomisation) assessed from routine data. Additionally, a primary implementation outcome of asthma action plan ownership at 12 months will be assessed by questionnaire to a random sub-group of people with asthma. Secondary outcomes include the number of asthma reviews conducted, prescribing outcomes (reliever medication and oral steroids), asthma symptom control, patients' confidence in self-management and professional support and resource use. A health economic analysis will assess cost-effectiveness, and a mixed methods process evaluation will explore implementation, fidelity and adaptation. DISCUSSION: The evidence for supported asthma self-management is overwhelming. This study will add to the literature regarding strategies that can effectively implement supported self-management in primary care to reduce unscheduled consultations and improve asthma outcomes and quality of life. TRIAL REGISTRATION: ISRCTN15448074. Registered on 2 December 2019.

Primary care for people with severe mental illness and comorbid obstructive airways disease: a qualitative study of patient perspectives with integrated stakeholder feedback.

OBJECTIVES: To explore patient and stakeholder perspectives on primary respiratory care for people with severe mental illness (SMI) and comorbid obstructive airways disease (OAD). DESIGN: Qualitative, semistructured qualitative interviews were undertaken with a purposive sample of people with a diagnosis of SMI (bipolar illness, schizophrenia, affective disorder with psychosis) and comorbid asthma or chronic obstructive pulmonary disease. Transcribed data were analysed using an interpretive phenomenological approach. Study results were discussed with stakeholders. SETTING: Eight UK general practices. PARTICIPANTS: 16 people aged 45-75 years, with SMI and comorbid asthma or chronic obstructive pulmonary disease, were interviewed. Twenty-one people, four with lived experience of SMI and seventeen health/social care/third sector practitioners, participated in discussion groups at a stakeholder event. RESULTS: Participants described disability and isolation arising from the interplay of SMI and OAD symptoms. Social support determined ease of access to primary care. Self-management of respiratory health was not person-centred as practitioners failed to consider individual needs and health literacy. Participants perceived smoking cessation impossible without tailored support. Less than half of the practices facilitated personalised access to timely primary care and continuity. Overall, there was a reliance on urgent care if service adaptations and social support were lacking. The stakeholder group expressed concern about gaps in care, the short-term funding of community organisations and fear of loss of benefits. Potential solutions focused on supported navigation of care pathways, relational continuity, individual and community asset building and the evolving social prescriber role. CONCLUSION: This study suggests that despite UK guidelines and incentives to optimise physical healthcare, primary care fails to consistently deliver integrated biopsychosocial care for patients with SMI and OAD. Collaborative, personalised care that builds social capital and tailors support for self-management is needed, alongside service-level interventions to enhance access to healthcare for patients with comorbid SMI and OAD.

Utility of the COM-B model in identifying facilitators and barriers to maintaining a healthy postnatal lifestyle following a diagnosis of gestational diabetes: a qualitative study.

OBJECTIVES: Previous qualitative research investigating the experiences of women diagnosed with gestational diabetes (GD) has provided important insights into the development of behaviour change interventions. However, these studies often lack a theoretical underpinning. This study explored the use of the capability, opportunity, motivation and behaviour (COM-B) framework (which proposes that individuals need the capability, opportunity and motivation to perform a particular behaviour) to code and the socioecological model to contextualise participant responses to better inform intervention development. DESIGN: Qualitative semistructured interviews are using purposive sampling. Interviews were audio-recorded, transcribed and coded using the COM-B framework. A socioecological approach was adopted to understand the context of intervention facets. SETTING: Interviews were conducted in a secondary care setting in South Yorkshire. PARTICIPANTS: Twenty-seven postnatal women with a previous diagnosis of GD were interviewed. RESULTS: Applying the COM-B framework to code participant, responses identified 16 key subthemes which reflected either: capability, opportunity or motivation components of the model. Four domains adapted from the socioecological model: individual, family life, community and healthcare provision; contextualised factors are important for these women in terms of behaviour change. Emotional response at the individual level was highly motivating or demotivating. Factors related to family life and community were particularly dominant and had the potential to either facilitate or impede change. We found many participants relied on healthcare provision during the prenatal and postnatal periods with timing and positive relationships being key to good care. CONCLUSIONS: Our study provides further insight into the factors crucial for behaviour change in women diagnosed with GD. By innovatively applying the COM-B framework in a socioecological context, it is clear intervention facets need to target microlevel through the macrolevel to engage this population in behaviour change. Future work should consider family-level intervention as this could allow for sustained behaviour change and consequently prevent the development of type 2 diabetes mellitus.

Endometrial sampling in low-risk patients with abnormal uterine bleeding: a systematic review and meta-synthesis.

BACKGROUND: One million women per year seek medical advice for abnormal uterine bleeding (AUB) in the United Kingdom. Many low-risk patients who could be managed exclusively in primary care are referred to hospital based gynaecology services. Performing endometrial sampling (ES) in the community may improve care, reduce the rate of referrals and minimise costs. We aimed to search and synthesise the literature on the effectiveness of ES (Pipelle versus other devices) in managing AUB in low-risk patients. METHODS: We undertook an electronic literature search in MEDLINE via OvidSP, Scopus, and Web of Science for relevant English-language articles from 1984 to 2016 using a combination of MeSH and keywords. Two reviewers independently pre-selected 317 articles and agreed on 60 articles reporting data from over 7300 patients. Five themes were identified: sample adequacy, test performance, pain and discomfort, cost-effectiveness, and barriers and complications of office ES. RESULTS: Pipelle seems to perform as well as dilation and curettage and, as well or better than other ES devices in terms of sampling adequacy and sensitivity. It also seems to be better regarding pain/discomfort and costs. However, Pipelle can disrupt the sonographic appearance of the endometrium and may be limited by cervical stenosis, pelvic organ prolapse and endometrial atrophy. CONCLUSIONS: The current evidence supports the use of Pipelle in the management of low-risk women presenting in the outpatient setting with symptomatic AUB when combined with clinical assessment and ultrasound scanning. However, the implications of its widespread use in primary care are uncertain and more research is required.

Reducing risk of type 2 diabetes after gestational diabetes: a qualitative study to explore the potential of technology in primary care.

BACKGROUND: Despite the seven-fold increased risk of type 2 diabetes mellitus (T2DM) among females previously diagnosed with gestational diabetes (GD), annual rates of follow-up in primary care are low. There is a need to consider how to reduce the incidence of progression to T2DM among this high-risk group. AIM: To examine the views of females diagnosed with GD to ascertain how to improve primary care support postnatally, and the potential role of technology in reducing the risk of progression to T2DM. DESIGN AND SETTING: A qualitative study of a purposive sample of 27 postnatal females leaving secondary care with a recent diagnosis of GD. METHOD: Semi-structured interviews were conducted with 27 females, who had been previously diagnosed with GD, at around 6-12 weeks postnatally. Interviews were audiotaped, transcribed, and analysed thematically. RESULTS: Facilitators and barriers to engaging in a healthy postnatal lifestyle were identified, the most dominant being competing demands on time. Although females were generally satisfied with the secondary care they received antenatally, they felt abandoned postnatally and were uncertain what to expect from their GP in terms of follow-up and support. Females felt postnatal care could be improved by greater clarity regarding this, and enhanced by peer support, multidisciplinary input, and subsidised facilities. Technology was seen as a potential adjunct by providing information, enabling flexible and personalised self-management, and facilitating social support. CONCLUSION: A more tailored approach for females previously diagnosed with GD may help reduce the risk of progression to T2DM. A need for future research to test the efficacy of using technology as an adjunct to current care was identified.

Primary care endometrial sampling for abnormal uterine bleeding: a pilot study.

AIM: To design and evaluate a pilot service for primary care endometrial sampling (PCES). DESIGN: Retrospective analysis of data from two service evaluations. SETTING: General practices and the gynaecology department in a large city in the UK. METHODS: These were two-fold: (1) To design the new service we identified all the endometrial samples taken in the city's gynaecology department in 2012/2013 and estimated the proportion of these with abnormal uterine bleeding (AUB) that would be suitable for PCES. (2) To evaluate the new PCES service we analysed data from the first year of activity. RESULTS: (1) A total of 1894 endometrial samples were taken in hospital in 2012/2013. An estimated 424 (22.4%) of these were from patients with AUB who fitted the criteria for PCES. (2) In the first year of the PCES service 108 samples were taken by general practitioners (GPs). Initial management of these patients was exclusively in primary care in 97.2% (104/108) of cases; most patients were treated with the Mirena intrauterine system (79/109; 73.1%) and there were no cases of hyperplasia or cancer. CONCLUSIONS: Most premenopausal patients with AUB could potentially be managed in primary care without referral to hospital if endometrial sampling (ES) was made available to appropriately trained and supported GPs. However, this study was limited by its retrospective, non-interventional design, and more research is required to demonstrate safety and cost-effectiveness.

Adapting primary care for new migrants: a formative assessment.

BACKGROUND: Immigration rates have increased recently in the UK. Migrant patients may have particular needs that are inadequately met by existing primary care provision. In the absence of national guidance, local adaptations are emerging in response to these new demands. AIM: To formatively assess the primary care services offered to new migrants and the ways in which practitioners and practices are adapting to meet need. DESIGN & SETTING: Online survey and case studies of current practice across primary care in the UK. Case studies were selected from mainstream and specialist general practice as well as primary care provision in the third sector. METHOD: Non-probability sample survey of primary care practitioners (n = 70) with descriptive statistical analysis. Qualitative case studies (n = 8) selected purposively; in-depth exploration of organisational and practitioner adaptations to services. Analysis is structured around the principles of equitable care. RESULTS: Survey results indicated that practitioners focused on working with communities and external agencies and adapting processes of, for example, screening, vaccination, and health checks. Lack of funding was cited most frequently as a barrier to service development (n = 51; 73%). Case studies highlighted the prominence partnership working and of an organisational and practitioner focus on equitable care. Adaptations centred on addressing wider social determinants, trauma, and violence, and additional individual needs; and on delivering culturally-competent care. CONCLUSION: Despite significant resource constraints, some primary care services are adapting to the needs of new migrants. Many adapted approaches can be characterised as equity-oriented.

Respiratory health screening for opiate misusers in a specialist community clinic: a mixed-methods pilot study, with integrated staff and service user feedback.

OBJECTIVES: Increased rates of illicit drug inhalation are thought to expose opiate misusers (OMUs) to an enhanced risk of respiratory health problems. This pilot study aimed to determine the feasibility of undertaking respiratory screening of OMUs in a community clinic. SETTING: Single-centre UK community substance misuse clinic. PARTICIPANTS: All clinic attendees receiving treatment for opiate misuse were eligible to participate. 36 participants (mean age=37) were recruited over a 5-week period. The sample included 26 males and 10 females. OUTCOME MEASURES: Spirometry without bronchodilation; health related quality of life EQ-5D-3L; Asthma Control Test; Mini Asthma Quality of Life; Clinical COPD Questionnaire and the Treatment Outcome Profile were used to assess the respiratory health of participants. Findings were discussed with staff and service users in 2 patient and public involvement events and feedback was analysed thematically. RESULTS: 34 participants reported that they had smoked heroin. 8 participants diagnosed with asthma, scored under 13 on the Asthma Control Test, suggesting poorly controlled asthma. Participants (n=28), without a diagnosis of asthma completed the Lung Function Questionnaire. Of these, 79% produced scores under 18, indicating symptoms associated with the development of chronic obstructive pulmonary disease. Spirometry showed 14% of all participants had forced expiratory volume in 1 s/forced vital capacity <0.7 (without bronchodilator), indicating potential obstructive lung disease. Feedback from service users and staff suggested a willingness and capacity to deliver respiratory health screening programmes. Insight towards the difficulties service users have in accessing services and the burden of respiratory health was also provided. CONCLUSIONS: It is feasible to undertake respiratory health screening of OMUs in a community clinic. Larger screening studies are warranted to determine the prevalence of respiratory health problems in this population. Research regarding asthma medicines adherence and access to healthcare among OMUs is also required.