Tensions in primary care cancer detection: An embedded qualitative intervention development study.

BACKGROUND: UK cancer mortality is worse than many other high-income countries, partly due to diagnostic delays in primary care. AIM: To understand beliefs and behaviour of GPs, and systems of general practice teams, to inform the Think Cancer! intervention development. DESIGN AND SETTING: An embedded qualitative study guided by behaviour change models (COM-B and TDF) in primary care in Wales, UK. METHOD: Twenty qualitative, semi-structured telephone interviews with GPs and four face-to-face focus groups with practice teams. Analysis used Framework, results were mapped to multiple, overlapping components of COM-B and TDF. RESULTS: Three themes illustrate (1) complex, multi-level referral considerations facing GPs and practice teams, (2) external influences and constraints, (3) the role of practice systems and culture. Tensions emerged between individual considerations of GPs (Capability, Motivation) and context-dependent external pressures (Opportunity). Detecting cancer was guided not only by external requirements, but also by motivational factors GPs described as part of their cancer diagnostics process. External influences on the diagnosis process often resulted from the primary-secondary care interface and social pressures. GPs adapted their behaviour to deal with this disconnect. Positive practice culture and supportive practice-based systems ameliorated these tensions and complexity. CONCLUSION: By exploring individual GP behaviours together with practice systems and culture we contribute new understandings on how cancer diagnosis operates in primary care and how delays can be improved. We highlight commonly overlooked dynamics and tensions, experienced by GPs as a tension between individual decision-making (Capability, Motivation) and external considerations such as pressures in secondary care (Opportunity).

A randomised controlled trial of a digital intervention (Renewed) to support symptom management, wellbeing and quality of life in cancer survivors.

BACKGROUND: Many cancer survivors following primary treatment have prolonged poor quality of life. AIM: To determine the effectiveness of a bespoke digital intervention to support cancer survivors. DESIGN: Pragmatic parallel open randomised trial. SETTING: UK general practices. METHODS: People having finished primary treatment (<= 10 years previously) for colo-rectal, breast or prostate cancers, with European-Organization-for-Research-and-Treatment-of-Cancer QLQ-C30 score <85, were randomised by online software to: 1)detailed 'generic' digital NHS support ('LiveWell';n=906), 2) a bespoke complex digital intervention ('Renewed';n=903) addressing symptom management, physical activity, diet, weight loss, distress, or 3) 'Renewed-with-support' (n=903): 'Renewed' with additional brief email and telephone support. RESULTS: Mixed linear regression provided estimates of the differences between each intervention group and generic advice: at 6 months (primary time point: n's respectively 806;749;705) all groups improved, with no significant between-group differences for EORTC QLQ-C30, but global health improved more in both intervention groups. By 12 months there were: small improvements in EORTC QLQ-C30 for Renewed-with-support (versus generic advice: 1.42, 95% CIs 0.33-2.51); both groups improved global health (12 months: renewed: 3.06, 1.39-4.74; renewed-with-support: 2.78, 1.08-4.48), dyspnoea, constipation, and enablement, and lower NHS costs (generic advice £265: in comparison respectively £141 (153-128) and £77 (90-65) lower); and for Renewed-with-support improvement in several other symptom subscales. No harms were identified. CONCLUSION: Cancer survivors quality of life improved with detailed generic online support. Robustly developed bespoke digital support provides limited additional short term benefit, but additional longer term improvement in global health enablement and symptom management, with substantially lower NHS costs.

Doctors being up there and we being down here: a metaphorical analysis of talk about student/doctor-patient relationships.

This paper describes the metaphorical conceptualisations of student/doctor-patient relationships, as articulated by multiple stakeholders in healthcare. Eight focus group discussions with 19 patients, 13 medical students and 15 medical educators (comprising doctors, other healthcare professionals and non-clinical academics) were conducted in England and we subjected our transcribed and audiotaped data to a secondary level of data analysis i.e. systematic metaphor analysis. The analysis revealed six over-arching metaphors associated with the target domain of student/doctor-patient relationships i.e. STUDENT/DOCTOR-PATIENT RELATIONSHIPS AS WAR, HIERARCHY, DOCTOR-CENTREDNESS, MARKET, MACHINE and THEATRE. All of the metaphors (except theatre) emphasised the oppositional quality of student/doctor-patient relationships. Three of the source domains emerging from our empirical data (i.e. hierarchy, doctor-centredness, and market) relate to metaphors already employed in the non-empirical literature to discuss doctor-patient relationships (e.g. paternalism, patient-centredness, and consumerism). The three remaining source domains (i.e. war, machine and theatre) were novel in their conceptualisation of student/doctor-patient relationships, albeit that they have been reported in previous empirical literature to describe other target domains. In this paper, we discuss each of these metaphors and their associated entailments, including those found in our data and those absent from our data. We also differentiate between the unconscious use of metaphorical linguistic expressions by our participants and those serving a rhetorical function. Although analysing metaphoric talk is not without its difficulties, the construction of metaphoric models can help social researchers better understand how individuals conceptualise and construct student/doctor-patient relationships.

"From the heart of my bottom": negotiating humor in focus group discussions.

Reporting and analyzing interactional data collected during focus groups can be a significant challenge for qualitative health researchers. In this article, the authors explore the use of humor among focus group participants as one area of interaction and negotiation that is methodologically interesting and theoretically insightful. They explore discussions about service user involvement in medical education across eight focus groups consisting of medical educators, medical students, and service users. The findings suggest that humor can be used among focus group participants to maintain solidarity, navigate coping strategies, and negotiate power. Not only is humor useful when exploring new concepts, it can also be an indication of wider views that might not be explicit in an analysis of focus group members' comments alone. The authors urge qualitative health researchers to examine interactions among focus group participants, and their analysis of humor illustrates how this can be achieved.