A qualitative exploration of the impact of educational social fields on mental health help-seeking in post-primary schools in Northern Ireland.

In a study of post-primary students in Northern Ireland, Bourdieu's concepts of cultural capital, habitus and fields are used to explore attitudes towards help-seeking from general practitioners (GPs). Findings from Grammar and Secondary Modern School students are compared using the role of educational fields in influencing help-seeking behaviours for mental health problems. Focus groups were conducted of 54 students at 10 post-primary schools in Northern Ireland, each consisting of 5-7 pupils, stratified by age (13-17 years) and gender. The data were analysed thematically to assess attitudinal and belief patterns within school environments. Participants from both types of schools expressed reluctance to seek help from GPs for mental health concerns. However, the attitudes towards help seeking differ between grammar schools (GSs) and secondary modern schools with regards to (a) the act of help-seeking; (b) service knowledge and medical professionalism; and (c) trust and disclosure. The field of GSs appears to produce students who feel more able and, importantly, more entitled to mental health support from health professionals. While this apparent conference of cultural norms increases some individuals' access to services, work is required to build help-seeking pathways which are responsive to diverse young people.

Anticipatory care planning for community-dwelling older adults at risk of functional decline: a feasibility cluster randomized controlled trial.

OBJECTIVES: To determine the feasibility, implementation and outcomes of an Anticipatory Care Planning (ACP) intervention in primary care to assist older adults at risk of functional decline by developing a personalized support plan. DESIGN: Feasibility cluster randomized control trial. SETTING AND PARTICIPANTS: Eight primary care practices (four in Northern Ireland, United Kingdom and four in the Republic of Ireland) were randomly assigned to either intervention or control arm. Eligible patients were those identified in each practice as 70 years of age or older and assessed as at risk of functional decline. Study participants (intervention n = 34, control n = 31) and research staff were not blinded to group assignment. ANTICIPATORY CARE INTERVENTION: The intervention delivered by a registered nurse including: a) a home-based patient assessment; b) care planning on the basis of a holistic patient assessment, and c) documentation of a support plan. OUTCOME MEASURES: A conceptual framework (RE-AIM) guided the assessment on the potential impact of the ACP intervention on patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and reduction of potentially inappropriate prescribing. Data were collected at baseline and at 10 weeks and six months following delivery of the intervention. RESULTS: All pre-specified feasibility indicators were met. Patients were unanimous in the acceptance of the ACP intervention. Health care providers viewed the ACP intervention as feasible to implement in routine clinical practice with attending community supports. While there were no significant differences on the primary outcomes (EQ-5D-5L: -0.07 (-0.17, 0.04) p = .180; CES-D: 1.2 (-2.5, 4.8) p = .468) and most secondary measures, ancillary analysis on social support showed responsiveness to the intervention. Incremental cost analysis revealed a mean reduction in costs of €320 per patient (95% CI -31 to 25; p = 0.82) for intervention relative to the control. CONCLUSIONS: We successfully tested the ACP intervention in primary care settings and have shown that it is feasible to implement. The ACP intervention deserves further testing in a definitive trial to determine whether its implementation would lead to better outcomes or reduced costs. TRIAL REGISTRATION: Clinicaltrials.gov, ID: NCT03902743 . Registered on 4 April 2019.

Successful implementation of a trans-jurisdictional, primary care, anticipatory care planning intervention for older adults at risk of functional decline: interviews with key health professionals.

BACKGROUND: Aging populations present a challenge to health systems internationally, due to the increasing complexity of care for older adults living with functional decline. This study aimed to elicit expert views of key health professionals on effective and sustainable implementation of a nurse-led, person-centred anticipatory care planning (ACP) intervention for older adults at risk of functional decline in a primary care setting. METHODS: We examined the feasibility of an ACP intervention in a trans-jurisdictional feasibility cluster randomized controlled trial consisting of home visits by research nurses who assessed participants' health, discussed their health goals and devised an anticipatory care plan following consultation with participants' GPs and adjunct clinical pharmacist. As part of the project, we elicited the views and recommendations of experienced key health professionals working with the target population who were recruited using a 'snowballing technique' in cooperation with older people health networks in the Republic of Ireland (ROI) and Northern Ireland (NI), United Kingdom [n = 16: 7 ROI, 9 NI]. Following receipt of written information about the intervention and the provision of informed consent, the health professionals were interviewed to determine their expert views on the feasibility of the ACP intervention and recommendations for successful implementation. Data were analyzed using thematic analysis. RESULTS: The ACP intervention was perceived to be beneficial for most older patients with multimorbidity. Effective and sustainable implementation was said to be facilitated by accurate and timely patient selection, GP buy-in, use of existing structures within health systems, multidisciplinary and integrated working, ACP nurse training, as well as patient health literacy. Barriers emerged as significant work already undertaken, increasing workload, lack of time, funding and resources, fragmented services, and geographical inequalities. CONCLUSIONS: The key health professionals perceived the ACP intervention to be highly beneficial to patients, with significant potential to prevent or avoid functional decline and hospital admissions. They suggested that successful implementation of this primary care based, whole-person approach would involve integrated and multi-disciplinary working, GP buy in, patient health education, and ACP nurse training. The findings have potential implications for a full trial, and patient care and health policy. TRIAL REGISTRATION: Clinicaltrials.gov, ID: NCT03902743 . Registered on 4 April 2019.

Patient and service-related barriers and facitators to the acceptance and use of interventions to promote communication in health and social care: a realist review.

BACKGROUND: More people living into old age with dementia. The complexity of treatment and care, particularly those with multiple health problems, can be experienced as disjointed. As part of an evaluation of a 'healthcare passport' for people living with dementia we undertook a realist review of communication tools within health and social care for people living with dementia. AIMS: To explore how a 'healthcare passport' might work in the 'real world' of people living with dementia through a better understanding of the theoretical issues related to, and the contextual issues that facilitate, successful communication. METHODS: A realist review was considered the most appropriate methodology to inform the further development and evaluation of the healthcare passport. We undertook a purposive literature search related to communication tools to identify (a) underlying programme theories; (b) published reports and papers on their use in various healthcare settings; (c) evidence on barriers and facliitators of their use. RESULTS: Communication tools were noted as a way of improving communication and outcomes through: (1) improvement of service user autonomy; (2) strengthening the therapeutic alliance; and (3) building integrated care. However, while intuitively perceived to of benefit, evidence on their use is limited and key barriers to their acceptance and use include: (1) difficulties in clearly defining purpose, content, ownership and usage; (2) understanding the role of family caregivers; and (3) preparation among healthcare professionsals. CONCLUSION: Patient-held communication tools may be helpful to some people living with dementia but will require considerable preparation and engagement with key stakeholders.

Adolescent trust and primary care: Help-seeking for emotional and psychological difficulties.

Although a quarter of adolescents are likely to experience emotional and psychological difficulties, only a third of them will seek professional help. In this exploratory study we undertook focus groups with 54 adolescents between the ages of 13 and 16 in eight post-primary schools in Northern Ireland. Young people do not trust their GPs, perceiving them as strangers, impersonal and uncaring. The basis of distrust is different among males and females. The findings are discussed in light of adolescents' developmental challenges of identity formation and the consequent demand to be respected and taken seriously by adults.

Adolescent mental well-being, religion and family activities: a cross-sectional study (Northern Ireland Schools and Wellbeing Study).

OBJECTIVES: In this study, we seek to explore the relationship between adolescent mental well-being, religion and family activities among a school-based adolescent sample from Northern Ireland. SETTING: The Northern Ireland Schools and Wellbeing Study is a cross-sectional study (2014-2016) of pupils in Northern Ireland aged 13-18 years. PARTICIPANTS: 1618 adolescents from eight schools participated in this study. OUTCOMES MEASURES: Our primary outcome measure was derived using the Warwick-Edinburgh Mental Wellbeing Scale. We used hierarchical linear regression to explore the independent effects of a range of personal/social factors, including religious affiliation, importance of religion and family activities. RESULTS: In fully adjusted models, older adolescents and females reported lower mental well-being scores-for the year-on-year increase in age ß=-0.45 (95% CI=-0.84, -0.06), and for females (compared with males) ß=-5.25 (95% CI=-6.16, -4.33). More affluent adolescents reported better mental well-being. No significant differences in mental well-being scores across religious groups was found: compared with Catholics, Protestant adolescents recorded ß=-0.83 (95% CI=-2.17, 0.51), other religious groups ß=-2.44 (95% CI=-5.49, 0.62) and atheist adolescents ß=-1.01 (95% CI=-2.60, 0.58). The importance of religion in the adolescents' lives was also tested: (compared with those for whom it was not important) those for whom it was very important had better mental well-being (ß=1.63: 95% CI=0.32, 2.95). Higher levels of family activities were associated with higher mental well-being: each unit increase in family activity produced a 1.45% increase in the mental well-being score (ß=0.78: 95% CI=0.67, 0.90). CONCLUSIONS: This study indicates that non-religious adolescents may have lower mental well-being scores when compared with their more religious peers, irrespective of religious denomination. This may relate to both a sense of lack of firm identity and perceived marginalisation. Additionally, adolescents with poor family cohesion are more vulnerable to poor mental well-being.

Lessons from a feasibility study testing an anticipatory care planning intervention for older adults at risk of functional decline: feedback from implementing stakeholders.

BACKGROUND: Anticipatory care is becoming increasingly important in effectively managing complex multimorbidity in aging populations, preventing further functional decline, and avoiding hospital admissions. This study aimed to elicit the feedback of participating general practitioners, practice managers, nurses and an adjunct pharmacist on the implementation strengths and limitations of a nurse-led, person-centered anticipatory care planning (ACP) intervention for older people at risk of functional decline in a primary care setting. The findings have implications for a full trial and intervention design. METHODS: As part of a feasibility cluster randomized controlled trial (cRCT) testing the ACP intervention, we sought feedback from implementing stakeholders: general practitioners (N = 3), practice staff (N = 3), research nurses (N = 5), and adjunct pharmacist (N = 1) in both the Republic of Ireland (ROI) and Northern Ireland (NI), UK. Following written, informed consent, they were interviewed to investigate their experience of participating in the implementation of the ACP intervention as part of the feasibility trial, and elicit any recommendations for a full trial. Using the Consolidated Framework for Implementation Research, thematic analysis was employed to analyze data. The intervention consisted of home visits by specially trained nurses who assessed participants' health, discussed with them their health goals and plans, and devised an anticipatory care plan following consultation with participants' General Practitioners and the adjunct clinical pharmacist. RESULTS: Participating stakeholders indicated that the strengths of the implementation process included the training provided to the nurses, constructive collaboration of the research team, and structure of implementation process. Perceived limitations included the selection process and screening tool, communication between the research team and the nurses, the assessment questionnaire, and the final document left with the patient, as well as lack of access to medical records for the adjunct pharmacist. Recommendations include better communication and team-wide consensus on alterations to procedure and documents, and standardized protocols for patient selection, data collection, and reporting for research nurses. CONCLUSIONS: The findings have identified strengths of the implementation process on which to build, and recognized limitations which can now be addressed to ensure improved efficiency and effectiveness in future trials. TRIAL REGISTRATION: Clinicaltrials.gov , ID: NCT03902743. Registered on 4 April 2019.

Acceptability of a nurse-led, person-centred, anticipatory care planning intervention for older people at risk of functional decline: A qualitative study.

BACKGROUND: As the population of older adults increases, the complexity of care required to support those who choose to remain in the community amplifies. Anticipatory Care Planning (ACP), through earlier identification of healthcare needs, is evidenced to improve quality of life, decrease aggressive interventions, and prolong life. With patient acceptability of growing importance in the design, implementation, and evaluation of healthcare interventions, this study reports on the acceptability of a primary care based ACP intervention on the island of Ireland. METHODS: As part of the evaluation of a feasibility cluster randomized controlled trial (cRCT) testing an ACP intervention for older people at risk of functional decline, intervention participants [n = 34] were interviewed in their homes at 10-week follow-up to determine acceptability. The intervention consisted of home visits by specifically trained registered nurses who assessed participants' health, discussed their health goals and plans, and devised an anticipatory care plan in collaboration with participants' GPs and adjunct clinical pharmacist. Thematic analysis was employed to analyze interview data. The feasibility cRCT involved eight general practitioner (GP) practices as cluster sites, stratified by jurisdiction, four in Northern Ireland (NI) (two intervention, two control), and four in the Republic of Ireland (ROI) (two intervention, two control). Participants were assessed for risk of functional decline. A total of 34 patients received the intervention and 31 received usual care. FINDINGS: Thematic analysis resulted in five main themes: timing of intervention, understanding of ACP, personality & individual differences, loneliness & social isolation, and views on healthcare provision. These map across the Four Factor Model of Acceptability ('4FMA'), a newly developed conceptual framework comprising four components: intervention factors, personal factors, social support factors, and healthcare provision factors. CONCLUSION: Acceptability of this primary care based ACP intervention was high, with nurses' home visits, GP anchorage, multidisciplinary working, personalized approach, and active listening regarded as beneficial. Appropriate timing, and patient health education emerged as vital.

Adolescent mental health problems, suicidality and seeking help from general practice: A cross-sectional study (Northern Ireland Schools and Wellbeing study).

BACKGROUND: Adolescent mental health problems and suicidality appear to be increasing in Western countries but contact with health services remains stubbornly low. While social disadvantage is often implicated in aetiology and help-seeking, evidence on the relative contribution of school and family life factors is limited. We sought (a) to examine the prevalence and factors associated with mental health problems in adolescent boys and girls; and (b) to examine factors associated with trust and contact with GPs for mental health problems. METHOD: Cross-sectional study of adolescent pupils in Northern Ireland RESULTS: High rates of mental health problems and suicidality were recorded, especially among females. While social circumstances do not influence mental health outcomes, factors of interest were atheist/agnostic beliefs and having a bedroom to oneself. While overall trust in GPs was high, more than 36% of the sample reported low trust. GP Trust was associated with positive home life factors. Importantly, adolescents with mental health problems including suicidality were much less likely to seek help. LIMITATIONS: Cross-sectional data CONCLUSIONS: This study confirms the high rates of mental health problems and suicidality among adolescents in Northern Ireland, particularly among young women. Those most in need of professional help appear least prepared to seek it. The influence of home life and environment on both poor mental health and trust and help-seeking from family doctors, is considerable and there is a need to find interventions that nurture appropriate levels of trust and help-seeking guidance for adolescents.

Anticipatory care planning for older adults: a trans-jurisdictional feasibility study.

BACKGROUND: As the population of older adults' increases, the complexity of care required to support those who choose to remain in the community has also increased. Anticipatory Care Planning (ACP) through earlier identification of healthcare needs is evidenced to improve quality of life, decrease the number of aggressive futile interventions, and even to prolong life. AIM: To determine the feasibility of a cluster randomised trial to evaluate the implementation and outcomes of Anticipatory Care Planning (ACP) in primary care to assist older adults identified as at risk for functional decline by developing a personalised support plan. METHOD: GP practices were randomised into control/intervention groups stratified by jurisdiction [Northern Ireland (UK) and the Republic of Ireland (RoI)], and by setting (urban and rural). Participants were included if they were a) aged ≥70 years, b) 2 or more chronic medical conditions, c) 4 or more prescribed medications. The Anticipatory Care Plan consisted of home visits where the study nurse discussed patients' goals and plans. An action plan was put in place following consultation with patient's GPs and study Pharmacist. RESULTS: Eight primary care practices participated; four in the UK and four in the RoI. Sample n = 64. Data was collected pertaining to patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and the use of potentially inappropriate medication. CONCLUSION: Unique insights relating to the trans-jurisdictional delivery of healthcare services in the UK and RoI were observed which has implications on service delivery for older adults.

Acceptability and use of a patient-held communication tool for people living with dementia: a longitudinal qualitative study.

OBJECTIVES: To assess the acceptability and use of a low-cost patient-held communication tool. DESIGN: Longitudinal qualitative interviews at three time points over 18 months and document content analysis. SETTING: Primary and community services. PARTICIPANTS: Twenty-eight dyads: People living with dementia in Northern Ireland and their informal carers. INTERVENTIONS: A patient-held healthcare 'passport' for people living with dementia. PRIMARY AND SECONDARY OUTCOMES: Acceptability and use of the passport-barriers and facilitators to successful engagement. RESULTS: There was a qualified appreciation of the healthcare passport and a much more nuanced, individualistic or personalised approach to its desirability and use. How people perceive it and what they actually do with it are strongly determined by individual contexts, dementia stage and other health problems, social and family needs and capacities. We noted concerns about privacy and ambivalence about engaging with health professionals. CONCLUSION: Such tools may be of use but there is a need for demanding, thoughtful and nuanced programme delivery for future implementation in dementia care. The incentivisation and commitment of general practitioners is crucial. Altering the asymmetrical relationship between professionals and patients requires more extensive attention.