Barriers and facilitators to GP-patient communication about emotional concerns in UK primary care: a systematic review

Factors associated with unvoiced concerns of patients attributed to embarrassment, modesty or a fear of being judged

BACKGROUND AND OBJECTIVE

It is important for patients to feel that they can address any topic during a consultation with a General Practitioner (GP), so that the care delivered is appropriate and relevant. This study aimed to investigate factors associated with unvoiced concerns of patients during a GP consultation, because of embarrassment, modesty and/or a fear of being judged.

METHODS

Cross-sectional, observational study between December 2023 and January 2024, using a ad hoc questionnaire completed by adult subjects who accepted to participate in the study. The factors associated with unvoiced concerns with a p-value < 0.20 by univariable analysis were included in a multivariable logistic regression model.

RESULTS

In total, 2104 participants were included (mean age 43.7 ± 15.9 years; 73% women). Of these, 680 (32.3%, (95% CI, 30.3-34.3)) reported that they had leaved unvoiced concerns during the consultation due to embarrassment, modesty and/or a fear of being judged. The main motives for embarrassment, modesty and/or fear of being judged were: "sexual behavior, libido, perception of your gender, erectile dysfunction, vaginal dryness" (15% of respondents), and "psychological disorders, low mood, anxiety" (14%). Factors associated with a higher likelihood of unvoiced concerns were female sex (adjusted odds ratio (aOR) 1.5 [95% CI 1.2-1.9]; p = 0.0001) and third-level education (aOR 1.3 [95% CI 1.05-1.7]; p = 0.02). Conversely, heterosexuality (aOR 0.7 [95% CI 0.5-0.98]; p = 0.04) and a relationship of trust with the GP (aOR 0.6 [95% CI 0.5-0.7]; p < 0.0001) were associated with a lower likelihood of unvoiced concerns during GP consultation. Forty-seven percent of respondents said that hearing their GP reaffirm the secrecy of anything said during the consultation would have helped them to be more forthcoming, and 78% reported that they would have felt more at ease if the GP had addressed the difficult topic first.

CONCLUSION

Simple tools that could be used during primary care consultations could help to address sensitive issues and create an environment where patients can more comfortably address all their health issues without discomfort.

Japanese family physicians' attitudes, difficulties, and perceived significance in managing mental health problems: A qualitative study

Background

Family physicians (FPs) are expected to identify, diagnose, and treat mental health problems. Despite challenges such as limited time and low confidence in their skill as mental health providers, FPs generally consider mental health as a meaningful part of their profession. However, the role of the FP in mental health services is not clearly established in Japan. Studies have not been performed in countries without an established role of FPs' in mental health care. This study investigated Japanese FP's attitudes, difficulties, and perceived significance in managing mental health problems.

Methods

Semi-structured interviews were conducted between September 2022 and February 2023. Participants were Japanese FPs involved in mental health care. Interview transcripts were subjected to thematic analysis.

Results

Thirteen FPs were interviewed. The FPs approached mental health problems "as a FP who provides holistic and comprehensive care" and "practice based on experience and self-reflection." The difficulties faced by FPs included "time management problems" and "referral management problems and conflicts." Regarding significance, FPs mentioned that "gaining a deeper understanding of humanity" is important for managing mental health problems.

Conclusions

The attitude of Japanese FPs toward mental health care was based on awareness of the FP's specialty. Despite difficulties such as time and referral management issues, managing mental health problems was generally considered rewarding for professional growth.

How patients experience discussing couple relationship problems with GPs: an interview study

BACKGROUND

Couple relationship satisfaction is related to good physical health, good mental health, and longevity. Many patients have discussed or wish to discuss their couple relationship with their GP and look for personalised care and support when discussing topics they perceive as sensitive.

AIM

To explore patient experiences of discussing couple relationship problems in GP consultations.

DESIGN & SETTING

Qualitative study employing semi-structured interviews with patients from general practice in Norway.

METHOD

Individual interviews with 18 patients who had discussed their couple relationship with their GP. Participants were recruited through both social media and traditional media, and all interviews were digitally recorded. The purposive sample comprised 13 women and five men, representing diverse age groups, backgrounds, and relationship problems. All participants identified as heterosexual. We analysed interview data thematically using systematic text condensation.

RESULTS

Three main themes emerged: 1) GPs in a facilitating role, not on an assembly line; 2) navigating the 'elephant in the room'; and 3) GPs as biomedically competent life witnesses. GP continuity was vital in fostering the trust required to discuss sensitive topics, such as relationship issues. Participants valued a biopsychosocial approach that incorporated knowledge of close relationships into medical consultations. They appreciated both GP support and constructive challenges that prompted them to take responsibility for relationship improvements.

CONCLUSION

Patients value their GPs' holistic, supportive, and direct approach in addressing couple relationship problems, although they perceive that GPs do not always have sufficient time. They welcome relevant challenges that can drive positive change.

Experience of choice of treatment for adults with depression: a systematic review and meta-synthesis of qualitative research

BACKGROUND

Treatment choices for depression are preference-sensitive (no "single best option"). However, factors or attributes that can enhance or inhibit patient choice have not been fully explored.

AIMS

To synthesize the qualitative literature on facilitators and barriers to treatment choice, from the perspective of people with depression and healthcare practitioners.

METHODS

A systematic literature search identified eligible qualitative studies (Protocol registration no. CRD42019151352). Findings from 56 studies were meta-synthesized using a thematic analysis approach.

RESULTS

Overarching facilitators to treatment choice that resonated with both patients and healthcare practitioners included: a trusting and respectful patient-practitioner relationship; information and guidance tailored to the individual and their preferred level of involvement in the decision-making process; eliciting and incorporating patient preferences and individual needs in order to find the best patient-treatment match. Prominent barriers to treatment choice that emerged were: limited time available to explore treatment options; inadequate mental health training, knowledge, skills, and experience; lack of psychological treatment services and waiting times; inflexibility of services.

CONCLUSIONS

By focusing on the factors identified, practitioners can facilitate patient participation in decision-making, which has the potential to improve engagement with treatment and outcomes for adults with depression.

Engagement with emotional concerns in general practice: a thematic analysis of GP consultations

BACKGROUND

Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress.

AIM

To examine how emotional concerns are engaged with during routine GP consultations.

DESIGN & SETTING

Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018.

METHOD

The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes.

RESULTS

The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised.

CONCLUSION

Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.

Depressive symptomatology from a network perspective: Differences in the experience of symptoms involved in the self-recognition of depression and the diagnosis process by social position

BACKGROUND

While social disparities in depression are well-documented, the symptom experience across social positions remains less studied.

AIMS

This study examines the connections between depressive symptoms and self-recognizing a depressive episode, on the one hand, and clinical diagnosis, on the other hand, by three social position indicators.

METHODS

We analyzed baseline data from a population-based cohort of adults living in France, grouping participants by three indicators: education, financial difficulties, and occupation, and stratifying by sex. Utilizing a psychometric network approach, we estimated 24 networks. Nodes corresponded to the 20 CES-D items and 1 external variable, either 'Limitations due to depression' or 'Clinical depression'. Comparisons between socially disadvantaged and advantaged groups across the three social indicators were made in terms of network structures, global strength, and edge weights involving symptoms and both external nodes.

RESULTS

The study included data from 201,952 participants. Individuals in lower social positions exhibited higher rates of depressive-related variables. Four depressive symptoms emerged as crucial, being linked both to 'Clinical depression' and 'Limitations' across all social positions. Socially disadvantaged groups had denser networks. Some of the tests comparing network structures according to social position were significant, suggesting differences in the symptom activation chains. Connections between each external node and 'Felt depressed' and 'Could not get going' were non-invariant in educational and financial-based networks.

CONCLUSIONS

Findings highlight four depressive symptoms, likely to play a key role in the experience of depression across all social positions. Other insights from specific symptoms could be used for improving depression care among disadvantaged populations.

Communication between healthcare providers and communicatively-vulnerable patients with associated health outcomes: A scoping review of knowledge syntheses

OBJECTIVE

Summarize literature on provider-patient communication linked to health outcomes in communicatively-vulnerable patient populations.

METHODS

Scoping review of reviews: systematically searched six databases.

INCLUSION CRITERIA

systematic searches and syntheses of literature; one or more providers and communicatively-vulnerable patients; synchronous in-person communication; intermediate or health outcome linked to communication.

RESULTS

The search yielded 14,615 citations; 47 reviews - with wide range of providers, communication vulnerabilities, communication practices, and health outcomes - met inclusion criteria. Methodology included qualitative, quantitative, and mixed approaches. Quality ranged from very low to high. Six categories of communication practices linked to health outcomes were identified: 1) motivation-based; 2) accommodation of language, culture, gender, sexual identity, and other concordance with the patient; 3) cultural adaptations of interventions; 4) use of interpreters; 5) other provider-patient communication practices; 6) patient communication practices.

CONCLUSION

Communication practices were studied in a wide range of providers, with common themes regarding best practices. A unique finding is the role of the patient's communication practices. The specificity of communication practices studied is heterogeneous, with many reviews providing insufficient details.

PRACTICE IMPLICATIONS

Motivation-based practices and culturally- and linguistically-appropriate care have impacts on patient outcomes across a range of settings with different professions and communicatively-vulnerable groups.

Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis

Background

Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care.

Objectives

Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services.

Methods

Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders.

Data sources

Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews.

Review methods

In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway.

Results

Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels.

Limitations

In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English.

Conclusions

The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services.

Recommendations for health policy and practice

These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it.

Future work

Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries.

Trial registration

This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

The patient's first point of contact (PINPOINT) - protocol of a prospective multicenter study of communication and decision-making during patient assessments by primary care registered nurses

BACKGROUND

A major challenge for primary care is to set priorities and balance demands with available resources. The registered nurses in this study are practice nurses working in primary care offices, playing a large role in initial assessments. The overall objective of this research is to investigate practices of communication and decision-making during nurses' initial assessment of patients' health problems in primary care, examine working mechanisms in good practices and develop feasible solutions.

METHODS

Project PINPOINT aims for a prospective multicenter study using various methods for data collection and analysis. A purposive sample of 150 patient‒nurse consultations, including 30 nurses and 150 patients, will be recruited at primary care centers in three different geographic areas of southwest Sweden. The study will report on outcomes of communication practices in relation to patient-reported expectations and experiences, communication processes and patient involvement, assessment and decision-making, related priorities and value conflicts with data from patient questionnaires, audio-recorded real-time communication, and reflective interviews with nurses.

DISCUSSION

This research will contribute to the knowledge needed for the guidance of first-line decision-making processes to best meet patient and public health needs. This knowledge is necessary for the development of assessments and decisions to be better aligned to patients and to set priorities. Insights from this research can empower patients and service providers and help understand and enhance feasible person-centered communication strategies tailored to patients' level of health literacy. More specifically, this research will contribute to knowledge that can strengthen nurses' communication, assessments, and clinical decision-making in primary care. In the long term, this will contribute to how the competencies of practice nurses and other professionals are organized and carried out to make the best use of the resources within primary care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06067672.

Meta-review of the barriers and facilitators to women accessing perinatal mental healthcare

Perinatal mental health (PMH) problems are common and can have an adverse impact on women and their families. However, research suggests that a substantial proportion of women with PMH problems do not access care.

OBJECTIVES

To synthesise the results from previous systematic reviews of barriers and facilitators to women to seeking help, accessing help, and engaging in PMH care, and to suggest recommendations for clinical practice and policy.

DESIGN

A meta-review of systematic reviews.

REVIEW METHODS

Seven databases were searched and reviewed using a Preferred Reporting Items for Systematic Reviews and Meta Analyses search strategy. Studies that focused on the views of women seeking help and accessing PMH care were included. Data were analysed using thematic synthesis. Assessing the Methodological Quality of Systematic Reviews-2 was used to assess review methodology. To improve validity of results, a qualitative sensitivity analysis was conducted to assess whether themes remained consistent across all reviews, regardless of their quality rating.

RESULTS

A total of 32 reviews were included. A wide range of barriers and facilitators to women accessing PMH care were identified. These mapped across a multilevel model of influential factors (individual, healthcare professional, interpersonal, organisational, political and societal) and across the care pathway (from decision to consult to receiving care). Evidence-based recommendations to support the design and delivery of PMH care were produced based on identified barriers and facilitators.

CONCLUSION

The identified barriers and facilitators point to a complex interplay of many factors, highlighting the need for an international effort to increase awareness of PMH problems, reduce mental health stigma, and provide woman-centred, flexible care, delivered by well trained and culturally sensitive primary care, maternity, and psychiatric health professionals.

PROSPERO REGISTRATION NUMBER

CRD42019142854.

Descriptive Study of Patients Treated in a Psychosomatic Internal Medicine Declared by Japanese Family Medicine Clinic

Background

Psychosomatic internal medicine (PSIM) assesses psychosocial factors and provides holistic consideration. In Japan, PSIM physicians seem to be recognized as providers of mental health services, but family medicine did not so. When family physicians confront with psychological problems, high dropout rate is reported so it is needed to reveal factors related to dropouts, The purpose of this study is to describe characteristics of patients, treatment dropouts and its related factors in PSIM practice by family physician.

Methods

This cross-sectional study used data from the medical records of the Kitaibaraki Center of Family Medicine located in Kitaibaraki City, Ibaraki, Japan. The study included all new patients who made an appointment and visited the PSIM in this clinic from January 2020 to December 2022.Chief complaints and diagnoses were coded based on the International Classification of Primary Care, version 2 (ICPC-2).

Results

In total, 377 new patients were included in this study. The mean age was 39.9 ± 20.2 years. We found that 69.2% of patients who visited the clinic had a psychological chief complaint and 84.1% of primary diagnoses consisted of a psychological problem. One hundred sixty-five patients (43.8%) were still receiving treatment 6 months after the initial visit. Of the patients who ended treatment within 6 months after the initial visit, 84 patients (39.2%) dropped out. In multivariate analysis, the dropouts were less likely to occur patients with primary diagnosis of psychological problem (odds ratio (OR): 0.35, 95% confidence interval (CI): 0.19 - 0.67).

Conclusions

Patients who visited a PSIM wanted consultation about psychological problems. Patients with a diagnosis of a psychological problem at the initial visit were less likely to drop out.

Self-Reported Hearing Aid Requirements among U.S. Military Personnel and the Association with Probable Posttraumatic Stress Disorder

BACKGROUND

 Auditory problems are ubiquitous among U.S. military personnel. Hearing aids are an effective treatment for both hearing loss and tinnitus, two of the most common diagnoses among veterans awarded disability compensation, but the prevalence of hearing aid requirements in the U.S. military is unknown. Another military health problem is posttraumatic stress disorder (PTSD), an anxiety disorder characterized by exposure to a traumatic event. While some studies have found an association between auditory problems and PTSD, no research has examined the relationship between hearing aid requirements and PTSD.

PURPOSE

 To identify the prevalence of self-reported hearing aid requirements in U.S. military personnel and examine the association with PTSD.

RESEARCH DESIGN

 Cross-sectional study.

STUDY SAMPLE

 The study population included 104,728 U.S. Navy and Marine Corps service members who completed a Periodic Health Assessment between August and December 2021.

DATA ANALYSIS

 Prevalence of self-reported hearing aid requirements was calculated. A multivariable logistic regression model was used to determine the association between hearing aid requirements and PTSD, while adjusting for covariates.

RESULTS

 Overall, 1.0% (1,088/104,728) of the study population self-reported requiring hearing aids. Hearing aid requirements were positively associated with age, and the highest prevalence was among those aged 40 years and older (3.8%). There was also a statistically higher prevalence among men compared with women (1.2 vs. 0.5%), Marines compared with Navy personnel (1.2 vs. 0.9%), and active duty compared with National Guard/Reserve components (1.1 vs. 0.6%). A significantly higher proportion of service members who required hearing aids screened positive for PTSD than those without hearing aids (30.4 vs. 7.5%). In multivariable regression, those who required a hearing aid, compared with those who did not, had more than three times higher odds of screening positive for PTSD (odds ratio: 3.45; 95% confidence interval: 3.00-3.96).

CONCLUSION

 To our knowledge, this is the first study to report the prevalence of self-reported hearing aid requirements in the U.S. military as well as an association between requiring hearing aids and screening positive for PTSD. Our findings reaffirm the need for interprofessional collaboration between audiologists and psychological health professionals when providing care for these patients.

Development of a booster intervention for graded sensorimotor retraining (RESOLVE) in people with persistent low back pain: A nested, randomised, feasibility trial

INTRODUCTION

Low back pain contributes to an increasing global health burden exacerbated by unsustained improvements from current treatments. There is a need to develop, and test interventions to maintain initial improvements from low back pain treatments. One option is to implement a booster intervention. This study aimed to develop and test the feasibility of implementing a booster intervention delivered remotely to supplement the benefits from a complex intervention for chronic low back pain.

METHOD

This study was nested in the RESOLVE trial. The booster intervention was developed by an expert group, including a clinical psychologist, exercise physiologist and physiotherapists, and based on a motivational interviewing framework. We developed a conversational flow chart to support the clinician to guide participants towards achieving their pre-specified personal goals and future low back pain self-management. Participants with chronic low back pain who were aged over 18 years and fluent in English were recruited. The booster intervention was delivered in one session, remotely, by telephone. The intervention was considered feasible if: participants were able to be contacted or <3 contacts were necessary to arrange the booster session; there were sufficient willing participants (<15% of sample unwilling to participate); and participants and research clinicians reported a perceived benefit of >7/10.

RESULTS

Fifty participants with chronic non-specific low back pain were recruited to test the feasibility of implementing the booster intervention. Less than three contact attempts were necessary to arrange the booster session, only one participant declined to participate. Participants perceived the session to be beneficial; on a 0 to 10 scale of perceived benefit, the average score recorded was 8.3 (SD 2.0). Clinicians also reported a moderate perceived benefit to the participant; the average score recorded by clinicians was 6.3 (SD 1.6).

CONCLUSION

We developed a step by step, simple booster intervention that was perceived to be beneficial to participants with chronic low back pain. The booster can feasibly be delivered remotely following a complex intervention.

Registered nurse-patient communication research: An integrative review for future directions in nursing research

AIM

To explore communication research in nursing by investigating the theoretical approaches, methods, content and perspectives in research on real-time registered nurse (RN)-patient communication.

DESIGN

An integrative review of real-time communication between RNs and patients.

DATA SOURCES

Empirical research papers were searched in PubMed, CINAHL Plus and Medline. The results from the database searches were supplemented with results from manual searches in reference lists.

REVIEW METHODS

A total of 1369 articles published between January 1996 and December 2021 were screened, which resulted in the inclusion of 52 articles.

RESULTS

The integration of various theories, such as nursing or communication theories, is weak in most of the included studies. RN-patient communication appears to influence relationship building. Even when nurses strive to meet patients' needs, they often focus primarily on nursing routines and physical care. The topic of the communication varies depending on the situation and different communication styles are used. When a patient-centred approach is adopted, the interpersonal communication becomes quite symmetrical, with complementary roles of nurses and patients. Within a more asymmetric communication context, nurses dominate communication, choose topics and function as instructors. How the nurses communicated subsequently influenced the patients' communication styles and strategies.

CONCLUSION

Communication is multifaceted, contains different strategies and is important for building trust and facilitating patient-centred care. The importance of RNs' communication for interaction and relationship-building seems to be well established within research, but few studies focused on patients' communication with RNs.

IMPACT

This integrative review gives an overview of the width and depth of observational studies on RN-patient communication research. The variety of studies indicates that this area is a less well-grounded field of research. Future research is warranted to support nurses in their communication, especially regarding the exploration of patients' communication and desired communication skills in nurse-patient interactions.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was included in this integrative review.

Person-centred education and advice for people with low back pain: Making the best of what we know

BACKGROUND

The first-line treatment consistently recommended for people with low back pain is patient education and advice. Regardless of the duration of low back pain, clinicians should provide education on the benign nature of low back pain, reassurance about the absence of a serious medical condition, and advice to remain active. There is little guidance on how best to provide this care.

OBJECTIVE

This Masterclass will draw on recent evidence to explore how physical therapy clinicians could deliver person-centred education and advice to people with low back pain to refine their clinical consultation.

DISCUSSION

First, we highlight the potential value of providing validation to acknowledge the distressing experience and consequences of low back pain. Second, we describe a tool to open channels of communication to provide education and advice in a patient-centred and efficient way. Clinicians could consider using the Attitude toward Education and advice for Low back pain Questionnaire to gain an insight into patient attitudes toward education and advice at the outset of a clinical encounter. Finally, we provide options for tailoring patient education and advice to promote self-management of low back pain based on patient attitudes. We present evidence that a positive attitude toward messages about causes rather than messages about physical activity predicts intention to self-manage low back pain. We combine this evidence to suggest a pathway for clinicians to provide education and advice to people with low back pain within the time constraints of a clinical consultation.

People with type 2 diabetes' experiences of emotional support in Australian general practice: a qualitative study

BACKGROUND

Diabetes distress, experienced by up to 40% of people with type 2 diabetes (T2D), is the negative emotional response to the burden of living with and managing diabetes. It is associated with suboptimal glycaemia and diabetes self-management. Research indicates that people with diabetes do not recall being asked about emotional distress by healthcare professionals.

AIM

To explore the experiences, needs, and expectations of people with T2D regarding emotional support received in Australian general practice.

DESIGN & SETTING

Exploratory qualitative study in Victoria, Australia.

METHOD

Semi-structured interviews were undertaken to explore emotional health and support received in general practice in 12 adults with T2D who primarily attend general practice. Interviews were audio-recorded, transcribed verbatim, and analysed using the framework approach.

RESULTS

The following three major themes were identified: (1) Beneath the surface of diabetes care; (2) Importance of GP-patient relationship; and (3) Communication counts. Participants experienced diabetes care as focused primarily on medical management rather than the emotional aspects of living with T2D. While people's experiences of diabetes care in general practice primarily focused on physical health, the GP care beyond the presenting complaint has an essential role in identifying emotional issues and enabling support. Emotional issues were more likely to be discussed and acknowledged by the GP where there was a long-standing relationship between GP and patient.

CONCLUSION

Pre-existing positive GP-patient relationships and supportive communication enable people with 2TD to raise emotional issues as part of diabetes care.

Motivations of the participants who post a message in an online health forum: a qualitative and quantitative descriptive study in French health forum Doctissimo

BACKGROUND

For more than 20 years, and despite the development of new social networks, health forums have remained a privileged place for people to discuss health issues. This study investigates the motivations of participants to post a message on a French online health forum (called 'Doctissimo') (Forum Santé - Doctissimo,  2022).

METHOD

Between January 1, 2017 and December 31, 2019, all the first messages recorded on the health forum doctissimo ( www.forum.doctissimo.fr ) were selected in their initial format by a crawler. The transcripts were imported into the qualitative analysis software Nvivo. Two researchers coded the data until a theoretical saturation was obtained.

RESULTS

We identified four categories of motivation: 1) 'Questioning' allows the exchange of mainly medical information, or sharing of feedback on experiences with the disease: 1722 codes, 44.8%, 2) Worry, need for reassurance: 1066 codes, 27.7% about symptoms or anticipatory anxiety, 3) 'Expressing oneself' mainly allows a catharsis and thus an emotional release, especially negative, but also to share a personal experience: 764 codes 19.9%, 4) Community spirit is a central element to create an emotional support group for psychological support, exchange ideas, meet people in similar situations: 291 codes, 7.6%. The relationship with a health professional when mentioned is generally marked by doubts 39.5%, confusion, or lack of information and the need for additional elements 64.6% or reassurance 60%. The relationship and the obstacles to a medical consultation are described in relation to the use of the forum: immediate availability, anonymity, absence of taboo and community spirit.

CONCLUSION

The use of information sources offered by the Internet is a way to ask questions, to be reassured, to express oneself or to be confirmed by the community in the hypothesis emitted by a health professional. Patients are looking for an immediate answer, they come to the community for reassurance, they feel free and legitimate.

Depression Screening Implementation: Quality Improvement Project in a Primary Care Clinic for First Responders

BACKGROUND

Depression in the U.S. population affects approximately 17.5 million people, with an approximate annual economic cost of US$326 billion. The overall objective of this quality improvement program was implementation of a standardized screening protocol using a validated screening instrument to identify depression in first responders in a primary care setting.

METHODS

This program applied the Knowledge-to-Action framework utilizing the 9-question Patient Health Questionnaire (PHQ-9) screening tool. The outcome measure was screening completion with a process measure of depression questionnaires provided to patients, and balance measures of time of visit and referral rate. In a pre-/postintervention project design, clinic staff were trained on depression screening. PHQ-9 questionnaires were placed in all exam rooms for patients and providers to discuss. Referrals were made to the staff psychologist or to medical providers based on evaluations.

FINDINGS

From pre- to postintervention, screening increased from less than 1% to a screening rate of 92%. Appointments for depression intervention increased to 50%, 44 patients for counseling and 12 for medical therapy.

CONCLUSIONS/APPLICATIONS TO PRACTICE

A standardized screening protocol using a validated self-assessment tool improved depression surveillance and increased referrals for treatment. A training program with an accompanying policy was designed to sustain this program and may serve as a model for other programs serving first responders.

The person-based development and realist evaluation of a pre-consultation form for GP consultations

Background

Use of telephone, video and e-consultations is increasing. These can make consultations more transactional, potentially missing patients' concerns. This study aimed to develop a complex intervention to address patients' concerns more comprehensively in general practice and test the feasibility of this in a cluster-randomised framework.The complex intervention used two technologies: a patient-completed pre-consultation form used at consultation opening and a doctor-provided summary report provided at consultation closure. This paper reports on the development and realist evaluation of the pre-consultation questionnaire.

Methods

A person-based approach was used to develop the pre-consultation form. An online questionnaire system was designed to allow patient self-completion of a form which could be shared with GPs. This was tested with 45 patients in three rounds, with iterative adjustments made based on feedback after each round.Subsequently, an intervention incorporating the pre-consultation form with the summary report was then tested in a cluster-randomised framework with 30 patients per practice in six practices: four randomised to intervention, and two to control. An embedded realist evaluation was carried out. The main feasibility study results are reported elsewhere.

Results

Intervention Development: 15 patients were recruited per practice. Twelve patients, six GPs and three administrators were interviewed and 32 changes were made iteratively in three rounds. Recruitment rates (proportion of patients responding to the text) increased from 15% in round one to 50% in round three.Realist evaluation: The pre-consultation form was most useful for people comfortable with technology and with hidden concerns or anxiety about the consultation. It resulted in more issues being discussed and support provided, more effective use of time and greater patient satisfaction.

Conclusions

The person-based approach was successful. The pre-consultation form uncovers more depth and improves satisfaction in certain consultations and patients. Technological improvements are required before this could be rolled out more widely.

Barriers and facilitators to asking adults with hearing loss about their emotional and psychological well-being: a COM-B analysis

OBJECTIVE

To explore the barriers and facilitators faced by hearing healthcare clinicians (HHCs) with respect to asking adults with hearing loss (HL) about their emotional well-being.

DESIGN

This qualitative study was conducted using semi-structured individual interviews and focus groups. The interview topic guide was developed based on the COM-B model.

STUDY SAMPLE

Fifteen HHCs of a single hearing services organisation in Western Australia across 13 clinic locations participated.

RESULTS

Barriers and facilitators that may influence HHCs' behaviour of routinely asking adults about their emotional well-being include having the knowledge and skills to ask about emotional well-being, forgetting to ask, awareness of the emotional impacts of HL, time and tools for asking, clients' reactions to being asked, supportive peers, normalisation of discussions relating to emotional well-being, presence of significant others, emotions associated with asking, being in the habit of asking, reminders, beliefs about consequences and confidence or capabilities, and scope of audiology practice.

CONCLUSIONS

Application of the COM-B model identified barriers in capabilities (e.g. knowledge), opportunities (e.g. tools), and motivation (e.g. beliefs about benefits of asking about emotions) that need to be addressed for HHCs to ask their clients about their emotional well-being.

Perspectives on Mental Health Screening in the Audiology Setting: A Focus Group Study Involving Clinical and Nonclinical Staff

PURPOSE

Audiology clinical guidelines recommend the use of mental health screening tools; however, they remain underutilized in clinical practice. As such, psychological concerns are frequently undetected in adults with hearing loss. This study aimed to better understand audiology clinic staff's perspectives (including audiologists, audiometrists, reception staff, and clinic managers) on how to improve detection of poor mental health by (a) exploring the role of audiology clinic staff in detecting psychological concerns in adults with hearing loss and (b) investigating the appropriateness, acceptability, and usability of several screening tools in an audiology setting.

METHOD

Eleven audiology clinic staff (M _age = 33.9 ± 7.3, range: 25-51 years) participated in a semistructured focus group. First, participants discussed the role of audiology clinic staff in detecting psychological difficulties in adults with hearing loss, including current practices and needs for improving practices. Second, participants discussed the appropriateness, acceptability, and usability of nine standardized mental health screening tools commonly used in wider health care settings.

RESULTS

Audiology clinic staff described their role in being aware of, and detecting, psychological difficulties, as well as their part in promoting an understanding of the link between hearing loss and mental health. Participants described the need to provide support following detection, and highlighted barriers to fulfilling these roles. The use of mental health screening tools was considered to be client and context specific. The language used within the screener was identified as an important factor for its acceptability by audiology clinic staff.

CONCLUSIONS

Audiology clinic staff acknowledged that they have an important role to play in the detection of psychological difficulties and identified the core barriers to using screening tools. Future research may explore the possibility of developing a mental health screening tool specific to the unique experiences of adults with comorbid hearing loss and mental health concerns.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.16702501.

When patients and clinician (dis)agree about the nature of the problem: The role of displays of shared understanding in acceptance of treatment

Globally, 4.4% of the world's population suffer from depressive disorder, and 3.6% from anxiety disorder. Previous work found considerable negotiation between providers and patients about the nature of mental health problems and frequent patient resistance to treatment. However, how doctor-patient shared understanding of the problem is reflected in treatment recommendations and whether this is consequential for patient acceptance of treatment is poorly understood. This study explored shared understanding of the problem and patient acceptance of treatment using conversation analysis. In 52 U.K. video recorded primary care consultations (collected July 2014-April 2015), 33 treatment recommendations for medication or talking therapy were identified. Shared understanding was explored focusing on: whether the patient presented the mental health problem as their primary initial concern and how they characterised the concern; whether the mental health concern was raised by the patient; and how the doctor aligned with the patient's earlier characterisation of the problem in the treatment recommendation itself. These phenomena were coded for each treatment recommendation and the impact on treatment acceptance was explored. Patients accepted the recommendation immediately in 38% cases and actively resisted in 62% cases. However, two communication behaviors were associated with patient acceptance: recommending treatment for the patient's initial focal concern and doctors' turn design in the recommendation itself, i.e., using the patient's earlier words from the initial problem presentation to describe and characterise the problem. Given the global burden of mental health problems and frequent patient resistance to treatment, understanding how professionals can engage more closely with the patient's perspective is important. When doctors use the patient's precise words from the initial problem presentation in the treatment recommendation, this displays an understanding of the patient's perspective and personalisation of treatment based on the underlying biomedical or social causes, which then impacts on patient acceptance of treatment.

GPs' and patients' views on the value of diagnosing anxiety disorders in primary care: a qualitative interview study

Background

In the UK between 1998 and 2008, GPs’ recording of anxiety symptoms increased, but their recording of anxiety disorders decreased. The reason for this decline is not clear, nor are the treatment implications for primary care patients.

Aim

To understand GPs’ and patients’ views on the value of diagnosing anxiety disorders in primary care.

Design and setting

In-depth interviews were conducted with 15 GPs and 20 patients, purposively sampled from GP practices in Bristol and the surrounding areas.

Method

Interviews were held either in person or by telephone. A topic guide was used to ensure consistency across the interviews. The interviews were audio-recorded, transcribed verbatim, and analysed thematically.

Results

GPs reported preferring to use symptom rather than diagnostic codes in order to avoid assigning potentially stigmatising labels, and because they felt diagnostic codes could encourage some patients to adopt a ‘sick role’. In addition, their decision to use a diagnostic code depended on symptom severity and chronicity, and these were hard to establish in a time-limited clinical consultation. In contrast, patients commented that receiving a diagnosis helped them to understand their symptoms, and encouraged them to engage with treatment.

Conclusion

GPs may be reluctant to diagnose an anxiety disorder, but patients can find a diagnosis helpful in terms of understanding their symptoms and the need for treatment. As limited consultation time can discourage discussions between GPs and patients, followup appointments and continuity of care may be particularly important for the management of anxiety in primary care.

'Relieved to be seen'-patient and carer experiences of psychosocial assessment in the emergency department following self-harm: qualitative analysis of 102 free-text survey responses

OBJECTIVES

We sought to explore patient and carer experiences of psychosocial assessments following presentations to hospital after self-harm.

DESIGN

Thematic analysis of free-text responses to an open-ended online survey.

SETTING

Between March and November 2019, we recruited 88 patients (82% women) and 14 carers aged ≥18 years from 16 English mental health trusts, community organisations, and via social media.

RESULTS

Psychosocial assessments were experienced as helpful on some occasions but harmful on others. Participants felt better, less suicidal and less likely to repeat self-harm after good-quality compassionate and supportive assessments. However, negative experiences during the assessment pathway were common and, in some cases, contributed to greater distress, less engagement and further self-harm. Participants reported receiving negative and stigmatising comments about their injuries. Others reported that they were refused medical care or an anaesthetic. Stigmatising attitudes among some mental health staff centred on preconceived ideas over self-harm as a 'behavioural issue', inappropriate use of services and psychiatric diagnosis.

CONCLUSION

Our findings highlight important patient experiences that can inform service provision and they demonstrate the value of involving patients/carers throughout the research process. Psychosocial assessments can be beneficial when empathetic and collaborative but less helpful when overly standardised, lacking in compassion and waiting times are unduly long. Patient views are essential to inform practice, particularly given the rapidly changing service context during and after the COVID-19 emergency.

Parents' expectations and experiences of the 6-week baby check: a qualitative study in primary care

Background

The Newborn and Infant Physical Examination (NIPE) programme requires all babies to have a comprehensive health check at 6–8 weeks of age. These are typically completed by GPs. Although person-centred care has achieved prominence in maternity care policy in recent years, there is limited empirical evidence on what parents and/or carers expect from the check, and how far experiences meet their needs.

Aim

 To explore the expectations and experiences of parents attending their GP for a baby check.

Design & setting

A qualitative study was undertaken in primary care in London.

Method

Content analysis was undertaken of transcripts of semi-structured interviews. Interviews were conducted with a total of 16 participants (14 mothers and two fathers) who had recently attended for a 6-week check for their baby.

Results

Despite the availability of plentiful sources of general advice on infants’ health and development, a thorough check by a trusted GP was an important milestone for most parents. They had few specific expectations of the check in terms of what examinations were undertaken, but even experienced parents anticipated reassurance about their baby’s normal development. Many also hoped for reassurance about their own parenting. Parents appreciated GPs who explained what they were doing during the examination; space to raise any concerns; and combined mother and baby checks. Referrals to secondary care were generally experienced as reassuring rather than a source of anxiety.

Conclusion

The baby check meets needs beyond those of the NIPE screening programme. Protecting the time for a thorough consultation is important for parents at what can be a vulnerable time.