Patients' perspectives on depression case management in general practice - a qualitative study

Objective

General practice-based case management is effective in improving symptoms, adherence, and the perceived process of care of patients living with major depression. The aim was to explore the patients’ perceptions of practice-based depression case management, their satisfaction with it and how living with depression contextualizes case management.

Methods

This qualitative study was nested in a large cluster-randomized controlled trial on the effectiveness of case management for patients living with major depression. Case management was provided over 12 months by practice-based health care assistants, who monitored symptoms. We undertook semi-structured interviews with 41 patients, then transcribed and analysed them using qualitative content analysis.

Results

Patients described depression as the unfortunate situation, where loneliness and lack of energy lead to being unable to actively seek help. Case management was appreciated because of regular, proactive contact and support by health care assistants. It was crucial to patients that they could trust the health care assistant. Some patients complained that case management was undertaken too mechanically and lacked empathy.

Conclusion

Patients living with depression may perceive practice-based case management as beneficial if carried out in a trustworthy and empathetic manner.

Practice implications

General practices should ensure that depression case management is patient-centered and non-mechanical.     

Barriers to the adoption of computerised decision support systems in general practice consultations: a qualitative study of GPs' perspectives

INTRODUCTION: Computerised decision support systems are increasingly important in primary care for the practice of evidence-based medicine and the development of shared GP-patient decision making. However, despite their emergence, such systems have not been entirely embraced by GPs. There is little qualitative research exploring practical barriers to the adoption of decision support systems in this setting. METHOD: Qualitative interviews with 15 GPs in the West Midlands. RESULTS: Several practical barriers were identified to the use of computerised support systems in primary care consultations. These included limitations of practitioners' IT skills, problems for GPs in understanding the risk output of systems and GP concerns about communicating risk sufficiently well to patients. Concerns over the time implications of using a system in a consultation was also identified as a barrier. CONCLUSION: Designers of decision support systems for use in primary care consultations must account for the practical needs of users when developing computerised support systems. Systems must be acceptable to the format of a consultation, include definitions of what output means, and help facilitate dialogue between the GP and the patient.     

Effectiveness and impact of networked communication interventions in young people with mental health conditions: a systematic review

Objective

Examine the effectiveness and impacts of the networked communication technologies used by health care professionals for the treatment of adolescents/young adults with mental health disorders.

Methods

Nine electronic databases were searched. Quantitative and qualitative study designs were included, technologies were described and a narrative synthesis of all included studies was undertaken.

Results

20,925 papers were identified from which 12 interventions met the inclusion criteria. Three categories of networked communication were identified: email and/or web-based electronic diary (n = 6); videoconference (n = 5); and virtual reality (n = 1). Three studies reported statistically significant improvements in symptoms post intervention; all involved email communication. Patients were willing to use networked communication in routine care in nine studies.

Conclusions

Networked communication technologies can increase the opportunity for communication between patient and health care professionals. Limited improvements in quality of life and continuity of care for patients were reported. Patients and health care professionals expressed some satisfaction with technologies. Further research exploring concerns over privacy and security is needed.

Practice implications

Networked communication technologies have the potential to be a useful addition to mental health services delivery, however the impact and effectiveness of these technologies is inconclusive.     

Active involvement of young people with T1DM during outpatient hospital consultations: Opportunities and challenges in transitional care services

ObjectiveLittle is known about active involvement of young people (YP) with type 1 diabetes (T1DM) in transitional care. This study aims to gain insight into patient-provider interactions during outpatient hospital consultations.MethodsSemi-structured observations (n = 61) of outpatient consultations with YP with T1DM (15–25 years) treated in 12 hospitals in the Netherlands. The consultations concerned pediatric care (n = 23), adult care (n = 17), and joint consultations (n = 21). Thematic data analysis focused on whether professionals engaged in open, in-depth conversations; used motivational interviewing techniques; involved YP in shared decision-making; and addressed non-medical topics.ResultsApart from some good examples, the healthcare professionals generally had difficulty interacting adequately with YP. They paid little attention to the YP’s individual attitudes and priorities regarding disease management; non-medical topics remained generally underexposed. Conversations about daily life often remained shallow, as YP’s cues were not taken up. Furthermore, decisions about personal and health-related goals were often not made together.ConclusionBy adopting a more person-centered approach, professionals could empower YP to take an active role in their diabetes management.Practice implicationsUsing a structured conversation model combined with a tool to encourage YP’s agenda-setting and shared decision-making is recommended for more person-centered transitional care in T1DM.     

Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: A qualitative study embedded in a randomized controlled trial

ObjectiveTo explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD).MethodsSemi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient–practitioner relationships. Transcribed data were analyzed using the Framework approach.Results38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring.ConclusionTelemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of ‘compliant self-management’ may paradoxically have promoted dependence on professionals.Practice implicationsPatients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support.     

Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: A qualitative study embedded in a randomized controlled trial

Objective

To explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD).

Methods

Semi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient–practitioner relationships. Transcribed data were analyzed using the Framework approach.

Results

38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring.

Conclusion

Telemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of ‘compliant self-management’ may paradoxically have promoted dependence on professionals.

Practice implications

Patients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support.     

A qualitative inquiry about weight counseling practices in community health centers

Objective

To use qualitative methods to explore how clinicians approach weight counseling, including who they counsel, how they bring up weight, what advice they provide, and what treatment referral resources they use.

Methods

Thirty primary care physicians, physician assistants, and nurse practitioners from four multi-clinic community health center systems (CHCs) in the state of Georgia (U.S.) completed one-on-one semi-structured interviews. Interviews were digitally recorded, transcribed verbatim, and coded.

Results

Clinicians report addressing weight with those who have weight-related chronic conditions, are established patients, or have a change in weight since the previous visit. Most clinicians address weight in the context of managing or preventing chronic conditions. Clinicians report providing detailed dietary advice to patients, including advice about adding or avoiding foods. Many clinicians base advice on their own experiences with weight. Most report no community-based resources to offer patients for weight loss. In the absence of resources, clinicians develop or use existing brochures, refer to in-house weight programs, or use online resources.

Conclusion

Clinicians use a variety of approaches for addressing weight, many of which are not evidence-based. Linkages with weight loss resources in the health care system or community are not widely reported.

Implications for practice

Clinicians and others from the primary care team should continue to offer weight-related counseling to patients with obesity, however, evidence-based treatment approaches for weight loss may need to be adapted or expanded for the CHC practice environment.     

The experiences of people with young-onset dementia: A meta-ethnographic review of the qualitative literature

Dementia is usually diagnosed in later life but can occur in younger people. The experiences of those with older-onset dementia are relatively well understood but little is known about the experiences of those with young-onset dementia (aged less than 65 years).This meta-ethnography therefore synthesised qualitative literature investigating the experiences of people with young-onset dementia (YOD). Six electronic databases were searched and 1155 studies were identified, of which eight fitted the inclusion criteria.These studies were all from Western countries, were mostly recent (2004–2015) and included the experiences of 87 people with YOD. Participants were generally in their fifties or early sixties and were living at home with others. Many reported difficulties both in the process of receiving a diagnosis and afterwards. Diagnosis felt unexpected, ‘out of time’ and led to changes in self-identity, powerlessness and changes in relationships. Social exclusion was common. Loss of meaningful activity exacerbated a difficult situation. However, the diagnosis did not mean people’s lives were over and many with YOD try to regain control by seeking connections with others with the same condition − sometimes a very important source of support.Overall, people living with YOD face unique social challenges which go beyond those of older people living with dementia and which result in an even greater negative impact on their lives. Interventions that facilitate peer support and allow people with YOD to engage in meaningful activity should be developed and could perhaps be provided by the voluntary sector.     

Coping with cancer: A qualitative study of adolescent and young adult perspectives

ObjectivesCancer can have long-term biopsychological impacts for young people that persist for years. To promote adjustment, it is essential to understand how young people cope, yet this is relatively understudied.MethodsThis study explored the coping strategies using semi-structured interviews with 16 young people with cancer aged 15–24 years. Eligible participants were diagnosed within the previous 24 months and recruited through Australian Youth Cancer Services. Transcribed interviews were analysed using content analysis.ResultsCoping strategies included: seeking support; controlling the focus; avoiding negatives and staying positive; meaning making and; changes with time. During treatment, seeking support, focussing on the present, distraction and avoidance were commonly applied. Following treatment, planning for the future, avoidance of re-traumatising situations and meaning making were used.ConclusionFindings support the concept of coping as a dynamic process where different strategies are used depending on the stressor, available resources and previous experiences.Practice ImplicationsComprehensive, developmentally appropriate psychosocial assessments, open communication, education and information provision, as well as appropriate referral for support are essential, particularly for young cancer survivors identified at risk.     

Women's experiences of health visitor delivered listening visits as a treatment for postnatal depression: A qualitative study

Objective

To explore women's experiences of health visitor delivered listening visits as a treatment for postnatal depression.

Methods

In-depth interviews with 22 women who had received listening visits as a treatment for postnatal depression.

Results

All the women reported the visits as beneficial, although many of them had required additional intervention to manage their symptoms. Women who had a previous history of depression and women whose depression was not attributed to events in the postnatal period perceived the listening visits to be less beneficial. Receiving visits from a research health visitor, rather than their practice health visitor, was felt to be advantageous.

Conclusion

Women with postnatal depression may report listening visits as helpful but insufficient to manage their depression. The extent to which women report listening visits as beneficial appears to be linked to the causes of their depression, the way in which the visits are delivered and by whom.

Practice implications

Practitioners managing women with postnatal depression should discuss possible causes and previous episodes of depression before suggesting listening visits as a treatment. They need to explain what the visits will entail, ensure that additional types of treatment remain available and encourage women to utilise other forms of support.     

Using qualitative methods to inform the design of a decision aid for people with advanced cystic fibrosis: The InformedChoices CF patient decision aid

ObjectiveTo assess information needs of adults with Cystic Fibrosis and their families toward designing a patient decision aid about invasive mechanical ventilation (IMV) and lung transplant.MethodsFocus groups and in-depth interviews explored participants’ knowledge, prior clinical conversations, and decisions about IMV and lung transplant. Interviews and focus groups were recorded and transcribed for analysis.ResultsN = 24 participants were recruited. Themes identified were: prior communication with clinicians, decision-making process, and living with CF. Participants having prior conversations with CF clinicians regarding: lung transplant (N = 17/74%), and IMV (N = 3/13%). Most 15(65%) felt it was important to hear patients’ real-life experience, others (3/13%) relied on their CF doctors for information. Most people (16/70%) believed hearing prognosis was helpful, but 5(22%) found this information frightening. High degrees of social isolation and a desire for more interaction with other CF adults were found.ConclusionsQualitative methods helped identify areas important for decision making about IMV and LT for CF adults. Future directions include usability and feasibility testing of the decision aid.Practice implicationsBecause IMV is rarely discussed with CF adults, clinicians might approach this topic, as with transplant, as lung function begins to decline. CF-care teams should also foster CF patient-level information exchange.     

Understanding what helps or hinders asthma action plan use: a systematic review and synthesis of the qualitative literature

Objective

To understand better what helps and/or hinders asthma action plan use from the professionals and patients/carers perspective.

Methods

Systematic review and qualitative synthesis (using meta-ethnography).

Results

Nineteen studies (20 papers) were included in an analysis of patients/carers’ and professionals’ views. Seven main influences on action plan implementation were identified including perceived un-helpfulness and irrelevance of the plans. Translation and synthesis of the original authors’ interpretations suggested that action plan promotion and use was influenced by professional and patient/carers’ asthma beliefs and attitudes and patient/carer experiences of managing asthma. Action plan use is hindered because professionals and patients/carers have different explanatory models of asthma, its management and their respective roles in the management process. Patients/carers, based on their experiential knowledge of their condition, perceive themselves as capable, effective in managing their asthma, but health professionals do not always share this view.

Conclusion

Professionally provided medically focused action plans that do not ‘fit’ with and incorporate the patients’/carers’ views of asthma, and their management strategies, will continue to be under-utilised.

Practice implications

Professionals need to develop a more patient-centred, partnership-based, approach to the joint development and review of action plans, recognising the experiential asthma knowledge of patients/carers.     

Perspectives of older people engaging in nurse-led cardiovascular prevention programmes: a qualitative study in primary care in the Netherlands

BackgroundCardiovascular prevention programmes are increasingly being offered to older people. To achieve the proposed benefits, adherence is crucial. Understanding the reasons for adherence and non-adherence can improve preventive care.AimTo gain insight into what motivates older people living in the community to partake in a cardiovascular prevention programme, and reasons for subsequent continuation or withdrawal.MethodSemi-structured interviews were conducted with a purposive sample of 15 participants (aged 76–82 years). Interviews were audiorecorded and analysed by two independent researchers using a thematic approach. Participants were asked about their motivation for participating in the programme, along with the facilitators and barriers to continue doing so.ResultsResponders reported that regular check-ups offered a feeling of safety, control, or being looked after, and were an important motivator for participation. For successful continuation, a personal relationship with the nurse and a coaching approach were both essential; the lack of these, along with frequent changes of nursing staff, were considered to be barriers. Participants considered general preventive advice unnecessary or patronising, but practical support was appreciated.ConclusionTo successfully engage older people in long-term, preventive consultations, the approach of the healthcare provider is crucial. Key elements are to offer regular check-ups, use a coaching approach and to build a personal relationship with the patient.     

Older people's preferences for involvement in their own care: a qualitative study in primary health care in 11 European countries

OBJECTIVE: The aim of the study was to explore the views of people aged over 70 years on involvement in their primary health care in 11 different European countries. METHODS: Older patients were asked about their views on patient involvement in a face-to-face interview. All interviews were audio-recorded, transcribed and analysed in accordance with the principles of 'qualitative content analysis'. An international code list was used. RESULTS: Four hundred and six primary care patients aged between 70 and 96 years were interviewed. Their views could be categorized into four major groups: doctor-patient interaction, GP related topics, patient related issues and contextual factors. CONCLUSION: People over 70 do want to be involved in their care but their definition of involvement is more focussed on the 'caring relationship', 'person-centred approach' and 'receiving information' than on 'active participation in decision making'. PRACTICE IMPLICATIONS: The desire for involvement in decision making is highly heterogeneous so an individual approach for each patient in the ageing population is needed. Future research and medical education should focus on methods and training to elicit older patients' preferences. The similar views in 11 countries suggest that methods for enhancing patient involvement in older people could be internationally developed and exchanged.     

Factors associated with readiness to start antiretroviral therapy (ART) among young people (15–24 years) at four HIV clinics in Mulago Hospital,Uganda

IntroductionGlobally, the HIV burden continues to rise among young people despite the discovery of ART. This study assessed demographic and psycho-social factors among young people associated with readiness to be initiated on ART.MethodsA quantitative cross-sectional study was conducted among newly diagnosed HIV positive young people aged 15–24 years at 4 HIV clinics at Mulago Hospital. Readiness was measured as a self-report by the individual to the question, “How ready do you feel to start ART?ResultsOf the 231 young people enrolled, the mean age (SD) was 20.7years (+/-2.8) and most were female (66.2%). Majority were very ready (53.3%) and very motivated (51.1%) to start ART. Higher treatment readiness was associated with being female (95% CI [5.62, 8.31], p=0.003), thinking that ART cures HIV (95% CI [0.43, 0.86], p=0.005), history of having unprotected sex (95% CI [0.79, 0.87], p=<0.001), anticipating negative HIV results (95% CI [0.26, 0.88], p=0.017), internalized stigma (95% CI [0.83, 0.98], p=0.018) and knowledge of positive ART effects for others (95% CI [0.84, 0.93], p=<0.001).ConclusionsUnderstanding the underlying factors associated with ART readiness among young people can inform strategies to support and increase individuals'' readiness to initiate ART and early engagement in care.