Multi-causational approach to illness in young children: the role of psychological and social factors

Thesis (M.S.)--Boston Universit

Exploratory study of victim advocacy practices, strategies, resistance and relationships among crime victim service agencies

Title from PDF of title page (University of Missouri--Columbia, viewed on March 1, 2010).The entire thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file; a non-technical public abstract appears in the public.pdf file.Dissertation advisor: Dr. Martha Markward.Vita.Ph.D. University of Missouri--Columbia 2009.Social work has long been a field of advocacy, and has progressively integrated into the crime victim advocacy movement by practicing in domestic violence shelters, prosecutors' offices, law enforcement, child advocacy centers and community agencies. This study surveyed 110 victim advocates employed in these agencies to examine the practice of advocacy within the individual, administrative and policy levels, strategies of practice, agency relationships, and resistance to advocacy between agencies. Results show victim advocates practice at all advocacy levels, use all strategies of advocacy, and have mostly allied relationships. Differences in advocacy strategies and relationships were found in rural areas, where advocates are more likely to use moral reasoning and value-based advocacy, have more adversarial relationships with law enforcement and prosecutors' offices, and experience more resistance. Recommendations include implementing multidisciplinary training, development of professional advocate standards, increased communication among agencies and implications for policy and future research.Includes bibliographical reference

The "unknown territory" of goal-setting: Negotiating a novel interactional activity within primary care doctor-patient consultations for patients with multiple chronic conditions.

Goal-setting is widely recommended for supporting patients with multiple long-term conditions. It involves a proactive approach to a clinical consultation, requiring doctors and patients to work together to identify patient’s priorities, values and desired outcomes as a basis for setting goals for the patient to work towards. Importantly it comprises a set of activities that, for many doctors and patients, represents a distinct departure from a conventional consultation, including goal elicitation, goal-setting and action planning. This indicates that goal-setting is an uncertain interactional space subject to inequalities in understanding and expectations about what type of conversation is taking place, the roles of patient and doctor, and how patient priorities may be configured as goals. Analysing such spaces therefore has the potential for revealing how the principles of goal-setting are realised in practice. In this paper, we draw on Goffman’s concept of ‘frames’ to present an examination of how doctors’ and patients’ sense making of goal-setting was consequential for the interactions that followed. Informed by Interactional Sociolinguistics, we used conversation analysis methods to analyse 22 video-recorded goal-setting consultations with patients with multiple long-term conditions. Data were collected between 2016 and 2018 in three UK general practices as part of a feasibility study. We analysed verbal and non-verbal actions for evidence of GP and patient framings of consultation activities and how this was consequential for setting goals. We identified three interactional patterns: GPs checking and reframing patients’ understanding of the goal-setting consultation, GPs actively aligning with patients’ framing of their goal, and patients passively and actively resisting GP framing of the patient goals. These reframing practices provided “telling cases” of goal-setting interactions, where doctors and patients need to negotiate each other’s perspectives but also conflicting discourses of patient-centredness, population-based evidence for treating different chronic illnesses and conventional doctor-patient relations

Support during birth interacts with prior trauma and birth intervention to predict postnatal post-traumatic stress symptoms

Background: Many women experience childbirth as traumatic and 2% develop post-traumatic stress disorder (PTSD). This study examined the role of health practitioner support and personal control during birth as predictors of PTS symptoms, adjusting for vulnerability factors of prior trauma, depression, control beliefs and birth intervention. It also investigated interactions between support, prior trauma and birth intervention and their association with PTS symptoms. Methods: A prospective longitudinal survey of 138 women recruited from UK NHS maternity clinics. Measures were taken in pregnancy, three-weeks and three-months after the birth. Results: Support and control during birth were not predictive of postnatal PTS symptoms. However, support was predictive of PTS symptoms in a subset of women with prior trauma (beta = -.41, R2 = 16%) at both three-weeks and three-months postpartum. The interaction of birth intervention and support was associated with PTS symptoms three-months after birth, the relationship between support and PTS symptoms was stronger in women experiencing more intervention. Conclusions: Low support from health practitioners is predictive of postnatal PTS symptoms in women who have a history of trauma. Longer-term effects of low support on postnatal PTS symptoms are also found in women who had more intervention during birth

Protocol: Which variables are useful for phenotyping dementia in primary care records? A meta-analysis

Dementia is usually identified in primary care by general practitioners (GPs) and most identified patients are referred on to memory assessment clinics for formal diagnosis. However, epidemiological studies suggest only 50% of dementia cases are recorded in general practice. The UK government and the NHS have made increasing diagnosis rates a strategic priority. A range of indicators in the primary care record are likely to be predictive of patients at high risk of dementia and could be combined in a predictive model to help increase diagnosis rates. As part of the Wellcome Trust funded ASTRODEM study, we aim to conduct a systematic review and meta-analysis to identify conditions and medications previously found to be associated with dementia in primary care records

“Giving something back”: a systematic review and ethical enquiry into public views on the use of patient data for research in the United Kingdom and the Republic of Ireland

Background: Use of patients’ medical data for secondary purposes such as health research, audit, and service planning is well established in the UK. However, the governance environment, as well as public understanding about this work, have lagged behind. We aimed to systematically review the literature on UK and Irish public views of patient data used in research, critically analysing such views though an established biomedical ethics framework, to draw out potential strategies for future good practice guidance and inform ethical and privacy debates. Methods: We searched three databases using terms such as patient, public, opinion, and electronic health records. Empirical studies were eligible for inclusion if they surveyed healthcare users, patients or the public in UK and Ireland and examined attitudes, opinions or beliefs about the use of patient data for medical research. Results were synthesised into broad themes using a framework analysis. Results: Out of 13,492 papers and reports screened, 20 papers or reports were eligible. While there was a widespread willingness to share patient data for research for the common good, this very rarely led to unqualified support. The public expressed two generalised concerns about the potential risks to their privacy. The first of these concerns related to a party’s competence in keeping data secure, while the second was associated with the motivation a party might have to use the data. Conclusions: The public evaluates trustworthiness of research organisations by assessing their competence in data-handling and motivation for accessing the data. Public attitudes around data-sharing exemplified several principles which are also widely accepted in biomedical ethics. This provides a framework for understanding public attitudes, which should be considered in the development in any guidance for regulators and data custodians. We propose four salient questions which decision makers should address when evaluating proposals for the secondary use of dat

Use of propensity score methods to address adverse events associated with the storage time of blood in an obstetric population: a comparison of methods

BACKGROUND: A recent topic of interest in the blood transfusion literature is the existence of adverse effects of transfusing red cells towards the end of their storage life. This interest has been sparked by conflicting results in observational studies, however a number of methodological difficulties with these studies have been noted. One potential strategy to address these difficulties is the use of propensity scores, of which there are a number of possible methods. This study aims to compare the traditional methods for binary exposures with more recently developed generalised propensity score methods. METHODS: Data were obtained from probabilistically linked hospital, births and blood bank databases for all women giving birth from 23 weeks gestation in New South Wales, Australia, between July 2006 and December 2010 with complete information on the birth admission and blood issued. Analysis was restricted to women who received 1–4 units of red cells. Three different propensity score methods (for binary, ordinal and continuous exposures) were compared, using each of four different approaches to estimating the effect (matching, stratifying, weighting and adjusting by the propensity score). Each method was used to determine the effect of blood storage time on rates of severe morbidity and readmission or transfer. RESULTS: Data were available for 2990 deliveries to women receiving 1–4 units of red cells. The rate of severe maternal morbidity was 3.7 %, and of readmission or transfer was 14.4 %. There was no association between blood storage time and rates of severe morbidity or readmission irrespective of the approach used. There was no single optimal propensity score method; the approaches differed in their ease of implementation and interpretation. CONCLUSIONS: Within an obstetric population, there was no evidence of an increase in adverse events following transfusion of older blood. Propensity score methods provide a useful tool for addressing the question of adverse events with increasing storage time of blood, as these methods avoid many of the pitfalls of previous studies. In particular, generalised propensity scores can be used in situations where the exposure is not binary

Diagnosis and management of perinatal depression and anxiety in general practice: a meta-synthesis of qualitative studies

BACKGROUND: Up to 20% of women experience anxiety and depression during the perinatal period. In the UK, management of perinatal mental health falls under the remit of GPs. AIM: This review aimed at synthesising the available information from qualitative studies on GPs' attitudes, recognition, and management of perinatal anxiety and depression. DESIGN AND SETTING: Meta-synthesis of the available published qualitative evidence on GPs' recognition and management of perinatal anxiety and depression. METHOD: A systematic search was conducted on Embase, Medline, PsycInfo, Pubmed, Scopus, and Web of Science, and grey literature was searched using Google, Google Scholar, and British Library EThOS. Papers and reports were eligible for inclusion if they reported qualitatively on GPs' diagnosis or treatment of perinatal anxiety or depression. The synthesis was constructed using meta-ethnography. RESULTS: Five themes were established from five eligible papers: labels: diagnosing depression; clinical judgement versus guidelines; care and management; use of medication; and isolation: the role of other professionals. GPs considered perinatal depression to be a psychosocial phenomenon, and were reluctant to label disorders and medicalise distress. GPs relied on their own clinical judgement more than guidelines. They reported helping patients make informed choices about treatment, and inviting them back regularly for GP visits. GPs sometimes felt isolated when dealing with perinatal mental health issues. CONCLUSION: GPs often do not have timely access to appropriate psychological therapies and use several strategies to mitigate this shortfall. Training must focus on these issues and must be evaluated to consider whether this makes a difference to outcomes for patients

Using electronic health records to support clinical trials: a report on stakeholder engagement for EHR4CR

Background. The conduct of clinical trials is increasingly challenging due to greater complexity and governance requirements as well as difficulties with recruitment and retention. Electronic Health Records for Clinical Research (EHR4CR) aims at improving the conduct of trials by using existing routinely collected data, but little is known about stakeholder views on data availability, information governance, and acceptable working practices. Methods. Senior figures in healthcare organisations across Europe were provided with a description of the project and structured interviews were subsequently conducted to elicit their views. Results. 37 structured interviewees in Germany, UK, Switzerland, and France indicated strong support for the proposed EHR4CR platform. All interviewees reported that using the platform for assessing feasibility would enhance the conduct of clinical trials and the majority also felt it would reduce workloads. Interviewees felt the platform could enhance trial recruitment and adverse event reporting but also felt it could raise either ethical or information governance concerns in their country. Conclusions. There was clear support for EHR4CR and a belief that it could reduce workloads and improve the conduct and quality of trials. However data security, privacy, and information governance issues would need to be carefully managed in the development of the platform

“You don’t immediately stick a label on them”: a qualitative study of influences on general practitioners’ recording of anxiety disorders

Objectives: Anxiety is a common condition usually managed in general practice (GP) in the UK. GP patient records can be used for epidemiological studies of anxiety as well as clinical audit and service planning. However it is not clear how General Practitioners (GPs) conceptualise, diagnose and document anxiety in these records. We sought to understand these factors through an interview study with GPs. Setting: United Kingdom (UK) NHS General Practice (England and Wales) Participants: 17 UK GPs Primary and Secondary Outcome Measures: Semi-structured interviews used vignettes to explore the process of diagnosing anxiety in primary care and investigate influences on recording. Interviews were transcribed verbatim and analysed using thematic analysis. Results: GPs chose 12 different codes for recording anxiety in the two vignettes, and reported that history, symptoms and management would be recorded in free text. GPs reported on four themes representing influences on recording of anxiety: “anxiety or a normal response”, “granularity of diagnosis”, “giving patients a label”, and “time as a tool”; and three themes about recording in general: “justifying the choice of code”, “usefulness of coding” and “practice specific pressures”. GPs reported using only a regular selection of codes in patient records to help standardise records within the practice and as a time saving measure. Conclusions: We have identified a coding culture where GPs feel confident recognising anxiety symptoms, however due to clinical uncertainty, a long term perspective and a focus on management they are reluctant to code firm diagnoses in the initial stages. Researchers using GP patient records should be aware that GPs may prefer free text, symptom codes and other general codes rather than firm diagnostic codes for anxiety