The 'demanding patient' : fact or fallacy? : investigating patient influence on somatically oriented treatment decisions for medically unexplained symptoms in general practice

BACKGROUND: Patients who present physical symptoms in the absence of physical pathology are common in primary care. They are often considered by doctors to be amongst the most difficult patients to manage and their overinvestigation and treatment has been well documented. Whilst the finger is often pointed at the patient as the instigator of such treatment, there is currently little objective evidence implicating the patient directly to this potentially iatrogenic treatment process. The concept of `patient demand' largely stems from anecdotal evidence of doctors concerning their feelings of being pressurised by such patients. AIMS AND OBJECTIVES: To investigate how patients with unexplained physical symptoms talk about their symptoms during routine primary care consultations with GPs and to determine whether or not somatically oriented interventions for these patients can be attributed to patient demand for this treatment. METHODS: Initial qualitative investigation: audio recording, transcribing and thematic analysis of 36 primary care consultations between GPs and patients with unexplained physical symptoms. Second quantitative investigation: audio recording, transcribing and coding of 420 primary care consultations between GPs and patients with unexplained physical symptoms using a coding scheme developed during the qualitative phase of the study. Hypotheses generated during the qualitative phase of the study were tested with Wilcoxon or Friedman tests. RESULTS: There was little evidence from the qualitative analysis to support the suggestion that patients with unexplained physical symptoms receive somatic interventions because this is what they direct their GPs to provide. However patients presented their symptoms in characteristic ways which might conceivably pressure GPs for somatic intervention. Aspects of GP speech were also identified that had the potential to influence somatic treatment decisions. Results of the quantitative analyses showed that GPs proposed somatic treatment in more consultations than did patients. Patients requested explanation for their symptoms in a greater number of consultations than they advocated any treatment intervention. Patients criticised GPs in a substantial number of consultations in the larger quantitative sample. This type of speech may be a particularly powerful source of pressure for somatic intervention. CONCLUSIONS: The over-investigation and treatment of patients with unexplained physical symptoms can no longer be attributed to overt patient demand for such interventions. The findings of the present analyses implicate both patient and GP in the decision to provide somatically oriented treatment. Patient influence, where apparent, involves the different and complex ways that patients talk about their symptoms rather than their specific requests for intervention. The type of explanations GPs offer for patients' symptoms may prompt some patients to respond in ways that might conceivably pressure GPs for somatic intervention. The provision of somatically oriented treatment for patients with unexplained physical symptoms might therefore be more appropriately explained as the outcome of critical doctor-patient communication processes rather than patient demand for such intervention

The health impacts of women's low control in their living environment: A theory-based systematic review of observational studies in societies with profound gender discrimination.

We conducted a systematic review of observational evidence on the health impacts of women's low control/autonomy in the living environment in societies with profound gender discrimination and gender bias. Thirty observational studies of varying methodological quality were included. Overall, the evidence suggests that women's lower control or autonomy (for example lack of freedom of movement outside the home, lack of authority to access healthcare for sick children) was associated with poorer mental and physical health for women and higher morbidity and mortality for their children, after adjusting for their socioeconomic circumstances. Further studies are needed to disentangle and understand the pathways between low control and health outcomes in contexts of profound gender discrimination. This systematic review has highlighted the general low quality of the evidence base on this research question. It identifies the pressing need for high quality, longitudinal studies in the future

Minding the gap: The importance of active facilitation in moving boundary objects from in-theory to in-use as a tool for knowledge mobilisation

The Health Inequalities Assessment Toolkit (HIAT) was developed to support those involved in health research to integrate a focus on health inequalities. Our study focuses on bringing together the concepts of boundary objects (BO) and brokers-as-bricoleurs to explain the implementation of the HIAT within a research capacity building programme. Exploring the extent to which (i) the HIAT operated as a BO and (ii) the ideal conditions to nurture and enhance its effectiveness during knowledge mobilisation. We employed a qualitative approach to analyse: semi-structured focus groups and telephone interviews; secondary data from an evaluation of the wider research programme within which the capacity building was situated. Data was thematically analysed incorporating the properties of a BO: meaningfulness, convergence, resonance and authenticity. Four main themes identified: (1) Generating convergence through creating a focus (2) Reconciling differences to create a common language (3) Workshop facilitators: boundary brokers-as-bricoleurs, (4) Thoughts into action. The HIAT operated as a BO, enabling individuals across the different project teams to galvanise around the issue of health inequalities, explore collaboratively and incorporate equity within service evaluations. Highlighting the importance of involving brokers with an ability to improvise and mobilise around the HIAT, using their expertise to translate and interpret across boundaries and emphasise shared goals. Reflecting on this, a modified tool with additional resources beyond socio-economic causes has been launched as a forum to consider health inequalities from diverse perspectives for use beyond UK health and social care research

Social prescribing practices and learning across the North West Coast region: essential elements and key challenges to implementing effective and sustainable social prescribing services

IntroductionSocial prescribing has become an important feature of the UK primary care offer. However, there remains limited evidence on how best to implement and deliver social prescribing programmes to maximise effectiveness and long-term sustainability.AimTo explore social prescribing practices and experience of implementing social prescribing programmes across National Institute for Health and Social Care Research (NIHR) Collaborative Leadership for Applied Health and Care Research (CLAHRC) North West Coast (NWC) and NIHR Applied Research Collaboration (ARC) NWC region to identify key learning points that can be applied to other settings.MethodWe held a learning exchange workshop attended by practitioners and Public Advisors who had been involved in implementing and evaluating eight different social prescribing programmes with the support of NIHR CLAHRC NWC. We followed this with an online survey of social prescribing practice and priorities within the NIHR ARC NWC area. We used the findings from the workshop and survey to develop an initial model of the elements needed to successfully implement and sustain a working social prescribing programme.FindingsWe identified three core essential elements for a successful social prescribing programme: a personalised approach; meaningful service-user and community involvement; and whole systems working. These core elements need to be supported with adequate resources in the form of continuity of funding and adequate community resources to refer people to, capacity building and appropriate evaluation.ConclusionWe were able to use a learning exchange workshop to both facilitate learning between practitioners and begin the process of identifying the ingredients needed for a successful social prescribing programme, which may be built on with further research

An exploration of young people's, parent/carers', and professionals' experiences of a voluntary sector organisation operating a Youth Information, Advice, and Counselling (YIAC) model in a disadvantaged area

BACKGROUND: The present evaluation explored young people’s, parents/carers, and healthcare professionals’ perceptions of the Youth Information, Advice and Counselling (YIAC) model operated by a voluntary sector organisation in North West England. With an aim to understand the key components that contribute to enhancing the success of the YIAC model. METHOD: Semi-structured interviews and focus groups with young people, parents/carers, and healthcare professionals were conducted. Data were analysed using thematic analysis. RESULTS: Five main themes were identified from the data: 1) Accessibility and flexibility; 2) Non-clinical model and environment; 3) Staff; 4) Partnership working; and 5) Promotion of positive mental health and wellbeing. CONCLUSION: Findings highlight the importance of non-clinical, community-based, ‘one-stop-shop’ hubs for young people in disadvantaged areas. The key components highlighted as facilitating access and engagement include: opportunity to self-refer, choice of location, timely provision of support, non-clinical environment, age appropriate services, a non-hierarchical workforce, inclusive support for family and carers, a focus on wider, often social, issues, and collaboration with partner organisations. These findings suggest that early support hubs for young people’s mental health should have consistent, long-term funding and should exist in every local area. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-022-07800-1

The perception of risk in contracting and spreading COVID-19 amongst individuals, households and vulnerable groups in England: a longitudinal qualitative study.

BackgroundSocial distancing restrictions to manage the COVID-19 pandemic were put in place from March 2020 in the United Kingdom (UK), with those classed as "highly clinically vulnerable" advised to shield entirely and remain at home. However, personal risk perception has been shown to comprise of various elements beyond those outlined in the national pandemic guidance. It is unclear whether those deemed COVID-19 vulnerable identified as high-risk to COVID-19 and thus complied with the relevant advice. The aim of this research is to explore the perception of risk in catching and spreading COVID-19, amongst individuals from individual households, and vulnerable groups in a region of the UK.MethodsTwo individual, semi-structured interviews were conducted, four-weeks apart, with adults living in households in the Liverpool City Region. At the follow-up interview, participants were given the option of using photo-elicitation to guide the discussion. Reflexive thematic analysis was employed to conceptualise themes. The qualitative analysis was underpinned with symbolic interactionism.ResultsTwenty-seven participants (13:14 males:females, and 20 with a vulnerable risk factor to COVID-19) completed a baseline interview, and 15 of these completed a follow-up interview four-weeks later. Following thematic analysis, two overarching themes were conceptualised, with subthemes discussed: theme 1) Confusion and trust in the risk prevention guidance; and theme 2) Navigating risk: compliance and non-compliance with public health guidance.ConclusionParticipants developed their own understanding of COVID-19 risk perception through personal experience and comparison with others around them, irrespective of vulnerability status. COVID-19 guidance was not complied with as intended by the government, and at times even rejected due to lack of trust. The format in which future pandemic guidance is conveyed must be carefully considered, and take into account individuals' experiences that may lead to non-compliance. The findings from our study can inform future public health policy and interventions for COVID-19 and future pandemics