Improving mental health service users' with medical co-morbidity transition between tertiary medical hospital and primary care services: A qualitative study

BACKGROUND: Mental health service users have high rates of medical co-morbidity but frequently experience problems accessing and transitioning between tertiary medical and primary care services. The aim of this study was to identify ways to improve service users’ with medical co-morbidity care and experience during their transition between tertiary medical hospitals and primary care services. METHOD: Experience-based co-design (EBCD) qualitative study incorporating a focus group discussion. The study took place in a large tertiary medical service, incorporating three medical hospitals, and primary care services, in Melbourne, Australia. A purposive sample of service users and their caregivers and tertiary medical and primary care clinicians participated in the focus group discussion, in August 2014. A semi-structured interview guide was used to inform data collection. A thematic analysis of the data was undertaken. RESULTS: Thirteen participants took part in the focus group interview, comprising 5 service users, 2 caregivers and 6 clinicians. Five themes were abstracted from the data, illustrating participants’ perspectives about factors that facilitated (clinicians’ expertise, engagement and accessibility enhancing transition) and presented as barriers (improving access pathways; enhancing communication and continuity of care; improving clinicians’ attitudes; and increasing caregiver participation) to service users’ progress through tertiary medical and primary care services. A sixth theme, enhancing service users’ transition, incorporated three strategies to enhance their transition through tertiary medical and primary care services. CONCLUSION: EBCD is a useful approach to collaboratively develop strategies to improve service users’ with medical co-morbidity and their caregivers’ transition between tertiary medical and primary care services. A whole-of-service approach, incorporating policy development and implementation, change of practice philosophy, professional development education and support for clinicians, and acceptance of the need for caregiver participation, is required to improve service users’ transition

Building workforce capacity for complex care coordination: a function analysis of workflow activity

Background The care coordination workforce includes a range of clinicians who manage care for patients with multiple chronic conditions both within and outside a hospital, in the community, or in a patient’s home. These patients require a multi-skilled approach to support complex care and social support needs as they are typically high users of health, community, and social services. In Australia, workforce structures have not kept pace with this new and emerging workforce. The aim of the study was to develop, map, and analyse workforce functions of a care coordination team. Methods Workflow modelling informed the development of an activity log that was used to collect workflow data in 2013 from care coordinators located within the care coordination service offered by a Local Health Network in Australia. The activity log comprised a detailed classification of care coordination functions based on two major categories – direct and indirect care. Direct care functions were grouped into eight domains. A descriptive quantitative investigation design was used for data analysis. The data was analysed using univariate descriptive statistics with results presented in tables and a figure. Results Care coordinators spent more time (70.9%) on direct care than indirect care (29.1%). Domains of direct care that occupied the most time relative to the 38 direct care functions were ‘Assessment’ (14.1%), ‘Documentation’ (13.9%), ‘Travel time’ (6.3%), and ‘Accepting/discussing referral’ (5.7%). ‘Administration’ formed a large component of indirect care functions (14.8%), followed by ‘Travel’ (12.4%). Sub-analyses of direct care by domains revealed that a group of designated ‘core care coordination functions’ contributed to 40.6% of direct care functions. Conclusions The modelling of care coordination functions and the descriptions of workflow activity support local development of care coordination capacity and workforce capability through extensive practice redesigns

Mental health consumers' with medical co-morbidity experience of the transition through tertiary medical services to primary care

Medical comorbidity in people with long‐term mental illness is common and often undetected; however, these consumers frequently experience problems accessing and receiving appropriate treatment in public health‐care services. The aim of the present study was to understand the lived experience of mental health consumers with medical comorbidity and their carers transitioning through tertiary medical to primary care services. An interpretative, phenomenological analysis approach was used, and semistructured, video‐recorded, qualitative interviews were used with 12 consumers and four primary caregivers. Four main themes and related subthemes were abstracted from the data, highlighting consumer's and carers’ experience of transition through tertiary medical to primary care services: (i) accessing tertiary services is difficult and time consuming; (ii) contrasting experiences of clinician engagement and support; (iii) lack of continuity between tertiary medical and primary care services; and (iv) Mental Health Hospital Admission Reduction Programme (MH HARP) clinicians facilitating transition. Our findings have implications for organisational change, expanding the role of MH HARP clinicians (whose primary role is to provide consumers with intensive support and care coordination to prevent avoidable tertiary medical hospital use), and the employment of consumer and carer consultants in tertiary medical settings, especially emergency departments

Care coordination for chronic and complex health conditions: an experienced based co-design study engaging consumer and clinician groups for service improvement

Background: Evidence shows that engaging consumers and clinicians in development of health services creates a more responsive, integrated service that better meets the needs of consumers and the community of practice it serves. Further, consumer and clinician participation in service development processes can boost confidence and motivation levels in organisational employees and help foster clinical accountability. Objective: To see where consumers’ care experiences could be improved by better understanding where care coordination organisational systems needed improvement. Methods: Experienced based co-design informed an investigation of consumer and clinician experiences of a care coordination service and involved the sharing of those experiences across service employees in a series of iterative and feedback loops over eighteen months (July 2012 January 2014). Formal participants included care coordination clinicians (n=13) and consumers. Data from formal participants were collected during September-December 2012, consisting of consumer video-recorded and clinician audio-recorded interviews. Interview transcriptions were analysed to identify service “touch points”, being emotionally significant events related to key service aspects that connect or disconnect consumers and/or clinicians. Results: Results revealed that consumers highly valued the transdisciplinary skill base of the care coordination workforce, though service improvements were needed for transition support, quality discharge planning and conveying better understandings of care coordination activity both internally and externally. Conclusion: Incorporating consumer and clinician view-points about their experiences, including the production of a DVD, facilitated conversations across the entire service about care coordination provision and provided a catalyst for design improvement that may otherwise have been difficult to achieve. Some changes to the service were made such as improved client complaints processes, new roles for the care coordination service, and enlisting clinical staff to undertake motivational interviewing training to promote greater consumer self-management capacity. In this study, the user experience was given a platform within a larger healthcare workforce capability development project

Population genetic analyses implicate biogenesis of translation machinery in human ageing

Reduced provision of protein translation machinery promotes healthy aging in a number of animal models. In humans, however, inborn impairments in translation machinery are a known cause of several developmental disorders, collectively termed ribosomopathies. Here, we use casual inference approaches in genetic epidemiology to investigate whether adult, tissue-specific biogenesis of translation machinery drives human aging. We assess naturally occurring variation in the expression of genes encoding subunits specific to the two RNA polymerases (Pols) that transcribe ribosomal and transfer RNAs, namely Pol I and III, and the variation in expression of ribosomal protein (RP) genes, using Mendelian randomization. We find each causally associated with human longevity (β = -0.15 ± 0.047, P = 9.6 × 10-4, q = 0.015; β = -0.13 ± 0.040, P = 1.4 × 10-3, q = 0.023; β = -0.048 ± 0.016, P = 3.5 × 10-3, q = 0.056, respectively), and this does not appear to be mediated by altered susceptibility to a single disease. We find that reduced expression of Pol III, RPs, or Pol I promotes longevity from different organs, namely visceral adipose, liver, and skeletal muscle, echoing the tissue specificity of ribosomopathies. Our study shows the utility of leveraging genetic variation in expression to elucidate how essential cellular processes impact human aging. The findings extend the evolutionary conservation of protein synthesis as a critical process that drives animal aging to include humans

“F*ck it! Let’s get to drinking – poison our livers!”: a thematic analysis of alcohol content in contemporary YouTube music videos

Purpose: To describe the portrayal of alcohol content in popular YouTube music videos. Methods: We used inductive thematic analysis to explore the lyrics and visual imagery in 49 UK Top 40 songs and music videos previously found to contain alcohol content, and watched by many British adolescents aged between 11-18 years, and to examine if branded content contravened alcohol industry advertising codes of practice. Results: The analysis generated three themes. First, alcohol content was associated with sexualised imagery or lyrics and the objectification of women. Second, alcohol was associated with image, lifestyle and sociability. Finally, some videos showed alcohol overtly encouraging excessive drinking and drunkenness, including those containing branding, with no negative consequences to the drinker. Conclusion: Our results suggest that YouTube music videos promote positive associations with alcohol use. Further, several alcohol companies adopt marketing strategies in the video medium that are entirely inconsistent with their own or others agreed advertising codes of practice. We conclude that, as a harm reduction measure, policies should change to prevent adolescent exposure to the positive promotion of alcohol and alcohol branding in music videos

Prospective cohort study of exposure to tobacco imagery in popular films and smoking uptake among children in southern India

Background Exposure to tobacco imagery in films causes young people to start smoking. Popular Indian films contain high levels of tobacco imagery, but those that do are required by law to display onscreen health warnings when smoking imagery occurs and to include other health promotion messaging before and during the film. We report a prospective cohort study of incident smoking in relation to exposure to film tobacco imagery and anti-tobacco messaging in a cohort of children in southern India. Methods We carried out a one-year longitudinal follow up questionnaire survey in 2018 of a cohort of 39,282 students in grades 6, 7 and 8 (aged between 10 and 15 years) in schools in the Udupi district of Karnataka State in India who participated in a 2017 cross-sectional study of exposure to smoking in films and ever smoking status. Results We obtained usable linked data in 2018 from 33,725 of the 39,282 (86%) participants with data from 2017. Incident smoking was reported by 382 (1.1%) participants. After adjusting for age, sex and common confounders significantly associated with incident smoking there was no significant independent effect of exposure to film smoking, either as a binary (Odds Ratio 1.6, 95% Confidence Interval (CI) 0.5 to 4.9) or as a graded variable, on smoking uptake. An exploratory analysis indicated that the presence of on-screen health warnings that complied fully with Indian law was associated with a significantly lower odds of smoking uptake (Odds Ratio 0.8 (0.6 to 1.0, p = 0.031) relative to the same exposure sustained in absence of compliant warnings. Conclusion Exposure to tobacco imagery in Indian films was not associated with a significantly increased risk of incident smoking in South Indian children. While it is possible that this finding is a false negative, it is also possible that the effect of film exposure has been attenuated by the presence of on-screen health warnings or other Indian tobacco-free film rules. Our findings therefore support the wider implementation of similar tobacco-free film measures in other countries

Potential risk factors of smokeless tobacco consumption among adolescents in South India

Introduction: Although most of the disease burden is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76,000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India. Methods: A cross-sectional questionnaire survey of all students in grades 6 to 8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever-SLT use status were estimated using multiple logistic regression. Results: Of 46,706 students from 914 participating schools, 39,282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use or friend’s use of SLT, low socio-economic status, high rebelliousness and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use [OR 3.7 95% CI (2.9,4.7)] and significantly lower among those not exposed to tobacco advertising [OR 0.7 95% CI (0.5,0.8). Conclusions: The prevalence of SLT use among children in Karnataka is relatively low as compared to other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising