Measuring change in patient quality of life over time : an evaluation of scale responsiveness and patient response shift.

Measuring change in quality of life is increasingly central to health services and clinical research evaluation. This requires instruments that are responsive to change, and that the construct being assessed is stable. I have, therefore, addressed two methodological themes: scale responsiveness and instability of the underlying quality of life construct - response shift. Responsiveness theme: I evaluated performance characteristics of a commonly reported effect size statistic, the standardised response mean (SRM). Computer simulations modelled the impact of varying computational method and distributional characteristics upon bias of estimated effect size compared to underlying true value. The studies provide evidence and reassurance that the SRM exhibits little bias when sample size, mean underlying effect size and shape of underlying distribution are varied. However, alternate approaches to handling negative values can produce markedly different effect sizes, making comparison across studies that use different methods problematic. Furthermore, parametric SRMs calculated from lognormal data may provide a greatly inflated estimate of effect size. Response shift theme: I interviewed patients at different stages of clinical management for knee injury twice over six months. A multi-method approach incorporating the individualised SEIQoL-DW measure and a retrospective pretest-posttest using EQ-5D identified evidence of re-calibration, re-prioritisation and re-conceptualisation response shift. An empirically based typology of changes was developed drawn from existing response shift theory, but which further distinguishes subtler forms of change. The studies provide evidence that re-prioritisation and re-conceptualisation may be different levels of the same process. Furthermore, mechanisms producing response shift were identified, in particular, the interaction between level of satisfaction with quality of life domain and its perceived importance. Additional approaches to studying response shift using group level comparison of SEIQoL data were critically evaluated. The thesis extends the methods for identifying, assessing and conceptualising response shift changes whilst also exploring mechanisms which may explain these changes

Doctors' decisions when disclosing their mental ill-health

Background Understanding of what prevents doctors from seeking help for mental ill-health has improved. However, less is known about what promotes timely disclosure and the nature of doctors’ decision making. Aims This study aimed to define how doctors make decisions about their own mental ill-health, and what facilitates disclosure. It explored the disclosure experiences of doctors and medical students; their attitudes to their decisions, and how they evaluate potential outcomes. Methods Qualitative, semi-structured interviews with UK doctors and medical students with personal experience of mental ill-health. Participants were recruited through relevant organizations, utilizing regular communications such as newsletters, e-mails and social media. Data were subject to a thematic analysis. Results Forty-six interviews were conducted. All participants had disclosed their mental ill-health to someone; not all to their workplace. Decision making was complex, with many participants facing multiple decisions throughout their careers. Disclosures were made despite the many obstacles identified in the literature; participants described enablers to and benefits of disclosing. The importance of appropriate responses to first disclosures was highlighted. Conclusions Motivations to disclose mental ill-health are complex and multifactorial. An obstacle for one was an enabler for another. Understanding this and the importance of the first disclosure has important implications for how best to support doctors and medical students in need

Exploratory studies to inform full-scale evaluations of complex public health interventions: the need for guidance

No abstract available

Establishing the international prevalence of self-reported child maltreatment: a systematic review by maltreatment type and gender

Background Estimating the prevalence of child maltreatment is challenging due to the absence of a clear ‘gold standard’ as to what constitutes maltreatment. This systematic review aims to review studies using self-report maltreatment to capture prevalence rates worldwide. Methods PubMed, Ovid SP and grey literature from the NSPCC, UNICEF, The UK Government, and WHO from 2000 to 2017 were searched. The literature review focused on the variation found in self-reported lifetime prevalence for each type of maltreatment between studies by continent and gender, and how methodological differences may explain differences found. Results Sexual abuse is the most commonly studied form of maltreatment across the world with median (25th to 75th centile) prevalence of 20.4% (13.2% to 33.6%) and 28.8% (17.0% to 40.2%) in North American and Australian girls respectively, with lower rates generally for boys. Rates of physical abuse were more similar across genders apart from in Europe, which were 12.0% (6.9% to 23.0%) and 27.0% (7.0% to 43.0%) for girls and boys respectively, and often very high in some continents, for example, 50.8% (36.0% to 73.8%) and 60.2% (43.0% to 84.9%) for girls and boys respectively in Africa. Median rates of emotional abuse were nearly double for girls than boys in North America (28.4% vs 13.8% respectively) and Europe (12.9% vs 6.2% respectively) but more similar across genders groups elsewhere. Median rates of neglect were highest in Africa (girls: 41.8%, boys: 39.1%) and South America (girls: 54.8%, boys: 56.7%) but were based on few studies in total, whereas in the two continents with the highest number of studies, median rates differed between girls (40.5%) and boys (16.6%) in North America but were similar in Asia (girls: 26.3%, boys: 23.8%). Conclusions Median prevalence rates differ substantially by maltreatment category, gender and by continent. The number of studies and available data also varies and relatively little is known about prevalence for some forms of maltreatment, particularly outside of the North American context. Prevalence rates require caution in interpretation as some variation will reflect methodological differences, including the data collection methods, and how the maltreatment is defined