Text Messaging as an Adjunct to CBT in Low-Income Populations: A Usability and Feasibility Pilot Study
published in Professional Psychology: Research and Practice
This paper will outline the development and usability/feasibility testing of an automated text messaging adjunct to... more This paper will outline the development and usability/feasibility testing of an automated text messaging adjunct to cognitive behavioral therapy (CBT) for depression in a public sector clinic serving low-income patients. The text-messaging adjunct is aimed at increasing homework adherence, improving self-awareness, and helping track patient progress. Daily text messages were sent to patients inquiring about their mood. Additional daily messages corresponded to themes of a manualized group CBT intervention. These included 1) thought tracking (both positive and negative), 2) tracking of pleasant activities, 3) tracking of positive and negative contacts, 4) tracking of physical well-being. We tested the adjunct in two CBT groups (1 English & 1 Spanish) consisting of 12 patients total during and after treatment. Participants responded at a rate of 65% to text messages and they reported overall positive experiences. We propose that text messaging has potential to improve mental health care broadly, and among low-income populations specifically, using cost effective means.
Download (.pdf) Multimorbidity in primary care: a systematic review of prospective cohort studies
by Frances Mair
Authors: France, Emma F1; Wyke, Sally2; Gunn, Jane M3; Mair, Frances S4; McLean, Gary4; Mercer, Stewart W4
Source: British Journal of General Practice, Volume 62, Number 597, April 2012 , pp. e297-e307(11)
Publisher: Royal College of General Practitioners
Abstract:
Background
Primary care increasingly deals with patients with multimorbidity, but relevant... more
Abstract:
Background
Primary care increasingly deals with patients with multimorbidity, but relevant evidence-based interventions are scarce. Knowledge about multimorbidity over time is required to inform the development of effective interventions.
Aim
This review identifies prospective cohort studies of multimorbidity in primary care to determine: their nature, scope and key findings; the methodologies used; and gaps in knowledge.
Design
Systematic review.
Method
Studies were identified by searching electronic databases, reviewing citations, and writing to authors. Searches were limited to adult populations with no restrictions on publication date or language. In total, 996 articles were identified and screened.
Results
Of the 996 articles, six detailing five completed prospective cohort studies were selected as appropriate. Three of the studies were undertaken in the US and two in The Netherlands; none was nationally representative. The main focus of the studies was: healthcare utilisation and/or costs (n = 3); patients' physical functioning (n = 1); and risk factors for developing multimorbidity (n = 1). The conditions that were included varied widely. The findings of these studies showed that multimorbidity increased healthcare costs (n = 2), inpatient admission (n = 1), death rates (n = 1), and service use (n = 3), and reduced physical functioning (n = 1). One study identified psychosocial risk factors for multimorbidity. No study used random sampling, sample sizes were relatively small (414-3745 patients at baseline), and study duration was relatively short (1-4 years). No study focused on prevalence, treatment use, patient safety, service models, cultural or socioeconomic factors, and patient experience, and no study collected qualitative data.
Conclusion
Few longitudinal studies based in primary care have investigated multimorbidity. Further large, long-term prospective studies are required to inform healthcare commissioning, planning, and delivery.
Practice size and quality attainment under the new GMS contract: a cross-sectional analysis
Authored by Yingying Wang, Catherine O'Donnell, Danny Mackay and Graham Watt and published in British Journal of General Practice
Background The Quality and Outcomes Framework (QOF) of the new General Medical Services contract, for the first time,... more Background The Quality and Outcomes Framework (QOF) of the new General Medical Services contract, for the first time, incentivises certain areas of general practice workload over others. The ability of practices to deliver high quality care may be related to the size of the practice itself. Aim: To explore the relationship between practice size and points attained in the QOF. Design of study: Cross-sectional analyses of routinely available data. Setting: Urban general practice in mainland Scotland. Method: QOF points and disease prevalence were obtained for all urban general practices in Scotland (n = 638) and linked to data on the practice, GP and patient population. The relationship between QOF point attainment, disease prevalence and practice size was examined using univariate statistical analyses. Results: Smaller practices were more likely to be located in areas of socioeconomic deprivation; had patients with poorer health; and were less likely to participate in voluntary practice-based quality schemes. Overall, smaller practices received fewer QOF points compared to larger practices (P = 0.003), due to lower point attainment in the organisational domain (P = 0.002). There were no differences across practice size in the other domains of the QOF, including clinical care. Smaller practices reported higher levels of chronic obstructive pulmonary disease (COPD) and mental health conditions and lower levels of asthma, epilepsy and hypothyroidism. There was no difference in the reported prevalence of hypertension or coronary heart disease (CHD) across practices, in contrast to CHD mortality for patients aged under 70 years, where the mortality rate was 40% greater for single-handed practices compared with large practices. Conclusions: Although smaller practices obtained fewer points than larger practices under the QOF, this was due to lower scores in the organisational domain of the contract rather than to lower scores for clinical care. Single-handed practices, in common with larger practices serving more deprived populations, reported lower than expected CHD prevalence in their practice populations. Our results suggest that smaller practices continue to provide clinical care of comparable quality to larger practices but that they may need increased resources or support, particularly in the organisational domain, to address unmet need or more demanding QOF criteria.
Impact of the 2004 GMS contract on practice nurses: a qualitative study
Authored by Wendy McGregor, Hussein Jabareen, Catherine O'Donnell, Stewart Mercer and Graham Watt and published in British Journal of General Practice
BackgroundThe new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and... more BackgroundThe new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and Outcomes Framework (QOF). AimThis study investigated how practice nurses perceive the changes in their work since the contract's inception. Design of study A qualitative approach, sampling practice nurses from practices in areas of high and low deprivation, with a range of QOF scores. Setting Glasgow, UK. MethodIndividual interviews were conducted, audiotaped, transcribed, and analysed using a thematic approach. Results Three themes emerged: roles and incentives, workload, and patient care. Practice nurses were positive about the development of their professional role since the introduction of the new GMS contract but had mixed views about whether their status had changed. Views on incentives (largely related to financial rewards) also varied, but most felt under-rewarded, irrespective of practice QOF achievement. All reported a substantial increase in workload, related to incentivised QOF domains with greater 'box ticking' and data entry, and less time to spend with patients. Although the structure created by the new contract was generally welcomed, many were unconvinced that it improved patient care and felt other important areas of care were neglected. Concern was also expressed about a negative effect of the QOF on holistic care, including ethical concerns and detrimental effects on the patient–nurse relationship, which were regarded as a core value. ConclusionsThe new GMS contract has given practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale.
Practice postcode versus patient population: a comparison of data sources in England and Scotland
Authored by Gary McLean, Bruce Guthrie, Graham Watt, Mark Gabbay and Catherine O'Donnell and published in International Journal of Health Geographics
BACKGROUND:Health professionals, policy-makers and researchers need to be able to explore potential associations... more BACKGROUND:Health professionals, policy-makers and researchers need to be able to explore potential associations between prevalence rates and quality of care with a range of possible determinants including socio-economic deprivation and morbidity levels to determine the impact of commissioning and service delivery. In the UK, data in England are only available nationally at practice postcode level. In Scotland, such data are available based on an aggregate of the practices population's postcodes. The use of data assigned to the practice postcode may underestimate the association between ill health and income deprivation. Here, we report on the impact of using data assigned to the practice population by comparing analyses using English and Scottish data.RESULTS:Income deprivation based on data assigned to the practice postcode under-estimated deprivation compared to using income deprivation data assigned to the practice population for the five least deprived deciles, and over-estimated deprivation for the five most deprived deciles. The biggest differences were found for the most deprived decile. A similar trend was found for limiting long-term illness (LLTI). Differences between the QOF prevalence rates of the least and most deprived deciles using practice postcode data were similar (0.2% points or less) in England and Scotland for 8 out of 10 clinical domains. Using practice population assigned deprivation, differences in the prevalence rate between the least and most deprived deciles increase for all clinical domains. A similar trend was again found for LLTI. Using practice population assigned deprivation, differences for population achievement increase for all CHD quality indicators with the exception of beta-blockers (CHD10). With practice postcode assigned deprivation, significant differences between the least and most deprived deciles were found for 2 out 8 indicators, compared to 5 using practice population assigned deprivation. For LLTI differences between the lowest and most deprived deciles increased for all indicators when ill health assigned to the practice population was used.CONCLUSION:We have found, through comparing deprivation and ill health data assigned to either the practice postcode or the practice population postcode in Scotland, that analyses based on practice postcode assigned data under-estimated the relationship between deprivation and ill health for both prevalence and quality care. Given the importance of understanding the effect of deprivation and ill health on a range of determinants related to health care, policy makers should ensure that practice population data are available and used at national level in England and elsewhere where possible
Practice nurses' workload, career intentions and the impact of professional isolation: A cross-sectional survey
Authored by Catherine O'Donnell, Hussein Jabareen and Graham Watt and published in BMC Nursing
BACKGROUND:Practice nurses have a key role within UK general practice, especially since the 2004 GMS contract. This... more BACKGROUND:Practice nurses have a key role within UK general practice, especially since the 2004 GMS contract. This study aimed to describe that role, identify how professionally supported they felt and their career intentions. An additional aim was to explore whether they felt isolated and identify contributory factors.METHODS:A cross-sectional questionnaire survey in one large urban Scottish Health Board, targeted all practice nurses (n = 329). Domains included demographics, workload, training and professional support. Following univariate descriptive statistics, associations between categorical variables were tested using the chi-square test or chi-square test for trend; associations between dichotomous variables were tested using Fisher's Exact test. Variables significantly associated with isolation were entered into a binary logistic regression model using backwards elimination.RESULTS:There were 200 responses (61.0% response rate). Most respondents were aged 40 or over and were practice nurses for a median of 10 years. Commonest clinical activities were coronary heart disease management, cervical cytology, diabetes and the management of chronic obstructive pulmonary disease. Although most had a Personal Development Plan and a recent appraisal, 103 (52.3%) felt isolated at least sometimes; 30 (15.5%) intended leaving practice nursing within 5 years.Isolated nurses worked in practices with smaller list sizes (p = 0.024) and nursing teams (p = 0.003); were less likely to have someone they could discuss a clinical/professional (p = 0.002) or personal (p < 0.001) problem with; used their training and qualifications less (p < 0.001); had less productive appraisals (p < 0.001); and were less likely to intend staying in practice nursing (p = 0.009). Logistic regression analysis showed that nurses working alone or in teams of two were 6-fold and 3.5-fold more likely to feel isolated. Using qualifications and training to the full, having productive appraisals and planning to remain in practice nursing all mitigated against feeling isolated.CONCLUSIONS:A significant proportion of practice nurses reported feeling isolated, at least some of the time. They were more likely to be in small practices and more likely to be considering leaving practice nursing. Factors contributing to their isolation were generally located within the practice environment. Providing support to these nurses within their practice setting may help alleviate the feelings of isolation, and could reduce the number considering leaving practice nursing
"They think we're OK and we know we're not". A qualitative study of asylum seekers' access, knowledge and views to health care in the UK
Authored by Catherine O'Donnell, Maria Higgins, Rohan Chauhan and Kenneth Mullen and published in BMC Health Services Research
BackgroundThe provision of healthcare for asylum seekers is a global issue. Providing appropriate and culturally... more BackgroundThe provision of healthcare for asylum seekers is a global issue. Providing appropriate and culturally sensitive services requires us to understand the barriers facing asylum seekers and the facilitators that help them access health care. Here, we report on two linked studies exploring these issues, along with the health care needs and beliefs of asylum seekers living in the UK.MethodsTwo qualitative methods were employed: focus groups facilitated by members of the asylum seeking community and interviews, either one-to-one or in a group, conducted through an interpreter. Analysis was facilitated using the Framework method.ResultsMost asylum seekers were registered with a GP, facilitated for some by an Asylum Support nurse. Many experienced difficulty getting timely appointments with their doctor, especially for self-limiting symptoms that they felt could become more serious, especially in children. Most were positive about the health care they received, although some commented on the lack of continuity. However, there was surprise and disappointment at the length of waiting times both for hospital appointments and when attending accident and emergency departments. Most had attended a dentist, but usually only when there was a clinical need. The provision of interpreters in primary care was generally good, although there was a tension between interpreters translating verbatim and acting as patient advocates. Access to interpreters in other settings, e.g. in-patient hospital stays, was problematic. Barriers included the cost of over-the-counter medication, e.g. children's paracetamol; knowledge of out-of-hours medical care; and access to specialists in secondary care. Most respondents came from countries with no system of primary medical care, which impacted on their expectations of the UK system.ConclusionMost asylum seekers were positive about their experiences of health care. However, we have identified issues regarding their understanding of how the UK system works, in particular the role of general practitioners and referral to hospital specialists. The provision of an Asylum Support nurse was clearly a facilitator to accessing primary medical care. Initiatives to increase their awareness and understanding of the UK system would be beneficial. Interpreting services also need to be developed, in particular their role in secondary care and the development of the role of interpreter as patient advocate.
Asylum seekers' expectations of and trust in general practice: a qualitative study
Authored by Catherine O'Donnell, Maria Higgins, Rohan Chauhan and Kenneth Mullen and published in British Journal of General Practice
Background: The UK has substantial minority populations of short-term and long-term migrants from countries with... more Background: The UK has substantial minority populations of short-term and long-term migrants from countries with various types of healthcare systems. Aim: This study explored how migrants' previous knowledge and experience of health care influences their current expectations of health care in a system relying on clinical generalists performing a gatekeeping role. Design of study: Two qualitative methods. Setting: Glasgow, UK. Method: Focus groups or semi-structured interviews were conducted with 52 asylum seekers. Analyses identified several areas where previous experience affected current expectations. An overview of health systems in each country of origin was established by combining responders' accounts with World Health Organization statistics. Results: Asylum seekers had previous experience of a diverse range of healthcare systems, most of which were characterised by a lack of GPs and direct access to hospital-based specialists. For some responders, war or internal conflict resulted in a complete breakdown of healthcare systems. Responders' accounts also highlighted the difficulties that marginalised groups had in accessing health care. Although asylum seekers were generally pleased with the care they received from the NHS, there were areas where they experienced difficulties: confidence in their GP and access to hospital-based specialists and medication. These difficulties encountered might be explained by previous experience. Conclusion: GPs and other healthcare professionals need to be aware that experience of different systems of care can have an impact on individuals' expectations in a GP-led system. If these are not acknowledged and addressed, a lack of confidence and trust in the GP may undermine the effectiveness of the clinical consultation.
Do health improvement programmes fit with MRC guidance on evaluating complex interventions?
Authored by Mhairi Mackenzie, Catherine O'Donnell, Emma Halliday, Sanjeev Sridharan, Steve Platt and published in the British Medical Journal
Normalisation process theory: a framework for developing, evaluating and implementing complex interventions
Authored by Elizabeth Murray, Shaun Treweek, Catherine Pope, Anne MacFarlane, Luciana Ballini, Chris Dowrick, Tracy Finch, Anne Kennedy, Frances Mair, Catherine O'Donnell, Pauline Ong, Tim Rapley, Anne Rogers, Carl May and published in BMC Medicine
BACKGROUND:The past decade has seen considerable interest in the development and evaluation of complex interventions... more BACKGROUND:The past decade has seen considerable interest in the development and evaluation of complex interventions to improve health. Such interventions can only have a significant impact on health and health care if they are shown to be effective when tested, are capable of being widely implemented and can be normalised into routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions into routine work (normalisation).DISCUSSION:In this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. The need to ensure trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data collection, as well as ensuring the intervention has good implementation potential.SUMMARY:The NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential. We encourage trialists to consider using it in their next trial
What is the 'problem' that outreach work seeks to address and how might it be tackled? Seeking theory in a primary health prevention programme
Mackenzie,M.; Turner,F.; Platt,S.; Reid,M.; Wang,Y.; Clark,J.; Sridharan,S.; O'Donnell,C.
BMC Health Services Research 2011; 11: 350
BACKGROUND:Preventive approaches to health are disproportionately accessed by the more affluent and recent health... more
BACKGROUND:Preventive approaches to health are disproportionately accessed by the more affluent and recent health improvement policy advocates the use of targeted preventive primary care to reduce risk factors in poorer individuals and communities. Outreach has become part of the health service response. Outreach has a long history of engaging those who do not otherwise access services. It has, however, been described as eclectic in its purpose, clientele and mode of practice; its effectiveness is unproven.Using a primary prevention programme in the UK as a case, this paper addresses two research questions: what are the perceived problems of non-engagement that outreach aims to address; and, what specific mechanisms of outreach are hypothesised to tackle these.
METHODS:Drawing on a wider programme evaluation, the study undertook qualitative interviews with strategically selected health-care professionals. The analysis was thematically guided by the concept of 'candidacy' which theorises the dynamic process through which services and individuals negotiate appropriate service use.
RESULTS:The study identified seven types of engagement 'problem' and corresponding solutions. These 'problems' lie on a continuum of complexity in terms of the challenges they present to primary care. Reasons for non-engagement are congruent with the concept of 'candidacy' but point to ways in which it can be expanded.
CONCLUSIONS:The paper draws conclusions about the role of outreach in contributing to the implementation of inequalities focused primary prevention and identifies further research needed in the theoretical development of both outreach as an approach and candidacy as a conceptual framework
Delivering a national programme of anticipatory care in primary care: a qualitative study
O'Donnell,C.A.; Mackenzie,M.; Reid,M.; Turner,F.; Clark,J.; Wang,Y.; Sridharan,S.; Platt,S.
British Journal of General Practice 2012; 62: e288-e296
Background: Primary prevention often occurs against a background of inequalities in health and health care. Addressing... more
Background: Primary prevention often occurs against a background of inequalities in health and health care. Addressing this requires practitioners and systems to acknowledge the contribution of health-related and social determinants and to deal with the lack of interconnectedness between health and social service providers. Recognising this, the Scottish Government has implemented a national programme of anticipatory care targeting individuals aged 45-64 years living in areas of socioeconomic deprivation and at high risk of cardiovascular disease. This programme is called Keep Well.
Aim: To explore the issues and tensions underpinning the implementation of a national programme of anticipatory care.
Design and setting: A qualitative study in five Wave 1 Keep Well pilot sites, located in urban areas of Scotland, and involving 79 general practices.
Method: Annual semi-structured interviews were conducted with 74 key stakeholders operating at national government level, local pilot level and within general practices, resulting in 118 interviews. Interview transcripts were analysed using the framework approach.
Results: Four underlying tensions were identified. First, those between a patient-focused general-practice approach versus a population-level health-improvement approach, linking disparate health and social services; secondly, medical approaches versus wider social approaches; thirdly, a population-wide approach versus individual targeting; and finally, reactive versus anticipatory care.
Conclusion: Implementing an anticipatory care programme to address inequalities in cardiovascular disease identified several tensions, which need to be understood and resolved in order to inform the development of such approaches in general practice and to develop systems that reduce the degree of fragmentation across health and social services
Reaching the hard-to-reach? Conceptual puzzles and challenges for policy and practice.
Mackenzie,M.; Reid,M.; Turner,F.; Wang,Y.; Clark,J.; Sridharan,S.; Platt,S.; O'Donnell,C.
Journal of Social Policy 2012 (on-line first)
Determinants of Common Mental Disorders Detection by General Practitioners in the Primary Health Care in Brazil
Authors: Daniel A. Gonçalves, Sandra Fortes, Luís Fernando Tófoli, Mônica Rodrigues Campos, Jair de Jesus Mari
Objective: Common Mental Disorders (CMD) are highly prevalent among patients attending primary care. Many of these... more Objective: Common Mental Disorders (CMD) are highly prevalent among patients attending primary care. Many of these disorders remain unrecognized by general practitioners (GPs), with the detection rates varying from 30 to 60%. This study aims to evaluate the CMD detection rates by Primary Heath Care (PHC) practitioners in Brazil—and factors that affect CMD detection. Methods: A cross sectional study was conducted with users of five PHC units in the city of Petrópolis. The CMD prevalence of psychiatric morbidity was estimated by the General Health Questionnaire-12, and the physician's CMD detection was evaluated by a questionnaire completed by GPs after each consultation. Results: Seven hundred and fourteen subjects participated of the study, and 400 (56%) were screened positive using GHQ-12 cut-off point of 2/3. GPs diagnosed 379 people with CMD (53.1%), and 256(36%) subjects were detected by both GHQ and the GPs with an OR of 3.04 (95%CI 2.23-4.13). CMD detection accuracy by GPs was 65%. There was a strong association between the detection of CMD and the report of medically unexplained physical symptoms by GPs. Being female, married, and a frequent service user was also related to higher detection rates. Conclusion: CMD detection rate was similar to those reported worldwide, but contrary to other studies, the presence of MUS increased detection rates. The high frequency of CMD in Primary Health Care highlights the need for improving GP and health worker's training in order to enable them to accurately recognize and treat psychological distress with evidence-based interventions.
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