Areas Of High Socioeconomic Deprivation Research Articles

Exploring the utility of self-determination theory in complex interventions in multimorbidity: A qualitative analysis of patient experiences of the CARE Plus intervention.

CARE Plus is a primary-care-based complex intervention for patients with multimorbidity living in areas of high socioeconomic deprivation. This study explores patients' experience of the intervention and whether self-determination theory is useful to understand reported impacts. Thematic analysis of semistructured interviews of 14 participants conducted during a randomised controlled trial of CARE Plus. Improvement in wellbeing in daily lives following CARE Plus was estimated from participants' accounts of their experiences of the intervention. Participants valued the CARE Plus consultations irrespective of perceived improvements. Six participants reported changes in wellbeing that improved daily life, three reported slight improvement (not impacting daily life) and five no improvement. Evidence of satisfaction of the three major self-determination theory psychological needs - relatedness, competence and autonomy - was prominent in the accounts of those experiencing improved wellbeing in daily life; this group also spoke in ways congruent with more self-determined motivational regulation. These changes were not evident in those with little or no improvement in wellbeing. This study suggests self-determination theory has utility in understanding the impact of CARE Plus on patients and may be a useful theory to inform development of future interventions to improve outcomes for patients with multimorbidity.

Effectiveness of Community-Links Practitioners in Areas of High Socioeconomic Deprivation.

To assess the effect of a primary care-based community-links practitioner (CLP) intervention on patients' quality of life and well-being. Quasi-experimental cluster-randomized controlled trial in socioeconomically deprived areas of Glasgow, Scotland. Adult patients (aged 18 years or older) referred to CLPs in 7 intervention practices were compared with a random sample of adult patients from 8 comparison practices at baseline and 9 months. health-related quality of life (EQ-5D-5L, a standardized measure of self-reported health-related quality of life that assesses 5 dimensions at 5 levels of severity). well-being (Investigating Choice Experiments for the Preferences of Older People Capability Measure for Adults [ICECAP-A]), depression (Hospital Anxiety and Depression Scale, Depression [HADS-D]), anxiety (Hospital Anxiety and Depression Scale, Anxiety [HADS-A]), and self-reported exercise. Multilevel, multiregression analyses adjusted for baseline differences. Patients were not blinded to the intervention, but outcome analysis was masked. Data were collected on 288 and 214 (74.3%) patients in the intervention practices at baseline and follow-up, respectively, and on 612 and 561 (92%) patients in the comparison practices. Intention-to-treat analysis found no differences between the 2 groups for any outcome. In subgroup analyses, patients who saw the CLP on 3 or more occasions (45% of those referred) had significant improvements in EQ-5D-5L, HADS-D, HADS-A, and exercise levels. There was a high positive correlation between CLP consultation rates and patient uptake of suggested community resources. We were unable to prove the effectiveness of referral to CLPs based in primary care in deprived areas for improving patient outcomes. Future efforts to boost uptake and engagement could improve overall outcomes, although the apparent improvements in those who regularly saw the CLPs may be due to reverse causality. Further research is needed before wide-scale deployment of this approach.

Residential mobility and socioemotional and behavioural difficulties in a preschool population cohort of New Zealand children

BackgroundFindings regarding early residential mobility and increased risk for socioemotional and behavioural (SEB) difficulties in preschool children are mixed, with some studies finding no evidence of an association once known...

Does Self-Determination Theory help explain the impact of social prescribing? A qualitative analysis of patients' experiences of the Glasgow 'Deep-End' Community Links Worker Intervention.

The Links Worker Programme is a primary care-based social prescribing initiative in Glasgow, Scotland, targeting patients with complex needs in areas of high socioeconomic deprivation. The programme aims to improve wellbeing by connecting patients to appropriate community resources. This study explored the utility of Self-Determination Theory in understanding the reported impacts of the intervention. Thematic analysis of semi-structured interviews with 12 patients (34-64 years, six female) referred to Community Links Practitioners using Self-Determination Theory as a framework. Impact was assessed from participants' description of their personal circumstances before and after interaction with the Community Links Practitioner. Four patients described no overall change in daily life, two described slight improvement and six described moderate or major improvement. Improvers described satisfaction of the three psychological needs identified in Self-Determination Theory: relatedness, competence and autonomy. This often related to greater participation in community activities and sense of competence in social interaction. Patients who benefitted most described a change towards more intrinsic regulation of behaviour following the intervention. Understanding the impact of this social prescribing initiative was facilitated by analysis using Self-Determination Theory. Self-Determination Theory may therefore be a useful theoretical framework for the development and evaluation of new interventions in this setting.

Protocol for a randomised controlled trial to evaluate the effectiveness of the diabetes community exercise and education programme (DCEP) for long-term management of diabetes

IntroductionType 2 diabetes is common in Māori and Pacific peoples and in those living in areas of high socioeconomic deprivation in New Zealand (NZ). People with type 2 diabetes often...

Indigenous health worker support for patients with poorly controlled type 2 diabetes: study protocol for a cluster randomised controlled trial of the Mana Tū programme

IntroductionType 2 diabetes mellitus (T2DM) and its complications are more common among Māori and Pacific people compared with other ethnic groups in New Zealand. Comprehensive and sustained approaches that address...

Influences of socioeconomic deprivation on GPs' decisions to refer patients to cardiology: a qualitative study.

Variation in GP referral practice may be a factor contributing to the lower uptake of cardiology specialist services for people living in socioeconomic deprivation. Cardiology referrals were chosen for this study due to higher rates of premature death and emergency admissions resulting from coronary heart disease for patients living in more deprived areas. To find out how socioeconomic deprivation influences GP referral practice. A qualitative study of GPs working in affluent and deprived areas of one large city in the UK. The authors used purposive and snowball sampling to recruit 17 GP participants to interviews and a focus group. Participants were asked to reflect on their own experience of making referrals. The authors used a framework approach to the analysis, with differences in themes for GPs working in least and most deprived areas being highlighted. The authors identified four main themes by which socioeconomic deprivation influenced GP referral practice: identifying problems; making decisions about referral; navigating the healthcare system; and external pressures. Using a published framework of consultation complexity, the authors then examined the data in relation to a fifth theme of complexity. Referrals from areas of high socioeconomic deprivation involved greater complexity in the majority of the domains of this framework. Socioeconomic deprivation influences GP referral decisions and navigation of the healthcare system in multiple ways. Referral practice for GPs working in deprived areas is more complex than for their peers working in more affluent areas.

Professional resilience in GPs working in areas of socioeconomic deprivation: a qualitative study in primary care.

GPs working in areas of high socioeconomic deprivation face particular challenges, and are at increased risk of professional burnout. Understanding how GPs working in such areas perceive professional resilience is important in order to recruit and retain a GP workforce in these areas. To understand how GPs working in areas of high socioeconomic deprivation consider professional resilience. A qualitative study of GPs practising in deprived areas within one primary care region of England. In total, 14 individual interviews and one focus group of eight participants were undertaken, with sampling to data saturation. A framework approach was used for data analysis. Participants described three key themes relating to resilience. First, resilience was seen as involving flexibility and adaptability. This involved making trade-offs in order to keep going, even if this was imperfect. Second, resilience was enacted through teams rather than through individual strength. Third, resilience required the integration of personal and professional values rather than keeping the two separate. This dynamic adaptive view, with an emphasis on the importance of individuals within teams rather than in isolation, contrasts with the discourse of resilience as a personal characteristic, which should be strengthened at the individual level. Professional resilience is about more than individual strength. Policies to promote professional resilience, particularly in settings such as areas of high socioeconomic deprivation, must recognise the importance of flexibility, adaptability, working as teams, and successful integration between work and personal values.

Association between antibiotic prescribing and deprivation in Wales: A multilevel analysis

IntroductionThe most recent Welsh Antimicrobial Resistance Programme (WARP) report on antibiotic use in primary care found significant variations between Health Boards and hospitals in gross antibiotic use in 2014. The aim of this study was to evaluate the association between socioeconomic deprivation and antibiotic prescribing volumes.
 Objectives and ApproachWelsh General Practitioner (GP) antibiotic prescribing data for years 2013 to 2016 for patients’ resident in Wales were extracted from the Secure Anonymised Information Linkage GP tables. Deprivation was assessed by linking prescribing events to the Welsh Index of Multiple Deprivation (WIMD) score for the patient’s neighbourhood area. The association between deprivation area and antibiotic prescribed (items per 1000 persons per day) was stratified according to the patient’s age, sex, prescription year and antibiotic class. A three-level multilevel Poisson regression model of 1.58 million patients nested within 349 GP practices, nested with 67 GP clusters, was specified to assess the associations
 ResultsJust over 7.97 million antibiotic items were prescribed between 2013 and 2016. Patients in the most deprived WIMD quintile had an overall prescription rate that was 25.2% higher than those in the least deprived WIMD quintile. The final model revealed that residing in the most deprived WIMD quintile (incidence rate ratio [IRR] = 1.1769, 95% confidence interval [CI] 1.1768 to 1.1770, being female (IRR = 1,2699, 95% CI 1.2698 to 1.2700), being aged $\geq$90 (IRR = 2.0687, 95% CI 2.0683 to 2.0690), and prescription year being 2013 were associated with significantly higher rate of antibiotics prescription. There were significant primary cares clustering of antibiotics prescription in Wales.
 Conclusion/ImplicationsThis study provides evidence that patients in areas of higher socioeconomic deprivation are more likely to be prescribed antibiotics in primary care in Wales. Population health prevention strategies aimed at reducing high antibiotic prescription rates should consider targeting areas of high deprivation.

Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations.

The influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation. We conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP's empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups. In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727). In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care.

How effective is community physical activity promotion in areas of deprivation for inactive adults with cardiovascular disease risk and/or mental health concerns? Study protocol for a pragmatic observational evaluation of the ’Active Herts' physical activity programme

IntroductionThere is a high prevalence of inactive adults in the UK, and many suffer from conditions such as cardiovascular disease (CVD) or poor mental health. These coexist more frequently in...

Probabilistic linking to enhance deterministic algorithms and reduce linkage errors in hospital administrative data

BackgroundThe pseudonymisation algorithm used to link together episodes of care belonging to the same patient in England [Hospital Episode Statistics ID (HESID)] has never undergone any formal evaluation to determine...

The Glasgow 'Deep End' Links Worker Study Protocol: a quasi-experimental evaluation of a social prescribing intervention for patients with complex needs in areas of high socioeconomic deprivation.

Background‘Social prescribing’ can be used to link patients with complex needs to local (non-medical) community resources. The ‘Deep End’ Links Worker Programme is being tested in general practices serving deprived populations in Glasgow, Scotland.ObjectivesTo assess the implementation and impact of the intervention at patient and practice levels.MethodsStudy design: Quasi-experimental outcome evaluation with embedded theory-driven process evaluation in 15 practices randomized to receive the intervention or not. Complex intervention: Comprising a practice development fund, a practice-based community links practitioner (CLP), and management support. It aims to link patients to local community organizations and enhance practices’ social prescribing capacity. Study population: For intervention practices, staff and adult patients involved in referral to a CLP, and a sample of community organization staff. For comparison practices, all staff and a random sample of adult patients. Sample size: 286 intervention and 484 comparator patients. Outcomes: Primary patient outcome is health-related quality of life (EQ-5D-5L). Secondary patient outcomes include capacity, depression/anxiety, self-esteem, and healthcare utilization. Practice outcome measures include team climate, job satisfaction, morale, and burnout. Outcomes measured at baseline and 9 months. Processes: Barriers and facilitators to implementation of the programme and possible mechanisms through which outcomes are achieved. Analysis plan: For outcome, intention-to-treat analysis with differences between groups tested using mixed-effects regression models. For process, case-study approach with thematic analysis.DiscussionThis evaluation will provide new evidence about the implementation and impact of social prescribing by general practices serving patients with complex needs living in areas of high deprivation.

Dispelling the nice or naughty myth: retrospective observational study of Santa Claus

Objective To determine which factors influence whether Santa Claus will visit children in hospital on Christmas Day.Design Retrospective observational study.Setting Paediatric wards in England, Northern Ireland, Scotland, and Wales.Participants 186...

The CARE Plus study - a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis.

BackgroundMultimorbidity is common in deprived communities and reduces quality of life. Our aim was to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation.MethodsWe used a phase 2 exploratory cluster randomised controlled trial with eight general practices in Glasgow in very deprived areas that involved multimorbid patients aged 30–65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and well-being (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement, and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible but outcome measurement and analysis were masked. Analyses were by intention to treat.ResultsOf 76 eligible practices contacted, 12 accepted, and eight were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68 %) participated and 67/76 (88 %) in each arm completed the 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative well-being), with an effect size of 0.33 (95 % confidence interval [CI] 0.11–0.55) at 12 months (p = 0.0036). Positive well-being, energy, and general well-being (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve over the 12 months was higher in the CARE Plus group (p = 0.002). The incremental cost in the CARE Plus group was £929 (95 % CI: £86–£1788) per participant with a gain in quality-adjusted life years of 0.076 (95 % CI: 0.028–0.124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per quality-adjusted life year gained. Modelling suggested that cost-effectiveness would continue.ConclusionsIt is feasible to conduct a high-quality cluster randomised control trial of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life for multimorbid patients in deprived areas.Trial registrationTrial registration: ISRCTN 34092919, assigned 14/1/2013.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-016-0634-2) contains supplementary material, which is available to authorized users.

The development and optimisation of a primary care-based whole system complex intervention (CARE Plus) for patients with multimorbidity living in areas of high socioeconomic deprivation.

ObjectivesTo develop and optimise a primary care-based complex intervention (CARE Plus) to enhance the quality of life of patients with multimorbidity in the deprived areas.MethodsSix co-design discussion groups involving 32 participants were held separately with multimorbid patients from the deprived areas, voluntary organisations, general practitioners and practice nurses working in the deprived areas. This was followed by piloting in two practices and further optimisation based on interviews with 11 general practitioners, 2 practice nurses and 6 participating multimorbid patients.ResultsParticipants endorsed the need for longer consultations, relational continuity and a holistic approach. All felt that training and support of the health care staff was important. Most participants welcomed the idea of additional self-management support, though some practitioners were dubious about whether patients would use it. The pilot study led to changes including a revised care plan, the inclusion of mindfulness-based stress reduction techniques in the support of practitioners and patients, and the stream-lining of the written self-management support material for patients.DiscussionWe have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas. CARE Plus will next be tested in a phase 2 cluster randomised controlled trial.

Socioeconomic deprivation and barriers to live-donor kidney transplantation: a qualitative study of deceased-donor kidney transplant recipients

ObjectivesSocioeconomically deprived individuals with renal disease are less likely to receive a live-donor kidney transplant than less-deprived individuals. This qualitative study aimed to identify reasons for the observed socioeconomic disparity...

Challenges of managing people with multimorbidity in today's healthcare systems.

Multimorbidity is a growing issue and poses a major challenge to health care systems around the world. Multimorbidity is related to ageing but many studies have now shown that it is also socially patterned, being more common and occurring at an earlier age in areas of high socioeconomic deprivation. There is lack of research on patients with multimorbidity, and thus guidelines are based on single-conditions. Polypharmacy is common in multimorbidity, increasing drug-disease and drug-drug interactions. Multimorbid patients need holistic care, but secondary care services are highly specialised and thus are often duplicative and fragmented and thus increase treatment burden in multimorbid patients. The cost of care is high in multimorbidity, due to high rates of primary and secondary care consultations and unplanned hospital admissions. The combination of mental and physical conditions increases complexity of care, and costs. Mental-physical multimorbidity is especially common in deprived areas.General practitioners and primary care teams have a key role in managing patients with multimorbidity, using a patient-centred generalist approach. Consultation length and continuity of care may need to be substantially enhanced in order to enable such patients. This will require a radical change in how health care systems are organised and funded in order to effectively meet the challenges of multimorbidity.

Exploring social inclusivity within the University of the Third Age (U3A): a model of collaborative research

ABSTRACTLifelong learning is believed to have physical, social and emotional benefits for older adults. In recognition of this, numerous programmes encouraging learning in later life exist worldwide. One example is the University of the Third Age (U3A) – a lifelong learning co-operative rooted in peer-support and knowledge sharing. This article is based on a collaborative study conducted by university researchers and members of a U3A in North-East England (United Kingdom) investigating the social inclusivity of the group in light of low attendance levels among those from social housing and non-professional backgrounds. A qualitative approach comprising semi-structured interviews and focus groups was adopted to explore knowledge and experience of lifelong learning and the U3A. Sixty individuals aged 50+ were interviewed. The demographic profile of participants largely reflected the socio-economic make-up of the area, with the majority living in areas of high socio-economic deprivation. Several barriers to lifelong learning were revealed, including: poor health, insufficient transport and caring responsibilities. Regarding U3A participation, three exclusionary factors were outlined: lack of knowledge, organisational name and location. Poor comprehension of the purpose and remit of the U3A can result in the development of ‘middle-class' myths regarding membership, perpetuating poor participation rates among lower socio-economic groups. Such perceptions must be dispelled to allow the U3A to fulfil its potential as a highly inclusive organisation.

Staphylococcus aureus infections in New Zealand, 2000-2011.

The incidence rate for invasive and noninvasive Staphylococcus aureus infections in New Zealand is among the highest reported in the developed world. Using nationally collated hospital discharge data, we analyzed the epidemiology of serious S. aureus infections in New Zealand during 2000-2011. During this period, incidence of S. aureus skin and soft tissue infections increased significantly while incidence of staphylococcal sepsis and pneumonia remained stable. We observed marked ethnic and sociodemographic inequality across all S. aureus infections; incidence rates for all forms of S. aureus infections were highest among Māori and Pacific Peoples and among patients residing in areas of high socioeconomic deprivation. The increased incidence of S. aureus skin and soft tissue infections, coupled with the demographic disparities, is of considerable concern. Future work should aim to reduce this disturbing national trend.