Deep End Research Articles

In at the Deep End: Innovative approaches to engaging underserved communities in Northern England

Abstract Background People living in socio-economically deprived communities have greater health needs, but worse access and outcomes from care. A growing international movement of Deep End (DE) general practice networks established to promote health equity, address challenges posed by the inverse care law and advocate for increased research involvement. Researchers, community members and practitioners in the North of England are exploring ways of engaging with underserved communities and addressing low levels of inclusion in research. Methods DE research i) co-designing the North East and North Cumbria (NENC) DE network with practitioners to prioritise service investment, research activities and initiatives for local communities; ii) Deep End Research Alliance Yorkshire and Humber (DERA-YH) and Participatory Action Research to increase research capacity and reflect upon the evolution of a novel primary care Community Research Link Worker role (CRLWs). Results Prioritisation activities in the NENC DE network, uncovered the volume and complexity of clinical and social need, leading to the co-design and evaluation of initiatives to improve mental health care, increase childhood immunisations, tailor deprescribing, support training, and increase patient inclusion in research. In the DERA-YH, the CRLW model increased participation in research from ethnic minority communities regarding prostate cancer, lung health, dementia, and contraceptive services. Community leaders stated that sharing resources and power in the research process builds trust and interest in research in their communities. Conclusions DE networks in Northern England have driven innovative approaches to engage underserved communities in research, fostering empowering and enduring relationships to address health and care inequalities. Co-design methodologies and CRLWs integration into research teams had a transformative impact on the accessibility of research for communities and for the researchers’ positionality. Key messages • Deep End networks are advancing approaches to meaningful engagement and partnership working with underserved communities, to address health, care and research participation inequalities. • We recommend co-design by default and CRLW models to build capacity and embed reflective practice, mutual respect, and power sharing across the research team.

At the deep end: towards a social emergency medicine

People experiencing the highest levels of social deprivation are more likely to present to emergency care across the spectrum of disease severity, and to have worse outcomes following acute illness....

'Challenging but ultimately rewarding' - lived experiences of Deep End Northern Ireland GPs: a qualitative study.

Living in socioeconomically deprived areas is associated with shorter lives and worse health. GPs working in these areas face additional challenges compared with those in more affluent locations. To establish GPs' motivation for working in these areas, to discover the challenges that GPs face, and to gain insights from GPs on potential improvements and changes. An interpretative phenomenological analysis was undertaken of GPs' lived experiences of working in the most socioeconomically deprived practices in Northern Ireland (NI), which is the most deprived country within the UK. Interviews were carried out with nine GPs to find out the challenges facing them, why they work in a Deep End area, and what suggestions, ideas, and solutions they have to improve patient care and GP experience at NI's Deep End. The challenges related to wider health service failures including the increased demand on GPs and feelings of powerlessness. Patient population challenges included 'missingness', late or crisis presentations, alongside the clinical difficulties of a highly 'medicalised' patient population, as well as the high prevalence of mental health problems. However, GPs choose to work in Deep End areas because the environments were seen as clinically stimulating and rewarding, as well as giving them feelings of belonging and fulfilling a duty to 'their' area. Improvements focused on providing more flexible access, increased mental health provision, and future training and recruitment, particularly around widening participation in medical school. Improving the environmental conditions, empowering individuals, and investing in communities are essential factors to achieving health. The current model of providing reactionary acute care is leading to GPs experiencing powerlessness and feelings of helplessness at the Deep End.

The lived experience of midwives’ transitioning from a clinical role into teaching in higher education in one jurisdiction of Australia: A pilot study

AimThe aim of this pilot study was to explore clinician’s experience of transitioning from midwifery clinical practice into university in an academic teaching role within one jurisdiction in Australia. BackgroundThere is a dire shortage of midwifery academics globally. In Australia the shortage is symbiotic with the persistent deficit in the midwifery clinical workforce, which is the predominant recruitment pool for universities. The midwifery workforce cannot be replenished without sufficient academics to provide education. DesignPhenomenology was selected as the most appropriate research approach for the study seeking to illuminate the lived experiences of clinicians as they transition into their new role as academics. MethodsSeven participants were recruited purposively from one jurisdiction in Australia between November 2022 and March 2023. Qualitative conversational interviews were performed facilitating each participant to share their narrative. Participants were then able to direct the conversation to share their lived experience of the transition from a midwifery clinician in practice to a midwifery academic in a university. Demographic details were collected for context. ResultsThematic analysis was used following Giorgi’s four stage phenomenological process. Four themes were identified from commonalities between the participants, ‘Being a drifter”, ‘Keeping a foot in both camps to maintain clinical credibility’, ‘In at the deep end: Not prepared for the reality of academia’ and ‘Best of both worlds’. ConclusionsThe lived experiences of the participants in this study, as they transitioned from clinical midwifery practice to academia can be related to the Theory of Transition where participants navigate: Preparation, Encounter, Adjustment and Stabilisation. A new role in higher education requires adjustment to the reality of working in academia. Midwives who had experiences of being a casual staff member felt they had the best of both worlds, as they gained an insight into the role of an academic whilst remaining in clinical practice. However, many reported that mentorship would have been beneficial to facilitate stabilisation.

Water dropped in the deep end

Water dropped in the deep end

Expectations and needs of patients with esophageal cancer during curative treatment regarding self-management, self-management support and eHealth: a qualitative study

PurposeSelf-management is an essential component of the curative treatment trajectory of esophageal cancer patients. The aims of this study were to explore expectations and needs of esophageal cancer patients during curative treatment regarding self-management, relevant aspects of self-management in which they need additional support, and to explore their willingness to use eHealth. MethodsSemi-structured interviews were conducted with esophageal cancer patients, who had been treated with neoadjuvant chemo(radio)therapy followed by surgery, maximally 1 year after surgery. Based on the general model of self-management, the following themes were discussed: experience-based knowledge, contribution to care, living with the condition, and organization of care and support. A stepwise systematic text condensation guided the data analysis. ResultsAll four domains of the general model of self-management were identified. All participants described a remarkable difference between the pre-operative pathway, when it felt like they were taken by the hand, and the postoperative pathway, when it felt like they were thrown into the deep end. They adjusted to their new life situation by learning new experiences, while dealing with their diminished confidence in their bodies. Patients expressed the need for support from different sources, and were open to the idea of using eHealth in addition to usual care. (digital) Self-management support should be easily accessible, person-centered, confidential, and include personal contact. ConclusionDifferences were found among esophageal cancer patients regarding self-management, self-management support and eHealth for self-management purposes, indicating there is no one approach that will meet the needs of all patients at all times.

Complex Martinique Intermediate‐Depth Earthquake Reactivates Early Atlantic Break‐Up Structures

AbstractEarthquakes that rupture several faults occur frequently within the shallow lithosphere but are rarely observed for intermediate‐depth events (70–300 km). On 29 November 2007, the Mw7.4 Martinique earthquake struck the Lesser Antilles Island Arc near the deep end of the Wadati‐Benioff‐Zone. The sparse regional seismic network of 2007 previously hampered a detailed examination of this unusually complex event. Here, we combine seismic data from different studies with regional moment tensor inversion results and 3D full‐waveform modeling. We show that the earthquake is a doublet consisting of dip‐slip and strike‐slip motion along two oblique structures, both activated under extensional stress along the strike of the slab. Comparison with tectonic reconstructions suggests that the earthquake ruptured along a re‐activated ridge‐transform segment of the subducted Proto‐Caribbean spreading ridge. The unprecedented resolution of the source process highlights the influence of pre‐existing structures on localizing slab deformation also at intermediate‐depth.

Thrown in the deep end

Thrown in the deep end

Where do we intervene to optimize sports systems? Leverage Points the way

ABSTRACT Sport and sports research are inherently complex systems. This appears to be somewhat at odds with the current research paradigm in sport in which interventions are aimed are fixing or solving singular broken components within the system. In any complex system, such as sport, there are places where we can intervene to change behaviour and, ideally, system outcomes. Meadows influential work describes 12 different points with which to intervene in complex systems (termed “Leverage Points”), which are ordered from shallow to deeper based on their potential effectiveness to influence transformational change. Whether research in sport is aimed at shallow or deeper Leverage Points is unknown. This study aimed to assess highly impactful research in sports science, sports nutrition/metabolism, sports medicine, sport and exercise psychology, sports management, motor control, sports biomechanics and sports policy/law through a Leverage Points lens. The 10 most highly cited original-research manuscripts from each journal representing these fields were analysed for the Leverage Point with which the intervention described in the manuscript was focused. The results indicate that highly impactful research in sports science, sports nutrition/metabolism, sports biomechanics and sports medicine is predominantly focused at the shallow end of the Leverage Points hierarchy. Conversely, the interventions drawn from journals representing sports management and sports policy/law were focused on the deeper end. Other journals analysed had a mixed profile. Explanations for these findings include the dual practitioner/academic needing to “think fast” to solve immediate questions in sports science/medicine/nutrition, limited engagement with “working slow” systems and method experts and differences in incremental vs. non-incremental research strategies

“Thoroughly out of my depth - A quality improvement project to improve junior clinician’s confidence in undertaking adult ADHD clinic appointments

IntroductionThere has been a 1000% increase in referrals for assessment of adult ADHD within Scotland over the past three years (The Scottish Government. 2023. NAIT adult Neurodevelopmental Pathways Report). These referrals are sent by general practitioners to the local community mental health team. The most junior clinicians (doctors who are pre-membership with the Royal College of Psychiatrists) in the team are often responsible for undertaking the initial assessment of these patients. Patients have on average waited almost a year to be seen and expectations are high.ObjectivesThe diagnosis of ADHD can be challenging, and adult ADHD is still a relatively new and evolving diagnostic entity. We set out to explore how junior clinicians were coping with this in their daily practice.MethodsWe developed a questionnaire that was sent to all junior clinicians working within Argyll & Bute (n=8) via an anonymised email link. The link was open for 1 week and then results were analysed.ResultsThe response rate to our survey was 87.5%. Prior to starting their current roles none of the respondents had ever undertaken an ADHD assessment before. All respondents answered “No” when asked if they felt they had adequate knowledge on ADHD in order to perform assessments. Only 14% (n=1) felt they had access to adequate resources about how to make an ADHD diagnosis. Participants were asked on a scale of 1-10 (1= not at all,10= very) to rate their confidence in conducting ADHD assessments. The average confidence score was 2.43. There was a space for free text feedback in which participants reported the following: “felt thoroughly out my depth”, “I felt chucked in the deep end”, “I felt very under qualified”Image:ConclusionsOur results showed that junior clinicians did not feel confident or knowledgeable about undertaking adult ADHD assessments. In response to this we have now produced, in association with the consultant psychiatrists within our health board, an informative and engaging quick reference poster which explains how to undertake an ADHD assessment (see QR code attached as Image 1). It contains useful pointers about diagnosis, and more importantly guidance on language/phrases to use when explaining to patients whether or not you feel a diagnosis of ADHD is appropriate. It then also explains next steps that can be offered i.e. psychological support/medication options and how to prescribe these. We plan to send out a repeat questionnaire to the next cohort of junior clinicians to assess if they have improved confidence in managing and diagnosing ADHD following this intervention.Disclosure of InterestNone Declared

GP careers: diving in at the Deep End?

GP careers: diving in at the Deep End?

Dynamic Modeling of Unmanned Underwater Vehicles with Online Disturbance Compensation Scheme

With the advancement in robotics technology over the recent years, underwater robots’ design and development are gaining interest. Unmanned underwater vehicles (UUVs) have many applications in aquaculture, deep-sea exploration, research, and enhanced rescue tasks. However, various factors must be considered when developing any underwater vehicle system to explore the deep ends of the underwater world. In this paper, we develop the most suitable model for understanding various system parameters. The new mathematical model considers certain constraints and external disturbances exerted on the system. Also, a control strategy is suggested for the UUV’s stability and robustness. The suggested observer and model are simple, allowing for accurate estimations of all system states and the global impacts of unknown limped perturbations with a minimal computational cost.

Thrown in at the deep end: a qualitative study with physicians on the purpose and challenges of discharge interviews

ABSTRACT Objectives Against the backdrop of poor discharge communication in hospitals, this study explores the purpose of discharge interviews from the physicians’ perspective and the challenges they are confronted with. Discharge interviews are legally required in Germany as part of the discharge management. Led by the ward physician, the discharge interview should summarize relevant information about the hospital stay, medication, lifestyle interventions and follow-up treatment. Methods Semi-structured interviews with n = 12 physicians were conducted at Heidelberg University Hospital between February and April 2020. Qualitative content analysis was carried out using MAXQDA. Results Physicians reported gaining information, providing information, and answering open-ended questions as the purpose of the discharge interview. Challenges in conducting discharge interviews were related to finding a common language, patient-related challenges, conditions of everyday ward life, and lack of training. Physicians reported receiving no explicit training on discharge interviews. While professional experience seems to mitigate the lack of training, some physicians expressed a prevailing sense of insecurity. Conclusion The lack of preparation for discharge interviews in medical school makes it particularly challenging for physicians to translate their theoretical knowledge into patient-centered discharge communication. Medical training on discharge interviews should be expanded in terms of theoretical input on the ideal content, its purpose and potential (e.g. in reducing readmissions), as well as practical exercises.

Severe mental illness and cardioprotective medication prescribing: a qualitative study in general practice.

Patients with severe mental illness (SMI) die 10-20 years earlier than the general population. They have a higher risk of cardiovascular disease (CVD) yet may experience lower cardioprotective medication prescribing. To understand the challenges experienced by GPs in prescribing cardioprotective medication to patients with SMI. A qualitative study with 15 GPs from 11 practices in two Scottish health boards, including practices servicing highly deprived areas (Deep End). Semi-structured one-to-one interviews with fully qualified GPs with clinical experience of patients with SMI. Interviews were transcribed verbatim and analysed thematically. Participants aimed to routinely prescribe cardioprotective medication to relevant patients with SMI but were hampered by various challenges. These structural and contextual barriers included the following: lack of funding for chronic disease management; insufficient consultation time; workforce shortages; IT infrastructure; and navigating boundaries with mental health services. Patient-related barriers included patients' complex health and social needs, their understandable prioritisation of mental health needs or existing physical conditions, and presentation during crises. Professional barriers comprised GPs' desire to practise holistic medicine rather than treating via cardioprotective prescribing in isolation, and concerns about patients' medication concordance if patients were not prioritising this aspect of their health care at that particular time. In terms of enablers for cardioprotective prescribing, participants emphasised continuity of care as fundamental in engaging this patient group in effective cardiovascular health management. A cross-cutting theme was the current GP workforce crisis leading to 'firefighting' and diminishing capacity for primary prevention. This was particularly acute in Deep End practices, which have a high proportion of patients with complex needs and greater resource challenges. Although participants aspire to prescribe cardioprotective medication to patients with SMI, professional-, system- and patient-level barriers often make this challenging, particularly in deprived areas owing to patient complexity and the inverse care law.

Logic in the deep end

Abstract Weak enough relevant logics are often closed under depth substitutions. To determine the breadth of logics with this feature, we show there is a largest sublogic of R closed under depth substitutions and that this logic can be recursively axiomatized.

Should we be concerned? A qualitative study of educators’ perceptions of medical student wellbeing in domestic violence training

Introduction Domestic violence (DV) is common in the Australian community so it is likely that there will be medical students who are affected personally by DV. Some of these students may find DV training confronting or even re-traumatising. A trauma-informed medical education (TIME) framework utilising trauma-informed care principles may minimise this risk to students. We aimed to explore educators’ perceptions of student well-being in Australian medical school DV training. Method This descriptive qualitative study interviewed 13 educators with experience teaching DV in Australian medical schools using an interpretivist methodology and a TIME framework. Interview data was thematically analysed to identify themes. Results Four key themes included (1) educators thrown in at the deep end; (2) keeping students emotionally safe; (3) a trauma-informed learning environment and; (4) challenges of student DV disclosures. Few of the participants had received training in DV. Educators used methods such as trigger warnings and ground rules to improve student’s emotional safety. Experienced educators dealt with disclosures of DV by students which led to role confusion. Discussion There is a need for increased training of medical educators that includes awareness and implementation of TIME principles when training medical students in DV as well as increased supports and resources for educators.

How to address the inverse care law and increase GP recruitment in areas of socioeconomic deprivation: a qualitative study of GP trainees' views and experiences in the UK.

The Deep End network in the North East and North Cumbria (NENC) was set up to tackle health inequalities in general practice. One aim is to address the inverse care law and improve recruitment of GPs, which is known to be especially challenging in areas of socioeconomic deprivation. To explore GP trainees' experiences and perceptions of working in Deep End or Deprived Area Practices (DE/DAPs) to identify how GP recruitment can be improved. Qualitative study recruiting 13 doctors training to be GPs from the Northumbria training programme. Audio-recorded, online, semi-structured interviews and discussion groups were undertaken, transcribed verbatim, and analysed with a grounded theory approach, using a process of thematic analysis. Overall, seven interviews and two discussion groups (13 participants in total) were conducted. Three themes were identified. The first theme was working in areas of socioeconomic deprivation is challenging but has many advantages. The challenges of working in DE/DAPs were not deterring factors for GP trainees wanting to work in areas of socioeconomic deprivation. The second theme was trainees are willing to work in areas of socioeconomic deprivation but clinical experience is important. Training in DE/DAPs gives trainees the confidence to work in areas of deprivation. Familiarity with a practice also makes them more likely to stay post-training. The third theme was financial incentives are not an important attracting factor but support and development opportunities are. Non-pecuniary measures, such as clinical support and protected time for continuing professional development (CPD), were found to be important. To improve recruitment to DE/DAPs, investments should be made to increase the opportunities to train in these environments. This can be achieved by supporting more DE/DAPs to become training practices, and providing clinical support and protected time for CPD.

A jump into the deep end - Women's strategies on the way to VBAC in Poland

ProblemIn Poland, as in other high-income countries, the rate of caesarean sections (CS) is alarmingly high. Promoting vaginal birth after caesarean section (VBAC) is one of the ways that may help to decrease CS rate. Despite the recommendations by the Polish Association of Gynaecologists and Obstetricians that one previous CS should not be an indication for a subsequent one and VBAC should be promoted, the rate of VBAC in Poland remains low. BackgroundResearch shows that in countries with high VBAC rates women felt supported by healthcare personnel to have VBAC. AimThis study aims to explore the elements of Polish maternity services that contribute to or hinder women’s chances of having a VBAC. MethodsThe study used qualitative methods of research based on semi-structured interviews.We interviewed 22 women. Each woman was interviewed twice, once during pregnancy and then between 6 and 12 weeks after she had given birth. FindingWomen who planned vaginal birth after one previous CS engaged in various strategies such as seeking supportive personnel, opting for fee-for-service dedicated midwifery care or traveled long distances to give birth in facilities supporting VBAC. ConclusionsPolish maternity services do not support women on the way to vaginal birth after surgery. Access to VBAC in Poland is highly unequal and dependent on women’s social and financial resources such as access to private care, place of residence, or social relationships. Efforts should be made to make access to VBAC more universal.

Experimental investigation of local scour around complex bridge pier of sea-crossing bridge under tidal currents

To study the process of local scour around the large-scale complex bridge pier under tidal currents, local scour experiments were carried out using the pile group-cap of the Hong Kong-Zhuhai-Macao Bridge (HZMB) as prototypes. The geological conditions at the bridge site were explored and the sampled soil was experimentally analyzed to determine the model sand. Based on the long-term observation data of tidal currents at the bridge site, a harmonic analysis of tidal currents was conducted to obtain the hydrodynamic characteristics of the tidal currents. Then a flume experiment of local scour around the large-scale pile groups under tidal currents was carried out. Research results indicate that the tidal currents velocity at the HZMB site exhibits the characteristic that the falling tide velocity is greater than the rising tide velocity. The frequency of the flow direction in the N and S directions is more significant. The tidal currents at the bridge site belong to the irregular semi-diurnal tide. The maximum depth of scour under tidal currents occurs on the side with highest velocity in the rising and falling tide process, and its value is slightly lower than the value under unidirectional flow. The duration of equilibrium scour under tidal currents is longer than under unidirectional flow. The shape of the equilibrium scour pit under tidal currents has changed from a circular arc shape on the upstream side to a saddle shape with deep ends and shallow middle, and has formed a longer sedimentation zone at both ends of the rising and falling tides compared to the situation under unidirectional flow. The size and layout of the pile foundation have a significant impact on the shape of the scour pits that achieve equilibrium scour.

Health inequalities, multimorbidity and primary care in Scotland

Scotland has an ageing population and the widest health inequalities in Western Europe. Multiple health conditions develop ∼10-15 years earlier in deprived areas than in affluent areas. General practice is central to the effective and safe management of such complex multiple health conditions, but the inverse care law has permeated deprived communities ('Deep End' general practices) for the past 50 years. A new, radical, Scottish GP contract was introduced in April 2018, which has a vision to improve quality of care through cluster working and expansion of the multidisciplinary team (MDT), enabling GPs to deliver 'expert generalism' to patients with complex needs. It states a specific intention to address health inequalities and also to support the integration of health and social care. Here, we discuss recent evidence for whether the ambition of the new GP contract, to reduce health inequalities, is being achieved.