Users Of Health Care Services Research Articles

Development and content validation of a questionnaire to assess the social determinants of mental health in clinical practice

IntroductionThere is growing consensus that consideration of the Social Determinants of Mental Health should be at the centre of mental health care provision. To facilitate this, a validated means to assess mental health service users' social contextual information is arguably needed. We therefore developed a questionnaire to assess the Social Determinants of Mental Health in clinical practice.MethodsOur guideline-informed development consisted of three steps; i) construct and purpose definition, ii) initial item generation based on the literature, similar questionnaires, and a selection of the ICD-10, iii) evaluation, revision, and content validation of the questionnaire. Initially we developed 249 items that were reduced, revised, and validated in several stages to 73 items. Content validation of the questionnaire was achieved through surveys and focus groups including mental health care service users and professionals.ResultsThe surveys and focus groups indicated the need for a standardised assessment of adverse social factors and highlighted that the benefits of such an assessment would be a more holistic approach to identifying and addressing fundamental factors involved in the development of mental health difficulties. Importantly, this study also revealed how any assessment of the Social Determinants of Mental Health must prioritise the assessed person having a central role in the process and control over their own data. The focus groups identified contradicting recommendations regarding the most suitable context to administer the questionnaire.DiscussionThe resulting questionnaire can be considered to be theoretically robust and partially validated. Future research is discussed.

Co-designing restrictive practice elimination: A systems thinking approach with mental health service users and practitioners in rural/regional Australia.

Elimination of restrictive practices (physical/mechanical restraint and seclusion) from adult acute mental health care services has been demanded internationally for many decades. This study aimed to: (1) Identify priority issues in the elimination of and use of alternative approaches to restrictive practices (seclusion and physical/mechanical restraint) in rural/regional acute adult mental healthcare services, as told by mental healthcare service users and practitioners, (2) identify the community-based, system-level feedback loops that enhance or reduce the use of restrictive practices and viable alternatives and, (3) identify potential action areas to improve system structures to increase regional mental healthcare services' ability to eliminate restrictive practices and use alternative approaches. Group model building (GMB) workshops were held with a small group (n = 9) of mental healthcare practitioners and service users with lived experience of restrictive practice use. This participatory approach enables exploration and visual mapping of local structures causing behaviour patterns of practitioner and service user concern over time - in this case, the barriers, and enablers to alternative approaches to restrictive practices in adult acute mental healthcare services within the Geelong-Barwon region. This is the first study that specifically applies GMB in the discussion of the elimination of restrictive practices in mental health in the non-metropolitan regional/rural context. Participants identified four key priorities in relation to eliminating restrictive practices: (1) self-advocacy, (2) continuity of care, (3) early intervention, and (4) safety for all. The study findings were distilled into a novel preliminary set of mental healthcare practitioner and service user action ideas.

Representations of alcohol and drug use in the Finnish reform of social and health care service users’ rights

BackgroundA growing body of research has analysed the representations of alcohol and other drugs (AOD) in policy-making, but few studies have focused on the representations reproduced in law-making processes, especially in the context of the regulation of the rights of social and health care service users. This study examined what kind of representations of AOD use are reproduced in the legislative reform of social and health care service users’ rights in Finland. The purpose of the reform is to strengthen social and health care service users’ rights to self-determination and to reduce the use of restrictive measures. MethodsAs its data, the study used a draft of the bill and stakeholder opinions regarding the reform. ‘What's the problem represented to be?’ approach as a methodological framework. ResultsThe study discovered three AOD-related discourses: the Control, Welfare, and Rights and Legality discourses. The Control discourse represented people who use AOD as risky individuals and called for ways to manage risks in treatment situations. The Welfare discourse portrayed people who use AOD as a vulnerable group whose problems should be addressed by the welfare system. The Rights and Legality discourse represented the vague legal definitions of AOD use as the main regulatory problem. The discourses differed in terms of their definitions of self-determination. ConclusionsThe study illustrated how the right to self-determination as a legal concept is contested and can be interpreted in different ways depending on the representations of AOD use. The differing representations highlight the tensions involved in improving the rights of people who use AOD.

Evaluating inhaler technique, patient preferences and opportunities for improvement in hospitals in the UK

Inhalers are a key aspect of managing airways disease, with effective use they can reduce symptoms, reduce the frequency of exacerbations and thus reduce usage of healthcare services.1 Inhalers are associated with a significant carbon footprint, accounting for 3% of NHS carbon emissions.2 We aimed to audit inhaler technique, patient preferences and inhaler prescribing/disposal to identify areas for improving the sustainability of respiratory care. An audit tool was created, and patient interviews conducted across 8 different sites. Our data demonstrates that inhaler users, while self-reporting high levels of confidence in their inhaler technique, frequently make errors in inhaler technique. Additionally, the majority of patients consider the carbon footprint of their inhalers important and would consider changing to a lower carbon alternative. The majority of patients surveyed were not disposing of their inhalers correctly. This short audit has identified key areas for improvement in the quality and sustainability of respiratory care.

Healthcare professionals’ perspectives on the key considerations for digital technology aiding the early detection of dementia-causing diseases: a qualitative approach

Abstract Introduction Digital health technologies (DHTs) can assist with the early detection of dementia-causing diseases.(1) Previous research has highlighted the benefits of involving health care professionals (HCPs) in their design and development.(2) Aim Explore HCPs’ perspectives on the key considerations when using DHTs for the early detection of dementia-causing diseases in healthcare settings. Methods HCPs in the National Health Service with a patient-facing role (independent of speciality or experience) were recruited using online clinical networks. Semi-structured interviews were conducted remotely (over Zoom) exploring their acceptance of DHTs and providing an early detection service, the optimal location for the service, and the challenges surrounding implementation. With the aid of NVivo, we applied an inductive framework approach using the ‘constant comparison’ to identify recurring themes in the data. Results Primary care (general practitioners [n=11]) and secondary care staff (mental health nurses [n=3], dementia specialist nurse [n=1], psychiatrist [n=1], community psychiatric nurse [n=1], care coordinator [n=1]) were interviewed. Three key themes were generated relating to healthcare service users, healthcare professionals, and DHTs (Table 1). HCPs stressed the importance of defining a target healthcare service user group to avoid wasting resources and avoiding contributing towards health inequities in terms of access to the service and post-detection care. Brain Health Centres, which use a combination of clinical and research methods for early detection, were favoured over traditional primary or secondary care settings, due to workload concerns. HCPs suggested training be provided to help interpret results and provide appropriate interventions post detection. Many HCPs were excited about the benefit of collecting longitudinal real-time data that could monitor patients over time but raised concerns around the accuracy of current digital tools. Conclusion Results highlighted important considerations for HCPs when developing and implementing DHTs to aid the early detection of dementia-causing diseases in clinical settings. Participants had an interest in older people’s health, dementia, mild cognitive impairment or digital health, which may have influenced their perspectives; however, our work shows DHTs should not contribute towards health inequities. Future work is needed to explore the perspectives of groups experiencing health inequities within the design, development and implementation of DHTs.

Assessment of modern maternal health care usage in Ethiopia

Ethiopia, like many developing nations, has struggled with the problem of low utilization of maternal healthcare services. The main objective of this study is to investigate the awareness and application of modern maternal healthcare usage and to identify the determinant factors that affect the usage of modern maternal healthcare services in Ethiopia. A quantitative approach to the survey questionnaire was employed. A simple random sampling technique was used to select 240 respondents from a sample of women aged between 18 and 49. Using statistical software, the collected data were analyzed using categorical variable tests and binary logistic regression. The findings showed that, from the total of 240 respondents, some of the respondents had not attended Antenatal care, delivery care, and postnatal care. Therefore, from the findings of the study, the researchers have concluded that to increase health care utilization, the concerned bodies should be expanding access to health services, improving the quality of antenatal care services, conducting awareness-raising promotions, and providing training for health workers to increase their skills and professional ethics. Keywords: Health care; maternity; modern health care service; women.

Exploring Effective Approaches: Integrating Mental Health Services into HIV Clinics in Northern Uganda.

Integrating mental health services into HIV clinics is recognized as a promising strategy. However, the literature reveals gaps, particularly in the unique context of Northern Uganda, where factors such as historical conflict, stigma, and limited resources pose potential barriers. This qualitative study, conducted between October and November 2023, employed a phenomenological design. The study involved primary healthcare facilities across diverse urban and rural settings, focusing on healthcare providers, village health teams, and service users. A purposive sampling approach ensured diverse demographics and perspectives. In-depth interviews and focus group discussions were conducted, with healthcare providers and service users participating individually, and village health teams engaged in group discussions. Thematic analysis was employed during data analysis. Findings revealed a predominance of females among healthcare providers (18 of 30) and service users (16 of 25), as well as in VHTs. Average ages were 33.4 (healthcare providers), 38.5 (service users), and 35.1 (VHTs). Most healthcare providers (15) held diplomas, while 12 service users and 4 VHTs had certificates. The majority of healthcare providers (n=20) and 4 VHTs had 6-10 years of experience. Thematic analysis highlighted three key themes: benefits of integrated mental health services, implementation challenges, and the role of community engagement and cultural sensitivity. This study contributes valuable insights into the integration of mental health services into HIV clinics in Northern Uganda. The perceived benefits, challenges, and importance of cultural sensitivity and community engagement should guide future interventions, fostering a holistic approach that enhances the overall well-being of individuals living with HIV/AIDS in the region. Policymakers can use this information to advocate for resource allocation, training programs, and policy changes that support the integration of mental health services into HIV clinics in a way that addresses the identified challenges.

Chemsex among men who have sex with men during the Mpox health crisis in Brazil: A nationwide web survey.

To understand the factors associated with the practice of chemsex among MSM in Brazil, especially during the Mpox health crisis, and to design effective prevention and intervention strategies specifically for this population. A cross-sectional and analytical study using an electronic survey, conducted from September to December 2022, during the peak of the Mpox outbreak in Brazil. A total of 1452 MSM aged 18 and older. Data were collected via the REDCap platform through a survey with 46 questions. These addressed demographic data, sexual affiliations, practices, experiences with Mpox, healthcare service usage, and stigma or fear related to Mpox. The prevalence of chemsex was 19.42% (n=282). Multivariate Poisson modeling indicated a high incidence of chemsex among those diagnosed with Mpox and those involved in high-risk behaviors. The practice of chemsex was six times higher among those diagnosed with Mpox (95% CI: 4.73-9.10). MSM who engage in bugchasing had a prevalence twice that of the main outcome (95% CI: 1.31-3.16). There is a significant need for targeted interventions for MSM in Brazil, especially given the Mpox outbreak. This study highlights the strong relationships between chemsex, experiences with Mpox, and various sexual behaviors, underscoring the importance of effective public health initiatives.

Data Governance in AI - Enabled Healthcare Systems: A Case of the Project Nightingale

The study investigates data governance challenges within AI-enabled healthcare systems, focusing on Project Nightingale as a case study to elucidate the complexities of balancing technological advancements with patient privacy and trust. Utilizing a survey methodology, data were collected from 843 healthcare service users employing a structured questionnaire designed to measure perceptions of AI in healthcare, trust in healthcare providers, concerns about data privacy, and the impact of regulatory frameworks on the adoption of AI technologies. The reliability of the survey instrument was confirmed with a Cronbach's Alpha of 0.81, indicating high internal consistency. The multiple regression analysis revealed significant findings: a positive relationship between the awareness of technological projects and trust in healthcare providers, countered by a negative impact of privacy concerns on trust. Additionally, familiarity with and perceived effectiveness of regulatory frameworks were positively correlated with trust in data, while perceptions of regulatory constraints and data governance issues were identified as significant barriers to the effective adoption of AI technologies in healthcare. The study highlights the critical need for enhanced transparency, public awareness, and robust data governance frameworks to navigate the ethical and privacy concerns associated with AI in healthcare. The study recommends adopting flexible, principle-based regulatory approaches and fostering multi-stakeholder collaboration to ensure the ethical deployment of AI technologies that prioritize patient welfare and trust.

Supported decision-making interventions in mental healthcare: A systematic review of current evidence and implementation barriers.

There is a growing momentum around the world to foster greater opportunities for the involvement of mental health service users in their care and treatment planning. In-principle support for this aim is widespread across mental healthcare professionals. Yet, progress in mental health services towards this objective has lagged in practice. We conducted a systematic review of quantitative, qualitative and mixed-method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning, to understand the current research evidence and the barriers to implementation. Seven databases were searched and 5137 articles were screened. Articles were included if they reported on an intervention for adult service users, were published between 2008 and October 2023 and were in English. Evidence in the 140 included articles was synthesised according to the JBI guidance on Mixed Methods Systematic Reviews. Research in this field remains exploratory in nature, with a wide range of interventions investigated to date but little experimental replication. Overarching barriers to shared and supported decision-making in mental health treatment planning were (1) Organisational (resource limitations, culture barriers, risk management priorities and structure); (2) Process (lack of knowledge, time constraints, health-related concerns, problems completing and using plans); and (3) Relationship barriers (fear and distrust for both service users and clinicians). On the basis of the barriers identified, recommendations are made to enable the implementation of new policies and programs, the designing of new tools and for clinicians seeking to practice shared and supported decision-making in the healthcare they offer. This systematic review has been guided at all stages by a researcher with experience of mental health service use, who does not wish to be identified at this point in time. The findings may inform organisations, researchers and practitioners on implementing supported decision-making, for the greater involvement of people with mental ill health in their healthcare.

Defining acceptable data collection and reuse standards for queer artificial intelligence research in mental health: protocol for the online PARQAIR-MH Delphi study

IntroductionFor artificial intelligence (AI) to help improve mental healthcare, the design of data-driven technologies needs to be fair, safe, and inclusive. Participatory design can play a critical role in empowering...

Stroke and suicide among people with severe mental illnesses

The associations between people with severe mental illnesses (SMI) and the risks of stroke, suicide, and death remain unclear. We examined healthcare service usage among adults with and without SMI and explored the risk of stroke, suicide, and death. We divided 18–80-year-old adults with SMI into catastrophic and non-catastrophic illness groups. These groups were subjected to a 1:5:5 propensity score matching with people without SMI. Data on demographic characteristics, economic factors, environmental factors, comorbid conditions, self-injury behavior, the number of outpatients and ED visits, and hospitalization were collected. The primary outcomes were risks of stroke, suicide, and death. We included 19,570 people with catastrophic SMI, 97,850 with non-catastrophic SMI, and 97,850 controls. Patients with SMI, especially those with catastrophic illnesses, had higher stroke risk, suicide, and death than those without SMI. People with SMI used health services more frequently than those without SMI. Patients with a history of hospitalization or ED access had a higher risk of stroke, suicide, and death. Our data indicate that special attention should be given to patients with SMI, particularly those with a history of healthcare service utilization, such as through more extended hospital stays with high-intensity interventions.

Trust in embedding co-design for innovation and change: considering the role of senior leaders and managers

PurposeIn this viewpoint article, the authors recognize the increased focus in health systems on co-design for innovation and change. This article explores the role of leaders and mangers in developing and enhancing a culture of trust in their organizations to enable co-design, with the potential to drive innovation and change in healthcare.Design/methodology/approachUsing social science analyses, the authors argue that current co-design literature has limited focus on interactions between senior leaders and managers, and healthcare staff and service users in supporting co-designed innovation and change. The authors draw on social and health science studies of trust to highlight how the value-based co-design process needs to be supported and enhanced. We outline what co-design innovation and change involve in a health system, conceptualize trust and reflect on its importance within the health system, and finally note the role of senior leaders and managers in supporting trust and responsiveness for co-designed innovation and change.FindingsHealthcare needs leaders and managers to embrace co-design that drives innovation now and in the future through people – leading to better healthcare for society at large. As authors we argue that it is now the time to shift our focus on the role of senior managers and leaders to embed co-design into health and social care structures, through creating and nurturing a culture of trust.Originality/valueBuilding public trust in the health system and interpersonal trust within the health system is an ongoing process that relies upon personal behavior of managers and senior leaders, organizational practices within the system, as well as political processes that underpin these practices. By implementing managerial, leadership and individual practices on all levels, senior managers and leaders provide a mechanism to increase both trust and responsiveness for co-design that supports innovation and change in the health system.

Exploring stakeholders’ perceived problems associated with the care and support of children and youth with mental ill health in Sweden: a qualitative study

BackgroundCare and support for children and youth with mental ill health have become more specialized and are provided by an increasing number of stakeholders. As a result, services are often fragmented, inefficient and unco-ordinated, with negative consequences for the service user and their family. Enhanced collaboration could lead to improved care and support but requires a shared understanding and a joint problem formulation between involved stakeholders to commence. The aim of this study was to explore different stakeholders’ perceived problems associated with delivering care and support to children and youth with mental ill health and to discuss how the perceived problems relate to collaboration.MethodsA qualitative descriptive study was conducted, using short statements of perceived problems written by stakeholders involved in the care and support of children and youth with mental ill health during an inter-organizational workshop. The 26 stakeholders represented school and student health, primary health care, specialist care, social services, and different service user organizations. Data were collected during February 2020. Inductive content analysis with a summative approach was used when analysing the data.ResultsThe perceived problems were summarized in a model consisting of four main categories: Resources and governance; Collaboration and co-ordination; Knowledge and competence; and Stigma and confidence, containing 24 subcategories. These categories and subcategories were distributed over three levels: Societal level, Organizational level and Individual level. The perceived problems were shared on the category level but to some extent varied between stakeholder groups on the subcategory level. The perceived problems were either directly or indirectly related to collaboration.ConclusionsThe perceived problems often acted as barriers to achieving successful collaboration. The problems were distributed on all three levels in the developed model, indicating a complex problem. Even though the perceived problems were shared by stakeholders on an overall level, the findings indicate that the stakeholders did not have a completely shared understanding of the perceived problems, as they tended to focus on aspects most relevant to their own organization or perceptions. The challenge is to find which perceived problems are appropriate for inter-organization problem-solving and which can be solved within individual organizations.

Complaint behaviour among healthcare users: self-reported complaint experience and complaint proneness in adult men

AimsWhen patients are harmed by, or dissatisfied with, healthcare, only a minority will lodge a complaint or file a claim for compensation. This survey aimed to investigate complaint behaviour and...

Evaluation of late effects during a 21-year follow-up of pediatric Hodgkin lymphoma survivors: Experience of a pediatric cancer center in Turkey, as a developing country model.

Long-term survivors of Hodgkin lymphoma (HL) are at risk of developing a range of late effects, with a second malignant neoplasm and cardiovascular diseases being the leading causes of death in these patients. The present study aims to evaluate the late side effects in children with HL. Out of 53 HL patients, we assessed the long-term effects of childhood HL survivors (HLSs; n = 50) diagnosed between 1998 and 2019. Patient data related to chronic health conditions, and sociodemographic characteristics were compared with their siblings (n = 56). The cumulative overall survival (OS) at 1, 5, and 10 years from diagnosis was 98.1 ± 1.9%, 93.3 ± 3.8%, and 93.3 ± 3.8%, respectively. Groups of HLSs and their siblings were matched according to age and gender. Compared with siblings, survivors had will be changed as 'a higher frequency of nephrotoxicity (P = 0.02)', cardiotoxicity (P = 0.12), thyroid dysfunction (P = 0.001), health care service usage (P < 0.01), limitation of physical function (P = 0.01), and pulmonary disease (P = 0.01). The control group of siblings had a higher incidence of marital status (P < 0.01), parenthood (P = 0.01), and smoking habit (P = 0.03). Thyroid dysfunction was associated with neck radiotherapy (P < 0.01). No secondaryneoplasm was detected. In relapsed, refractory setting (n = 10), autologous transplantation (n = 9) is performed after a complete remission. Brentuximab vedotin with or without bendamustine and rituximab is also used in selected patients. Increased number of chronic health conditions and social problems point to the significance of long-term follow-up of HLSs. We are currently preparing a survivorship guideline appropriate for Turkey's conditions. Renal, heart, pulmonary impairment, thyroid dysfunction, limitation in physical functioning, and deterioration in social status (marriage, having children, education).

Exploring long-term breast cancer survivors' care trajectories using dynamic time warping-based unsupervised clustering.

Long-term breast cancer survivors (BCS) constitute a complex group of patients, whose number is estimated to continue rising, such that, a dedicated long-term clinical follow-up is necessary. A dynamic time warping-based unsupervised clustering methodology is presented in this article for the identification of temporal patterns in the care trajectories of 6214 female BCS of a large longitudinal retrospective cohort of Spain. The extracted care-transition patterns are graphically represented using directed network diagrams with aggregated patient and time information. A control group consisting of 12412 females without breast cancer is also used for comparison. The use of radiology and hospital admission are explored as patterns of special interest. In the generated networks, a more intense and complex use of certain healthcare services (eg, radiology, outpatient care, hospital admission) is shown and quantified for the BCS. Higher mortality rates and numbers of comorbidities are observed in various transitions and compared with non-breast cancer. It is also demonstrated how a wealth of patient and time information can be revealed from individual service transitions. The presented methodology permits the identification and descriptive visualization of temporal patterns of the usage of healthcare services by the BCS, that otherwise would remain hidden in the trajectories. The results could provide the basis for better understanding the BCS' circulation through the health system, with a view to more efficiently predicting their forthcoming needs and thus designing more effective personalized survivorship care plans.

The impact of the COVID-19 pandemic on healthcare services utilization among people living with HIV in Catalonia, Spain: A population-based cohort study

BackgroundThe COVID-19 pandemic disrupted healthcare services usage. We estimated the impact of the COVID-19 pandemic on healthcare services utilization among people living with HIV (PLWH) in Catalonia, Spain. MethodsWe accessed public healthcare usage in HIV units, primary care, hospitals, and emergency departments among 17,738 PLWH in the PISCIS cohort from January 1, 2017, to December 31, 2020. We performed an interrupted time series analysis using the autoregressive integrated moving average to estimate the effect of COVID-19 on medical visits and HIV monitoring among PLWH. ResultsA non-significant decrease of 17.1% (95% CI: [−29.4, 0.4]) in overall medical visits was observed during the lockdown, followed by a steady resumption until the end of 2020. Three health facilities presented statistically significant declines in visits during the lockdown: HIV units (−44.8% [−56.7, −23.6]), hospitals (−40.4% [−52.8, −18.1]), and emergency departments (−36.9% [−47.0, −21.9]); thereafter, the visits have begun to increase steadily but not to previous levels as of December 2020. In contrast, primary care visits remained unchanged during the lockdown by 1.9% (95% CI: −13.5, 23.9). CD4 cell (54.2% [95% CI: −64.4, −36.0]) and HIV RNA viral load (53.1% [95% CI: −62.9, −36.1]) laboratory monitoring reduced significantly during the lockdown. ConclusionCOVID-19 lockdowns significantly disrupted in-person healthcare services usage among PLWH. The reduction in healthcare utilization however did not affect primary care services. Despite services gradually rebounding to pre-pandemic levels, it is imperative to effectively prepare for future pandemics and implement measures to ensure continuous provision of care to PLWH during pandemic lockdowns.

Synthesis of relevant information around non-core domains to support Multi-Criteria Decision Analysis (MCDA) for decision making.

Countries fundamentally base macro and micro decision making in the field of health on economic considerations, the budgetary impact of technologies being a major criterion. Nevertheless, the value of the technology of interest and its dimensions are more complex if we seek to take decisions based on the value itself. The use of structured and explicit approaches that require the assessment of multiple criteria that reflect the dimensions of this value may significantly improve the quality of the decision making. Multi-criteria decision analysis (MCDA) is a complementary decision-making tool that is able to systematically incorporate dimensions or domains such as ethical, organisational, legal, environmental and social considerations, as well as costs and benefits of medical interventions, together with the distinct perspectives of the interested parties. The objective of this article is to propose the implementation of analysis of non-core domains, in reports of Health Technology Assessment (HTA) agencies/units. To assess the scientific evidence on MCDA techniques a systematic review was conducted using structured searches in biomedical databases and websites of various HTA organisations. A consensus group was held using the nominal group technique and involving users of healthcare services, providers, managers and academics. Complementary, a survey was sent to HTA agencies to ascertain the degree of implementation of MCDA in their methods. 42 articles reporting the use of non-core criteria for the assessment of health technologies were included in the analysis. From these articles, a total of 216 non-core criteria were retrieved and categorised into domains by the researchers, and of these, 56 were classified as socioeconomic, 59 as organisational, 10 as legal, 8 as environmental and 47 as ethical, while 36 were considered to relate to other domains. The consensus group, based on the 216 non-core criteria obtained from the systematic review, proposed, and defined 26 criteria that participants considered necessary for decision making in healthcare. The consensus group did not consider that any of the domains should be given more weight than others or that any individual criteria should dominate. These approaches can serve as a framework of reference for a well-structured systematic discussion concerning the basis of individual criteria and the evidence supporting them.

Understanding education for healthcare service users aligned to social media platforms

Understanding education for healthcare service users aligned to social media platforms