Health Service Users Research Articles

Maddening Post-Qualitative Inquiry: An Exercise in Collective (Mad) Theorising.

Both post-qualitative inquiry and Mad methodologies sit on the fringes of qualitative health research, although their potential for creating new knowledges and practices is increasingly recognised. In this article, we explore the possibilities created by bringing these approaches together within research led by, or centring, mental health service users and survivors. We outline and reflect on a workshop undertaken with peer support workers to map affective intensities within mental health assemblages. We suggest the tensions between post-qualitative and Mad research approaches hold potential for mental health research, and qualitative health research more broadly, bringing together theory and the experiences of service users/survivors to think-feel-become otherwise in relation to health care, peer support, and activism.

Elimination of restrictive practices from acute adult mental health care services: A qualitative evidence synthesis of the lived experience literature.

The calls to eliminate restrictive practices (e.g., seclusion and physical restraint) from mental health care services have been gaining momentum over time and have been one of the many issues at the forefront of international mental health care systems. Whilst it is known that restrictive practices are often harmful and traumatic for the mental health service user, there is a lack of synthesis of the factors that are influencing restrictive practices’ ultimate reduction and elimination from the perspective of mental health service users and practitioners. The aim of this research was to conduct a qualitative evidence synthesis of the literature regarding the perceptions and experiences of mental health service users and practitioners about restrictive practices in mental health care services. A systematic search and inclusion strategy identified 44 relevant articles for review. Inductive thematic synthesis resulted in five themes across the articles: (1) Meaning and emotional experience, (2) Re-traumatisation and dehumanisation, (3) Professional competencies and varying experiences, (4) Balancing safety versus care, and (5) Alternatives to restrictive practices. Discussion of these themes highlighted the many layered and often uncomfortable nature of restrictive practices which can pervade mental health facilities across the world.

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.

Health vulnerability: evidence of validity of an item bank

Objective: To analyze the evidence of content validity and response process of a health vulnerability item bank. Methods: Psychometric study with support of Pasquali’s theoretical pole in which 62 specialists with different sociodemographic and academic characteristics were selected and 15 of them responded to the content validity questionnaire. After adjustments, the bank moved to the response process validity phase and was evaluated by 12 health service users. A content validity coefficient was used to evaluate the items and the bank, which had the reliability assessed by the binomial test, considering a percentage of 80% and p-value >0.05. Results: The bank presented good evidence of content validity by experts. The coefficients were 0.87 for the subject element, 0.86 for the social element and 0.865 for the general element. The target audience made suggestions in the response process validity phase to better understand the items (total coefficient: 0.89), which were considered clear, accurate and understandable. Conclusion: The final version of the item bank has 535 items, 238 for the subject and 297 for the social element. It presents evidence of validity of content and response process and is suitable for testing the validity of internal structure.

Selective under-representation of Pacific peoples in population estimates for health indicator measurements in Aotearoa New Zealand misinforms policy making

BackgroundThe Census of Populations and Dwellings’ is the five yearly population count of Aotearoa New Zealand. Best available populations (BAP) are subnational projections based on census data and demographic assumptions developed for healthcare planning and funding allocation but are also used as the denominator for health indicator monitoring. Pacific people are systematically undercounted, but the impact on health statistics is not well studied. For COVID-19 vaccination coverage, health service user (HSU) data were considered a more reliable denominator than BAP but introduced new biases. We aimed to understand how the choice of denominator population impacts estimates of population size and health system performance for Pacific people at a local level.MethodsWe described how declining census response rates affected population data quality. We compared BAP and HSU data at district level. For the indicators ‘access to primary care’ and ‘cervical cancer screening uptake’ we replaced currently used BAP denominators with HSU and examined the impact for different ethnic groups in different geographic districts.ResultsOverall Census 2018 response declined by 10%, but for Māori and Pacific people by 21% and 23%, respectively. This inequitably affected BAP accuracy. Census undercount was highest in the district with the largest Pacific populations, where HSU exceeded BAP most. Notably, ‘access to primary care’ for Pacific people in this district consistently exceeds 100%. Using BAP, both health indicators are currently estimated as highest for Pacific people compared to other ethnic groups, but when based on HSU, they dropped to lowest. Similar, but less pronounced trends occurred in other districts. Changes in trends over time for both indicators coincided mostly with adjustments in BAP, rather than changes in the numerators.ConclusionsThe current use of BAP denominators for health statistics does not enable reliable monitoring of key health indicators for Pacific people. HSU denominators are also unsuitable for monitoring health. Exploring the feasibility of a real-time population register is strongly recommended as a new, transparent, way of obtaining more reliable, timely population data to guide policymaking and underpin a more equitable health system under the health reforms. Meanwhile, reporting of ethnic specific outcomes need to include a clear assessment of the potential for bias due to inaccurate population estimates.

THE PHENOMENON OF THE "INFORMED PATIENT": ACCESS TO HEALTH-CARE CONTENT AVAILABLE ON THE WEB AND RECONFIGURATIONS IN THE RELATIONSHIPS BETWEEN HEALTH-CARE PROFESSIONALS AND USERS

The popularization of the internet has significantly expanded access to information, giving rise to a more active and well-informed society. In the health area, it is possible to find, on the web, more and more information available about diseases, symptoms, diagnoses, prevention, medicines, treatment, professionals, etc. This has given rise to a more informed, active, questioning and critical user, who seeks information about their health on the internet, in order to gain more autonomy in the face of these processes: the “expert patient” or the “informed patient”. This research aims to identify and analyze the forms of interaction between people (users and health professionals in general) and health content available on the internet, seeking to understand the changes and reconfigurations that access to this information has been promoting in relationships between users of health systems, professionals and services in general. This is a qualitative research of an ethnomethodological nature, which was based on a bibliographical review and a field study, organized in two stages: an exploratory one, with the application of an online questionnaire, and a systematic one, with interviews in depth. The analysis of the research results was based on the methodology adapted from the Collective Subject Discourse (CSD), according to Lefèvre, which made it possible to create the categories. Through a cross-sectional analysis of the collected material, it was possible to identify numerous aspects that surround the search for health information on the web. Among them, the autonomy and “empowerment” of users, who, in an attempt to move towards the humanization of health care, begin to seek contributions from external means, in order to satisfy their desires and needs, to fill the gaps left by the services of health and to find other agents to place trust and credibility.

Are SMART goals fit-for-purpose? Goal planning with mental health service-users in Australian community pharmacies.

Goal planning is an important element in brief health interventions provided in primary healthcare settings, with specific, measurable, achievable, realistic/relevant, and timed (SMART) goals recommended as best practice. This study examined the use of SMART goals by Australian community pharmacists providing a brief goal-oriented wellbeing intervention with service-users experiencing severe and persistent mental illnesses (SPMIs), in particular, which aspects of SMART goal planning were incorporated into the documented goals. Goal data from the PharMIbridge Randomized Controlled Trial (RCT) were used to investigate how community pharmacists operationalized SMART goals, goal quality, and which SMART goal planning format aspects were most utilized. Goals were evaluated using the SMART Goal Evaluation Method (SMART-GEM) tool to determine how closely each documented goal met the SMART criteria. Goals were also categorized into five domains describing their content or purpose. Descriptive analysis was used to describe the SMART-GEM evaluation results, and the Kruskal-Wallis H test was used to compare the evaluation results across the goal domains. All goals (n = 512) co-designed with service-users (n = 156) were classified as poor quality when assessed against the SMART guidelines for goal statements, although most goals contained information regarding a specific behaviour and/or action (71.3% and 86.3%, respectively). Less than 25% of goals identified how goal achievement would be measured, with those related to lifestyle and wellbeing behaviours most likely to include measurement information. Additionally, the majority (93.5%) of goals lacked details regarding monitoring goal progress. Study findings raise questions regarding the applicability of the SMART goal format in brief health interventions provided in primary healthcare settings, particularly for service-users experiencing SPMIs. Further research is recommended to identify which elements of SMART goals are most relevant for brief interventions. Additionally, further investigation is needed regarding the impact of SMART goal training or support tools on goal quality.

A prospective study of nightmare disorder among Chinese adults in Hong Kong: Persistence and mental health outcomes

ABSTRACT Objectives Previous studies showed that nightmares are prevalent and are associated with negative health outcomes. However, no empirical data is available demonstrating the extent to which nightmare disorder persists over time. Current literature provides a limited understanding of the trajectory and wider mental health outcomes of nightmare disorder. This longitudinal study examined the persistence and mental health outcomes of nightmare disorder. Methods A total of 230 Hong Kong Chinese adults completed standardized assessments twice with an interval of about 6 months. Results Over half (66.7%) of the participants with probable nightmare disorder at baseline remained to meet the DSM-5 criteria for the disorder at follow-up. Participants with probable nightmare disorder at baseline were significantly more likely to screen positive for PTSD (82.1% vs 18.3%) (p < .001) (p < .001), and they reported higher rates of mental health service usage at both timepoints (p = .001 to .003). Baseline nightmare disorder severity was negatively associated with subsequent self-rated mental health (β = -.151, p = .010) and self-esteem (β = -.141, p = .009) and it also predicted subsequent PTSD symptoms (β = .122, p = .012). Conclusions This study provides first empirical data showing that nightmare disorder could be persistent over time. Nightmare disorder symptoms are associated not only with PTSD symptoms but also with a broader range of mental health issues. This study points to the public health importance of identifying and managing nightmare disorder symptoms in the community. Additionally, the presence of nightmare disorder symptoms may be a helpful indicator for identifying post-traumatic stress.

Risk factors for homelessness and housing instability in the first episode of mental illness: Initial findings from the AMONT study.

People living with mental illness are more likely than the general population to experience adverse housing outcomes, including homelessness. The aim of the current study is to examine residential status when participants have their first contact with mental health services, and the correlates of residential status at that moment. First-time mental health service users were recruited from seven clinical sites across Québec. Data on residential status at entry in the project, as well as demographic, clinical and social variables, were collected using self-report and interviewer-rated questionnaires. Participants were classified as 'Homeless', 'At risk of homelessness' and 'Stably Housed', and correlates of residential status were identified through multivariate logistic regression and unbiased recursive partitioning. Among the 478 participants, 206 (43.1%) were in stable housing, 171 (35.8%) were at risk of homelessness and 101 (21.1%) were classified as homeless. Placement in a youth protection facility was strongly associated with adverse housing outcomes, while having a high school diploma and more social support were associated with more stable housing situations. First-time mental health service users are likely to experience a range of adverse housing situations, indicating the potential for clinical sites to implement homelessness primary prevention strategies. Factors related to family, foster care and schooling seem to be particularly salient in understanding risk of homelessness in first-time mental health service users, calling for intersectoral action to prevent adverse psychosocial outcomes in this population.

The paradoxes of telehealth platforms: what did we learn from the use of telehealth platforms?

This article is an overview and reflection of the findings of an evaluative study conducted on a program called "Techno-Covid Partnership" (TCP) implemented in April 2020 at the Centre Hospitalier de l'Université de Montréal (CHUM) in Montreal, Canada. In the context of the COVID-19 pandemic, the CHUM decided in April 2020 to implement telehealth, virtual care, and telemonitoring platforms and technologies to maintain access to care and reduce the risks of contamination and spread of COVID-19 as well as to protect users of health services and health professionals. Three technological platforms for telehealth and remote care and monitoring have been developed, implemented, and evaluated in real-time within the framework of the TCP program. A cross-sectional study was carried out in which a questionnaire was used and administered to users of telehealth platforms including patients and healthcare professionals. The methods and results of the study have been published previously published. In the completion of the two articles published in this context, in this paper, we briefly recall the context of the study and the method performed. The main focus of the paper is on presenting a critical overview and reflection on the major findings of our evaluation of the use of telehealth platforms from the point of view of patients and health professionals and discuss certain paradoxes i.e., the advantages, challenges, recommendations, and other perspectives that emerged in this study.

Experiences of delivering and receiving mental healthcare in the acute hospital setting: a qualitative study

BackgroundRecent investment in UK liaison psychiatry services has focused on expanding provision for acute and emergency referrals. Little is known about the experiences of users and providers of these services. The aim of this study was to explore the experiences of users of acute liaison mental health services (LMHS) and those of NHS staff working within LMHS or referring to LMHS. A secondary aim was to explore the potential impact of a one-hour service access target on service delivery.MethodsCross-sectional qualitative study. Individual interviews were audio-recorded, transcribed verbatim and interpreted using framework analysis.ResultsService users reported mixed experiences of LMHS, with some reporting positive experiences and some reporting poor care. Most service users described the emergency department (ED) environment as extremely stressful and wished to be seen as quickly as possible. Staff described positive benefits of the one-hour access target but identified unintended consequences and trade-offs that affected other parts of the liaison service.ConclusionsThe assessment and treatment of people who attend ED with mental health problems needs to improve and particular attention should be given to the stressful nature of the ED environment for those who are extremely agitated or distressed.

Acceptability and consumers' willingness to pay for comprehensive medication management services in Brazil.

Aim: Comprehensive medication management (CMM) is a clinical service that aims to optimize the therapeutic results of patients at the individual level. Studies carried out in Brazil and in several parts of the world have found a positive impact of the service, mainly in the resolution of drug therapy problems and in improving clinical outcomes and patients' quality of life. This service is not widespread and its acceptability and willingness to pay were not defined by the population yet. Objective: This work aims to conduct a study with users of private health services to determine the acceptability and willingness to pay for CMM services. Methods: This is a cross-sectional survey conducted through face-to-face interviews, among residents over 18years of age of the metropolitan region of Belo Horizonte, capital of Minas Gerais State, Brazil. Results: For this study, 563 individuals were interviewed. Most respondents were female (55.1%), had completed high school (46.8%) and were employed (62.5%). The acceptability for the service was 93,25%, and among all respondents, 37 would not accept the service even if it was free. The amount of consumers' willingness to pay for the CMM service was estimated at $17.75 (40.00 BRL). Conclusion: The research results show that most people are willing to pay for the CMM service. This study can contribute to the decision-making regarding the implementation and pricing of the service in Brazil.

'I Can't Get No Satisfaction'… Experience in the treatment, satisfaction, and professional support of young depressed people using SPARX.

Depression in young people is common and can lead to poor long-term outcomes. Digital therapies are a promising means of promoting access to care. Currently, among the digital treatments for depression in adolescents recognized by the NICE guidelines, there is SPARX (Smart, Positive, Active, Realistic, X-factor), based on Cognitive Behavioral Therapy, CBT. This narrative review aimed to evaluate: 1) Who were the depressed young people who used SPARX and what was their experience with the treatment? 2) Were users satisfied with the SPARX treatment? Did the youth's perceived level of satisfaction with using SPARX impact completion rates? 3) What was the role of professionals (researchers, consultants, teachers) in the SPARX studies? Has their support in running SPARX affected completion rates? A narrative review of the English literature was performed. The articles were searched in Pubmed, SCOPUS, and Web of Science databases (from 2012 to 2023) with keywords such as 'SPARX,' depression' and 'young adult'. Of 557 papers, 18 were included in our review. The young people who used SPARX were students or adolescents from special help-seeker populations at risk or with mild to moderate depression. The highest satisfaction levels were present in users of primary health services, such as general practice and counseling services. The support of the school counselor and experts in mental health clinicians was instrumental in impacting user satisfaction and completion rates. The personalization of the game in terms of user culture - symbols, language, norms, values, and artifacts; the customization of the avatar, the gender identity; the narrative structure; the presence of a guide character (virtual therapist); the CBT homework seemed to represent crucial SPARX characteristics related to satisfaction and completion rates. Our narrative review provides an overview of the main results of using SPARX with interesting considerations that may suggest improvements for broader use and diffusion of this digital treatment.

Comparing stigma between French people experiencing schizophrenia versus bipolar disorders.

Among the multiple challenges that people experiencing mental illness in general, and schizophrenia or bipolar disorders in particular, have to face, stigma appears to be one of the most difficult to tackle. In France, the body of research about stigma regarding people experiencing schizophrenia or bipolar disorders is growing, but not as much as in other western countries. In this context, our study aims to explore and compare stigma in French people experiencing schizophrenia or bipolar disorders, along with their respective mental healthcare system experience, in order to better address them within public health policies. 20 French mental health service users experiencing schizophrenia and 20 experiencing bipolar disorders answered the Stigma Scale, which assesses three dimensions of stigma (discrimination, difficulties of divulgation and lack of positive aspects). A semi-structured interview was used to collect information about the experience of the mental healthcare system (level of information, access to diagnosis, treatment, access to psychoeducation, etc.). People experiencing schizophrenia and people experiencing bipolar disorders are different populations in terms of social impairment. However, they share a comparable negative experience of the mental healthcare system and a comparable level of information about their illness, to the exception of diagnosis divulgation, as people experiencing bipolar disorders have a better access to their diagnosis. People experiencing schizophrenia perceive a higher actual discrimination than people experiencing bipolar disorders. Public health policies should take into account the strong perception of actual discrimination of people experiencing schizophrenia, with capitalizing on what seems beneficial for people experiencing bipolar disorders.

What Do Health Service Users Think About the Use of Their Data for AI Development?

AI tools are being introduced within health services around the globe. It is important that tools are developed and validated using the available health information of the population where it is intended to be used. We set out to determine what patients thought about the use of their health information for this purpose. In interviews we found that the patients of a health service in Auckland, Aotearoa New Zealand, are generally comfortable with their health information being used for these purposes but with conditions (around public good, governance, privacy, security, transparency, and restrictions on commercial gain) and with careful consideration of their perspectives. We suggest that health services should take the time to have these conversations with their communities and to provide open and clear communication around these developments in their services.

Childhood Bullying as a Predictor of Suicidality in Young Adults in a Nationwide Population-Based Health Examination Study

Objective Having been bullied at school in childhood links to suicidality. We aimed at verifying earlier findings and delivering diverse data from a representative population-based sample of young adults to characterize the impacts beyond childhood. Method A random sample of adults, aged 18–28 years and representative of the general population living in Finland, participated in a nationwide health examination study. Adverse childhood experiences before the age of 16 years were analyzed for 779 participants in relation to lifetime suicidality (suicidal ideation, suicide attempts), current suicidal thoughts (HSCL-25), mental disorders (self-reports for lifetime, M-CIDI for DSM-IV during the past 12 months), current usage of mental health services, current usage of prescription medicines (ATC codes), current psychological distress (GHQ-12), and current work capacity and work ability. Results Having been bullied in childhood contributed to greater suicidality (p < 0.001), more frequent current usage of antipsychotics (p < 0.001) as well as antidepressants (p < 0.001), greater current psychological distress (p < 0.001), and poorer current work capacity (p < 0.001) as well as work ability (p < 0.001). Of the self-reported mental disorders on lifetime basis, psychosis had the strongest association (p = 0.03) with having been bullied, whereas the interview-based diagnosis of mental disorders during the past 12 months had no significant association. Conclusions Having been bullied at school before the age of 16 years was independently associated not only with suicidality, but also with the self-report of psychosis as well as a range of indicators of poorer mental health at the age of 18–28 years.

The changes in health service utilisation in Malawi during the COVID-19 pandemic.

The COVID-19 pandemic and the restriction policies implemented by the Government of Malawi may have disrupted routine health service utilisation. We aimed to find evidence for such disruptions and quantify any changes by service type and level of health care. We extracted nationwide routine health service usage data for 2015-2021 from the electronic health information management systems in Malawi. Two datasets were prepared: unadjusted and adjusted; for the latter, unreported monthly data entries for a facility were filled in through systematic rules based on reported mean values of that facility or facility type and considering both reporting rates and comparability with published data. Using statistical descriptive methods, we first described the patterns of service utilisation in pre-pandemic years (2015-2019). We then tested for evidence of departures from this routine pattern, i.e., service volume delivered being below recent average by more than two standard deviations was viewed as a substantial reduction, and calculated the cumulative net differences of service volume during the pandemic period (2020-2021), in aggregate and within each specific facility. Evidence of disruptions were found: from April 2020 to December 2021, services delivered of several types were reduced across primary and secondary levels of care-including inpatient care (-20.03% less total interactions in that period compared to the recent average), immunisation (-17.61%), malnutrition treatment (-34.5%), accidents and emergency services (-16.03%), HIV (human immunodeficiency viruses) tests (-27.34%), antiretroviral therapy (ART) initiations for adults (-33.52%), and ART treatment for paediatrics (-41.32%). Reductions of service volume were greatest in the first wave of the pandemic during April-August 2020, and whereas some service types rebounded quickly (e.g., outpatient visits from -17.7% to +3.23%), many others persisted at lower level through 2021 (e.g., under-five malnutrition treatment from -15.24% to -42.23%). The total reduced service volume between April 2020 and December 2021 was 8 066 956 (-10.23%), equating to 444 units per 1000 persons. We have found substantial evidence for reductions in health service delivered in Malawi during the COVID-19 pandemic which may have potential health consequences, the effect of which should inform how decisions are taken in the future to maximise the resilience of healthcare system during similar events.

Unsung heroes in Ghana’s healthcare system: the case of community health volunteers and community health management committee

BackgroundIn Ghana, the community-based health planning and services (CHPS) policy highlights the significance of both community health management committees (CHMCs) and community health volunteers (CHVs) in the Ghanaian health system. However, research into their specific effects on health system improvement is scarce. Some research has focussed on the roles of the CHMCs/CHVs in implementing specific targeted health interventions but not on improving the overall health system. Therefore, this research aims to examine the role of the CHMCs and CHVs in improving the Ghanaian health system.MethodsThe study was conducted in three districts in the Ashanti region of Ghana. A total of 35 participants, mainly health service users and health professionals, participated in the study. Data were collected using semi-structured individual in-depth interviews. Participants were selected according to their patient–public engagement or community health activity roles. Data were transcribed and analysed descriptively using NVIVO 12 Plus.ResultsWe found that the effectiveness of CHMCs and CHVs in health systems improvement depends largely on how members are selected. Additionally, working through CHMC and CHVs improves resource availability for community health services, and using them in frontline community health activities improves health outcomes.ConclusionsOverall, we recommend that, for countries with limited healthcare resources such as Ghana, leveraging the significant role of the CHMCs and CHVs is key in complementing government’s efforts to improve resource availability for healthcare services. Community health management committees and CHVs are key in providing basic support to communities with limited healthcare personnel. Thus, there is a need to strengthen their capacities to improve the overall health system.

Change Laboratory intervention for promoting learning about causes and prevention of workplace aggressions in a mental health facility

AimTo assess a Change Laboratory (CL) intervention concerning the promotion of learning about the causes and prevention of workplace aggression in a Healthcare Service for Drug and Alcohol Users. BackgroundIt is estimated that one fourth of all healthcare professionals worldwide have already experienced some kind of workplace violence. In mental health facilities, aggressions have multiple origins, including moments when physical restraint is applied or situations when the patients’ demands are not met. This problem is aggravated in facilities known for their practice of imposing disciplinary measures. Several studies have shown the need to reduce disciplinary means, as well as the importance of health service teams and user participation in designing strategies to prevent aggression. DesignThis study employed a qualitative approach with an exploratory and descriptive design. An intervention was conducted in a Healthcare Service for Drug and Alcohol Users, in Brazil. The COREQ guidelines were followed for reporting. MethodsThis study is a qualitative analysis of nine sessions of a CL, which was conducted in 2022 with 12 healthcare professionals, mainly women from the nursing staff. ResultsThese workers identified the main causes of aggression after a historical and empirical analysis of the nature of the work performed and the contradictions inherent within it. They also recognized the need for cooperative teams prepared to recognize potentially aggressive situations beforehand. ConclusionsThis article brings practical contributions by showing a detailed analysis of how the CL intervention method, using the principle of Transformative Agency Double Stimulation, promotes a sequence of learning actions. The method helped participants to systematically understand the causes of the situations that give rise to workplace violence, examining the goal of the activity as something socially and historically constructed. Likewise, this method helped the professionals to collectively build the key components of a potential prevention program against aggression in the workplace.

What affects how Chinese patients wish to be involved in health care delivery? Perspectives of the Chinese policy and institutional contexts.

The benefits of involving patients and carers include improving health outcomes and safety, reducing costs and enhancing an open, accountable and equitable relationship between service providers and users. However, the willingness for involvement and participation is largely affected by a range of factors, including those at the micro, meso and macro levels. As the previous studies have given much attention to the factors at the individual level, it is worthwhile to explore the factors at the broader levels of the policy and institutional contexts. The objective of the research is to understand how the policy and institutional contexts in China affect how patients wish to be involved in their health care delivery. An abductive research strategy was used to generate emergent hypotheses in the first stage of data construction. In the second stage of fieldwork, hypotheses were tested using the deductive approach. Three local hospitals in Shandong Province, China, were selected. The case study method was designed with qualitative methods of policy documents and interviews. Interviews included health professionals, health board managers, local administrators and service users. Thematic analysis and framework analysis were conducted. Four policy and institutional contexts were identified: insufficient policy support, the current institutional design of involving users, the heterogeneity of organisational autonomy and resources, as well as the demography of the population of service users. As a policy strategy at the state level, there is a lack of policy support for patient involvement and participation in the Chinese health system. The heterogeneity of the institutional context of health facilities plays a key role in affecting how patients wish to be involved in health care delivery.