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1.  A critical analysis of the implementation of service user involvement in primary care research and health service development using normalization process theory 
There have been recent important advances in conceptualizing and operationalizing involvement in health research and health‐care service development. However, problems persist in the field that impact on the scope for meaningful involvement to become a routine – normalized – way of working in primary care. In this review, we focus on current practice to critically interrogate factors known to be relevant for normalization – definition, enrolment, enactment and appraisal.
Ours was a multidisciplinary, interagency team, with community representation. We searched EBSCO host for papers from 2007 to 2011 and engaged in an iterative, reflexive approach to sampling, appraising and analysing the literature following the principles of a critical interpretive synthesis approach and using Normalization Process Theory.
Twenty‐six papers were chosen from 289 papers, as a purposeful sample of work that is reported as service user involvement in the field. Few papers provided a clear working definition of service user involvement. The dominant identified rationale for enrolling service users in primary care projects was linked with policy imperatives for co‐governance and emancipatory ideals. The majority of methodologies employed were standard health services research methods that do not qualify as research with service users. This indicates a lack of congruence between the stated aims and methods. Most studies only reported positive outcomes, raising questions about the balance or completeness of the published appraisals.
To improve normalization of meaningful involvement in primary care, it is necessary to encourage explicit reporting of definitions, methodological innovation to enhance co‐governance and dissemination of research processes and findings.
PMCID: PMC5055238  PMID: 25059330
critical interpretive synthesis; normalization process theory; patient participation; primary health care; service user involvement
2.  Mental health problems of undocumented migrants (UMs) in the Netherlands: a qualitative exploration of help-seeking behaviour and experiences with primary care 
BMJ Open  2014;4(11):e005738.
To explore health-seeking behaviour and experiences of undocumented migrants (UMs) in general practice in relation to mental health problems.
Qualitative study using semistructured interviews and thematic analysis.
15 UMs in the Netherlands, varying in age, gender, country of origin and education; inclusion until theoretical saturation was reached.
4 cities in the Netherlands.
UMs consider mental health problems to be directly related to their precarious living conditions. For support, they refer to friends and religion first, the general practitioner (GP) is their last resort. Barriers for seeking help include taboo on mental health problems, lack of knowledge of and trust in GPs competencies regarding mental health and general barriers in accessing healthcare as an UM (lack of knowledge of the right to access healthcare, fear of prosecution, financial constraints and practical difficulties). Once access has been gained, satisfaction with care is high. This is primarily due to the attitude of the GPs and the effectiveness of the treatment. Reasons for dissatisfaction with GP care are an experienced lack of time, lack of personal attention and absence of physical examination. Expectations of the GP vary, medication for mental health problems is not necessarily seen as a good practice.
UMs often see their precarious living conditions as an important determinant of their mental health; they do not easily seek help for mental health problems and various barriers hamper access to healthcare for them. Rather than for medication, UMs are looking for encouragement and support from their GP. We recommend that barriers experienced in seeking professional care are tackled at an institutional level as well as at the level of GP.
PMCID: PMC4244440  PMID: 25416057
3.  Can generalism help revive the primary healthcare vision? 
PMCID: PMC3184534  PMID: 21969476
4.  Development and evaluation of culturally sensitive psychosocial interventions for under-served people in primary care 
BMC Psychiatry  2014;14:217.
Psychological therapy is effective for symptoms of mental distress, but many groups with high levels of mental distress face significant barriers in terms of access to care, as current interventions may not be sensitive to their needs or their understanding of mental health. There is a need to develop forms of psychological therapy that are acceptable to these groups, feasible to deliver in routine settings, and clinically and cost effective.
We developed a culturally sensitive wellbeing intervention with individual, group and sign-posting elements, and tested its feasibility and acceptability for patients from ethnic minorities and older people in an exploratory randomised trial.
We recruited 57 patients (57% of our target) from 4 disadvantaged localities in the NW of England. The results of the exploratory trial suggest that the group receiving the wellbeing interventions improved compared to the group receiving usual care. For elders, the largest effects were on CORE-OM and PHQ-9. For ethnic minority patients, the largest effect was on PHQ-9. Qualitative data suggested that patients found the intervention acceptable, both in terms of content and delivery.
This exploratory trial provides some evidence of the efficacy and acceptability of a wellbeing intervention for older and ethnic minority groups experiencing anxiety and depression, although challenges in recruitment and engagement remain. Evidence from our exploratory study of wellbeing interventions should inform new substantive trial designs.
Trial registration
Current controlled trials ISRCTN68572159
PMCID: PMC4149271  PMID: 25085447
5.  Aiming to improve the quality of primary mental health care: developing an intervention for underserved communities 
BMC Family Practice  2014;15:68.
The purpose of the study was to improve the quality of primary mental healthcare in underserved communities through involvement with the wider primary care team members and local community agencies.
We developed training intended for all GP practice staff which included elements of knowledge transfer, systems review and active linking. Seven GP Practices in four localities (North West England, UK) took part in the training. Qualitative evaluation was conducted using thirteen semi-structured interviews and two focus groups in six of the participating practices; analysis used principles of Framework Analysis.
Staff who had engaged with the training programme reported increased awareness, recognition and respect for the needs of patients from under-served communities. We received reports of changes in style and content of interactions, particularly amongst receptionists, and evidence of system change. In addition, the training program increased awareness of – and encouraged signposting to - community agencies within the practice locality.
This study demonstrates how engaging with practices and delivering training in a changing health care system might best be attempted. The importance of engaging with community agencies is clear, as is the use of the AMP model as a template for further research.
PMCID: PMC4004464  PMID: 24741996
Mental health; Underserved populations; Primary care
6.  The long-term impact of early parental death: lessons from a narrative study 
To explore the individual experiences of those who had experienced the death of a parent(s) before the age of 18, and investigate how such experiences were perceived to impact on adult life.
An exploratory qualitative design using written (n = 5) and oral (n = 28) narratives and narrative analysis was adopted to explore the experiences 33 adults (7 men and 26 women) who had experienced parental death during childhood.
Individuals living in the North West of England who had lost a parent(s) before the age of 18.
Main outcome measures
Views of adults bereaved of a parent before the age of 18 of impact of parental loss in adult life.
While individual experiences of bereavement in childhood were unique and context bound, the narratives were organized around three common themes: disruptions and continuity, the role of social networks and affiliations and communication and the extent to which these dynamics mediated the bereavement experience and the subsequent impact on adult life. Specifically they illustrate how discontinuity (or continuity that does not meet the child's needs), a lack of appropriate social support for both the child and surviving parent and a failure to provide clear and honest information at appropriate time points relevant to the child's level of understanding was perceived to have a negative impact in adulthood with regards to trust, relationships, self-esteem, feeling of self-worth loneliness and isolation and the ability to express feelings. A model is suggested for identifying and supporting those that may be more vulnerable to less favourable outcomes in adult life.
The findings suggest that if the negative consequences are to be minimized it is crucial that guidelines for ‘best practice’ that recognize the complex nature of the bereavement experience are followed.
PMCID: PMC3569022  PMID: 23392851
7.  What Do Patients Choose to Tell Their Doctors? Qualitative Analysis of Potential Barriers to Reattributing Medically Unexplained Symptoms 
Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor–patient communication, though not necessarily patient health.
To examine patient experiences of GPs’ attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome.
Qualitative study.
Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general.
Thematic analysis of in-depth interviews.
Potential barriers include the complexity of patients’ problems and patients’ judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution.
Improving GP explanation of unexplained symptoms is insufficient to reduce patients’ concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor–patient relationship in which patients can perceive psychosocial enquiry as appropriate.
PMCID: PMC2659146  PMID: 19089505
doctor–patient communication; medically unexplained symptoms; reattribution
8.  Qualitative study of an educational intervention for GPs in the assessment and management of depression 
Previous research has not shown any significant health gain for patients as a result of providing education about depression for GPs. Reasons for this, however, are unclear.
To explore relationships between process and outcome in the setting of a randomised controlled trial of a complex educational intervention designed to provide GPs with training in the assessment and management of depression.
Design of study
Qualitative study utilising semi-structured interviews.
General practice in the northwest of England.
Semi-structured interviews with 30 GPs in Liverpool and Manchester who participated in a randomised controlled trial.
Three major barriers to the effectiveness of the intervention were identified: the lack of the GP's belief that he/she could have an impact on the outcome of depression, the appropriateness of the training, and the organisational context in which doctors had to implement what they had learned.
Attitudes toward treating depression may need addressing at a much earlier point in medical education. If students are introduced to a biosocial model of depression at an early stage, they may feel more hopeful about their ability to intervene when faced with patients who exhibit significant degrees of functional disability in the context of apparently socially determined disorders. Postgraduate interventions should be tailored to the treatment of depression as a common chronic condition and be focused at the level of the organisation, not the individual practitioner.
PMCID: PMC1570781  PMID: 16282001
depression; education; primary care

Results 1-8 (8)