Evelyn van Weel-Baumgarten

The risk for depression comorbidity in patients with COPD.

INTRODUCTION Patients with COPD are believed to have a high risk for the development of depression. However, it remains unclear whether or not there is a temporal relation between COPD and depression, and if the higher risk for depression is a result of having a chronic disease, or is specific for COPD. The aim of this study is to compare the risk for physician-diagnosed depression in patients with COPD, patients with diabetes mellitus (DM), and control subjects without chronic conditions. METHODS The study was a prospective cohort study based on the Continuous Morbidity Registration database. Cox proportional hazards analysis was used to identify the risk of a first episode of depression in patients with COPD compared to patients with DM and matched control subjects without chronic conditions. The following covariates were added to the model: age, the general practice the patient was listed with, socioeconomic status, comorbidity, and gender. All patients with a diagnosis of depression preceding the date of first diagnosis of COPD or DM (dummy date in control subjects) were excluded. RESULTS The hazard ratios for a first episode of depression in the COPD group compared to the DM group and healthy controls subjects were 1.80 (95% confidence interval [CI], 1.16 to 2.81) and 1.68 (95% CI, 1.20 to 2.35), respectively. DISCUSSION We found a temporal relation between COPD and physician-diagnosed depression. Patients with COPD are more likely to have depression diagnosed than patients with DM and control subjects without chronic conditions.

Experts' opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials

BACKGROUND The feasibility as well as the suitability of several therapies for medically unexplained symptoms (MUS) in primary care applied by the family physician (FP) appeared to be low. FPs need effective and acceptable strategies to manage these functionally impaired patients. OBJECTIVE To review important and effective elements in the treatment of patients with MUS in primary care according to experts in MUS research. METHODS We performed a systematic search of narrative reviews and scientific editorials in Medline and PsycINFO and triangulated our findings by conducting a focus group with MUS experts. RESULTS We included 7 scientific editorials and 23 narrative reviews. According to MUS experts, the most important elements in the treatment of MUS are creating a safe therapeutic environment, generic interventions (such as motivational interviewing, giving tangible explanations, reassurance and regularly scheduled appointments) and specific interventions (such as cognitive approaches and pharmacotherapy). Furthermore, MUS experts indicate that a multi-component approach in which these three important elements are combined are most helpful for patients with MUS. In contrast to most specific interventions, opinions of MUS experts regarding generic interventions and creating a safe therapeutic relationship seem to be more based on theory and experience than on quantitative research. CONCLUSIONS MUS experts highlight the importance of generic interventions and doctor-patient communication and relationship. However, studies showing the effectiveness of these elements in the management of MUS in primary care is still scarce. Research as well as medical practice should focus more on these non-specific aspects of the medical consultation.

Communication in cross-cultural consultations in primary care in Europe: the case for improvement. The rationale for the RESTORE FP 7 project

The purpose of this paper is to substantiate the importance of research about barriers and levers to the implementation of supports for cross-cultural communication in primary care settings in Europe. After an overview of migrant health issues, with the focus on communication in cross-cultural consultations in primary care and the importance of language barriers, we highlight the fact that there are serious problems in routine practice that persist over time and across different European settings. Language and cultural barriers hamper communication in consultations between doctors and migrants, with a range of negative effects including poorer compliance and a greater propensity to access emergency services. It is well established that there is a need for skilled interpreters and for professionals who are culturally competent to address this problem. A range of professional guidelines and training initiatives exist that support the communication in cross-cultural consultations in primary care. However, these are commonly not implemented in daily practice. It is as yet unknown why professionals do not accept or implement these guidelines and interventions, or under what circumstances they would do so. A new study involving six European countries, RESTORE (REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings), aims to address these gaps in knowledge. It uses a unique combination of a contemporary social theory, normalisation process theory (NPT) and participatory learning and action (PLA) research. This should enhance understanding of the levers and barriers to implementation, as well as providing stakeholders, with the opportunity to generate creative solutions to problems experienced with the implementation of such interventions.

Bridging the gap: How is integrating communication skills with medical content throughout the curriculum valued by students

OBJECTIVE To describe a program with integrated learning of communication and consultation skills developed with the intention of preventing deterioration of communication skills, and to present student evaluation data. METHODS Description and evaluation of the program through: (1) monthly student evaluations; (2) questionnaire on student perceptions about the integrated curriculum; (3) a questionnaire about the value of one specific integrated training preceding the pediatric clerkship. RESULTS Key components of training throughout years 3-6 are reinforcement throughout the clinical years, adapting communication training to the clinical context of clerkships using a sandwich model with cycles of preparation, clerkship, and reflection. EVALUATION response rates were 69%, 93% and 93%, respectively. Students value practicing integration of communication and medical content with SPs who represent the population of their next clerkships. They appreciate the multisource feedback during the training, feedback by clerkship specific specialists and SPs is valued most. CONCLUSIONS This description shows an example of an integrated curriculum that helps students to feel well prepared for their communication tasks in subsequent clerkships. PRACTICE IMPLICATIONS Designing and implementing communication curricula to address the issue of integration is feasible. The effects of such integrated programs should be subject to future studies.

REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol

BackgroundThe implementation of guidelines and training initiatives to support communication in cross-cultural primary care consultations is ad hoc across a range of international settings with negative consequences particularly for migrants. This situation reflects a well-documented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization Process Theory and participatory research methodology—Participatory Learning and Action—to investigate and support implementation of such guidelines and training initiatives in routine practice.MethodsThis is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders—migrant service users, general practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory’s four constructs—coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting. We will prospectively investigate and support the implementation journeys for the five selected interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings.DiscussionThis research employs a unique combination of Normalization Process Theory and Participatory Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and methodological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes.

Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network

BACKGROUND Unexplained symptoms are associated with depression and anxiety. This association is largely based on cross-sectional research of symptoms experienced by patients but not of symptoms presented to the GP. AIM To investigate whether unexplained symptoms as presented to the GP predict mental disorders. DESIGN AND SETTING Cross-sectional and longitudinal analysis of data from a practice-based research network of GPs, the Transition Project, in the Netherlands. METHOD All data about contacts between patients (n = 16,000) and GPs (n = 10) from 1997 to 2008 were used. The relation between unexplained symptoms episodes and depression and anxiety was calculated and compared with the relation between somatic symptoms episodes and depression and anxiety. The predictive value of unexplained symptoms episodes for depression and anxiety was determined. RESULTS All somatoform symptom episodes and most somatic symptom episodes are significantly associated with depression and anxiety. Presenting two or more symptoms episodes gives a five-fold increase of the risk of anxiety or depression. The positive predictive value of all symptom episodes for anxiety and depression was very limited. There was little difference between somatoform and somatic symptom episodes with respect to the prediction of anxiety or depression. CONCLUSION Somatoform symptom episodes have a statistically significant relation with anxiety and depression. The same was true for somatic symptom episodes. Despite the significant odds ratios, the predictive value of symptom episodes for anxiety and depression is low. Consequently, screening for these mental health problems in patients presenting unexplained symptom episodes is not justified in primary care.

Barriers and facilitators to effective communication experienced by patients with malignant lymphoma at all stages after diagnosis.

This study aims to gain insight into patient‐perceived communication barriers and facilitators at different stages after the diagnosis of malignant lymphoma. We have detected patterns to explain when these factors influence communication predominantly.

Reducing the health care burden for marginalised migrants: The potential role for primary care in Europe

There is a growing interest in the health of migrants worldwide. Migrants, particularly those in marginalised situations, face significant barriers and inequities in entitlement and access to high quality health care. This study aimed to explore the potential role of primary care in mitigating such barriers and identify ways in which health care policies and systems can influence the ability of primary care to meet the needs of vulnerable and marginalised migrants. The study compared routinely available country-level data on health system structure and financing, policy support for language and communication, and barriers and facilitators to health care access reported in the published literature. These were then mapped to a framework of primary care systems to identify where the key features mitigating or amplifying barriers to access lay. Reflecting on the data generated, we argue that culturally-sensitive primary care can play a key role in delivering accessible, high-quality care to migrants in vulnerable situations. Policymakers and practitioners need to appreciate that both individual patient capacity, and the way health care systems are configured and funded, can constrain access to care and have a negative impact on the quality of care that practitioners can provide to such populations. Strategies to address these issues, from the level of policy through to practice, are urgently needed.

Using Participatory Learning & Action research to access and engage with 'hard to reach' migrants in primary healthcare research

BackgroundCommunication problems occur in general practice consultations when migrants and general practitioners do not share a common language and culture. Migrants’ perspectives have rarely been included in the development of guidelines designed to ameliorate this. Considered ‘hard-to-reach’ on the basis of inaccessibility, language discordance and cultural difference, migrants have been consistently excluded from participation in primary healthcare research. The purpose of this qualitative study was to address this gap.MethodsThe study was conducted in the Republic of Ireland, 2009 – 2011. We developed a multi-lingual community-university research team that included seven established migrants from local communities. They completed training in Participatory Learning & Action (PLA) - a qualitative research methodology. Then, as trained service-user peer researchers (SUPERs) they used their access routes, language skills, cultural knowledge and innovative PLA techniques to recruit and engage in research with fifty-one hard-to-reach migrant service-users (MSUs).Results & discussionIn terms of access, university researchers successfully accessed SUPERs, who, in turn, successfully accessed, recruited and retained MSUs in the study. In terms of meaningful engagement, SUPERs facilitated a complex PLA research process in a language-concordant manner, enabling inclusion and active participation by MSUs. This ensured that MSUs’ perspectives were included in the development of a guideline for improving communication between healthcare providers and MSUs in Ireland. SUPERs evaluated their experiences of capacity-building, training, research fieldwork and dissemination as positively meaningful for them. MSUs evaluated their experiences of engagement in PLA fieldwork and research as positively meaningful for them.ConclusionsGiven the need to build primary healthcare ‘from the ground up’, the perspectives of diverse groups, especially the hard-to-reach, must become a normative part of primary healthcare research. PLA is a powerful, practical ‘fit-for-purpose’ methodology for achieving this: enabling hard-to-reach groups to engage meaningfully and contribute with ease to academic research. PLA has significant potential to become a ‘standard’ or generic approach in building community-based primary health care. Community–university partnerships have a significant role to play in this, with capacity to radically influence the shape of healthcare research, expanding the research agenda to incorporate the views and needs of hard-to-reach and vulnerable populations.

Work-related health complaints in surgical residents and the influence of social support and job-related autonomy

Medical Education 2010: 44: 835–844