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Adapting in interaction involving Mandarin speakers with aphasia: A conversation analysis of turn initial responses to healthcare professionals’ questions

Background: Aphasia is a communication disorder caused by brain damage. People with aphasia (PWA) often experience difficulties in interaction. Methods: This study uses conversation analysis (CA) and examines the interactions of 10 PWA (5 fluent and 5 non-fluent speakers) and their healthcare professionals. Aims: The study aims to to explore how Mandarin-speaking PWA adapt to difficulties in initiating responses to questions from healthcare professionals. It also examines how the ways PWA adapt may vary across different types of aphasia. Results: Two adaptive practices were identified: turn initial repeats and turn initial iconic gesture. The findings suggest that fluent speakers with aphasia tended to adapt with turn initial repeats, while non-fluent speakers relied more on iconic gestures in starting a response turn. These practices allow PWA to maintain progressivity in responding to questions and assist them in formulating answers. Conclusions & Implications: The study provides empirical evidence on how linguistic and multimodal resources can enhance everyday interactions and be applied in interaction-focused therapy for Mandarin-speaking PWA. WHAT THIS PAPER ADDS: What is already known on the subject Existing research has primarily focused on communication challenges and adaptation strategies among individuals with aphasia who speak English, German and Finnish. There is a noticeable gap in the literature concerning Mandarin speakers with aphasia and their experiences in everyday communication. To our knowledge, no study has yet explored the specific challenges they encounter and how they cope with them. What this paper adds to the existing knowledge This study explores the communication challenges faced by Mandarin speakers with aphasia during interactions with health professionals, with a particular focus on turn initial responses to questions. Two distinct approaches (i.e., ‘turn initial repeat’ and ‘turn initial iconic gesture’) to manage communicative difficulties were identified, with a possible relation between approaches and aphasia types. Fluent speakers compensated with ‘turn initial repeat’ whereas non-fluent speakers employed ‘turn initial iconic gesture’ for successful communication with their health professionals. What are the potential or actual clinical implications of this work? The strategies initiated in response to question difficulties contribute to effective turn construction and represent valuable resources for PWA managing aphasia. The study offers empirical evidence on how these communication resources (both linguistical and multimodal) can enhance everyday interactions and be integrated into interaction-focused therapy for Mandarin speakers with aphasia.

Making people with aphasia speak for themselves in conversation: non-collaboration by significant others in the production of answers to test questions

Background: Non-collaboration by significant others (SOs) in interactions with people with aphasia has been previously observed in the context of known-response activities. However, there is no evidence in these studies of an overtly negative stance or criticism by the SOs or interactional discord. Aims: This study aims to explore a more extreme form of non-collaboration in test question activities. Specifically, we examine how SOs’ practice in these testing activities relates to (1) the typically prolonged nature of the person with aphasia’s (PWA) attempts; and (2) the negative stances by the SOs and the interactional discord that are regularly displayed in these conversations when this practice is employed. Second, we use these findings to provide an overview of the different practices employed by SOs in test question activities, comparing them in the form of a continuum of options (or interactional “styles”) available to SOs, and we highlight the dilemmas faced by SOs in knowing what to do for the best when interacting with their family members with aphasia. Methods: We use Conversation Analysis (CA) to analyze domestic conversations between two PWA-SO couples, focusing on the practice employed by SO in test question sequences when the PWA struggles to produce an adequate answer. Conclusion: The practices employed by SOs indicate that they treat their partner with aphasia as someone who should be autonomous and “speak for themselves” in that they should produce a certain type of utterance in the conversation (here, an answer to a test question) by themselves and without any substantive assistance from the SO. When this practice is employed by the SOs, the activity ceases being solely about eliciting the correct answer; it regularly also becomes a locus of interactional discord.

Participants’ perspectives of being recruited into a randomised trial of a weight loss intervention before colorectal cancer surgery: a qualitative interview study

Background: The period between cancer diagnosis and surgery presents an opportunity for trials to assess the feasibility of behaviour change interventions. However, this can be a worrying time for patients and may hinder recruitment. We describe the perspectives of patients with excess weight awaiting colorectal cancer surgery about their recruitment into a randomised trial of a prehabilitation weight loss intervention. Methods: We interviewed the first 26 participants from the 8 recruitment sites across England in the ‘CARE’ feasibility trial. Participants were randomised into either usual care (n = 13) or a low-energy nutritionally-replete total diet replacement programme with weekly remote behavioural support by a dietitian (n = 13). The semi-structured interviews occurred shortly after recruitment and the questions focused on participants’ recollections of being recruited into the trial. We analysed data rapidly and then used a mind-mapping technique to develop descriptive themes. Themes were agreed by all co-authors, including a person with lived-experience of colorectal surgery. Results: Participants had a mean body mass index (± SD) of 38 kg/m2 (± 6), age of 50 years (± 12), and 42% were female. People who participated in the trial were motivated by the offer of structured weight loss support that could potentially help them improve their surgical outcomes. However, participants also had concerns around the potential unpalatability of the intervention diet and side effects. Positive attitudes of clinicians towards the trial facilitated recruitment but participants were disappointed when they were randomised to usual care due to clinical teams’ overemphasis on the benefits of losing weight. Conclusions: Patients were motivated to take part by the prospect of improved surgical outcomes. However, the strong preference to be allocated to the intervention suggests that balanced communication of equipoise is crucial to minimise disappointment from randomisation to usual care and differential dropout from the trial. Clinical trial registration: ISRCTN39207707, Registration date 13/03/2023.

Managing recurrent vulvovaginal thrush from patient and healthcare professional perspectives: A systematic review and thematic synthesis

Objective: This systematic review aims to identify what is known about patient and healthcare professional experiences of managing recurrent vulvovaginal thrush by synthesising published findings. Methods: Five databases were searched for studies on patient and healthcare professional experiences managing recurrent thrush. Two reviewers independently screened and quality assessed qualitative, quantitative, and mixed-methods studies. Findings from eligible studies were thematically synthesised. Results: 720 papers were identified, and 29 were included. Four descriptive themes were developed to depict the repeated management of recurrent thrush. These themes were: (re)experiencing impacts, (re)identifying recurrent thrush, (re)considering consultations, and (re)trying treatments. An analytic high-order frame of ‘interwoven and reoccurring uncertainties’ was used to understand these themes. Conclusions: Patients and healthcare providers face uncertainties when managing recurrent thrush. The inconsistencies raised across papers suggests an unaddressed gap in knowledge about patient experiences and their informational and support needs; this includes insights about this condition's diagnosis, management, treatment, impacts, and meaning. Practice implications: This review has implications for patient education, health promotion, and communication between patients and providers. Our interpretations suggest the need for more research and resources to help support patients and clinicians in managing this condition to promote more understanding, communication, and collaborative care.

Psychiatry Algorithms for Primary Care

The “snowflakes” of modern society: a qualitative investigation of female university students' anxiety about adulting

Purpose: The paper aims to explore the anxiety of university students. The authors note that the rhetoric of the snowflake is frequently invoked in lay discourse to characterise a generation of young people as overly sensitive. This misleading conceptualisation is potentially stigmatising. Design/methodology/approach: Interviews were conducted with tweleve young women (18–25 years) about anxiety during their transition through university and into adulthood. Findings: The authors identified three themes: (1) students in a modern world, (2) gendered demands and (3) anxiety of adulting. Analysis demonstrated numerous, transecting and discourse-informed anxieties about modern life. Practical implications: University professionals may benefit from understanding the gendered dimensions of anxiety associated with transitions to adulthood, including the increased pressures to succeed and achieve. Originality/value: The arguably pejorative label of “snowflake” could negatively impact the social progress made in recognising the importance of taking care of mental health and help-seeking. This is especially concerning for females, as they have higher prevalence of anxiety conditions than males.

#TreatmentResistantDepression: A qualitative content analysis of Tweets about difficult-to-treat depression

Introduction: Treatment-resistant depression (TRD) is depression unresponsive to antidepressants and affects 55% of British primary care users with depression. Current evidence is from secondary care, but long referral times mean general practitioners (GPs) manage TRD. Studies show that people with depression use Twitter to form community and document symptoms. However, Twitter remains a largely unexplored space of documented patient experience. Twitter data could provide valuable insights into learning about primary care experiences of TRD. In this study, we explored Twitter comments and conversations about TRD and produced patient-driven recommendations. Methods: Tweets from UK-based users were collected manually and using a browser extension in June 2021. Conventional content analysis was used to provide an overview of the Tweets, followed by interpretation to understand why Twitter may be important to people with TRD. Results: A total of 415 Tweets were organised into five clusters: self-diagnosis, symptoms, support, small wins and condition experts. These Tweets were interpreted as showing Twitter as a community for people with TRD. People had a collective sense of illness identity and were united in their experiences of TRD. However, users in the community also highlighted the absence of effective GP care, leading users to position themselves as condition experts. Users shared advice from a place of lived experience with the community but also shared potentially harmful information, including recommendations about nonevidence-based medications. Conclusions: Findings illuminate the benefits of the TRD Twitter community and also highlight that the perception of a lack of knowledge and support from GPs may lead community members to advise nonevidenced-based medications. Patient and Public Contribution: This study was led by a person with lived experience of TRD and bipolar. Two public contributors with mental health conditions gave feedback on our study protocol and results.

Adolescent perspectives on gendered ideologies in physical activity within schools: Reflections on a female-focused intervention

There has been growing concern about rising physical inactivity levels in female adolescents, with schools taking some responsibility to address this. Programmes designed for and by girls are increasingly being used by developing or delivering a programme of change and consultation to improve physical activity, physical education, and sport in school. However, to build an understanding of the nuances of such interventions, and better appreciate any gendered benefits and challenges, girls’ voices need to be heard. Based on data from 16 focus groups from 8 schools participating in a female-focused intervention trial (“Girls Active”), we explored adolescent girls’ views of this type of intervention. We used reflexive organic thematic analysis to understand key issues. Four themes were developed: stereotypes; choice; empowerment and voice; and equality. Our feminist approach centralised adolescent girls’ voices, thereby recognising that physical activity is rooted in patriarchal constructions that position girls as naturally uninterested in sport and activity. We suggest gender-focused interventions can actively address stereotypes by listening to girls.

The 'snowflakes' of modern society: A qualitative investigation of female university students’ anxiety about adulting

Experiences of treatment-resistant mental health conditions in primary care: a systematic review and thematic synthesis

Background: Most adults fail to achieve remission from common mental health conditions based on pharmacological treatment in primary care alone. There is no data synthesising the reasons. This review addresses this gap through a systematic review and thematic synthesis to understand adults’ experiences using primary care for treatment-resistant mental health conditions (TRMHCs). We use the results to produce patient-driven recommendations for better support in primary care. Methods: Eight databases were searched from inception to December 2020 for qualitative studies reporting research on people’s experience with TRMHCs in primary care. We included the following common mental health conditions defined by NICE: anxiety, depression, panic disorder, post-traumatic stress, and obsessive-compulsive disorder. Two reviewers independently screened studies. Eligible studies were analysed using an aggregative thematic synthesis. Results: Eleven studies of 4456 were eligible. From these eleven studies, 4 descriptive themes were developed to describe a cycle of care that people with TRMHCs experienced in primary care. In the first stage, people preferred to self-manage their mental health and reported barriers that prevented them from seeing a GP (e.g., stigma). People felt it necessary to see their GP only when reaching a crisis point. In the second stage, people were usually prescribed antidepressants, but were sceptical about any benefits they had to their mental health. In the third stage, people self-managed their mental health (e.g., by adjusting antidepressant dosage). The fourth stage described the reoccurrence of mental health and need to see a GP again. The high-order theme, ‘breaking the cycle,’ described how this cycle could be broken (e.g., continuity of care). Conclusions: People with TRMHCs and GPs could break the cycle of care by having a conversation about what to do when antidepressants fail to work. This conversation could include replacing antidepressants with psychological interventions like talking therapy or mindfulness.

The management of LGBTQ+ identities on social media: A student perspective

Social media can be used to both enhance and diminish students’ experiences of university and its influence is strong for lesbian, gay, bisexual, transgender, queer and other non-heterosexual and gender-diverse (LGBTQ+) people facing stigma and discrimination. Students may feel exposed when identifying as LGBTQ+, particularly while transitioning to university life. In this study, we used theories of performance and digital personhood to explore how LGBTQ+ students use social media for identity management. We report a thematic analysis of 16 interviews. Four themes were generated from the data, showing that students use social media to explore, conceal, protect and express their identities. We found that different social media provide stages where LGBTQ+ identities are constrained by different and distinctive social factors. Thus, LGBTQ+ students’ online identities are multiple, situated and bound to specific platforms, with some alternatives to Facebook offering a space where students may feel more comfortable performing their authentic selves.

Living Better: How I Learned To Survive Depression

People with weight-related long-term conditions want support from GPs: A qualitative interview study

Two-thirds of UK adults do not have an up-to-date weight record in primary care. Some studies suggest that doctors do not raise the topic of weight management for fear of causing embarrassment or offence, or are doubtful whether people will make changes. However, for people with weight-related long-term conditions, conversations with general practitioners (GPs) can be crucial. Our study explores how people with long-term conditions associated with overweight recall and interpret conversations about weight in British primary care. An experienced qualitative researcher interviewed 41 people aged <42 years with long-term conditions associated with overweight. A maximum variation sample was sought, and transcribed interviews were analysed thematically. We revealed that patients with weight-related long-term conditions have different experiences and expectations about the role of GPs in supporting weight management. If a GP did not raise weight management in the context of the long-term condition patients formed the impression that their overweight was not seen as “doctorable” that is, as an appropriate topic for the consultation, rather than a personal or “lifestyle” concern. This was explained in multiple ways, which are captured in two themes; perceiving weight as “doctorable”; and weight doctoring in primary care. The findings highlight the need for increased attention on weight-related long-term conditions in primary care. Interventions from GPs would be welcome if conducted in a sensitive, non-judgmental manner and based on sound evidence about what works.

Navigating possible endometriosis in primary care: A qualitative study of GP perspectives

Background Endometriosis affects approximately 6-10% of women, with well documented delays between initial presentation with symptoms and diagnosis. In England, women typically seek help first in primary care, making this setting pivotal in women's pathways to diagnosis and treatment. English GP perspectives on managing possible endometriosis have not been previously reported. Aim To explore what GPs identify as important considerations when caring for women with symptoms that raise the possibility of endometriosis. Design and setting Qualitative study in English primary care. Method Semi-structured scenario-based telephone interviews with 42 GPs from April 2019 to January 2020, based around a fictional scenario of a woman presenting to primary care with symptoms suggesting possible endometriosis. Interviews were thematically coded and analysed. Results Managing possible endometriosis in primary care brings challenges. While knowledge and awareness were prerequisites for considering endometriosis, other important considerations were raised. Symptoms suggestive of endometriosis are non-specific, making endometriosis one possible consideration of many. GPs move through a diagnostic hierarchy to exclude sinister causes and utilise trials of treatment as both therapeutic interventions and diagnostic tools; processes which take time. An endometriosis label or diagnosis has advantages and risks. GPs reported sharing decisions about investigation and referral while holding women's priorities as pivotal. These conversations were underpinned by their knowledge of uncertainties and unknowns, including the wide spectrum and unpredictability of endometriosis. Conclusion GPs considerations are more complex than simply lacking awareness. The unknowns surrounding endometriosis matter to GPs. Further research and tailored resources for primary care, where women present with undifferentiated symptoms, are needed.

Gender in the consolidated criteria for reporting qualitative research (COREQ) checklist

An overview of childhood cancer care and outcomes in Egypt: a narrative review

Childhood cancer is an urgent priority in Egypt, owing to a large number of children with cancer, the great need and demand for paediatric oncology services, limited resources/ funds and inferior survival outcomes. Therefore, an overview of the status of childhood cancer care in Egypt and an evidence-based approach towards optimal utilisation of resources/funds to improve this care are needed. This paper summarises key evidence about childhood cancer care and outcomes in Egypt. We conducted a narrative literature review using a structured search strategy of the MEDLINE database through the PubMed interface. All relevant evidence was summarised under five main sub-topics: (1) burden of childhood cancer in Egypt; (2) treatment approaches; (3) health outcomes; (4) costs and cost-effectiveness of treatment; and (5) barriers and facilitators to optimal childhood cancer care. We found high estimates of disease burden of childhood cancer in Egypt. Furthermore, childhood cancer treatment in Egypt is based on either implementing intensity-regulated protocols or adopting international protocols with or without adaptations to local contexts, leading to varying standards of care among the different treating centres. Limited data about the survival outcomes, costs and cost-effectiveness of treatment exist, although high-quality data from retrospective cohort studies were published from a large paediatric oncology centre (Children’s Cancer Hospital Egypt–57357). As Egypt joins the WHO Global Initiative for Childhood Cancers as a focus country, it is prepared to move towards streamlining national efforts to implement a national childhood cancer plan to advance care, improve health outcomes and optimise resource use. Through these efforts, Egypt could become a beacon of hope and a role model to other low- and middle-income countries seeking to improve their childhood cancer care.

Cost-effectiveness of childhood cancer treatment in Egypt: Lessons to promote high-value care in a resource-limited setting based on real-world evidence

Background: Childhood cancer in low-and middle-income countries is a global health priority, however, the perception that treatment is unaffordable has potentially led to scarce investment in resources, contributing to inferior survival. In this study, we analysed real-world data about the cost-effectiveness of treating 8886 children with cancer at a large resource-limited paediatric oncology setting in Egypt, between 2013 and 2017, stratified by cancer type, stage/risk, and disease status. Methods: Childhood cancer costs (USD 2019) were calculated from a health-system perspective, and 5-year overall survival was used to represent clinical effectiveness. We estimated cost-effectiveness as the cost per disability-adjusted life-year (cost/DALY) averted, adjusted for utility decrement for late-effect morbidity and mortality. Findings: For all cancers combined, cost/DALY averted was $1384 (0.5 × GDP/capita), which is very cost-effective according to WHO–CHOICE thresholds. Ratio of cost/DALY averted to GDP/capita varied by cancer type/sub-type and disease severity (range: 0.1–1.6), where it was lowest for Hodgkin lymphoma, and retinoblastoma, and highest for high-risk acute leukaemia, and high-risk neuroblastoma. Treatment was cost-effective (ratio <3 × GDP/capita) for all cancer types/subtypes and risk/stage groups, except for relapsed/refractory acute leukaemia, and relapsed/progressive patients with brain tumours, hepatoblastoma, Ewing sarcoma, and neuroblastoma. Treatment cost-effectiveness was affected by the high costs and inferior survival of advanced-stage/high-risk and relapsed/progressive cancers. Interpretation: Childhood cancer treatment is cost-effective in a resource-limited setting in Egypt, except for some relapsed/progressive cancer groups. We present evidence-based recommendations and lessons to promote high-value in care delivery, with implications on practice and policy. Funding: Egypt Cancer Network; NIHR School for Primary Care Research; ALSAC.

Understanding the roles and work of paramedics in primary care: A national cross-sectional survey

Objectives This research aimed to fill a current knowledge gap, namely the current scope of clinical role of paramedics in primary care, in relation to specific constructs such a level of education and clinical experience. Setting The survey was distributed to paramedics in primary care across the UK through the College of Paramedics. Participants A total of 341 surveys were returned (male=215). 90% of responses were from paramedics in England, 1.7% from paramedics in Northern Ireland, 4.6% from paramedics in Scotland and 2.9% from paramedics in Wales. This represents approximately 33% of the primary care paramedic workforce in England and Wales. Estimates for percentages in Northern Ireland and Scotland are unavailable due to the lack of workforce datasets capturing paramedics in primary care. Results Considerable variation was found in job titles, level of education and provision of clinical supervision of paramedics in primary care. Differing levels of practice were noted, despite guidance documents that attempt to standardise the role. Statistical analysis of quantitative data highlighted that relationships exist between paramedic clinical exposure in primary care, level of education, and ability of independently prescribe medicines and the extent to which clinical presentations are seen and examinations performed. However, free-Text responses indicated that challenges in relation to access to further education and clinical supervision to support clinical development resulted in frustration for paramedics who work in this setting. Conclusions As well as offering an insight into the demographics of the primary care paramedic work force, there is indication of the clinical scope of role undertaken in this setting. Based on our findings, we recommend changes to education and support, governance and legislation to ensure paramedics employed in primary care can work to achieve the full extent of their professional capability.

Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes

Objective: To assess the effectiveness of self monitoring blood glucose levels in people with non-insulin treated type 2 diabetes compared with clinical management without self monitoring, and to explore the effects in specific patient groups. Design: Meta-analysis based on individual participant data. Data sources: Medline, Embase, and a recent systematic review of trialson self monitoring of blood glucose. Chief investigators of trials published since 2000 were approached for additional information and individual patient data. Inclusion criteria: Randomised controlled trials in patients with non-insulin treated type 2 diabetes comparing an intervention using self monitoring of blood glucose with clinical management not using self monitoring. Trials published from 2000 with at least 80 participants were included. Data collection: Individual patient data were collected from electronic files and checked for integrity. Analysis: All randomised participants were analysed using the intention to treat principle. A random effects model of complete cases was used to assess efficacy, a sensitivity analysis comprised imputed data, and prespecified subgroup analyses were carried out for age, sex, previous use of self monitoring, duration of diabetes, and levels of glycated haemoglobin (HbA 1c) at baseline. Results: 2552 patients were randomised in the six included trials. A mean reduction in HbA 1c level of -2.7 mmol/mol (95% confidence interval -3.9 to -1.6; 0.25%) was observed for those using self monitoring of blood glucose levels compared with no self monitoring at six months. The mean reduction in HbA1c level between groups was 2.0 mmol/mol (3.2 to 0.8; 0.25%) at three months (five trials) and 2.5 mmol/mol (4.1 to 0.9; 0.35%) at 12 months (three trials). These estimates were unchanged after imputing missing data, and estimates of effect in trials with higher loss to follow-up or a possibility of co-intervention compared with those with lower loss to follow-up and no co-intervention did not differ significantly (P=0.21). The difference in HbA 1c levels between groups was consistent across age, baseline HbA 1c level, sex, and duration of diabetes, although the numbers of older and younger people and those with HbA 1c levels >86 mmol/mol (10%) were insufficient for interpretation. No changes occurred in systolic blood pressure (-0.2 mm Hg, 95% confidence interval -1.4 to 1.0), diastolic blood pressure (-0.1 mm Hg, -0.9 to 0.6), or total cholesterol level (-0.1 mol/L, 95% confidence interval -0.2 to 0.1). Conclusions: Evidence from this meta-analysis of individual patient data was not convincing for a clinically meaningful effect of clinical management of non-insulin treated type 2 diabetes by self monitoring of blood glucose levels compared with management without self monitoring, although the difference in HbA 1c level between groups was statistically significant. The difference in levels was consistent across subgroups defined by personal and clinical characteristics.

Variation in diagnostic test requests and outcomes: A preliminary metric for OpenPathology.net

Efforts to reduce healthcare costs have led to the development of metrics to identify unwarranted variation in care. Previous work assessing diagnostic tests is limited, despite their substantial contribution to expenditure. We explored C-reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) tests ordered across Oxfordshire NHS General Practices, and the proportion of tests that yielded an abnormal result, and identified practices that had a proportion of abnormal CRP and ESR results 3 standard deviations below the mean. We estimated the adjusted average proportion of abnormal CRP and ESR tests that yielded abnormal results from each practice, after adjusting for differences in practice populations. These proportions were plotted against the total CRP and ESR requests per practice. We constructed funnel plots to identify practices 3 standard deviations below the mean proportion of abnormal CRP and ESR tests. We analysed 143,745 CRP and 30,758 ESR requests from 69 practices. Twelve (17%) and 7 (10%) practices were more than 3 standard deviations below the mean for CRP and ESR testing respectively. Two practices (3%) were below the 99.8% limit for both CRP and ESR ordering. Variation in the proportion of tests with an abnormal result shows promise for auditing variation in care.