Home self-administration of intravenous antibiotics as part of an outpatient parenteral antibiotic therapy service: a qualitative study of the perspectives of patients who do not self-administer.

OBJECTIVES: This study aimed to use a theoretical approach to understand the determinants of behaviour in patients not home self-administering intravenous antibiotics. SETTING: Outpatient care: included patients were attending an outpatient clinic for intravenous antibiotic administration in the northeast of Scotland. PARTICIPANTS: Patients were included if they had received more than 7 days of intravenous antibiotics and were aged 16 years and over. Twenty potential participants were approached, and all agreed to be interviewed. 13 were male with a mean age of 54 years (SD +17.6). OUTCOMES: Key behavioural determinants that influenced patients' behaviours relating to self-administration of intravenous antibiotics. DESIGN: Qualitative, semistructured in-depth interviews were undertaken with a purposive sample of patients. An interview schedule, underpinned by the Theoretical Domains Framework (TDF), was developed, reviewed for credibility and piloted. Interviews were audio-recorded and transcribed verbatim. Data were analysed thematically using the TDF as the coding framework. RESULTS: The key behavioural determinants emerging as encouraging patients to self-administer intravenous antibiotics were the perceptions of being sufficiently knowledgeable, skilful and competent and that self-administration afforded the potential to work while administering treatment. The key determinants that impacted their decision not to self-administer were lack of knowledge of available options, a perception that hospital staff are better trained and anxieties of potential complications. CONCLUSION: Though patients are appreciative of the skills and knowledge of hospital staff, there is also a willingness among patients to home self-administer antibiotics. However, the main barrier emerges to be a perceived lack of knowledge of ways of doing this at home. To overcome this, a number of interventions are suggested based on evidence-based behavioural change techniques.

"I try and smile, I try and be cheery, I try not to be pushy. I try to say 'I'm here for help' but I leave feeling... worried": a qualitative study of perceptions of interactions with health professionals by community-based older adults with chronic pain.

BACKGROUND: Over 50% of community-dwelling older adults experience chronic pain, which threatens their quality of life. Of importance to their pain management is older people's interaction with health professionals that, if unsatisfactory, may impair the outcome. AIMS: To add to the limited research specific to older people living with chronic pain in the community, we explored how they perceive their experiences of interacting with health professionals, seeking factors that might optimise these interactions. METHODS: Purposive sampling was used to recruit men and women >65 years with self-reported musculoskeletal chronic pain. Qualitative individual interviews and one group interview were undertaken with 23 participants. Data were transcribed verbatim and underwent Framework Analysis. RESULTS: Three themes were identified. Seeking help illustrates issues around why older people in the community may or may not seek help for chronic pain, and highlights the potential involvement of social comparison. Importance of diagnosis illustrates the desire for professional validation of their condition and an aversion to vague explanations based on the person's age. Being listened to and being heard illustrates the importance of empathic communication and understanding expectations, with due respect for the person's age. CONCLUSIONS: In common with people of all ages, an effective partnership between an older person in pain and health professionals is essential if pain is to be reported, appropriately assessed and managed, because of the subjective nature of pain and its treatment responses. For older people with pain, perception about their age, by both parties in the partnership, is an additional factor that can unnecessarily interfere with the effectiveness of this partnership. Health professionals should engage with older adults to clarify their expectations about pain and its management, which may be influenced by perceptions about age; and to encourage expression of their concerns, which may also be affected by perceptions about age.

Systematically searching for and assessing the literature for self-management of chronic pain: a lay users' perspective.

BACKGROUND: The Engaging with older adults in the development of strategies for the self management of chronic pain (EOPIC) study aims to design and develop self management strategies to enable older adults to manage their own pain. Involving older adults in research into chronic pain management will better enable the identification and development of strategies that are more appropriate for their use, but how can perspectives really be utilised to the best possible outcomes? METHOD: Seven older adults were recruited through a local advertising campaign to take part. We also invited participants from the local pain services, individuals who had been involved in earlier phase of the EOPIC study and a previous ESRC funded project. The group undertook library training and research skills training to facilitate searching of the literature and identified sources of material. A grading tool was developed using perceived essential criteria identified by the older adults and material was graded according to the criteria within this scale. RESULTS: Fifty-seven resources from over twenty-eight sources were identified. These materials were identified as being easily accessible, readable and relevant. Many of the web based materials were not always easy to find or readily available so they were excluded by the participants. All but one were UK based. Forty-four items were identified as meeting the key criteria for inclusion in the study. This included five key categories as follows; books, internet, magazines, leaflets, CD's/Tapes. CONCLUSION: This project was able to identify a number of exemplars of self management material along with some general rules regarding the categories identified. We must point out that the materials identified were not age specific, were often locally developed and would need to be adapted to older adults with chronic pain. For copyright issues we have not included them in this paper. The key message is really related to the format rather than the content. However, the group acknowledge that these may vary according to the requirements of each individual older adult and therefore recommend the development of a leaflet to help others in their search for resources. This leaflet has been developed as part of Phase IV of the EOPIC study.

Methadone prescribing under supervised consumption on premises: a Scottish clinician's perspective on prescribing practice.

INTRODUCTION AND AIMS: Specialist services have increased their capacity considerably in recent years to initiate and/or provide ongoing treatment for drug misuse. Consequently, methadone prescribing has substantially increased and over 17,000 patients are currently receiving methadone. Clinical guidance promotes consumption on the premises (COP) initially to ensure patients take medication as prescribed and also to prevent diversion. Diversion poses two risks: the patient may remain under-treated and continue illicit heroin use; diverted drugs put others at risk. However, COP can be restrictive. Current UK guidance is vague and not evidence-based recommending 'around three months subject to assessment of compliance and individual circumstances'. The overall aim of this study was to describe clinical practice regarding prescribing methadone under COP in Scotland, and reasons for this. Design and Methods. A structured, postal questionnaire was sent to all lead clinicians in specialist drug treatment centres in Scotland in 2009 (n=42). The questionnaire explored current practice, influence of supervision on retention, views of best practice and contingency management. RESULTS: The response rate was 76% (n=32). Clinicians usually supervise for a minimum of three months with patient-centred criteria used to determine when to reduce or stop COP. Employment, clinical stability, family support and concerns for the safety of children in the home influenced decision making. Contingency management approaches to supervision were widely used (62%). DISCUSSION AND CONCLUSION: In Scotland, clinicians' practice is variable and individualised to patients, but generally cautious regarding relaxing supervision conditions. This may reflect the lack of evidence-based guidance.

"I feel so stupid because I can't give a proper answer " How older adults describe chronic pain: a qualitative study.

BACKGROUND: Over 50% of older adults experience chronic pain. Poorly managed pain threatens independent functioning, limits social activities and detrimentally affects emotional wellbeing. Yet, chronic pain is not fully understood from older adults' perspectives; subsequently, pain management in later life is not necessarily based on their priorities or needs. This paper reports a qualitative exploration of older adults' accounts of living with chronic pain, focusing on how they describe pain, with a view to informing approaches to its assessment. METHODS: Cognitively intact men and women aged over sixty-five who lived in the community opted into the study through responding to advertisements in the media and via contacts with groups and organisations in North-East Scotland. Interviews were transcribed and thematically analysed using a framework approach. RESULTS: Qualitative individual interviews and one group interview were undertaken with 23 older adults. Following analysis, the following main themes emerged: diversity in conceptualising pain using a simple numerical score; personalising the meaning of pain by way of stories, similes and metaphors; and, contextualising pain in relation to its impact on activities. CONCLUSIONS: The importance of attending to individuals' stories as a meaningful way of describing pain for older adults is highlighted, suggesting that a narrative approach, as recommended and researched in other areas of medicine, may usefully be applied in pain assessment for older adults. Along with the judicious use of numerical tools, this requires innovative methods to elicit verbal accounts, such as using similes and metaphors to help older adults describe and discuss their experience, and contextualising the effects of pain on activities that are important to them.

A pilot randomised controlled trial of brief versus twice weekly versus standard supervised consumption in patients on opiate maintenance treatment.

INTRODUCTION AND AIMS: Methadone maintenance remains the mainstay of treatment for opiate dependence in Scotland. Guidelines recommend supervised self-administration for at least 3 months, yet this is often interpreted as long-term supervision. However, there is no evidence base for deciding the optimal period of supervision. We tested the feasibility of conducting a randomised controlled trial (RCT) of different supervision models. DESIGN AND METHODS: Three armed pilot RCT, set in three Scottish treatment areas, recruited opiate-dependent patients who had received methadone treatment for 3 months. Participants were randomised to: (i) no supervision; (ii) twice weekly supervision; or (iii) daily supervision for further 3 months. As a pilot, key process measures were: recruitment rates, follow-up rates and treatment fidelity. We also wanted to estimate effect sizes of two co-primary outcomes for a full RCT: treatment retention and illicit heroin use. The recruitment target was 60 participants. RESULTS: One hundred and two eligible patients were identified, 60 (59%) participated, and 46 followed up (77%). Study fidelity was good with two participants moving group. Those randomised to no supervision were significantly happier with their group allocation. No significant differences were found in primary outcomes, although retention decreased with increased supervision, while illicit heroin use was least in those most supervised. DISCUSSION AND CONCLUSIONS: It is possible to recruit and randomise participants to an RCT comparing different forms of supervised consumption. Pilot data suggest increased supervision may reduce illicit heroin use, but may decrease retention. This should now be tested in a large-scale multicentre RCT.

'It's not my job. I'm the patient not the doctor': patient perspectives on medicines management in the treatment of schizophrenia.

OBJECTIVES: Medicines management plays a key role in schizophrenia treatment. Objectives were to investigate the feasibility of undertaking in-depth research involving in-patients with a diagnosis of schizophrenia and to determine patients' views and experiences of medicines management. METHODS: Research was carried out in the forensic ward of a psychiatric hospital and two rehabilitation settings in north-east Scotland. A qualitative methodology was adopted incorporating semi-structured interviews. Full text transcripts were produced and analysed. RESULTS: Fifteen of 16 patients approached were willing to participate. Ages ranged from 27 to 70 years and they had been prescribed antipsychotics from six months to 27 years. Nearly everyone was aware of their medication regimen. Most relied on staff for information, but this was supplemented by learning from other patients' experiences. Most were happy to leave decisions to staff and few sought any role in shared decision making. CONCLUSION: The research demonstrated the feasibility of undertaking qualitative work with patients with schizophrenia. Findings indicated that it should not be assumed that all patients want to take responsibility for their medications. PRACTICE IMPLICATIONS: Patients' reluctance to assume responsibility needs to be explored and patients' wishes taken into account when planning future medicine related education.

Assessing and prioritizing the preferences of injecting drug users in needle and syringe exchange service development.

BACKGROUND: Needle exchange services are vital for the distribution of clean injecting equipment and disposal of equipment used for intravenous drug users. From the number of clean needles and syringes distributed and the estimated number of injecting drug users (IDUs), there may be insufficient use of needle exchange services. This highlighted the need to consider how services could be improved to encourage the use. METHODS: A structured, short, anonymous questionnaire was distributed to IDUs through a wide range of agencies and services in North East Scotland. A form of snowball sampling was also used. RESULTS: A total of 370 individuals responded. Respondents noted the following in their two prioritized preferred options: 'Provision of paraphernalia' (citric acid, water and filters; 54%), 'weekend opening hours' (24%) and 'antibiotic prescribing' (23%). Other service developments noted were: 'friendly, approachable staff' (16%), 'family planning' (10.4%), 'dressings for wounds/sores' (9%), 'leaflets on safer injecting' (7.0%), 'advice from staff on safer injecting' (3.0%) and 'evening opening hours' (0.8%). Geographical gaps in current needle exchange services were identified. There was homogeneity of responses across demographic groups. CONCLUSION: IDUs were willing to participate and suggested more provision of paraphernalia.