Fiona MacKichan | University of Bristol (original) (raw)

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Papers by Fiona MacKichan

Objectives To describe how processes of primary care access influence decisions to seek help at t... more Objectives To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). Design Ethnographic case study combining non-participant observation, informal and formal interviewing. Setting Six general practitioner (GP) practices located in three commissioning organisations in England. Participants and methods Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). Results Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. Conclusions This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.

Age and Ageing , 2013

Background: although maintaining activity is key to successful pain management, and important to ... more Background: although maintaining activity is key to successful pain management, and important to health and wellbeing, it is known that older people in pain frequently alter or reduce activity levels. A ‘fear-avoidance’ model is often used to explain avoidance of activity in the face of pain. However, this model is not intended to take account of the wider context in which activity changes take place, nor older people's own explanations for their behaviour.

Objective: to investigate the reasons why older people in the community adjust their activity levels when living with chronic pain.

Methods: thirty-one people aged between 67 and 92 were purposively sampled from respondents to a community-based cross-sectional survey. All participants had reported long-term pain and were interviewed about this. Data were collected and analysed using a qualitative constructivist grounded theory approach.

Findings: explanations for deliberative reduction or ceasing of activities reflected a desire to prevent pain exacerbation, thereby avoiding medical intervention. It also reflected a desire to safeguard autonomy in the face of pain in older age. Restrictions were often rationalised as normal in older age, although co-existing accounts of perseverance and frustration with limitation were also evident.

Conclusions: a rational desire to avoid pain exacerbation and medical intervention motivated restrictions to activity. However, deliberative limitation of activity has the potential to compromise autonomy by increasing social isolation and de-conditioning. Supporting older people with pain to be active requires sensitivity to the function of activity restriction, especially as a means of preventing deterioration.

Family Practice, Oct 5, 2012

Background. Promotion of self-care for persistent back pain and other long-term conditions has ... more Background.
Promotion of self-care for persistent back pain and other long-term conditions has become a central component in health care policy in the UK, and general practitioners face increasing demands to support patients’ self-care efforts. Gaining insight into patients’ views may facilitate support.
Objective.
To describe patients’ experience of self-care for long-term back pain and their views on provision of support for self-care.
Methods.
Adults experiencing persistent back pain were purposively sampled from a community-based survey. In-depth qualitative interviews were audiotaped, transcribed and analysed using the constant comparative method to inductively derive a thematic account of the data.
Results.
Most of the 23 interviewees felt a responsibility to self-care. Individual capacity for self-care, however, was variable and could be inhibited by factors such as caring roles or lack of diagnosis and information. GP support for self-care was largely considered to be desirable, although the feasibility of greater provision of support was questioned. Some interviewees expressed a strong preference for alternative models of care and support.
Conclusion.
Self-care for back pain is contextualized by the individual’s capacity to self-care and preferences for support. Doubt over the ability of GPs to provide support for self-care may mean that those who have specific needs are reticent to seek help. The role of self-care in the management of back pain should be discussed openly at the consultation level, and GPs may be well placed to signpost patients and provide guidance on the safety of specific self-care activities.

Oral …, Jan 1, 2012

Incorporating user's perspectives in healthcare delivery is important. Si... more Incorporating user's perspectives in healthcare delivery is important. Simple questionnaires may not capture these as well as a discrete choice experiment (DCE) which enables the exploration of users' trade-offs between different service attributes. Qualitative methods are increasingly used to improve a DCE's face validity, but few studies adequately describe them. This paper describes the qualitative investigations in the development of a DCE questionnaire to elicit parents' perspectives on centralized services for children with cleft lip and palate. Semi-structured telephone interviews were conducted with 16 parents from across the UK, except Wales. Data analysis was carried out by the constant comparative method. Five attributes and their levels were inductively identified: usefulness and amount of information (four levels); staff attitude at cleft centres (two levels); continuity of care (two levels); personal costs of attending appointments (four levels); and cleft centres facilities (two levels). An unexpected finding was that parents' sense of responsibility towards their child made a 'willingness-to-travel' attribute unacceptable to them, but they were receptive to a 'willingness-to-pay' attribute. Using qualitative methods with service users in attribute development for a DCE helps to uncover issues that may not be apparent to researchers or health service staff.

BMC Family Practice

Background: Self-care is a key component of current policies to manage long term conditions. Alth... more Background:
Self-care is a key component of current policies to manage long term conditions. Although most people with long-term health problems care for themselves within lay networks, consultation rates for long-term undifferentiated illness remain high. Promotion of self-care in these individuals requires an understanding of their own self-care practices and needs to be understood in the context of health care pluralism. The aim was to investigate the extent and nature of self-care practices in patients experiencing long term health problems, sources of information used for self-care, and use of other forms of health care (conventional health care and complementary and alternative medicine).
Methods:
The study involved a cross-sectional community-based survey set in three general practices in South West England: two in urban areas, one in a rural area. Data were collected using a postal questionnaire sent to a random sample of 3,060 registered adult patients. Respondents were asked to indicate which of six long term health problems they were experiencing, and to complete the questionnaire in reference to a single (most bothersome) problem only.
Results:
Of the 1,347 (45% unadjusted response rate) who responded, 583 reported having one or more of the six long term health problems and 572 completed the survey questionnaire. Use of self-care was notably more prevalent than other forms of health care. Nearly all respondents reported using self-care (mean of four self-care practices each). Predictors of high self-care reported in regression analysis included the reported number of health problems, bothersomeness of the health problem and having received a diagnosis. Although GPs were the most frequently used and trusted source of information, their advice was not associated with greater use of self-care.
Conclusions:
This study reveals both the high level and wide range of self-care practices undertaken by this population. It also highlights the importance of GPs as a source of trusted information and advice. Our findings suggest that in order to increase self-care without increasing consultation rates, GPs and other health care providers may need more resources to help them to endorse appropriate self-care practices and signpost patients to trusted sources of self-care support.


Patients’ own explanatory models, including those of causation, have bearing on subsequent illnes... more Patients’ own explanatory models, including those of causation, have bearing on subsequent illness behaviour and the degree of concordance between patients’ and practitioners’ accounts can impact on treatment outcomes. The multidimensional, subjective nature of chronic pain makes research into causation particularly challenging. The objective of this study was to explore patients’ own understandings of the cause of their chronic pain. Methods: As part of a cross-sectional survey on chronic pain, free text commentaries of patients’ perceptions on cause were invited from respondents. Data from 548 adults were analysed qualitatively for recurrent themes relating to pain antecedents, and subsequently transformed into quantitative variables. Results and conclusion: This study found that people have well-conceptualised explanations for the causes of their chronic pain, and these often involved a combination of lay and biomedical constructs. Over half of all respondents gave commentaries describing more than one cause. This complexity may not be captured adequately in research, yet may have significant bearing on the management of chronic pain. Free text commentaries provide a useful tool to achieve data on complex phenomena in health research.

Rheumatic Disease Clinics of North …, Jan 1, 2008

Pain is a primary symptom in musculoskeletal conditions, and aspects of the pain experience (eg, ... more Pain is a primary symptom in musculoskeletal conditions, and aspects of the pain experience (eg, severity) are key considerations in clinical decision-making and in the outcome of trials and interventions. Consequently, appropriate assessment of pain is essential. This article reviews the measures most commonly used in rheumatology practice, arguing that many are significantly limited in their ability to reflect the complexity of the patient's experience. The authors provide examples of alternative approaches, concluding that there is real scope for improving assessment and measurement of musculoskeletal pain in the clinical setting.

Arthritis Care & …, Jan 1, 2007

Objective: To explore the pain experience of persons with chronic pain of the hip or knee in the ... more Objective:
To explore the pain experience of persons with chronic pain of the hip or knee in the context of self-assessment instruments commonly used to assess pain severity in individuals with osteoarthritis.
Methods:
Participants who reported that they currently had either hip or knee pain were recruited from the UK Somerset and Avon Survey of Health. A total of 28 participants (14 men and 14 women, ages 57-89 years) took part in 6 focus groups stratified according to pain site and severity. Using the "questerviews" technique, participants described and discussed their experience of joint pain in the context of standard self-assessment questionnaires: the Hip Disability and Osteoarthritis Outcome Score and the Knee Injury and Osteoarthritis Outcome Score. The focus groups were audio recorded and transcribed. Data were analyzed by identifying emergent codes that were grouped and compared, resulting in the identification of key categories.
Results:
Both knee pain and hip pain participants expressed similar pain experiences. Four key categories were identified, all of which impacted upon participants' responses to the standardized questionnaires: pain is intermittent and variable, pain elsewhere in the body influences the experience of joint pain, pain is inextricable from function, and adaptation and avoidance strategies modify the experience of pain.
Conclusion:
The assessment or measurement of pain should take into account the importance of pain experience as well as severity through use of patient narrative accounts.

European Journal of Pain, Jan 1, 2007

Interdisciplinary pain management programs have an established record of significantly improving ... more Interdisciplinary pain management programs have an established record of significantly improving the functioning of persons disabled with chronic pain. There is a group of pain sufferers, however, who have difficulty accessing these programs and for whom the effectiveness of these treatments in unknown, these are patients whose mobility and self-care deficits leave them unable to meet the practical demands of many treatment environments. The purpose of this study was to examine the results of a treatment program designed to meet the needs of these highly disabled individuals (n=53) in comparison to results obtained from a standard less-disabled group attending treatment at the same facility (n=234). Results from the highly disabled patients showed statistically significant change after treatment in eight of nine outcome variables, including improvements in pain-related distress, disability, depression, pain-related anxiety, daytime rest, and performance during an activity tolerance test. Effect size calculations showed a number of large treatment effects, for psychosocial disability, depression, and acceptance of pain. Analysis of reliable change and clinical significance demonstrated that results were not merely statistically significant but clinically meaningful. Results appeared stable at three months following treatment. This research plays an important part in establishing an evidence base to inform service development, ensuring that chronic pain services do not exclude people on the basis of the severity of their disability.

Talks by Fiona MacKichan

Objectives To describe how processes of primary care access influence decisions to seek help at t... more Objectives To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). Design Ethnographic case study combining non-participant observation, informal and formal interviewing. Setting Six general practitioner (GP) practices located in three commissioning organisations in England. Participants and methods Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). Results Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. Conclusions This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.

Age and Ageing , 2013

Background: although maintaining activity is key to successful pain management, and important to ... more Background: although maintaining activity is key to successful pain management, and important to health and wellbeing, it is known that older people in pain frequently alter or reduce activity levels. A ‘fear-avoidance’ model is often used to explain avoidance of activity in the face of pain. However, this model is not intended to take account of the wider context in which activity changes take place, nor older people's own explanations for their behaviour.

Objective: to investigate the reasons why older people in the community adjust their activity levels when living with chronic pain.

Methods: thirty-one people aged between 67 and 92 were purposively sampled from respondents to a community-based cross-sectional survey. All participants had reported long-term pain and were interviewed about this. Data were collected and analysed using a qualitative constructivist grounded theory approach.

Findings: explanations for deliberative reduction or ceasing of activities reflected a desire to prevent pain exacerbation, thereby avoiding medical intervention. It also reflected a desire to safeguard autonomy in the face of pain in older age. Restrictions were often rationalised as normal in older age, although co-existing accounts of perseverance and frustration with limitation were also evident.

Conclusions: a rational desire to avoid pain exacerbation and medical intervention motivated restrictions to activity. However, deliberative limitation of activity has the potential to compromise autonomy by increasing social isolation and de-conditioning. Supporting older people with pain to be active requires sensitivity to the function of activity restriction, especially as a means of preventing deterioration.

Family Practice, Oct 5, 2012

Background. Promotion of self-care for persistent back pain and other long-term conditions has ... more Background.
Promotion of self-care for persistent back pain and other long-term conditions has become a central component in health care policy in the UK, and general practitioners face increasing demands to support patients’ self-care efforts. Gaining insight into patients’ views may facilitate support.
Objective.
To describe patients’ experience of self-care for long-term back pain and their views on provision of support for self-care.
Methods.
Adults experiencing persistent back pain were purposively sampled from a community-based survey. In-depth qualitative interviews were audiotaped, transcribed and analysed using the constant comparative method to inductively derive a thematic account of the data.
Results.
Most of the 23 interviewees felt a responsibility to self-care. Individual capacity for self-care, however, was variable and could be inhibited by factors such as caring roles or lack of diagnosis and information. GP support for self-care was largely considered to be desirable, although the feasibility of greater provision of support was questioned. Some interviewees expressed a strong preference for alternative models of care and support.
Conclusion.
Self-care for back pain is contextualized by the individual’s capacity to self-care and preferences for support. Doubt over the ability of GPs to provide support for self-care may mean that those who have specific needs are reticent to seek help. The role of self-care in the management of back pain should be discussed openly at the consultation level, and GPs may be well placed to signpost patients and provide guidance on the safety of specific self-care activities.

Oral …, Jan 1, 2012

Incorporating user's perspectives in healthcare delivery is important. Si... more Incorporating user's perspectives in healthcare delivery is important. Simple questionnaires may not capture these as well as a discrete choice experiment (DCE) which enables the exploration of users' trade-offs between different service attributes. Qualitative methods are increasingly used to improve a DCE's face validity, but few studies adequately describe them. This paper describes the qualitative investigations in the development of a DCE questionnaire to elicit parents' perspectives on centralized services for children with cleft lip and palate. Semi-structured telephone interviews were conducted with 16 parents from across the UK, except Wales. Data analysis was carried out by the constant comparative method. Five attributes and their levels were inductively identified: usefulness and amount of information (four levels); staff attitude at cleft centres (two levels); continuity of care (two levels); personal costs of attending appointments (four levels); and cleft centres facilities (two levels). An unexpected finding was that parents' sense of responsibility towards their child made a 'willingness-to-travel' attribute unacceptable to them, but they were receptive to a 'willingness-to-pay' attribute. Using qualitative methods with service users in attribute development for a DCE helps to uncover issues that may not be apparent to researchers or health service staff.

BMC Family Practice

Background: Self-care is a key component of current policies to manage long term conditions. Alth... more Background:
Self-care is a key component of current policies to manage long term conditions. Although most people with long-term health problems care for themselves within lay networks, consultation rates for long-term undifferentiated illness remain high. Promotion of self-care in these individuals requires an understanding of their own self-care practices and needs to be understood in the context of health care pluralism. The aim was to investigate the extent and nature of self-care practices in patients experiencing long term health problems, sources of information used for self-care, and use of other forms of health care (conventional health care and complementary and alternative medicine).
Methods:
The study involved a cross-sectional community-based survey set in three general practices in South West England: two in urban areas, one in a rural area. Data were collected using a postal questionnaire sent to a random sample of 3,060 registered adult patients. Respondents were asked to indicate which of six long term health problems they were experiencing, and to complete the questionnaire in reference to a single (most bothersome) problem only.
Results:
Of the 1,347 (45% unadjusted response rate) who responded, 583 reported having one or more of the six long term health problems and 572 completed the survey questionnaire. Use of self-care was notably more prevalent than other forms of health care. Nearly all respondents reported using self-care (mean of four self-care practices each). Predictors of high self-care reported in regression analysis included the reported number of health problems, bothersomeness of the health problem and having received a diagnosis. Although GPs were the most frequently used and trusted source of information, their advice was not associated with greater use of self-care.
Conclusions:
This study reveals both the high level and wide range of self-care practices undertaken by this population. It also highlights the importance of GPs as a source of trusted information and advice. Our findings suggest that in order to increase self-care without increasing consultation rates, GPs and other health care providers may need more resources to help them to endorse appropriate self-care practices and signpost patients to trusted sources of self-care support.


Patients’ own explanatory models, including those of causation, have bearing on subsequent illnes... more Patients’ own explanatory models, including those of causation, have bearing on subsequent illness behaviour and the degree of concordance between patients’ and practitioners’ accounts can impact on treatment outcomes. The multidimensional, subjective nature of chronic pain makes research into causation particularly challenging. The objective of this study was to explore patients’ own understandings of the cause of their chronic pain. Methods: As part of a cross-sectional survey on chronic pain, free text commentaries of patients’ perceptions on cause were invited from respondents. Data from 548 adults were analysed qualitatively for recurrent themes relating to pain antecedents, and subsequently transformed into quantitative variables. Results and conclusion: This study found that people have well-conceptualised explanations for the causes of their chronic pain, and these often involved a combination of lay and biomedical constructs. Over half of all respondents gave commentaries describing more than one cause. This complexity may not be captured adequately in research, yet may have significant bearing on the management of chronic pain. Free text commentaries provide a useful tool to achieve data on complex phenomena in health research.

Rheumatic Disease Clinics of North …, Jan 1, 2008

Pain is a primary symptom in musculoskeletal conditions, and aspects of the pain experience (eg, ... more Pain is a primary symptom in musculoskeletal conditions, and aspects of the pain experience (eg, severity) are key considerations in clinical decision-making and in the outcome of trials and interventions. Consequently, appropriate assessment of pain is essential. This article reviews the measures most commonly used in rheumatology practice, arguing that many are significantly limited in their ability to reflect the complexity of the patient's experience. The authors provide examples of alternative approaches, concluding that there is real scope for improving assessment and measurement of musculoskeletal pain in the clinical setting.

Arthritis Care & …, Jan 1, 2007

Objective: To explore the pain experience of persons with chronic pain of the hip or knee in the ... more Objective:
To explore the pain experience of persons with chronic pain of the hip or knee in the context of self-assessment instruments commonly used to assess pain severity in individuals with osteoarthritis.
Methods:
Participants who reported that they currently had either hip or knee pain were recruited from the UK Somerset and Avon Survey of Health. A total of 28 participants (14 men and 14 women, ages 57-89 years) took part in 6 focus groups stratified according to pain site and severity. Using the "questerviews" technique, participants described and discussed their experience of joint pain in the context of standard self-assessment questionnaires: the Hip Disability and Osteoarthritis Outcome Score and the Knee Injury and Osteoarthritis Outcome Score. The focus groups were audio recorded and transcribed. Data were analyzed by identifying emergent codes that were grouped and compared, resulting in the identification of key categories.
Results:
Both knee pain and hip pain participants expressed similar pain experiences. Four key categories were identified, all of which impacted upon participants' responses to the standardized questionnaires: pain is intermittent and variable, pain elsewhere in the body influences the experience of joint pain, pain is inextricable from function, and adaptation and avoidance strategies modify the experience of pain.
Conclusion:
The assessment or measurement of pain should take into account the importance of pain experience as well as severity through use of patient narrative accounts.

European Journal of Pain, Jan 1, 2007

Interdisciplinary pain management programs have an established record of significantly improving ... more Interdisciplinary pain management programs have an established record of significantly improving the functioning of persons disabled with chronic pain. There is a group of pain sufferers, however, who have difficulty accessing these programs and for whom the effectiveness of these treatments in unknown, these are patients whose mobility and self-care deficits leave them unable to meet the practical demands of many treatment environments. The purpose of this study was to examine the results of a treatment program designed to meet the needs of these highly disabled individuals (n=53) in comparison to results obtained from a standard less-disabled group attending treatment at the same facility (n=234). Results from the highly disabled patients showed statistically significant change after treatment in eight of nine outcome variables, including improvements in pain-related distress, disability, depression, pain-related anxiety, daytime rest, and performance during an activity tolerance test. Effect size calculations showed a number of large treatment effects, for psychosocial disability, depression, and acceptance of pain. Analysis of reliable change and clinical significance demonstrated that results were not merely statistically significant but clinically meaningful. Results appeared stable at three months following treatment. This research plays an important part in establishing an evidence base to inform service development, ensuring that chronic pain services do not exclude people on the basis of the severity of their disability.