Francine Toye

Background: Urinary tract infections (UTIs) are common in primary care. Qualitative studies suggest that the way primary care practitioners (PCPs) manage UTIs may be influenced by a complex interplay of factors. Aim: To explore views, perceptions, and experiences of PCPs in the management of UTIs. Design and setting: Qualitative evidence synthesis of studies set in general practice. Methods: We systematically searched four databases from inception to June 28th, 2024 and performed forward citation searching of included studies. We synthesised findings using Braun and Clarke’s reflexive thematic analysis and applied the Critical Appraisal Skills Programme (CASP) to assess the quality of studies. Results: We identified 3,956 records and reviewed 190 reports in full. We included 32 qualitative studies reporting on 690 PCPs, generating the following themes: (1) I am confident, (2) …until patient X presents, (3) I am a victim of an overstretched healthcare system, (4) I must weigh up benefits and impact of antibiotic treatment, (5) It all comes down to our relationship. Using the CASP checklist, we rated the quality of research as high. Conclusion: PCPs felt confident in managing UTIs but uncertainty arose when patient X (children, males, older patients, recurrent UTIs) presented, and PCPs perceived consultations as more complex. Our analysis highlights the persistent and complex clinical challenge of assessing the risks and benefits of prescribing antibiotics. Chronic underfunding, staff shortages, and conflicting provider-patient expectations further complicated care, particularly when patients fall outside the ordinary (patient X).

Although most UK National Health Service (NHS) consultations take place in primary care, healthcare research is dominated by secondary care and higher education institutions. The Royal College of General Practitioners has called for increased academic activity by developing research capability in General Practice. However, little is known about the challenges for GPs involved in research. We aimed to explore general practitioners' (GPs) experiences of using a screening tool embedded in a research study. We recruited GPs from three practises participating in the study. An independent researcher interviewed GPs virtually. The interviews were recorded, transcribed verbatim, checked against recordings, and de-identified. We used Reflexive Thematic Analysis to develop essential themes. We developed four themes giving insight into barriers to research activity: (1) it's rare that things are black or white, (2) it's a clinical tool, not a clinician, (3) it's about balancing valuable time, (4) we don't see every patient face-to-face anymore. Quantitative research design, underpinned by positivist epistemology does not always align with primary care practice. Our findings highlight competing epistemologies that can make it challenging for GPs to complete standardised measures in a primary care setting. General practice involves a complex reasoning process grounded on interpretive knowledge. Closed questioning does not always comfortably align with a primary care setting where "a simple answer" is rare. Compatibility with primary care should be considered in all research design.

Background: Endometriosis affects approximately 10% of those assigned female at birth. Diagnostic journeys can be complex. The average 8–9 years between presenting symptoms and diagnosis has not changed significantly despite guidance. Aim: To explore primary care clinicians’ diagnostic considerations in the context of symptoms that suggest possible endometriosis. Design and setting: Qualitative semi-structured interviews with general practice clinicians working in England. Method: We report a further analysis of 56 interviews from two inter-linked datasets with GPs and primary care clinicians about supporting patients with symptoms aligned with endometriosis. Analysis was informed by sociologies of diagnosis and ambivalence. Results: Clinicians valued the importance of diagnoses to patients. Diagnoses support longitudinal care throughout episodes of intermittent specialist input, anticipating and responding to current and future health needs, and delivering evidence-based (biomedical) medicine. Diagnoses help clinicians feel more confident and comfortable, and may confer protection from medicolegal risk. Clinicians balanced these considerations against known uncertainties, including recognition that diagnosis might not change the treatment offered, may not be accessible if empirical trials of treatment relieve symptoms, and that an endometriosis diagnosis may not enable individualised advice or risk prediction. Potential advantages were balanced against diagnostic test risks and system pressures. Recognising that patient care remains with them, GPs anticipate and actively ensure ongoing relationships and care, whatever the outcome of tests. Holding these opposing role- based priorities and expectations in parallel creates tensions, which can be characterised through the concept of sociological ambivalence. Conclusion: Diagnostic considerations are complex. Educational interventions that do not recognise this may be ineffective in improving or enabling endometriosis diagnostic care journeys.

Osteoporosis is a global health concern that is likely to increase with a rapidly ageing world population. It affects one in three women and one in five men over the age of 50. Although there is a large body of qualitative research exploring the experience of living with osteoporosis, far fewer studies have focused on men. We aimed to explore the experiences of men with osteoporotic vertebral fracture. We interviewed 13 White British men aged 63 to 94 with an osteoporotic vertebral fracture. We used the six stages of reflexive thematic analysis: familiarisation with the data; coding; generating initial themes; developing and reviewing themes through discussion; refining and naming themes; writing up. We developed six themes giving insight into the existential losses of men with osteoporosis: I have felt a step change coming; I regret that I am no longer the person I once was; it is demeaning (but others are worse off than me); I need to know where I am heading; I need to understand why me; I need to feel like I am in someone’s hands. We describe moral narratives used in defence of self. Our findings highlight the challenge of deciphering the symptoms of osteoporosis and age-related changes. We also see the impact on self and a struggle to repair self. Healthcare providers are in a unique and privileged position to accompany their patients at points of existential crisis. As such, they attend to the repair of both identity and body. This comes with an ethical responsibility and has implications for clinical education. Health professionals should feel equipped to be alongside people facing existential losses. Qualitative research can give valuable insight into the phenomenology of illness and contribute to improvements in care pathways.

Summary: The Vfrac clinical screening tool was developed to help primary care healthcare practitioners decide if an older woman with back pain is at high risk of a vertebral fragility fracture (VFF) and requires a spinal radiograph to confirm diagnosis. The Vfrac tool developmental work was carried out in women because of the higher background prevalence of VFF. We now wish to assess Vfrac in men. Purpose: To understand and characterise pain symptoms of men with VFF, to evaluate the wording of the Vfrac tool from men’s perspective, and to establish if a gender-specific version of the Vfrac tool was needed. Methods: Individual interviews were conducted with 15 men using an interview topic guide based on the original Vfrac topic guide with the addition of a ‘think aloud’ section to discuss the wording of the current questions within the Vfrac tool. Thematic analysis was conducted by two researchers. Results: Seven themes highlight that physical measurements can be potentially upsetting for those being measured (‘Weighed, measured and found wanting’), that closed questions cannot capture the complexity of experience (there is no room on the paper; pain is dynamic, not static; walking can make it better or worse; well, it depends on which chair), and that gendered roles are varied and dynamic (I try to do my share of domestic work; no more do-it-yourself). Conclusions: This research has allowed the male perspective of osteoporosis to be heard and importantly identified that the Vfrac tool had no gender-specific barriers.

A recent Lancet Commission raised concerns about the management of child and adolescent pain. We aimed to undertake a comprehensive review of qualitative research to understand children and adolescent pain experiences across contexts. We used the 7 stages of meta-ethnography to synthesise findings. We combined the strengths of arts-based methods, translating themes into poems in a range of languages. We screened 7471 titles, 464 abstracts, and 302 full texts, including 189 reports (177 unique samples) incorporating 5875 young people. Age range across studies was 2 to 38 years, with 93% including those between the age of 11 and 20 years old. Studies spanned 30 years (1993-2023) with 121 (64%) published in the last 10 years. Almost all (93%) were set-in high-income countries. We report 6 themes focusing on transition to adulthood: (1) I want to stay within the safety of home; (2) don't exclude me from my own care; (3) it might hurt but it's for my own good; (4) I rely on others but I want some independence; (5) I am no longer a child but I am not an adult yet; and (6) I wasn't prepared for the transfer to adult health care. Our findings focus on the complex transition into adulthood and the importance of creating a genuine healthcare partnership with young people by acknowledging their perspectives, creating a safe and supportive environment, and preparing them for the transition to adult pain care. Arts-based methods have the potential to make findings from qualitative evidence syntheses accessible and impactful for compassionate health care.

Background: There is an intricate relationship between the mind and the body in experiences of health and wellbeing. This can result in complexity of both symptom presentation and experience. Although the contribution of life trauma to illness experience is well described, this is not always fully recognised or addressed in healthcare encounters. Negotiating effective and acceptable trauma-informed conversations can be difficult for clinicians and patients.Aim: To explore the experience of primary care practitioners caring for women through a trauma-informed care lens.Design and setting: Qualitative study in the general practice setting of England, with reflections from representatives of a group with lived experience of trauma.Method: This was a secondary thematic analysis of 46 qualitative interviews conducted online/by telephone to explore primary care practitioners’ experiences of supporting women’s health needs in general practice, alongside consultation with representatives of a lived-experience group to contextualise the findings.Results: Four themes were constructed: ‘you prioritise physical symptoms because you don’t want to miss something’; you do not want to alienate people by saying the wrong thing; the system needs to support trauma-informed care; and delivering trauma-informed care takes work that can have an impact on practitioners.Conclusion: Primary care practitioners are aware of the difficulties in discussing the interface between trauma and illness with patients, and request support and guidance in how to negotiate this supportively. Lack of support for practitioners moves the focus of trauma-informed care from a whole-systems approach towards individual clinician–patient interactions.