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Abstract
Objective Shared medical appointments (SMAs) are an innovative care delivery method that provides delivery of clinical care while also supporting self-management. Their usefulness for mental health conditions has only briefly been explored, though early evidence demonstrates their utility for supporting mental health management. Therefore, this study set out to better understand the views that adults with anxiety and depression have towards SMAs as a way of receiving care to support self-management in primary care.
Design and methods A qualitative study using 1:1 semi-structured interviews which were analysed thematically following Braun and Clarke’s six-phase reiterative process. We employed a deductive, theory-informed approach to thematically analyse the data.
Participants The final sample consisted of 17 predominantly White ethnic adults with a clinical diagnosis of anxiety and/or depression from five different regions in England. Participants represented a broad age group (22–74 years) and a range of socioeconomic backgrounds.
Results Three main themes were established: (1) motivation to attend an SMA, (2) barriers and challenges to SMA engagement and (3) implementation preferences. The concept of SMAs was largely acceptable to participants, although participants reported several factors that would influence their decision to attend an SMA. Participants held some reservations but were on the whole receptive to the idea. The main benefits reported were peer support, support for self-management and quicker access to care. Drawbacks reported included risks to patient confidentiality, negative impact on emotional well-being and the unsuitability of the group setting for some patients. Some salient preferences identified included face-to-face/hybrid delivery formatting and mental health specialist involvement.
Conclusions SMAs in primary care to support anxiety and depression self-management would be acceptable to patients, contingent on the mode of delivery of the SMAs. Future acceptability research should explore SMA appropriateness for diverse patient populations of different ethnic backgrounds, to inform their potential wider roll-out in English primary care.
- Primary Care
- Depression & mood disorders
- Anxiety disorders
Data availability statement
Data are available upon reasonable request. Selected anonymised qualitative data from the interviews can be made available upon request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
A public contributor was actively involved in refining the interview materials, ensuring they were relevant and more impactful.
The interviews were thematically analysed, facilitating the development of meaningful themes to best represent the experiences reported by the participants.
There was an under-representation of participants from Black, Asian and minority ethnic backgrounds despite people from these minoritised ethnic groups more commonly experiencing anxiety and depressive symptoms than people of White ethnicity.
Introduction
Anxiety and depression are highly prevalent debilitating mental health conditions which frequently co-occur and are approximated to affect 17% of the English population.1 2 Both conditions are recurrent in nature; most often, patients who reach remission status experience a relapse within the following 4 years.3 Symptoms can also remain persistent after an initial episode.4 5 Primary care services, who provide the initial point of contact in the healthcare system and include care such as diagnosis, treatment and prevention rather than specialised hospital-based services, are normally the first point of contact for people experiencing symptoms of anxiety and depression.6 Although the National Health Service (NHS) offers effectively proven treatment options, for example, NHS Talking Therapies7 (formely known as Improving Access to Psychological Therapies (IAPT)) referral and drug treatments prescribed by general practitioners (GPs),8–10 they characteristically focus on treating sudden/short-term or severe episodes. Excluding some patients who attend regular medication reviews, ongoing support to manage symptoms and/or self-management support in the primary care pathway for anxiety and depression is limited.
The NHS has pledged to revise current care pathways with aims of preventing avoidable admissions to their services and supporting the ongoing recovery of patients with mental health conditions.11 Improving patient support would be economically beneficial; anxiety and depression result in considerable service and societal costs that are projected to increase. Lost employment accounts for the majority of this cost as many become economically inactive due to their mental health condition.12 Modifying the current primary care pathway to incorporate more support for self-management of anxiety and depression, a key process in reducing the burden of long-term physical conditions,13 could be what is required to improve patient outcomes that are sustainable and reduce economic demand. Self-management of anxiety and depression can consist of engaging in meaningful activities (eg, a hobby which holds value to the individual), socialising and maintaining a healthy lifestyle through regular exercise and a balanced diet.14 15
Shared medical appointments (SMAs) are an innovative care delivery model that enables healthcare professionals (HCPs) to provide clinical expertise while supporting patient self-management through education and support.16 Patients are usually referred to attend a period of SMAs by their healthcare provider. In a SMA, approximately 6–10 patients with a common health condition will share an appointment with one or more HCPs (such as GPs, nurse practitioners, pharmacists and psychologists) at the same time. These 60–90 minute long appointments usually run over a 6-month period and serve as an alternative to private 1:1 consultations. If the patient wishes to continue after the 6-month period has elapsed, they are able to be referred again by their healthcare provider (eg, typically their GP in the primary care context). SMAs allow patients to receive individual consultations within a supportive shared learning environment.17 18 The sessions often involve a structured agenda, during which the HCP(s) conduct assessments, provide education, offer treatment options, address questions and concerns raised by patients, and facilitate group discussions. SMAs may also include medication adjustments16 which differ to current services/models of care, such as NHS Talking Therapies,7 which only offers psychological interventions and does not involve prescribing/reviewing medications. Therefore, bringing different HCPs together in sessions could offer more holistic care for patients.
Currently, evaluative research on SMAs has focused on their use in long-term physical condition management, such as diabetes, and has identified several patient-related and service-related benefits.16 19–24 These include improved resource efficiency, opportunity for peer support and improvements to self-efficacy which may boost self-care and augment patients’ motivation to engage in self-management practices.20 21 Although there are few evaluations of mental health-specific SMA programmes, a single US-based study has demonstrated their potential to improve symptom outcomes for generalised anxiety disorder.25 While these findings are promising, it is important to understand that successful implementation and potential wider roll-out largely depend on acceptance of the intervention by patients.26 Without adequate patient engagement, there would be an absence of beneficial outcomes and implementation could be a waste of resource and expense.
In Canada, patients have been receptive to the potential replacement of individual care with SMAs for the purpose of supporting their mental health.27 However, recruitment and retention have been low in SMAs for this population,25 which could translate into low acceptability and adherence if rolled out in the English primary care context.
To date, the acceptability and feasibility of SMAs to support the self-management of anxiety and depression, in England, have received no empirical investigation. It is imperative to explore whether potential service users would consider them a useful way to receive care, to support their self-management, and be willing to attend the sessions. Subsequently, if SMAs were considered acceptable, it would be useful to better understand the mode of delivery and qualities of SMAs that patients would find most helpful. This qualitative investigation explored service users’ views of SMAs for self-management of anxiety and depression in primary care.
Method
Approach
A pragmatic approach was taken to tackle the research question, opting for a qualitative approach that involved the utilisation of 1:1 semi-structured interviews.
Participant recruitment
Using purposive sampling, participants residing in England with anxiety and/or depression were recruited from various sources: charitable organisations based in the Northeast and Northwest of England, VOICE (an online participation platform that connects researchers and the public who want to partake in health research) and social media channels (ie, Facebook, Twitter, Instagram and LinkedIn) (online supplemental material 1). Participants had to contact the researcher via email to take part. Inclusion criteria included a self-reported clinical diagnosis of anxiety and/or depression for longer than 2 weeks so that participants would have had time to process their diagnosis before being invited to take part in research. Participants were also required to be over the age of 18 and living in England. Exclusion criteria included individuals without the capacity to consent (eg, those with dementia or significant learning difficulties). Upon successful completion of the study (ie, the semi-structured interview), participants were eligible to enter a prize draw to win two £50 electronic Amazon vouchers.
Supplemental material
Data collection
An interview guide was developed to explore participant views on the use of SMAs for anxiety and depression, specifically previous care experiences, acceptability of SMAs (ie, their views on them) and preferences/expectations for implementation procedures. All participants provided informed consent prior to completing a demographic-based pre-interview questionnaire and agreeing a mutually accepted interview time. A vignette describing an SMA (figure 1) was provided to participants prior to their interview describing a typical session so the participants understood how an SMA would run. Interviews were conducted remotely via the Zoom teleconference platform (an alternative method to Zoom, ie, a phone call, was offered but none of the participants chose this option). Data were analysed alongside data collection, and when new data repeated what was expressed in previous data (ie, no new patterns and codes emerged), this was considered as achieving data saturation and recruitment was stopped.28
SMA vignette characterising a typical shared medical appointment.
Patient and public involvement
The interview topic guide (online supplemental material 2) and vignette were first co-developed by the research team based on their previous work on SMAs,19 21 29 and were then refined with a public representative, who had a clinical diagnosis of anxiety and depression, to ensure the terms used were meaningful and the questions elicited meaningful responses with the aims of the study in mind.
Supplemental material
Data analysis
Interviews were audio-recorded, transcribed verbatim and then anonymised. Data were analysed by MH using reflexive thematic analysis (RTA) following the six-phase reiterative process as outlined by Braun and Clark.30 This involved familiarising oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. RTA was deemed most appropriate over alternative analytical strategies, as this method allows for the analysis of substantial amounts of data to be synthesised into a meaningful account and the identification of key themes across a data set.31 This was important to identify commonalities between participant views.
Exploration was approached from a pragmatist epistemology perspective and data were coded following a hybrid approach of semantic level coding as outlined by Swain.32 This method guided our analysis, ensuring comparability with other acceptability research21 while also allowing us to uncover of new insights, particularly given that there is a dearth of research focused on a mental health population. First, a top-down, deductive, theory-derived process was performed. The systematic review of barriers and facilitators to implementing SMAs for managing long-term physical health conditions in primary care by Graham et al21 was considered appropriate to collect the pre-existing codes. Then, new codes were generated using a bottom-up, inductive, data-driven process due to the paucity of research within this area and to capture participants’ views. Both descriptive (eg, ‘receives regular care’) and interpretive codes (eg, ‘overcoming feelings of isolation’) were collected and generated during this process. Codes were grouped and transformed into broad themes, which were later assessed and sometimes collapsed to make a superordinate theme. Themes were then checked against the data to ensure they represented participants’ views and that there were sufficient data to support their existence. Consequentially, some themes were removed. After an intense recursive process, a final list consisted of three overarching themes and corresponding subthemes. Participant quotes were edited for clarity, to remove utterances or repetition.
Researcher characteristics and reflexivity
Two researchers on this study (FG and MYT) co-authored the review used to derive deductive codes.21 However, one researcher (MH), who was a postgraduate student, conducted all the interviews alone and data analysis with input from the research team. The researcher (MH) was of the same ethnicity and sex as most of the participants (ie, White and female) which could have encouraged participant disclosure due to shared demographic characteristics. However, the researcher was not part of the target population and does not hold lived experience of anxiety or depression, or any other mental health condition. This could perhaps be beneficial, as with no personal dissatisfaction towards current provision and neither a prospect of attending a SMA for mental health purposes, the researcher could remain both impartial and objective. Conversely, limited relatability leaves room for error in interpretation and increases potential for misunderstanding in data analysis. This risk was mitigated using follow-up questions where clarity was needed to ensure full understanding of each participant’s experience.
Results
In total, 17 interviews (lasting 20–58 min) were conducted via Zoom between May 2022 and June 2022. The final sample included 13 women and 4 men, with an age range of 22–74 years (see table 1). Most participants were of White ethnicity and resided in England, based in five different geographical regions (Northeast, East Midlands, Southwest, Southeast and Southern England). Participants represented a range of socioeconomic backgrounds (determined by home postcode), residing in areas of the lowest and higher levels of multiple deprivation (1–10, in accordance with the index of multiple deprivation).33 Regarding clinical diagnoses, a majority possessed a comorbid diagnosis of anxiety and depression. A full summary of participant characteristics can be found in table 1.
Participant characteristics
Three core themes were identified that captured the similar and contrasting views of SMAs expressed by participants: (1) motivation to attend an SMA, (2) barriers and challenges to SMA engagement and (3) implementation preferences. The overarching themes and associated subthemes are illustrated in online supplemental material 3. The data largely aligned with the subthemes and codes identified in the review21 (eg, patient suitability, peer support, self-management support, vicarious learning), additional data related to mental health emerged as novel.
Supplemental material
Theme 1: motivation to attend a shared medical appointment
Initial attitudes to shared medical appointments
All participants expressed a desire or were at least willing to attend an SMA for their mental health condition. Many agreed that SMAs should be an option in primary care for anxiety and depression, indicating that it would be beneficial for those with a mental health condition:
It should be an option for everybody—DEP, P16
I like the idea, I think especially in the context of mental health, when people come together it really does help you…that coming together, you know, can be therapeutic—ANX/DEP, P9
However, it was reported that mental ill-health may be an uncomfortable topic for some patients as they may feel ashamed or it could be triggering for them to speak about in front of others, which could compromise acceptability:
…the initial reaction…with something like mental health disorders, is that people aren’t always as open or comfortable talking about them in a group—ANX/DEP, P5
Further, there were reservations about having a 1:1 consultation in front of the group, with concerns that this encounter would be ‘quite unsettling’ and may feel ‘voyeuristic’, implying a negative feeling of exposure during this overt consultation. Despite the vignette describing what the session would involve, initial reservations eased once the interviewer clarified that the 1:1 consultation would comprise of general assessment information (eg, asking about their experience with their medication or discussing therapeutic options). Perhaps the vignette (figure 1) was not clear enough in describing the depth of what the HCP would ask patients in front of the group.
Supports self-management
SMAs could provide a means of regular care for patients, to support the management of their condition and help avoid relapse. Participants anticipated that SMAs would be an opportunity to gain skills such as stress management or relaxation techniques, confidence and knowledge, vicariously and directly from other group members:
…hearing about others’ experiences is so helpful…because you learn—ANX/DEP, P9
Sharing toolkits is always very, very useful—ANX/DEP, P5
This would support patients’ self-management as they learn to manage their symptoms and optimise their well-being by adopting different methods of self-care:
…depression and anxiety affect different people at different ways, and I think for me just learning off them, learning how they deal with it, how they cope…what their triggers are…and just seeing if this stuff in their lives [is something] that I can put in mine. Also, the other way around, if there’s anything in my experience that I can share, can help other people—DEP, P15
Participants were asked to share which aspects of their condition they found most difficult or would like more support with, and whether they felt this was something that could be feasibly addressed within an SMA. In response, most anticipated that SMAs could support their self-management by educating patients on approaches to self-care, for example, alternative coping strategies, managing panic attacks and other symptoms, while others did not mention self-management as a benefit.
Peer support
SMAs were described as a ‘safe space’ in which patients could share, feel understood and supported, and experience a sense of belonging. Some participants described living with a mental health condition as an isolating experience and SMAs were thought as an opportunity to reduce these feelings and normalise their experiences. Conversely, one participant was concerned that being among peers who they did not identify with could perhaps exacerbate feelings of isolation:
…on the other hand, it could be even more isolating for some people…you’ve got a group of people who do seem to share characteristics or experience and you don’t feel like you share those experiences, that can actually, on the other hand, can be really isolating—ANX/DEP, P17
Improving access and quality of care
An inquiry into the context of participants’ usual care evoked both positive and negative commentary of their care experiences. Most participants reported inadequate service provision, including long waiting lists, short appointment times and overreliance on drug treatments:
I think the main issue has been the waiting lists…you get extremely unwell waiting to see people…when you’re already at a position where you’re quite unwell—ANX/DEP, P13
… for me, it all comes down to access…that’s my biggest issue with everything related to mental health, is access—ANX/DEP, P3
[they] just throw drugs at you—ANX/DEP, P4
Few participants received regular care for their mental health condition but, when they did, they spoke about their care experiences in a positive way. Thus, participants expressed a need for better care to support their recovery and most emphasised the importance of regularity.
Not only did participants foresee personal gain, but they also anticipated that SMAs could benefit HCPs who are often ‘busy’ and ‘extremely overworked’ by reducing clinician burnout and therefore improving the quality of care provided to each patient:
…thinking about it, when you see clinicians who are extremely overworked…you don’t always get the kind of care and compassion that they want to give you or that you need…so potentially, this could also…reduce clinician burnout and give you a better experience of going to your GP in times when you have potentially been put off by their response—ANX/DEP, P13
Theme 2: barriers and challenges to shared medical appointment engagement
Confidentiality concerns
Participants were concerned that SMAs would pose risks to their confidentiality, for example, group members breaking confidentiality and recognising group members in public. This was particularly the case for participants who lived and attended healthcare practices in smaller communities:
I live in quite a small city, so I have attended group therapy sessions before and bumped into people that I knew through various chains. So, that would be a concern. I wouldn’t want to share anything particularly personal and then I would worry that I wouldn’t ask for the services that I necessarily need—ANX/DEP, P13
Emotional influence
Three emotional concerns were described that could impact engagement: emotional triggers, negative effects of empathy and the influence of emotional states. The possibility of being emotionally triggered (ie, a response of intense negative emotion) by patients openly discussing sensitive topics/sharing anecdotes is more likely among a group of patients with mental health conditions. Further, witnessing group members in a triggered state could be detrimental to others who are empathising strongly with them.
One participant reported that “depression…pulls you massively into yourself”, suggesting social avoidance. The consensus was that engagement relied upon a patient’s emotional state on the day of the session; thus, engagement may be unpredictable and vary from session to session. For example, one participant anticipated that her engagement would reduce when feeling low, whereas another reported that when she is feeling in a more positive mental state her engagement would reduce:
…it would all depend on my mood on the day. So, if I’m in a bad place I’m not very talkative. If I’m in a good place I’m very talkative—ANX/DEP, P3
…if I was having a good day and then going to an appointment, I’d have nothing to talk about…I don’t even know why I’m here, like I’m fine, and then so doing the shared medical appointment…if I’m having a good day I might sit and think, like I don’t need to be here—ANX/DEP, P2
Perceived patient suitability
SMAs were not considered to be suitable for all stages of the recovery process. The consensus was that those who were recently diagnosed would not be suitable attendees as they would have limited experience to share regarding the management of their condition, or they would be in a vulnerable mindset and the group discussions could trigger some overwhelming emotions:
I think it probably could be a little bit off-putting if your… anxiety and your depression… levels are quite high. You know, and…[you’re] just at the start of your recovery journey. That might be quite challenging for people—ANX, P12
Some also expressed concerns regarding patient well-being, suggesting that some patients may be disadvantaged if they were less comfortable among a group as they may not share their difficulties and remain unnoticed at a time of vulnerability:
…if it’s in front of the group, people might, you know, shut down…and then you’d risk not knowing what was going on with them…it might end up missing an opportunity to monitor somebody who needed to be monitored—ANX/DEP, P5
Thus, continuing to have an option of regular 1:1 consultation with a HCP would be valued, as reported by many.
Theme 3: implementation preferences
Delivery format
Face-to-face sessions were most preferred, primarily because they were considered more intimate and personal, which could help build an emotional connection with other group members. Participants reported several benefits of remote sessions, including increased accessibility for users who do not leave their homes, feeling comfortable in one’s own surroundings, an easier opportunity to step back/switch off if the situation becomes overwhelming, and convenience. However, many concerns also arose including limited internet connection, reduced engagement caused by more distractions, limited access to private spaces, digital exclusion and increased risk of confidentiality breaches. Despite these limitations, many expressed a desire to have flexibility regarding which delivery format to attend by. One participant recommended hybrid delivery due to the unpredictability of her additional long-term physical condition, which would allow patients the opportunity to decide which mode to attend by on the day of the appointment. As a result, the remaining participants were asked their opinion of a hybrid method; most were positive about this possibility.
Attending healthcare professionals
Most participants desired a mental health practitioner to either lead or assist the SMA. The type of practitioner varied (eg, psychologists, mental health nurse, counsellors), but regardless a professional with mental health experience was both expected and preferred. Several participants reported that GPs lacked the experience and understanding for mental health-related care, mentioning that “GPs aren’t experts in mental health”, and therefore, other HCPs would be more useful. Some expressed that SMAs could be a positive ‘learning experience’ for GPs. It was implied that if a GP were involved, it would be a useful experience for them to expand their knowledge and gain an appreciation of patients’ lived experiences. These views were expressed by those who either had negative perceptions/experiences with GPs in relation to their mental health or were not in touch with their GPs on a regular basis for their mental health specifically. Some felt as though their GP did not take their mental health concerns seriously or were insensitive towards their problems, for example:
…when I was heading towards a complete breakdown… I phoned up my GP on my way to work cause I had a panic attack and said to them I really need some help, and I basically got asked, “well what do you want us to do about it?”… I had another GP when I had my breakdown…I’d said that I had stepped down from a managerial position… to kind of relieve the pressure and the stress that I was getting and then he started lecturing me on “well you’ve got a family to provide for, how, how do you expect to do that?”. Which was exactly what was going on through my head anyway, but he’s now like vocalising it and it’s like well I don’t really need to hear this right now…I don’t think he realised how damaging what he said was.—ANX/DEP, P1
f you go to your GP and they haven’t experienced it themselves like it can be very hard to not feel like they’re just judging you.—ANX/DEP, P2
However, GPs being considered as redundant in this context was not the consensus among all; some expressed both an expectation and preference for a GP to either run the session, review their medication and/or attend to keep informed about the current state of their recovery. One participant reported that their GP would be a ‘friendly face’; however, only few mentioned the importance of continuity of care, perhaps because the participant majority was not receiving regular GP check-ups.
Group characteristics
Most anticipated that “having a diverse group would be quite beneficial” and were willing to share the appointment with various demographics. For those that reported preferences, this mainly consisted of group members being at a similar stage as them, either within their recovery or life stages (eg, age), as general milestones you reach at certain stages could be a beneficial similarity which could enhance relatability, and thus engagement.
There was no consensus for a preferable group size; the full range was between 3 and 12. Some participants preferred a larger group to allow them the opportunity to listen while not feeling obligated to share and to gain more ‘breadth of experience’. Others preferred a smaller group to shorten appointment times, reduce risks of confidentiality breaches and allow enough time for all to share.
Discussion
Participant responses indicated that SMAs to support self-management of anxiety and depression in primary care seemed acceptable to them overall. However, acceptability appeared to be multifaceted and nuanced as several factors influencing attendance and engagement emerged. The opportunity to receive self-management support, peer support and better care were all perceived to facilitate attendance. Perceived barriers to engagement included confidentiality risks, emotional influence and perceived patient suitability. Feasibility was assessed by participant acceptability; however, perceived barriers provide some insight into whether SMAs would be feasible for patients with anxiety and depression. Further, an exploration into implementation procedures (ie, session characteristics and delivery formats) revealed a few salient preferences. Face-to-face or hybrid delivery was most frequently preferred, and all desired involvement from a mental health practitioner; however, their preferred/expected role varied; the remaining preferences were heterogenous.
Participants were unanimous in their willingness to attend an SMA for their mental health indicates high acceptability. This is in line with broader literature that has implicitly suggested acceptability of SMAs with similar populations in other western countries.25 27 The present study goes on to extend these broader findings by exploring acceptability on a narrower scope, directly from potential service users, and is the first study to our knowledge to provide a novel investigation that explores the acceptability of SMAs for anxiety and depression explicitly within England.
The benefits of SMAs that were anticipated to facilitate attendance echo that of those found in the wider literature.20 21 We also found that participants expected SMAs would provide higher quality comprehensive care due to longer appointment times. Further, participants considered SMAs a solution to clinician burnout by improving care delivery efficiency which would ultimately improve care quality. However, if patients were to attend SMAs in addition to regular consultations rather than in place of, this may inadvertently increase workload. So, although an interesting outlook, this is an assumption that warrants further exploration from a HCP perspective.
It must be noted that acceptability was based on a hypothetical discussion of SMAs and opinions were not based on direct SMA experience, and barriers remain for some people. Some of the barriers regarding confidentiality risks and patient suitability have previously been identified as potential drawbacks of this approach.21 Though, unlike previous studies, SMAs were considered as potentially harmful. Participants expressed that listening to personal anecdotes involving sensitive topics may elicit intense negative emotions from onlooking group members. Thus, emotional influence has major implications for SMA feasibility, questioning whether patients with anxiety and/or depression would be suited to attend. While past research has demonstrated success in SMAs for participants with anxiety,25 as the first to unravel this assumption from the perspective of potential service users, more research is required to determine potential impact upon patients with anxiety and depression.
Some salient preferences were identified that may warrant consideration from future intervention designersists to increase the acceptability of SMAs. First, it is likely that employing a hybrid approach, using synchronous in-person and remote contact, may improve acceptability. This preference perhaps frequently emerged because mental health conditions can be unpredictable, and emotions can fluctuate;34 hence, employing such a flexible approach that could allow patients to choose which delivery mode to attend by may be beneficial for the target population. Further, participants frequently preferred to have a mental health practitioner in attendance rather than a GP due to their specialised knowledge and because ‘GPs aren’t experts in mental health’. However, it was not considered who would prescribe and discuss medications, and in primary care that would typically be a GP. Thus, the misappreciation of the SMA lead’s role may have contributed to this preference. Nevertheless, participants in this sample would deem a SMA more acceptable if a mental health practitioner were in attendance.
Limitations and directions for future research
When interpreting the results of this study, a few limitations warrant acknowledgement. First, reflecting on the approach taken to provide participants with an understanding of SMAs, solely providing a vignette prior to the interview did not have the intended effect that is, providing full understanding; SMAs were frequently referred to as group therapy by participants. This model of care is still being developed and adapted for different long-term conditions, so the exact nature and content of the session are being refined, and the service user perspective collected in this study could help inform this process. However, when exploring patient acceptability in the future, researchers and commissioners should clarify how this model differs to existing care (eg, NHS Talking Therapies7) and explore whether there is preference to them being used as an alternative or additional to 1:1 appointment in GP practice or other health settings. Further suggestions include involving more Patient and Public Involvement (PPI) contributors in developing the vignette to ensure readability to different audiences, or working with an artist to create a visual summary outlining what SMAs are and what they involve.
Second, due to the ongoing COVID-19 pandemic at the time, interviews were conducted online, and recruitment depended solely on internet platforms, excluding those lacking digital connectivity or usage opportunities.35 This can result in selection bias as some demographic groups may be under-represented due to limited internet access or lower usage. A recent UK-based survey revealed that digital exclusion was more prevalent among those with mental health conditions and has been identified as an exacerbator of mental ill-health.36 Therefore, excluding those who are not well versed or without access to digital equipment may have instilled bias in the sample, omitting important representatives of the target population. To ensure all kinds of service users can contribute their views to potential future revisions of care pathways, it may be appropriate for future research to explore acceptability in an alternative way (eg, paper-based surveys deployed in healthcare practices), which will allow those digitally excluded to share their views on this model. Also, session characteristics can be informed by existing mental health services, for example, remote group-based interventions are currently offered for anxiety and depression by NHS Talking Therapies7 suggesting that remote delivery is suitable for patients from this population in a group context.
A final limitation regards our sample. It is possible that there was a risk of selection bias, whereby participants who took part in the present study were more likely to have less severe levels of anxiety/depression to allow for participation. Further, 94.1% of respondents were White British. According to recent English statistics, those from Black, Asian and minority ethnic (BAME) backgrounds more commonly experience anxiety and depression than White ethnic patients,37 yet these ethnic groups were not present in this sample. Thus, the views identified may not be generalisable to the wider population. Further, researchers have suggested that SMA acceptability to patients from BAME backgrounds might be expected to be different to that of White ethnic patients.20 There may be beliefs embedded within certain BAME cultures (eg, stigmatising beliefs towards mental ill-health) that could discourage acceptability to SMAs on account of desires to conceal mental ill-health38 and practical issues such as language barriers. As such, future research must explore SMA acceptability to patients from BAME backgrounds before considering wider roll-out. Engaging with underserved groups is a challenge for researchers and a lack of representation is a wider bias in research, and this needs to be considered during initial recruitment.39 Approaches should be designed to encourage participation from underserved groups (eg, connecting with local community groups and leaders who have established trust within underserved communities). Including additional PPI contributors from minoritised ethnic backgrounds in various stages of the research process would also be beneficial. Their involvement can help engage diverse recruitment channels and aid in the development of materials that are culturally sensitive and accessible.
Conclusion
The present findings may offer clinical implications for the implementation of SMAs for the purpose of supporting self-management of anxiety and depression in primary care. It can be interpreted that, if implemented, SMAs could be welcomed by patients but with some reservations that must be acknowledged including concerns for confidentiality and emotional well-being. Policymakers have pledged to trial new models of care to improve current care pathways for mental health conditions, with intentions to prevent avoidable admissions and support patients’ ongoing recovery.11 Owing to the present findings, SMAs can be considered a potentially acceptable care delivery model deserving of consideration. Future research should therefore begin to explore the perspectives of SMAs from marginalised groups and HCPs to create a comprehensive understanding of their viability and challenges.
Data availability statement
Data are available upon reasonable request. Selected anonymised qualitative data from the interviews can be made available upon request.
Ethics statements
Patient consent for publication
Ethics approval
This study involved human participants and was approved by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University’s Research Ethics Committee, on 11/05/2022 (Reference: 2304/20231). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would like to thank all interviewees who took part in the study, for sharing their views and personal experiences. This research was conducted as part of MH’s MSc dissertation. Participants were compensated for their involvement with Amazon vouchers provided by the School of Psychology, Newcastle University. FG’s contributions to the research supervisory team and the publication of this paper were supported by the NIHR Policy Research Unit in Behavioural Science at Newcastle University.
References
Footnotes
Contributors MYT and FG designed the study. MH obtained ethical approval, recruited participants, conducted interviews and undertook the data analysis. MH wrote the first draft of this paper. MYT and FG commented on the draft manuscripts and contributed to the final version of the paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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