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One year after the first COVID lockdown the backlog at the Magistrates’ and Crown Courts together totalled approximately half a million cases. This article reports on the impact of court delays on domestic abuse victims using data from the ESRC-funded ‘Shadow Pandemic’ project. Using this data as illustrative, the paper goes on to discuss the causes of delays in all criminal cases, challenging the assertion that COVID caused the backlog. Instead, the paper contends that austerity measures have been the underlying cause with COVID merely extending the scale of the crisis. The paper then questions whether post-COVID recovery plans are realistic, particularly in relation to any increase in remote hearings and out of court disposals. It concludes that a more fundamental shift needs to take place in dealing with criminal cases to enable speedier and more effective access to justice for victims of all crimes including domestic abuse.

Purpose The purpose of this paper is to reflect upon the challenges posed for the ongoing implementation of multi-agency risk assessment conferences (MARACs) for police forces in England and Wales during the 2020 pandemic. Design/methodology/approach This is rapid response research involving qualitative methods primarily online semi-structured interviewing with a sample of police domestic abuse leads in England and Wales. Findings The findings point to increased use of virtual platforms particularly for MARACs and that this has beneficial consequences both for the police and in their view also for victim-survivors. Research limitations/implications The findings reported here are from policing domestic abuse leads. More work needs to be done to explore the value of engaging in virtual MARACs for all the agencies concerned but also whether MARACs continue to be the best way to ensure the victim-survivor is kept in view. Practical implications The use of virtual platforms carries a range of practice implications for the future of MARACs for the foreseeable future. These range from ensuring attendance of the appropriate agencies to the range and frequency of meetings, to infrastructural support for all agencies to engage. Originality/value This is an original study funded by the Economic and Social Research Council examining police and court responses to domestic abuse during the covid-19 pandemic.

Covid-19 and the associated public health response directing people to stay at home and/or shelter in place generated acute awareness of, and concerns about, the likely impact on violence(s) agains...

Objective Our aim was to understand whether, why and how patients choose to modify their diets after developing gout. Methods We conducted an inductive thematic secondary analysis of qualitative data from 43 interviews and four focus groups with UK participants with gout (n = 61). Results Participants commonly initiated dietary changes as part of a self-management strategy for gout. Reasons for making such dietary changes included: desperation; a desire for control; and belief that it would be possible to achieve successful management through diet alone; but not weight loss. Participants who did not make changes or who reverted to previous dietary patterns did so because: they believed urate-lowering therapy was successfully managing their gout; medication allowed normal eating; they did not find ‘proof’ that diet would be an effective treatment; or the dietary advice they found was unrealistic, unmanageable or irrelevant. Dietary modification was patient led, but patients would have preferred the support of a health-care professional. Beliefs that diet could potentially explain and modify the timing of flares gave patients a sense of control over the condition. However, the belief that gout could be controlled through dietary modification appeared to be a barrier to acceptance of management with urate-lowering therapy. Conclusions Perceptions about gout and diet play a large role in the way patients make decisions about how to manage gout in their everyday lives. Addressing the reasons why patients explore dietary solutions, promoting the value of urate-lowering therapy and weight loss and drawing on strong evidence to communicate clearly will be crucial in improving long-term clinical management and patient experience.

Resume Objectifs Determiner la prevalence de l’anxiete et de la depression dans le contexte de la goutte, examiner les liens entre certaines caracteristiques de la goutte et ces comorbidites et identifier le role de l’allopurinol dans ces relations. Methodes Dans le cadre d’une etude de cohorte prospective, un questionnaire initial a ete envoye a 1805 participants goutteux âges de 18 ans et plus et patients de cabinets de soins primaires britanniques. Ont ete retenus les patients dont le dossier medical faisant mention d’un diagnostic de goutte ou de prescriptions d’allopurinol ou de colchicine deux ans avant le debut de l’etude. La prevalence de l’anxiete a ete definie au moyen du questionnaire sur le trouble d’anxiete generalisee (TAG) et celle de la depression, par l’auto-questionnaire Patient Health Questionnaire (PHQ). Une analyse par regression logistique a ete realisee pour explorer les eventuelles associations entre les caracteristiques de la goutte (frequence des crises sur 12 mois, goutte oligo/polyarticulaire et duree de la maladie) et l’anxiete ou la depression. Les associations brutes et apres ajustement ont ete exprimees en odds ratio (OR) et intervalle de confiance (IC) 95 %. Les caracteristiques de la goutte ajustees ont ete stratifiees en fonction de la prise d’allopurinol. Resultats Au total, 1184 participants (65,6 %) ont repondu au questionnaire initial. La prevalence de l’anxiete et de la depression etait respectivement de 10,0 % et de 12,6 %. Aucune association n’a ete observee entre les caracteristiques de la goutte et l’anxiete. Toutefois, la frequence des crises et la depression ont ete associees chez les patients goutteux sous allopurinol (OR 2,87 [IC 95 % 1,2 a 6,6]) et un lien a egalement ete releve entre la goutte oligo/polyarticulaire et la depression (2,01 [1,3][1,2 a 3,3]), aussi bien chez les patients sous allopurinol (2,09 [1,1 a 4,0]) que chez ceux n’en prenant pas (2,64 [1,8][1,0 a 6,8]). Conclusion Les patients souffrant de crises de goutte frequentes ou touchant plusieurs articulations sont susceptibles de presenter des symptomes depressifs meme lorsqu’ils prennent de l’allopurinol. La depression peut influencer l’observance du traitement et la participation aux examens de routine, ce qui se repercute negativement sur les resultats de la prise en charge de la goutte.

This short report aims to give some insight into current publication patterns for high quality qualitative health research, using the Research Excellence Framework (REF) 2014 database. We explored patterns of publication by range and type of journal, by date and by methodological focus. We also looked at variations between the publications submitted to different Units of Assessment (UoAs), focusing particularly on the one most closely aligned with our own research area of Primary Care. Our brief analysis demonstrates that general medical/health journals with high impact factors are the dominant routes of publication, but there is variation according to the methodological approach adopted by articles. The number of qualitative health articles submitted to REF 2014 overall was small, and even more so for articles based on mixed methods research, qualitative methodology, or reviews/syntheses that included qualitative articles. Keywords: qualitative research; Research Excellence Framework (REF); publishing

Objectives To determine the prevalence of anxiety and depression in gout, examine associations between gout characteristics and these comorbidities and determine the role of allopurinol in any such relationships. Method As part of a prospective cohort study, a baseline questionnaire was sent to 1805 participants with gout aged ≥ 18 years from UK primary care. Participants had a gout diagnosis or prescriptions for allopurinol or colchicine in their medical records 2 years prior to baseline. Prevalence of anxiety was defined using the Generalised Anxiety Disorder questionnaire and depression using the Patient Health Questionnaire. Logistic regression was used to examine any association between gout characteristics (12-month attack frequency, oligo/polyarticular gout and gout duration) and the presence of anxiety or depression. Crude and adjusted associations were reported as odds ratios (OR) and 95% confidence intervals (CI). Adjusted gout characteristics were stratified by allopurinol use. Results One thousand one hundred and eighty-four participants responded to baseline (65.6%). Prevalence of anxiety and depression were 10.0% and 12.6% respectively. There was no association between gout characteristics and anxiety. However, there was an association between attack frequency and depression amongst those gout patients using allopurinol (2.87 [1.2 to 6.6]) and also between oligo/polyarticular gout and depression (2.01 [1.2 to 3.3]), irrespective of allopurinol use (2.09 [1.1 to 4.0]) or not (2.64 [1.0 to 6.8]). Conclusion Patients experiencing frequent gout attacks or attacks in multiple joints are likely to experience depressive symptoms, even when using allopurinol. Depression may influence medication adherence and participation in routine reviews, hence impacting adversely on gout management outcomes.

In March 2020, the UK Research and Innovation announced an emergency call for research to inform policy and practice responses to the COVID-19 pandemic. This call implicitly and explicitly required researchers to work rapidly, remotely and responsively. In this article, we briefly review how rapid response methods developed in health research can be used in other social science fields. After outlining the literature in this area, we use the early stages of our applied research into criminal justice responses to domestic abuse during COVID-19 as a case study to illustrate some of the practical challenges we faced in responding to this rapid funding call. We review our use of and experience with remote research methods and describe how we used and adapted these methods in our research, from data gathering through to transcription and analysis. We reflect on our experiences to date of what it means to be responsive in fast-changing research situations. Finally, we make some practical recommendations for conducting applied research in a ‘nimble’ way to meet the demands of working rapidly, remotely, responsively and, most importantly, responsibly.

Objective: To examine how older people can best be helped to live well with musculoskeletal pain. Methods: A mixed-methods study integrating quantitative analysis of a longitudinal cohort survey with 60 semi-structured interviews. Results: Comparison of “expected” to “reported” interference suggested that social activity, physical activity, and “involvement” were important for participants who reported minimal interference from their pain. Discussion: For many older people with chronic pain, activity and involvement may not simply be outcomes of living with minimal interference from pain, but factors that contribute to this outcome and give meaning to their lives.

BackgroundPolymyalgia rheumatica (PMR) is one of the most common inflammatory arthritic disorders seen in older individuals. Most patients with PMR are diagnosed and managed exclusively in general practice, yet primary care-focused research is lacking.AimTo identify and explore the challenges of diagnosis and management of PMR in general practice.Design and settingA multi-methods study in UK primary care.MethodThe multi-methods study comprised two complementary studies: a national questionnaire survey of 5000 randomly selected GPs from across the UK; and a qualitative semi-structured telephone interview study of UK GPs. Simple descriptive statistics were used to analyse questionnaire data. A thematic approach was used to analyse verbatim transcripts of the GP interviews.ResultsIn total, 1249 (25%) GPs responded to the questionnaire survey. From this total, 24 GPs were interviewed for the qualitative study. Features used by GPs to identify PMR were largely in line with current guidance. Diagnosis was found to be challenging, with GPs relying heavily on response to treatment with glucocorticoids. Investigations advised by current British PMR guidance to attempt to rule out other causes for symptoms were not routinely requested. Concerns surrounding ongoing treatment with glucocorticoids were widespread in relation to both potential adverse effects and ongoing monitoring.ConclusionFocused strategies to investigate and therefore exclude non-PMR differential diagnoses are required for patients with new-onset suspected PMR symptoms. Additionally, ongoing active review for alternative causes for symptoms as well as vigilance for treatment complications needs to be implemented.

Objectives: To examine gout-related, comorbid, and sociodemographic characteristics associated with generic and disease-specific health-related quality of life (HRQOL) in gout. \ud \ud Methods: Adults with gout from 20 general practices were mailed a questionnaire containing the Health Assessment Questionnaire-Disability Index (HAQ-DI), Short-Form-36 Physical Function subscale (PF-10), Gout Impact Scale (GIS), and questions about gout-specific, comorbid and sociodemographic characteristics. Variables associated with HRQOL were examined using multivariable linear regression models. \ud \ud Results: A total of 1184 completed questionnaires were received (response 65.9%). Worse generic and gout-specific HRQOL was associated with frequent gout attacks (>= 5 attacks PF-10 beta = -4.90, HAQ-DI beta = 0.14, GIS subscales beta = 8.94, 33.26), current attack (HAQ-DI beta = 0.15, GIS beta = -1.94, 18.89), oligo/polyarticular attacks (HAQ-DI beta = 0.11, GIS beta = 0.78, 7.86), body pain (PF-10 beta = -10.68, HAQ-DI beta = 0.29, GIS beta = 2.61, 11.89), anxiety (PF-10 beta = -1.81, HAQ-DI beta = 0.06, GIS beta = 0.38, 1.70), depression (PF-10 beta = -1.98, HAQ-DI beta = 0.06, GIS 0.42, 1.47) and alcohol non-consumption (PF-10 beta = -16.10, HAQ-DI beta = 0.45). Gout-specific HRQOL was better in Caucasians than non-Caucasians (GIS beta = -13.05, -13.48). Poorer generic HRQOL was associated with diabetes mellitus (PF-10 beta = -4.33, HAQ-DI beta = 0.14), stroke (PF-10 beta = -12.21, HAQ-DI beta = 0.37), renal failure (PF-10 beta = -9.43, HAQ-DI beta = 0.21), myocardial infarction (HAQ-DI beta = 0.17), female gender (PF-10 beta = -17.26, HAQ-DI beta = 0.43), deprivation (PF-10 beta = 7.80, HAQ-DI beta = 0.19), and body mass index >= 35 kg/m(2) (PF-10 beta = -6.10, HAQ-DI beta = 0.21). \ud \ud Conclusions: HRQOL in gout is impaired by gout-specific, comorbid, and sociodemographic characteristics, highlighting the importance of comorbidity screening and early urate-lowering therapy. Both gout specific and generic questionnaires identify the impact of disease-specific features on HRQOL but studies focusing on comorbidity should include generic instruments.

ObjectivesClinical management of giant cell arteritis (GCA) involves balancing the risks and burdens arising from the disease with those arising from treatment, but there is little research on the nature of those burdens. We aimed to explore the impact of giant cell arteritis (GCA) and its treatment on patients’ lives.MethodsUK patients with GCA participated in semi-structured telephone interviews. Inductive thematic analysis was employed.Results24 participants were recruited (age: 65–92 years, time since diagnosis: 2 months to >6 years). The overarching themes from analysis were: ongoing symptoms of the disease and its treatment; and ‘life-changing’ impacts. The overall impact of GCA on patients’ lives arose from a changing combination of symptoms, side effects, adaptations to everyday life and impacts on sense of normality. Important factors contributing to loss of normality were glucocorticoid-related treatment burdens and fear about possible future loss of vision.ConclusionsThe impact of GCA in patients’ everyday lives can be substantial, multifaceted and ongoing despite apparent control of disease activity. The findings of this study will help doctors better understand patient priorities, legitimise patients’ experiences of GCA and work with patients to set realistic treatment goals and plan adaptations to their everyday lives.

Individual-focused self-management interventions are one response to both an ageing society and the purported increase in chronic conditions. They tend to draw on psychological theories in self-management interventions, but over-reliance on these theories can reinforce a narrow focus on specified attitudinal and behavioural processes, omitting aspects of living with a chronic condition. While advances have been made in health behaviour change theory and practice, scant attention has been paid to the social, with the question of social context remaining under-theorised and under-explored empirically. This is particularly noticeable in trials of behaviour change interventions for self-management. The common sociological critique is that these ignore context and thus no explanation can be given as to why, for whom and under what circumstances a treatment works. Conversely, sociologists are criticised for offering no positive suggestions as to how context can be taken into account and for over-emphasising context with the risk of inhibiting innovation. This article provides an overview of these issues and provides examples of how context can be incorporated into the rigid method of trials of self-management for chronic conditions. We discuss modifications to both trial interventions and design that make constructive use of the concept of context.

In this article, we explore ethical issues in qualitative secondary analysis through a comparison of the literature with practitioner and participant perspectives. To achieve this, we integrated critical narrative review findings with data from two discussion groups: qualitative researchers and research users/consumers. In the literature, we found that theoretical debate ran parallel to practical action rather than being integrated with it. We identified an important and novel theme of relationships that was emerging from the perspectives of researchers and users. Relationships were significant with respect to trust, sharing data, transparency and clarity, anonymity, permissions, and responsibility. We provide an example of practice development that we hope will prompt researchers to re-examine the issues in their own setting. Informing the research community of research practitioner and user perspectives on ethical issues in the reuse of qualitative data is the first step toward developing mechanisms to better integrate theoretical and empirical work.

Multi-morbidity is receiving considerable attention in public policy, health and social care. From the perspective of the individual, multi-morbidity is a more complex experience than solely having a clinical diagnosis. In this article, we will argue that understanding multi-morbidity can be facilitated by considering the relationship between adversity (in this case multi-morbidity), resilience and social connectedness within a life course framework. This provides an approach that can capture the dynamics of social relationships, social connectedness and the fluctuations in the experience of multi-morbidity. We draw on a qualitative study of 17 people who have multiple conditions, but consider themselves as being able to maintain a sense of identity and self over time and in the face of adversity. From their accounts, a more varied picture emerges of living with multi-morbidity. This then depicts a more realistic representation of how each person shapes their multi-morbidity and resilient responses within their own social context, which can help to formulate more effective ways of supporting them.

Objectives. To identify the instruments that have been used to measure health-related quality of life (HRQOL) in gout and assess their clinimetric properties, determine the distribution of HRQOL in gout and identify factors associated with poor HRQOL. Methods. Medline, CINAHL, EMBASE and PsycINFO were searched from inception to October 2012. Search terms pertained to gout, health or functional status, clinimetric properties and HRQOL. Study data extraction and quality assessment were performed by two independent reviewers. Results. From 474 identified studies, 22 met the inclusion criteria. Health Assessment Questionnaire Disability Index (HAQ-DI) and Short Form 36 (SF-36) were most frequently used and highest rated due to robust construct and concurrent validity, despite high floor and ceiling effects. The Gout Impact Scale had good content validity. Gout had a greater impact on physical HRQOL compared to other domains. Both gout-specific features (attack frequency and intensity, intercritical pain and number of joints involved) and comorbid disease were associated with poor HRQOL. Evidence for objective features such as tophi and serum uric acid was less robust. Limitations of existing studies include cross-sectional design, recruitment from specialist clinic settings and frequent use of generic instruments. Conclusion. Most studies have used the generic HAQ-DI and SF-36. Gout-specific characteristics and comorbidities contribute to poor HRQOL. There is a need for a cohort study in primary care (where most patients with gout are treated) to determine which factors predict changes in HRQOL over time. This will enable those at risk of deterioration to be identified and better targeted for treatment.

Objective A lack of agreement between clinician and patient priorities can impact the clinician–patient relationship, treatment concordance, and potential health outcomes. Studies have suggested that patients with osteoarthritis (OA) may prioritize comorbidities over their OA, but as yet no explicit systematic exploration of OA patients' priorities in relation to comorbidities exists. This study aims to explore how patients prioritize their OA among their conditions, which factors underlie this prioritization, and whether and why these priorities change over time. Methods A secondary analysis of qualitative data was conducted utilizing 4 existing data sets collated from the 3 research centers involved. Purposive sampling provided a sample of 30 participants who all had OA and comorbidities. The research team collectively coded and analyzed the data thematically. Results Three groups of patients emerged from the analysis. The 2 smaller groups had stable priorities (where OA was or was not prioritized) and illustrated the importance of factors, such as personal social context and the specific nature of the comorbid conditions. The third and largest group reported priorities that shifted over time. Shifting appeared to be influenced by the participants' perceptions of control and/or interactions with clinical professionals, and could have important consequences for self-management behavior. Conclusion The various factors underlying patients' priorities among their conditions, and the fluctuating nature of these priorities, highlight the importance of regular assessments during clinician–patient consultations to allow better communication and treatment planning, and ultimately optimize patient outcomes.

Context Authentic early experience (AEE) describes experiences provided to new medical students to undertake ‘human contact’ to enhance learning. Although the concept of AEE is not new, and was commonplace prior to the Flexner Report of 1910, little is known about how or why meaning and knowledge are constructed through early student placements in medical, social and voluntary workplaces. Variance among settings means AEE is a collection of non-uniform, complex educational interventions which require students to make repeated transitions between different workplaces and their university institution. The purpose of this paper is to develop theory in this context. Methods We report on a study undertaken in a UK medical school using interviews and discussion groups to generate data from students, workplace supervisors and school faculty staff. We used narrative analysis to access knowledge and meaning construction, in combination with analytic tools drawn from thematic and interpretative approaches to phenomena. We sought to refine theoretical understanding through the application of mētis, a socio-cultural theory novel to the field of medical education. Results Scott’s concept of mētis provides a useful theoretical framework for understanding how AEE works for students in terms of their creation of meaning and how they choose to use it in relation to formally recognised knowledge. Knowledge and meaning, generated as a consequence of AEE, contained dichotomies and paradoxes. Students improvised, in the face of unpredictability and uncertainty, to create a form of mētis that allowed them to handle the perceived competing demands of AEE settings and the medical school. Discussion We demonstrate how meaning making can be conceived of as student mētis arising from social processes in students’ learning interactions. We suggest that the development of collaborative working with students could potentiate positive forms of student mētis, thereby maximising desirable educational consequences. Further work is required to establish effective ways to do this.

This paper addresses the question 'what are the variables influencing social interactions and learning during Authentic Early Experience (AEE)?' AEE is a complex educational intervention for new medical students. Following critique of the existing literature, multiple qualitative methods were used to create a study framework conceptually orientated to a socio-cultural perspective. Study participants were recruited from three groups at one UK medical school: students, workplace supervisors, and medical school faculty. A series of intersecting spectra identified in the data describe dyadic variables that make explicit the parameters within which social interactions are conducted in this setting. Four of the spectra describe social processes related to being in workplaces and developing the ability to manage interactions during authentic early experiences. These are: (1) legitimacy expressed through invited participation or exclusion; (2) finding a role-a spectrum from student identity to doctor mindset; (3) personal perspectives and discomfort in transition from lay to medical; and, (4) taking responsibility for 'risk'-moving from aversion to management through graded progression of responsibility. Four further spectra describe educational consequences of social interactions. These spectra identify how the reality of learning is shaped through social interactions and are (1) generic-specific objectives, (2) parallel-integrated-learning, (3) context specific-transferable learning and (4) performing or simulating-reality. Attention to these variables is important if educators are to maximise constructive learning from AEE. Application of each of the spectra could assist workplace supervisors to maximise the positive learning potential of specific workplaces. © 2012 Springer Science+Business Media Dordrecht.

Background: Theoretical integration is a necessary element of study design if clarification of experiential learning is to be achieved. There are few published examples demonstrating how this can be achieved. Aims: This methodological article provides a worked example of research methodology that achieved clarification of authentic early experiences (AEEs) through a bi-directional approach to theory and data. Methods: Bi-directional refers to our simultaneous use of theory to guide and interrogate empirical data and the use of empirical data to refine theory. We explain the five steps of our methodological approach: (1) understanding the context; (2) critique on existing applications of socio-cultural models to inform study design; (3) data generation; (4) analysis and interpretation and (5) theoretical development through a novel application of Metis. Results: These steps resulted in understanding of how and why different outcomes arose from students participating in AEE. Our approach offers a mechanism for clarification without which evidence-based effective ways to maximise constructive learning cannot be developed. In our example it also contributed to greater theoretical understanding of the influence of social interactions. Conclusion: By sharing this example of research undertaken to develop both theory and educational practice we hope to assist others seeking to conduct similar research. © 2013 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.

In light of the ambiguity of meanings attributed to the concept of stoicism we critically explore its use as a label to explain and describe health and illness behaviour, juxtaposing the often negative portrayals of contemporary stoicism against its classical and philosophical origins. By reflecting critically on the term ‘stoicism’, its application and dimensionality, we show how the term has evolved from classical to contemporary times in relation to changing context, and explore different understandings of the term across medical and health literature. We attend to sociocultural factors that are seen to influence the conceptualization of stoicism such as generational influences, gender and geographies. We make the assertion that by applying the label of ‘stoicism’ as it is known today, there is a danger of too readily accepting a term that masks particular health behaviours while missing an array of sociological factors that are important to how people deal with adversity arising from chronic health problems. We therefore encourage further questioning of this term.

Objective: A lack of agreement between health-care providers and patient priorities can impact the health-care provider–patient relationship, treatment concordance and potentially health outcomes. Evidence suggests that people living with multiple morbidities do prioritise among their long-term conditions. However, the evidence revealing the underlying reasons behind this prioritisation remains limited. Given the potential implications for day-to-day self-management activity and ultimately patient outcomes, this study aims to explore how and why people with multimorbidity prioritise some long-term conditions over others and what the potential implications may be for self-management activity, and in turn, suggest how such information may help clinicians negotiate the management of multimorbidity patients. Methods: A secondary analysis of qualitative data was conducted utilising four existing data sets collated from the three research centres involved. Purposive sampling provided a sample of 41 participants who had multimorbidity. The research team collectively coded and analysed the data thematically. Results: All participants, except two, identified one ‘main’ priority long-term condition. Current priorities were arrived at by participants making comparisons between their long-term conditions, specifically by trading off the various attributes, impacts and perceived consequences of their individual long-term conditions. Two main themes emerged as to why participants identified a particular main long-term condition: (a) proximate issues surrounding barriers to functional health and (b) prioritisation of long-term conditions perceived to have a particular future risk. Conclusions: The recent focus on multimorbidity within the medical literature reflects its prevalence. It is therefore important to understand the complexities of the multimorbidity illness experience. We have added to the limited literature on condition prioritisation by revealing some novel understandings of the process of condition prioritisation which can feed into patient–provider consultations in order to allow better communication and treatment planning as well as, ultimately, optimise patient outcomes.

The need to improve the treatment and management of long-term conditions is one of the most important challenges facing the NHS. The idea of ‘resilience’ represents a paradigm shift to a treatment model that promotes positive adaptation, using an asset-based model of resilience, in the context of long-term health issues.

The impact of pain and chronic illness on the family has been documented, but there is little information about living with chronic widespread pain in the context of the family. This article uses data from a qualitative study of the experience of living with chronic widespread pain to examine the experience and meaning of support for people with this condition in the context of their families. It focuses on the varying, dynamic and reciprocal nature of practical and emotional support in the family. Family members may provide support but are also receivers of support from the person with chronic widespread pain. The factors mediating the provision of this support are also explored, including the nature of the pain and the needs of the person with pain, and the roles, responsibilities and characteristics of other family members.

Background\ud Gout is more common in men, and is often perceived by both patients and health practitioners to be a disorder of men, but its prevalence in women is increasing. Little is known about women’s experience of gout and the impact it has on their lives. It is important for practitioners to be aware of these areas, given the increasing numbers of women with gout they are likely to see in the future. This study aimed to explore women’s experiences of gout.\ud \ud Methods\ud A qualitative research design was used. Semi-structured interviews were conducted with 43 people, of whom 14 were women. Interviews were video and/or tape recorded and transcribed verbatim. Data from the interviews was first grouped into broad categories, followed by a more detailed thematic analysis and interpretation.\ud \ud Results\ud Participants’ ages ranged from 32 to 82. Nine participants were retired and five were in fulltime work. Four themes emerged: (1) experience of onset, help seeking and diagnosis (2) understanding and finding information about gout, (3) impact on identity, and (4) impact on roles and relationships.\ud \ud Conclusions\ud The diagnostic process for women with gout can be uncertain due to lack of awareness of gout in women (by health care professionals and women themselves). Women do not have a good understanding of the condition and find it difficult to find information that feels relevant to them. Gout has a major impact on women’s identity and on their roles and relationships. These findings are of importance to health care professionals dealing with women with potential gout and those with an existing diagnosis.

Objective To explore patients’ experiences from initial symptoms to receiving a diagnosis of gout. Design Data from in-depth semistructured interviews were used to construct themes to describe key features of patients’ experiences of gout diagnosis. Participants and setting A maximum variation sample of 43 UK patients with gout (29 men; 14 women; age range 32–87 years) were recruited from general practices, rheumatology clinics, gout support groups and through online advertising. Results Severe joint pain, combined with no obvious signs of physical trauma or knowledge of injury, caused confusion for patients attempting to interpret their symptoms. Reasons for delayed consultation included self-diagnosis and/or self-medication, reluctance to seek medical attention, and financial/work pressures. Factors potentially contributing to delayed diagnosis after consultation included reported misdiagnosis, attacks in joints other than the first metatarsophalangeal joint, and female gender. The limitations in using serum uric acid (SUA) levels for diagnostic purposes were not always communicated effectively to patients, and led to uncertainty and lack of confidence in the accuracy of the diagnosis. Resistance to the diagnosis occurred in response to patients’ beliefs about the causes of gout and characteristics of the people likely to be affected. Diagnosis prompted actions, such as changes in diet, and evidence was found of self-monitoring of SUA levels. Conclusions This study is the first to report data specifically about patients’ pathways to initial consultation and subsequent experiences of gout diagnosis. A more targeted approach to information provision at diagnosis would improve patients’ experiences.

BACKGROUND: Foot problems are common in people with gout yet the prevalence of current foot problems in people with gout and the burden they present to healthcare systems is not known. This cross-sectional study aimed to determine the prevalence and associations of hallux valgus, foot pain and disability in people with gout, and to assess the frequency with which foot problems lead to consultation with healthcare professionals. METHODS: Adults registered with 20 general practices who had consulted their GP about gout or been prescribed allopurinol or colchicine in the preceding two years were mailed a questionnaire. Prevalence of hallux valgus, foot pain in the last month, and disabling foot pain in the mailed population were ascertained using validated instruments and estimated by inverse-weighted logistic regression. Associations with socio-demographic, comorbid and gout-specific factors were examined using logistic regression. Participants were asked if they had seen health care professionals for foot problems within the preceding 12 months. RESULTS: One thousand one hundred eighty-four questionnaires were received (response 66 %). Prevalence of hallux valgus was 36.3 %, foot pain in the last month 22.3 % and disabling foot pain 14.5 %. Hallux valgus associated with age (adjusted OR 1.47 per 10-year increase, 95 % CI 1.26, 1.72) and female gender (2.03; 1.31, 3.15). Foot pain in the last month associated with age (1.24; 1.00, 1.55), obesity (BMI 30.0-34.9 2.67; 1.32, 5.38; BMI ≥ 35.0 3.16; 1.44, 6.93), mild depression (2.04; 1.09, 3.81) and polyarticular gout attacks (1.86; 1.18, 2.95). Disabling foot pain associated with age (1.42; 1.08, 1.87), obesity (BMI 30.0-34.9 3.73; 1.54, 9.09; BMI ≥ 35.0 4.36; 1.64, 11.64), depression (mild 2.63; 1.25, 5.53; moderate 3.53; 1.11, 11.26) and ischaemic heart disease (2.45; 1.32, 4.53). In the previous 12 months, 495 (42.8 %) reported consulting their GP about their feet and 281 (23.7 %) a podiatrist/chiropodist. CONCLUSIONS: Foot problems are common in people with gout and frequently lead to healthcare consultation. Hallux valgus has similar associations to those seen in the general population, whereas foot pain associates with obesity and gout characteristics, and disabling foot pain with obesity and comorbidity. Patient assessment should consider foot problems and offer specific treatment where relevant.

Objectives: This paper reports findings from a larger study that aimed to explore how people with chronic widespread pain experience, understand and make meaning of their `condition', and attempt to influence or exert control over their pain. This included an exploration of sufferers' understanding of the past and future as well as of their present situation. Methods: A combination of data generation methods was used, including lifegrid interviews, diaries and diary interviews, with eight people with chronic widespread pain. Five family members also participated in interviews. Analytical methods were based on interpretative phenomenological analysis (IPA). Results: With regard to their views about the future, participants could be categorized into those who were `optimistic' (`things can only get better'), those who were pessimistic (`things will get worse'), and those who were overwhelmed with uncertainty about the future. Uncertainty was a dominant feature in all the accounts of the future. Discussion: The pervading uncertainty of chronic widespread pain, in which there is no framework for the trajectory of the condition, affects perceptions of the future and makes planning for the future difficult. The findings also raise the question of how this makes chronic widespread pain different from other chronic conditions in terms of understanding of chronicity, time and future, and hence `acceptance'.

Transcribed archived interviews are a data source which are becoming more widely used across a range of disciplines. Their use raises important ethical issues, particularly in the areas of relationships with research participants; informed consent; and confidentiality. The existing ethical guidelines that are available for social scientists or historians refer to the carrying out of interviews, but not to the secondary use of the transcripts that sometimes result from oral history or qualitative social research projects. This paper therefore questions whether the ethical relationship between interviewer and interviewee can be adopted and maintained by the reader of a transcripted interview and suggests that the ethical use of transcripted life-narratives cannot be governed by legal or contractual rules of possession, nor solely by the regulations laid down by oral history/archival organisations. The article concludes by asserting a need for social scientists and historians to develop and negotiate a share...

Objective To explore women's knowledge and understanding of osteoporosis and of dual energy x-ray absorptiometer (DEXA) scans; the factors influencing their decision to have a scan and their experience of undergoing a DEXA scan. Design In-depth interviews (using a topic guide) were carried out with 12 women [before a DEXA scan and after they had discussed the results with their general practitioner (GP)] and with three women who chose not to have a scan. Setting Stoke-on-Trent, Staffordshire, UK. Participants Women who responded to a primary-care based questionnaire were purposively selected for interview. Results The women interviewed had varied levels of understanding of osteoporosis. For the majority of participants the scan was an overwhelmingly positive experience, despite some women's negative expectations. Findings are also explored in terms of the influences on women's decision-making about whether to have a scan and the concept of `knowing' one's risk status. Conclusions The main implication for primary care is how to improve women's understanding of osteoporosis and DEXA scans in order to promote the strategy of scanning high-risk women.

Active aging, using the conventional sense of activity, might be difficult to achieve for people with chronic musculoskeletal pain (CMP). Given that a large number of older people will develop CMP, it is important to consider a broader conceptualization of activity and how this might fit into discourses of aging. We report findings from a study of the experiences of chronic pain in the daily life of 60 older people. In this article we focus on the role and meanings of physical activity for those older people. We develop a typology of styles—deliberate, strategic, and natural—to show how people approached physical activity and how its meaning differed for individuals in different contexts and across their life course. We suggest a more balanced perspective of aging in which “slowing down” might also be a desirable outcome for some older people with CMP but is not incompatible with well-being.

It is common for people with chronic conditions to report their health as good, although models of healthy ageing do not account for this. The concept of successful ageing focuses on overcoming problems, in contrast to the concept of resilience, which can acknowledge vulnerability. Osteoarthritis (OA) is the main cause of joint pain in older people, but research in this area has tended to focus on OA as an illness. Consequently, our research aimed to explore OA from the perspective of wellness. We undertook a longitudinal qualitative study to explore ‘wellness and resilience’ in a group of older people who reported chronic joint pain and considered themselves healthy. We interviewed 27 people and followed them up with monthly diary sheets, responding to reports of changes using their chosen contact method. This article focuses on how resilience relates to how people consider themselves to be well. Participants' experience of the adversity of their pain varied, and was influenced by context and meaning. Participants described ‘keeping going’ in body, mind and everyday life. Flexibility and pragmatism were key aspects of keeping going. The findings support a broader version of resilience that incorporates vulnerabilities. In the context of health care we suggest that treating the frail body should not come at the expense of undermining an older person's sense of a resilient self.

BACKGROUND Current recommendation are that women with clinical indicators of low bone mineral density should be offered a DEXA (dual energy X-ray absorptiometer) scan to help assess the need for treatment, but little is known about GPs' attitudes towards DEXA scans. OBJECTIVE Our aim was to explore GPs' beliefs about diagnosis and management of osteoporosis, including the role that DEXA scanning can play. METHODS Semi-structured interviews with five GPs in the North Staffordshire area were used to explore how GPs make decisions about diagnosis and treatment of osteoporosis, including the use of scans and the application of potential clinical risk factors to decisions about screening and treatment. RESULTS The decision-making process about whether and who to scan is complex and was influenced by a range of factors including issues of diagnosis, treatment, patient pressure and 'external' factors such as practice protocol and the perceived local availability of scans. CONCLUSIONS GPs found it difficult to decide who and when to scan despite guidelines for primary care. Perceived local availability of DEXA scans is important and has implications for raising awareness.

Background Chronic widespread pain (CWP) affects 10% of adults and often causes significant disability in everyday life. Research on time in chronic conditions has focused on biographical disruption and perceptions of past and future. However, more mundane aspects of time are also disrupted in a condition such as CWP, which is uncertain on a minute-to-minute, day-to-day basis, as well as in the longer term. The results presented here are part of a wider study, the aim of which was to explore how people with CWP experience and give meaning to their 'condition'. This article focuses on how mundane, repetitive and taken-for-granted aspects of everyday life are disrupted for people with CWP. Methods Eight people aged 40–60 years living with CWP took part in multiple in-depth interviews, diaries and family interviews, exploring the meanings and interpretations of participants and individuals' experiences in a social context. Results The findings illuminate the ways in which the experience of time is changed by CWP: carrying out the tasks of everyday life takes longer, routines are disrupted, and changes are needed in how time is managed. Some strategies for managing these tasks rely on ability to control one's time. However, this is not always possible and, for some, the experience of CWP becomes characterised by lack of such control. Conclusion This study explored the concept of controllable time in the experience of CWP. Regaining control over time is an important element in coping with chronic pain, and helping patients to regain such control has potential as a target for health professionals involved in pain management.

The impact of pain and chronic illness on the family has been documented, but there is little information about living with chronic widespread pain in the context of the family. This article uses data from a qualitative study of the experience of living with chronic widespread pain to examine the experience and meaning of support for people with this condition in the context of their families. It focuses on the varying, dynamic and reciprocal nature of practical and emotional support in the family. Family members may provide support but are also receivers of support from the person with chronic widespread pain. The factors mediating the provision of this support are also explored, including the nature of the pain and the needs of the person with pain, and the roles, responsibilities and characteristics of other family members.

Objective: To explore patients' experiences from initial symptoms to receiving a diagnosis of gout. Design: Data from in-depth semistructured interviews were used to construct themes to describe key features of patients' experiences of gout diagnosis. Participants and setting: A maximum variation sample of 43 UK patients with gout (29 men; 14 women; age range 32-87 years) were recruited from general practices, rheumatology clinics, gout support groups and through online advertising. Results: Severe joint pain, combined with no obvious signs of physical trauma or knowledge of injury, caused confusion for patients attempting to interpret their symptoms. Reasons for delayed consultation included self-diagnosis and/or self-medication, reluctance to seek medical attention, and financial/work pressures. Factors potentially contributing to delayed diagnosis after consultation included reported misdiagnosis, attacks in joints other than the first metatarsophalangeal joint, and female gender. The limitations in using serum uric acid (SUA) levels for diagnostic purposes were not always communicated effectively to patients, and led to uncertainty and lack of confidence in the accuracy of the diagnosis. Resistance to the diagnosis occurred in response to patients' beliefs about the causes of gout and characteristics of the people likely to be affected. Diagnosis prompted actions, such as changes in diet, and evidence was found of self-monitoring of SUA levels. Conclusions: This study is the first to report data specifically about patients' pathways to initial consultation and subsequent experiences of gout diagnosis. A more targeted approach to information provision at diagnosis would improve patients' experiences.

Videoconferencing is a highly flexible teaching tool. It can assist in delivery of a rapidly changing curriculum and can solve some of the problems caused by trying to deliver teaching to an audience dispersed across campuses. When well planned and delivered effectively, videoconferenced teaching sessions can be stimulating and enjoyable. An enthusiastic approach, a well-planned session, interactive teaching, use of site facilitators and a good working relationship with technical support are keys to success.

Sufferers of chronic illness face delegitimation of their condition and threats to their identities. One way of establishing the legitimacy of their position is for sufferers of chronic illness to emphasize the ‘ordinary’ in their accounts. Sufferers of conditions which are chronic, invisible and contested, such as chronic widespread pain, have the same, and possibly greater, need to legitimize their condition and refute allegations of ‘malingering’ or psychological instability. The article uses interviews with women with chronic widespread pain to illustrate the ways in which the invisible, subjective and everyday nature of chronic pain leads to sufferers experiencing delegitimation of their condition. It suggests that the accounts of women suffering from chronic widespread pain are constructed to portray a positive identity in the face of this experience, particularly through the emphasis on the ‘extraordinary’.

BACKGROUND Current recommended practice for the use of dual X-ray absorptiometry (DEXA) scans in screening for osteoporosis is to concentrate on women at 'high risk'. OBJECTIVE We have applied such a screening strategy, in a general practice setting, to estimate the number of women requiring scans. METHODS A two-phase survey was carried out: (i). postal screen of clinical indicators for low bone mineral density (BMD) to define women at 'high risk'; and (ii). DEXA scanning of the sample at 'high risk' set in two general practices in North Staffordshire. Computerized general practice records were used to define a purposive sample of 1001 women, to receive the screening tool, consisting of three equal size groups (i). those with an early hysterectomy; (ii). those receiving oral corticosteroids on repeat prescription; and (iii). those on the practice cervical smear register. A random sample of women defined at 'high risk' by the screening tool were invited to have a DEXA scan. The main outcome of interest was the presence of low BMD as measured by a DEXA scanner. RESULTS Sixty-five out of 95 women invited (68%) agreed to undergo a DEXA scan: median age = 52 years (interquartile range 44-64 years). Twenty-nine of these 65 women (45%) were classified with low BMD (WHO criteria): 90% had densities below their age-matched mean. Extrapolating from the observed findings to the main study practice (n = 9000 total population), we estimate that 162 women would be defined at 'high risk', and, if all were offered a scan, 105 would comply and 56 would be defined with low BMD. CONCLUSIONS Using this approach, we estimate the unmet need, in women, for DEXA scans to be 180 per 10000 total practice population. Allowing for scan uptake, this would define approximately 60 women per 10000 total practice population with low BMD. The application of this screening strategy has identified a group of women who might benefit from treatment or prophylaxis for osteoporosis.

Background Giant Cell Arteritis (GCA) is the commonest large vessel vasculitis yet a full time UK general practitioner (GP) can expect to see just 1 case every 1-2 years [Barraclough]. GCA may be difficult to identify, particularly in atypical cases. For example headache has been shown to be absent in just under a quarter of GCA patients which may falsely reassure clinicians resulting in delayed diagnosis and potential visual loss [Ezeonyeji]. Objectives The aim of this study was to investigate how GPs identify GCA. Methods A postal questionnaire survey of 5000 randomly selected UK general practitioners was undertaken. Questions included experience of managing patients with GCA, presenting symptoms used to identify GCA and the referral pathways used. Results 1249 questionnaires were returned. The mean age of responder was 43 years and they had been qualified as a GP for a mean of 14 years (SD 9.03). Respondents were more likely to be from larger practices. 879 responders (70.4%) indicated that they had diagnosed and managed a patient with GCA. [Figure 1][1] illustrates the combinations of the main symptoms that GPs use to identify GCA with headache being the predominant feature (n=1071 (86%)). Other commonly reported features were visual disturbances (n=671 (53.9%)), jaw symptoms (n=420 (33.7%)) and temporal artery/scalp tenderness (n=468 (37.6%)). 21.86% (n=273) indicated that they only use headache as a symptom for identifying GCA. ![Figure 1.][2] Figure 1. Venn diagram of symptoms used to identify GCA. Conclusions General practitioners in the UK rely overly on headache when diagnosing GCA. Educating clinicians about other presenting symptoms and atypical presentations is essential to optimise diagnosis and reduce the potential for visual loss for this patient group and to reduce potentially serious long term complications. References 1. Barraclough K et al. Br J Gen Pract. 2012 Jun;62(599):329-3 2. Ezeonyeji A et al. Clin Rheumatol. 2011;30(2):259-262 Acknowledgements Administration and support staff at Keele University Department of Primary Care and Health Sciences. IT Staff Zoe Mason and Ashley Ford. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4634 [1]: #F1 [2]: pending:yes

Gout is the most common form of inflammatory arthritis, affecting around 1-2% of the population in the UK. Worldwide, it is increasing in prevalence due to a variety different factors. However, we know little about patients9 experiences of this condition. Our study therefore aimed to explore people9s experiences of gout and to produce a section on gout for the website Health Talk Online. This award-winning website currently covers over 75 different health conditions and provides reliable, experience -based information about illnesses and health problems, for patients and health professionals. We carried out 43 semi-structured one-to-one interviews with a diverse sample of people with gout in the United Kingdom. Interviews were video- and/or audio recorded, transcribed and analysed thematically. This presentation will focus on what patients told us about where they looked for information on gout, what sort of information they found and what was valued. People spent a lot of time looking for information when they were first diagnosed, with information about causes and how to prevent attacks being particularly important. Some people wanted to know more about medications and possible side effects, and many looked for information about diet. Some people wanted as much information as possible, while others preferred not to know too much. Many people found a lot of conflicting and confusing information about diet and complementary treatments on the internet. Understanding the broad range of patient experience can be helpful to both patients and practitioners. For patients, knowing more about other people9s experience can help them to make decisions about their own care. For practitioners, knowing more about patients9 views and experiences may help them in supporting patient choices. This can also apply to other common inflammatory arthritis conditions and I will also talk briefly about a developing project on people9s experience of polymyalgia rheumatica (PMR). Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6112

Background Gout has a significant impact on Health Related Quality Of Life (HRQOL). Existing studies are limited by use of only generic HRQOL questionnaires or being undertaken in selective populations such as hospital clinics. We undertook the first large primary care study of gout to use both disease-specific and generic HRQOL questionnaires. Objectives To investigate the cross-sectional associations between socio-demographic, comorbid and gout characteristics and HRQOL using the Health Assessment Questionnaire Disability Index (HAQ-DI), Short-Form 36 Physical Function subscale (PF10) and Gout Impact Scale (GIS). Methods Patients with gout registered with 20 UK general practices were identified by gout consultations or prescriptions for colchicine or allopurinol in the preceding 2 years. 1805 eligible patients were mailed a questionnaire to ascertain self-reported gout characteristics, comorbidities and HRQOL. Serum uric acid and tophi were ascertained from consenting participants9 medical records. Differences between mean scores of HRQOL were assessed using t test and analysis of variance (ANOVA). Associations between HRQOL and independent variables were assessed in univariable and multivariable linear regression models (adjusted for age, gender, socio-economic status and comorbidities). Results 1184 completed questionnaires were received (adjusted response 65.5%). Mean age (SD) of the responders was 65.63 (12.48), 83.6% were males and 95.1% Caucasian. The mean frequency (SD) of attacks over the last year was 1.66 (1.72) and 36.8% had polyarticular gout. The median (Interquartile range) dose of allopurinol was 300 mg (100 mg-300 mg). The commonest co-existing comorbidity was hypertension (61.8%). Worse generic and gout-specific HRQOL was seen in females, current or polyarticular gout, increasing attack frequency, comorbidities (stroke and renal failure), anxiety, depression, body pain, obesity, no further education, and highest neighbourhood deprivation (p Those taking allopurinol had greater HAQ-DI disability but lower GIS unmet treatment need. Diabetes and hypertension were risks for worse health (PF10) and disability (HAQ-DI) but led to lower GIS medication side effects and concern overall respectively. Using the GIS, poor HRQOL was seen with hyperuricaemia, non- Caucasian ethnicity and being unmarried/living alone. On multivariable analysis attack frequency, polyarticular gout, allopurinol use, current gout attack and anxiety remained significantly associated (p Conclusions Gout characteristics were associated only with gout-specific HRQOL and frequency of alcohol intake only with generic HRQOL measures. Pain and depression were associated with both types of measure. Use of the GIS and generic questionnaires together may provide the optimal chance of detecting gout-specific and other characteristics affecting all aspects of HRQOL. Further prospective studies of HRQOL measures will help identify factors that are predictive of a poor outcome and hence help target early intervention. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1638