Feasibility study: qualitative findings

Some of the information in this chapter is reported in Chew-Graham et al. (paper under review).

Participants

Study participants

Eleven study participants were interviewed from five of the eight participating CPs. Nine study participants had completed between four and six ESI sessions (seven study participants had completed all six ESI sessions) and two study participants did not start the ESI sessions (ESI non-completers). All of the study participants were of white ethnicity. Table 11 provides demographic details for the interviewed study participants. Interviews with participants explored their experiences of receiving the ESI and their acceptability of the ESI.

Enhanced support intervention facilitators

A total of 17 ESI facilitators completed the ESI training as part of the feasibility study and 13 were available to deliver the ESI during the intervention period, of whom nine supported at least one participant through the ESI. Thirteen interviews were conducted with nine ESI facilitators from seven of the recruiting CPs (see Table 12). Four ESI facilitators completed two interviews (the first focused on their experiences of the ESI training and the second focused on their experience of delivering the ESI). Five ESI facilitators completed a single interview on their experiences of ESI training and delivery. Table 12 details the demographic details of the interviewed ESI facilitators.

Five pharmacy staff from three participating CPs participated in the focus group.

Thematic analysis

The initial thematic analysis is presented in Table 13, with illustrative data included. Illustrative data are provided to support the analysis and are labelled by identifier and number.

Theoretical framework of acceptability analysis

The main results will be reported following the analysis mapping onto the TFA:47 intervention coherence, perceived effectiveness, self-efficacy, burden, opportunity costs and affective attitudes. There were no data related to the construct ethicality.

Intervention coherence

This construct assessed the extent to which the ESI participants understood the ESI and how it worked.

The identification of mood problems and the provision of subsequent support made sense to participants who received (‘intervention participants’) and delivered (‘ESI facilitators’) the ESI. Intervention participants and ESI facilitators acknowledged the link between physical and mental health and ill health:

I think they are linked. I think if somebody gets diagnosed with, whether it be asthma or diabetes, we, we initially think oh my goodness, how am I gonna cope with this? Some people are really strong and can cope with it and take it all on board, other people really struggle, and in that struggle it affects the day-to-day life of everything else, it’s not just the fact they’ve got diabetes, unfortunately it affects every aspect of their life.

. . . it, I can’t do, there’s things that you can’t do; I can’t hold things in me right hand and; so it does get us depressed not being able to do what I want to do. Me colitis sometimes gets us depressed because if I’ve got a flare up I can’t go out the house, because I need to use the toilet all the time. Me COPD [chronic obstructive pulmonary disease], as long as I’m taking me inhalers I’m not too bad, you know. But yes, it definitely reflects on me mood, on me moods and things and, yeah.

The ESI made sense to those who undertook it, with the intervention participants reflecting on the usefulness of the workbook, the structured nature of the ESI, the homework required of them and the benefits of the ESI to them as an individual:

Yes, it did [make sense]. It was particularly in the workbook, it mentioned things like can’t be bothered, not going out, making excuses; and I thought yes, that, that, that’s me, but I thought it was just getting older and, you know, not wanting to do things like that, so. That wa, that was, that was very useful.

I thought, and I, I, perfectly honest, it has done me the world of good. It’s been therapeutic, because I was getting a regular call on a Wednesday, and I would work to that call on the Wednesday, because I was given a plan, I was given advice, keeping me diary, for example, on how I felt from day to day, planning to do tasks, even though they seemed insurmountable at times.

The CP was seen as an appropriate and logical setting in which to deliver the ESI, with the location seen as familiar and non-stigmatising by both intervention participants and ESI facilitators:

We have a lotta people that come in and tend to, for whatever reason, see it, us in a pharmacy, as someone as a, who they can talk to openly and honestly.

Perceived effectiveness

The TFA construct of perceived effectiveness describes the extent to which participants perceive that the intervention will achieve its purpose.76

A number of aspects of the ESI were perceived as likely to achieve their purpose. Although some intervention participants disclosed initial uncertainty about the preliminary assessment, these feelings were quashed once the assessment had been undertaken:

Yeah, I thought it was a bit [sighs] a bit strange at first, and then when you read and understand what everybody’s trying to say and get to and get your answers from you, I think it, it’s done in a very sensitive way and I think it, it’s positive.

The materials were thought to achieve their purpose; in particular, the patient workbook was well received by intervention participants and also by ESI facilitators who described working through them with the participants:

We went through it together. So she was like asking us the questions out the book that I already had, you know, so went through together. So yes, it was all right, I understood it, yeah.

I thought that was fine, I just, I thought it made more sense once I got the self-help work book, everything, once I got that, I read this from beginning to end. So I didn’t even, you know, I, once I got this I thought oh so we’re gonna be doing this and gonna be doing that; but that’s the person I am. Some people might just do one stage as, at a time, I read the whole thing to see what it was gonna entail before; so I was well aware what I was going into, and if there was something I didn’t like I would have said; but I thought oh this is all right, seems all right to me. So, there you go.

Intervention participants said that the activity planner in the workbook was particularly valuable:

I gave up filling the end part of the book up cos I thought what activities do yer like to keep, help yer keep well? There’s a lotta things that I could, I could be doing more, but that’s gonna come in time. I’m more worried about, I’m, was more interested in filling this chart to say, right, this is what I did.

Very, yeah. Ess, essential in fact, cos that’s a whole part of the, the, the study, isn’t it, the kind of, help the, the patient, if you will, to use the book to help themselves. So yeah, very good, kind of well set out and easy to understand.

Intervention participants reflected on the importance of confidentiality and trust in the ESI facilitator, which appeared to give them confidence to engage in the ESI and faith that it could produce a positive outcome or ‘good result’:

I know [the facilitator], I can speak to [her] and I know it’ll be confidential and it wouldn’t go any, any further, it wouldn’t go any further with any of the staff or anything like that, she would give me a good result and I would give her a good result . . .

Self-efficacy

Enhanced support intervention facilitators expressed mixed views about whether or not they had developed the confidence to deliver the ESI following the ESI training. Notably, anxiety and uncertainty particularly focused around participant risk assessment:

. . . OK. I think one of the questions I would, I would find it quite awkward asking people where you had to just say have you thought about killing yerself in the last week; I think that might come across as, I don’t know what the word is, a bit blunt [laughs]. But yeah, apart from that . . .

However, some ESI facilitators described how they gained confidence with increasing experience of ESI delivery:

I didn’t really find it difficult. I found, I did, at first, at first, when I first started, I thought asking the questions, the risk questions I’d asked be quite daunting and impersonal and whether they would be quite negative, but when we’ve done it on a regular basis I can see that there’s a need for it and you can see, especially with one, with one of them, even with the one that decided at 4 weeks, decided she didn’t want to go any further, it was a noticeable difference in the scores that it had improved, so at least there was some benefit. So with regards to that, I think it was quite OK, to be honest, I didn’t really have any problems with that.

Intervention participants all described confidence in goal-setting, keeping diaries and being monitored by their ESI facilitator:

. . . in particular when we were talking about breaking activities down into smaller parts, because again me mobility has really restricted me with a lot of things, and even a simple thing like making the bed [laughs] you, you know, we used that as an ex, one, one example, and it was a case of not making it and changing the blankets all in one go and, you know, so we did it sort of like, you know, with [names ESI facilitator] help we, we broke that down into smaller steps.

Not all intervention participants were confident that they could continue to practice what they had learned during their work with the ESI facilitators:

I think I try to now, yeah, I think on things a bit more. Whereas before I would just sit, now I try to get up and do something and I try to have a different outlook on, on the way it was to the way it is now, even though I’ve got the pressure of my wife it’s still, it’s still a bit different than what it was.

However, other intervention participants described continued use of the BA techniques learned, including monitoring mood, and indeed their own adaptions to the study materials:

Having a mood chart but, I mean I’ve, I’m using me own calendar and I’m putting me score; so I just do, I just do morning and night, because morning I’m usually, nine times out of ten, I’m very high in a morning, because I like getting up, I’ll get up early, I do everything on a morning, so my mood’s quite high, it’s when I get, after work I’m tired. Obviously, it lowers and things like that, and at the minute it’s, it’s on about a 5 when I come back from work, cos when I come back from work I’m thinking about me sister, so. But it’ll, it’ll be like that, and I’m not worried about that being low when it’s been an 8 on the morning, because you haven’t had time to think, you know, things like that . . .

Burden

Both ESI facilitators and intervention participants alluded to the burden that participating in the study entailed. For example, ESI facilitators described the challenge of discussing the study with pharmacy customers and specifically the difficulty of finding the words to describe the purpose of the study and the description of ‘mood’:

Like my big problem was how to initially say to people ‘do you want to participate?’, cos I didn’t want to say it’s about low mood or subthreshold depression, I just didn’t wanna mention those terms cos I just knew people would be put off. So I was like I need some key words to throw in here [laughs] and she said ‘Say it’s a psychological well-being study’. And as soon as she said that I was like, right, that’s much easier [laughs]. I approached a lot more people then, yeah.

All ESI facilitators and pharmacy staff described some difficulty in fitting aspects of the study into their daily routine:

. . . it’s sort of 15/20 minutes taken off my time and I’m very needed on the shop floor. So, it means that somebody has to drop down, and then I feel like I’ve left two very capable dispensers having to cover a shop floor with a queue full of people, which sometimes I do feel guilty about.

However, this ESI facilitator added:

But then when you think of the impact it’s gonna have on the customers that we see, it’s worthwhile doing; regardless of how many staff we’ve got on the counter, if we can help just one person it’s been worthwhile.

In addition, the impact of the study, in particular the recruitment process, was echoed by the wider pharmacy staff in the participating CPs:

A bit, like you said, like it’s the, the, [facilitator] would have to go, she’d want to sit and prepare before somebody came in, to read the notes, to see where she was at. I think the first person that came in took about three-quarters of an hour and then, then there was the phone call with [names clinical supervisor] to then catch up; it just seemed to take a lotta time and I know, obviously I, there was another three pharmacies in my group, one of them didn’t do it because they do like 17,000, like 18,000 items, just don’t have time to do it, they said they just don’t have time to get the staff to go and give the packs out, never mind seeing people; and it’s, it’s unfortunately about money sometimes that they . . .

Despite the difficulties experienced, pharmacy staff were keen to stress the generalisability of the training and skills learned in being part of the study:

Yeah, and it’s expanded my knowledge, it’s made me aware to, to look for what’s in our community, not further afield, because people don’t want to travel, but to see what’s openly available. So now I’ve got a list of what’s openly available for people who are overweight or struggling with anything and; men’s football clubs for the over fifties, running clubs. I’ve been looking at everything so that if anybody says to me I need to do that, I’ve got a folder; and I would never have done that if it hadn’t have done the CHEMIST study.

Descriptions of burden from intervention participants, however, were seen infrequently; rather, the sessions with the ESI facilitators were viewed positively:

In fact when she said when it was the last one I was quite disappointed really because it was becoming a regular on the Wednesday morning, you know, about an hour we would have talking together.

A minority of intervention participants described how a lack of motivation affected their enthusiasm to attend ESI sessions:

. . . but it was just the, just the, just the mood I was in, I would say to [the facilitator] ‘I’ll come in tomorrow’. And then when the, the tomorrow come, I thought oh I, I really didn’t want to come, you know. but I did, I mean I did do it all, I finished it; took a bit of a while. But just, like I said, all depending; I mean today, the way my hand is, I, I found difficulty driving, to tell you the truth, ‘cos I had to drive with them two fingers. So there is times where I’ve got to push meself, otherwise I’m just in the house, you know. But, but yeah, I, I, I, I think it’s, like I say, I still come, but it was a bit difficult sometimes not wanting to come, so.

Opportunity costs

The TFA domain of opportunity costs describes if benefits, profits or values need to be relinquished to engage in the intervention.76

Discussion of opportunity costs was reported by ESI facilitators and pharmacy staff in terms of the time cost on regular pharmacy work as a result of the ESI facilitator delivering the ESI intervention:

So I think it’s got a big impact on the pharmacy, if you’re working in a busy pharmacy, ‘cos you’re taking somebody away for a good 30 minutes and then, which is a good hour, because then you have to call [supervisor] and then you go through the session with [supervisor]; so you’re talking about, sometimes that can be another 15/20 minutes, depends. So you’re taking like a, a body out of the pharmacy; so while that, while that’s getting done my work at the back’s not getting done.

Intervention participants did not feel that being involved in the study had any impact on their day-to-day activities (‘opportunity costs’), but one intervention participant acknowledged the difficulty of fully participating in the study owing to a recent bereavement:

But I can only do; and obviously with just losing me sister, everything’s gone a bit pear-shaped at the minute, but I can only do so much and it, it, it is what it is, but I will get there.

Affective attitudes

The construct affective attitudes describes participants’ feelings about the intervention.76

The ESI facilitators were generally known to the intervention participants and this appeared to be a key enabler of their positive feelings towards participating in the study and working with the ESI facilitator to complete the ESI:

. . . but knowing the pharmacy, this particular pharmacy as I do, I wasn’t surprised that they were interested in it.

. . . I think a big part of it is like how the staff are with the patients, like you said you know your patients very well . . .

In addition, the personal qualities of the ESI facilitators were deemed to be important in relationship building and persisting with the ESI:

Oh great, absolutely great, great, because she’s [the facilitator] friendly, she’s approachable, you know what I mean, so; and I mean that, that’s what you need because it, it, some people can find it intimidating.

No, no, I just, I really found [names ESI facilitator] to be very helpful, very understanding; there was one time, again it was me mobility, I couldn’t get to the chemist, she was quite happy to change the appointment, you know, and, and she was just really, really helpful.

The training was valued not just to help in the delivery of the study, but to assist in their usual, routine work within the pharmacy:

Yeah, and it’s expanded my knowledge, it’s made me aware to, to look for what’s in our community, not further afield, because people don’t want to travel, but to see what’s openly available. So now I’ve got a list of what’s openly available for people who are overweight or struggling with anything and; men’s football clubs for the over fifties, running clubs. I’ve been looking at everything so that if anybody says to me I need to do that, I’ve got a folder; and I would never have done that if it hadn’t have done the CHEMIST study.

Reflections on the use of the theoretical framework of acceptability

We used the TFA47 to explore the acceptability of an intervention in this feasibility study. This provided a useful analytical framework and allowed a more in-depth, multidimensional, theoretically informed analysis of acceptability across the data sets than the initial thematic analysis of each data set allowed.

The TFA can be used to investigate acceptability in three ways: prospective acceptability (prior to participation in the intervention), concurrent acceptability (while participating in the intervention) and retrospective acceptability (after participating in the intervention). We collected data at one time point (after participants had participated in the intervention) and, therefore, undertook a retrospective assessment of acceptability.

Sekhon et al.47 present the constructs of the TFA in alphabetical order and outline the extent to which they may cluster or influence each of the temporal assessments of acceptability as an empirical question. The process of mapping subthemes from the thematic analysis to TFA constructs was not always straightforward, as some subthemes were aligned with more than one TFA construct. When this happened the research team made decisions about which construct best represented the theme. Our analysis suggests that the constructs are interconnected. For example, intervention participants’ perceptions about how they felt towards the ESI (affective attitudes) were often linked with feelings about how recommendations from the ESI facilitator added extra work (burden).

Although all of the TFA constructs represented in these findings were important for assessing acceptability of the ESI, some were more populated than others. For instance, most of the data that contributed the most insight and support for intervention participant acceptability of the ESI were mapped across three TFA constructs (affective attitudes, intervention coherence and perceived effectiveness). Less data were mapped to the TFA constructs of self-efficacy and opportunity costs, and no data were mapped to the TFA construct of ethicality. This lack of findings linked to ethics issues may be explained by the fact that the topic guide was not developed using the TFA constructs.

Chapter summary

The ESI was found to be acceptable to the intervention participants as well as to the ESI facilitators who found that the ESI training was valuable and that it enabled them to deliver the ESI. There were examples of burden, opportunity costs and low self-efficacy for a small number of intervention participants, but more opportunity costs for the CPs in which the ESI was delivered, with challenges described by pharmacy staff and ESI facilitators in allocating time to incorporate CHEMIST work into routine work.

Learning from the feasibility study that informed the pilot RCT is described in Chapter 5. The barriers to and facilitators of implementation of the ESI were the focus of exploration in the pilot RCT.