qualitative research course bristol

Professional/Short course Qualitative Health Research

15 credit level 7 module

Page last updated 12 October 2023

Introduction

This 15 credit Qualitative Health Research module examines qualitative approaches to health and well-being research. It focuses on the key features of qualitative research methodologies and methods, and provides an important theoretical and conceptual grounding in qualitative research. Undertaking this module will be key preparation for completing a qualitative research project and for critiquing qualitative studies.

On successful completion of this level 7 (Masters level) module, you will be able to:

• identify the advantages and disadvantages of qualitative methods for health and well-being research.
• explore qualitative research traditions and methodologies, and understand how and when to use them.
• use the main methods used in qualitative research for generating data, and carry out qualitative data analysis in primary research and in qualitative synthesis.
• show how qualitative research is presented in the form of research papers and other publications.

The module syllabus will typically include:

• Definition, nomenclature, epistemology: what is qualitative research; traditions of qualitative research; diverse methodological approaches (grounded theory; ethnography; phenomenology; narrative inquiry); the place of qualitative research in health research and evidence-based healthcare.
• Current methodological debates: the value of qualitative research; ethics; sampling; reflexivity; quality criteria: validity, reliability and rigour; critical appraisal.
• Methods for qualitative data collection (QDC): interviewing; observation and field notes; focus groups and group facilitation; online qualitative approaches.
• Methods for qualitative data analysis (QDA): basic principles; transcribing; field notes; data management; coding; inductive and deductive analysis; approaches to data analysis (thematic content analysis; framework approach; narrative analysis; discourse); qualitative approaches to evidence synthesis.

A 3,000 word written assignment.

This assessment requires you to complete a written assignment in two parts. The first part requires them to produce an analysis of how qualitative approaches and methods are utilised in health and wellbeing research. The second part requires you to interpret and critically appraise published qualitative research showing understanding of how qualitative methodologies are applied to research problems.

Study facilities

The College of Health, Science and Society has an excellent reputation for the quality of its teaching and the facilities it provides.

Get a feel for the Health Professions facilities we have on offer here from wherever you are.

Prices and dates

There is currently no published fee data for this course.

Supplementary fee information

Please visit full fee information to see the price brackets for our modules.

Funding may be available to support your learning. Please contact your Trust Education Lead. If you work in the Private, Independent and Voluntary Sector, please contact your employer who will advise you.

Please click on the Apply Now button to view dates.

How to apply

Please click on the Apply Now button to apply for your CPD module, which you can take as a stand-alone course or as part of an undergraduate or postgraduate (Masters level) programme.

Extra information

If the course you are applying for is fully online or blended learning, please note that you are expected to provide your own headsets/microphones.

For further information

• Email: [email protected]
• Telephone: +44 (0)117 32 81158

Bristol Medical Education Research Group

Group run by academics from University of Bristol Medical School with an interest in Medical Education Research. Opinions expressed are those of the authors and not of Bristol Medical School or the University.

External Event: National Centre for Social Research – Analysis of Qualitative Data

The National Centre for Social Research is running a training course in partnership with the Social Research Association on Analysis of Qualitative Data.

This live online course (over three days) is designed to equip participants with a clear understanding of the principles of high quality data analysis. (NatCen trainers) * Price:  £330 for SRA members, £440 for non-members. It runs over three consecutive part-days and uses Zoom software *

Introduction/Overview

This three day course is designed to equip participants with a clear understanding of the principles and practice of high quality, rigorous qualitative data analysis. The course primarily focuses on ‘Framework’, an approach to qualitative data management developed at NatCen, and how this approach can be used to conduct descriptive and explanatory qualitative data analysis. The course will be delivered through a mixture of taught sessions and practical exercises.

By the end of the workshop, participants will:

• be able to recognise different approaches to qualitative data analysis (QDA)
• be able to describe key stages in the analytical process in qualitative research
• be able to describe and use the ‘Framework’ approach to data management
• have gained experience of interpreting qualitative data from analytical charts
• be able to describe the factors which can affect the generalisability of qualitative data
• be able to evaluate the quality of qualitative analysis presented to them

The key stages and objectives of the analytical process in qualitative research

• Overview of the range of approaches to QDA
• The qualitative analytical hierarchy
• Tools for qualitative data management
• Using Framework for data management
• Developing the conceptual framework for analysis
• Descriptive analysis for qualitative data
• Introducing typologies in qualitative research
• The nature of linkage and explanations in qualitative data
• Searching for linkages and explanations
• Drawing wider inference from qualitative data

Who will benefit?

This course will be useful to you if you:

• are an experienced qualitative researcher who wants to learn new skills in qualitative data analysis or to broaden and refresh your existing skills
• are experienced in other aspects of qualitative research but are new to the analysis of qualitative data
• commission or manage qualitative research in central or local government, health or other applied policy sectors and need to understand the qualitative data analysis process

More information at: https://natcen.ac.uk/events/analysis-qualitative-data

The National Centre for Social Research a leading provider of social research training in the UK. See their calendar of events at: https://natcen.ac.uk/training-courses

Qualitative Health Research Network

• QHRN Training programme

Training programme

QHRN provides face-to-face and on-line workshops on specific qualitative methodologies and their applications in health research.

Our courses are for researchers at all levels of seniority, and in any area of health research who already have some basic understanding of qualitative research and wish to develop, refresh or expand their methodological skills and knowledge in specific areas.

Courses are delivered by workshop leads who are experts in the specific methodological topic of the workshop. Live sessions create friendly, informal settings, with numbers capped at 25-30 so that participants can share their particular concerns and create connections with other qualitative health researchers. These are complemented by non-synchronous content such as pre-recorded videos, preparatory reading or viewing, and follow-up resources. There may be expectations in some workshops for participants to complete specific tasks or preparatory work before attending the live component of the workshop.

We aim to offer a selection of training workshops every six months, with popular courses repeated according to demand.

The courses we currently offer

• Writing and Publishing Qualitative Research (Online)
• Applied Conversation Analysis: A practical workshop (In person)
• Introduction to Ethnography in Healthcare (Online)
• Introduction to Qualitative Process Evaluation in Healthcare (Online)
• Supervising a Qualitative or Mixed-Methods PhD (Online)

These courses will be run again in the future. 

Our next training courses

Details of our March/April workshops are provided below. 

Course dates and times

Course details

For more details about each course, please see below:

This course is a comprehensive introduction to ethnographic research, focusing on current understandings, ethics and access in healthcare settings, research design, observational and interview-based methods of data collection, data management, analysis, and the written account.

Who this course is for:

The workshop is aimed at those who work in:

• Academic reseach
• Health and social care related charities
• Policy groups and think tank  

It's suitable for those with limited experience of conducting ethnographies, although some knowledge about ethnography and/or qualitative research generally is beneficial.

Course content

There are three parts to the course:

1. Pre-recorded videos

In four short pre-recorded videos (15-30 minutes each) we will talk you through the basics of ethnography in healthcare: •    What is ethnography and what does it tell us: how to use ethnography in healthcare settings,  •    Methodology and methods of ethnography,  •    Fieldwork preparation •    Analysis and writing up for publication.  These short lectures will prepare you to know how, why and when ethnography is useful as a research tool in healthcare, how to develop an ethnographic research question and how to use the different tools of ethnography as well as the basics of analysis and writing up. The videos will guide you step by step through the process of your self-directed fieldwork. They can be watched and re-watched as many times as you like and you should watch all the videos before coming to the live session.

2. Self-directed fieldwork

We would like you to experience what it is like to do some ethnographic data collection. You should complete the fieldwork before coming to the live session .

3. The live session

We will have a live session via Zoom that will extend your learning from the preparatory work. There will be time to discuss queries and further develop your understanding of ethnography.

Teaching and structure

This course takes up to three days to complete. The pre-recorded videos and self-directed fieldwork can be completed any time before the live session. The live session lasts 2.5 hours. You'll learn as part of a group, interacting through activities and questions and learning from others by taking part in the discussions that accompany each step.

Learning outcomes

By the end of the course you'll be able to:

•    explain how and why ethnography can be used in healthcare research •    develop an ethnographic research question •    conduct ethnographic fieldwork •    understand how to analyse and write-up ethnography for publication

Facilitators

Jennie gamlin.

Jennie is Associate Professor in Anthropology and Global Health in the UCL Institute for Global Health and director of the IGH Centre for Gender, Health and Social Justice. She leads the Wellcome Trust Funded research programme “Gender, Health and the Afterlife of Colonialism: Engaging new problematisations to improve maternal and infant health”, a mixed methods historical and ethnographic investigation into the historicity of gender in Indigenous Wixárika communities (see virtual exhibition of this project here). She is also co-investigator on the ‘Embodied Inequalities of the Anthropocene project’ together with Professor Sahra Gibbon (UCL Anthropology) , and collaborators in Mexico and Brazil. With Ros Greiner Jennie Co-Leads the MSc Module Gender and Global Health. She has previous led teaching modules Anthropology of Global Health, Qualitative Research Methods, Maternal Health and Risk (UCL Anthropology), and taught on undergraduate and postgraduate modules in UCL  Anthropology and Global Health.

Rosamund Greiner

Ros is a doctoral researcher in the UCL Institute for Global Health. Her PhD research is an ethnography of families raising children with Congenital Zika Syndrome in Barranquilla, Colombia. In her thesis she brings together critical disability studies with decolonial feminism, and explores themes of care work and reproductive labour, health system navigation and caregiver agency, and the social construction of disability. Together with Jennie, Ros co-leads the MSc module ‘Gender and Global Health’ and has taught on a range of modules including qualitative methods for global health and anthropological perspectives on global health.

This course provides an introduction to the methods and uses of applied conversation analysis in health, education, and social care research. The course introduces the core principles of CA before providing an opportunity for participants to take part in a live data session: making observations and shaping them into a more evidence-based formulation. The course will include presentations on data collection and formulating CA research questions. It will conclude with a focus on taking the next step to using CA and developing skills as an analyst.

The following topics will be discussed during the workshop:

• What CA is, and how it can be applied in health, education, and social settings.
• How data is collected, transcribed and analysed in CA.
• How to develop CA skills and how to embed CA methods in one's research

Who this course is for? 

This course would be of value to researchers, students and clinicians looking to conduct CA-informed research using recordings from naturally occurring conversations (particularly from health, education, or social care settings). A foundation in/familiarity with qualitative research methods would be preferred, as some basic knowledge will be assumed.

This is a single interactive workshop, lasting 4 hours, preceded by 2 hours online preparatory work.

Teaching will be delivered in person face-to-face by experienced applied CA researchers. You'll learn as part of a group, interacting through activities and questions and learning from others by taking part in the discussions that accompany each step. The final 30 minutes of the session will be for developing your personal goals and for further discussion.

We expect the course will require 6 hours to complete in total (including the preparatory work and the face-to-face session).

By the end of the course, you'll be able to:

• Understand the core principles of investigating naturally occurring conversation in applied health, education and social care settings.
• Recognise CA transcription conventions and be able to identify and describe basic features of talk-in-interaction.
• Understand the potential relevance, value and limitations of a CA approach to your own area(s) of enquiry

We are all from UCL’s Department of Language and Cognition, Division of Psychology and Language Sciences, Faculty of Brain Sciences

Suzanne Beeke

Dr Suzanne Beeke is a clinical academic whose research focuses on the impact of communication and cognitive disorders on the everyday conversations of adults with acquired neurological conditions talking to family, friends and health and social care professionals. She leads the Better Conversations Lab, a group of academics and clinical researchers using CA to understand communication difficulties and needs, and to underpin co-produced interventions: www.tinyurl.com/BetterConversationsLab 

Steven Bloch

Professor Steven Bloch is a clinical academic in communication and social interaction. He has a special interest in end-of life-care conversation, helpline interactions, and also interactions between people with progressive neurological conditions and family members. He is currently Head of Language and Cognition in the Division of Psychology and Language Sciences at UCL.

Andrea Bruun

Dr Andrea Bruun completed her PhD at the Marie Curie Palliative Care Research Department at UCL. She is specialised in the CA method and has worked with a variety of interactional data such as homecare visits, student counselling sessions, advanced lung cancer consultations, and hospice multidisciplinary team meetings. She is currently working at Kingston University as a postdoctoral researcher on a project on end-of-life care planning with people with learning disabilities.  

The session will cover how to write a qualitative academic paper, as well as tips for how to get your paper published in a peer-reviewed journal.  There are three parts to the course:

Who this course is for

The workshop is aimed at those who:

• Know the key principles of qualitative research
• Are already writing a paper based on qualitative research

This course may benefit those who have attended other QHRN training courses.

This is a one day course, lasting 2.5hrs.

Teaching will be delivered entirely online by experienced researchers. You'll learn as part of a group, interacting through activities and questions and learning from others by taking part in the discussions that accompany each step.

You will bring an example of your own writing based on qualitative research, and use it to learn principles of clear communication and effective writing.

By the end of the course you'll have gained knowledge about:

• How to write qualitative research for an academic journal
• How to increase the chances of a  paper being accepted by a journal
• How to practice thinking and writing clearly 

Julia Bailey

Dr Julia Bailey is a sexual health specialty doctor in South East London and senior researcher at the UCL eHealth Unit. Julia has a passion for bringing social science insights into health research, and is an expert in health communication including doctor-patient interaction, science communication for different audiences, and academic writing.

Tom Witney  

Cost and booking.

The cost of each course is £80, and places are limited to 25. Please use the link above to book.

Please note that bookings for each course close 5 days before the live workshop date. 

To support learning and encourage the dissemination of high quality qualitative research methodology we are pleased to offer a small number of bursary places for this course. 

Please email us at [email protected] before registering if you feel that you would benefit from this course, but the cost presents a barrier to your learning, and provide any details that you would like us to consider. If selected, the fees for this course will be reduced to £30. Note that the number of bursaries we will offer are limited so we encourage interested parties to contact us at their earliest convenience.

Certification

If you would like a certificate of attendance, please contact us after the course.

Terms and conditions

Our bursary policy is included in the terms and conditions, please send [email protected] a brief description of your need for a bursary towards specific training courses.

For information on terms and conditions, please read our training workshop terms and conditions document:

terms_and_conditions_for_qhrn_workshops_march_2024.pdf

Please contact us on:  [email protected]  if you have any questions about the training courses. 

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• Acknowledgements
• Conflict of interest

Subjects and Keywords

Related content.

• Next Article

Introduction to the special issue: Prospective qualitative research: new directions, opportunities and challenges

The combination of qualitative approaches and longitudinal research designs is a powerful way to explore changes in individual life courses as they occur. While qualitative research is mostly associated with retrospective studies that analyse lives ‘backwards’ in time, prospective qualitative studies that track lives as they unfold have grown in popularity over the past two decades. Their increased importance goes hand in hand with the growing attention in the social sciences to process and change versus stability and continuity through time. Prospective qualitative studies are uniquely suited to analysing continuity and change in people’s lives, offering a complex understanding of critical junctures, transitions and gradual, non-linear or contradictory processes of change as they are interpreted and revisited by individuals with the unfolding of their lives. With its intrinsic focus on time and temporalities, prospective qualitative research allows us to address not only changing meanings and perceptions, but how people examine their pasts and look into their futures, and how these temporal perspectives are modified along with life events and transitions.

Together with its undoubted advantages, a range of analytical and methodological challenges arise in the process of engaging with participants in a prospective qualitative study, where time, lives, perceptions and meanings are continually shifting and under revision. The benefits of combining prospective and retrospective insights and meanings involve a complex and demanding analytical effort that addresses potentially emerging discrepancies in the reporting of the same event or transition. The notion of a linear temporality that structures social action needs to be reconciled with narratives that reflect the fluidity of past and future time, stagnation, zigzag or even reversible developments. Questions of archiving are a source of concern for researchers whose data sets are iteratively generated over time, raising issues about consent, anonymity and ownership. Ethical issues also sharpen as the level of personal involvement between researcher and participant increases with repeated interactions across the different waves. With the increased availability of qualitative prospective studies, there is a growing agreement about the benefits of using secondary data. Arguments about research costs and underexploitation of existing data are gaining ground against the traditional reluctance of qualitative researchers to make their data available for reuse. There is, hence, an emerging need to reflect on the strategies and practices of data creation and management for long-term storage and use by others. In parallel, challenges of combining different data sources with similar foci for analytical and comparative purposes are increasingly recognised.

These are just a few of the challenges facing prospective qualitative researchers, but they clearly point to the need for further methodological reflection on how time impacts on the design, conduct and theoretical underpinnings of qualitative longitudinal studies. This special issue advances current debates and explores new theoretical and methodological directions in this field through a range of contributions that are both international and interdisciplinary in scope.

The first article, ‘Relative time and life course research’, by Núria Sánchez-Mira and Laura Bernardi argues the need for a more comprehensive theoretical conceptualisation of time in life course research integrating absolute and relative time. Building on the interdisciplinary literature, this theoretical piece proposes a tripartite definition of relative time (multidirectional, telescopic and elastic times), and shows the value of applying these concepts to analyse the intersection of biographical and social times. The authors discuss the implications of an explicit integration of relative time in life course research, and the suitability of prospective qualitative research for enhancing our understanding of the complex temporal processes that shape the lives.

In the second article, ‘Studying turning points in labour market trajectories – benefits of a panel-based mixed methods design’, Nicolas Legewie and Ingrid Tucci look at the potential of having a qualitative study nested into a population representative panel study and the added value of a mixed methods design for the fine-grained analysis of turning points in labour market trajectories. The example given concerns a qualitative study of migrants added to the German Socio-economic Panel. Combining the information obtained in retrospective in-depth interviews with panel survey data allows a double entry and a more integrated understanding of the complexity of processes involving critical junctures and their multifaceted nature, including their objective measurement and their subjective reporting. The authors argue how mixing methods yields not only complementary but also analytically valuable discrepant information, which can help avoid under-theorisation and misinterpretation of life sequences. Linking panel survey data and repeated qualitative interviews in the study of life course processes is outlined as a promising future avenue for research.

The next two articles deal more specifically with challenges and opportunities related to research design and data management and analysis in qualitative panels. In their contribution ‘Little and large: methodological reflections from two qualitative longitudinal policy studies on welfare conditionality’, Peter Dwyer and Ruth Patrick compare two UK research projects with which they have been involved. They reflect on the potentialities and challenges of working with different scales of study and time spans, and the existing trade-offs in terms of explanatory breadth and depth. Their article shows the value of analysing people’s experiences through time in order to understand how and why processes of behaviour change may occur, while highlighting the challenges and benefits of the demanding analytical effort specific to qualitative longitudinal research. The authors explain why qualitative longitudinal research is ideally and uniquely suited to address how individuals engage with policy interventions and the resulting effects on their lives.

Susanne Vogl and Ulrike Zartler base their contribution, ‘Interviewing adolescents through time: balancing continuity and flexibility in a qualitative longitudinal study’, on a project in Vienna. They address the challenges of maintaining a qualitative study through time, looking in particular at the necessary balance between flexibility and continuity in the generation of temporal interview data. Change being a core aspect of qualitative longitudinal research, a certain degree of openness, adaptation and innovation are crucial for maximising the advantages of this approach. At the same time, a given degree of continuity is needed to maintain the focus and comparability over time. The authors discuss the challenges involved in achieving this delicate balance and offer practical advice based on their own experiences in managing an interview panel study, focusing on two main issues: panel maintenance and substantive changes in the research setup or the research team.

In her final commentary, ‘Promises and pitfalls of qualitative longitudinal research’, Betina Holstein addresses the promises and expectations raised by qualitative longitudinal research, as well as some of the main challenges and potential pitfalls involved in the design of a qualitative longitudinal study. The commentary provides interesting insights on how choices about methods for data collection and data analysis along with sampling strategies crucially influence the comparisons that can be drawn across cases and over time and, thus, which inferences can and cannot be made from the data. Holstein shows how different methods of data collection and analysis are not independent from the degree of stability and change that is identified with the analysis. She argues that the temporal aspects of the research design must match the expected rhythm of change and stability that the study aims to enquire, and that a minimum degree of standardisation must be ensured to be able to bring out dynamic developments. Finally, she reflects on how sampling strategies determine the study’s explanatory power.

It is the hope of the co-editors that this special issue will provide useful theoretical and methodological avenues for facing the challenges built into prospective qualitative research. At the same time, we hope that we have contributed another stone to bridge quantitative and qualitative life course research, by arguing in favour of the integration of multiple time perspectives and of different kinds of panel studies.

Bren Neale, a pioneer in the theoretical conceptualisation of temporalities, acted as consultant for the special issue. We are grateful to Bren for her critical advice on themes covered in this special issue.

The authors declare that there is no conflict of interest.

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• Published: 20 August 2024

“Because people don’t know what it is, they don’t really know it exists” : a qualitative study of postgraduate medical educators’ perceptions of dyscalculia

• Laura Josephine Cheetham 1  

BMC Medical Education volume  24 , Article number:  896 ( 2024 ) Cite this article

Metrics details

Dyscalculia is defined as a specific learning difference or neurodiversity. Despite a move within postgraduate medical education (PGME) towards promoting inclusivity and addressing differential attainment, dyscalculia remains an unexplored area.

Using an interpretivist, constructivist, qualitative methodology, this scoping study explores PGME educators’ attitudes, understanding and perceived challenges of supporting doctors in training (DiT) with dyscalculia. Through purposive sampling, semi-structured interviews and reflexive thematic analysis, the stories of ten Wales-based PGME educators were explored.

Multiple themes emerged relating to lack of educator knowledge, experience and identification of learners with dyscalculia. Participants’ roles as educators and clinicians were inextricably linked, with PGME seen as deeply embedded in social interactions. Overall, a positive attitude towards doctors with dyscalculia underpinned the strongly DiT-centred approach to supporting learning, tempered by uncertainty over potential patient safety-related risks. Perceiving themselves as learners, educators saw the educator-learner relationship as a major learning route given the lack of dyscalculia training available, with experience leading to confidence.

Conclusions

Overall, educators perceived a need for greater dyscalculia awareness, understanding and knowledge, pre-emptive training and evidence-based, feasible guidance introduction. Although methodological limitations are inherent, this study constructs novel, detailed understanding from educators relating to dyscalculia in PGME, providing a basis for future research.

Peer Review reports

Dyscalculia is categorised as a specific learning difference or part of neurodiversity in the UK and a learning disability in North America. Learners with dyscalculia are said to have significant difficulties in numerical processing [ 1 ]. It is increasingly acknowledged that these relate to arithmetic, statistics, ordinance, number and code memorisation and recall, with other individual variance [ 2 , 3 ]. Here, I chose to use “specific learning difference” (SpLD) to acknowledge that some feel SpLDs relate to a difference in learning needs but may not always result in learners identifying as disabled [ 4 , 5 ]. Most contemporary definitions state that these challenges are out of keeping with learner age, intelligence level and educational background [ 1 ], evolve over time but persist during adulthood.

Dyscalculia is a comparatively recently recognised SpLD with a relatively low ‘diagnosed’ population prevalence, with estimates ranging between 3% and 7% [ 2 ]. Awareness of dyscalculia is lower than more highly ‘diagnosed’ SpLDs such as dyslexia, dyspraxia and Attention Deficit and Hyperactivity Disorder (ADHD) [ 3 ], with a paucity of research-based evidence, especially relating to adult learners [ 2 ]. Of the two studies exploring dyscalculia in Higher Education Institutions (HEI), from the perspective of learners, both Drew [ 3 ] and Lynn [ 6 , 7 ] outlined poor understanding within adult learning environments and a lack of recognition of dyscalculia and of HEI learning support provision. Additionally, learner challenges were different to those described in dyslexia and dyspraxia studies, with understanding and perception of time, distance, finances, non-integer numbers, memorisation and recall of numerical codes and values being frequent issues. Potential complexity arose through possible coexistence of dyslexia or mathematical anxiety, varying learner-developed coping strategies effectiveness and learner coping mechanisms becoming ineffective during undergraduate or postgraduate education [ 3 ]. Drew’s [ 3 ] three healthcare learner participants had also experienced potential fitness to practice concerns either from themselves or educators.

Context for medical education

The number of DiT in postgraduate medical education (PGME) with dyscalculia remains unknown. Similarly, awareness levels of PGME educators, or what their experiences might be, of facilitating the learning of DiT with dyscalculia is unexplored. Indeed, there has been no published research to date relating to dyscalculia in PGME or undergraduate medical education.

This paucity of knowledge is set in the context of a presumed increasing proportion of UK PGME DiT learners with a disability resulting from increasing numbers of medical students in the UK reporting a disability [ 8 , 9 ] and in other countries such as Australia [ 10 ]. Data collection via the statutory education bodies, and the medical regulator, the General Medical Council (GMC), is challenging given the voluntary nature of SpLD declaration and persisting concerns regarding discrimination and stigma [ 11 ]. My Freedom of Information request to the GMC in February 2022 revealed that 1.25% of registered doctors have declared a ‘learning disability’ (including SpLDs) such as dyslexia.

The impact of dyscalculia on DiT and their educators is unknown. The GMC defines differential attainment as the gap in assessment outcomes between learners grouped by protected characteristic [ 12 ]. It recently commissioned research into recommending education providers create more inclusive learning environments for disabled learners [ 13 ]. Other recent research indicates that differential attainment may persist from school-based examinations through to medical school exit ranking scores and onto PGME examinations [ 14 ].

Currently, there is no publicly available information addressing the support of PGME DiT with dyscalculia within the UK, and no known prospective screening in place. Support, including reasonable adjustments for PGME DiT with additional learning needs is accessed through, and coordinated by, education bodies’ Professional Support Units (PSU), including Health Educator and Improvement Wales’ (HEIW) PSU in Wales. More widely, HEIW, the education body in Wales, is responsible for delivery and quality management of PGME in accordance with UK-level standards set by the GMC and medical speciality Royal Colleges and Faculties. Reasonable adjustments are changes, additions, or the removal of learning environment elements to provide learners with additional support and remediate disadvantage [ 15 ]. They are frequently purported to enable learners with SpLDs to learn and perform to their potential, although evidence for this is variable [ 16 , 17 ], with a marked lack of research relating to adult learners with dyscalculia.

Despite recent shifts from more teacher-centred to more student-centred learning approaches, with a range of andrological learning theories emphasising the learner being at the centre of learning [ 18 ], the educationalist remains a key element of many learning theories and PGME. Many PGME educators are practising doctors and, alongside this, must maintain a contemporaneous understanding of learning theory, training delivery, teaching, supervision and wider educational policies. However, how they approach, or would plan to approach, supporting learning for DiT with dyscalculia is unknown. Therefore, exploring the attitudes and perspectives of PGME DiT or educators regarding dyscalculia, both unresearched previously, through this paradigm could be valuable [ 19 ].

Educational challenges, learning needs and local context

For educators, a pivotal part of facilitating learning is understanding the learning needs of learners, felt to be a cornerstone of adult pedagogy [ 19 , 20 ]. Davis et al. [ 20 ] define learning needs as ‘’any gap between what is and what should be”. These can be established subjectively, objectively or a combination approach. However, Grant [ 19 ] cautions against conducting limiting, formulaic learning need assessments.

Identifying attitudes and understanding

Furthermore, attitudes are said to frame educator approaches and thus the learning experiences learners will have [ 21 ]. Attitudes are defined as “a feeling or opinion about something or someone, or a way of behaving that is caused by this” [ 22 ]. Interpretivism offers a route to exploring such attitudes by outlining that there is no one universal truth or fact, but instead many equally valid realities constructed by different individuals, their meaning-making and their experiences.

Again, research is absent within medical education relating to educators’ attitudes and understanding of learners with dyscalculia and how these might influence their approach. Current research indicates attitudes of HEI educators are often formed through their past - or absent past - experiences, lack of legal obligations knowledge and, for healthcare educators, the patient-centred role of clinical learners [ 23 ]. These appeared to help form their approach to facilitating teaching [ 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. Therefore, understanding PGME educationalist attitudes towards DiT with dyscalculia would be important in helping understand how learning is facilitated.

Thus, there exists a clear lack of published knowledge and understanding regarding dyscalculia set in a context of increasing awareness of the importance of inclusivity and addressing differential attainment within medical education. The importance of educators in facilitating learning of such PGME DiT suggests that exploring their perspectives and understanding could provide valuable insights into this understudied area. Such knowledge could provide benefit to learners and those designing and delivering programmes of learning for DiT and programmes of support for educators. This includes potentially exploring the attitudes and understanding of educators who have no direct experience of dyscalculia, given that this could be the context in which a DiT with dyscalculia finds themselves in a postgraduate learning environment. Assumptions, or perceptions generated without experience or knowledge of dyscalculia, are equally important to understand in a learning context when the awareness level and prevalence of dyscalculia within DiT is unknown. This allows understanding of how learning for DiT with dyscalculia may be facilitated in a knowledge and understanding-poor context, and furthermore, what educator needs exist and what further research is needed.

Consequently, the research question and aims below were constructed.

Research question:

What are the attitudes towards , understanding and perceived challenges of dyscalculia within postgraduate medical training by postgraduate medical educators?

Research aims:

To explore the awareness and understanding of dyscalculia that postgraduate medical educators may or may not have.

To determine the attitudes that postgraduate educators have towards dyscalculia and DiT with dyscalculia and how these might be formed.

To establish the challenges that postgraduate educators perceive they encounter or might encounter when facilitating the learning of a DiT who has dyscalculia.

To provide the basis for future research studies exploring how to facilitate the learning of DiT with dyscalculia during postgraduate training.

This scoping study was designed using an interpretivist, constructivist qualitative methodology to understand the phenomenon, in detail [ 30 ] as part of a Masters in Medical Education programme.

A literature review was undertaken to enable research question and aim construction. Firstly, a focused literature search ascertained the level, and lack, of evidence existing for the study phenomenon followed by four, progressively broader, searches to understand the wider context, between October 2021 and May 2022, revealing the lack of, or limited, literature existing.

The literature search was then performed by me using guidance [ 31 , 32 ] and twenty-seven research search engines. Additionally, a spectrum of journals was searched directly. Literature was also identified through snowballing.

Keyword search terms were developed and refined during the literature search, with limits on further broadening the search based on relevance to the areas of interest: postgraduate learners, educators and SpLDs using different term combinations exploring dyscalculia and postgraduate education, SpLDs and postgraduate healthcare learners, postgraduate educators and attitudes or knowledge or experiences of facilitating learning (appendix 1, supplementary material). Broadening of search terms allowed for exploration of analogous phenomena (other SpLDs), in other postgraduate healthcare and learning contexts, and for further research question development, returning 2,638 items. Papers were initially screened using their titles and the inclusion/exclusion criteria (below) generating 182 articles, papers and theses, with abstracts and reference lists reviewed. 174 papers and eight PhD theses were appraised using guidance [ 32 , 33 , 34 ].

Inclusion criteria were:

Primary research or review.

International or UK-based research reported in English.

Postgraduate higher education (university-level, post Bachelor or equivalent degree) setting.

Relating to postgraduate or higher educationalists’ views from any discipline and knowledge of SpLDs.

Exclusion criteria were:

Literature published in non-English languages.

Opinion and commentary articles.

Undergraduate setting, unless mixed cohort/study with postgraduate learners.

Ultimately, 17 papers and one doctoral thesis were included. Whilst grey literature, this thesis [ 3 ] was included due to the dyscalculia-focused insights provided and limited adult-based dyscalculia research elsewhere. After literature appraisal, research aims and a research question were formed.

Semi-structured interviews were chosen to enable data collection and interpretation through a constructivist lens, via open enquiry rather than hypothesis testing [ 30 , 35 , 36 ]. Study participants were PGME educators, actively involved in DiT learning within any PGME programme within Wales whilst holding a Medical Trainer agreement with HEIW. Participants held a range of educationalist roles, from education supervisor to local speciality-specific Royal College tutor (local speciality training lead) to training programme director (responsible for delivery of speciality-specific training across a region).

Interview question and guide design (appendix 2, supplementary material) drew on the six qualitative and six quantitative research-based, validated published tools used to explore similar phenomena, particularly those of O’Hara [ 37 ], Ryder [ 38 ], L’Ecuyer [ 23 ] and Schabmann et al. [ 39 ]. Design also drew upon Cohen et al’s [ 40 ] recommendations of composing open, neutral questioning.

Interview format was piloted using a PGME educator from England (thus ineligible for study recruitment) with modifications resulting from participant feedback and through adopting reflexivity; as per Cohen et al. [ 41 ] and Malmqvist et al. [ 42 ]. Participant interviews took place between May and June 2022 and were recorded via the University-hosted Microsoft Teams platform, due to the pandemic-based situation and large geographical area involved, whilst maintaining interviewer-interviewee visibility during the dialogue [ 35 ]. Recruitment occurred via purposive sampling, through two HEIW gatekeepers, the national Directors of Postgraduate Secondary (hospital-based) and Primary (General Practice-based) Medical Training in Wales. An email-based invitation with project information was distributed to all postgraduate medical educators with a current HEIW Medical Trainer agreement, regularly engaging in the support of learners within PGME training, in Wales. In this case, the gatekeepers in HEIW were individuals who could grant permission and make contact with all potential eligible participants on behalf of myself, through their email databases, whilst adhering to UK data protection regulations [ 43 , 44 ].

Ethical considerations

Formal ethics approval was gained from the Cardiff University School of Medicine Research Ethics Committee. Health Research Authority ethics approval was considered but deemed unnecessary. Informed written and verbal participant consent was obtained prior to, and at the point of, interview respectively. Additionally, verbal consent for video recording was sought, offering audio recording or notetaking alternatives; however, participant discomfort was not reported. Mitigation options to avoid selection bias included selecting alternative volunteers if significant relationships between the researcher and participant had existed.

Invitations to participate were circulated to approximately 2,400 to 2,500 postgraduate secondary care trainers and 600 primary care trainers. 18 individuals indicated interest in participating, one cancelled and seven did not respond to follow-up within the two-month timeframe the MSc project schedule allowed for. Subsequent reasons given for two out of seven who subsequently responded out of timeframe included clinical demands and unexpected personal matters. 10 postgraduate educators were interviewed and all allowed video-based interview recording. Interviews lasted between 40 and 60 min. Interviews were transcribed verbatim by me and checked twice for accuracy, with participants assigned pseudonyms. Data analysis was conducted using reflexive thematic analysis (RTA) and undertaken by me, the author, as the single coder and Masters student, with transcripts analysed three times.

RTA followed the six-step approach of Braun et al. [ 45 ], Braun and Clarke [ 46 ] and Braun and Clarke [ 47 ], with a primarily inductive approach [ 47 , 48 ] through an iterative process. Both latent and semantic coding approaches were used, guided by meaning interpretation [ 49 ].

RTA allowed exploration through an interpretivist lens. Discussions persist regarding how RTA sample size sufficiency and ‘data saturation’ are determined, with RTA placing more emphasis on the analyst-based individualism of meaning-making. Therefore, mechanisms for determining thematic saturation are purportedly inconsistent and unreliable [ 50 ]. Consequently, sample size was based on the maximum number of participants recruited within the set project time limits.

Reflexivity

I strove to adopt reflexivity throughout, using a research diary and personal reflections, referring to Finlay [ 51 ] who stated that such subjectivity can evolve into an opportunity. My interest in the studied phenomenon resulted partially from my experiences as a DiT with SpLDs and from being a DiT representative. Acknowledging this was important given my perspective, as an intrinsic part of this research, could have affected data gathering, interpretation, and, ultimately, study findings through introducing insider status.

Additionally, holding an influential role within the research, with potential for ‘interviewer bias’ [ 52 ], I adopted Cohen et al.’s [ 53 ] recommendations, committing to conscious neutrality during interviews and use of an interview prompt list, whilst striving to maintain a reflexive approach. Alongside this, the impact on credibility of this study being part of a Masters project, limiting scale and timeframes were considered and mitigated by exploring these within the discussion and referring to this research as a scoping study.

Educators with limited to no direct experience of learners with dyscalculia knew little to nothing about dyscalculia (Fig.  1 ).

Summary of themes and subthemes generated

Furthermore, of the participants who did, these educators cited close second-hand experiences with family members or past learners with dyscalculia which helped shape their understanding of dyscalculia. Those that had no direct experience drew on empathy and generalisation, extrapolating from the greater knowledge and confidence they had in their understanding regarding dyslexia or other SpLDs or even analysis of the term ‘dyscalculia’ to form definitions and perceptions.

“Absolutely nothing… I saw it , [dyscalculia in the study invitation] didn’t know what it was and Googled it so very , very little really. I suppose in my simplistic surgical sieve head , I would just sort of apply the bits and pieces I know around dyslexia.” P10 .

All suggested dyscalculia represented a specific set of challenges and associated learning needs relating to numbers, numeracy or quantity where overall intelligence was preserved. Educators saw each learner as being an individual, therefore felt dyscalculia would present as a spectrum, with varying challenges and needs existing. Dyscalculia was seen as persisting lifelong, with the challenges and needs evolving with age and experiences. Common challenges suggested related to calculations, statistics, critical appraisal, awareness of time, organisation and recall of number-based information (such as job lists, blood results), spatial dimension quantification, prescribing, fast-paced tasks and emergencies, exams and learning-based fatigue or high cognitive load. Wellbeing issues relating to dyscalculia were also frequently perceived, with this potentially negatively affecting self-confidence and anxiety levels. All educators saw a key aspect of their role to be provision of pastoral support, in enabling effective learning.

Past educator experiences of dyscalculia were linked to perceived confidence in ability to support future DiT with dyscalculia. Educators felt their limited knowledge, with the primary source of information regarding dyscalculia being DiT with dyscalculia themselves, to be reflective of low levels of awareness, knowledge and identification within PGME, education systems and wider society. Some felt the proportion of PGME DiT with dyscalculia would be lower than for the general population, following challenging assessments during secondary school and undergraduate studies, but might be changing given widening participation initiatives within medicine. Others saw a potential hidden iceberg of later career stage doctors with unidentified dyscalculia who had completed training when speciality assessments relied less on numeracy.

“[It] was only because of my own experiences and my [relative] that I was able to kind of wheedle around and , you know , make them recognise that there was an issue and that , you know. But I - I think had I not had an awareness of it , I probably wouldn’t have recognised it , I think.” P7 .

Educators frequently used empathy when attempting to understand dyscalculia. Educators had mixed feelings about ‘labelling’ DiT as having dyscalculia although all felt identification of additional learning needs was key. Some felt labels were necessary to enable and better support DiT with dyscalculia in the absence of effective, feasible, inclusive education approaches, others noted the potential for stigma or generalisations.

None of the participants had received dyscalculia training. Some felt widespread societal normalisation of mathematics challenges adversely impacted upon if, and at what educational stage, dyscalculia identification occurred and needs were recognised. Many felt assumptions might occur regarding dyscalculia through others making generalisations from better known SpLDs, including dyslexia and dyspraxia, in the absence of other knowledge sources but that these extrapolations could be inaccurate and unhelpful.

“And I think there’s a lot of ‘oh you’re just bad with numbers’ or ‘ohh , you just can’t do , you know people are just , I , I suspect there’s a lot of people who have just been told they’re not very good at maths , aren’t there? And it’s just , you know they can’t , can’t do it , which you know is not really very fair , is it?” P7 .

Many felt PGME might represent a critical juncture for DiT with dyscalculia, where effective coping mechanisms developed in the past become ineffective. A variety of such coping mechanisms were suggested or hypothesised, often outlined as depending on the dyscalculia-based experience level of the educator, including checking work with others, calculator use and avoidance of numeracy-dense work or specialities.

Mechanisms were generally viewed positively except where perceived to reduce the likelihood of a DiT recognising dyscalculia themselves and seeking support.

Most felt positively towards learners with dyscalculia and their learning facilitation, especially those with greater experience of dyscalculia. Many balanced this positivity with potential concerns regarding patient safety. Concerns focused especially on heavily numeracy-based tasks, fast-paced situations, or when working independently in surgical or emergency prescription-based situations. Overall, concerns were heightened due to the clinical patient-based context to PGME learning. Two participants felt that not all DiT with dyscalculia should be supported to continue training in particular specialities where numeracy skills were seen as critical, such as ophthalmology.

“I am , and it just seemed really unfair that this one small thing could potentially have such a big impact and could potentially prevent [them] progressing and succeeding in the way that I think you know , [they , they] had the potential to.” P6 .

Educators outlined a dependence on the bidirectionality of learner-educator relationships to best facilitate DiT learning per se, and it was felt all DiT had a responsibility to be honest with educators. Some cited potential barriers to this collaboration, including past negative learner experiences, felt stigma, limited educator time and frequent DiT rotations.

“It’s a wonderful opportunity for learning which I really enjoy , because I think that this is a two-way process. You know , I think the DiT gives you things that you reflect on and you should be giving the DiT things that they reflect on” P5 .

Most felt they would take a one-to-one learning approach for DiT with dyscalculia. Group-based, fast-paced or numeracy-rich, higher risk clinical activity-based teaching would be more challenging to cater for.

For some, patient safety uncertainties abutted with the duality of being a clinician and educator, with perceived difficulty in quantifying clinical risks associated with learning and educators’ clinical workload demands limiting available time and resources. Thus, many felt that their educator roles always needed to be tempered with their duties as a doctor, prioritising patient safety and quality of care above all else.

“So , it’s not so much the learning , uh , issue that worries me. I think even if someone had dyscalculia the , uh , concepts of medicine could be understood and the basic outline of what we’re doing , but actually you’ve got to be quite precise in the vocational aspect of , of , of the training , and if you get it wrong , it’s a potential major clinical risk and obviously patient safety has to come first in everything that , that we do.” P4 .

Educators wished strongly for pre-emptive support in facilitating the learning of DiT with dyscalculia, feeling great responsibility both for DiT learning but also for upholding clinical standards and safety. Many felt they would approach HEIW’s PSU for reactive support, including seeking learner ‘diagnosis’, although some predicted this support, and their knowledge, might be limited. However, two participants outlined positive experiences after seeking PSU support.

Most educator participants supported reasonable adjustment use if patient safety and quality of care remained prioritised and preserved. Other conditions for supporting reasonable adjustments included if they enabled without giving undue advantage and if educator-related workload was not overly burdensome. Those with experience of dyscalculia more confidently volunteered reasonable adjustments suggestions, ranging from calculation-table or App access to additional time for numeracy-rich activities. Some perceived a challenging divide between clinical educators and SpLD education experts who could make potentially unfeasible reasonable adjustment recommendations, with participants suggesting the importance of greater involvement of clinical educators in developing support processes.

“If I’m honest , I don’t think we do it very well…They’re [reasonable adjustments offered] very simplistic , … you know , they’re very much based on a sort of global ability rather than realising that processing and other things might be impacted… We’re , we’re probably behind the curve and not really doing what could be done” P8 .

Further example quotes for each theme and subtheme can be found within appendix 3, supplementary material.

Experience shapes educator knowledge, understanding and attitudes

This study reveals novel findings regarding dyscalculia in PGME within a vacuum of prior research. Notably, participants’ views towards PGME learners with dyscalculia, including DiT potential to learn, practise and develop effective coping strategies, were substantially more positive and empathetic than in the closest comparable healthcare studies of other SpLDs [ 23 , 24 , 27 , 29 , 54 ]. Furthermore, the potential impact of societal normalisation of numeracy challenges on awareness of, and attitudes towards, dyscalculia explored by some participants has only previously been noted by Drew [ 3 ].

Educators’ expressions of a sense of personal or healthcare-wide lack of awareness and understanding of dyscalculia aligns with the current UK position [ 2 ]. But they also built on this, outlining how generalisation from other SpLDs or disabilities was frequently used to bridge the dyscalculia knowledge gap with some not recognising this as potentially problematic. This suggests a need for enhanced awareness and understanding within the healthcare education community of the potential fallibility of using generalisation to support learners with poorly understood additional needs.

Moreover, no other studies have revealed that healthcare educators with personal experience of a learner relative with a SpLD displayed universally positive attitudes towards DiT with the same SpLD. Whilst this could reflect inter-study methodological differences, inter-professional differences or the increasing emphasis on compassionate clinical practice [ 55 ], it also suggests influence of educator experience in attitude formation.

In addition to their attitudes, the impact of prior experience of learners with dyscalculia on educators’ knowledge, understanding and confidence was often acknowledged as important by participants. This was seen to an extent in the closest comparable SpLD studies, [ 24 , 54 ] and further shows the diverse influence of past educationalist experiences, particularly the establishment of deep, longitudinal relative-based relationships, aligning with social constructivism [ 56 ].

Unlike HEI lecturers in dyslexia studies [ 24 , 54 ], who frequently questioned the needs of learners, educators saw DiT with dyscalculia as intelligent and high-functioning, having credible additional learning needs. Needs were seen as variable unlike elsewhere. Additionally, the level of detail constructed regarding educators’ perceptions of the needs, strengths and challenges of each DiT with dyscalculia, evolving over time and experience, is not seen in non-dyscalculia SpLD studies and only alluded to for dyscalculia [ 3 ]. These differences, which may be partially explained by varying methodologies or cultural norms regarding how different SpLDs are regarded, are important to better understand.

Furthermore, the preferred educator approach of individualising learning for DiT with dyscalculia is not seen elsewhere in the literature, although this aligns with supporting learning within their zone of proximal development (ZPD). Rather, Ryder and Norwich found HEI educators actually expressed negative attitudes towards individualising learning [ 24 ]. Methodological and SpLD-specific factors may contribute to these differences, with this study’s findings aligning more closely with Swanwick’s proposal that PGME often emulates apprenticeship-type learning [ 57 ]. It would be valuable to establish the efficacy of individualised PGME-based approaches to facilitating learning with dyscalculia from DiT and educator perspectives.

Greater educator support and training regarding dyscalculia is needed

Educators’ perceived need for wider awareness of dyscalculia, alongside greater pre-emptive training and guidance tailored towards dyscalculia within PGME learning environments has also been described for other SpLDs [ 23 , 58 , 59 ]. Greater research is needed to develop such awareness and evidence-based training, with similar needs identified more widely in HEI for dyscalculia [ 3 ] and for other SpLDs [ 23 , 24 , 27 ]. Akin to some participants, Swanwick and Morris [ 60 ] discuss the increasing expectations on clinical educationalists to deliver professional-level education and Sandhu [ 61 ] explores participants’ expressed need for greater faculty development whilst rectifying the deficit of evidence-base for PGME educators to use.

The crucial importance of the bidirectionality of the educator-learner relationship, with educators perceiving themselves as learners too, is only subtly alluded to elsewhere [ 3 ]. Given the bidirectional learning relationship was reportedly undermined by frequent DiT placement rotations, fast-paced clinical environments and shift-based training patterns, further exploration of the appropriateness of current UK PGME training design for DiT with dyscalculia could be important.

Coping strategies are important to better understand

As with this study, Drew’s research suggested coping strategies for learners with dyscalculia to be potentially important, effective and helpful but could have limitations [ 3 ]. However, this study provides the first examples of coping strategies, potential or already used, by DiT with dyscalculia. It is crucial that research to develop better understanding of both positive and negative dyscalculia-based coping mechanisms occurs in the future given the broad participant concerns.

Identification is key but not fully enabling

Educators perceived early identification of dyscalculia to be key, showing commonality with dyscalculia, dyslexia and dyspraxia-based studies [ 3 , 25 , 28 ]. That identification was not seen as an absolute solution reinforces the need for further research exploring other disabling factors. However, the witnessed or potential negatives of being ‘labelled’ following dyscalculia ‘diagnosis/identification’, outlined by some participants, have been found only minimally elsewhere within learner-based dyslexia and dyscalculia HEI studies [ 3 , 25 , 28 ]. Negative consequences to labelling included the attitudes learners encountered within the clinical community, suggesting a need to understand cultural norm-related impacts. In contrast, the far greater positives to identification, and the necessity of labelling perceived by educators, were also seen in other SpLD studies [ 3 , 25 , 28 ], enabling self-understanding and access to support. Certainly, the need for improved dyscalculia identification approaches and training is highlighted by the lack of educator confidence in identifying dyscalculia where they had no relative-based experience.

Within the UK, voluntary dyslexia ‘screening’ processes are now offered to some medical students and DiT and similar opportunities could be offered for dyscalculia in the future. Moreover, accumulating evidence indicates an ever-greater importance of establishing equity of learning opportunity and that identification has a positive performance effect for DiT with dyslexia [ 16 , 62 , 63 ].

The PGME clinical context may limit support

Whilst educators clearly adopted a strongly student-centred approach to supporting learning with dyscalculia, addressing the influence of the duality of clinical educator roles on this approach is important. Educator supportive intent was twinned with tension between balancing effective DiT learning with guaranteeing patient safety within diverse, predominantly clinical learning PGME environments, sharing commonalty with L’Ecuyer’s nursing study [ 23 ]. Swanwick and Morris [ 60 ] note this influence on delivering training, with Sandhu [ 61 ] exploring general concerns regarding risk and clinical learning.

Even more pronounced perceived patient safety concerns were expressed in other nursing SpLD studies [ 23 , 29 , 54 , 64 ], and further post-qualification independent working concerns emerged [ 23 , 65 , 66 ], which limited educators’ willingness to support learning. Together, these tensions appear to set learning facilitation for those with dyscalculia within healthcare apart from non-healthcare settings. Therefore, healthcare-specific education research and training is needed to address this, especially given thus far, analogous concerns regarding dyslexia and clinical risk remain unproven.

The influence of educator-reported increasing clinical workload and resource limitations on approach towards supporting DiT with dyscalculia was similarly seen within nursing studies [ 23 , 29 ]. Whilst the impact of clinical demands on UK-based educators are broadly known [ 67 ], greater recognition of the potentially disproportionately negative impact on DiT with dyscalculia needs to be made by those overseeing training delivery.

Uncertainty regarding reasonable adjustments need addressing

Additionally, whilst educators were generally supportive of RAs for DiT with dyscalculia, most intending these to be enabling, caveats to RA introduction were substantial for some. Concerns regarding RA implementation for DiT with dyscalculia were similar to nursing and wider HEI SpLD studies [ 24 , 66 ], but less common or absolute, most relating to feasibility, fairness and adverse impact on educators. These are important to explore if inclusivity in PGME is to be further embraced. Furthermore, and similarly to HEI findings [ 24 ], participant concerns about externally-mandated RAs derived from distant SpLD experts suggest that harnessing coproduction, with greater involvement of clinical educators in RA design, could be important for future endorsement. Additionally, whilst the scale of potential RA suggestions for dyscalculia made in this study is novel, it is important that the experiences of DiT with dyscalculia themselves are captured and used to ensure adjustments are truly enabling.

Therefore, whilst this study reveals important and novel discoveries relating to educators, PGME and dyscalculia, establishing DiT experiences of dyscalculia and PGME is the most crucial avenue of future research to next undertake to better understand and enable both DiT and educators to fulfil their roles effectively and inclusively.

Limitations

As a small, qualitative scoping study undertaken in Wales, study findings cannot and should not be generalisable. Seemingly the first study in this area, transferability should also be considered carefully. Due to purposive sampling, those volunteering may have been more interested in this topic; therefore, findings may not reflect the range of knowledge, attitudes, and experiences of all PGME educators.

Furthermore, use of interviews for data collection and the resultant lack of anonymity may have altered participant contributions. Moreover, despite adopting reflexivity, as a relatively inexperienced, sole researcher, I will have engaged in interviews and analysed data with intrinsic unconscious biases, introducing variability and affecting finding credibility. Despite methodological limitations within this small scoping study, my intention was to construct detailed understanding, providing a basis for future research.

This study reveals, seemingly for the first time, the attitudes, understanding and perceptions of PGME educators relating to DiT with dyscalculia. It highlights that lack of awareness and understanding of dyscalculia exists within the PGME educator community, especially in the absence of relatives with dyscalculia, and that widely accessible, evidence-based approaches to identification, support, teaching approaches and RA provisions are needed and wanted by PGME educators.

The rich stories of participants illuminate the emphasis educators place on experiential learning in informing their perceptions and training approaches, especially in the absence of prospective dyscalculia training or evidence base to draw upon. Given this, including the impact of limited or complete lack of dyscalculia experience and the substitution of generalisation to fill knowledge gaps found in this study, there is a real need for greater PGME-focused research to pre-emptively inform and support all educators.

Furthermore, greater acknowledgement and understanding of the seminal influence that clinical context has on educators, their attitudes towards supporting DiT with dyscalculia and the highly prized bidirectional learning relationships, as revealed in this study, are needed. It highlights the need for greater research to better understand the impact that specific nuances of PGME might have on educators’ support of DiT with dyscalculia and further characterise unmet needs. Future research must begin to address educator uncertainties revealed in this study around potential concerns relating to patient safety and care and differential approaches for dyscalculia and unfairness to other learners to move PGME forward in an effective, inclusive and enabling way.

Notable in this study is the lack of the learner voice, and future research needs to begin to better understand the perceptions and experiences of DiT with dyscalculia of PGME across a wide range of aspects. These could involve those suggested by participants, including DiT PGME learning and assessment experiences, coping strategies, reasonable adjustments and cultural norm impact. Furthermore, clarifying the wider awareness and knowledge levels of PGME educators regarding dyscalculia via more quantitative approaches could help build breadth to the understanding of this poorly understood phenomenon alongside the depth provided by this study.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Attention Deficit and Hyperactivity Disorder

Doctors in Training

General Medical Council

Higher Education Institution

Health Education and Improvement Wales

Postgraduate Medical Education

Professional Support Unit

Reasonable Adjustment

Reflexive Thematic Analysis

Specific Learning Difference

United Kingdom

Zone of Proximal Development

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Acknowledgements

LJC would like to thank her academic supervisor Ms Helen Pugsley, Centre for Medical Education at Cardiff University, for her guidance and encouragement during LJC’s Masters project. LJC would also like to thank all the interview participants who took an active part in shaping this project. LJC is extremely grateful for their time, honesty and for providing such vivid and illuminating windows into their roles as educators. LJC would also like to thank Dr Colette McNulty, Dr Helen Baker and wider staff members at HEIW for their support in circulating her study invitation to trainers across Wales.

LJC did not receive any funding for, or as part of, the research project described in this paper.

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LJC designed and undertook the entirety of the research project described in this paper. She also wrote this paper in entirety.

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This study received ethical approval from Cardiff University’s Medical Ethics Committee. After discussions, it was felt that NHS Research Ethics Committee approval was not needed. Written and verbally informed consent to participate was obtained, with prospective participants being provided with information regarding the study and their rights at least three weeks before interviews took place.

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LJC is currently a final year GP registrar working in Wales with keen interests in differential attainment, inclusivity within education and civil learning environments. This paper is borne from a project she designed and undertook as part of her Masters in Medical Education at Cardiff University.

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Cheetham, L.J. “Because people don’t know what it is, they don’t really know it exists” : a qualitative study of postgraduate medical educators’ perceptions of dyscalculia. BMC Med Educ 24 , 896 (2024). https://doi.org/10.1186/s12909-024-05912-2

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Patient perspectives on the Tailored intervention for Anxiety and Depression Management in COPD (TANDEM): a qualitative evaluation

• Ratna Sohanpal 1 ,
• Kristie-Marie Mammoliti 2 ,
• Amy Barradell 3 ,
• Moira Kelly 1 ,
• Sian Newton 1 ,
• Liz Steed 1 ,
• Vari Wileman 4 ,
• Vickie Rowland 5 ,
• Clarisse Dibao-Dina 6 ,
• Anna Moore 7 ,
• Hilary Pinnock 8 &
• Stephanie J. C. Taylor 1  

BMC Health Services Research volume  24 , Article number:  960 ( 2024 ) Cite this article

Metrics details

Chronic obstructive pulmonary disease (COPD) is commonly associated with anxiety/depression which can affect self-management and quality of life. The TANDEM trial evaluated a cognitive behavioural approach intervention targeting COPD-related symptoms of anxiety and/or depression, comprising up to eight one-to-one sessions delivered by respiratory healthcare professionals prior to pulmonary rehabilitation (PR). The intervention showed no improvement in anxiety/depression or uptake/completion of PR. We present patient perspectives of the intervention to help understand these results.

Semi-structured individual interviews, using a semi-structured topic guide informed by Sekhon’s Theoretical Framework of Acceptability, were conducted with 19 patients between September 2019 and April 2020. The interviews were audio-recorded, transcribed verbatim and analysed thematically.

The following could have limited the impact of the intervention: (1) The lives of patients were complex and commonly affected by competing comorbidities or other external stressors which they managed through previously adopted long-standing coping strategies. (2) Some patients were reluctant to talk about their mood despite the Facilitators' training and person centred-skills which aimed to enable patients to talk freely about mood. (3) The intervention handouts and ‘home-practice’ were perceived as helpful for some, but not suitable for all. (4) Many patients perceived improvements in their physical and mental health, but this was not sustained due to a mix of personal and external factors, and some did not perceive any benefits. (5) PR non-attendance/non-completion was a result of personal and PR service-related reasons. (6) Discussing COPD and mental health with the Facilitator was a novel experience. Many patients felt that TANDEM could be of benefit if it was offered earlier on/at different time points in the COPD illness journey.

We found the delivery of TANDEM prior to PR was not helpful for patients with advanced COPD often experiencing other comorbidities, and/or difficult personal/external events. These patients already utilised long-standing coping strategies to manage their COPD. Holistic interventions, that address the impact of COPD in relation to wider aspects of a patients’ life, may be more beneficial.

Trial registration

ISRCTN Registry 59,537,391. Registration date 20 March 2017.

Peer Review reports

Introduction

Patients with long-term conditions, such as chronic obstructive pulmonary disease (COPD), are two to three times more likely to experience mental health problems compared to the general population [ 1 ]. Patients with COPD suffer from physically disabling symptoms such as breathlessness, chronic cough and sputum production [ 2 ], and typically have one or more comorbidities such as anxiety and depression [ 1 , 3 , 4 , 5 ]. The mean prevalence of anxiety and depression in patients living with COPD are estimated at 36% (range 6%-74%) and 40% (range 8%-80%), respectively [ 6 ]. These comorbidities reduce patients’ ability to manage COPD effectively, affecting physical activity and quality of life and increasing their susceptibility to exacerbations, hospital admissions and readmissions [ 6 , 7 , 8 ] at major cost to health and care services [ 9 ].

There is a clear relationship between breathlessness and anxiety and/or depression, where one can negatively influence the other and a vicious cycle can develop [ 5 , 6 , 10 , 11 , 12 ] resulting in poorer health outcomes. This emphasises the importance of individually-targeted holistic treatments rather than purely focusing on the disease [ 13 ].

Unmet physical and psychological well-being needs [ 14 ], could be a result of patient and professional barriers [ 15 ]. Patients’ reluctance to ask for – or accept—support offered by health services may be due to stigma, reluctance to talk about emotional problems, physical symptoms masking mood symptoms [ 15 ], or having already adapted to the progressive and fluctuating nature of their COPD and comorbidities; [ 16 , 17 , 18 ] conversely, they may want to seek support but lack knowledge of mental health issues, treatment options, where to seek help, or have difficulty in accessing the support they need [ 14 , 15 , 19 ] further increasing the burden of disease/s [ 1 , 2 , 20 ].

The goals of non-pharmacological self-management interventions in COPD include reducing physical symptoms and functional impairments in daily life and improving emotional well-being [ 21 ]. Completion of evidence-based supervised exercise and self-management support programmes such as pulmonary rehabilitation (PR) is known to improve both physical and emotional well-being among patients with COPD [ 22 ]. However, anxiety or depression being associated with reduced uptake and completion of PR, remain [ 6 ]. Evidence of effective strategies to improve referral to, or uptake and completion of, PR treatment is limited [ 23 ]. Psychological treatment using cognitive-behavioural therapy (CBT) is an effective treatment for anxiety and depression but there is less evidence of benefit in COPD-related depression [ 24 , 25 ] and anxiety [ 25 , 26 ]. A systematic review by Coventry [ 27 ] found some improvement in anxiety and depression from interventions combining exercise with psychological and lifestyle interventions in COPD, and there have been calls for more high quality research into this [ 24 , 26 ].

In response to calls for further research, we developed a tailored, psychological cognitive behavioural approach intervention for patients with moderate to very severe COPD and mild to moderate anxiety and/or depression, to be delivered prior to patient attendance in PR, for evaluation in the TANDEM (Tailored intervention for Anxiety and Depression Management in COPD) randomised controlled trial [ 28 ]. We hypothesised that the intervention (referred to as the TANDEM intervention) delivered by trained respiratory health care professionals (referred to as TANDEM ‘Facilitators’) prior to patient’s attendance in PR would improve anxiety and/or depression (intervention aim and primary trial outcome) which in turn would improve patients’ uptake and completion of PR which would further improve both their physical and mental health (included in the secondary trial outcomes). The respiratory professionals involved in delivery of the TANDEM sessions were not involved in PR sessions delivery. Table 1 shows the patient inclusion/exclusion criteria in the TANDEM trial.

Table 2 describes the content of the TANDEM intervention. The intervention delivery comprised 6–8 weekly individual, face-to-face sessions with practice of skills between sessions to embed them in everyday life. Weekly or fortnightly telephone support calls to patients prior to patients starting PR and then weekly/fortnightly over the course of PR and for two weeks after completion of PR ensured continuity of support until the end of PR. The TANDEM intervention was designed as a precursor to PR but it was also developed to function as a stand-alone intervention in recognition of the fact that not all participants would want to or be able to take up the opportunity to attend PR. Patients who did not take up previous offers of PR, or who had previously dropped out of PR, were eligible for inclusion in the study. Addressing PR-related barriers was just one of the topic covered in the TANDEM intervention. In the UK, following patient referral to PR, the timeline of patients attending the PR assessment appointment following referral can take 4–9 weeks and from assessment to first attendance at a PR session can take a further 1–8 weeks. We worked with PR study sites that could accommodate our recruitment and intervention delivery timeline. In addition, to ensure patients had sufficient time to receive the intervention prior to starting PR, we included patients who had at least 4 weeks before starting the PR exercise class.

The TANDEM trial comprised a parallel health economic evaluation and a process evaluation using qualitative and quantitative methods to inform the implementation of the TANDEM intervention if the trial is positive, or assist interpretation of the findings if it was negative [ 28 , 31 ]. The intervention did not reduce anxiety and/or depression and there was no improvement in uptake/completion of PR [ 29 ].

Specific to this qualitative evaluation, the objectives of the study, developed a priori, were to explore from a patient perspective: [ 31 ].

The acceptability of the intervention among patients, considering intervention content (in session, home practice); therapeutic alliance; and practicalities (location, timing).

Experiences of the intervention, including: its impact on health, quality of care and post-trial implementation.

Any unintended consequences of the intervention.

The qualitative study was conducted between September 2019 and April 2020.

Sampling and participant recruitment

As part of trial recruitment, consent from patients to be approached for an interview was obtained. Those with scores suggestions severe anxiety/depression were ineligible and were referred to their general practitioner for more intensive mental health support. We planned to conduct 20 interviews with patients in the intervention group to meet sampling requirements to help address the research aim and to meet the trial timelines [ 31 , 32 ]. We reviewed the sampling during data collection to help decide if saturation was reached and whether there was need to conduct more interviews or stop data collection. Purposive sampling [ 33 ], using a sampling frame (Table  3 ), was used to identify patients who completed/dropped out of the TANDEM intervention and/or PR. The interviews were planned after the 6-month (i.e., after intervention delivery)) or 12-month (i.e., after PR delivery) follow up assessment during the trial. Patients were contacted by telephone to request an interview.

Data collection

Semi-structured interviews were conducted to explore patients’ perceptions of the intervention and its potential usefulness for future service development. It was led by a topic guide (Table  4 ) informed by the conceptual framework for the TANDEM process evaluation [ 31 ] and Sekhon’s theoretical framework of acceptability [ 34 ]. See Supplementary file 1 for the interview topic guide used in the interviews.

The interviews were conducted face-to-face, in the patients’ home or by telephone, at a date, location and time that suited the patient or in accordance with COVID regulations (mid-March 2020-April 2020). Interviews were audio-recorded using a digital encrypted recorder. They were conducted by three mixed-method researchers, KMM (Global Health Development, MSc), AB (Health Psychology, MSc), RS (Health Services Researcher, PhD). The researchers were involved in trial recruitment and data collection and were experienced in conducting qualitative interviews and were part of the patient working group within the wider process evaluation team and were involved in the discussions that informed the methods of the study. The researchers were not known to the interviewees. The interview planning was coordinated between the researchers in line with the trial milestones.

Data analysis

Audio-recordings of interviews were transcribed verbatim. Nvivo (version 12) data management software was used to support data analysis. Thematic analysis was conducted [ 35 , 36 ]. Researchers (KMM, AB, RS) independently used inductive, semantic, and latent coding to analyse two transcripts and prepare an initial coding framework. The researchers discussed this to reach consensus on the coding framework. The remaining transcripts were individually coded in line with the coding framework and new codes were added to the framework as required, with consensus. Once all transcripts were coded, the researchers jointly reviewed patterns and relationship within the data to generate potential themes and sub-themes. These were discussed with the wider process evaluation team [ 31 ] with the correct experience and expertise [ 37 ] to finalise the content and themes (Table  5 ).

Public involvement

Public involvement was incorporated in the design and delivery of the TANDEM trial [ 31 ]. Specific to this qualitative enquiry, patient and public involvement (PPI) colleagues (people with COPD, carers of people with COPD) provided comments and feedback to support the clarity, readability, and acceptability of the interview process specified in the participant documents. PPI colleagues reviewed the findings in relation to the main trial results and provided feedback, which supported our interpretations of the results.

Patient characteristics

Of the 29 patients invited for interview, 19 agreed to participate. Data collection occurred between September 2019 to April 2020. Due to the Covid-19 pandemic (19 March 2020—1 April 2020), eight interviews were conducted by telephone. The interview duration was between 30–60 min.

Table 6 presents the patient characteristics. Eleven were male. Two were in the 35–55-year age-group, five in 56–65 year age-group, seven in 66–75 year age-group and two in 76–85 year age group. Three interviewees did not provide their age. Thirteen patients had moderate COPD, six had severe/very severe COPD. Ten had both symptoms of anxiety and depression, five had symptoms of depression only and four had symptoms of anxiety only. Regarding other comorbidities, fifteen patients mentioned other comorbidities namely Heart disease, Stroke, High blood pressure, Parkinson’s, Diabetes, Kidney disease, Fatigue, Epilepsy, Diabetes, Pain and Cancer. Interview participants were comparable to main trial participants in terms of age, gender, COPD severity and other comorbidities, although as a group fewer of the interviewees reported comorbidities (79%) than amongst all the trial participants (90%).

Reasons for non-participation were family bereavement ( n  = 1), difficulty with hearing on the telephone ( n  = 1), uncontactable ( n  = 4), not interested ( n  = 3) and busy ( n  = 1). Those who declined taking part in the interview were mostly from the TANDEM intervention completion group ( n  = 7).

Over-arching findings

The findings generated four themes and nine subthemes, three themes related to intervention acceptability in line with Sekhon’s [ 34 ] theoretical framework of acceptability (TFA). The findings are exemplified with quotes. Theme 1 ‘Patient lives are complex’ encompasses patients living with and managing their COPD alongside other comorbidities and ongoing life/social situations, the challenging interplay of external situations, their own needs, and the adoption-refinement of self-coping strategies over time. Theme 2 ‘Relationship with the TANDEM Facilitator and engagement in the intervention sessions’ highlights the building of rapport and partnership between the patient and Facilitator to deliver the TANDEM intervention sessions and patient engagement with the intervention. This theme links with the Affective attitude TFA construct where patients spoke about how they felt about the intervention and with the Intervention coherence TFA construct where patients understood the purpose of the intervention, what was expected of them to engage in the intervention and spoke about their experience of engagement with the intervention materials [ 34 ]. Theme 3 ‘Impact of the TANDEM intervention sessions’ explores the perceived benefits (or lack of sustained benefit), from the intervention in relation to patients’ physical, mental, and social health. In this theme, patients, through their understanding of the intervention (Intervention coherence TFA construct); how they felt about the intervention (Affective attitude TFA construct); and whether they were able to apply the learnt skills following receipt of the intervention (Self-efficacy TFA construct) clearly stated whether they benefitted or not from the intervention (Perceived effectiveness TFA construct) [ 34 ]. Theme 4 ‘Distinguishing TANDEM in COPD care’ discusses lack of previous provision of psychological support and that TANDEM type of care should be offered to patients earlier in their illness journey. This theme links with the Burden TFA construct where patients spoke about their ease of being able to participate in the intervention. We have not presented the themes under the TFA constructs as these constructs are interlinked and overlapped in how patients spoke about their experience of the intervention.

Core themes and subthemes

Patient lives are complex, impact of copd and competing comorbidities/other external stressors.

Patients described how the fluctuation of COPD symptoms, suffering from exacerbations, several other health conditions and negative life events could have a cumulative effect on their physical, psychological, and social health. Many patients had previous experience of bad days, “frightening” breathlessness, and chest infections. Several mentioned the combination of COPD symptoms, along with symptoms of other comorbidities, resulted in low mood. Getting a new diagnosis (e.g., cancer), experiencing a sudden injury (e.g., a fall), an exacerbation of COPD symptoms, or other long-term comorbidities (e.g., stroke, diabetes, sepsis, dementia) made patients feel they could not fully recover physically and mentally.

“The thing that gets me down is I’ve got Parkinson’s as well, which is making walking difficult at the moment. It’s got much worse recently. And I get out of breath when I’m… Although I’m walking slowly it takes a lot of effort. So I get out of breath as well.” (Male, 66–75, Depressed, Moderate COPD, PAT5)

They described the adjustments/adaptations (e.g., sitting and resting) they made to manage their condition. Others described having become resigned to what they could or could not do (e.g., avoiding going out of the house).

“I used to go out a lot. And now I just don’t go out. I even used to do my own shopping with a relative or something. But I don’t even do that now. It’s just too much even with the help of a trolley. Walking around supermarkets, it’s just too much.” (Male, 56–65, Anxious and depressed, Severe COPD, PAT1)

Some patients felt that their COPD or its limitations were not always visible or well understood by others and this caused embarrassment and frustration. A few patients prioritised needs of others over their own health needs.

“….Well, I was outside trying to jet wash, and of course it takes it out of you. Always having a job breathing. Of course, I stopped to get my breath back. And it started to rain. Come on, get inside [partner said]. Hang on [I said], let me bloody breathe will you. Just let me try and breathe, and then I might be able to do something. But yeah. Don’t you realise I have difficulty breathing? …” (Male, 76–85, Anxious and depressed, Moderate COPD, PAT15)

Stoicism and self management

Patients described living with COPD and/or other comorbidities or life events as “I live with it and put up with it” . Several patients had learnt to adapt and developed coping strategies either alone or with the help of family and friends to overcome their physical limitations and anxiety, panic state or mood.

“…it was one of the guys, he lives across the road from me,… He said to me, … the way to look at your breathing is smell the roses and blow out the candles. And that’s always stuck. So when I do feel a bit anxious or panicky I think smell the roses and blow out the candles.” (Female, Age unknown, Anxious and depressed, Moderate COPD, PAT12)

Relationship with the TANDEM facilitator and engagement in the intervention sessions

Knowledge, skills and open communicative partnership.

The patients developed a good rapport and a positive relationship with their Facilitator over the course of the TANDEM intervention sessions. The positive relationship was nurtured by the Facilitator’s knowledge and skills, delivery of weekly sessions and the Facilitator’s ability to tailor content to the patient. Their adaptability to modify home practice to suit the patient’s level of health literacy and providing practical examples to enhance understanding of a topic was valued.

“Anything to do with writing, I’d just wait until she came and we did it. I didn’t do that bit.” (Female, 35–55, Anxious, Severe COPD, PAT2)

Patients praised the Facilitator’s knowledge of both COPD and mental health and their strong communication and counselling skills. Patients felt that their Facilitator was friendly, empathetic, supportive, and genuinely interested in them. They felt listened to and gently encouraged to speaking openly about their mood which for some was related to their social situations and not COPD.

“Yeah, and maybe asked questions that I would’ve not fancied talking about possibly. So she did probe. But it wasn’t putting me on the spot. Then it made me think, oh yeah, I don’t mind talking about that.” (Female, 56–65, Anxious and depressed, Very severe COPD, PAT18)

However, some patients did find it difficult to talk about their anxiety or mood with the Facilitator and preferred to discuss other things in the sessions.

“We discussed a little bit of anxiety, because the anxiety, I don’t really like to discuss my anxiety, because it just gets to me after a while when I’m talking about it.” (Male, 66–75, Anxious and depressed, Moderate COPD, PAT7)

Some patients who lived alone described enjoying the Facilitator’s company and the continued opportunity to discuss their illness. A few said that it was like conversing with a friend.

“…And like I say, people are probably the same as me, more benefits with just having that person coming for the company as well as talking about a specific illness.” (Male, 56–65, Anxious and depressed, Severe COPD, PAT1)

Engagement with the TANDEM intervention materials and sessions

Most patients understood that the TANDEM study was about education and discussions around their physical and/or emotional health with a focus on improving it. Patients recalled receiving various study-related materials such as leaflet/s, handouts, DVDs, and worksheets for home-practice and setting goals. Some patients had difficulty remembering the home-practice requirements. A few patients chose not to watch the DVD due to lack of interest or lost interest shortly after starting because it felt too repetitive and replicated the handouts/leaflets provided or the exercises shown were not deemed suitable to them.

“The CD was pretty boring. It was very repetitive and I lost interest quite quickly I’m afraid.” (Male, 66–75, Depressed, Moderate COPD, PAT5)

Two patients stopped receiving the intervention after two and three sessions because they described not being affected by their mood and were already familiar with the information provided. The third patient chose to discontinue after receiving two sessions because their sessions began to overlap with PR and they wanted to prioritise PR instead.

“Yeah, it was sort of a joint decision. If I had any problems I could give her a ring. But then I more or less carried on with the breathing thing [PR programme], so I did see people over at this breathing session. So any questions and the information you got from that at the beginning was very good Interviewer: And how soon did you join that exercise class after your one-to-one sessions? More or less straightaway.” (Male, Age unknown, Anxious, Severe COPD, PAT11)

Two patients did not complete any sessions and had no recollection of the intervention.

Impact of the TANDEM intervention sessions

Perceived benefits and the lack of perceived benefits.

The effects of the TANDEM intervention sessions on thoughts, feelings, behaviours and/or symptom management were varied and wide-ranging. Several patients described improvements to their mental health and had adopted positive coping strategies. They described the intervention having helped to shift negative thoughts to positive ones, feel more at ease and able to take control of their anxiety.

“I’ve got to be honest, when I had this chest infection I thought I was suffocating. My ribs, I thought they were breaking with this cough. And so it [TANDEM sessions] helped me a sense up here [thoughts], keep the anxiety [under control]. Because I was struggling to breathe at one stage.” (Female, 56–65, Anxious and depressed, Very severe COPD, PAT18)

Patients felt they made connections between their physical and mental health by acknowledging the presence of depression or anxiety. Patients realised the value of self-reflection. Some adopted a resilient mindset, refusing to let breathlessness, anxiety and/or depression stop them. Instead, they emphasised the importance of not giving up, setting goals, accepting help, and being kind to themselves. This realisation gave them confidence to move forward and see the value of life again.

“I didn’t realise I was depressed at the time because I was going to the bed most days in the afternoon, and that was more because I was… I retired last year, so I think it’s because I’d recently retired. I was just bored. So I was going to bed in the afternoons just to kill time. And then I realised through talking to [Facilitator] that that was more me being depressed….I’m going to say it [the TANDEM project] changed my outlook on life. … helped me realise if I get a little bit fitter I’ll be a lot happier and I’ll probably increase my…not going to say I’m going to live longer, but the years I’ve got to live I’ll be fitter, happier…” (Male, age group unknown, Anxious, Moderate COPD, PAT6)

Many patients described learning skills, techniques and adopting healthy behaviours to enhance their daily management of COPD/COPD-related breathlessness and COPD-related anxiety such as relaxation techniques (e.g., mindfulness, distraction, breathing techniques). These techniques were successfully applied during daily activities, such as walking, climbing stairs, gardening, getting to the car, and shopping. The perceived benefits varied for different individuals and comprised, an increase in knowledge, confidence, acceptance of condition and improvements to social life.

“Well I slow down a bit. I have a lady, [facilitator], from your research team come down last year. And she took me out for little walks, and she discovered that I was taking in too much air. So she did me little techniques of when I go out for a little walk, like doing things in your head, like counting odd numbers or counting from 100 backwards. Little bits like that to get your breathing under control.” (Female, 56–65, Depressed, Severe COPD, PAT8)

For a few patients, the sessions did not provide any new material but helped to reaffirm their existing knowledge about their condition and its management or reminded them of techniques/behaviours that could help them to effectively manage their condition. Others did not perceive any benefits from the intervention. One patient did not expect to learn anything new whilst another patient explained they knew most of what was being covered and that they were used to doing things on their own.

“Interviewer: Do you think your confidence levels have changed? “No, I don’t think so. No.” Interviewer: … Are there any other changes in your social life? No, not really…. I see my friends, at least once a week, sometimes twice. So yeah, I mean I don’t want to stay indoors, or watch TV. I do go out and see my friends.” (Male, 56–65, Anxious, Moderate COPD, PAT4)

Attendance and completion of pulmonary rehabilitation

Patients recalled discussions with their Facilitator regarding PR, specifically focusing on how PR could potentially benefit them and what they could anticipate from attending the programme. Some patients mentioned they always planned to attend PR despite the TANDEM sessions, whilst others were encouraged to attend PR following receipt of the TANDEM sessions. The reasons given by those who did not attend/complete PR were competing comorbidities which needed prioritisation, and health service-related reasons.

“I’ve done the pulmonary rehab before and I did go to an appointment but they wanted…because I was waiting for an ECG. They wanted to wait for the results for that, and that kept getting pushed back and pushed back…” (Female, 35–55, Anxious and depressed, Moderate COPD, PAT9)

Difficulties keeping up learnt skills or new activity due to personal or external factors

The application of learnt skills/techniques by patients varied over time with the perceived benefits not viewed as sustainable by some patients. Whereas others stated their learnings from the intervention had become in-built and they now knew what to do to manage their condition.

“Emotionally I was quite low, no self-esteem before I saw [facilitator], but afterwards I felt quite a lot better and I’ve still kept feeling more positive and more confident in those quite a few months since I saw her. I’ve not slipped back into my old way of thinking and everything.” (Female, 66–75, Anxious and depressed, Moderate COPD, PAT13)

For various reasons, some patients were unable to maintain changes they had adopted due to internal or external factors. (e.g., injury, new diagnosis with poor prognosis, new disabling symptoms from COPD, disabling comorbidities affected patient mood negatively; reduced motivation to be physically active, increased gym costs or changes made to the gym made it unsuitable to attend led patients unable to start or keep up with their physical activity; and Covid-19 restrictions affected both mood and physical activity negatively). Some patients attributed their worsening physical and mental health specifically to the Covid-19 lockdown and reduced access to services, whilst others described coping well and trying to continue activities at home, albeit on a much smaller scale to their usual routine.

“I think my breathing’s actually got worse …because now we can’t go out. So it’s…yeah, it’s… I’m definitely wheezing a lot more than I was before and get breathless. …if I sit still it’s fine. It’s when I start moving around. So I think it’s probably because I was going out literally every day. I was going out for a half hour walk, I was doing exercises. And of course now you’re stuck in the house and you can’t get out. So yeah…” (Female, Age unknown, Anxious and depressed, Moderate COPD, PAT12)

Distinguishing TANDEM in COPD care

Tandem is different to current care.

Patients described the intervention as incomparable to other currently available COPD services. Most interviewees had never previously received any psychological therapy for anxiety/depression. Some had undergone counselling (e.g., for grief, stress) but felt the counselling was not specific to their COPD. One patient who had previously received CBT felt the TANDEM sessions were more helpful.

“I’ve spoken to my GP just about general depression, not to do with my COPD. And I’ve had a couple of CBT appointments. But I didn’t really find those too helpful. They just seemed to give me one of these assessment sheets every time and I had to write down in the boxes how I felt about each situation. And then they were just adding my score up, oh, this week you’ve scored a bit higher than last week. They didn’t really offer me any advice as to how to improve the situation.” Interviewer: And what was different from the one-to-one sessions you had with [Facilitator]? I was able to talk through all sorts of problems that I’ve had over the last couple of years to do with my COPD and to do with personal stuff as well.” (Female, 66–75, Anxious and depressed, Moderate COPD, PAT13)

Having flexibility in the location (e.g., patient’s home, GP practice or local hospital) for intervention delivery was highly valued. This flexibility recognised the physical limitations experienced by people living with COPD and was conducive in creating a safe, comfortable, and private environment. Some patients expressed appreciation for not being excluded from receiving the intervention just because they were unable to leave their home. Others preferred the sessions at a GP practice or a public space to avoid distractions at home.

“…Because I said I don’t drive, I can’t afford the taxi fare. I can’t use public transport…So having the opportunity to have her [facilitator] come to the house was a god send, because otherwise I don’t think I would’ve done it. I couldn’t have done. I couldn’t have got anywhere to do it.” (Female, Age unknown, Anxious and depressed, Moderate COPD, PAT12)

Need for psychological support at different time points of the illness journey

Several patients suggested that the sessions would be helpful at diagnosis because some felt they were given insufficient information or support at this time point. Whilst others recommended the sessions at differing stages of their illness because symptoms can evolve over time or be influenced by external life events.

“I think it’s the whole package that matters. The cognitive therapy, you might just need that, mightn’t you? … So I just embraced it. It’s obviously valuable, and I suppose they’ll roll it out one day if you have got COPD or have an operation, it’ll be offered to you. It’s down to the individual.” The same participant continued “See generally it’s going to be older people doing this thing, I think. I mean younger people there might be more benefit. So a lot of them brought up to keep it…they can’t express their emotions. So I wonder…this might be for future generations. But older people are a bit reluctant to talk about themselves. It’s like get on with it.” (Female, 56–65, Anxious and depressed, Very severe COPD, PAT18)

Despite the overall acceptability for TANDEM, a few patients were considerate of the cost and the time impact upon NHS services. However, it was made very clear that the flexibility of intervention delivery (e.g., at home) should not be compromised.

“I think [home visits] should never be dropped and it should be moved to a place where it’s set for you to save money. Because that’s when everything starts going down hill then. And people trying to cut corners and then we have a meeting maybe every six months. And they say well, this never used to happen when we used to do one-on-ones at home. And now it is happening. So I think you should carry on exactly the way you are doing.” (Male, 56–65, Anxious and depressed, Severe COPD, PAT1)

As part of an integrated process evaluation of the TANDEM intervention, we explored patients’, experience of intervention receipt and acceptability to help us understand the trial findings. We found the fluctuation of patients’ COPD symptoms combined with comorbidities, and challenging social circumstances meant many patients had already developed coping strategies, including stoicism. Positive experiences of the intervention were attributed to the Facilitator’s knowledge in COPD and mental health, their supportive, empathetic, and person-centred communication skills. This enabled many patients to talk freely about their mental health, acknowledge the connection between their physical and mental health, and disclose interacting social circumstances. Some, but not all, patients found the intervention materials and home practice helpful. Most completers of the intervention perceived improvements in their mood/mental health, physical and social benefits. Sustaining these benefits was challenging for many due to personal, health-related, and external factors (including Covid-19). Patients described the intervention as novel, they valued the flexibility in how it could be delivered. Some patients suggested making the intervention sessions available ‘on demand’ throughout the illness trajectory so the patient could take them up when needed.

Comparison with other literature

We found only one qualitative study [ 38 ] exploring experiences of a home-based psychoeducation intervention within a trial, however, the structure and delivery were different to TANDEM. The intervention targeted symptoms related to breathlessness and anxiety [ 39 ] among patients with advanced COPD who reported perceived benefits such as anxiety becoming more manageable and taking control of cognitions [ 38 ]. TANDEM intervention completers also perceived improvements such as coping better with anxiety, feeling more content and at ease with oneself, and experiencing a shift from negative thoughts to a more positive outlook. Additionally, patients cited increase in knowledge, confidence, acceptance of condition and improvements to social life/daily activities.

However, the perceived improvements were not sustained and may therefore explain the trial outcomes. In Bove’s trial [ 39 ], the timing of the outcome assessment was one month and three-month post intervention delivery. Bove explained that this duration was a period for new knowledge and skills to be integrated into everyday life and was the right time for qualitative exploration. In contrast, the outcome assessments for TANDEM were at six- and twelve-months post intervention, [ 28 ], recommended for COPD self-management interventions [ 40 ]. Our findings show that several personal factors and external events prevented patients from long-term application or adherence of their TANDEM learnings. Non-adherence to learnt self-management skills is known to result in worse health outcomes [ 41 ]. Part of our intervention delivery occurred during the Covid-19 pandemic meaning some patients were unable to attend PR or continue their planned physical/social activities and this may have impacted the trial outcomes. The negative impact of Covid-19 on physical activity, social isolation and mental health has been shown in advanced respiratory disease [ 42 ]. A recent COPD study [ 43 ] reported initial gains made by an intervention were lost without content teaching about how to maintain health behaviours even in times of stress. Although we included problem solving as a topic, for future iterations of TANDEM, it may be useful to include a session involving specific discussions about the likelihood of setbacks/external stressors and practical strategies for dealing with them, possibly as a ‘booster’ session or ‘on demand’ during times of stress. It may also have been possible to deliver TANDEM alongside PR rather than as a precursor, however this would have increased patient burden and was not in line with our programme theory that reduction in depression and/or anxiety would be helpful to increased uptake and completion of PR.

Another explanation for the perceived lack of sustained benefits could be the severity of disease and disabling experience of patients from the burden of COPD and interacting comorbidities [ 44 , 45 ]. Many patients in this study talked about the fluctuating and unpredictable nature of COPD symptoms and the negative impact of ongoing comorbidities. Recognising the comorbidities in COPD, a study [ 46 ] discussing future interventions in COPD has suggested inclusion of a ‘feedback loop’ to assess progress of desired outcomes and treatment expectations related to comorbidities among patients. However, before this, further work is required to understand how comorbidities impact on/interact with COPD [ 47 ] and what outcomes are important to this patient group to support intervention development and its assessment in research for better health outcomes. Managing and adapting to the fluctuating nature of ongoing health conditions and its limitations and interactions with the surrounding social environment made achieving ‘normality’ out of reach for some patients. The perceived lack of understanding about COPD among family members and wider society, was felt to affect mood for some patients. One study, with comparable findings to ours, found difficult living situations, other life events and comorbidities negatively influence COPD-related distress [ 48 ]. The Facilitators reported working through problems (social, psychological, physical) with patients that were unrelated to COPD which shifted the focus away from the intervention targeting mood related to COPD symptoms/breathlessness [ 49 ]. The latter was perceived as a challenge during intervention delivery [ 49 ] and could contribute to explaining the trial outcomes, although overall fidelity to the intervention has been reported to be high [ 49 ]. Focusing on the physical/social environment of patients with COPD is important for future interventions in COPD [ 50 ], but will require gaining better understanding of the social environment and its impact on individuals [ 51 ].

Several patients in our study were stoic, and the stance taken was ‘to get on with it’. Stoicism can make patients hold on to strategies they perceive are working for them, they may be reluctant towards the treatment or they may have less realistic expectations of treatment benefits [ 52 ] which could have affected the trial outcomes. Some patients found the intervention unsuitable for their needs or failing to meet their expectations. The lack of perceived benefits amongst some is not surprising as, needs, expectations and preferences will vary among individuals. Some patients felt that they had not learnt anything new, whilst for some the intervention helped to reinforce strategies they were already using to manage their condition which will have reduced the potential for improvement in trial outcomes. A person-centred approach, only offering intervention to those with perceived need to reduce anxiety/depression may be more appropriate.

Although not reflected in the trial outcome analysis, a positive experience of the TANDEM intervention was that the patients particularly valued the therapeutic relationship with the Facilitator (a key element of the TANDEM intervention) [ 30 ]. The intervention sessions gave patients an opportunity to reflect on what COPD meant to them, recognise their actions were a result of anxiety and/or depression, make connections between their physical and mental health, and adopt home-practice activities which helped to improve their physical activity and symptoms. Despite the trial outcomes, the positive experiences of patients suggest that it might be useful to provide opportunities in practice to enable patients to reflect on the relationship between their physical and mental health [ 49 , 53 ]. An explanation for the lack of improvement in outcomes, supported by these findings, is that some patients did not do any independent home-practice between intervention sessions because they did not like to write things down or read. Not doing the home-practice may have made it difficult to embed the learning from the TANDEM sessions. The latter could be attributed to comorbidities or poor health literacy previously reported for this population [ 54 ]. It has been suggested that not doing CBT-related homework can lead to negative health outcomes [ 55 , 56 ]. A recent review [ 57 ] assessing the efficacy of psychosocial interventions on physical and psychological outcomes in COPD highlighted that older age may yield limited effects as they would be less adept to learn skills and techniques taught in a psychosocial intervention. The median age of patients in the TANDEM trial was 69 years and there were high intervention uptake and completion rates [ 29 ], so the offer of psychosocial interventions should continue among this population regardless of their age [ 57 ]. However, assessment of health literacy needs should be considered for interventions comprising written materials [ 43 , 46 , 50 , 54 ]. Production of intervention materials needs to be more creative than paper-based materials and need to be available in various formats to match patient choice, preferences and literacy levels.

Some patients in our study were reluctant to talk about their mood, which could be due to such discussion being unfamiliar within a healthcare setting. Few had received any psychological support previously for their mental health in relation to their COPD. The new treatment and the lack of familiarity of this psychological approach may have had an impact on trial outcomes. This could be related to the perceived stigmatisation of COPD [ 24 ] and mental health [ 48 ] or that having a one-off, short-term intervention may not be enough. There are reports of limited screening of mental health issues, and limited review of mental health issues as part of routine COPD review appointments, leading to under-diagnosis and consequently under-treatment [ 6 , 15 ]. A recent review [ 57 ] concluded that more research is needed to identify the ideal duration, or regularity of a psychosocial intervention in COPD, as long duration can have small effects due to waning of the effect or becoming dependent on the therapist. The duration of the TANDEM intervention was not a perceived problem for our interviewees, but they suggested offering TANDEM at diagnosis or at different timepoints in line with the illness journey allowing the opportunity for the patient to take it up when needed. The TANDEM Facilitators felt that offering TANDEM earlier on in the illness trajectory might be more suitable for patients with less complex needs [ 49 ]. This highlights the need for more mental health support to be available for patients with COPD.

Strengths and limitations

This study forms one part of the process evaluation work of the TANDEM trial and has provided an insight into why the TANDEM intervention may have not worked. The findings, via Sekhon’s acceptability framework [ 34 ], highlighted that most patients found the intervention acceptable but the acceptability of the intervention and the positive experiences were not translated into improvement in the trial outcome measures relative to controls. The reported positive and negative experiences of the TANDEM intervention might be useful for researchers and clinicians looking to improve mental health comorbidities in COPD and beyond COPD/COPD-related breathlessness.

We only interviewed patients in the intervention arm and conducted more interviews with those who had completed the intervention. We achieved data saturation among our sample of patients that had completed the TANDEM intervention with and without completion of pulmonary rehabilitation. We would have liked to speak to more patients who dropped out of the intervention as two patients did not attend any TANDEM intervention sessions and could not recall the reasons for non-attendance. However, we were unable to invite more patients due to administrative delays. Despite this we were able to show a balance of views among the interviewees to help explain the trial findings. A few trial participants had received the intervention by telephone due to the pandemic, but this was not anticipated and hence they were not interviewed.

Implications

More opportunities need to be created in practice to ask about mental health by professionals trained in person-centred skills, psychological skills, knowledge about COPD and common comorbidities associated with/linked to COPD. This is because patients may not be able to ask for treatment or it might not be the right time to seek treatment due to competing demands resulting from the fluctuating and unpredictable nature of COPD, the influence of individual social contexts and interaction with other conditions. Cognitive behavioural approach treatments may be more suited for patients earlier on in their COPD illness journey with built-in sustained follow up, allowing patients to include the learnt skills into their coping mechanisms for improved outcomes.

There is an increased need for co-production work among patients with COPD and comorbidities to develop intervention materials related to cognitive behaviour approach treatments suitable for patients at varying literacy levels, including those who do not like to read any materials or engage in independent home-practice. There is scope to develop interventions that consider an individual’s primary symptoms and interacting social environment to improve the physical and mental health outcomes of patients living with moderate to very severe COPD and anxiety and depression. Future research could look into the role of assistive technology interventions (e.g. adaptive and telecare equipment) [ 58 ] in COPD [ 29 ] that are relevant to improve function, independence, wellbeing and quality of life, particularly technology (e.g. personal digital assistant device) targeted at people with psychosocial disability including anxiety and depression with some evidence of benefit [ 59 ].

This study provides an insight into why a person-centred psychological intervention, evaluated in a randomised controlled trial, did not improve symptoms of anxiety/depression brought on by COPD symptoms, particularly breathlessness in patients with moderate to very severe COPD and did not improve uptake/completion of PR. Patients in our study were affected by other comorbidities or difficult social situations that caused anxiety/depression not necessarily related to COPD. Patients had learnt to manage their conditions or situations through long-established coping strategies. Patients who had not received any psychological treatment specific to COPD and mental health previously felt the intervention might be more suited to people earlier on in their illness journey or at different time points to gain benefits. There were patients who did not want to talk about mood, did not perceive any benefits from the intervention and did not want to use the intervention materials or do any home practice work independently. Our study further highlights that the time spent with the skilled Facilitator led some patients to talk freely about their mental health and they perceived improvements in their health including mental health through discussions, use of intervention materials and home practice work but the benefits were not sustainable due to personal/external factors. To improve the mental health of patients with advanced COPD, more opportunities need to be created to discuss mental health in routine assessments for COPD/for multimorbidity with availability of a sustained intervention that considers the holistic and dynamic nature of social and clinical complexities in COPD.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We are deeply grateful to the study participants that took part in the study.

The study is funded by the NIHR Health Technology Assessment programme (project number 13/146/02). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

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Queen Mary University of London, London, UK

Ratna Sohanpal, Moira Kelly, Sian Newton, Liz Steed & Stephanie J. C. Taylor

University of Birmingham, Birmingham, UK

Kristie-Marie Mammoliti

University Hospitals of Leicester NHS Trust, Leicester, UK

Amy Barradell

King’s College London, London, UK

Vari Wileman

Hertfordshire City Council, Hertfordshire, UK

Vickie Rowland

University of Tours, Tours, France

Clarisse Dibao-Dina

Barts Health NHS Trust, London, UK

University of Edinburgh, Edinburgh, UK

Hilary Pinnock

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Contributions

R.S., K.M.M., A.B. were involved in data collection, data analysis and interpretation of data. R.S. was the major contributor in writing the manuscript and K.M.M. and A.B. contributed to the revision of the manuscript. S.J.C., H.P. were chief investigators and S.J.C., H.P., M.K., L.S., V.W., V.R., R.S., A.B., K.M.M., C.D.D., A.M. formed the process evaluation team for the TANDEM trial and designed the study. S.J.C., H.P., M.K., L.S., V.W., V.R., C.D.D. K.M.M. and A.M. contributed to the data analysis, data interpretation and the revision of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Ratna Sohanpal .

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The study was approved by the London-Queen Square Research Ethics Committee, reference 17/LO/0095. All participants provided written informed consent for the interview.

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Sohanpal, R., Mammoliti, KM., Barradell, A. et al. Patient perspectives on the Tailored intervention for Anxiety and Depression Management in COPD (TANDEM): a qualitative evaluation. BMC Health Serv Res 24 , 960 (2024). https://doi.org/10.1186/s12913-024-11370-9

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Received : 15 April 2024

Accepted : 29 July 2024

Published : 21 August 2024

DOI : https://doi.org/10.1186/s12913-024-11370-9

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University home > Unit and programme catalogues in 2020/21 > Unit catalogue > Faculty of Social Sciences and Law > School for Policy Studies > Introduction to Quantitative Research Methods in the Social Sciences (SPS)

Unit information: Introduction to Quantitative Research Methods in the Social Sciences (SPS) in 2020/21

Please note: you are viewing unit and programme information for a past academic year. Please see the current academic year for up to date information.

Description including Unit Aims

• To provide a philosophical appreciation of the underpinnings of quantitative research methods
• To develop a critical understanding of the potential of various quantitative methodologies and key epistemological and methodological ‘problems’ raised in quantitative methodologies
• To introduce ethical, political and value concerns arising from the interpretation and analysis of quantitative data
• To develop students’ understanding of the application, strengths and weaknesses of a range of quantitative methods and develop basic skills in the use of quantitative research techniques

Students will apply these methods and techniques in the particular context of their own discipline.

Intended Learning Outcomes

• Module specific details • Develop a philosophical appreciation of the underpinnings or quantitative research methods. • A critical understanding of and the ability to apply to their own work, the appropriate uses, strengths and weaknesses of quantitative methods. • Ability to evaluate the research practice, data and interpretations of others. • Sensitivity to ethical, political and value concerns in quantitative research. • Appreciation of a reflexive approach to social science research. • Demonstrate basic skills in the use of quantitative research techniques. • Discipline specific skills • Develop an appreciation of the philosophical underpinning of quantitative approaches in relation to the discipline. • Understand how quantitative research can address specific challenges within a disciplinary context. • Demonstrate and apply a critical understanding of quantitative methods used in the discipline. • Understand how quantitative methods are used in the discipline and gain an overview of some current quantitative research examples within the discipline. • Develop an understanding of discipline specific ethical, political and value issues, related to quantitative research. • Personal and key skills. • Critical analysis. • Ability to reflect on personal/ethical issues raised in quantitative research. • Team work. • Presentation skills.

The summative assessment tests all of the ILOs and accounts for 100% of the unit mark.

Teaching Information

The unit will be delivered through blended learning involving a combination of lectures, group discussion and self-directed exercises.

Assessment Information

Formative Group presentation 15 mins Personal and key skills Principles of Quantitative research design Verbal

Formative (alternative)Essay 1500 words Principles of Quantitative research design Written

Summative 100% Essay 4,000 words Module and discipline specific skills Written

Summative (alternative)100% Essay + Research design 2,500 words + 1,500 words Module and discipline specific skills Written

Summative (alternative)100% Analysis of (primary or secondary) data set 4,000 words Module and discipline specific skills Written

The choice between summative assessment options will be negotiated with the Unit Tutor

Reading and References

• Babbie, E (2007) The Practice of Social Research (11th ed). Belmont: Wadsworth Pub. Co. [Arts & Social Sciences H62 BAB] (Chapters 7 & 9)

• Bryman, A. (2012) Social Research Methods [4th edition] Oxford: Oxford University Press. [Arts & Social Sciences H62 BRY] (Chapters 7, 8, 10, 11, 14, & 15)

• Field, A (2009) Discovering Statistics using SPSS [3rd edition], London: Sage. [Arts & Social Sciences BF39 FIE] (Chapters 1& 2)

Gilbert, N. (ed.) (2008) Researching Social Life [third edition], London: Sage. [Arts & Social Sciences HM48 RES](Chapters 2, 3, 5, 6 &16)

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