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  • Neurosurgeons’ experiences of conducting and disseminating clinical research in low-income and middle-income countries: a reflexive thematic analysis

    Whiffin, Charlotte Jane; Smith, Brandon George; Esene, Ignatius N; Karekezi, Claire; Bashford, Tom; Mukhtar Khan, Muhammad; Hutchinson, Peter John; Kolias, Angelos G; Fontoura Solla, Davi Jorge; Paiva, Wellingson S; et al. (BMJ, 2021-09-22)
    Low-income and-middle-income countries (LMICs) are increasing investment in research and development, yet there remains a paucity of neurotrauma research published by those in LMICs. The aim of this study was to understand neurosurgeons’ experiences of, aspirations for, and ability to conduct and disseminate clinical research in LMICs. This was a two-stage inductive qualitative study situated within the naturalistic paradigm. This study committed to an interpretivist way of knowing (epistemology), and considered reality subjective and multiple (ontology). Data collection used online methods and included a web-based survey tool for demographic data, an asynchronous online focus group and follow-up semistructured interviews. Data were analysed using Braun and Clarke’s Reflexive Thematic Analysis supported by NVivo V.12. Setting LMICs. In April–July 2020, 26 neurosurgeons from 11 LMICs participated in this study (n=24 in the focus groups, n=20 in follow-up interviews). The analysis gave rise to five themes: The local landscape; creating capacity; reach and impact; collaborative inquiry; growth and sustainability. Each theme contained an inhibitor and stimulus to neurosurgeons conducting and disseminating clinical research, interpreted as ‘the neurosurgical research potential in LMICs’. Mentorship, education, infrastructure, impact and engagement were identified as specific accelerators. Whereas lack of generalisability, absence of dissemination and dissemination without peer review may desensitise the impact of research conducted by neurosurgeons. The geographical, political and population complexities make research endeavour challenging for neurosurgeons in LMICs. Yet in spite of, and because of, these complexities LMICs provide rich opportunities to advance global neurosurgery. More studies are required to evaluate the specific effects of accelerators of research conducted by neurosurgeons and to understand the effects of desensitisers on high-quality, high-impact clinical research.
  • A qualitative study of the understanding of compassion through completing a brief online CMT intervention among non-clinical population in Czechia and Poland

    Michalczyk, Magdalena; Taubenhanslova, Ester; University of Derby (University of Derby, 2021-11-03)
    Assess participants understanding of the concept of compassion in Czechia and Poland after completion of a brief online Compassionate Mind Training (CMT) intervention.
  • The role of social connection on the experience of COVID-19 related post-traumatic growth and stress

    matos, marcela; McEwan, Kirsten; Kanovský, Martin; Halamová, Júlia; Steindl, Stanley R.; Ferreira, Nuno; Linharelhos, Mariana; Rijo, Daniel; Asano, Kenichi; Vilas, Sara P.; et al. (Public Library of Science (PLoS), 2021-12-15)
    Historically social connection has been an important way through which humans have coped with large-scale threatening events. In the context of the COVID-19 pandemic, lockdowns have deprived people of major sources of social support and coping, with others representing threats. Hence, a major stressor during the pandemic has been a sense of social disconnection and loneliness. This study explores how people’s experience of compassion and feeling socially safe and connected, in contrast to feeling socially disconnected, lonely and fearful of compassion, effects the impact of perceived threat of COVID-19 on post-traumatic growth and post-traumatic stress. Adult participants from the general population (N = 4057) across 21 countries worldwide, completed self-report measures of social connection (compassion for self, from others, for others; social safeness), social disconnection (fears of compassion for self, from others, for others; loneliness), perceived threat of COVID-19, post-traumatic growth and traumatic stress. Perceived threat of COVID-19 predicted increased post-traumatic growth and traumatic stress. Social connection (compassion and social safeness) predicted higher post-traumatic growth and traumatic stress, whereas social disconnection (fears of compassion and loneliness) predicted increased traumatic symptoms only. Social connection heightened the impact of perceived threat of COVID-19 on post-traumatic growth, while social disconnection weakened this impact. Social disconnection magnified the impact of the perceived threat of COVID-19 on traumatic stress. These effects were consistent across all countries. Social connection is key to how people adapt and cope with the worldwide COVID-19 crisis and may facilitate post-traumatic growth in the context of the threat experienced during the pandemic. In contrast, social disconnection increases vulnerability to develop post-traumatic stress in this threatening context. Public health and Government organizations could implement interventions to foster compassion and feelings of social safeness and reduce experiences of social disconnection, thus promoting growth, resilience and mental wellbeing during and following the pandemic.
  • Compassion Protects Mental Health and Social Safeness During the COVID‑19 Pandemic Across 21 Countries

    Matos, Marcela; McEwan, Kirsten; Kanovsky, Martin; University of Coimbra; University of Derby (Springer, 2022-01-04)
    The COVID-19 pandemic is having an unprecedented detrimental impact on mental health in people around the world. It is important therefore to explore factors that may buffer or accentuate the risk of mental health problems in this context. Given that compassion has numerous benefits for mental health, emotion regulation, and social relationships, this study examines the buffering effects of different flows of compassion (for self, for others, from others) against the impact of perceived threat of COVID-19 on depression, anxiety, and stress, and social safeness. The study was conducted in a sample of 4057 adult participants from the general community population, collected across 21 countries from Europe, Middle East, North America, South America, Asia, and Oceania. Participants completed self-report measures of perceived threat of COVID-19, compassion (for self, for others, from others), depression, anxiety, stress, and social safeness. Perceived threat of COVID-19 was associated with higher scores in depression, anxiety, and stress, and lower scores in social safeness. Self-compassion and compassion from others were associated with lower psychological distress and higher social safeness. Compassion for others was associated with lower depressive symptoms. Self-compassion moderated the relationship between perceived threat of COVID-19 on depression, anxiety, and stress, whereas compassion from others moderated the effects of fears of contracting COVID-19 on social safeness. These effects were consistent across all countries. Our findings highlight the universal protective role of compassion, in particular self-compassion and compassion from others, in promoting resilience by buffering against the harmful effects of the COVID-19 pandemic on mental health and social safeness.
  • Intention to consume halal pharmaceutical products: evidence from Indonesia

    Kasri, Rahmatina Awaliah; Ahsan, Abdillah; Widiatmoko, Dono; Hati, Sri Rahayu Hijrah; Universitas Indonesia, Depok, Indonesia; University of Derby (Emerald, 2021-12-28)
    Despite the importance of pharmaceutical products in everyday life, particularly after the coronavirus outbreak in early 2020, only a few studies have attempted to analyse consumer behaviour with regard to halal pharmaceutical products. Therefore, this study aims to investigate the factors influencing purchase intention for halal pharmaceutical products among Indonesian Muslims. This study uses a theory of planned behaviour approach, in which religiosity and knowledge of halal product variables are added to attitude, subjective norms and perceived behavioural control variables. Primary data were collected from 225 Indonesian Muslims in Jakarta, the capital city of Indonesia and analysed using structural equation modelling. The study found that the intention to purchase halal pharmaceutical products is positively affected by attitude, religiosity, knowledge of halal products and perceived behavioural control. However, the influence of the subjective norm variable was found to be insignificant in this study. It is possible to improve the empirical model by including more explanatory variables and investigating the mediating effect of the variables. The study could also be scaled up to reach more respondents in different regions and countries. These additional aspects would provide better insights into the behaviour of consumers when considering halal pharmaceutical products. The findings suggest the importance of designing and implementing appropriate strategies and campaigns to enhance knowledge of halal products, of positive attitudes and of better resources/opportunities to consume halal pharmaceutical products. The industry needs to highlight its products’ halal and tayyib aspects through proper branding and promotion strategies. The government and other stakeholders could also implement education campaigns to increase halal products and halal literacy knowledge. These are ultimately expected to enhance the effectiveness of halal regulations and meet Muslim consumer expectations in the country. Despite the importance of halal pharmaceutical products, this area has received limited attention in the academic literature. Thus, this study attempts to elaborate on consumer behaviour in this niche area.
  • Telephone Consultation as a Substitute for Routine Out-patient Face-to-face Consultation for Children With Inflammatory Bowel Disease: Randomised Controlled Trial and Economic Evaluation

    Akobeng, Anthony K.; O'Leary, Neil; Vail, Andy; Brown, Nailah; Fagbemi, Andrew; Thomas, Adrian G.; Widiatmoko, Dono; University of Manchester; Royal Manchester Children's Hospital, Central Manchester NHS Foundation Trust, Manchester, UK; Sidra Medical and Research Centre, Doha, Qatar; et al. (Elsevier, 2015-08-08)
    Evidence for the use of telephone consultation in childhood inflammatory bowel disease (IBD) is lacking. We aimed to assess the effectiveness and cost consequences of telephone consultation compared with the usual out-patient face-to-face consultation for young people with IBD. We conducted a randomised-controlled trial in Manchester, UK, between July 12, 2010 and June 30, 2013. Young people (aged 8–16 years) with IBD were randomized to receive telephone consultation or face-to-face consultation for 24 months. The primary outcome measure was the paediatric IBD-specific IMPACT quality of life (QOL) score at 12 months. Secondary outcome measures included patient satisfaction with consultations, disease course, anthropometric measures, proportion of consultations attended, duration of consultations, and costs to the UK National Health Service (NHS). Analysis was by intention to treat. This trial is registered with, number NCT02319798. Eighty six patients were randomised to receive either telephone consultation (n = 44) or face-to-face consultation (n = 42). Baseline characteristics of the two groups were well balanced. At 12 months, there was no evidence of difference in QOL scores (estimated treatment effect in favour of the telephone consultation group was 5.7 points, 95% CI − 2.9 to 14.3; p = 0.19). Mean consultation times were 9.8 min (IQR 8 to 12.3) for telephone consultation, and 14.3 min (11.6 to 17.0) for face-to-face consultation with an estimated reduction (95% CI) of 4.3 (2.8 to 5.7) min in consultation times (p < 0.001). Telephone consultation had a mean cost of UK£35.41 per patient consultation compared with £51.12 for face-face consultation, difference £15.71 (95% CI 11.8–19.6; P < 0.001). We found no suggestion of inferiority of telephone consultation compared with face-to-face consultation with regard to improvements in QOL scores, and telephone consultation reduced consultation time and NHS costs. Telephone consultation is a cost-effective alternative to face-to-face consultation for the routine outpatient follow-up of children and adolescents with IBD.
  • Enabling safer bathing for people living with epilepsy

    Collier, Elizabeth; Grant, Mandy; University of Derby (University of Derby, 2021-12-14)
    This public involvement consultation (PIC) was set up to explore the opinions and ideas of people living with epilepsy for developing a full research project on the topic of prevention of drowning in the bath. The general advice available for people living with epilepsy (PLE) is to have showers instead of baths, or to have a chaperone and not to bath if alone (Epilepsy Action 2019). However, we know that people with epilepsy do have baths and have them alone, and that there are fatal and non-fatal accidents. Twelve people (7 men and 5 women) took part in the PIC via online meetings and written feedback. Principles of thematic content analysis were applied to detailed notes that were taken, and these were examined independently by the two authors to identify similarities and key issues. Seven categories were identified: Research issues and methods, encouraging language, advice and information, options available, consequences, influencing factors and perceptions of risk. The PIC confirmed that people do bathe alone and that the reasoning behind this is complex and warrants investigation. This includes consideration of language, emotions, personal biography and context, and the role of specialists.
  • The Value and Potential of Qualitative Research Methods in Neurosurgery

    Whiffin, Charlotte J.; Smith, Brandon G.; Selveindran, Santhani M.; Bashford, Tom; Esene, Ignatius N.; Mee, Harry; Barki, M. Tariq; Baticulon, Ronnie E.; Khu, Kathleen J.; Hutchinson, Peter J.; et al. (Elsevier BV, 2021-12-18)
    To explore the value and potential of qualitative research to neurosurgery and provide insight and understanding to this underused methodology. The definition of qualitative research is critically discussed and the heterogeneity within this field of inquiry explored. The value of qualitative research to the field of neurosurgery is articulated through its contribution to understanding complex clinical problems. To resolve some of the misunderstanding of qualitative research, this paper discusses research design choices. We explore approaches that use qualitative techniques but are not, necessarily, situated within a qualitative paradigm in addition to how qualitative research philosophy aids researchers to conduct interpretive inquiry that can reveal more than simply what was said by participants. Common research designs associated with qualitative inquiry are introduced, and how complex analysis may contribute more in-depth insights is explained. Approaches to quality are discussed briefly to support improvements in qualitative methods and qualitative manuscripts. Finally, we consider the future of qualitative research in neurosurgery, and suggest how to move forward in the qualitative neurosurgical evidence base. There is enormous potential for qualitative research to contribute to the advancement of person-centered care within neurosurgery. There are signs that more qualitative research is being conducted and that neurosurgical journals are increasingly open to this methodology. While studies that do not engage fully within the qualitative paradigm can make important contributions to the evidence base, due regard should be given to immersive inquiry within qualitative paradigms to allow complex, in-depth, investigations of the human experience.
  • Principles and Practice of Nurse Prescribing

    Gould, Jill; Bain, Heather; University of Derby; Robert Gordon University (SAGE, 2022-02)
    Feel prepared to take on nurse prescribing with this short and accessible text. Whether you are pre-registration or undertaking a prescribing course, this book is your perfect introduction to the world of nurse prescribing. Covering the legal, professional and pharmacological considerations as well as core skills such as assessment and teamworking, this accessible text explores all aspects of non-medical prescribing in clear, straightforward terms.
  • Impact of occupational therapy in an integrated adult social care service: Audit of Therapy Outcome Measure Findings

    Davenport, Sharon J.; University of Derby (Emerald, 2021-09-21)
    Health and social care services should demonstrate the quality of their interventions for commissioners, patients and carers, plus it is a requirement for occupational therapists to measure and record outcomes. Use of the “Therapy Outcome Measure” (TOMs) standardised tool was implemented by an occupational therapy adult social care service to demonstrate outcomes from April 2020, following integration to a community NHS Trust. The aim was to demonstrate occupational therapy outcomes in adult social care through a local audit of the TOMs. The objective was to determine if clients improved following occupational therapy intervention in the four domains of impairment, activity, participation and wellbeing/carer wellbeing. 70 cases were purposively sampled over a 2-month timeframe, extracting data from the local electronic recording system. Occupational therapy in adult social care clearly makes an impact with their client group and carers. Evidence from the dataset demonstrates clinically significant change, as 93% of clients seen by adult social care occupational therapy staff showed an improvement in at least one TOMs domain during their whole episode of care. 79% of activity scores, 20% of participation scores and 50% of wellbeing scores improved following intervention. 79% of carer wellbeing scores improved following occupational therapy. Research limitations/implications The audit did not collect data on uptake from the separate teams (equipment, housing, STAR and adult social care work) in occupational therapy adult social care. Potential sampling bias occurred as cases with completed scores only were purposively sampled. Sampling was not random which prevented data gathering on uptake of TOMs across the separate teams. Additionally, the audit results can only be applied to the setting from which the data was collected, so has limited external validity. These novel findings illustrate the valuable and unique impact of occupational therapy in this adult social care setting. The integration of adult social care into an NHS Community Trust has supported the service to measure outcomes, by utilising the same standardised tool in use by allied health professions across the Trust.
  • Improving recognition and support for women experiencing the menopause

    Collier, Elizabeth; Clare, Alicia; University of Derby; BlueSCI Wellbeing Service (RCN, 2021-11-09)
    Menopause most commonly occurs in women aged 45-55 and may last for many years. The experience of menopause is a very individual one though many common symptoms are reported such as insomnia, hot flushes, anxiety and poor memory. Many workplaces have no recognition of the disabling effects that menopause can have nor any supportive infrastructure. Nor do workplaces have well informed managers or staff, unsurprising when women themselves often cannot recognise menopause. In addition, symptoms can be interpreted as mental illness. Medical research tends to conceptualise the psychological effects of menopause as psychiatric disorder, but this is not necessarily helpful when treatments for menopause will alleviate experiences rather than the potential inappropriate prescribing of antidepressants for example. Professional awareness is poor generally but there are many actions that can be taken to improve recognition and support; evaluate your services, introduction of specific assessment and information resources for staff and patients and also provide reasonable adjustments. Taking individual responsibility for improving knowledge and skills in this area will mean we can all contribute to a better and more effective environment for women where they feel that their needs are addressed, without having to wait for access to ‘specialist’ services, if available.
  • Investigating the benefits of Family learning (FL) with parents

    Lumenze, Chinenye; University of Derby (University of Derby, 2021-11-03)
    This study investigates the benefits of Family Learning (FL) with parents. It seeks to establish how FL can be used as a tool to address poverty, promote health and provide quality education for all.
  • Sexuality and student mental health nurse experience in education and practice

    Milward, Ben; Collier, Elizabeth; University of Derby (Mark Allen Group, 2021-10-07)
    Lesbian, Gay, bisexual and transgender (LGBT) identifying student mental health nurses (MHNs) in higher education can feel less safe than others which affects performance. People ‘come out’ multiple times and this is difficult in a classroom situation. Lecturers can make a difference to LGBT student nurses experience and this can have an impact on clinical practice. The emotional impact of ‘coming out’ in the classroom can have far reaching consequences for their mental health. The response of educational staff can have a huge impact on the ability to learn and the marks achieved. Student lecturer relationships can have transformative consequences. Student MHN’s make meaning from their educational experiences in the classroom and clinical practice. If they do not see themselves (LGBT perspective) this can affect engagement and motivation. Safe nursing practice is role modelled from lecturer to student and has implications for service user experience in clinical settings.
  • The needs of clients coming to counselling following second harm: A Q methodology study

    Kenward, Linda; whiffin, charlotte; Townend, Michael; University of Derby (Wiley, 2021-09-30)
    Second harm is the added psychological distress from an inadequate response by healthcare providers in response to medical errors or neglect. This inadequate response may require patients to seek counselling. The counselling needs of patients who have experienced second harm have received limited research attention. This Q methodology study addresses this gap in knowledge in order to further inform counselling practice. Participants sorted 42 pre-determined statements online followed by interviews to establish the rationale for the sorting pattern choices. Data from the online sort were analysed using factor analysis to establish the viewpoints expressed. The interview data added to the interpretation of the viewpoints. Through a factor analysis, two ‘viewpoints’ and 11 counselling needs were identified. Nine of these needs were generic to the counselling relationship and two specific to second harm. This study concluded that people seeking counselling following second harm have needs beyond those expected from a general counselling relationship. These included not being blamed for what happened and a need for the counsellor to be able to demonstrate that they are able to understand the impact of harm. The needs identified in this study as being generic can give counsellors confidence in working with clients that have experienced second harm, knowing that many of the needs identified are not unique. Counsellors can also be confident that those needs that are unique can be understood through extending their knowledge of the topic and listening to those that have been harmed.
  • Noninvasive continuous intradialytic blood pressure monitoring: the key to improving haemodynamic stability

    Stewart, Paul; Stewart, Jill; University of Derby (Ovid Technologies (Wolters Kluwer Health), 2021-08-27)
    Intradialytic hypotension (IDH) occurs in 20% of haemodialysis treatments, leading to end-organ ischaemia, increased morbidity and mortality; and contributing to poor quality of life for patients. Treatment of IDH is reactive since brachial blood pressure (BP) is recorded only intermittently during haemodialysis, making early detection and prediction of hypotension impossible. Noninvasive continuous BP monitoring would allow earlier detection of IDH and thus support the development of methods for its prediction and consequently prevention. Noninvasive continuous BP monitoring is not yet part of routine practice in renal dialysis units, with a small number of devices (e.g. finger cuffs) having occasionally been used in research settings. In use, patients frequently report pain or discomfort at measurement sites. Additionally, these devices can be unreliable in patients with reduced blood flow to the digits, often manifest in dialysis patients. All existing methods are sensitive to patient movement. A new method for continuously estimating BP has been developed by monitoring arterial pressure near the arteriovenous fistula which can be achieved without any extraneous monitoring equipment attached to the patient. Additionally, artificial intelligence-based methods for real-time prediction of IDH are currently emerging.Key monitoring technologies and computational methods are emerging to support the development of real-time IDH prediction.
  • The Role of the Liver in Iron Homeostasis and What Goes Wrong?

    Robalino Gonzaga, Ernesto; Riestra Guiance, Irene; Henriquez, Richard; Mortimore, Gerri; Freeman, Jan; University of Central Florida, Orlando, FL, USA; University Hospitals of Derby and Burton on Trent; University of Derby (Codon Publications, 2021-09-18)
    Iron is an essential mineral that is vital for growth development, normal cellular function, synthesis of hormones and connective tissue, and most importantly, serves as a component of hemoglobin to carry oxygen to body tissues. The body finely regulates the amount of circulating and stored iron within the body to maintain concentration levels within range for optimal physiologic function. Without iron, the ability for cells to participate in electron transport and energy metabolism decreases. Furthermore, hemoglobin synthesis is altered, which leads to anemia and decreased oxygen delivery to tissue. Problems arise when there is too little or too much iron. This review explores the role of the liver in iron physiology, iron overload and discusses the most common causes of primary and secondary hepatic iron overload.
  • Perineal Trauma & Suturing

    Chapman, Vicky; Independent Researcher (Wiley Blackwell, 2018-01-18)
  • How does a narrative understanding of change in families post brain injury help us to humanise our professional practice?

    Whiffin, C J; Ellis-Hill, C; University of Derby; Bournemouth University (Cambridge university press, 2021-09-17)
    In this paper we critically explore the discourse of change post brain injury and challenge the dominant discourse of negative change which alone leaves little room for other perspectives to exist. These negative changes pose a considerable risk to the well-being of families who may benefit from engaging in richer accounts making room for a more coherent and connected sense of self and family post-injury. We explore how narrative approaches provide opportunities for all practitioners to expand their professional scripts and support families to move toward a future which is not dominated by a discourse of loss. While loss and negative change is an important, and very real consequence, of brain injury, focusing purely on stories of loss is life limiting for family members and can cause psychological distress. The life thread model is offered as a visible tool for all practitioners to engage with and use while working with families; providing a concrete focus for reflection and discussion of narratives relating to change which otherwise can feel quite abstract in everyday practice. We argue that one way we can humanise our professional practice is to support all practitioners to engage in a narrative understanding of family change following ABI.
  • Oro-mucosal midazolam maleate: Use and effectiveness in adults with epilepsy in the UK

    Shankar, Rohit; Goodwin, Melesina; Toland, John; Boyle, Andrew; Grant, Amanda; Pearson, Josephine; Storer, Amanda; Higgins, Richard; Hudson, Sharon; Reuber, Markus; et al. (Elsevier, 2021-08-07)
    Oro-mucosal midazolam maleate (OMM) with suitable training to family and carers is being increasingly recognized as the treatment of choice to mitigate the development of status epilepticus in non-hospital community settings. There are no studies to describe the use, effectiveness, and suitable dosing of OMM in adults with epilepsy in community settings. To describe the use, effectiveness, and dosing of OMM in the emergency treatment of epileptic seizures in community settings. A retrospective observational study (2016–17) design was used with participant recruitment from four UK NHS secondary care outpatient clinics providing epilepsy management. Study sample was of adult people with epilepsy (PWE) having had a recent seizure requiring OMM. Data on patient demographics, patient care plans, details of a recent seizure requiring emergency medication, and dose of OMM were collected from medical records. Study data from 146 PWE were included. The mean age of PWE was 41.0 years (SD 15.2) and mean weight was 64.8Kg (SD 18.2). Fifty-three percent of PWE were recorded as having intellectual disability. The most frequently used concomitant medications were lamotrigine (43%). The majority of seizures occurred at people’s homes (n = 92, 63%). OMM was most often administered by family/professional care-givers (n = 75, 48.4%). Generalized (tonic/clonic) seizures were recorded in most people (n = 106, 72.6%). The most common initial dose of OMM was 10 mg (n = 124, 84.9%). The mean time to seizure cessation after administration of this initial dose was 5.5 minutes (SD = 4.5, Median 5.0, IQR 2.1–5.0). Only a minority of seizures led to ambulance callouts (n = 18, 12.3%) or hospital admissions (n = 13, 9%). This is the first observational study describing the use and effectiveness of OMM in adults in community settings. Minimal hospital admissions were reported in this cohort and the treatment was effective in ending seizures in adults in community settings.
  • 'Mixed white and Black Caribbean' millennials in Britain: An exploration of identity

    Clarke, Yasmine; University of Derby (Wiley, 2021-07-26)
    This study presents a qualitative exploration of individuals identifying as ‘mixed white and Black Caribbean’ (MWBC) in Britain. The focus of this research aimed to answer the question, 'how do mixed white and Black Caribbean millennials in Britain experience their identity?' Six participants, aged 22–31 years, were interviewed about their family, relationships and personal values. The results were analysed using interpretative phenomenological analysis and highlighted three main themes: ‘Public Perception’, ‘Caribbean Heritage’ and ‘Conversations’. Each theme was analysed from an integrative psychotherapeutic viewpoint, before concluding with suggestions for counsellors and psychotherapists working with this client group in clinical practice.

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