Dementia prevention and the GP’s role: a qualitative interview study

Danielle Jones; Rachael Drewery; Karen Windle; Sara Humphrey; Andreia Fonseca de Paiva

doi:10.3399/BJGP.2023.0103

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Re-thinking the role of primary care in dementia prevention
Tamara M. Willows and Dipesh P Gopal

Published on: 26 November 2023
Judgement of data saturation: reply
Danielle Jones

Published on: 29 September 2023
Judgment of data saturation
Junki Mizumoto

Published on: 21 September 2023

Published on: (26 November 2023)
Page navigation anchor for Re-thinking the role of primary care in dementia prevention
Re-thinking the role of primary care in dementia prevention
Tamara M. Willows, Academic General Practitioner Trainee, Queen Mary University of London
Other Contributors:
Dipesh P Gopal, SPCR Primary Care Clinicians Career Progression Fellow, Queen Mary University of London
We read Jones and colleagues’ paper on the role of GPs in dementia prevention with great interest¹. Whilst the research introduces a novel strategy for addressing this challenge and acknowledges barriers to communicating dementia risk such as time, there are some notable absences.

Firstly, while GPs might be better placed than secondary care colleagues to prevent dementia in the community, concerted effort towards a ‘public brain health agenda’ may be more effective for reducing the risk of dementia in the wider population than opportunistic dementia screening². More focus could be placed on dementia prevention strategies initiated before people present to primary care and rather than relying on a form of dementia screening for which there is limited evidence³. The brain health agenda might include social participation, as well as cognitive and physical activity, access to which is predicated by societal structures and individual motivation, which are outside the remit of general practices.

Secondly, the article insufficiently addresses how its proposed suggestions would be implemented within primary care. While it suggested including dementia screening within the NHS health checks, there is limited data illustrating the impact of NHS health checks on health outcomes³. Pre-pandemic data revealed that only 48% of those invited to take part in NHS health checks had done so and among those, mo...
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We read Jones and colleagues’ paper on the role of GPs in dementia prevention with great interest¹. Whilst the research introduces a novel strategy for addressing this challenge and acknowledges barriers to communicating dementia risk such as time, there are some notable absences.

Firstly, while GPs might be better placed than secondary care colleagues to prevent dementia in the community, concerted effort towards a ‘public brain health agenda’ may be more effective for reducing the risk of dementia in the wider population than opportunistic dementia screening². More focus could be placed on dementia prevention strategies initiated before people present to primary care and rather than relying on a form of dementia screening for which there is limited evidence³. The brain health agenda might include social participation, as well as cognitive and physical activity, access to which is predicated by societal structures and individual motivation, which are outside the remit of general practices.

Secondly, the article insufficiently addresses how its proposed suggestions would be implemented within primary care. While it suggested including dementia screening within the NHS health checks, there is limited data illustrating the impact of NHS health checks on health outcomes³. Pre-pandemic data revealed that only 48% of those invited to take part in NHS health checks had done so and among those, most were older people or those with a family history of coronary disease³. Furthermore, other than GPs, there were no other primary care practitioners in the study so it is unclear whether they would have the capacity to accommodate this additional work¹.

Finally, although the article presents dementia screening as overlapping with other conditions in the NHS health check, the authors should explore potential barriers to successfully implementing dementia screening into primary care practice through this route⁴. We need to understand how this might affect the work of people in primary care and explore the associated unintended consequences. In a time of declining general practice workforce numbers, perhaps we should heed Iona Heath’s wise words: “An excessive and unrealistic commitment to prevention of sickness could destroy our capacity to care for those who are already sick."5, 6

References

1. Jones D, Drewery R, Windle K, Humphrey S, De Paiva AF. Dementia prevention and the GP’s role: A qualitative interview study. Br J Gen Pract 2023; 2023-07-04: BJGP.2023.0103. doi: 10.3399/BJGP.2023.0103
2. Hussenoeder FS, Riedel-Heller SG. Primary prevention of dementia: From modifiable risk factors to a public brain health agenda? Psychiatry Psychiatr Epidemiol 2018; 53(12):1289-1301. doi: 10.1007/s00127-018-1598-7.
3. Martin A, Saunders CL, Harte E, Griffin SJ, MacLure C, Mant J et al. Delivery and impact of the nhs health check in the first 8 years: A systematic review. Br J Gen Pract 2018; 68(672): e449-e59.
4. Greenhalgh T, Abimbola S. The nasss framework-a synthesis of multiple theories of technology implementation. Stud Health Technol Inform 2019; 263:193-204.
5. Shembavnekar N, Buchan J, Bazeer N, Kelly E, Beech J. Projections: General practice workforce in England. The Health Foundation. 2022. www.health.org.uk/publications/reports/projections-general-practice-workforce-in-england
6. Heath I. In defence of a national sickness service. BMJ 2007; 334(7583):19. doi: 10.1136/bmj.39066.541678.B7.

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Competing Interests: None declared.
Published on: (29 September 2023)
Page navigation anchor for Judgement of data saturation: reply
Judgement of data saturation: reply
Danielle Jones, Associate Professor in Dementia Studies, University of Bradford
Dear Junki Mizumoto,

Thank you for the interest in the article and for the questions raised about the method.

As we detailed, our sample was relatively homogenous, all GPs were located in the UK, 82% were female, and over half have specialist postgraduate dementia education. As we did not aim to correlate findings with participant characteristics, collecting further participant information was unnecessary. We acknowledge that using convenience sampling can attract participants interested in the research topic. We do not suggest within the article that findings are transferrable to other populations or indeed outside the UK. As identified, further study in other populations would be required.

The scope of the study was discrete, defined to answer the identified research questions only, with interview questions limited to this focus. Unstructured questions about prevention may have yielded further insight, as you suggest, but this was not the approach for this study. We do not suggest we exhausted all views of GPs about dementia prevention, but those identified in the scope of the study.

We acknowledge there is no universal approach to thematic analysis (TA), or indeed identifying saturation. Braun and Clark suggest that when themes are conceptualised as analytic inputs, using this type of coding approach to TA, possible or actual themes will ‘saturate’ early. We had a rigorous process of coding data, reviewing codes and them...
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Dear Junki Mizumoto,

Thank you for the interest in the article and for the questions raised about the method.

As we detailed, our sample was relatively homogenous, all GPs were located in the UK, 82% were female, and over half have specialist postgraduate dementia education. As we did not aim to correlate findings with participant characteristics, collecting further participant information was unnecessary. We acknowledge that using convenience sampling can attract participants interested in the research topic. We do not suggest within the article that findings are transferrable to other populations or indeed outside the UK. As identified, further study in other populations would be required.

The scope of the study was discrete, defined to answer the identified research questions only, with interview questions limited to this focus. Unstructured questions about prevention may have yielded further insight, as you suggest, but this was not the approach for this study. We do not suggest we exhausted all views of GPs about dementia prevention, but those identified in the scope of the study.

We acknowledge there is no universal approach to thematic analysis (TA), or indeed identifying saturation. Braun and Clark suggest that when themes are conceptualised as analytic inputs, using this type of coding approach to TA, possible or actual themes will ‘saturate’ early. We had a rigorous process of coding data, reviewing codes and themes within the research team and, while themes remained somewhat semantic, no new codes were identified in the final two interviews.

We appreciate your time in reading and commenting on the paper.

Reference

1. Braun, V., & Clarke, V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Research in Sport, Exercise and Health 2021; 13:2: 201-216, DOI: 10.1080/2159676X.2019.1704846.

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Competing Interests: None declared.
Published on: (21 September 2023)
Page navigation anchor for Judgment of data saturation
Judgment of data saturation
Junki Mizumoto, Family physician, Department of Medical Education Studies, International Research Center for Medical Education, The University of Tokyo
I read the article by Jones et al.¹with great interest and strongly appreciate the importance of this study. The research question sheds light on the unique and indispensable role of GPs. The research topic, which focuses on dementia prevention and the GP's role, is expected to encompass a wide range of relevant themes.
The authors mention that data saturation was achieved by interviewing 11 participants for an average of 26 minutes each. In the broader context, data saturation refers to the point in data collection where no additional insights are identified, and further data collection becomes redundant. Given the depth and breadth of the area covered by this research topic, it is challenging to imagine data saturation being reached in short-term interviews with a relatively small number of participants.
Two possible factors may have influenced the judgment of data saturation in this study. First, the participants might be from a homogeneous and small community. Hennink and Kaiser² suggest that saturation may be reached within a few interviews (typically between 9 to 17) when participants belong to relatively homogenous populations with narrowly defined objectives. As a reader of the article, I am curious about the participants, but the authors did not provide detailed information about them, only stating that they recruited participants via convenience sampling from existing networks in the UK. It raises suspicion that the particip...
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I read the article by Jones et al.¹with great interest and strongly appreciate the importance of this study. The research question sheds light on the unique and indispensable role of GPs. The research topic, which focuses on dementia prevention and the GP's role, is expected to encompass a wide range of relevant themes.
The authors mention that data saturation was achieved by interviewing 11 participants for an average of 26 minutes each. In the broader context, data saturation refers to the point in data collection where no additional insights are identified, and further data collection becomes redundant. Given the depth and breadth of the area covered by this research topic, it is challenging to imagine data saturation being reached in short-term interviews with a relatively small number of participants.
Two possible factors may have influenced the judgment of data saturation in this study. First, the participants might be from a homogeneous and small community. Hennink and Kaiser² suggest that saturation may be reached within a few interviews (typically between 9 to 17) when participants belong to relatively homogenous populations with narrowly defined objectives. As a reader of the article, I am curious about the participants, but the authors did not provide detailed information about them, only stating that they recruited participants via convenience sampling from existing networks in the UK. It raises suspicion that the participants might be from a specific small and homogenous population, which could explain why no novel opinions were collected.
Second, although there is no gold standard to confirm whether data saturation is reached, the authors' procedure appears to be relatively basic. Guest et al.³ propose that data saturation consists of three distinct elements: the base size, the run length, and the new information threshold. They suggest a straightforward yet more robust method to assess data saturation.
Providing specific information about the participants and detailing the methods of data collection and analysis would help readers from different cultural backgrounds better understand the content of the article. Therefore, the authors should pay more attention to improving the transferability and dependability of their study.

References

1. Jones D, Drewery R, Windle K, Humphrey S, de Paiva AF. Dementia prevention and the GP's role: a qualitative interview study [published online ahead of print, 2023 Jul 4]. Br J Gen Pract 2023; BJGP.2023.0103. doi:10.3399/BJGP.2023.0103.
2. Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med 2022; 292:114523. doi:10.1016/j.socscimed.2021.114523.
3. Guest G, Namey E, Chen M. A simple method to assess and report thematic saturation in qualitative research. PLoS One 2020;15(5): e0232076. doi:10.1371/journal.pone.0232076.
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Competing Interests: None declared.