Qualitative Lead(s)
Professor Vanessa Lawrence
Project Lead & Team
Chief Investigator: Professor Ulrike Schmidt (King’s College London)
The multidisciplinary team included psychiatrists, psychologists, health economists, statisticians, trial methodologists, clinicians from specialist eating-disorder services, and patient/carer representatives.
Project Dates
2020–2023
Funding Source(s)
NIHR Health Technology Assessment Programme (HTA 17/123/03)
Qualitative Design used
Field of Research
Eating disorders; severe anorexia nervosa; intensive treatment services; trial implementation; complex intervention evaluation.
Geographic/Contextual Setting
UK specialist eating-disorder inpatient and day-patient services.
Stepping into Day Treatment versus Inpatient Treatment for Adults with Severe Anorexia Nervosa
DAISIES was an NIHR HTA-funded multicentre randomised controlled trial designed to evaluate the acceptability, clinical effectiveness and cost-effectiveness of a stepped-care day patient treatment (DPT) approach compared with inpatient treatment as usual (IP-TAU) for adults with severe anorexia nervosa. Qualitative research formed a major component of the programme, examining clinician and patient perspectives on intensive treatment approaches and the implementation of the trial. Although the trial was terminated early due to recruitment challenges, the embedded qualitative programme generated important insights into treatment preferences, implementation barriers, and methodological lessons for future trials in intensive eating-disorder services.
Qualitative Approach and Methods
Aim of the qualitative component
To explore stakeholder perspectives on intensive treatment approaches for severe anorexia nervosa and to understand patient, clinician, and organisational factors influencing engagement with treatment and implementation of the DAISIES trial.
Qualitative methodology
A multi-study qualitative programme using reflexive thematic analysis, followed by framework-informed analyses, informed by implementation science frameworks.
Which qualitative methods were used?
- Qualitative interviews with patients, carers, and clinicians regarding treatment experiences.
- Individual interviews and focus groups with clinicians, trial investigators, and stakeholders involved in trial implementation.
- Analysis of trial management documentation to understand implementation challenges.
- Participatory consultation with clinical and lived-experience stakeholders during trial design and delivery.
Sampling & recruitment
Participants included clinicians, patients receiving intensive treatment for severe anorexia nervosa, carers, and trial stakeholders. Individuals were purposively sampled across participating specialist eating-disorder services to capture variation in treatment setting, professional role, service context, and treatment experience, including patients eligible for or receiving intensive treatment within the DAISIES programme.
Data analysis: how the team made sense of the data
Interview data on intensive treatment approaches were analysed using reflexive thematic analysis. Interview data and documentary data relating to DAISIES implementation were analysed using an implementation-science-informed interpretive approach (i.e. NASSS framework) to identify barriers and facilitators to implementation, treatment acceptability, and contextual influences on recruitment and engagement.
Findings, Learning & Impact
Summary of main findings
Qualitative findings showed that both inpatient and day-patient treatment approaches were valued by clinicians and patients but differed in perceived advantages related to autonomy, continuity with everyday life, and intensity of support. Strong patient treatment preferences, organisational pressures within specialist services, and system-level disruptions associated with the COVID-19 pandemic were major contributors to recruitment challenges and the eventual termination of the trial. Adoption challenges occurred across multiple levels, including patient, clinician, organisational, and wider health-system contexts, highlighting the complexity of conducting pragmatic trials within highly pressured specialist services.
Why were qualitative methods used in this project, and what did they enable?
Qualitative methods enabled the research team to:
- Understand stakeholder views on intensive treatment models for severe anorexia nervosa.
- Identify barriers to recruitment and participation that could not be detected through trial metrics alone.
- Examine organisational and systemic challenges affecting trial delivery.
- Generate methodological learning regarding trial design in complex service settings
Lessons learnt / reflections?
- Patient treatment preferences play a major role in recruitment feasibility for trials comparing intensive service models.
- Implementation challenges in NHS specialist services often arise from organisational capacity constraints and external system pressures.
- Qualitative research is essential for understanding why trials succeed or fail and for informing alternative trial designs that better align with patient and service realities.
Impact & influence
Despite early trial termination, the qualitative programme generated important methodological insights into the design and implementation of trials in intensive mental-health service settings and informed recommendations for future studies, including the use of alternative designs, such as naturalistic longitudinal studies or offering a partially randomised patient preference design.
Links, Outputs & Resources
Links to publications
- Phillips, M., İnce, B., Webb, H., Dalton, B., McCombie, C., Irish, M., Mercado, D., Peachey, G., Zenasni, Z., Himmerich, H., Robinson, P., Arcelus, J., Byford, S., Treasure, J., Landau, S., Lawrence, V., & Schmidt, U. (2023). Autopsy of a failed trial part 1: A qualitative investigation of clinician’s views on and experiences of the implementation of the DAISIES trial in UK-based intensive eating disorder services. European Eating Disorders Review, 31(4), 489–504. Available here.
- İnce, B., Phillips, M. D., Zenasni, Z., Shearer, J., Dalton, B., Irish, M., Mercado, D., Webb, H., McCombie, C., Au, K., Kern, N., Clark-Stone, S., Connan, F., Johnston, A. L., Lazarova, S., Zadeh, E., Newell, C., Pathan, T., Wales, J., … Schmidt, U. (2024). Autopsy of a failed trial part 2: Outcomes, challenges, and lessons learnt from the DAISIES trial. European Eating Disorders Review, 32(3), 476–489. İnce B, Phillips MD, Zenasni Z, Shearer J, Dalton B, Irish M, Mercado D, Webb H, McCombie C, Au K, Kern N, Clark-Stone S, Connan F, Johnston AL, Lazarova S, Zadeh E, Newell C, Pathan T, Wales J, Cashmore R, Marshall S, Arcelus J, Robinson P, Byford S, Landau S, Lawrence V, Himmerich H, Treasure J, Schmidt U. Autopsy of a failed trial part 2: Outcomes, challenges, and lessons learnt from the DAISIES trial. Eur Eat Disord Rev. 2024 May;32(3):476-489. doi: 10.1002/erv.3058. Epub 2023 Dec 18. PMID: 38109218.
- Webb, H., Dalton, B., Irish, M., Mercado, D., McCombie, C., Peachey, G., Arcelus, J., Au, K., Himmerich, H., Louise Johnston, A., Lazarova, S., Pathan, T., Robinson, P., Treasure, J., Schmidt, U., & Lawrence, V. (2022). Clinicians’ perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings. Journal of Eating Disorders, 10(1), 3. Available here.
- Webb, H., Dalton, B., Irish, M., Mercado, D., McCombie, C., Peachey, G., Arcelus, J., Au, K., Himmerich, H., Johnston, A. L., Lazarova, S., Pathan, T., Robinson, P., Treasure, J., Schmidt, U., & Lawrence, V. (2022). Clinicians’ perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings during the COVID-19 pandemic. Journal of Eating Disorders, 10(1), 30. https://doi.org/10.1186/s40337-022-00555-4 Available here.