Public Health & Dugald Baird Centre University of Aberdeen Medical School Aberdeen AB25 2ZD Scotland UK
van.teijlingen@abdn.ac.uk
Edwin R. van Teijlingen is a Reader in Public Health at the University of Aberdeen and has academic background in Medical Sociology. His research interests lie in a range of social aspects of health and illness. He has published in the areas of Health Promotion Evaluation, Organisation of Maternity Care; and Psycho-social aspects of medicine and medical care. He has been co-editor of several academic books (Nova Science; Routledge) as well as textbooks (Oxford University Press; Elsevier).
Abstract: OBJECTIVE: To explore women's preferences for, and trade-offs between, key attributes of intrapartum care models. DESIGN: Mixed-methods study using discrete choice experiments (DCEs) and focus groups. SETTING: The North of Scotland. POPULATION: Women from the catchment areas of eight rural maternity units in the North of Scotland. METHODS: Based on current policy, 'model of care' and 'time travelled' were selected as key attributes of intrapartum care in remote and rural settings. A DCE questionnaire explored women's preferences for and trade-offs between these attributes. Focus groups validated the DCE attributes and provided valuable information about the drivers of women's preferences for place of delivery. MAIN OUTCOME MEASURES: Preferences for attributes of intrapartum care. RESULTS: Eight focus groups were conducted, and 877 eligible women completed the questionnaire. Overall, the DCE results found women preferred delivery in a unit to home birth and consultant-led care (CLC) to midwife-managed care (MMC). Women preferring CLC associated it with covering every eventuality and increased safety. Although women preferred shorter travel times, trade-offs indicated a willingness to travel for approximately 2 hours to get one's preferred choice. Focus group findings and subgroup DCE analysis showed heterogeneity of preferences related to experience, risk status, geographic location, perception of care and family circumstances. CONCLUSIONS: In contrast to service redesign offering local midwife-managed intrapartum care, most rural women in our study expressed a preference to give birth in hospital and have CLC because they felt safer. Women were willing to travel for this but within limits. Qualitative results showed that women's preferences were influenced by their home and family context, beliefs and previous pregnancy experiences. Challenges for service redesign are to provide comprehensive obstetric services within acceptable travel time, while responding to the heterogeneity of women's preferences.
Abstract: BACKGROUND: Men's lifestyles are generally less healthy than women's. This study identifies associations between health-related behaviour in different groups of men working in a Higher Education (HE) institution. In addition, men were asked whether they regarded their health-related behaviours as a concern. This article highlights smoking, consumption of alcohol and physical activity as most common men's health-related lifestyle behaviours. METHODS: A descriptive cross-sectional survey was conducted among all male staff employed by a Higher Education institute in Scotland using a postal self-completed questionnaire. A total of 1,335 questionnaires were distributed and 501 were returned completed (38% return rate). The data were analysed using SPSS 13.0 for Windows. RESULTS: Less than 10% currently smoked and almost 44% of these smokers were light smokers. Marital status, job title, consumption of alcohol and physical activity level were the major factors associated with smoking behaviour. Men in manual jobs were far more likely to smoke. Nearly all (90%) consumed alcohol, and almost 37% had more than recommended eight units of alcohol per day at least once a week and 16% had more than 21 units weekly. Younger men reported higher amount of units of alcohol on their heaviest day and per week. Approximately 80% were physically active, but less than 40% met the current Government guidelines for moderate physical activity. Most men wanted to increase their activity level. CONCLUSION: There are areas of health-related behaviour, which should be addressed in populations of this kind. Needs assessment could indicate which public health interventions would be most appropriately aimed at this target group. However, the low response rate calls for some caution in interpreting our findings.
Abstract: BACKGROUND: The HIV/AIDS epidemic remains of global significance and there is a need to target (a) the adolescent age-groups in which most new infections occur; and (b) sub-Saharan Africa where the greatest burden of the epidemic lies. A focused systematic review of school-based sexual health interventions in sub-Saharan Africa to prevent HIV/AIDS and Sexually Transmitted Infections (STI) in this age group was therefore conducted. METHODS: Searches were conducted in Medline, Embase, Cinahl and PsychINFO according to agreed a priori criteria for studies published between 1986 and 2006. Further searches were conducted in UNAIDS and WHO (World Health Organization) websites, and 'Google'. Relevant journals were hand-searched and references cited in identified articles were followed up.Data extraction and quality assessment was carried out on studies selected for full text appraisal, and results were analysed and presented in narrative format. RESULTS: Some 1,020 possible titles and abstracts were found, 23 full text articles were critically appraised, and 12 articles (10 studies) reviewed, reflecting the paucity of published studies conducted relative to the magnitude of the HIV epidemic in sub-Saharan Africa. Knowledge and attitude-related outcomes were the most associated with statistically significant change. Behavioural intentions were more difficult to change and actual behaviour change was least likely to occur. Behaviour change in favour of abstinence and condom use appeared to be greatly influenced by pre-intervention sexual history. CONCLUSION: There is a great need in sub-Saharan Africa for well-evaluated and effective school-based sexual health interventions.
Abstract: INTRODUCTION: Rising health care costs and the need to consolidate expertise in tertiary services have led to the centralisation of services. In the UK, the result has been that many rural maternity units have become midwife-led. A key consideration is that midwives have the skills to competently and confidently provide maternity services in rural areas, which may be geographically isolated and where the midwife may only see a small number of pregnant women each year. Our objective was to compare the views of midwives in rural and urban settings, regarding their competence and confidence with respect to 'competencies' identified as being those which all professionals should have in order to provide effective and safe care for low-risk women. METHOD: This was a comparative questionnaire survey involving a stratified sample of remote and rural maternity units and an ad hoc comparison group of three urban maternity units in Scotland. Questionnaires were sent to 82 midwives working in remote and rural areas and 107 midwives working in urban hospitals with midwife-led units. RESULTS: The response rate from midwives in rural settings was considerably higher (85%) than from midwives in the urban areas (60%). Although the proportion of midwives who reported that they were competent was broadly similar in the two groups, there were some significant differences regarding specific competencies. Midwives in the rural group were more likely to report competence for breech delivery (p = 0.001), while more urban midwives reported competence in skills such as intravenous fluid replacement (p <0.001) and initial and discharge examination of the newborn (p <0.001). Both groups reported facing barriers to continuing professional development; however, more of the rural group had attended an educational event within the last month (p <0.001). Lack of time was a greater barrier for urban midwives (p = 0.02), whereas distance to training was greater for rural midwives (p = 0.009). Lack of motivation or interest was significantly higher in urban units (p = 0.006). CONCLUSION: It is often assumed that midwives in rural areas where there are fewer deliveries, will be less competent and confident in their practice. Our exploratory study suggests that the issue of competence is far more complex and deserves further attention.
Abstract: There are increasing concerns regarding inequities in access to health care, and hence calls for routine data collection to improve monitoring. For many developing countries, such as Bangladesh, increasing the availability and uptake of emergency obstetric care (EmOC) is vital in improving maternal health. It is crucial, however, that women of all socio-economic status benefit from this. This paper describes the development and validation of a proxy wealth index for assessing women's socio-economic status in Bangladesh as they are admitted to hospital. Existing poverty assessment tools are unsuitable for use in this context as they are too lengthy or need to be administered at household or community level. We sought to develop a tool with a limited number of indicators to allow quick administration and avoid interference with treatment. We also aimed to develop a pragmatic tool to be able to calculate a score in the field. The steps, involving selecting and weighting indicators, assigning a proxy wealth score and validating the score, are outlined. Indicators were selected from the Bangladeshi Demographic and Health Survey (DHS) data, which allowed comparison of socio-economic status between women using EmOC and those in the wider population. The tool proved quick and easy to use and was acceptable to women and their families. The validity of the tool was established by means of factor analysis. Our comparison with DHS data suggested that women using EmOC were significantly wealthier than women in the wider population. The implications of this, as well as the strengths and limitations of the proxy wealth index, are discussed. The proxy wealth index offers potential as a pragmatic and quick means of assessing poverty status in a busy hospital setting. Such a tool may enable monitoring of equity in access to treatment and identification of those least able to afford treatment, to enable any mechanisms in place to pay for care to be applied in a timely fashion, so avoiding delays in treating life-threatening complications.
Abstract: BACKGROUND: Cesarean section rates throughout the developed world continue to rise. Although satisfaction with cesarean section has been widely studied, relatively little is known about the causes of "distress" that may contribute to dissatisfaction. The aim of this study was to explore the factors that women identified as "distressing" so as to understand their responses to standard questions on satisfaction. METHODS: A questionnaire study of 1,661 women who had delivered their first babies by cesarean section in Aberdeen, Scotland, between 1980 and 1995 elicited a 75 percent response rate and showed that 81 percent of women were satisfied with the experience. Nevertheless, 36 percent rated an aspect as distressing, and 42 percent provided written descriptions of one or more experiences that had distressed them. These responses were coded using content analysis into 5 major categories: before, during, and after the birth, psychological/general, and overall. RESULTS: The most distressing factors were of a psychological or general nature, with 66 percent of distressed women mentioning poor communications, fears, missing out on the birth or the immediate postpartum period, or other emotions. Events happening before, during, and after the birth caused 23, 45, and 44 percent of women to be distressed, respectively. Surgical complications and infections were distressing, but anesthesia was the single factor that caused most distress, leaving 102 women (20%) with unsatisfactory memories of the birth. CONCLUSIONS: The impact of cesarean birth on women's psychological well-being is highlighted by this study. Enhanced communication during labor and delivery, and preparation or education on issues surrounding cesarean section, can reduce distress and improve women's satisfaction with birth.
Abstract: OBJECTIVE: a national study of midwives' perceptions of women's decision-making in the technical interventions in the birth process. DESIGN: questionnaire survey of women and their midwives. Midwives completed a maternity record for each woman in the study after the birth, and the women completed a demographic questionnaire at to 20-24 weeks gestation. SETTING: a stratified sample of 25 Dutch midwifery practices based on rural or urban location. Each of these 25 independent practices agreed to approach 25 eligible consecutive pregnant women on a randomly assigned day. PARTICIPANTS: in total 637 women were invited and 625 participated (response rate 98%). FINDINGS AND KEY CONCLUSIONS: midwives reported that they had a large influence in the decision to refer a woman to an obstetrician, but far and far less so when it comes to decisions around taking pharmaceutical pain relief. Midwives felt women had least say in the decision around augmentation of labour and most in the decision to sweep the membranes, whilst obstetricians had most input in the decision around primary induction of labour and least in the decision to refer from primary to secondary care. Our analysis indicated that midwives saw younger women (29 and younger) as having more influence in the decision-making process than old ones. Our analysis suggests there might be a tension between midwives own professional ideology and their non-interventionist focus and women's choice, which leads to an increase in medicalisation of childbirth.
Abstract: Previous research and clinical experience suggest that Huntington's disease (HD) can considerably affect family life, particularly for young people (YP) at risk. The goal of this study was to describe the experiences of YP from families affected by HD. YP were identified through the regional genetics clinic and the Scottish Huntington's Association. In-depth interviews were used to explore YP's experiences of finding out about HD in the family; perceptions of their own risk; caring activities; protective or risk factors; and the impact of HD on relationships with siblings, parents, extended family members, and the wider community. Thirty-three YP between the ages of 9 and 28 years were interviewed. A qualitative thematic analysis was undertaken. The analysis revealed four main themes: YP as carers, the worried well, those who cope, and those at risk/in need. These themes highlight the varied experience of growing up in a family affected by HD. Whilst some YP successfully coped, others experienced considerable problems and were at risk of physical and/or emotional harm. In understanding why some cope better than others, our findings suggest protective and risk factors within these themes. In particular, participants who grew up knowing about HD from an early age seemed to cope better.
Abstract: AIM: This paper reports a review of the literature on skills, competencies and continuing professional development necessary for sustainable remote and rural maternity care. BACKGROUND: There is a general sense that maternity care providers in rural areas need specific skills and competencies. However, how these differ from generic skills and competencies is often unclear. METHODS: Approaches used to access the research studies included a comprehensive search in relevant electronic databases using relevant keywords (e.g. 'remote', 'midwifery', 'obstetrics', 'nurse-midwives', education', 'hospitals', 'skills', 'competencies', etc.). Experts were approached for (un-)published literature, and books and journals known to the authors were also used. Key journals were hand searched and references were followed up. The original search was conducted in 2004 and updated in 2006. FINDINGS: Little published literature exists on professional education, training or continuous professional development in maternity care in remote and rural settings. Although we found a large literature on competency, little was specific to competencies for rural practice or for maternity care. 'Hands-on' skills courses such as Advanced Life Support in Obstetrics and the Neonatal Resuscitation Programme increase confidence in practice, but no published evidence of effectiveness of such courses exists. CONCLUSION: Educators need to be aware of the barriers facing rural practitioners, and there is potential for increasing distant learning facilitated by videoconferencing or Internet access. They should also consider other assessment methods than portfolios. More research is needed on the levels of skills and competencies required for maternity care professionals practising in remote and rural areas.
Abstract: BACKGROUND: Postnatal care is uncommon in Nepal, and where it is available the quality is often poor. Adequate utilisation of postnatal care can help reduce mortality and morbidity among mothers and their babies. Therefore, our study assessed the utilisation of postnatal care at a rural community level. METHODS: A descriptive, cross-sectional study was carried out in two neighbouring villages in early 2006. A total of 150 women who had delivered in the previous 24 months were asked to participate in the study using a semi-structured questionnaire. RESULTS: The proportion of women who had received postnatal care after delivery was low (34%). Less than one in five women (19%) received care within 48 hours of giving birth. Women in one village had less access to postnatal care than women in the neighbouring one. Lack of awareness was the main barrier to the utilisation of postnatal care.The woman's own occupation and ethnicity, the number of pregnancies and children and the husband's socio-economic status, occupation and education were significantly associated with the utilisation of postnatal care.Multivariate analysis showed that wealth as reflected in occupation and having attended antenatal are important factors associated with the uptake of postnatal care. In addition, women experiencing health problems appear strongly motivated to seek postnatal care. CONCLUSION: The postnatal care has a low uptake and is often regarded as inadequate in Nepal. This is an important message to both service providers and health-policy makers. Therefore, there is an urgent need to assess the actual quality of postnatal care provided. Also there appears to be a need for awareness-raising programmes highlighting the availability of current postnatal care where this is of sufficient quality.
Abstract: OBJECTIVE: The long-term effects on women in childbirth with a history of sexual abuse have only been studied to a limited degree. We estimated the prevalence of lifetime experience among low-risk pregnant women (non-clinical) in The Netherlands as well as the association with (1) psycho-social outcomes, and (2) the birth process. METHODS: Study of 625 randomly selected low-risk pregnant women. At 20-24 weeks gestation, participants completed a questionnaire covering socio-demographic variables, sexual attitude, and psychological determinants. Midwives recorded details of the birth process. RESULTS: Nearly one-in-nine (11.2%) women had experienced sexual abuse. They were on average younger, more likely to smoke, and had lower household income. They reported more conflicting feelings about sex than women who did not report a history of abuse (p = 0.02). Multiparous women with a history of sexual abuse reported more emotional distress (p = 0.037), more internal beliefs concerning health (p = 0.004), and they were also more likely to suffer pelvic pain (p = 0.045). Sexually-abused women reported higher levels of autonomy (p = < 0.001). Referral rates to secondary care were equal. Sexually-abused women were less likely to receive episiotomies (p < 0.005). CONCLUSION: Little difference was observed in major birth-related technical interventions between women with and without a history of sexual abuse.
Abstract: Cross-national comparison is an important tool for health care research, but too often those who use this method fail to consider important inter-national differences in the social organisation of health care and in the relationship between health care practices and social experience. In this article we make the case for a context-sensitive and reflexive analysis of health care that allows researchers to understand the important ways that health care systems and practices are situated in time and place. Our approach--decentred comparative research--addresses the often unacknowledged ethnocentrism of traditional comparative research. Decentred cross-national research is a method that draws on the socially situated and distributed expertise of an international research team to develop key concepts and research questions. We used the decentred method to fashion a multilevel framework that used the meso level of organisation (i.e., health care organisations, professional groups and other concrete organisations) as an analytical starting point in our international study of maternity care in eight countries. Our method departs from traditional comparative health systems research that is most often conducted at the macro level. Our approach will help researchers develop new and socially robust knowledge about health care.
Abstract: OBJECTIVE: The aim of this study was to report clinical treatment recommendations for low back pain (LBP) based on 5 international guidelines and best evidence from the Cochrane database of systematic reviews. METHODS: Five LBP guidelines available in English language were appraised, including 4 studies published since the seminal work by Koes et al (Spine 2001;26:2504-5213). The guidelines were examined for treatment recommendations concerning nonspecific LBP and guideline quality with application of the Appraisal of Guidelines for Research and Evaluation instrument. Secondly, a systematic literature search for reviews and randomized controlled trials was conducted using a modified version of the search strategy recommended by the Cochrane Back Review Group. Two systematic reviews were identified. RESULTS: According to best evidence from review of the Cochrane database of systematic reviews, there remains a lack of consensus regarding reported efficacy of spinal manipulative therapy for the treatment of nonspecific LBP. Furthermore, the guidelines reviewed in the present study have not changed significantly with respect to treatment recommendations for nonspecific LBP since the original review, and there is inconsistency between the guidelines regarding optimal time to introduce spinal manipulation to treat nonspecific LBP. CONCLUSION: Treatment recommendations for nonspecific LBP, particularly spinal manipulation, remain inconclusive. Guideline developers need to consider guidelines in neighboring countries and reach consensus on how evidence is graded and incorporated into guidelines. Guidelines should continue to be regularly updated to incorporate new evidence and methods of grading the evidence.
Abstract: BACKGROUND: Recent developments within the United Kingdom's (UK) health care system have re-awakened interest in community hospitals (CHs) and their role in the provision of health care. This integrative literature review sought to identify and assess the current evidence base for CHs. METHODS: A range of electronic reference databases were searched from January 1984 to either December 2004 or February 2005: Medline, Embase, Web of Knowledge, BNI, CINAHL, HMIC, ASSIA, PsychInfo, SIGLE, Dissertation Abstracts, Cochrane Library, Kings Fund website, using both keywords and text words. Thematic analysis identified recurrent themes across the literature; narrative analyses were written for each theme, identifying unifying concepts and discrepant issues. RESULTS: The search strategy identified over 16,000 international references. We included papers of any study design focussing on hospitals in which care was led principally by general practitioners or nurses. Papers from developing countries were excluded. A review of titles revealed 641 potentially relevant references; abstract appraisal identified 161 references for review. During data extraction, a further 48 papers were excluded, leaving 113 papers in the final review. The most common methodological approaches were cross-sectional/descriptive studies, commentaries and expert opinion. There were few experimental studies, systematic reviews, economic studies or studies that reported on longer-term outcomes. The key themes identified were origin and location of CHs; their place in the continuum of care; services provided; effectiveness, efficiency and equity of CHs; and views of patients and staff.In general, there was a lack of robust evidence for the role of CHs, which is partly due to the ad hoc nature of their development and lack of clear strategic vision for their future. Evidence for the effectiveness and efficiency of the services provided was limited. Most people admitted to CHs appeared to be older, suggesting that admittance to CHs was age-related rather than condition-related. CONCLUSION: Overall the literature surveyed was long on opinion and short of robust studies on CHs. While lack of evidence on CHs does not imply lack of effect, there is an urgent need to develop a research agenda that addresses the key issues of health care delivery in the CH setting.
Abstract: BACKGROUND: Women participate in research for many reasons, some of them therapeutic. This paper retrospectively analyses women's motivations for participating in a study on decision making at the end of in vitro fertilization (IVF) treatment. METHODS: A mixed methods study conducted by a practising midwife had focused on women's experiences of stopping IVF treatment after one or more unsuccessful attempts, and raised awareness of women's motivations for participating. Thematic analysis of interview transcripts permitted issues raised by the participants in the context of 'research as a therapeutic experience' to be explored. RESULTS: Reasons for participating in the study included: (1) altruism; (2) appreciation/gratitude for care received; (3) the need to debrief; and (4) gaining self-awareness and readjustment, which challenged the acceptance of childlessness. Reasons for using the research study as 'a therapeutic experience' in the context of failed IVF may be attributed to: (1) access to direct clinical care and advice; (2) opportunity for self-reflection and rationalization; (3) acceptance of reality; (4) resolution of conflict; and (5) opportunity to unburden themselves. CONCLUSION: Women appeared to use the interview process to reassure themselves about decisions made, and to seek direct clinical advice on whether to continue IVF using donor gametes.
Abstract: BACKGROUND: The care of drug-using pregnant women is a growing health and social care concern in many countries. A specialist clinic was established offering multidisciplinary care and advice to pregnant drug users in and around Aberdeen (UK) in 1997. The majority of women stabilise and reduce their drug use. By determining the needs and views of the women more appropriate services and prevention strategies may be developed. There has been little research conducted in this area and none in Scotland. METHODS: This is a qualitative study that aimed to gain an understanding of the experiences of women drug users, seeking and receiving prenatal care and drug services from a specialist clinic. Twelve women participated in semi-structured one-to-one interviews. RESULTS: The women preferred the multidisciplinary clinic (one-stop shop) to traditional prenatal care centred within General Practice. The relationships of the clients to the range of Clinic professionals and in hospital were explored as well as attitudes to Clinic care. The study participants attributed success in reducing their drug use to the combination of different aspects of care of the multi-agency clinic, especially the high level prenatal support. It is this arrangement of all aspects of care together that seem to produce better outcomes for mother and child than single care elements delivered separately. Some women reported that their pregnancy encouraged them to rapidly detoxify due to the guilt experienced. The most important aspects of the Clinic care were found to be non-judgemental attitude of staff, consistent staff, high level of support, reliable information and multi-agency integrated care. CONCLUSION: There is an impetus for women drug users to change lifestyle during pregnancy. The study highlighted a need for women to have access to reliable information on the effects of drugs on the baby.Further research is required to determine whether positive outcomes related to clinic attendance in the prenatal period are sustained in the postnatal period. Early referral to a specialist clinic is of benefit to the women, as they reported to receive more appropriate care, especially in relation to their drug use. A greater awareness of needs of the pregnant drug user could help the design of more effective prevention strategies.
Abstract: AIM: This paper reports a study investigating health visitors' and practice nurses' attitudes, beliefs and practice associated with routinely advising patients about physical activity. BACKGROUND: There is worldwide concern about increasing rates of obesity and decreasing population levels of physical activity, and it has been argued that primary healthcare professionals are ideally placed to promote physical activity within local communities. In recent years, the public health role of primary care-based nurses in the United Kingdom has been considerably expanded to include playing a key role in improving the health of their local practice populations. A systematic literature search revealed that very few studies investigating nurses' views and experiences of this type work have been published. The limited amount of research that has been conducted is generally small-scale and primarily concerned with general medical practitioners' practice and attitudes, and not those of nurses. METHODS: A questionnaire survey (n = 630) and 20 in-depth interviews were conducted with health visitors and practice nurses in four health regions in Scotland between March and April 2004. The response rate was 63% overall. RESULTS: Ninety per cent (n = 149) of health visitors and 88% (n = 186) of practice nurses said that they were very likely or likely to recommend all apparently healthy adult patients to take moderate exercise. Health visitors were more likely to discuss psychological benefits than practice nurses. However, only 9% (n = 15) of practice nurses and 11% (n = 15) of health visitors correctly described the current recommendations - an accumulation of 30 minutes of moderate physical activity five times a week. Interview data suggested that most nurses gave physical activity advice based on their beliefs about the patient's willingness to change and their impressions of the patient's presenting condition, underlying physical condition and life circumstances. No measure of underlying physical fitness was used. There was a lack of agreement between the questionnaire and interview data associated with levels of physical activity advising. CONCLUSION: There were high levels of enthusiasm for physical activity promotion amongst health visitors and practice nurses. However, nursing leaders and opinion-makers should challenge practitioners' current beliefs and assumptions about physical activity promotion in the general population.
Abstract: This paper highlights the key steps to follow when conducting a systematic review (see Box 2). Healthcare practitioners may be limited by time and resources when conducting literature reviews, however, a systematic and transparent approach should be adopted wherever possible. Further detailed guidance on conducting systematic reviews is available from the NHS Centre for Reviews and Dissemination (NHS CRD, 2001) and the Cochrane Reviewers' Handbook (Alderson et al, 2003).
Abstract: BACKGROUND: Women who deliver by caesarean section have been shown to be less likely to have a subsequent pregnancy. It is not clear whether this is due to a direct effect of the procedure on future fertility or due to deliberate avoidance of a future pregnancy. OBJECTIVE: To investigate whether absence of conception following caesarean section is voluntary or involuntary. DESIGN: Follow up of a population-based retrospective cohort. SETTING: Grampian region, Scotland. POPULATION: Women who had no further viable pregnancies within 5 years of an initial delivery. METHODS: Cases included women who delivered their first child by caesarean section between 1980 and 1995 but had no further viable pregnancies by December 2000. Controls included women who delivered their first child during the same period, by means of either spontaneous vaginal delivery (SVD) or instrumental vaginal delivery (IVD), and who had no further viable pregnancies by December 2000. Eligible women were identified from the Aberdeen Maternity and Neonatal Databank (AMND) and sent postal questionnaires to determine the extent to which not conceiving after first delivery was voluntary and the reasons for avoiding further pregnancies. Characteristics of the different mode of delivery groups were compared using univariate techniques. MAIN OUTCOME MEASURES: Extent to which absence of conception following an initial delivery by caesarean section is voluntary. RESULTS: Questionnaires were returned by 3204 (60%) of 5300 women identified from the AMND. Of these, 1675 women had not conceived at all during the follow-up period (median duration = 13 years). Absence of conception was voluntary in 488 (69%; 95% CI 66-73%) women following caesarean section, 340 (71%; 95% CI 67-76%) following SVD and 354 (72%; 95% CI 68-76%) following IVD. Few women considered seeking fertility treatment (caesarean section = 72 [10%], SVD = 50 [11%], IVD = 39 [8%]). Of the women who decided to delay or avoid a further pregnancy, fewer women who delivered by SVD reported that the birth experience influenced their decision (caesarean section = 163 [32%], SVD = 67 [18%], IVD = 136 [35%]; P < 0.001). CONCLUSIONS: Irrespective of mode of delivery, not conceiving following the birth of the first child is mainly voluntary. The experience of the previous birth is one of several factors affecting women's decisions to avoid a subsequent pregnancy.
Abstract: BACKGROUND: United Kingdom public health policy has recently re-emphasised the role of primary health care professionals in tackling increasing levels of physical inactivity within the general population. However, little is known about the impact that this has had in practice. This study explores Scottish primary care staff's knowledge, attitudes and experiences associated with advising patients about physical activity during routine consultations. METHODS: A cross-sectional questionnaire survey of general practitioners (or family physicians), practice nurses and health visitors based in four health regions was conducted during 2004. The main outcome measures included: (i) health professionals' knowledge of the current physical activity recommendations; (ii) practice related to routine physical activity advising; and (iii) associated attitudes. RESULTS: Questionnaires were returned by 757 primary care staff (response rate 54%). Confidence and enthusiasm for giving advice was generally high, but knowledge of current physical activity recommendations was low. In general, respondents indicated that they routinely discuss and advise patients about physical activity regardless of the presenting condition. Health visitors and practice nurses were more likely than general practitioners to offer routine advice.Lack of time and resources were more likely to be reported as barriers to routine advising by general practitioners than other professional groups. However, health visitors and practice nurses were also more likely than general practitioners to believe that patients would follow their physical activity advice giving. CONCLUSION: If primary health care staff are to be fully motivated and effective in encouraging and supporting the general population to become more physically active, policymakers and health professionals need to engage in efforts to: (1) improve knowledge of current physical activity recommendations and population trends amongst frontline primary care staff; and (2) consider the development of tools to support individual assessment and advice giving to suit individual circumstances. Despite the fact that this study found that system barriers to routine advising were less of a problem than other previous research has indicated, this issue still remains a challenge.
Abstract: OBJECTIVE: To explore what happened to poor women in Bangladesh once they reached a hospital providing comprehensive emergency obstetric care (EmOC) and to identify support mechanisms. DESIGN: Mixed methods qualitative study. SETTING: Large government medical college hospital in Bangladesh. SAMPLE: Providers and users of EmOC. METHODS: Ethnographic observation in obstetrics unit including interviews with staff and women using the unit and their carers. RESULTS: Women had to mobilise significant financial and social resources to fund out of pocket expenses. Poorer women faced greater challenges in receiving treatment as relatives were less able to raise the necessary cash. The official financial support mechanism was bureaucratic and largely unsuitable in emergency situations. Doctors operated a less formal "poor fund" system to help the poorest women. There was no formal assessment of poverty; rather, doctors made "adjudications" of women's need for support based on severity of condition and presence of friends and relatives. Limited resources led to a "wait and see" policy that meant women's condition could deteriorate before help was provided. CONCLUSIONS: Greater consideration must be given to what happens at health facilities to ensure that (1) using EmOC does not further impoverish families; and (2) the ability to pay does not influence treatment. Developing alternative finance mechanisms to reduce the burden of out of pocket expenses is crucial but challenging. Increased investment in EmOC must be accompanied by an increased focus on equity.
Abstract: Throughout Europe women are having fewer babies, but more of them are being delivered by caesarean section. There is some evidence that this major surgical procedure discourages women and/or their partners from having further children. This study is aimed at ascertaining the extent to which mode of delivery in first confinement affected women's decision-making about having another child. This paper reports results from (1) a questionnaire sent to 5300 women who delivered their first baby in Aberdeen in northeast Scotland between 1980 and 1995, but who did not have another viable pregnancy within 5 years, and (2) in-depth interviews with a stratified random sample of 82 of these respondents which covered experiences of birth, decision-making about subsequent pregnancies and infertility. Verbatim transcripts were analysed thematically. Questionnaires were returned by 3204 women (60%). Among those who had no further pregnancies, 1182 (71%) had deliberately limited their fertility. Of those who had a second child, 696 (66%) deliberately left a gap of 5 or more years between them. The factors which apparently influenced the decision to limit fertility included early intention, experience of the first, or index birth, health, lifestyle, influence of partner, age, first child and fertility problems. In interviews, women presented these factors as constraints on their behaviour, which restrained them from freely choosing to have more children and in some cases to have the number they had planned. As the decision to have only one child or to leave a large gap between children is unusual, women may have been presenting their choices in this way to make their actions appear more socially acceptable and their motivations as blameless.
Abstract: BACKGROUND: The decision not to pursue further in vitro fertilization (IVF) after one or more unsuccessful attempts is an important and often difficult one for couples. Relatively little is known about the woman's perception of this decision-making process. The aim of this study was to examine patients' perspectives of decision-making, including circumstances influencing it and satisfaction with the decision-making process. METHODS: Semi-structured interviews were conducted with a purposive sample of 25 women who had decided to end treatment after unsuccessful IVF treatment. Interviews were tape-recorded and transcribed by means of thematic analysis using the open coding technique. RESULTS: Women experienced difficulty in accepting that their infertility would remain unresolved. Many felt that they had started with unrealistic expectations of treatment success and felt vulnerable to the pressures of both the media and society. Although the decision to end treatment was difficult, it offered many women a way out of the emotional distress caused by IVF; however, the process of decision-making created a sense of 'confrontation' for the women in which they had to address issues they had previously avoided. Adoptive parents perceived less societal pressure than those who remained childless. CONCLUSIONS: Efforts to improve the psychological preparation of couples who decide to end IVF treatment should be directed towards examination of the existing system of consultation, which has certain limitations in terms of the quality of communication and the provision of post-treatment support. Further efforts to develop strategies, which facilitate the decision-making process, should be considered.
Abstract: OBJECTIVES: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations. DESIGN: Interview and postal survey. SETTING: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003). PARTICIPANTS: Staff proportionally representative of professional groups involved in maternity care. RESULTS: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for "generalists" in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use. CONCLUSIONS: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.
Abstract: Theories of professions and healthcare organisation have difficulty in explaining variation in the organisation of maternity services across developed welfare states. Four countries - the United Kingdom, Finland, the Netherlands and Canada - serve as our case examples. While sharing several features, including political and economic systems, publicly-funded universal healthcare and favourable health outcomes, these countries nevertheless have distinct maternity care systems. We use the profession of midwifery, found in all four countries, as a 'touchstone' for exploring the sources of this diversity. Our analysis focuses on three key dimensions: (1) welfare state approaches to legalising midwifery and negotiating the role of the midwife in the division of labour; (2) professional boundaries in the maternity care domain; and (3) consumer mobilisation in support of midwifery and around maternity issues.
Abstract: BACKGROUND: Since Huntington's Disease (HD) is a familial disease with an average onset in the mid-thirties, one might expect that spousal carers are concerned with providing care for off-spring who may turn out to be affected. METHODS: This study involved ten face-to-face interviews with carers of spouses affected by HD in Northeast Scotland. Carers were recruited through two channels: a genetic clinic and the Scottish Huntington's Association (SHA). Interviews were conducted in carers' own homes. A thematic analysis of the transcripts was conducted. RESULTS: Although carers did worry about their children, they did not envisage being involved in their care. Many avoided talking about the disease, both within and outwith their family; this may have greatly reduced the level of support provided by family members. Conversely, avoidance was often accompanied by symptom-spotting. For example, several people had given up driving, before they were incapable of doing so. The explanation appears to be that they avoided getting into situations in which HD may express itself. Support meetings seem to be valued amongst patients with other serious diseases and their carers, however, although all participants had had contact with the SHA, only one regularly attended meetings. It was felt that seeing others with HD provided a constant reminder of the possible effect of HD on the wider family, which seemed to outweigh the benefit of attending. Overall, the analysis highlighted 'avoidance' as a key theme. CONCLUSION: Many denied symptoms of HD in their spouses, pre-diagnosis. All had pretended at some point that it was not happening, through ignoring early signs and 'obvious' symptoms. Some partners had refused to go to the doctor until it was no longer possible to deny symptoms. Formal health and social care seemed to play a very small role compared to informal care arrangements.
Abstract: BACKGROUND: Cross-cultural and international research are important components of public health research, but the challenges of language barriers and working with interpreters are often overlooked, particularly in the case of qualitative research. METHODS: A case-study approach was used to explore experiences of working with an interpreter in Bangladesh as part of a research project investigating women's experiences of emergency obstetric care. THE CASE STUDY: Data from the researcher's field notes provided evidence of experiences in working with an interpreter and show how the model of interviewing was adapted over time to give a more active role to the interpreter. The advantages of a more active role were increased rapport and "flow" in interviews. The disadvantages included reduced control from the researcher's perspective. Some tensions between the researcher and interpreter remained hard to overcome, irrespective of the model used. Independent transcription and translation of the interviews also raised questions around accuracy in translation. CONCLUSION: The issues examined in this case study have broader implications for public health research. Further work is needed in three areas: 1) developing effective relationships with interpreters; 2) the impact of the interpreter on the research process; and 3) the accuracy of the translation and level of analysis needed in any specific public health research. Finally, this paper highlights the importance to authors of reflecting on the potential impact of translation and interpretation on the research process when disseminating their research.
Abstract: BACKGROUND: A home confinement with midwifery care is still an integral part of Dutch maternity care. It has been argued that the existence of home birth itself influences the course of the birth process positively, which is why obstetric interventions are low in comparison with neighboring countries. This study examined the impact of women's intended place of birth (home or hospital) and the course of pregnancy and labor when attended by midwives. METHODS: This is a prospective study of 625 low-risk pregnant women, gestation 20 to 24 weeks, enrolled in 25 independently working midwifery practices. The course of labor was measured by the frequency of interventions by midwives and obstetricians. RESULTS: A more non-technological approach to childbirth was observed within the women opting for a home birth compared with the women opting for a hospital birth. Data showed a relationship between interventions and planned birth site: sweeping membranes and amniotomy by midwives were more likely to be conducted in women opting for a home birth. Multiparas opting for hospital birth were more likely to experience consultations and referrals. Within the group of multiparas referred for obstetrician care, women intending to have a home birth experienced fewer interventions (e.g., induction, augmentation, pharmacologic pain relief, assisted delivery, cesarean section) compared with those who had opted for a hospital birth. CONCLUSIONS: A large proportion of women desire a home birth. The impact of that choice demonstrated a smoother course of the birth process, compared with women who desired to deliver in the hospital, as measured by fewer obstetric interventions. We suggest that psychological factors (expectation and perceptions) influence both a woman's decision of birthplace and the actual birth process.
Abstract: INTRODUCTION: The increasing importance accorded the social and behavioural sciences in medical education presents opportunities for developing new and innovative forms of teaching and learning in this field. Yet social and behavioural scientists often feel isolated and marginalized. This research was designed to build a network of such practitioners to share and compare current practice, and to develop better models and resources. METHODS: Questionnaire survey and workshop discussions describe current practice among social and behavioural scientists in UK medical education, and identify current and future issues. RESULTS: Most UK medical curricula feature a significant social and behavioural science component, often in multidisciplinary contexts. Questions of core content, and how this relates to desired learning outcomes, particularly in the attitudinal sphere, remain unresolved. Identity problems result from differing perspectives of medics and social and behavioural scientists, staffing constraints, assessment regimes, and relationships with external examiners. DISCUSSION: This project identified barriers and opportunities for providing adequate training in the social and behavioural sciences in medical schools. Some of the barriers are common to higher education generally. Through our network, a database of core cases and assessments can be developed that would be available to all for teaching purposes. CONCLUSION: Social and behavioural scientists involved in medical education show commonality and difference in the extent and scope of their input. While they have made great progress, there remains much to achieve.
Abstract: This paper provides the background statistics and trends on multiple births. It highlights a number of factors that influence parents with multiples, including social situation, psychological adjustment and economic circumstances. It is often assumed that these areas of concern arise only after the babies have been born, but clinicians should be aware that many are seen in the antenatal period as well. Apart from the socioeconomic cost to individual families, multiple births also carry a cost to society. A number of self-help groups and voluntary organisations can assist parents of multiples. This is especially important if parents find that family and friends cannot or will not come forward.
Abstract: This study was undertaken to assess patient satisfaction with the decision making process as well as with the decision made at the end of in-vitro fertilization (IVF) treatment. Couples who had decided to end treatment after unsuccessful IVF at a single hospital within the last 24 months were invited to complete a questionnaire. Valid questionnaires were returned by 71 (51%) out of a total of 139 couples. Sixty-nine (97%) questionnaires were completed by the female partner. Most women (73%) felt that they were adequately informed about the issues important to the decision. Fifty-eight women (81%) were involved with the decision making process; 38 (58%) felt supported by the clinic doctor and 41 (62%) were satisfied with the decision made. In response to a number of questions about information provision, few women (18 - 24%, depending on the individual question) felt that they had received enough information from the IVF clinician about advantages and disadvantages of stopping treatment and options such as adoption and fostering. Women contemplating the end of IVF treatment appear to be satisfied with the clinician's attitude, the decision making process and the decision made. While information provided during the final consultation is felt to be adequate for decision making, discussion about certain important options such as adoption and fostering could be more detailed.
Abstract: Although family communication is important in clinical genetics only a small number of studies have specifically explored the passing on of genetic knowledge to family members. In addition, many of these present exploratory or tentative findings based upon small sample sizes, or data collected only a short time after testing. Nevertheless, if health professionals are to develop effective strategies to help patients' deal with communication issues, we need to know more about what actually happens in families. The aim of this commentary is to identify factors which appear to influence whether patients share information about genetic risk with relatives who are unaware of that risk, with whom they share it and how they go about it. The paper draws upon evidence and thinking from the disciplines of psychology (including family therapy), sociology, medicine and genetic counselling. It is presented under the following headings: disease factors, individual factors, family factors and sociocultural factors. It concludes by highlighting a number of key issues which are relevant for health professionals.
Abstract: This third paper in a series on research emphasises the importance of interviews in both qualitative and quantitative research. It explores the key aspects of conducting effective interviews.
Abstract: BACKGROUND: Health policymakers throughout the developed world are paying close attention to factors in maternity care that may influence women's satisfaction. This paper examines some of these factors in the light of observations from previous studies of satisfaction with health services. METHODS: The Scottish Birth Study, a cross-sectional questionnaire survey, sought the views of all women in Scotland delivering during a 10-day period in 1998. A total of 1,137 women completed and returned questionnaires (response rate = 69%). RESULTS: Women were overwhelmingly satisfied with their prenatal, intrapartum, and postnatal care. As is common in this type of study, reports of dissatisfaction were relatively low. However, differences occurred in satisfaction levels between subgroups; for example, the fewer the number of caregivers the woman had during childbirth, the more likely she was to be satisfied with the care received. A range of factors appeared to influence reported satisfaction levels, such as characteristics of the care provided and the woman's psychosocial circumstances. CONCLUSIONS: In addition to the inherent limitations of satisfaction studies found in the literature, problems may arise if such surveys are used uncritically to shape the future provision of maternity services, because service users tend to value the status quo over innovations of which they have no experience. Therefore, although satisfaction surveys have a role to play, we argue that they should only be used with caution, and preferably as part of an array of tools.
Abstract: OBJECTIVE: To review the methods and findings of studies that assess the costs and consequences of interventions to reduce mother-to-child HIV transmission in sub-Saharan Africa. DESIGN: Systematic literature review. METHODS: A literature search was conducted to identify studies that assessed the costs and consequences of interventions aimed at reducing mother-to-child HIV transmission in African populations. The methodological quality of included studies was appraised using the British Medical Journal Economic Evaluation Working Party checklist and data were extracted for comparison using a data extraction template. RESULTS: Nine studies, all of which used modelling techniques to predict the cost-effectiveness of anti-retroviral interventions, were identified for inclusion in the review. The quality of reporting was found to be lacking in several key areas. In particular a lack of detail was given regarding quantities of resources required for interventions, and the methods for valuing health outcomes and unit costs. In general, the more recent evaluations report more favourable cost-effectiveness ratios than earlier studies due to lower drug costs and in some cases the use of shorter drug regimens. CONCLUSIONS: Comparisons between studies were hampered by variations in the values attached to model parameters and by differences in the structure and design of models. The most encouraging findings have been reported for the CDC short zidovudine regimen and the HIVNET012 single dose nevirapine regimen. The generalizability of these findings is limited by the use of incremental costing, combined with uncertainty surrounding the level of infrastructure required to implement the interventions. In low-income sub-Saharan countries, the costs of strengthening the infrastructure to levels capable of providing such interventions, needs to be assessed before an optimal policy for the prevention of mother-to-child HIV transmission in sub-Saharan Africa can be established.
Abstract: AIMS: To describe the level of involvement of general practitioners (GPs) in the management of illicit drug dependency; nature of current practice in the management of illicit drug dependency; influence of guidelines on practice; GP training experience and needs; and to consider the policy implications of the findings. DESIGN: A cross-sectional postal questionnaire survey. SETTING: General practice in Scotland. PARTICIPANTS: A 1 : 4 randomized sample (n = 926) of general practice principals, stratified according to age, gender and number of practice partners. MEASUREMENTS: A structured postal questionnaire. FINDINGS: A 63% response rate was achieved after two reminders (n = 583). Sixty per cent of respondents treated drug users, 51.5% provided methadone maintenance but only 58% used doses in the recommended range. Maintenance prescribing of dihydrocodeine and benzodiazepines was provided by 24% and 44.8% of respondents, respectively. While 79.3% had received the national clinical guidelines only 22.5% believed this had influenced their practice. Only a third of respondents had received drug dependency training. Beliefs about whether prescribing for drug misusers is part of a GPs professional remit was split. CONCLUSIONS: There was relatively high involvement with drug users, with methadone maintenance being the most common treatment provided. Maintenance prescribing of dihydrocodeine and benzodiazepines were common despite a lack of clinical evidence supporting the effectiveness of these treatments. This may reflect the nature of the presenting drug problems and highlights the difficulties some GPs may face in managing multiple drug dependencies within current guidelines. Further local training to implement guidelines along with trials of alternative treatments currently outwith guidelines should be considered.
Abstract: This fourth paper in a series on research emphasises the importance of conducting comparative research across cultures and countries. It highlights the advantages of such research and outlines some methodological issues inherent within it.
Abstract: Communication about genetic risk in families is an important issue for genetic counsellors. The objective of this study was to explore the barriers and facilitators in family communication about genetic risk. Semi-structured interviews were undertaken with patients in the Northeast of Scotland who had attended genetic counselling for risk of hereditary breast and ovarian cancer and Huntington's disease, and with some spouses/partners. The interviews confirmed that the issue of disclosure was a problem for some, and that there were generic communication issues common to both groups. Telling family members about genetic risk was generally seen as a family responsibility and family structures, dynamics and 'rules' influenced disclosure decisions. A sense of responsibility towards younger generations was also important. The level of certainty felt by a person in relation to his or her own risk estimate also influenced what he or she could tell other family members. Communication within a family about genetic risk is a complex issue and is influenced by both pre-existing familial and cultural factors and individuals' responses to risk information. If genetic counsellors understood how these factors operate in individual families they might be able to identify effective strategies to promote considered decisions and prevent unnecessary emotional distress.
Abstract: The global rise in the rate of Caesarean sections (CS) during the last 20 years has coincided with an increase in the number of couples seeking help for infertility. There have been attempts to examine the link between these two conditions, and available data confirm an association between CS and infertility. The relationship is complex, however, involving more than a simple patho-physiological association. There may be a voluntary component to the causal relationship between CS and infertility, which is best explored using qualitative methods. We argue that CS does cause infertility, but the mechanism could be social/psychological rather than pathological.
Abstract: BACKGROUND: The scientific community views the publication of academic papers as a means of disseminating information, ensuring transparency and good practice in terms of research utilization. However, the choice of journal in which to publish is frequently influenced by other, less obvious, factors. This paper describes the lengthy route taken to get a methodological paper about pilot studies into print. AIM AND METHOD: This paper shares some of our experiences and discusses the lessons that we learned about the process of getting into print. A case study approach is adopted to help the reader understand the different influences on this process. FINDINGS: Our methodological paper was submitted to six different academic journals before it was finally accepted for publication. The choice of journal was influenced by the need to reach an appropriate academic audience, the estimated turn around time (the time taken between submission of a paper and its subsequent publication) and the level of academic credibility of the journal (often assessed by the journal's Impact Factor). Publishing in 'high impact' academic journals assumed considerable importance for us in view of the UK Research Assessment Exercise (RAE). However, the consequence of going down the journal status hierarchy was that we lost about 1 year through submitting, rewriting according to each of the journal's specific requirements and resubmitting. The case study also demonstrates that getting into print often depends on a range of factors, not just the quality of the written text. CONCLUSIONS: Getting a paper published may depend not only on the intrinsic quality of the paper, but also whether it is submitted to the 'right' academic journal. Moreover, if journals do not take certain papers (e.g. ones with negative findings or those reporting multi-disciplinary studies) then this can lead to publication bias.
Abstract: OBJECTIVE: to compare data obtained from two sources, service providers and service users, regarding the maternity services in Scotland. DESIGN: an audit of maternity services involving site visits, staff interviews and a cross-sectional survey of service users. PARTICIPANTS: lead professionals in every consultant-led maternity unit in Scotland and all 1639 women giving birth in Scotland during a ten-day period. DATA COLLECTION:structured group interviews with service providers and a questionnaire survey of recently delivered women. DATA ANALYSIS: professionals' and women's responses were cross-tabulated and differences in proportions were tested for statistical significance using the chi-square test. FINDINGS: a total of 1137 women completed the questionnaire (response rate 69%). Overall, there was good agreement between professionals' and women's perceptions of the aspects of care studied. However, there were disparities in some areas. For example, staff in eight units reported mechanisms to ensure early distribution of a free national pregnancy book; however, in six of these units less than 75% of women actually received this book prior to their first hospital visit. Eighteen units reported that they offer a postnatal 'reunion meeting'; in ten of these units, less than 50% of women were aware of the reunion meeting. Eighteen units reported a policy of each woman having a lead professional or care co-ordinator; in three of these units, less than 50% of women perceived that they had a care co-ordinator and for most women, the profession (midwife, general practitioner or obstetrician) of their perceived co-ordinator differed from that expected on the basis of staff reports. There was some evidence overall that unit policies had a direct influence on women's responses. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this study demonstrates the importance of using a range of complementary methods of data collection and of ascertaining both service users' and providers' views when assessing the quality of care. Further research is required to explore differences in service provider's and women's perceptions and how this information can be used to improve the quality of maternity care. The finding that service provision may influence women's preferences has important implications for service planning, in particular the introduction of new models of care, and this needs further exploration.
Abstract: This second paper in a series on research emphasises the importance of conducting 'pilot' or 'feasibility' studies prior to embarking on more in-depth research. It focuses on piloting the two main data collection methods used by midwives in social or health research--quantitative questionnaires and qualitative interviews.
Abstract: This paper introduces the preliminary steps in taking a clinical question or observation from practice and turning it into a potential research project. Future papers in this series will look at aspects of the research process in more detail.
Abstract: The term 'pilot studies' refers to mini versions of a full-scale study (also called 'feasibility' studies), as well as the specific pre-testing of a particular research instrument such as a questionnaire or interview schedule. Pilot studies are a crucial element of a good study design. Conducting a pilot study does not guarantee success in the main study, but it does increase the likelihood of success. Pilot studies fulfill a range of important functions and can provide valuable insights for other researchers. There is a need for more discussion among researchers of both the process and outcomes of pilot studies.
Abstract: BACKGROUND: In many research papers, pilot studies are only reported as a means of justifying the methods. This justification might refer to the overall research design, or simply to the validity and reliability of the research tools. It is unusual for reports of pilot studies to include practical problems faced by the researcher(s). Pilot studies are relevant to best practice in research, but their potential for other researchers appears to be ignored. OBJECTIVE: The primary aim of this study was to identify the most appropriate method for conducting a national survey of maternity care. METHODS: Pilot studies were conducted in five hospitals to establish the best of four possible methods of approaching women, distributing questionnaires and encouraging the return of these questionnaires. Variations in the pilot studies included (a) whether or not the questionnaires were anonymous, (b) the staff involved in distributing the questionnaires and (c) whether questionnaires were distributed via central or local processes. For this purpose, five maternity hospitals of different sizes in Scotland were included. RESULTS: Problems in contacting women as a result of changes in the Data Protection Act (1998) required us to rely heavily on service providers. However, this resulted in a number of difficulties. These included poor distribution rates in areas where distribution relied upon service providers, unauthorized changes to the study protocol and limited or inaccurate information regarding the numbers of questionnaires distributed. CONCLUSIONS: The pilot raised a number of fundamental issues related to the process of conducting a large-scale survey, including the method of distributing the questionnaire, gaining access to patients, and reliance on 'gatekeepers'. This paper highlights the lessons learned as well as the balancing act of using research methods in the most optimal way under the combined pressure of time, ethical considerations and the influences of stakeholders. Reporting the kinds of practical issues that occur during pilot studies might help others avoid similar pitfalls and mistakes.
Abstract: BACKGROUND: Limited resources coupled with unlimited demand for healthcare mean that decisions have to be made regarding the allocation of scarce resources across competing interventions. Policy documents have advocated the importance of public views as one such criterion. In principle, the elicitation of public values represents a big step forward. However, for the exercise to be worthwhile, useful information must be obtained that is scientifically defensible, whilst decision-makers must be able and willing to use it. AIMS AND OBJECTIVES: The aim was to identify techniques that could be reasonably used to elicit public views on the provision of healthcare. Hence, the objectives were: (1) to identify research methods with the potential to take account of public views on the delivery of healthcare; (2) to identify criteria for assessing these methods; (3) to assess the methods identified according to the predefined criteria; (4) to assess the importance of public views vis-Ã -vis other criteria for setting priorities, as judged by a sample of decision-makers; (5) to make recommendations regarding the use of methods and future research. METHODS: A systematic literature review was carried out to identify methods for eliciting public views. Criteria currently used to evaluate such methods were identified. The methods identified were then evaluated according to predefined criteria. A questionnaire-based survey assessed the relative importance of public views vis-Ã -vis five other criteria for setting priorities: potential health gain; evidence of clinical effectiveness; budgetary impact; equity of access and health status inequalities; and quality of service. Two techniques were used: choice-based conjoint analysis and allocation of points technique. The questionnaire was sent to 143 participants. A subsample was followed up with a telephone interview. RESULTS: The methods identified were classified as quantitative or qualitative. RESULTS - QUANTITATIVE TECHNIQUES: Quantitative techniques, classified as ranking, rating or choice-based approaches, were evaluated according to eight criteria: validity; reproducibility; internal consistency; acceptability to respondents; cost (financial and administrative); theoretical basis; whether the technique offered a constrained choice; and whether the technique provided a strength of preference measure. Regarding ranking exercises, simple ranking exercises have proved popular, but their results are of limited use. The qualitative discriminant process has not been used to date in healthcare, but may be useful. Conjoint analysis ranking exercises did well against the above criteria. A number of rating scales were identified. The visual analogue scale has proved popular within the quality-adjusted life-year paradigm, but lacks constrained choice and may not measure strength of preference. However, conjoint analysis rating scales performed well. Methods identified for eliciting attitudes include Likert scales, the semantic differential technique, and the Guttman scale. These methods provide useful information, but do not consider strength of preference or the importance of different components within a total score. Satisfaction surveys have been frequently used to elicit public opinion. Researchers should ensure that they construct sensitive techniques, despite their limited use, or else use generic techniques where validity has already been established. Service quality (SERVQUAL) appears to be a potentially useful technique and its application should be researched. Three choice-based techniques with a limited application in healthcare are measure of value, the analytical hierarchical process and the allocation of points technique, while those more widely used, and which did well against the predefined criteria, include standard gamble, time trade-off, discrete choice conjoint analysis and willingness to pay. Little methodological work is currently available on the person trade-off. RESULTS - QUALITATIVE TECHNIQUES: Qualitative techniques were classified as either individual or group-based approaches. Individual approaches included one-to-one interviews, dyadic interviews, case study analyses, the Delphi technique and complaints procedures. Group-based methods included focus groups, concept mapping, citizens' juries, consensus panels, public meetings and nominal group techniques. Six assessment criteria were identified: validity; reliability; generalisability; objectivity; acceptability to respondents; and cost. Whilst all the methods have distinct strengths and weaknesses, there is a lot of ambiguity in the literature. Whether to use individual or group methods depends on the specific topic being discussed and the people being asked, but for both it is crucial that the interviewer/moderator remains as objective as possible. The most popular and widely used such methods were one-to-one interviews and focus groups. (ABSTRACT TRUNCATED)
Abstract: A national study of patients with motor neurone disease (MND) and their carers was conducted in Scotland in late 1996. A questionnaire covering areas such as: use of medical, social and voluntary services; use of or waiting for specialised equipment; satisfaction with provided services; and standard demographic data was used in face-to-face interviews conducted by the four Scottish Motor Neurone Disease Association care advisers. The care advisers also assessed the respondent's level of impairment, using a standard instrument: the Amyotrophic Lateral Sclerosis Severity Scale (ALSSS). The data was analysed using SPSS-PC. In total 153 people participated (response rate 92%), and as expected with this patient group the study recruited more men (57%) than women. Sixty per cent of the sample was severely disabled as measured on the ALSSS. Health services did not meet the needs of respondents in 19% of the cases and social services failed to do so according to 24% of respondents. Eighty per cent of patients with MND had an identified carer. Nearly four out of 10 of these carers had their sleep disturbed regularly, and nearly a quarter of them would have liked to have more help. In addition, differences were found in service provision between the East and West of Scotland, and consequently differences in respondent's perceptions about the extent to which needs were met. As found in similar studies, the formal health and social care sectors in conjunction with voluntary organisations are only partially managing the trajectory of patients with a rare progressive degenerative disease.
Abstract: OBJECTIVE: A survey of women's views of their care was undertaken as part of a national audit of maternity services in Scotland. The overall aim of the audit was to determine the extent to which recommendations from recent national policy documents had been adopted in practice. DESIGN: A cross-sectional study seeking the views of all women giving birth throughout Scotland during a 10-day period in September 1998. PARTICIPANTS: All women giving birth in Scotland within the survey period were eligible to participate in the study. Women unable to complete the questionnaire in English, women for whom the midwife deemed it inappropriate, and women who delivered but no longer resided in Scotland by their 10th postnatal day were excluded. DATA COLLECTION: A self-complete questionnaire given to the woman by her community midwife for completion on her 10th postnatal day. DATA ANALYSIS: Analysis was carried out using the statistical package SPSS for Windows. Descriptive statistics were produced for all variables. Statistical tests of significance were not used, as this was primarily a descriptive survey. FINDINGS: Of the 1152 questionnaires returned, 1137 were suitable for analysis. This gave a response rate of 69% of the eligible population (1639). Most women (80%) had the majority of their antenatal care in the community but only one third had a choice about this. Sixty-nine per cent of women received care from one or two people. However, only 37% had a choice about who these people were. The majority of women gave birth in hospital (99%). Sixty-one per cent felt that they had a choice about where they could have their baby. However, fewer women had a choice about having a home birth (41%) or a DOMINO delivery (23%). Just over half the women felt that it was important to be cared for by a midwife that they had met during pregnancy but only 12% of women achieved this. Sixty-two per cent of women had talked to a health professional about what happened during labour and delivery but less than half had spoken with a professional who was present during her labour or birth. CONCLUSIONS: Considerable efforts have been made to improve information and choice for women. However, it is clear that further work is needed if women are to be offered informed choice in the provision of their maternity care.
Abstract: Health service reforms have led to relocation of care of the chronic mentally ill from institutions to the community, with subsequent demands on the primary health care team. Few studies have attempted to identify satisfactory models of care for this patient group. This study explores the impact of the employment of a community psychiatric nurse (CPN) by a general practice in Aberdeen city to co-ordinate care of discharged long-stay psychiatric patients resettled in hostels. A similar general practice with a comparable group of registered patients was selected as a control group. Patient health outcome was measured using the Health of the Nation Outcome Scales (HoNOS) and service providers' views on dedicated psychiatric care within general practice were explored using qualitative methods. Improvements in communication, liaison and drug management were reported in the intervention practice. A primary care-based CPN service dedicated to the care of the chronic mentally ill promoted a smooth transfer of care from long-term institutionalized care to the community setting.
Abstract: Smokebusters is a community-based smoking prevention initiative for young children which aims to prevent them from starting to smoke. Despite the increase of Smokebusters clubs throughout the UK and Europe there is little published evidence of the effectiveness of this health promotion intervention. The aim of this study was to conduct a literature review of the effectiveness of established UK and Irish Smokebusters clubs. Over 60 clubs and agencies were contacted with a total of 36 reports received. Of those reviewed, most clubs have conducted process and impact evaluation to assess the popularity and quality of the programme. Attempts have been made to measure children's knowledge, attitudes and behaviour in relation to smoking and the Smokebusters intervention. Only three clubs have conducted long-term outcome evaluations which have measured changes in knowledge, attitudes and smoking behaviour. There is some evidence that changes occur in knowledge and attitudes after the establishment of clubs. To date, there are no reports of sustained change in smoking behaviour following the establishment of Smokebusters clubs.
Abstract: OBJECTIVE: There is limited information about the prevalence of recreational drug use over the postsecondary experience in Scotland. The purpose of this study was to investigate the patterns of alcohol, tobacco and marijuana use in postsecondary helping-profession students (medical, nursing, education and psychology) in Scotland in regards to gender, age and course of study. METHOD: The Queensland Alcohol and Drug Study Questionnaire was completed by students enrolled in helping-profession courses from 22 departments at universities and colleges in five Scottish cities. The sample consisted of 717 male and 2,537 female students. RESULTS: A slightly (p < .05) higher percent of women (92.7%) consumed alcohol compared to men (90%), but men consumed significantly (p < .001) more drinks per week (26.7) compared to women (17.3). There was no difference between the two groups when U.K. recommendations of maximum limits for each gender were considered. About 50% of men and women consumed over 21 drinks and 14 drinks per week, respectively. A higher (p < .05) percent of men (42.5%) smoked compared to women (36.9%) and a higher (p < .001) percent of men (40.1%) consumed marijuana compared to women (24.1%). There was no difference in the quantity of tobacco consumed. For both men and women, the prevalence of alcohol and marijuana was highest 2 or 3 years before the maximum use of tobacco (students over 24 years of age). Male and female psychology students consumed the most marijuana. Psychology students, together with nursing students, also consumed the most tobacco. CONCLUSIONS: In view of the increasing prevalence of tobacco over the university experience, especially among nursing and psychology students, and heavier alcohol consumption among younger students, health education programs for Scottish postsecondary helping-profession students should expand from the recently introduced school programs.
Abstract: OBJECTIVE: To document service use by people living with HIV/AIDS discharged from hospital, to identify gaps and overlaps in service provision after discharge, and to evaluate liaison between hospital-based and community-based services. DESIGN: Four week follow-up diary and interview study of service users, and interview/questionnaire study of service providers. SETTING: Services used by people discharged from the wards of two units of two Lothian hospitals. SUBJECTS: All patients with HIV infection admitted to the wards of two units of two Lothian hospitals from October 1992 to February 1993, and their service providers. RESULTS AND CONCLUSION: General practitioners were the most contacted service post discharge, but general practitioners did not appear to play a co-ordination role in service provision. Liaison on discharge was found to be effective in terms of continuity of care in most cases; and from a service user perspective, liaison between hospital and primary care agencies did not appear a major concern. The majority of hospital discharges were organised in a setting with a large number of services, with complex communication patterns and informal procedures of discharge arrangements. This created uncertainty among service providers as to the arrangements which had been made, and fear and anxiety that they fall through. On the other hand, the informality of discharge procedures also ensured flexibility and responsiveness to unexpected events and changes in service users' circumstances and was a vital factor in continuity of care experienced by them. A more important issue for service users was the poor integration of services concerned with social/material support in the system of medical and emotional care.
Abstract: BACKGROUND. The Health of the nation aims 'to reduce the number of young people who start to smoke'. Smokebusters is a specific health promotion approach with the aim of encouraging non-smoking as the norm and developing a non-smoking peer group. METHODS. This study of the Grampian club was undertaken to measure any change in the prevalence of smoking as well as knowledge and awareness of the regional Smokebusters club in the target group (10-13-year-olds). School-based questionnaires were administered to a one in ten sample of the target population, followed up four years after the launch of the club, to establish the prevalence of self-reported smoking in comparison with Scottish national smoking surveys, attitudes to smoking and the Smokebusters club, and to explore lifestyle factors. RESULTS. The club was very popular and attracted over half of the eligible children. After four years, smoking prevalence in Grampian was similar to Scottish levels, and former club members were just as likely to have started smoking as those who had never joined. CONCLUSIONS. Membership of Smokebusters does not seem to reduce the smoking prevalence among young people. However, Smokebusters competes in a social environment where many adults and children smoke, where it is still fairly easy for children to obtain cigarettes and where tobacco is extensively promoted. This evaluation focused on the outcome of the Smokebusters, and not on the process and impact. Finally, results of this intervention might include long-term benefits for children and the wider community which are not measured by this study.
Abstract: BACKGROUND: Lothian has a high prevalence rate of HIV infection associated particularly with injecting drug use in the mid-1980s. During the late 1980s a number of services were introduced to support general practitioners to care for drug users and people with HIV infection. AIM: To ascertain the practice distribution of patients with HIV infection and drug users, and the experience and confidence of Lothian GPs in a number of HIV and drug related tasks, and to see how these changed over a five year period after the introduction of support services. METHOD: Information about practice distribution of patients with HIV infection and drug users and information about GP experience and confidence was obtained from a survey of individual GPs in 1988. Two practice surveys in 1991 and 1993, using a chosen GP for each practice, gave information about practice distribution of people with HIV infection and drug users, while a second survey of individual GPs in 1993, concentrating on GP experience and confidence, acted as a follow up to the 1988 survey. RESULTS: GPs are in touch with an increasing number of people with symptomatic HIV infection. They are increasingly involved and confident in caring for drug users. Offering support and training to GPs appears to have encouraged their involvement. There are a significant number of people with HIV infection in Lothian who are not known to GPs or to hospital services. A combination of practice and individual GP surveys was found to provide the most reliable information. It is planned to repeat the practice survey in 1995.
Abstract: To determine the effect of a Smoke Busters club in reducing the numbers of children recruited to smoking, levels of smoking in Grampian amongst 11-14 year olds were determined at the launch of the club and again 22 months later, using a self-completion questionnaire. Initial smoking levels were similar to Scottish Office of Population Censuses and Surveys (OPCS) 1986 figures taken 2 years prior to the first Grampian survey. OPCS findings indicated that in Scotland smoking levels had remained fairly stable among girls and had increased among boys between 1986 and 1990. At the second survey in Grampian, smoking levels among girls and boys were lower than in Scotland generally, but it is not possible to know whether this was a result of the campaign or not. There was evidence of a relationship between the smoking habits of children and parents, particularly their mothers. Life-style questions showed that smokers were more likely to take part in activities characteristic of older teenagers and to prefer music which was associated with alternative, rebellious attitudes. Smoke Busters clubs aim to promote a non-smoking life-style amongst young teenagers. After 22 months of a Smoke Busters club, it was evident that at least 32.9% of the target group had joined the club at some point and that it was very popular with its members. Those who joined Smoke Busters were more than twice as likely to remain non-smokers as those who were non-members, but this might not be a function of cause and effect. A further survey is to be undertaken at 4 years after the launch of the club and may allow assessment of any longer-term effects of the club in Grampian.
Abstract: Maternity home care assistants in the Netherlands assist the midwife (or GP) during the delivery, help and advise the new mother with the baby during the postnatal period at home. They are trained separately from nurses. Currently, more than three-quarters of mothers use this service. Birth statistics of deliveries attended by maternity home care assistants compare favourably with national statistics. The existence of this profession allows midwives to concentrate on midwifery tasks. It also enables pregnant women to consider giving birth at home or during a short-stay hospital delivery. These options are limited to certain groups in other industrialized countries.
