Perceptions and experiences of blood pressure self-monitoring during hypertensive pregnancy: A qualitative analysis of women's and clinicians' experiences in the OPTIMUM-BP trial

BACKGROUND

Self-monitoring of blood pressure (BP) has been shown to be effective at improving BP control in the general population. The OPTIMUM-BP feasibility study was a prospective randomised controlled trial of self-monitoring of BP (SMBP) during hypertensive pregnancy.

OBJECTIVE

To explore experiences, perceptions, and use of the OPTIMUM-BP self-monitoring intervention.

STUDY DESIGN

Qualitative study within the OPTIMUM-BP feasibility trial. Semi-structured interviews with a purposive sample of pregnant women with chronic hypertension (n = 24) and their clinicians (n = 8) as well as 38 ethnographic observations of antenatal visits.

RESULTS

Women found self-monitoring of BP feasible and acceptable and were highly motivated and pro-active in their monitoring, reporting greater control and knowledge of BP and reassurance. Women's persistence with SMBP was driven by a perceived need to safeguard the pregnancy, particularly among those taking antihypertensive medication. Clinicians also described the intervention as acceptable, though BP variability could cause uncertainty. Clinicians used different heuristics to integrate home and clinic readings. Observations suggested close working relationships between women and clinicians were key for confident integration of self-monitoring.

CONCLUSIONS

Self-monitoring of BP was acceptable both to pregnant women with hypertension and their clinicians. More research is needed to understand BP variability within pregnancy to help interpret and integrate home BP readings for improved BP management. Clinical pathways that use BP self-monitoring should aim to maintain the continuity of care and relationships that are valued and appear pivotal for the confident and safe use of self-monitoring in pregnancy.

A core outcome set for pre-eclampsia research: an international consensus development study

OBJECTIVE

To develop a core outcome set for pre-eclampsia.

DESIGN

Consensus development study.

SETTING

International.

POPULATION

Two hundred and eight-one healthcare professionals, 41 researchers and 110 patients, representing 56 countries, participated.

METHODS

Modified Delphi method and Modified Nominal Group Technique.

RESULTS

A long-list of 116 potential core outcomes was developed by combining the outcomes reported in 79 pre-eclampsia trials with those derived from thematic analysis of 30 in-depth interviews of women with lived experience of pre-eclampsia. Forty-seven consensus outcomes were identified from the Delphi process following which 14 maternal and eight offspring core outcomes were agreed at the consensus development meeting. Maternal core outcomes: death, eclampsia, stroke, cortical blindness, retinal detachment, pulmonary oedema, acute kidney injury, liver haematoma or rupture, abruption, postpartum haemorrhage, raised liver enzymes, low platelets, admission to intensive care required, and intubation and ventilation. Offspring core outcomes: stillbirth, gestational age at delivery, birthweight, small-for-gestational-age, neonatal mortality, seizures, admission to neonatal unit required and respiratory support.

CONCLUSIONS

The core outcome set for pre-eclampsia should underpin future randomised trials and systematic reviews. Such implementation should ensure that future research holds the necessary reach and relevance to inform clinical practice, enhance women's care and improve the outcomes of pregnant women and their babies.

TWEETABLE ABSTRACT

281 healthcare professionals, 41 researchers and 110 women have developed #preeclampsia core outcomes @HOPEoutcomes @jamesmnduffy. [Correction added on 29 June 2020, after first online publication: the order has been corrected.].

Methodological decisions influence the identification of potential core outcomes in studies related to pre-eclampsia: an analysis informing the development of recommendations for future core outcome set developers

OBJECTIVE

To quantify the effect of different methodological decisions on the identification of potential core outcomes to inform the development of recommendations for future core coutcome set developers.

DESIGN

Mixed methods study.

SETTING

A core outcome set for pre-eclampsia was used as an exemplar.

SAMPLE

A long list of potential core outcomes was developed by undertaking a systematic review of pre-eclampsia trials and performing a thematic analysis of in-depth patient interviews.

METHODS

Specific methods used to generate long lists of potential core outcomes were evaluated.

RESULTS

Different methodological decisions had a substantial impact on the identification of potential core outcomes. Extracting outcomes from published pre-eclampsia trials was an effective way of identifying 48 maternal, eight fetal, 25 neonatal outcomes, and eight patient-reported outcomes. Limiting the extraction of outcomes to primary outcomes or outcomes commonly reported in pre-eclampsia trials reduced the number and diversity of potential core outcomes identified. Thematic analysis of in-depth patient interviews ensured an additional five patient reported outcomes and six outcomes related to future child health were identified.

CONCLUSIONS

Future core outcome set developers should use quantitative and qualitative methods when developing a long list of potential core outcomes. TWEETABLE ABSTRACT: @OfficialNIHR research published in @BJOGtweets informs new recommendations for future @coreoutcomes developers.

Communication practices for delivering health behaviour change conversations in primary care: a systematic review and thematic synthesis

BACKGROUND

Clinical guidelines exhort clinicians to encourage patients to improve their health behaviours. However, most offer little support on how to have these conversations in practice. Clinicians fear that health behaviour change talk will create interactional difficulties and discomfort for both clinician and patient. This review aims to identify how healthcare professionals can best communicate with patients about health behaviour change (HBC).

METHODS

We included studies which used conversation analysis or discourse analysis to study recorded interactions between healthcare professionals and patients. We followed an aggregative thematic synthesis approach. This involved line-by-line coding of the results and discussion sections of included studies, and the inductive development and hierarchical grouping of descriptive themes. Top-level themes were organised to reflect their conversational positioning.

RESULTS

Of the 17,562 studies identified through systematic searching, ten papers were included. Analysis resulted in 10 top-level descriptive themes grouped into three domains: initiating; carrying out; and closing health behaviour change talk. Of three methods of initiation, two facilitated further discussion, and one was associated with outright resistance. Of two methods of conducting behaviour change talk, one was associated with only minimal patient responses. One way of closing was identified, and patients did not seem to respond to this positively. Results demonstrated a series of specific conversational practices which clinicians use when talking about HBC, and how patients respond to these. Our results largely complemented clinical guidelines, providing further detail on how they can best be delivered in practice. However, one recommended practice - linking a patient's health concerns and their health behaviours - was shown to receive variable responses and to often generate resistance displays.

CONCLUSIONS

Health behaviour change talk is smoothly initiated, conducted, and terminated by clinicians and this rarely causes interactional difficulty. However, initiating conversations by linking a person's current health concern with their health behaviour can lead to resistance to advice, while other strategies such as capitalising on patient initiated discussions, or collaborating through question-answer sequences, may be well received.

Inadequate safety reporting in pre-eclampsia trials: a systematic evaluation

BACKGROUND

Randomised trials and their syntheses in meta-analyses offer a unique opportunity to assess the frequency and severity of adverse reactions.

OBJECTIVE

To assess safety reporting in pre-eclampsia trials.

SEARCH STRATEGY

Systematic search using bibliographic databases, including Cochrane Central Register of Controlled Trials, Embase, and MEDLINE, from inception to August 2017.

SELECTION CRITERIA

Randomised trials evaluating anticonvulsant or antihypertensive medication for pre-eclampsia.

DATA COLLECTION AND ANALYSIS

Descriptive statistics appraising the adequacy of adverse reaction and toxicity reporting.

MAIN RESULTS

We included 60 randomised trials. Six trials (10%) were registered with the International Clinical Trials Registry Platform, two registry records referred to adverse reactions, stating 'safety and toleration' and 'possible side effects' would be collected. Twenty-six trials (43%) stated the frequency of withdrawals within each study arm, and five trials (8%) adequately reported these withdrawals. Adverse reactions were inconsistently reported across eligible trials: 24 (40%) reported no serious adverse reactions and 36 (60%) reported no mild adverse reactions. The methods of definition or measurement of adverse reactions were infrequently reported within published trial reports.

CONCLUSIONS

Pre-eclampsia trials regularly omit critical information related to safety. Despite the paucity of reporting, randomised trials collect an enormous amount of safety data. Developing and implementing a minimum data set could help to improve safety reporting, permitting a more balanced assessment of interventions by considering the trade-off between the benefits and harms.

FUNDING

National Institute for Health Research (DRF-2014-07-051), UK; Maternity Forum, Royal Society of Medicine, UK.

TWEETABLE ABSTRACT

Developing @coreoutcomes could help to improve safety reporting in #preeclampsia trials. @NIHR_DC.

Conducting a team-based multi-sited focused ethnography in primary care

Focused ethnography is an applied and pragmatic form of ethnography that explores a specific social phenomenon as it occurs in everyday life. Based on the literature a problem-focused research question is formulated before the data collection. The data generation process targets key informants and situations so that relevant results on the pre-defined topic can be obtained within a relatively short time-span. As part of a theory based evaluation of alternative forms of consultation (such as video, phone and email) in primary care we used the focused ethnographic method in a multisite study in general practice across the UK. To date there is a gap in the literature on using focused ethnography in healthcare research.The aim of the paper is to build on the various methodological approaches in health services research by presenting the challenges and benefits we encountered whilst conducing a focused ethnography in British primary care. Our considerations are clustered under three headings: constructing a shared understanding, dividing the tasks within the team, and the functioning of the focused ethnographers within the broader multi-disciplinary team.As a result of using this approach we experienced several advantages, like the ability to collect focused data in several settings simultaneously within in a short time-span. Also, the sharing of experiences and interpretations between the researchers contributed to a more holistic understanding of the research topic. However, mechanisms need to be in place to facilitate and synthesise the observations, guide the analysis, and to ensure that all researchers feel engaged. Reflection, trust and flexibility among the team members were crucial to successfully adopt a team focused ethnographic approach. When used for policy focussed applied healthcare research a team-based multi-sited focused ethnography can uncover practices and understandings that would not be apparent through surveys or interviews alone. If conducted with care, it can provide timely findings within the fast moving context of healthcare policy and research.

'A mastectomy for something that wasn't even truly invasive cancer'. Women's understandings of having a mastectomy for screen-detected DCIS: a qualitative study

OBJECTIVES

To explore women's understandings of having a mastectomy for screen-detected ductal carcinoma in situ (DCIS).

SETTING

Participants recruited throughout the United Kingdom and interviewed in their own homes by an anthropologist.

METHODS

Qualitative study using semi-structured interviews and thematic analysis. Thirty-five women with screen-detected DCIS were interviewed, of whom twenty had a mastectomy.

RESULTS

A qualitative thematic analysis of women's understandings of having a mastectomy for DCIS identified four key themes: understandings of routine breast screening; uncertainty about DCIS and its natural progression; uncertainty about whether a mastectomy is justified for DCIS; information gaps and treatment decisions. Women were often concerned that a mastectomy for screen-detected DCIS was a 'drastic' treatment for an asymptomatic, precancerous condition of which they had been previously unaware. Some questioned why they were treated with such urgency, even suspecting that their clinicians were responding to targets.

CONCLUSION

Given the uncertainties about DCIS and its complexity, it is important that women have the information they need to make treatment decisions. Better information about the uncertainties and the rationale for using mastectomy as a treatment may help women to make better informed choices and feel more comfortable about their decisions.

Viewing the body after bereavement due to a traumatic death: qualitative study in the UK

OBJECTIVE

Whether bereaved relatives should be encouraged to view the body after a traumatic death is uncertain. This analysis of narrative interviews interprets people's accounts of why and how they decided whether to view the body and their emotional reactions to this, immediately and at a later stage.

DESIGN

In depth interviews with qualitative analysis.

PARTICIPANTS

A maximum variation sample of 80 people bereaved because of suicide or other traumatic death.

SETTING

Most people were interviewed in their homes.

RESULTS

For those who had the option, decisions about seeing the body varied. Some wanted someone else to identify the body, because they feared how it might look or preferred to remember their relative as they had been in life. Those who had wanted to see the body gave various reasons beyond the need to check identity. Some felt they ought to see the body. Others felt that the body had not lost its social identity, so wanted to make sure the loved one was "being cared for" or to say goodbye. Some people wanted to touch the body, in privacy, but the coroner sometimes allowed this only after the postmortem examination, which made relatives feel that the body had become police property. Seeing the body brought home the reality of death; it could be shocking or distressing, but, in this sample, few who did so said they regretted it.

CONCLUSIONS

Even after a traumatic death, relatives should have the opportunity to view the body, and time to decide which family member, if any, should identify remains. Officials should prepare relatives for what they might see, and explain any legal reasons why the body cannot be touched. Guidelines for professional practice must be sensitive to the needs and preferences of people bereaved by traumatic death. The way that relatives refer to the body can be a strong indication for professionals about whether the person who died retains a social identity for the bereaved.

Patients? perceptions of transrectal prostate biopsy: a qualitative study

This study explored men's experiences of transrectal prostate biopsy. Fifty men who had had a prostate biopsy talked about the experience as part of an in-depth interview; 36 were interviewed in 2000 about all aspects of prostate cancer, and 14 in 2005 about their experience of prostate-specific antigen testing, subsequent investigations and treatment. Men were recruited via urologists, general practitioners and support groups. In both studies, we aimed to include men of various ages, from different backgrounds, who lived, and had been investigated and treated, in different parts of the UK. A qualitative interpretive approach was taken, combining thematic analysis with constant comparison. Most men described the procedure as merely 'uncomfortable', but some found it stressful, exhausting and extremely painful. Worries included the fear that cancer cells might pass from a man to his wife during ejaculation, and that a biopsy might spread cancer cells to other parts of the body. Men should be given detailed information before a biopsy, so that they are well aware of what might happen. They should also be given the opportunity to voice their fears, so that they can be reassured, and offered some form of pain relief.

What people close to death say about euthanasia and assisted suicide: a qualitative study

OBJECTIVE

To explore the experiences of people with a "terminal illness", focusing on the patients' perspective of euthanasia and assisted suicide.

METHOD

A qualitative study using narrative interviews was conducted throughout the UK. The views of the 18 people who discussed euthanasia and assisted suicide were explored. These were drawn from a maximum variation sample, who said that they had a "terminal" illness, malignant or non-malignant.

RESULTS

That UK law should be changed to allow assisted suicide or voluntary euthanasia was felt strongly by most people. Those who had seen others die were particularly convinced that this should be a right. Some had multiple reasons, including pain and anticipated pain, fear of indignity, loss of control and cognitive impairment. Those who did not want to be a burden also had other reasons for wanting euthanasia. Suicide was contemplated by a few, who would have preferred a change in the law to allow them to end their lives with medical help and in the company of family or friends. The few who opposed a change in UK law, or who felt ambivalent, focused on involuntary euthanasia, cited religious reasons or worried that new legislation might be open to abuse.

CONCLUSION

Qualitative research conducted on people who know they are nearing death is an important addition to the international debate on euthanasia and assisted suicide. Those who had seen others die were particularly convinced that the law should be changed to allow assisted death.

Stigma, shame, and blame experienced by patients with lung cancer: qualitative study

OBJECTIVES

To draw on narrative interviews with patients with lung cancer and to explore their perceptions and experience of stigma.

DESIGN

Qualitative study.

SETTING

United Kingdom.

PARTICIPANTS

45 patients with lung cancer recruited through several sources.

RESULTS

Participants experienced stigma commonly felt by patients with other types of cancer, but, whether they smoked or not, they felt particularly stigmatised because the disease is so strongly associated with smoking. Interaction with family, friends, and doctors was often affected as a result, and many patients, particularly those who had stopped smoking years ago or had never smoked, felt unjustly blamed for their illness. Those who resisted victim blaming maintained that the real culprits were tobacco companies with unscrupulous policies. Some patients concealed their illness, which sometimes had adverse financial consequences or made it hard for them to gain support from other people. Some indicated that newspaper and television reports may have added to the stigma: television advertisements aim to put young people off tobacco, but they usually portray a dreadful death, which may exacerbate fear and anxiety. A few patients were worried that diagnosis, access to care, and research into lung cancer might be adversely affected by the stigma attached to the disease and those who smoke.

CONCLUSION

Patients with lung cancer report stigmatisation with far reaching consequences. Efforts to help people to quit smoking are important, but clinical and educational interventions should be presented with care so as not to add to the stigma experienced by patients with lung cancer and other smoking related diseases.

Does stage of change predict outcome in a primary-care intervention to encourage an increase in fruit and vegetable consumption?

Our aim was to investigate the response of participants in different Stage of Change (SOC) groups to an intervention to increase fruit and vegetable consumption. Participants recruited from a primary-care health centre were entered into a trial investigating an intervention to increase fruit and vegetable consumption. A total of 729 men and women were randomized into intervention and control groups. Participants attended two appointments 6 months apart and completed postal questionnaires before each appointment. The questionnaire included SOC questions which were used to classify participants into 'pre-contemplation', 'contemplation' and 'action' groups at baseline and at follow-up. All intervention participants received a standard intervention to increase consumption of fruit and vegetables to at least five portions per day. After 6 months at the end of the trial control participants received the same intervention. The main outcome measures were the changes in plasma concentrations of antioxidant vitamins. Changes in self-reported fruit and vegetable intake were a secondary outcome measure. At baseline, 38% (113/297) of the intervention participants were described as being in the 'pre-contemplation' stage, 35% in 'contemplation' and 27% in 'action' groups. For control participants, 36% (112/310) were in 'pre-contemplation', 34% in 'contemplation' and 30% in 'action' groups. In the intervention groups, 50% (57/113) of 'pre-contemplators' moved to the 'action' stage and 37% (42/113) moved to 'contemplation'. There was little movement in the control 'SOC' groups between baseline and follow-up, other than a small drift to 'contemplation'. Overall, the intervention group reported a greater increase in fruit and vegetable consumption than the controls (mean difference in change of 1.4 daily portions; 95% confidence interval 1.2, 1.6; after adjustment for baseline intake and gender) and significantly greater changes were reported in all three intervention 'SOC' groups compared to the corresponding 'control' groups (P < 0.001 in each case). These results suggest that peoples' SOC may have little bearing on their success in increasing fruit and vegetable consumption.

Body image and weight change in middle age: a qualitative study

AIMS

To explore men's and women's experiences of weight change in adulthood, body image preferences and beliefs about the health consequences of overweight and to inform the development of a primary care intervention to prevent obesity.

SAMPLE

Seventy-two men and women aged 35-55, with a range of BMIs from 22 to 29.9, were identified from two UK general practice registers and invited to participate in an interview about experiences of weight change in adulthood.

METHODS

Audio tape recorded, semi-structured interviews were conducted in respondents' homes by trained researchers. Open-ended questions were used to collect experiences of weight change since early adulthood and views about weight change in middle age. Illustrations of a range of men's and women's body shapes were used to prompt discussion of respondents' preferences for male and female body shapes and their perspectives of the health, social and practical problems associated with underweight and overweight. The data were analysed using both quantitative and qualitative methods.

RESULTS

Some 87% (33/38) of the women and 59% (20/34) of the men said that they had ever tried to lose weight. At least one instance of successful weight loss was reported by 58% of the women and 47% of the men, although many of these attempts were relatively short-lived and often motivated by specific goals such as a holiday or a wedding. Respondents were sceptical of the possibility of controlling weight without considerable personal sacrifice. Explanations for middle-age weight gain included a sedentary lifestyle, as well as several gender-specific reasons, including hormonal changes and comfort eating for women and beer drinking for men. Nearly all (97%) respondents associated heart disease with overweight, while diabetes was mentioned by only 22% and none mentioned cancer.

CONCLUSION

People who have gained weight in middle age may be deterred from trying to prevent further gain by pessimism about the effort required. The efficacy of interventions to encourage relatively small substitutions and changes to diet and physical activity need to be tested. Interventions to help prevent weight gain in middle age could include information about the less widely known health risks such as diabetes and cancer.

Is 'watchful waiting' a real choice for men with prostate cancer? A qualitative study

OBJECTIVE

To understand what leads men to choose 'watchful waiting' rather than active treatment for cancer of the prostate.

PATIENTS AND METHODS

Fifty men with confirmed prostate cancer in England, Wales and Scotland were interviewed about all aspects of their illness, for a Database of Individual Patients' Experience of illness. The sample included men at different stages of diagnosis and with experience of a wide range of treatments. We report here only what men said about their choice of treatment and the decision-making process.

RESULTS

Watchful waiting would have been clinically inappropriate for almost half of the men (those with serious urinary symptoms and those with metastatic disease). However, few of the men who might have chosen watchful-waiting remembered this being presented as a serious option. Most in this group chose radical prostatectomy, radiotherapy, brachytherapy or cryosurgery. The few who chose watchful waiting had found doctors who supported their decision, had assessed the evidence from Internet sites, and were concerned about the side-effects and uncertain outcome of treatment. Men who chose watchful waiting, as well as those who opted for treatment, described considerable pressure from family members, doctors or support groups, to seek active treatment.

CONCLUSION

This study helps to explain why some men will not contemplate watchful waiting, and why others may find it difficult to pursue that option. Understanding men's concerns may help clinicians to support men's treatment decisions. Treatment for prostate cancer is highly controversial because no randomized, controlled trials have shown whether or not active intervention increases survival. If trials are not completed it cannot be determined whether active treatments are the best course of action for men with prostate cancer.

Effects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: a randomised controlled trial

BACKGROUND

High dietary intakes of fruit and vegetables are associated with reduced risks of cancer and cardiovascular disease. Short-term intensive dietary interventions in selected populations increase fruit and vegetable intake, raise plasma antioxidant concentrations, and lower blood pressure, but long-term effects of interventions in the general population are not certain. We assessed the effect of an intervention to increase fruit and vegetable consumption on plasma concentrations of antioxidant vitamins, daily fruit and vegetable intake, and blood pressure.

METHODS

We undertook a 6-month, randomised, controlled trial of a brief negotiation method to encourage an increase in consumption of fruit and vegetables to at least five daily portions. We included 690 healthy participants aged 25-64 years recruited from a primary-care health centre.

FINDINGS

Plasma concentrations of alpha-carotene, beta-carotene, lutein, beta-cryptoxanthin, and ascorbic acid increased by more in the intervention group than in controls (significance of between-group differences ranged from p=0.032 to 0.0002). Groups did not differ for changes in lycopene, retinol, alpha-tocopherol, gamma-tocopherol, or total cholesterol concentrations. Self-reported fruit and vegetable intake increased by a mean 1.4 (SD 1.7) portions in the intervention group and by 0.1 (1.3) portion in the control group (between-group difference=1.4, 95% CI 1.2-1.6; p<0.0001). Systolic blood pressure fell more in the intervention group than in controls (difference=4.0 mm Hg, 2.0-6.0; p<0.0001), as did diastolic blood pressure (1.5 mm Hg, 0.2-2.7; p=0.02).

INTERPRETATION

The effects of the intervention on fruit and vegetable consumption, plasma antioxidants, and blood pressure would be expected to reduce cardiovascular disease in the general population.

Development and validation of the Day in the Life Questionnaire (DILQ) as a measure of fruit and vegetable questionnaire for 7-9 year olds

The Day in the Life Questionnaire (DILQ) was developed as a supervised classroom exercise to measure children's consumption of fruit and vegetables. The DILQ uses words and pictures to encourage the child to recall and describe a range of activities from the previous day, including their entire food intake. This study tested the validity and reliability of the DILQ for children aged 7-9 years (n = 255) in four English schools. Reliability, validity and sensitivity to change were assessed through repeated rounds of data collection. Comparisons were made of observations during school breaks and classroom completion of the DILQ. Children enjoyed completing the DILQ and teachers thought it appropriate for the age group. The questionnaire performed either well or acceptably on all validity, reliability and sensitivity tests. The DILQ can be recommended as a method of collecting data for fruit and vegetable consumption from children aged 7-9 in the classroom. The validation study included comparison of schools with and without 'fruit only' breaktime policies, and sensitivity to a brief intervention in which free fruit was distributed at morning break. The results suggest that it would be a sensitive measure for descriptive studies, before and after studies and controlled trials.

Database of patients' experiences (DIPEx): a multi-media approach to sharing experiences and information

The Database of Individual Patients' Experience of illness (DIPEx) is a multimedia website and CD-ROM that links patients' experiences with evidence-based information about treatments and the illness itself and with a range of other resources that may be useful, including support groups and links to other websites. DIPEx aims to identify the questions that matter to people when they are ill and it has potential for informing patients, educating healthcare professionals, and providing a patient-centred perspective to researchers and those who manage health services.

Emergency contraception: an anomalous position in the family planning repertoire?

Emergency contraception (EC) can be used up to 72 h after sex to prevent pregnancy. Internationally there is wide variation in the availability of EC. In the USA it has only recently (1997) won approval from the FDA, while the UK and New Zealand have seen calls for over the counter availability. In recent years surveys, editorials and opinion pieces in medical journals have pointed out that increased access to EC could help to tackle the unwanted pregnancy rate, especially among teenagers, and concluded that lack of knowledge of EC is the major barrier to use. However, women in a UK study have expressed concerns that it is not safe to use the method repeatedly and cited general practitioners (GPs) as one of the sources of this belief, which contradicts the professional guidelines and the rationale for de-regulation. A subsequent study sought to seek the views of GPs about prescribing EC and explored reasons for the gap between the views of women using UK family planning services, GPs and professionals at the public policy level. Data from two studies are presented. In the first study, 53 women seeking emergency contraception were interviewed at two family planning clinics. In the second, semi-structured telephone interviews were completed with a random sample of 76 GPs from three English health authorities. Interviews were recorded, transcribed and thematic analysis was conducted using the constant comparative method. EC was rarely described, by users or GPs, as an acceptable contraceptive option. Consultations for emergency contraception were viewed by GPs as an important opportunity to discuss the woman's future contraceptive needs. Repeated use of EC was not encouraged and a discussion of contraceptive needs could range from a mild enquiry to quite forceful messages contrasting EC to 'regular' and 'proper' methods. The medical literature suggests that EC is underused because of a lack of awareness. Commentators have recommended educating health professionals and women about EC and increasing availability through de-regulation. The data presented in this paper show that British GPs are not enthusiastic about the de-regulation of EC, but the reasons are complex and related to concerns about planned contraception and sexual behaviour. It is suggested that it may be because EC is used after sex that it seems to occupy an uncomfortable place within the contraceptive repertoire.

Computer support for recording and interpreting family histories of breast and ovarian cancer in primary care (RAGs): qualitative evaluation with simulated patients

OBJECTIVES

To explore general practitioners' attitudes towards and use of a computer program for assessing genetic risk of cancer in primary care.

DESIGN

Qualitative analysis of semistructured interviews and video recordings of simulated consultations.

PARTICIPANTS

Purposive sample of 15 general practitioners covering a range of computer literacy, interest in genetics, age, and sex.

INTERVENTIONS

Each doctor used the program in two consultations in which an actor played a woman concerned about her family history of cancer. Consultations were videotaped and followed by interviews with the video as a prompt to questioning. MAIN OUTCOME MESURESs: Use of computer program in the Consultation.

RESULTS

The program was viewed as an appropriate application of information technology because of the complexity of cancer genetics and a sense of "guideline chaos" in primary care. Doctors found the program easy to use, but it often affected their control of the consultation. They needed to balance their desire to share the computer screen with the patient, driven by their concerns about the effect of the computer on doctor-patient communication, against the risk of premature disclosure of bad news.

CONCLUSIONS

This computer program could provide the necessary support to assist assessment of genetic risk of cancer in primary care. The potential impact of computer software on the consultation should not be underestimated. This study highlights the need for careful evaluation when developing medical information systems.

Concerns and cautions about prescribing and deregulating emergency contraception: a qualitative study of GPs using telephone interviews

OBJECTIVES

We aimed to describe GPs' responses to a clinical scenario of a request for a repeat prescription for hormonal emergency contraception (EC), their views about over-the-counter availability and beliefs about absolute contraindications.

DESIGN

We conducted semi-structured tape-recorded telephone interviews with 76 GPs randomly selected from the medical registers of three health authorities which were chosen for high, medium and low prescribing rates for EC.

RESULTS

There was a wide variation in the number of times that GPs would be happy to prescribe EC to the same woman in a year. The content of the consultations appeared patchy. While 59 (77.6%) of the GPs said that they would discuss future contraception with the woman, only 16 (21.1%) said they would talk about possible side effects and 28 (36.3%) would discuss the timing of the next menstrual period and the possibility of method failure. Fifty-two of the practices had a family-planning-trained practice nurse, yet only four (7.7%) had arrangements whereby the nurse could provide EC. Unqualified enthusiasm for deregulation was rare. Concerns included that women would lose out on the benefits of the consultation; worries about the safety of the method; that some women might 'abuse' it by using it frequently; and that certain characteristics of the pharmacy might make it an unsuitable setting for provision of EC.

CONCLUSIONS

This qualitative telephone survey revealed concerns about repeated use of EC and caution about the prospects of deregulation. Respondents were worried that pharmacists might not be able to address all of the features of the consultation that may be valued, yet in this sample nor do most GPs. Family-planning-trained practice nurses are an under-utilized resource and could act as a halfway house between provision by GPs and deregulation.

Patients' views of routine hospital follow-up: a qualitative study of women with breast cancer in remission

OBJECTIVE

To investigate the experience of specialist hospital follow-up among 109 women with breast cancer in remission.

METHODS

Qualitative interviews explored views of follow-up at an outpatient clinic.

RESULTS

Continuity of care and an unrushed consultation were considered to be both desirable and efficient. There were concerns that discontinuity led to a lack of personal and case familiarity and communication difficulties. Access to cancer expertise, the availability of diagnostic tests and specialist facilities were valued features of hospital follow-up, and further analysis indicated that this was particularly important in the early stages of follow-up.

DISCUSSION

A preference for continuity of care may suggest that GP follow-up would be preferred, but access to specialist services is valued and may be of particular importance during the early stages of follow-up. The diversity of patients' needs during follow-up must be recognised when formulating policy.

Lack of willpower or lack of wherewithal? "Internal" and "external" barriers to changing diet and exercise in a three year follow-up of participants in a health check

The aims of this paper were to assess whether anticipated barriers to change in diet and exercise which were cited before a health check intervention were related to subsequent behaviour changes. In 1989 a health and lifestyle questionnaire was posted to 17,965 people aged 35-64 who were registered with five general practices in Bedfordshire. Taking account of non-contacts, a response rate of 80.3% was achieved and 11,090 people described their exercise and dietary habits. Those expressing an interest in changing each behaviour were asked to identify reasons why change might be difficult. Two types of barriers--"internal" and "external"--were identified. A total of 2205 respondents were invited to attend a health check in Year One and a recheck three years later and 1660 attended. In this subgroup improvement in exercise and diet was examined in relation to the participants' baseline characteristics, including the type of barriers selected. Internal barriers to change (e.g. lack of willpower, too lazy, too busy) were chosen most frequently. In a logistic regression including a range of baseline variables those who selected only internal barriers were less likely to take more exercise (OR 0.59, 95% CI 0.41, 0.86) than those who cited only external (e.g. no transport, can't afford sports facilities) or mixed barriers to changing. There was a similar but not statistically significant trend for changing diet (OR 0.78, 95% CI 0.48, 1.28). Those who are aware of external limitations may be better placed to circumvent them. Further research is needed to explore this relationship between type of barrier and behaviour change.

Not a 'proper' solution? The gap between professional guidelines and users' views about the safety of using emergency contraception

OBJECTIVES

As a form of contraception which is used after sex, emergency contraception occupies a singular place in the birth control repertoire. The relatively high UK incidence of pregnancy terminations and of teenage pregnancy, combined with the recognition that much early sex remains unplanned and unprotected, has led to calls for better access to emergency contraceptive methods. In this study a combination of self-completion questionnaires and semi-structured interviews was used to explore views of emergency contraception among women who were using the method.

METHODS

Five hundred and ten women attending two family planning clinics in Oxford and London completed a questionnaire in the waiting room and 53 women who were attending for emergency contraception took part in semi-structured interviews.

RESULTS

The view, presented in recently published UK guidelines, that emergency contraception is a reliable method and not dangerous to repeat, was not shared by the respondents. The rationale for and sources of women's concerns about the strength of the dose of hormonal emergency contraception and the nature of side-effects are explored.

Smoking cessation interventions for dental patients--attitudes and reported practices of dentists in the Oxford region

OBJECTIVE

To investigate various aspects of dentists' beliefs and practices with respect to helping their patients stop smoking.

DESIGN

Postal questionnaire survey conducted in 1996.

SETTING

The general dental practitioners on the health authority lists of Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire.

SUBJECTS

The 869 dentists registered on 1 April 1996.

RESULTS

A high response rate (78%; 674/869) was obtained. The majority of respondents (82%; 95% CI: 79, 85) thought dentists should encourage their patients to stop smoking although only 37% (95% CI: 34, 41) believed dentists to be effective in smoking cessation and even fewer (18%; 95% CI: 15, 21) routinely recorded their patients' smoking status. Of respondents, 51% (95% CI: 46, 55) said they always discussed smoking with patients who had periodontal problems but only 9% (95% CI: 7, 12) always did so with patients who had no major oral health problem. Newer graduates were more likely to routinely record their patients' smoking status (P = 0.02), and to think that doctors' advice (P = 0.001) and nicotine replacement therapy (P < 0.001) were effective in promoting smoking cessation. Dentists in mainly private practices were more active than those in NHS or mixed practices in recording patients' smoking status (P < 0.001) and in discussing smoking (P = 0.002).

CONCLUSIONS

Most respondents thought that dentists should encourage their patients to stop smoking but few are active in this area.

The short form 36 health status questionnaire: clues from the Oxford region's normative data about its usefulness in measuring health gain in population surveys

OBJECTIVES

To determine the potential of the short form 36 health status questionnaire (SF-36) for indicating changes in the health status of a general population by examining the recently published normative data.

DESIGN

The sensitivity of the SF-36 was tested through hypothesising two dramatic changes in health status whereby (i) the scores of people in social class V are improved to the level of social class I, and (ii) the scores of men and women aged 55 to 64 are altered to the level of current 45 to 54 year olds. The size of the effect measured by the SF-36 was considered.

RESULTS

Small to moderate effects were evident when SF-36 mean scores for social class V were increased to the level of social class I, and primarily negligible effects were apparent on all domains but physical function for the postulated "10 years of age" improvement.

CONCLUSION

The SF-36 may be a useful measure for detecting changes in health status in homogenous treatment groups, but the variation in responses in a general population make it an inadequate tool for assessing the diffuse impact of health interventions directed at the whole community.

Transition questions to assess outcomes in rheumatoid arthritis

The importance of patient-based assessments of outcomes of care in RA is increasingly recognized. There are a number of methods of gaining such data. One method is to request patients to assess change in health status by means of transition questions. This is considered advantageous to other methods because is directly addresses perceptions of change over time and is short and simple. One hundred patients with RA completed a range of clinical, laboratory and health status assessments on two occasions 3 months apart. On the second occasion they also completed a transition question. Results show the question to be valid and to correlate with a number of different changes obtained from assessments. Psychological mood did not appear to influence transition judgements. A small minority of patients experienced changes for specific dimensions of health status in the opposite direction of the transition item. Transition judgements may have an important role in evaluation studies and audit.

Tacit models of disability underlying health status instruments

In recent years much attention has been paid to the development of measures of subjective health status yet, although statistical criteria of reliability and validity have been quite rigourously tested, there has been little consideration of the different theories of disability which underlie the design. The sociology of disability may illuminate such tacit theories. It is suggested that the development of health status questionnaires has not been one of simple rational accumulation in response to methodological advances. Through an examination of the content of health assessment questionnaires, four distinct models of disability are identified. These are shown to influence not only the focus of the content and phrasing of the questions but also, crucially, the way that they perform and how responsive they are to change. The models (the functional, subjective distress, comparative and dependence) are illustrated and discussed in terms related to research design.

A comparison of the sensitivity to change of several health status instruments in rheumatoid arthritis

We carried out a study to compare the sensitivity to change of disease specific compared with more generic health status instruments in relation to rheumatoid arthritis (RA). A sample of 102 patients was recruited and assessed by means of 4 health status instruments and standard rheumatological measures on 3 occasions separated by 3 monthly intervals. Sensitivity to change for mobility, activities of daily living, household, pain, emotions and social dimensions were calculated. For some dimensions disease specific health status instruments performed less well. However overall there was no evidence of consistent differences between the 2 approaches. We conclude that generic instruments have a role in the assessment of RA.

Comparison of two approaches to measuring change in health status in rheumatoid arthritis: the Health Assessment Questionnaire (HAQ) and modified HAQ

As an alternative to the calculation of change scores for health status questionnaires used in clinical trials or longitudinal studies, transitional questions have been developed for patients to assess changes directly themselves. Here the original Health Assessment Questionnaire (HAQ) is compared with a modified version of the HAQ (MHAQ) which contains transition questions used at follow up. These, together with a set of standard rheumatological tests, were all completed by 100 patients with rheumatoid arthritis on two occasions, three months apart. Change scores were calculated for the HAQ and for the clinical measures and compared with the MHAQ. The results were strikingly in favour of encouraging patients to assess their own degree of change through the use of transition questions in the MHAQ.

Importance of sensitivity to change as a criterion for selecting health status measures

OBJECTIVE

To assess the sensitivity to change over time of four health status instruments in relation to patients with rheumatoid arthritis.

DESIGN

Observational three month study of four self assessed instruments (arthritis impact measurement scales (AIMS), health assessment questionnaire (HAQ), Nottingham health profile (NHP), functional limitations profile (FLP)).

SETTING

One rheumatology unit.

PATIENTS

101 patients with definite or classic rheumatoid arthritis.

MAIN MEASURES

Change scores for dimensions of instruments, as determined by effect size (mean change in score/baseline standard deviation of variable) and conventional rheumatological measures, at baseline and after three months.

RESULTS

Change scores for comparable dimensions (mobility, activities of daily living, household, pain, mood or emotion, and social scales) of the instruments were compared among 30 patients who considered their health status to have improved over three months. For all dimensions of health status the magnitude of change varied considerably according to the instrument. Maximum range in effect size was for social scales (AIMS 0.06, NHP 0.24, FLP 0.60). No single instrument seemed consistently to show the most change over all dimensions.

CONCLUSION

Selection of health status instruments for audit or evaluation may have a considerable impact on the pattern of results obtained, and the "responsiveness" of such scales should be as carefully examined as their reliability and acceptability when selecting outcome measures.

A generic health status instrument in the assessment of rheumatoid arthritis

Seventy-three patients with RA were assessed by means of the Nottingham Health Profile (NHP), the Arthritis Impact Measurement Scales (AIMS) and a number of clinical measures. Patients with RA scored higher than controls on the NHP scales for energy, pain, mobility and sleep. Energy, pain, mobility and emotions scales of the NHP correlate significantly with other measures such as clinical assessments, matching scales of the AIMS and the Beck Depression Inventory, indicating satisfactory validity for the instrument with RA. Five of the six scales of the NHP are stable on retesting. The social scale of the NHP on the other hand does not correlate with the matching instrument of the AIMS and is relatively unstable over time. Measurement properties of generic health status instruments such as the NHP will require serious attention as they are increasingly used in evaluation studies.

The social dimension of health status measures in rheumatoid arthritis

Fifty-six patients with rheumatoid arthritis (RA) were assessed on two occasions three months apart. They completed two health status instruments--the Arthritis Impact Measurement Scales (AIMS) and the Nottingham Health Profile (NHP)--and the Beck Depression Inventory. In addition, clinical and serological data were gathered in order to calculate severity of disease according to the Mallya and Mace index. Health status instruments and the severity of disease index showed agreement in the assessment of mobility; similar agreement was found for different assessments of emotions. However, the two instruments provided social interaction scores with little agreement either cross-sectionally or in terms of change over time. It is argued that the generic NHP may be a valid instrument as an outcome measure in RA but the NHP and AIMS assess different aspects of social interaction. Care is needed in the selection of outcome measures to evaluate interventions.