The reported views and experiences of cancer service users from minority ethnic groups: a critical review of the literature

There is growing evidence of inequalities in access to high-quality cancer services between minority and majority ethnic groups. However, little research has been carried out from the perspective of users from minority ethnic groups themselves. This paper reports a review of the British literature exploring the views and experiences of cancer service users from minority ethnic groups. We reviewed 25 qualitative studies that reported the experiences of people from minority ethnic groups. The studies highlighted significant issues and challenges, including comprehension and communication barriers, a lack of awareness of the existence of services and a perceived failure by providers to accommodate religious and cultural diversity. This paper critically discusses some of the explanations commonly invoked for ethnic inequalities in access to high-quality care, such as the belief that the lack of use of services reflects a lack of need. Despite positive initiatives to respond better to the needs of minority groups, we suggest the impact of these remains highly variable. Institutional racism within services is still much in evidence.

Psychological effects of a low-grade abnormal cervical smear test result: anxiety and associated factors

Receipt of an abnormal cervical smear result often generates fear and confusion and can have a negative impact on a woman's well-being. Most previous studies have focussed on high-grade abnormal smears. This study describes the psychological and psychosocial effects, on women, of having received a low-grade abnormal smear result. Over 3500 women recruited to TOMBOLA (Trial Of Management of Borderline and Other Low-grade Abnormal smears) participated in this study. Anxiety was assessed using the Hospital Anxiety and Depression Scale (HADS) at recruitment. Socio-demographic and lifestyle factors, locus of control and factors associated with the psychosocial impact of the abnormal smear result were also assessed. Women reported anxiety levels consistent with those found in previous studies of women with high-grade smear results. Women at highest risk of anxiety were younger, had children, were current smokers, or had the highest levels of physical activity. Interventions that focus particularly on women's understanding of smear results and pre-cancer, and/or directly address their fears about cancer, treatment and fertility might provide the greatest opportunity to reduce the adverse psychosocial impact of receiving a low-grade abnormal cervical smear result.

Developing a questionnaire to measure the psychosocial impact of an abnormal cervical smear result and its subsequent management: the TOMBOLA (Trial of Management of Borderline and Other Low-grade Abnormal Smears) trial

This paper describes the process of developing and testing a new questionnaire, Process Outcome Specific Measure (POSM), including an assessment of its content validity and reliability. The questionnaire was developed within the context of Trial Of Management of Borderline and Other Low-grade Abnormal smears (TOMBOLA) to assess the psychosocial impact of a low-grade abnormal cervical smear result and the subsequent management. A literature search, focus groups and thorough pre-testing involving experts and patients resulted in a short (15-item), easily completed and understood questionnaire. Questions address issues including cancer, health, fertility and sexual concerns. Repeatability was assessed in 110 TOMBOLA recruits using weighted k; all but one of the questions showed levels of reliability near to, or above, 0.5. Cronbach's standardised alpha was 0.73, indicating acceptable internal consistency. Each POSM item was correlated with the anxiety and depression sub-scales of the Hospital Anxiety Depression Scale (HADS). All except one of the questions correlated more highly with the total POSM score than with the HADS sub-scales thus indicating discriminant validity. The POSM will enable comparison of the alternative management policies for low-grade cervical smears in terms of the benefits (or otherwise) perceived by the women managed by these policies.

An evaluation of the introduction of Clinical Trial Officer roles into the cancer clinical trial setting in the UK

The National Cancer Research Network (NCRN) was created in 2001 to improve the infrastructure for cancer research within the National Health Service (NHS) in the UK and ensure that research is better integrated with cancer care. The NCRN consists of 34 regional networks which map onto the 34 cancer networks that were established following the publication of the NHS Cancer Plan with its aim of improving the coordination and delivery of cancer care and treatment nationally. An objective of the NCRN is to increase recruitment into cancer trials through improved support. One cancer research network responded by introducing Clinical Trial Officers (CTOs) into the cancer clinical trial setting in order to combine the range of tasks required to support clinical trials into a single role with the ultimate aim of increasing recruitment into cancer clinical trials. Evaluation during the first 14 months of their introduction assessed the impact of the new CTO role on cancer trial recruitment, its acceptability to those involved in trials and its effectiveness in achieving increased recruitment. Evaluation identified appropriate induction and training programmes required to support these new roles and the identification of a model for the introduction of CTO posts in other networks across the country. The findings presented in this paper identify that CTO roles can effectively be introduced into a cancer network and have an impact on recruitment to clinical trials within that network. The data collected provided an in-depth insight into how these roles were perceived, have developed and what supporting structures need to be in place to enable them to flourish. Recruitment in the network has increased and there has been a raising of awareness of clinical trials and cancer research across the whole of the cancer network where the CTOs were based. We conclude that CTO roles can offer a creative alternative to staffing cancer clinical trial units and that such a model could be introduced across other networks. Similar models could also be introduced into other disease settings where clinical research is taking place.

Knowledge of cervical cancer and screening among women in east-central England

This study assesses the extent and accuracy of women's knowledge of cervical cancer, risk factors, and the efficacy of the national screening program. Data were obtained from a questionnaire survey of randomly selected women eligible for screening, drawn from a population in east-central England. The majority of women in the sample overestimated the current incidence of cervical cancer, both absolutely and relative to other cancers. Perceiving incidence to be high was associated with reporting worries about the disease. With respect to the screening process, 78.3% believe that the smear abnormality rate is higher than it actually is, and only 7.6% correctly appreciate that the abnormality rate is highest at younger ages. With respect to performance, 16.3% believed the smear test to be completely accurate, and more than half overestimated the likely number of cancer cases prevented by screening. While certain cervical cancer risk factors were correctly assigned by the majority of women, undue emphasis was placed on genetic influence, while the risks posed by human papillomavirus infection were unfamiliar to almost half of the sample. We conclude that women typically possess only a partial picture of risk factors and overestimate both the incidence of cervical cancer and the efficacy of screening.

Knowledge of cervical cancer and screening among women in east-central England

This study assesses the extent and accuracy of women's knowledge of cervical cancer, risk factors, and the efficacy of the national screening program. Data were obtained from a questionnaire survey of randomly selected women eligible for screening, drawn from a population in east-central England. The majority of women in the sample overestimated the current incidence of cervical cancer, both absolutely and relative to other cancers. Perceiving incidence to be high was associated with reporting worries about the disease. With respect to the screening process, 78.3% believe that the smear abnormality rate is higher than it actually is, and only 7.6% correctly appreciate that the abnormality rate is highest at younger ages. With respect to performance, 16.3% believed the smear test to be completely accurate, and more than half overestimated the likely number of cancer cases prevented by screening. While certain cervical cancer risk factors were correctly assigned by the majority of women, undue emphasis was placed on genetic influence, while the risks posed by human papillomavirus infection were unfamiliar to almost half of the sample. We conclude that women typically possess only a partial picture of risk factors and overestimate both the incidence of cervical cancer and the efficacy of screening

Women's interpretation of cervical smear test results

Screening for cervical cancer using the Papanicolaou smear test has been available in England since the 1960s, yet very little is known about how women interpret their test results. This questionnaire study required women to explain, in their own words, the meaning of normal and abnormal test results. It was discovered that the use of the word cell as a description of findings was extremely common, and that a proportion of subjects equated abnormal results with technical inadequacy. The frequency of circularity in the interpretations, i.e. interpreting 'normal' as 'not abnormal' and vice versa, was striking. Contrary to previous research, we find that, whilst many women interpret normal results as indicating the current absence of cancer, few appear to believe that future cancer is thereby definitively ruled out. By the same token, only a very small minority interpret abnormal results as definitive of cancer.

Communicating mild and borderline abnormal cervical smear results: how and what are women told?

The way in which women are informed about borderline or mild smear results can have a significant psychological impact. By means of a questionnaire survey of general practices in Nottingham, England, this study audited the means by which abnormal smear results were normally communicated to subjects and analysed the content of these communications. Transmitting abnormal smear results, either by letter or by telephone call, was typically the responsibility of the practice nurse, and communications varied widely in informational content. We conclude that the method and content of communications imparting mild or borderline smear results differs between general practices, even within a small geographical area.

Common reasons why peer education fails

Peer education frequently fails. The reasons are numerous and can usually be avoided with clear planning. The most common reasons cited for failure relate to project design and implementation difficulties. The aim of this review is to identify the primary reasons for the failure of peer education programmes in order to help project managers avoid making similar mistakes in the future.

Objectivity in nursing research: observations and objections

Recent writings on nursing research methodology have introduced paradigms of research that challenge conventional notions about truth and objectivity which hold that scientific research is the factual and value-free study of objective reality. The purpose of this paper is to question these trends in nursing research by examining the critique of objectivity in science. The paper will propose that there is a conceptualisation of objectivity that does permit fruitful research on human subjects, which rebuts a relativist view of human knowledge, and it will argue that a rejection of the conventions of objectivity cannot licence new paradigms of research.

Incorporating patients' voices in the audit process

Obtaining patients' views about their experiences of care should be an integral part of clinical audit. The importance of listening to patients as an aspect of quality can be attributed, in part, to the growth of consumerism in health care, and this in turn has led to the widespread use of satisfaction surveys to obtain patients' views. This paper raises some doubts about current methods for assessing patient satisfaction, and recommends the use of qualitative methods to capture patients' voices in audit.

Ethical and practical problems of early anti-cancer drug trials: a review of the literature

Early clinical trials for new anti-cancer drug treatments typically use patients with cancer as research subjects. This paper identifies some of the ethical and practical concerns that arise from the recruitment of a vulnerable group of patients and their exposure to a drug of unknown risk or benefit. This review discusses the ethical principles related to recruitment and informed consent in cancer trials, and indicates that there is a lack of consensus concerning the requirements, process and practice of informed consent. It is suggested that, as yet, little is known about patients' decision making framework in this situation, and the need for further work that concentrates on the patient's point of view is highlighted. The paper concludes by discussing some of the difficulties associated with obtaining patients' opinions, and suggests that the use of a qualitative approach may overcome some of these problems.

Psychosocial aspects of participation in early anticancer drug trials. Report of a pilot study

Despite improvements in the treatment of many cancers, the need for effective new therapies is as great as ever. However, evaluating new drug treatments for cancer in clinical practice raises complex problems. Early trials of new drugs offer little in the way of therapeutic benefit, since their main aim is to identify toxic effects of the drug and subsequent doses for testing. The ethical and practical problems that these trials raise have received some attention in the literature. The main focus of previous studies has been the process of informed consent for trial participation, which has tended to reflect the perspective of the clinicians involved. Little attention has been given to patients' views in this context, and still less work has explored the total experience of clinical trial participation. In order to address these gaps in the literature, a research study was developed to explore the psychosocial aspects of participation in early anticancer drug trials from the perspective of the patient. This article reports the findings of a pilot study. The pilot study obtained the views of seven patients as they progressed through an anticancer drug trial. The informed consent process, the reasons behind decision-making concerning trial participation, and the impact of participation on the lives of the patients were explored, along with changing needs for information, care, and support as the trial progressed. Findings identify psychosocial aspects of clinical trial participation related to information, decision-making, and support from the perspective of those actually taking part.

Valid arguments? a consideration of the concept of validity in establishing the credibility of research findings

Validity is an important concept in establishing the credibility of research findings. However, the current debate about the criteria used to substantiate claims for the validity of research evidence is largely based on a set of distinctions between qualitative and quantitative methodology which are outdated and misleading. This paper argues that validity is an epistemological concept, whose application depends upon some fundamental positions taken about the nature of truth, representation and scientific methodology. There remain important, unresolved questions about the meaning and application of the concept of validity which have a crucial bearing on what criteria are used to establish the credibility of research evidence.

Satisfying solutions? A review of some unresolved issues in the measurement of patient satisfaction

The measurement of patient satisfaction has been encouraged by a growing consumer orientation in health care, especially since it yields information about consumers' views in a form which can be used for comparison and monitoring. However, drawing on literature from a variety of sources, this paper suggests that there remain several unresolved issues relating to the measurement of satisfaction, and some serious questions about the validity of the concept. It is argued that current approaches to measuring satisfaction may not be grounded in the values and experiences of patients; therefore satisfaction surveys could be denying patients the opportunity to have their opinions included in the planning and evaluation of health care services.

Exploring patient satisfaction with out-patient services

Despite the widespread use of satisfaction surveys to obtain patients' views about health services, the validity and relevance of self-completion questionnaire surveys has been questioned. This paper reports on an exploratory, qualitative investigation into patients' perspectives on satisfaction and dissatisfaction with out-patient care. Eighty-one new referrals to two out-patient clinics were interviewed before and after their first consultation. Of this initial sample, 23 were interviewed again at their follow-up appointment and a further 10 were interviewed in depth at a location of their choice. The features of the service that drew appreciative comments when they were thought to be present, and criticism when they were felt to be lacking, were: humanity, efficiency, informativeness and continuity of communication. Examples of these features are discussed using patients' own words to illustrate their perspectives. The study demonstrates that unstructured approaches to service evaluation can be employed to develop services which are genuinely listening to their users' views.

Reading research critically. II. An introduction to appraisal: assessing the evidence

This is the second of two articles providing an introduction to the critical appraisal of research reports. In this paper guidelines for evaluating the quality of evidence and the validity of conclusions are suggested, and a check-list of evaluation points is presented.

Reading research critically. I. An introduction to appraisal: designs and objectives

This is the first of two articles providing an introduction to appraising published research critically. In this paper three styles of research are presented and the basic types of research objectives and designs are briefly described.

Choice cuts: an exploratory study of patients' views about participation in decision-making in a day surgery unit

Patient participation is widely recognized as a principle of ethical health care and linked to benefits in treatment outcome. Even so there is evidence that patients do not recognise their participatory role. This exploratory study aimed to investigate patients' perspectives on choice in a day surgical unit. It involved non-participant observation of 12 patients in a pre-surgical assessment clinic and in depth interviews with 10 patients following surgery. Their expectations of participation can be summarised as "being told" and "going in to get it fixed". Patients had an instrumental model of involvement and considered themselves as the professional's "work object", which constrained scope for participation.

Silent partners. Patients' views about choice and decision making in a day unit

The profile of day case surgery has been gaining prominence in the last decade. Improvements in surgical techniques have allowed a greater range and number of surgical procedures to be performed on a day case basis. Day case surgery also offers considerable efficiency benefits, with lower cost per case than the equivalent in patient treatment. Consequently, the number of surgical day cases has been increasing rapidly although considerable variation still exists between districts. A further advantage of day case surgery arises from its compatibility with the consumerism inherent in the health service reforms. The flexibility and speed of day case surgery permits a response to consumers' demands for a service that meets their needs rather than the hospitals. It offers a reduction in waiting times and the choice to avoid the arduous and often traumatic experience of being admitted to hospital. Bowling, in a short review of the research evidence, suggests that day case surgery generally meets with consistently high levels of patient satisfaction. The most welcome aspect of the recent health service reform is, perhaps, the emphasis on patients' rights and individual choice. Nurses, who are often the closest to the patients, have frequently drawn attention to the need for partnership, and an informed and participative relationship with the patient. While the Department of Health's genuine commitment to patient choice and participation may be little more than skin deep, in the case of day case surgery it appears that consumption and the improvements in efficiency desired by the government may be compatible with nurses' aspirations for greater patient choice.