Journal articles
Pitchforth E, Thornber K (In Press). Communicating antimicrobial resistance: the need to go beyond human health. JAC-Antimicrobial Resistance
Ghiga I, Sidorchuk A, Pitchforth E, Stålsby Lundborg C, Machowska A (2023). 'If you want to go far, go together'-community-based behaviour change interventions to improve antibiotic use: a systematic review of quantitative and qualitative evidence.
J Antimicrob Chemother,
78(6), 1344-1353.
Abstract:
'If you want to go far, go together'-community-based behaviour change interventions to improve antibiotic use: a systematic review of quantitative and qualitative evidence.
INTRODUCTION: a large proportion of the burden of infections with antibiotic-resistant bacteria is linked to community-associated infections. This suggests that interventions set in community settings are needed. Currently there is a gap in understanding the potential of such interventions across all geographies. This systematic review aimed to synthesize the evidence on the value of community-based behaviour change interventions to improve antibiotic use. These are any interventions or innovations to services intended to stimulate behaviour changes among the public towards correct antibiotic use, delivered in a community setting and online. METHODS: Systematic searches of studies published after 2001 were performed in several databases. of 14 319 articles identified, 73 articles comprising quantitative, qualitative and mixed-methods studies met the inclusion criteria. RESULTS: Findings showed positive emerging evidence of the benefits of community-based behaviour change interventions to improve antibiotic use, with multifaceted interventions offering the highest benefit. Interventions that combine educational aspects with persuasion may be more effective than solely educational interventions. The review uncovered difficulties in assessing this type of research and highlights the need for standardized approaches in study design and outcomes measurements. There is emerging, but limited, indication on these interventions' cost-effectiveness. CONCLUSIONS: Policy makers should consider the potential of community-based behaviour change interventions to tackle antimicrobial resistance (AMR), complementing the clinical-based approaches. In addition to the direct AMR benefits, these could serve also as a means of (re)building trust, due to their inclusive participation leading to greater public ownership and use of community channels.
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Ghiga I, Pitchforth E, Stålsby Lundborg C, Machowska A (2023). Family doctors' roles and perceptions on antibiotic consumption and antibiotic resistance in Romania: a qualitative study.
BMC Prim Care,
24(1).
Abstract:
Family doctors' roles and perceptions on antibiotic consumption and antibiotic resistance in Romania: a qualitative study.
BACKGROUND: Antimicrobial resistance (AMR) is a major global health issue, bringing significant health burden and costs to societies. Increased antibiotic consumption (ABC) is linked to AMR emergence. Some of the known drivers of ABC are antibiotics over-prescription by physicians and their misuse by patients. Family doctors are recognised as important stakeholders in the control of ABC as they prescribe antibiotics and are considered a reliable source of medical information by patients. Therefore, it is important to explore their perceptions, especially in Romania, which has the highest ABC among European Union Member States. Furthermore, there is no published research exploring Romanian family doctors' perceptions regarding this phenomenon. METHODS: This was a qualitative study with data collection via semi-structured interviews among 12 family doctors. Manifest and latent content analysis was used to gain an in-depth understanding of their perceptions. Findings were mapped onto the domains of the Behaviour Change Wheel to facilitate a theory driven systematization and analysis. RESULTS: Two main subthemes emerged: i) factors affecting ABC and prescribing and ii) potential interventions to tackle ABC and antibiotic resistance. The factors were further grouped in those that related to the perceived behaviour of family doctors or patients as well as those that had to do with the various systems, local contexts and the COVID-19 pandemic. An overarching theme: 'family doctors in Romania see their role differently when it comes to antibiotic resistance and perceive the lack of patient education or awareness as one of the major drivers of ABC' was articulated. The main findings suggested that the perceived factors span across the capability, opportunity and motivational domains of the behaviour change wheel and could be addressed through a variety of interventions - some identified by the participants. Findings can also be viewed through cultural lenses which shed further light on the family doctor- patient dynamic when it comes to antibiotics use. CONCLUSION: Potential interventions to tackle identified factors emerged, revolving mostly on efforts to educate patients or the public. This exploratory research provides key perspectives and facilitates further research on potential interventions to successfully address AMR in Romania or similar settings.
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Treadgold BM, Campbell JL, Abel GA, Sussex J, Froud R, Hocking L, Pitchforth E (2023). Investigating Clinical Excellence and Impact Awards (INCEA): a qualitative study into how current assessors and other key stakeholders define and score excellence.
BMJ Open,
13(6), e068602-e068602.
Abstract:
Investigating Clinical Excellence and Impact Awards (INCEA): a qualitative study into how current assessors and other key stakeholders define and score excellence
ObjectivesThe National Clinical Excellence Awards (NCEAs) in England and Wales were designed, as a form of performance-related pay, to reward high-performing senior doctors and dentists. To inform future scoring of applications and subsequent schemes, we sought to understand how current assessors and other stakeholders would define excellence, differentiate between levels of excellence and ensure unbiased definitions and scoring.DesignSemistructured qualitative interview study.Participants25 key informants were identified from Advisory Committee on Clinical Excellence Awards subcommittees, and relevant professional organisations in England and Wales. Informants were purposively sampled to achieve variety in gender and ethnicity.FindingsParticipants reported that NCEAs had a role in incentivising doctors to strive for excellence. They were consistent in identifying ‘clinical excellence’ as involving making an exceptional difference to patients and the National Health Service, and in going over and above the expectations associated with the doctor’s job plan. Informants who were assessors reported: encountering challenges with the current scoring scheme when seeking to ensure a fair assessment; recognising tendencies to score more or less leniently; and the potential for conscious or unconscious bias in assessments. Particular groups of doctors, including women, doctors in some specialties and settings, doctors from minority ethnic groups, and doctors who work less than full time, were described as being less likely to self-nominate, lacking support in making applications or lacking motivation to apply on account of a perceived likelihood of not being successful. Practical suggestions were made for improving support and training for applicants and assessors.ConclusionsParticipants in this qualitative study identified specific concerns in respect of the current approaches adopted in applying for and in assessing NCEAs, pointing to the importance of equity of opportunity to apply, the need for regular training for assessors, and to improved support for applicants and potential applicants.
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Ongenda IO-N, Mengistu Z, Tincello D, Williams C, Pitchforth E (2023). Opinion: pelvic floor disorders: learning from chronicity & chronic care models.
Front Glob Womens Health,
4 Author URL.
Pitchforth E, Gemma-Clare A, Smith E, Taylor J, Rayner T, Lichten C, d'Angelo C, Gradmann C, Berridge V, Bertscher A, et al (2023). What and how can we learn from complex global problems for antimicrobial resistance policy? a comparative study combining historical and foresight approaches. Journal of Global Antimicrobial Resistance, 35, 110-121.
Leach B, Parkinson S, Gkousis E, Abel G, Atherton H, Campbell J, Clark C, Cockcroft E, Marriott C, Pitchforth E, et al (2022). Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review.
Journal of Medical Internet Research,
24(7), e33911-e33911.
Abstract:
Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review
. Background
. The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation—referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services—may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear.
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. Objective
. This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation.
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. Methods
. Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach.
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. Results
. A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients’ trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation.
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. Conclusions
. Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations.
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. Trial Registration
. PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019
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Thornber K, Adshead F, Balayannis A, Brazier R, Brown R, Comber S, Court C, Davidson I, Depledge M, Farmer C, et al (2022). First, do no harm: time for a systems approach to address the problem of health-care-derived pharmaceutical pollution. The Lancet Planetary Health, 6(12), e935-e937.
Pitchforth E, Smith E, Taylor J, Davies S, Ali G-C, d'Angelo C (2022). Global action on AMR: lessons from the history of climate change and tobacco control policy.
BMJ Global HealthAbstract:
Global action on AMR: lessons from the history of climate change and tobacco control policy
What is already known? Antimicrobial resistance (AMR) is one of the most pressing global health challenges currently. Recognised as a complex policy issue, efforts to mitigate AMR transcend national boundaries and require global coordination.
What this commentary adds. Some parallels have been drawn with other complex problems such as climate change and tobacco control yet few analyses have taken a comparative and historial approach to draw lessons for AMR policy.
How might the study affect research or policy. Practical suggestions are made for improved AMR governance globally, working on the basis of shared goals but reflecting needs and priorities at a national level.
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Anderson M, Pitchforth E, Vallance-Owen A, Mossialos E, Millner P, Fistein J (2022). Misconceiving patient reported outcome measures (PROMs) as primarily a reporting requirement rather than a quality improvement tool: perceptions of independent healthcare sector stakeholders in the UK.
Journal of Patient-Reported Outcomes,
6(1).
Abstract:
Misconceiving patient reported outcome measures (PROMs) as primarily a reporting requirement rather than a quality improvement tool: perceptions of independent healthcare sector stakeholders in the UK
Abstract
. Background
. The independent healthcare sector in the UK collects PROMs for several surgical procedures, but implementation has been challenging. We aimed to understand the enablers and barriers to PROMs implementation in the independent healthcare sector in the UK.
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. Method
. Between January and May 2021, we remotely conducted semi-structured interviews with hospital consultants, hospital managers and other clinical staff using a topic guide developed from an implementation science framework called the Theoretical Domains Framework (TDF).
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. Results
. We interviewed 6 hospital consultants, 5 hospital managers, and 3 other clinical staff (1 nurse and 2 physiotherapists) across 8 hospitals. Common barriers included: the perception that PROMs are predominantly a reporting requirement rather than a quality improvement tool, absence of feedback mechanisms for PROMs data for clinicians, poor awareness of PROMs among healthcare professionals and the public, absence of direction or commitment from leadership, and limited support from hospital consultants. Common enablers included: regular feedback of PROMs data to clinicians, designating roles and responsibilities, formally embedding PROMs collection into patient pathways, and involvement of hospital consultants in developing strategies to improve PROMs uptake.
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. Conclusion
. To support PROMs implementation, independent hospitals need to develop long-term organisational strategies that involve sustained leadership commitment, goals or targets, training opportunities to staff, and regular feedback of PROMs data at clinical or governance meetings. The primary purpose of PROMs needs to be reframed to independent healthcare sector stakeholders as a quality improvement tool rather than a reporting requirement.
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Kismödi E, Pitchforth E (2022). Sexual and reproductive health, rights and justice in the war against Ukraine 2022.
Sex Reprod Health Matters,
30(1).
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Brown EL, Poltawski L, Pitchforth E, Richards SH, Campbell JL, Butterworth JE (2022). Shared decision-making between older people with multimorbidity and GPs: focus group study. British Journal of General Practice, 72(721).
Anderson M, Pitchforth E, Edwards N, Alderwick H, McGuire A, Mossialos E (2022). United Kingdom: Health System Review.
Health Syst Transit,
24(1), 1-194.
Abstract:
United Kingdom: Health System Review.
This analysis provides a review of developments in financing, governance, organisation and delivery, health reforms and performance of the health systems in the United Kingdom. The United Kingdom has enjoyed a national health service with access based on clinical need, and not ability to pay for over 70 years. This has provided several important benefits including protection against the financial consequences of ill-health, redistribution of wealth from rich to poor, and relatively low administrative costs. Despite this, the United Kingdom continues to lag behind many other comparable high-income countries in key measures including life expectancy, infant mortality and cancer survival. Total health spending in the United Kingdom is slightly above the average for Europe, but it is below many other comparable high-income countries such as Germany, France and Canada. The United Kingdom also has relatively lower levels of doctors, nurses, hospital beds and equipment than many other comparable high-income countries. Wider social determinants of health also contribute to poor outcomes, and the United Kingdom has one of the highest levels of income inequality in Europe. Devolution of responsibility for health care services since the late 1990s to Scotland, Wales and Northern Ireland has resulted in divergence in policies between countries, including in prescription charges, and eligibility for publicly funded social care services. However, more commonalities than differences remain between these health care systems. The United Kingdom initially experienced one of the highest death rates associated with COVID-19; however, the success and speed of the United Kingdom's vaccination programme has since improved the United Kingdom's performance in this respect. Principal health reforms in each country are focusing on facilitating cross-sectoral partnerships and promoting integration of services in a manner that improves the health and well-being of local populations. These include the establishment of integrated care systems in England, integrated joint boards in Scotland, regional partnership boards in Wales and integrated partnership boards in Northern Ireland. Policies are also being developed to align the social care funding model closer to the National Health Service funding model. These include a cap on costs over an individual's lifetime in England, and a national care service free at the point of need in Scotland and Wales. Currently, and for the future, significant investment is needed to address major challenges including a growing backlog of elective care, and staffing shortfalls exacerbated by Brexit.
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Anderson M, Pitchforth E, Asaria M (2021). LSE-Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19 (vol 397, pg 1915, 2021).
LANCET,
397(10288), 1884-1884.
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Anderson M, Pitchforth E, Asaria M, Brayne C, Casadei B, Charlesworth A, Coulter A, Franklin BD, Donaldson C, Drummond M, et al (2021). LSE–Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. The Lancet, 397(10288), 1915-1978.
Pitchforth E, Hussein J (2021). Moving ahead together, on a foundation of rights-based evidence.
Sex Reprod Health Matters,
29(1).
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Booton RD, Meeyai A, Alhusein N, Buller H, Feil E, Lambert H, Mongkolsuk S, Pitchforth E, Reyher KK, Sakcamduang W, et al (2021). One Health drivers of antibacterial resistance: Quantifying the relative impacts of human, animal and environmental use and transmission. One Health, 12, 100220-100220.
Anderson M, O'Neill C, Macleod Clark J, Street A, Woods M, Johnston-Webber C, Charlesworth A, Whyte M, Foster M, Majeed A, et al (2021). Securing a sustainable and fit-for-purpose UK health and care workforce. The Lancet, 397(10288), 1992-2011.
Anderson M, Pitchforth E, McGuire A, Mossialos E (2021). The UK Health and Care Bill: failure to address fundamental issues of coverage and funding.
Lancet,
397(10281).
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Fletcher E, Campbell J, Pitchforth E, Freeman A, Poltawski L, Lambert J, Hawthorne K (2020). Comparing international postgraduate training and healthcare context with the UK to streamline overseas GP recruitment: four case studies.
BJGP Open,
4(3), bjgpopen20X101034-bjgpopen20X101034.
Abstract:
Comparing international postgraduate training and healthcare context with the UK to streamline overseas GP recruitment: four case studies
BackgroundThere are ambitious overseas recruitment targets to alleviate current GP shortages in the UK. GP training in European Economic Area (EEA) countries is recognised by the General Medical Council (GMC) as equivalent UK training; non-EEA GPs must obtain a Certificate of Eligibility for General Practice Registration (CEGPR), demonstrating equivalence to UK-trained GPs. The CEGPR may be a barrier to recruiting GPs from non-EEA countries. It is important to facilitate the most streamlined route into UK general practice while maintaining registration standards and patient safety.AimTo apply a previously published mapping methodology to four non-EEA countries: South Africa, US, Canada, and New Zealand.Design & settingDesk-based research was undertaken. This was supplemented with stakeholder interviews.MethodThe method consisted of: (1) a rapid review of 13 non-EEA countries using a structured mapping framework, and publicly available website content and country-based informant interviews; (2) mapping of five ‘domains’ of comparison between four overseas countries and the UK (healthcare context, training pathway, curriculum, assessment, and continuing professional development (CPD) and revalidation). Mapping of the domains involved desk-based research. A red, amber, or green (RAG) rating was applied to indicate the degree of alignment with the UK.ResultsAll four countries were rated ‘green’. Areas of differences that should be considered by regulatory authorities when designing streamlined CEGPR processes for these countries include: healthcare context (South Africa and US), CPD and revalidation (US, Canada, and South Africa), and assessments (New Zealand).ConclusionMapping these four non-EEA countries to the UK provides evidence of utility of the systematic method for comparing GP training between countries, and may support the UK’s ambitions to recruit more GPs to alleviate UK GP workforce pressures.
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Butterworth JE, Hays R, McDonagh STJ, Bower P, Pitchforth E, Richards SH, Campbell JL (2020). Involving older people with multimorbidity in decision-making about their primary healthcare: a Cochrane systematic review of interventions (abridged).
Patient Educ Couns,
103(10), 2078-2094.
Abstract:
Involving older people with multimorbidity in decision-making about their primary healthcare: a Cochrane systematic review of interventions (abridged).
OBJECTIVE: to assess the effects of interventions aimed at involving older people with multimorbidity in decision-making about their healthcare during primary care consultations. METHODS: Cochrane methodological procedures were applied. Searches covered all relevant trial registries and databases. Randomised controlled trials were identified where interventions had been compared with usual care/ control/ another intervention. A narrative synthesis is presented; meta-analysis was not appropriate. RESULTS: 8160 abstracts and 54 full-text articles were screened. Three studies were included, involving 1879 patient participants. Interventions utilised behaviour change theory; cognitive-behavioural therapy and motivational interviewing; multidisciplinary, holistic patient review and organisational changes. No studies reported the primary outcome 'patient involvement in decision-making about their healthcare'. Patient involvement was evident in the theory underpinning interventions. Certainty of evidence (assessed using GRADE) was limited by small studies and inconsistency in secondary outcomes measured. CONCLUSION: the evidence base is currently too limited to interpret with certainty. Transparency in design and consistency in evaluation, using validated measures, is required for future interventions involving older patients with multimorbidity in decisions about their healthcare. PRACTICE IMPLICATIONS: There is a large gap between clinical guidelines for multimorbidity and an evidence base for implementation of their recommendations during primary care consultations with older people.
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Booton RD, Meeyai A, Alhusein N, Buller H, Feil E, Lambert H, Mongkolsuk S, Pitchforth E, Reyher KK, Sakcamduang W, et al (2020). One Health drivers of antibacterial resistance: quantifying the relative impacts of human, animal and environmental use and transmission.
Abstract:
One Health drivers of antibacterial resistance: quantifying the relative impacts of human, animal and environmental use and transmission
AbstractIntroductionAntimicrobial resistance (AMR), particularly antibacterial resistance (ABR) is a major global health security threat projected to cause over ten million human deaths annually by 2050. There is a disproportionate burden of ABR within lower- and middle-income countries (LMICs), but it is not well understood how ‘One Health’ drivers, where human health is co-dependent on the health of animals and environmental factors, might also impact the burden of ABR in different countries. Thailand’s “National Strategic Plan on Antimicrobial Resistance in Thailand” (NSP-AMR) aims to reduce AMR morbidity by 50% through a reduction of 20% in human antibacterial use and a 30% reduction in animal use starting in 2017. There is a need to understand the implications of such a plan within a One Health perspective that mechanistically links humans, animals and the environment.MethodsA mathematical model of antibacterial use, gut colonisation with extended-spectrum beta-lactamase (ESBL)-producing bacteria and faecal/oral transmission between populations of humans, animals and the environment was calibrated using estimates of the prevalence of ESBL-producing bacteria in Thailand, taken from published studies. This model was used to project the reduction in human ABR (% reduction in colonisation with resistant bacteria) over 20 years (2020-2040) for each potential One Health driver, including each individual transmission rate between humans, animals and the environment, exploring the sensitivity of each parameter calibrated to Thai-specific data. The model of antibacterial use and ABR transmission was used to estimate the long-term impact of the NSP-AMR intervention and quantify the relative impacts of each driver on human ABR.ResultsOur model predicts that human use of antibacterials is the most important factor in reducing the colonisation of humans with resistant bacteria (accounting for maximum 72.3 – 99.8% reduction in colonisation over 20 years). The current NSP-AMR is projected to reduce the human burden of ABR by 7.0 – 21.0%. If a more ambitious target of 30% reduction in antibacterial use in humans were set, a greater (9.9 – 27.1%) reduction in colonisation among humans is projected. We project that completely limiting antibacterial use within animals could have a lower impact (maximum 0.8 – 19.0% reductions in the colonisation of humans with resistant bacteria over 20 years), similar to completely stopping animal-to-human transmission (0.5 – 17.2%). Entirely removing environmental contamination of antibacterials was projected to reduce the percentage colonisation of humans with resistant bacteria by 0.1 – 6.2%, which was similar to stopping environment-human transmission (0.1 – 6.1%).DiscussionOur current understanding of the interconnectedness of ABR in a One Health setting is limited and precludes the ability to generate projected outcomes from existing ABR action plans (due to a lack of fit-for-purpose data). Using a theoretical approach, we explored this using the Thai AMR action plan, using the best available parameters to model the estimated impact of reducing antibacterial use and transmission of resistance between populations. Under the assumptions of our model, human use of antibacterials was identified as the main driver of human ABR, with slightly more ambitious reductions in usage (30% versus 20%) predicted to achieve higher impacts within the NSP-AMR programme. Considerable long-term impact may be also achieved through increasing the rate of loss of resistance and limiting One Health transmission events, particularly human-to-human transmission. Our model provides a simple framework to explain the mechanisms underpinning ABR, but further empirical evidence is needed to fully explain the drivers of ABR in LMIC settings. Future interventions targeting the simultaneous reduction of transmission and antibacterial usage would help to control ABR more effectively in Thailand.
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Butterworth J, Richards S, Warren F, Pitchforth E, Campbell J (2020). Randomised feasibility trial and embedded qualitative process evaluation of a new intervention to facilitate the involvement of older patients with multimorbidity in decision-making about their healthcare during general practice consultations: the VOLITION study protocol.
Pilot Feasibility Stud,
6Abstract:
Randomised feasibility trial and embedded qualitative process evaluation of a new intervention to facilitate the involvement of older patients with multimorbidity in decision-making about their healthcare during general practice consultations: the VOLITION study protocol.
BACKGROUND: the number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today's older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function. AIMS: to undertake feasibility testing of an intervention ('VOLITION') aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations.To inform the design of a fully powered trial to assess intervention effectiveness. METHODS: This study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days. DISCUSSION: Shared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care. TRIAL REGISTRATION: CLINICAL TRIALS.GOV registration number NCT03786315, registered 24/12/18.
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Ghiga I, Pitchforth E, Lepetit L, Miani C, Ali G-C, Meads C (2020). The effectiveness of community-based social innovations for healthy ageing in middle- and high-income countries: a systematic review.
J Health Serv Res Policy,
25(3), 202-210.
Abstract:
The effectiveness of community-based social innovations for healthy ageing in middle- and high-income countries: a systematic review.
OBJECTIVES: Community-based social innovations (CBSIs) are one type of intervention that may help to address the complex needs of ageing populations globally. The aim of this research was to assess evidence for the effectiveness and cost-effectiveness of CBSIs involving in such contexts. METHODS: We conducted a systematic review of CBSIs for healthy ageing in middle- and high-income countries, including any CBSI that aimed to empower people aged 50 and over by motivating them to take initiative for their own health and wellbeing. The protocol was registered with Prospero (CRD 42016051622). A comprehensive search was conducted in 15 academic databases and advanced search in Google. We included published studies from 2000 onwards in any language. Exploratory meta-analysis was conducted for quantitative studies reporting similar outcomes, and qualitative studies were analysed using thematic analysis. Narrative synthesis was conducted. Searches yielded 13,262 unique hits, from which 44 papers met the inclusion criteria. RESULTS: Most studies reported interventions having positive impacts on participants, such as reduced depression, though the majority of studies were classified as being at medium or high risk of bias. There was no evidence on costs or cost-effectiveness and very little reporting of outcomes at an organization or system level. CBSIs have the potential for positive impacts, but with nearly half of studies coming from high-income urban settings (particularly the United Kingdom and the United States of America), there is a lack of generalizability of these findings. CONCLUSIONS: Our research highlights the need to improve reporting of CBSIs as complex interventions, and for improved conceptualization of these interventions to inform research and practice.
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Newbould J, Ball S, Abel G, Barclay M, Brown T, Corbett J, Doble B, Elliott M, Exley J, Knack A, et al (2019). A ‘telephone first’ approach to demand management in English general practice: a multimethod evaluation.
Health Services and Delivery Research,
7(17), 1-158.
Abstract:
A ‘telephone first’ approach to demand management in English general practice: a multimethod evaluation
. Background
. The increasing difficulty experienced by general practices in meeting patient demand is leading to new approaches being tried, including greater use of telephone consulting.
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. Objectives
. To evaluate a ‘telephone first’ approach, in which all patients requesting a general practitioner (GP) appointment are asked to speak to a GP on the telephone first.
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. Methods
. The study used a controlled before-and-after (time-series) approach using national reference data sets; it also incorporated economic and qualitative elements. There was a comparison between 146 practices using the ‘telephone first’ approach and control practices in England with regard to GP Patient Survey scores and secondary care utilisation (Hospital Episode Statistics). A practice manager survey was used in the ‘telephone first’ practices. There was an analysis of practice data and the patient surveys conducted in 20 practices using the ‘telephone first’ approach. Interviews were conducted with 43 patients and 49 primary care staff. The study also included an analysis of costs.
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. Results
. Following the introduction of the ‘telephone first’ approach, the average number of face-to-face consultations in practices decreased by 38% [95% confidence interval (CI) 29% to 45%; p < 0.0001], whereas there was a 12-fold increase in telephone consultations (95% CI 6.3-fold to 22.9-fold; p < 0.0001). The average durations of consultations decreased, which, when combined with the increased number of consultations, we estimate led to an overall increase of 8% in the mean time spent consulting by GPs, although there was a large amount of uncertainty (95% CI –1% to 17%; p = 0.0883). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload. Comparing ‘telephone first’ practices with control practices in England in terms of scores in the national GP Patient Survey, there was an improvement of 20 percentage points in responses to the survey question on length of time to get to see or speak to a doctor or nurse. Other responses were slightly negative. The introduction of the ‘telephone first’ approach was followed by a small (2%) increase in hospital admissions; there was no initial change in accident and emergency (A&E) department attendance, but there was a subsequent small (2%) decrease in the rate of increase in A&E attendances. We found no evidence that the ‘telephone first’ approach would produce net reductions in secondary care costs. Patients and staff expressed a wide range of both positive and negative views in interviews.
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. Conclusions
. The ‘telephone first’ approach shows that many problems in general practice can be dealt with on the telephone. However, the approach does not suit all patients and is not a panacea for meeting demand for care, and it is unlikely to reduce secondary care costs. Future research could include identifying how telephone consulting best meets the needs of different patient groups and practices in varying circumstances and how resources can be tailored to predictable patterns of demand.
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. Limitations
. We acknowledge a number of limitations to our approach. We did not conduct a systematic review of the literature, data collected from clinical administrative records were not originally designed for research purposes and for one element of the study we had no control data. In the economic analysis, we relied on practice managers’ perceptions of staff changes attributed to the ‘telephone first’ approach. In our qualitative work and patient survey, we have some evidence that the practices that participated in that element of the study had a more positive patient experience than those that did not.
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. Funding
. The National Institute for Health Research Health Services and Delivery Research programme.
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Abstract.
Newbould J, Exley J, Ball S, Corbett J, Pitchforth EL, Roland M (2019). GPs’ and staff views of a ‘telephone-first’ approach to demand management: a qualitative study in primary care. British Journal of General Practice
Exley J, Abel GA, Fernandez J-L, Pitchforth E, Mendonca S, Yang M, Roland M, McGuire A (2019). Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis.
BMJ Open,
9(3).
Abstract:
Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis.
OBJECTIVES: to estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN: Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING: 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES: Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS: By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS: the Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.
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Author URL.
Fletcher E, Sansom A, Pitchforth E, Curnow G, Freeman A, Campbell J (2019). Overseas GP recruitment: comparing international GP training with the UK and ensuring that registration standards and patient safety are maintained. British Journal of General Practice (Open)
Ball SL, Newbould J, Corbett J, Exley J, Pitchforth E, Roland M (2018). Qualitative study of patient views on a 'telephone-first' approach in general practice in England: speaking to the GP by telephone before making face-to-face appointments.
BMJ Open,
8(12).
Abstract:
Qualitative study of patient views on a 'telephone-first' approach in general practice in England: speaking to the GP by telephone before making face-to-face appointments.
OBJECTIVE: to understand patients' views on a 'telephone-first' approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP). DESIGN: Qualitative interviews with patients and carers. SETTING: Twelve general practices in England. PARTICIPANTS: 43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English. RESULTS: Patients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the 'telephone-first' approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients' needs better than others and practices varied significantly in how they had implemented the approach. CONCLUSIONS: the 'telephone-first' approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the 'telephone-first' approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome.
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Author URL.
Mossialos E, McGuire A, Anderson M, Pitchforth E, James A, Horton R (2018). The future of the NHS: no longer the envy of the world?. The Lancet, 391, 1001-1003.
Pitchforth E (2017). Book Review: Writing your Thesis. Sociological Research Online, 9(2), 126-126.
Pitchforth E, Nolte E, Corbett J, Miani C, Winpenny E, van Teijlingen E, Elmore N, King S, Ball S, Miler J, et al (2017). Community hospitals and their services in the NHS: identifying transferable learning from international developments – scoping review, systematic review, country reports and case studies. Health Services and Delivery Research, 5.19, 1-248.
Okeke EN, Pitchforth E, Exley J, Glick P, Abubakar IS, Chari AV, Bashir U, Gu K, Onwujekwe O (2017). Going to scale: design and implementation challenges of a program to increase access to skilled birth attendants in Nigeria.
BMC Health Serv Res,
17(1).
Abstract:
Going to scale: design and implementation challenges of a program to increase access to skilled birth attendants in Nigeria.
BACKGROUND: the lack of availability of skilled providers in low- and middle- income countries is considered to be an important barrier to achieving reductions in maternal and child mortality. However, there is limited research on programs increasing the availability of skilled birth attendants in developing countries. We study the implementation of the Nigeria Midwives Service Scheme, a government program that recruited and deployed nearly 2,500 midwives to rural primary health care facilities across Nigeria in 2010. An outcome evaluation carried out by this team found only a modest impact on the use of antenatal care and no measurable impact on skilled birth attendance. This paper draws on perspectives of policymakers, program midwives, and community residents to understand why the program failed to have the desired impact. METHODS: We conducted semi-structured interviews with federal, state and local government policy makers and with MSS midwives. We also conducted focus groups with community stakeholders including community leaders and male and female residents. RESULTS: Our data reveal a range of design, implementation and operational challenges ranging from insufficient buy-in by key stakeholders at state and local levels, to irregular and in some cases total non-provision of agreed midwife benefits that likely contributed to the program's lack of impact. These challenges not only created a deep sense of dissatisfaction with the program but also had practical impacts on service delivery likely affecting households' uptake of services. CONCLUSION: This paper highlights the challenge of effectively scaling up maternal and child health interventions. Our findings emphasize the critical importance of program design, particularly when programs are implemented at scale; the need to identify and involve key stakeholders during planning and implementation; the importance of clearly defining lines of authority and responsibility that align with existing structures; and the necessity for multi-faceted interventions that address multiple barriers at the same time.
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Author URL.
Winpenny EM, Miani C, Pitchforth E, King S, Roland M (2017). Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary-secondary care interface.
Journal of Health Services Research and Policy,
22(1), 53-64.
Abstract:
Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary-secondary care interface
Objectives: Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services. Methods: a scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour. Results: the 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness. Conclusions: There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’skills through education or joint consultations with complex patients.
Abstract.
Kendrick D, Ablewhite J, Achana F, Benford P, Clacy R, Coffey F, Cooper N, Coupland C, Deave T, Goodenough T, et al (2017). Keeping Children Safe: a multicentre programme of research to increase the evidence base for preventing unintentional injuries in the home in the under-fives.
Programme Grants for Applied Research,
5(14), 1-834.
Abstract:
Keeping Children Safe: a multicentre programme of research to increase the evidence base for preventing unintentional injuries in the home in the under-fives
BackgroundUnintentional injuries among 0- to 4-year-olds are a major public health problem incurring substantial NHS, individual and societal costs. However, evidence on the effectiveness and cost-effectiveness of preventative interventions is lacking.AimTo increase the evidence base for thermal injury, falls and poisoning prevention for the under-fives.MethodsSix work streams comprising five multicentre case–control studies assessing risk and protective factors, a study measuring quality of life and injury costs, national surveys of children’s centres, interviews with children’s centre staff and parents, a systematic review of barriers to, and facilitators of, prevention and systematic overviews, meta-analyses and decision analyses of home safety interventions. Evidence from these studies informed the design of an injury prevention briefing (IPB) for children’s centres for preventing fire-related injuries and implementation support (training and facilitation). This was evaluated by a three-arm cluster randomised controlled trial comparing IPB and support (IPB+), IPB only (no support) and usual care. The primary outcome was parent-reported possession of a fire escape plan. Evidence from all work streams subsequently informed the design of an IPB for preventing thermal injuries, falls and poisoning.ResultsModifiable risk factors for falls, poisoning and scalds were found. Most injured children and their families incurred small to moderate health-care and non-health-care costs, with a few incurring more substantial costs. Meta-analyses and decision analyses found that home safety interventions increased the use of smoke alarms and stair gates, promoted safe hot tap water temperatures, fire escape planning and storage of medicines and household products, and reduced baby walker use. Generally, more intensive interventions were the most effective, but these were not always the most cost-effective interventions. Children’s centre and parental barriers to, and facilitators of, injury prevention were identified. Children’s centres were interested in preventing injuries, and believed that they could prevent them, but few had an evidence-based strategic approach and they needed support to develop this. The IPB was implemented by children’s centres in both intervention arms, with greater implementation in the IPB+ arm. Compared with usual care, more IPB+ arm families received advice on key safety messages, and more families in each intervention arm attended fire safety sessions. The intervention did not increase the prevalence of fire escape plans [adjusted odds ratio (AOR) IPB only vs. usual care 0.93, 95% confidence interval (CI) 0.58 to 1.49; AOR IPB+ vs. usual care 1.41, 95% CI 0.91 to 2.20] but did increase the proportion of families reporting more fire escape behaviours (AOR IPB only vs. usual care 2.56, 95% CI 1.38 to 4.76; AOR IPB+ vs. usual care 1.78, 95% CI 1.01 to 3.15). IPB-only families were less likely to report match play by children (AOR 0.27, 95% CI 0.08 to 0.94) and reported more bedtime fire safety routines (AOR for a 1-unit increase in the number of routines 1.59, 95% CI 1.09 to 2.31) than usual-care families. The IPB-only intervention was less costly and marginally more effective than usual care. The IPB+ intervention was more costly and marginally more effective than usual care.LimitationsOur case–control studies demonstrate associations between modifiable risk factors and injuries but not causality. Some injury cost estimates are imprecise because of small numbers. Systematic reviews and meta-analyses were limited by the quality of the included studies, the small numbers of studies reporting outcomes and significant heterogeneity, partly explained by differences in interventions. Network meta-analysis (NMA) categorised interventions more finely, but some variation remained. Decision analyses are likely to underestimate cost-effectiveness for a number of reasons. IPB implementation varied between children’s centres. Greater implementation may have resulted in changes in more fire safety behaviours.ConclusionsOur studies provide new evidence about the effectiveness of, as well as economic evaluation of, home safety interventions. Evidence-based resources for preventing thermal injuries, falls and scalds were developed. Providing such resources to children’s centres increases their injury prevention activity and some parental safety behaviours.Future workFurther randomised controlled trials, meta-analyses and NMAs are needed to evaluate the effectiveness and cost-effectiveness of home safety interventions. Further work is required to measure NHS, family and societal costs and utility decrements for childhood home injuries and to evaluate complex multicomponent interventions such as home safety schemes using a single analytical model.Trial registrationCurrent Controlled Trials ISRCTN65067450 and ClinicalTrials.gov NCT01452191.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 14. See the NIHR Journals Library website for further project information.
Abstract.
Winpenny EM, Corbett J, Miani C, King S, Pitchforth E, Ling T, van Teijlingen E, Nolte E (2016). Community Hospitals in Selected High Income Countries: a Scoping Review of Approaches and Models.
Int J Integr Care,
16(4).
Abstract:
Community Hospitals in Selected High Income Countries: a Scoping Review of Approaches and Models.
BACKGROUND: There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries. METHODS: We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis. RESULTS: 75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists. CONCLUSIONS: Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care.
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Author URL.
Murray SF, Bisht R, Pitchforth E (2016). Emplacing India's "medicities".
Health Place,
42, 69-78.
Abstract:
Emplacing India's "medicities".
Plans for 'medicities', announced in the Indian press from 2007 onwards, were to provide large scale 'one-stop-shops' of super-speciality medical services supplemented by diagnostics, education, research facilities, and other aspects of healthcare and lifestyle consumption. Placing this phenomenon within the recent domestic and global political economy of health, we then draw on recent research literatures on place and health to offer an analysis of the narration of these new healthcare places given in promotional texts from press media, official documents and marketing materials. We consider the implications of such analytic undertakings for the understanding of the evolving landscapes of contemporary health care in middle-income countries, and end with some reflections on the tensions now appearing in the medicity model.
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Author URL.
Winpenny E, Miani C, Pitchforth E, Ball S, Nolte E, King S, Greenhalgh J, Roland M (2016). Outpatient services and primary care: scoping review, substudies and international comparisons.
Health Services and Delivery Research,
4(15), 1-290.
Abstract:
Outpatient services and primary care: scoping review, substudies and international comparisons
AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: a Scoping Review of Research into Strategies for Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.
Abstract.
Exley J, Pitchforth E, Okeke E, Glick P, Abubakar IS, Chari A, Bashir U, Gu K, Onwujekwe O (2016). Persistent barriers to care; a qualitative study to understand women's experiences in areas served by the midwives service scheme in Nigeria.
BMC Pregnancy Childbirth,
16Abstract:
Persistent barriers to care; a qualitative study to understand women's experiences in areas served by the midwives service scheme in Nigeria.
BACKGROUND: the Nigerian Midwives Service Scheme (MSS) is an ambitious human resources project created in 2009 to address supply side barriers to accessing care. Key features include the recruitment and deployment of newly qualified, unemployed and retired midwives to rural primary healthcare centres (PHCs) to ensure improved access to skilled care. This study aimed to understand, from multiple perspectives, the views and experiences of childbearing women living in areas where it has been implemented. METHODS: a qualitative study was undertaken as part of an impact evaluation of the MSS in three states from three geo-political regions of Nigeria. Semi-structured interviews were conducted around nine MSS PHCs with women who had given birth in the past six months, midwives working in the PHCs and policy makers. Focus group discussions were held with wider community members. Coding and analysis of the data was performed in NVivo10 based on the constant comparative approach. RESULTS: the majority of participants reported that there had been positive improvements in maternity care as a result of an increasing number of midwives. However, despite improvements in the perceived quality of care and an apparent willingness to give birth in a PHC, more women gave birth at home than intended. There were some notable differences between states, with a majority of women in one northern state favouring home birth, which midwives and community members commented stemmed from low levels of awareness. The principle reason cited by women for home birth was the sudden onset of labour. Financial barriers, the lack of essential drugs and equipment, lack of transportation and the absence of staff, particularly at night, were also identified as barriers to accessing care. CONCLUSIONS: Our research highlights a number of barriers to accessing care exist, which are likely to have limited the potential for the MSS to have an impact. It suggests that in addition to scaling up the workforce through the MSS, efforts are also needed to address the determinants of care seeking. For the MSS this means that the while the supply side, through the provision of skilled attendance, still needs to be strengthened, this should not be in isolation of addressing demand-side factors.
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Author URL.
Okeke E, Glick P, Chari A, Abubakar IS, Pitchforth E, Exley J, Bashir U, Gu K, Onwujekwe O (2016). The effect of increasing the supply of skilled health providers on pregnancy and birth outcomes: evidence from the midwives service scheme in Nigeria.
BMC Health Serv Res,
16(1).
Abstract:
The effect of increasing the supply of skilled health providers on pregnancy and birth outcomes: evidence from the midwives service scheme in Nigeria.
BACKGROUND: Limited availability of skilled health providers in developing countries is thought to be an important barrier to achieving maternal and child health-related MDG goals. Little is known, however, about the extent to which scaling-up supply of health providers will lead to improved pregnancy and birth outcomes. We study the effects of the Midwives Service Scheme (MSS), a public sector program in Nigeria that increased the supply of skilled midwives in rural communities on pregnancy and birth outcomes. METHODS: We surveyed 7,104 women with a birth within the preceding five years across 12 states in Nigeria and compared changes in birth outcomes in MSS communities to changes in non-MSS communities over the same period. RESULTS: the main measured effect of the scheme was a 7.3-percentage point increase in antenatal care use in program clinics and a 5-percentage point increase in overall use of antenatal care, both within the first year of the program. We found no statistically significant effect of the scheme on skilled birth attendance or on maternal delivery complications. CONCLUSION: This study highlights the complexity of improving maternal and child health outcomes in developing countries, and shows that scaling up supply of midwives may not be sufficient on its own.
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Goodenough T, Kay B, Deave T, Towner E, Stewart J, Ablewhite J, Hawkins A, McDaid LA, Pitchforth E, Beckett K, et al (2015). Barriers and facilitators to delivering injury prevention interventions in English children's centres. International Journal of Health Promotion and Education, 54(2), 60-71.
Miani C, Hinrichs S, Pitchforth E, Bienkowska-Gibbs T, Disbeschl S, Roland M, Nolte E (2015). Best Practice: Medical Training from an International Perspective.
Rand Health Q,
5(1).
Abstract:
Best Practice: Medical Training from an International Perspective.
This study seeks to help inform the further development of medical education and training for primary care in Germany. It explores approaches to medical education and training in a small number of high-income countries and how these seek to address shortages of doctors practising in primary or ambulatory care through reforming their education and training systems. It does so by means of an exploratory analysis of the experiences of three countries: England, France and the Netherlands, with Germany included for comparison. Data collection involved a review of the published and grey literature, using a structured template, complemented by information provided by key informants in the selected countries. The study sets out the general context within which the medical education and training systems in the four countries operate, and describe the education and training pathways for general practice for each. We highlight options for medical education and training in Germany that arise from this study by placing our observations in the context of ongoing reform activity. This study will be of relevance for decisionmakers and practitioners concerned with ensuring a medical workforce that is prepared for the demands in a changing healthcare environment.
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Author URL.
Pitchforth E, Roland M (2015). Specialist services in the community: a qualitative study of consultants holding novel types of employment contracts in England. Future Hospital Journal, 2, 173-179.
MacKenzie Bryers H, VanTeijlingen E, Pitchforth E (2014). Advocating mixed-methods approaches in health research.
Nepal Journal of Epidemiology,
4(5), 417-422.
Abstract:
Advocating mixed-methods approaches in health research
This methods paper provides researchers in Nepal with a broad overview of the practical and philosophical aspects of mixed-methods research. the three authors have a wide-ranging expertise in planning and conducting mixed-methods studies. the paper outlines the different paradigms or philosophies underlying quantitative and qualitative methods and some of the on-going debates about mixed-methods. the paper further highlights a number of practical issues, such as (a) the particular mix and order of quantitative and qualitative methods; (b) the way of integrating methods from different philosophical stance; and (c) how to synthesise mixed-methods findings. DOI: http://dx.doi.org/10.3126/nje.v4i5.12018 Nepal Journal of Epidemiology 2014; 4(5):417-22
Abstract.
Friedberg MW, Chen PG, Van Busum KR, Aunon F, Pham C, Caloyeras J, Mattke S, Pitchforth E, Quigley DD, Brook RH, et al (2014). Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy.
Rand Health Q,
3(4).
Abstract:
Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy.
The American Medical Association asked RAND Health to characterize the factors that affect physician professional satisfaction. RAND researchers sought to identify high-priority determinants of professional satisfaction by gathering data from 30 physician practices in six states, using a combination of surveys and semistructured interviews. This article presents the results of the subsequent analysis.
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Author URL.
Deave T, Towner E, McColl E, Reading R, Sutton A, Coupland C, Cooper N, Stewart J, Hayes M, Pitchforth E, et al (2014). Multicentre cluster randomised controlled trial evaluating implementation of a fire prevention Injury Prevention Briefing in children's centres: study protocol.
BMC Public Health,
14Abstract:
Multicentre cluster randomised controlled trial evaluating implementation of a fire prevention Injury Prevention Briefing in children's centres: study protocol.
BACKGROUND: the UK has one of the highest fatality rates for deaths from fire-related injuries in children aged 0-14 years; these injuries have the steepest social gradient of all injuries in the UK. Children's centres provide children under five years old and their families with a range of services and information, including home safety, but their effectiveness in promoting injury prevention has yet to be evaluated. We developed a fire prevention intervention for use in children's centres comprising an Injury Prevention Briefing (IPB) which provides evidence on what works and best practice from those running injury prevention programmes, and a facilitation package to support implementation of the IPB. This protocol describes the design and methods of a trial evaluating the effectiveness and cost-effectiveness of the IPB and facilitation package in promoting fire prevention. METHODS/DESIGN: Pragmatic, multicentre cluster randomised controlled trial, with a nested qualitative study, in four study centres in England. Children's centres in the most disadvantaged areas will be eligible to participate and will be randomised to one of three treatment arms comprising: IPB with facilitation package; IPB with no facilitation package; usual care (control). The primary outcome measure will be the proportion of families who have a fire escape plan at follow-up. Eleven children's centres per arm are required to detect an absolute difference in the percentage of families with a fire escape plan of 20% in either of the two intervention arms compared with the control arm, with 80% power and a 5% significance level (2-sided), an intraclass correlation coefficient of 0.05 and assuming outcomes are assessed on 20 families per children's centre. Secondary outcomes include the assessment of the cost-effectiveness of the intervention, other fire safety behaviours and factors associated with degree of implementation of the IPB. DISCUSSION: This will be the first trial to develop and evaluate a fire prevention intervention for use in children's centres in the UK. Its findings will be generalisable to children's centres in the most disadvantaged areas of the UK and may also be generalisable to similar interventions to prevent other types of injury. TRIAL REGISTRATION: http://NCT01452191 (date of registration: 13/10/2011).
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Miani C, Ball S, Pitchforth E, Exley J, King S, Roland M, Fuld J, Nolte E (2014). Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment.
Health Services and Delivery Research,
2(52), 1-178.
Abstract:
Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment
BackgroundAvailable evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay.ObjectivesThis study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs.Data sourcesWe searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type.MethodsWe conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England.ResultsA total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings.LimitationsWe only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review.ConclusionsThe design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economy.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Abstract.
Schweppenstedde D, Hinrichs S, Ogbu U, Schneider EC, Kringos DS, Klazinga NS, Healy J, Vuorenkoski L, Busse R, Guerin B, et al (2014). Regulating Quality and Safety of Health and Social Care: International Experiences.
Rand Health Q,
4(1).
Abstract:
Regulating Quality and Safety of Health and Social Care: International Experiences.
This study is concerned with "standards of quality and safety" within health and social care systems. Care standards are intended to support efforts in maintaining and improving the quality of care; they have been developed across countries, although the ways in which they are implemented and applied differs between nations. Taking a range of six countries, we review the regulatory mechanisms that have been implemented to ensure that essential standards of care are applied and are being adhered to, and consider the range of policy instruments used to encourage and ensure continuous quality improvement. We report on Australia, England, Finland, Germany, the Netherlands and the USA. The study is intended to inform policy thinking for the Department of Health and others in developing the regulation of safety and quality of health and social care in England. It was prepared as part of the project "An 'On-call' Facility for International Healthcare Comparisons" funded by the Department of Health in England through its Policy Research Programme.
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Author URL.
Nolte E, Pitchforth E, Miani C, Mc Hugh S (2014). The Changing Hospital Landscape: an Exploration of International Experiences.
Rand Health Q,
4(3).
Abstract:
The Changing Hospital Landscape: an Exploration of International Experiences.
The nature of hospital activity is changing in many countries, with some experiencing a broad trend towards the creation of hospital groups or chains and multi-hospital networks. This study seeks to contribute to the understanding of experiences in other countries about the extent to which different hospital "models" may provide lessons for hospital provision in England by means of a review of four countries: France, Germany, Ireland and the United States, with England included for comparison. We find that there has been a trend towards privatisation and the formation of hospital groups in France, Germany, and the United States although it is important to understand the underlying market structure in these countries explaining the drivers for hospital consolidation. Thus, and in contrast to the NHS, in France, Germany, and the United States, private hospitals contribute to the delivery of publicly funded healthcare services. There is limited evidence suggesting that different forms of hospital cooperation, such as hospital groups, networks or systems, may have different impacts on hospital performance. Available evidence suggests that hospital consolidation may lead to quality improvements as increased size allows for more costly investments and the spreading of investment risk. There is also evidence that a higher volume of certain services such as surgical procedures is associated with better quality of care. However, the association between size and efficiency is not clear-cut and there is a need to balance "quality risk" associated with low volumes and "access risk" associated with the closure of services at the local level.
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Baskayne K, Willars J, Pitchforth E, Tincello DG (2014). Women's expectations of prolapse surgery: a retrospective qualitative study.
Neurourol Urodyn,
33(1), 85-89.
Abstract:
Women's expectations of prolapse surgery: a retrospective qualitative study.
AIMS: to explore the expectations of prolapse surgery held by women before that surgery and to examine reasons why such expectations were met, or not met. METHODS: Qualitative study using one-to-one interviews with women who had undergone prolapse surgery in a large UK teaching hospital. Interviews were conducted by a third party, trained interviewer using a piloted interview guide, but women were encouraged to speak freely. Transcripts were analyzed based on the constant comparative method and interviews continued until no new themes emerged. RESULTS: Fifty-two women were contacted; 32 took part. Twenty-eight women's interviews were used for analysis, after pilot interviews with four women. Median age was 58 (32-86), 19 were Caucasian, nine of South Indian ethnicity. Anticipated benefits of surgery included global themes of cure without specific definitions, focusing on physical symptoms. A few women anticipated psychological benefit. Most women had expectations of a permanent cure. After surgery, most women considered their surgery a success, for physical symptom improvement. Some women had modified their prior expectations (downwards) and success was interpreted in this light. Provision of information about recovery and symptom resolution was felt to be inadequate by the majority. CONCLUSIONS: in this study, resolution of physical symptoms was the prevalent expectation, along with restoration of "normality." Normality was often redefined during recovery, indicating the complexity of assessing fulfillment of expectations, and that specific goal-setting may be inadequate. A chronic illness framework for prolapse may be helpful. Information exchange, especially in the post-operative period can be improved.
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de-Graft Aikins A, Pitchforth E, Allotey P, Ogedegbe G, Agyemang C (2012). Culture, ethnicity and chronic conditions: reframing concepts and methods for research, interventions and policy in low- and middle-income countries.
Ethn Health,
17(6), 551-561.
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de-Graft Aikins A, Arhinful DK, Pitchforth E, Ogedegbe G, Allotey P, Agyemang C (2012). Establishing and sustaining research partnerships in Africa: a case study of the UK-Africa Academic Partnership on Chronic Disease.
Global Health,
8Abstract:
Establishing and sustaining research partnerships in Africa: a case study of the UK-Africa Academic Partnership on Chronic Disease.
This paper examines the challenges and opportunities in establishing and sustaining north-south research partnerships in Africa through a case study of the UK-Africa Academic Partnership on Chronic Disease. Established in 2006 with seed funding from the British Academy, the partnership aimed to bring together multidisciplinary chronic disease researchers based in the UK and Africa to collaborate on research, inform policymaking, train and support postgraduates and create a platform for research dissemination. We review the partnership's achievements and challenges, applying established criteria for developing successful partnerships. During the funded period we achieved major success in creating a platform for research dissemination through international meetings and publications. Other goals, such as engaging in collaborative research and training postgraduates, were not as successfully realised. Enabling factors included trust and respect between core working group members, a shared commitment to achieving partnership goals, and the collective ability to develop creative strategies to overcome funding challenges. Barriers included limited funding, administrative support, and framework for monitoring and evaluating some goals. Chronic disease research partnerships in low-income regions operate within health research, practice, funding and policy environments that prioritise infectious diseases and other pressing public health and developmental challenges. Their long-term sustainability will therefore depend on integrated funding systems that provide a crucial capacity building bridge. Beyond the specific challenges of chronic disease research, we identify social capital, measurable goals, administrative support, creativity and innovation and funding as five key ingredients that are essential for sustaining research partnerships.
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Bisht R, Pitchforth E, Murray SF (2012). Understanding India, globalisation and health care systems: a mapping of research in the social sciences.
Global Health,
8Abstract:
Understanding India, globalisation and health care systems: a mapping of research in the social sciences.
National and transnational health care systems are rapidly evolving with current processes of globalisation. What is the contribution of the social sciences to an understanding of this field? a structured scoping exercise was conducted to identify relevant literature using the lens of India - a 'rising power' with a rapidly expanding healthcare economy. A five step search and analysis method was employed in order to capture as wide a range of material as possible. Documents published in English that met criteria for a social science contribution were included for review. Via electronic bibliographic databases, websites and hand searches conducted in India, 113 relevant articles, books and reports were identified. These were classified according to topic area, publication date, disciplinary perspective, genre, and theoretical and methodological approaches. Topic areas were identified initially through an inductive approach, then rationalised into seven broad themes. Transnational consumption of health services; the transnational healthcare workforce; the production, consumption and trade in specific health-related commodities, and transnational diffusion of ideas and knowledge have all received attention from social scientists in work related to India. Other themes with smaller volumes of work include new global health governance issues and structures; transnational delivery of health services and the transnational movement of capital. Thirteen disciplines were found represented in our review, with social policy being a clear leader, followed by economics and management studies. Overall this survey of India-related work suggests a young and expanding literature, although hampered by inadequacies in global comparative data, and by difficulties in accessing commercially sensitive information. The field would benefit from further cross-fertilisation between disciplines and greater application of explanatory theory. Literatures around stem cell research and health related commodities provide some excellent examples of illuminating social science. Future research agendas on health systems issues need to include innovative empirical work that captures the dynamics of transnational processes and that links macro-level change to fine-grained observations of social life.
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Murray SF, Bisht R, Baru R, Pitchforth E (2012). Understanding health systems, health economies and globalization: the need for social science perspectives.
Global Health,
8Abstract:
Understanding health systems, health economies and globalization: the need for social science perspectives.
The complex relationship between globalization and health calls for research from many disciplinary and methodological perspectives. This editorial gives an overview of the content trajectory of the interdisciplinary journal 'Globalization and Health' over the first six years of production, 2005 to 2010. The findings show that bio-medical and population health perspectives have been dominant but that social science perspectives have become more evident in recent years. The types of paper published have also changed, with a growing proportion of empirical studies. A special issue on 'Health systems, health economies and globalization: social science perspectives' is introduced, a collection of contributions written from the vantage points of economics, political science, psychology, sociology, business studies, social policy and research policy. The papers concern a range of issues pertaining to the globalization of healthcare markets and governance and regulation issues. They highlight the important contribution that can be made by the social sciences to this field, and also the practical and methodological challenges implicit in the study of globalization and health.
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Pitchforth E, Weaver S, Willars J, Wawrzkowicz E, Luyt D, Dixon-Woods M (2011). A qualitative study of families of a child with a nut allergy.
Chronic Illn,
7(4), 255-266.
Abstract:
A qualitative study of families of a child with a nut allergy.
OBJECTIVES: the aim of this study was to explore, using qualitative methods, the experiences of children and their parents living with nut allergy. METHODS: Children with a confirmed diagnosis of peanut allergy were identified from a database of patients maintained at an allergy clinic at a large teaching hospital. Interviews with 26 families were conducted involving 11 children, 25 mothers and 12 fathers. RESULTS: the diagnosis of nut allergy signalled a critical transition-or biographical disruption-in the life of the family. Parents took on the role of 'alert assistant' and sought to create 'safe places' where nuts were not permitted, but often struggled when outside the home environment. The option of 'passing as normal', often used by people with a chronic illness to avoid stigma, was not available to them. Consequently, parents often reported being treated as faddy, demanding, and neurotic, and children suffered from teasing and exclusion. The social consequences of nut allergy were worsened by poor labelling and control of foods and products containing nuts. DISCUSSION: in many ways, nut allergy may be considered a form of disability, because it imposes social barriers on participating fully in society.
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Bakali E, Pitchforth E, Tincello DG, Kenyon S, Slack M, Toozs-Hobson P, Mayne C, Jones DR, Taylor D (2011). Clinicians' views on the feasibility of surgical randomized trials in urogynecology: results of a questionnaire survey.
Neurourol Urodyn,
30(1), 69-74.
Abstract:
Clinicians' views on the feasibility of surgical randomized trials in urogynecology: results of a questionnaire survey.
AIMS: to survey the views of clinicians (urologists and gynecologists) about a proposed randomized surgical trial comparing two approaches for the treatment of women with urinary incontinence and vaginal prolapse. METHODS: a questionnaire survey nested within a pilot randomized controlled trial of colposuspension versus anterior repair plus TVT (CARPET1) for women with incontinence and anterior vaginal prolapse. Members of the UK Continence Society, British Society of Urogynaecology, and International Continence Society were sent a single electronic mailing of semi-structured questionnaires containing closed and open questions and free text response boxes. Free text responses were analyzed using a thematic qualitative analysis. RESULTS: One hundred fifty-seven questionnaires were returned, from a potential total of 400 from UK and 1,700 international respondents. Fifty-eight percent thought the trial ethical, 44% desirable, and 47% feasible. Thirty-three percent would recruit to the full study, and 22% would enroll themselves or their partner. Analysis of free text responses identified three themes impacting participation: issues of patient choice and consent; clinicians' views of perceived benefit and complications of the two arms; and issues about the chosen trial design. CONCLUSIONS: This study highlights the difference between collective and individual equipoise and their impact upon surgical trials. Clinicians held strong views preventing them from regarding the study favorably. Difficulty with relinquishing control over choice of procedure appeared central. These findings support the growing evidence in favor of detailed qualitative pilot work for surgical trials. The role of expertise-based randomization deserves further consideration.
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van Teijlingen E, Pitchforth E (2011). One-stop shop.
Midwives,
14(1), 30-32.
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van Teijlingen E, Simkhada B, Porter M, Simkhada P, Pitchforth E, Bhatta P (2011). Qualitative research and its place in health research in Nepal.
Kathmandu Univ Med J (KUMJ),
9(36), 301-305.
Abstract:
Qualitative research and its place in health research in Nepal.
There has been a steady growth in recent decades in Nepal in health and health services research, much of it based on quantitative research methods. Over the same period international medical journals such as the Lancet, the British Medical Journal (BMJ), the Journal of the American Medical Association (JAMA) and the Journal of Family Planning and Reproductive Health Care and many more have published methods papers outlining and promoting qualitative methods. This paper argues in favour of more high-quality qualitative research in Nepal, either on its own or as part of a mixed-methods approach, to help strengthen the country's research capacity. After outlining the reasons for using qualitative methods, we discuss the strengths and weaknesses of the three main approaches: (a) observation; (b) in-depth interviews; and (c) focus groups. We also discuss issues around sampling, analysis, presentation of findings, reflexivity of the qualitative researcher and theory building, and highlight some misconceptions about qualitative research and mistakes commonly made.
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Pitchforth E, Lilford RJ, Kebede Y, Asres G, Stanford C, Frost J (2010). Assessing and understanding quality of care in a labour ward: a pilot study combining clinical and social science perspectives in Gondar, Ethiopia.
Soc Sci Med,
71(10), 1739-1748.
Abstract:
Assessing and understanding quality of care in a labour ward: a pilot study combining clinical and social science perspectives in Gondar, Ethiopia.
Ensuring high quality intrapartum care in developing countries is a crucial component of efforts to reduce maternal and neonatal mortality and morbidity. Conceptual frameworks for understanding quality of care have broadened to reflect the complexity of factors affecting quality of health care provision. Yet, the role of social sciences within the assessment and understanding of quality of care in this field has focused primarily on seeking to understand the views and experiences of service users and providers. In this pilot study we aimed to combine clinical and social science perspectives and methods to best assess and understand issues affecting quality of clinical care and to identify priorities for change. Based in one referral hospital in Ethiopia, data collection took place in three phases using a combination of structured and unstructured observations, interviews and a modified nominal group process. This resulted in a thorough and pragmatic methodology. Our results showed high levels of knowledge and compliance with most aspects of good clinical practice, and non-compliance was affected by different, inter-linked, resource constraints. Considering possible changes in terms of resource implications, local stakeholders prioritised five areas for change. Some of these changes would have considerable resources implications whilst others could be made within existing resources. The discussion focuses on implications for informing quality improvement interventions. Improvements will need to address health systems issues, such as supply of key drugs, as well as changes in professional practice to promote the rational use of drugs. Furthermore, the study considers the need to understand broader organizational factors and inter-professional relationships. The potential for greater integration of social science perspectives as part of currently increasing monitoring and evaluation activity around intrapartum care is highlighted.
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Williams CD, Pitchforth EL, O’Callaghan C (2010). Computers, the Internet and medical education in Africa. Medical Education, 44(5), 485-488.
Tucker J, McVicar A, Pitchforth E, Farmer J, Bryers H (2010). Maternity care models in a remote and rural network: assessing clinical appropriateness and outcome indicators.
Qual Saf Health Care,
19(2), 83-89.
Abstract:
Maternity care models in a remote and rural network: assessing clinical appropriateness and outcome indicators.
BACKGROUND: Little is known about performance of small rural maternity units, including stand-alone midwife units. AIM: to describe the proportions of women delivering locally, clinical appropriateness of model of care at delivery and outcome indicators for three rural staffing models of care. DESIGN: Case note review. SETTING: Remote and rural maternity units in NHS North of Scotland Region. SUBJECTS AND METHODS: 1400 deliveries to women from the catchments of eight rural units (stratified by staffing model) included those in local rural units and in associated distant referral units. Descriptive analysis examined women's risk, clinical appropriateness of model of care at delivery and outcomes aggregated by local catchment unit type and delivery unit type. RESULTS: Local deliveries by staffing model were 31% (214/697) in midwife stand-alone units, 70% (236/336) in midwife units alongside non-obstetric medical support and 86% (317/367) in small obstetric-led units. Model of care at delivery was generally appropriate according to risk. Judged inappropriate were 3% (22/696) of women with complications delivering in midwife stand-alone units; and of referral unit deliveries, 6% (37/632) with suspected complications unconfirmed, plus 5% (31/633) discharged undelivered by referral hospital at >36 weeks' gestation. Risk profiles of catchment samples were similar, but caesarean section rates appeared lower and neonatal unit admissions higher for women from stand-alone midwife units. CONCLUSIONS: Rural women were generally referred appropriately for specialist care. These stand-alone midwife units provided intrapartum care for approximately one-third of rural women who remained without complications. Further evidence is needed about outcomes by staffing models of care.
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van Teijlingen ER, Pitchforth E (2010). Rural maternity care: can we learn from Wal-Mart?.
Health Place,
16(2), 359-364.
Abstract:
Rural maternity care: can we learn from Wal-Mart?
In many countries rural maternity care is under threat. Consequently rural pregnant women will have to travel further to attend larger maternity units to receive care and deliver their babies. This trend is not dissimilar from the disappearance of other rural services, such as village shops, banks, post offices and bus services. We use a comparative approach to draw an analogy with large-scale supermarkets, such as the Wal-Mart and Tesco and their effect on the viability of smaller rural shops, depersonalisation of service and the wider community. The closure of a community-maternity unit leads to women attending a different type of hospital with a different approach to maternity care. Thus small community-midwifery units are being replaced, not by a very similar unit that happens to be further away, but by a larger obstetric unit that operates on different models, philosophy and notions of risk. Comparative analysis allows a fresh perspective on the provision of rural maternity services. We argue that previous discussions focusing on medicalisation and change in maternity services can be enhanced by drawing on experience in other sectors and taking a wider societal lens.
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Al-Attas AH, Williams CD, Pitchforth EL, O’Callaghan CO, Lewallen S (2010). Understanding Delay in Accessing Specialist Emergency Eye Care in a Developing Country: Eye Trauma in Tanzania. Ophthalmic Epidemiology, 17(2), 103-112.
Pitchforth E, van Teijlingen E, Watson V, Tucker J, Kiger A, Ireland J, Farmer J, Rennie A-M, Gibb S, Thomson E, et al (2009). "Choice" and place of delivery: a qualitative study of women in remote and rural Scotland.
Qual Saf Health Care,
18(1), 42-48.
Abstract:
"Choice" and place of delivery: a qualitative study of women in remote and rural Scotland.
OBJECTIVE: to explore women's perceptions of "choice" of place of delivery in remote and rural areas where different models of maternity services are available. SETTING AND METHODS: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. RESULTS: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from "acceptors" to "active choosers." the presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in "choice." CONCLUSIONS: Provision of different models of maternity services may not be sufficient to convince women they have "choice." the paper raises fundamental questions about the meaning of "choice" within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.
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Dixon-Woods M, Suokas A, Pitchforth E, Tarrant C (2009). An ethnographic study of classifying and accounting for risk at the sharp end of medical wards.
Soc Sci Med,
69(3), 362-369.
Abstract:
An ethnographic study of classifying and accounting for risk at the sharp end of medical wards.
An understanding of how staff identify, classify, narrativise and orient to patient safety risks is important in understanding responses to efforts to effect change. We report an ethnographic study of four medical wards in the UK, in hospitals that were participating in the Health Foundation's Safer Patients Initiative, an organisation-wide patient safety programme. Data analysis of observations and 49 interviews with staff was based on the constant comparative method. We found that staff engaged routinely in practices of determining what gets to count as a risk, how such risks should properly be managed, and how to account for what they do. Staff practices and reasoning in relation to risk emerged through their practical engagement in the everyday work of the wards, but were also shaped by social imperatives. Risks, in the environment we studied, were not simply risks to patient safety; when things went wrong, professional identity was at risk too. Staff oriented to risks in the context of busy and complex ward environments, which influenced how they accounted for risk. Reasoning about risk was influenced by judgements about which values should be promoted when caring for patients, by social norms, by risk-spreading logics, and by perceptions of the extent to which particular behaviours and actions were coupled to outcomes and were blameworthy. These ways of identifying, evaluating and addressing risks are likely to be highly influential in staff responses to efforts to effect change, and highlight the challenges in designing and implementing patient safety interventions.
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Poobalan AS, Pitchforth E, Imamura M, Tucker JS, Philip K, Spratt J, Mandava L, van Teijlingen E (2009). Characteristics of effective interventions in improving young people's sexual health: a review of reviews. Sex Education, 9(3), 319-336.
Doshani A, Pitchforth E, Mayne C, Tincello DG (2009). The value of qualitative research in urogynaecology.
BJOG,
116(1), 3-6.
Author URL.
Edelstein M, Pitchforth E, Asres G, Silverman M, Kulkarni N (2008). Awareness of health effects of cooking smoke among women in the Gondar Region of Ethiopia: a pilot survey.
BMC Int Health Hum Rights,
8Abstract:
Awareness of health effects of cooking smoke among women in the Gondar Region of Ethiopia: a pilot survey.
BACKGROUND: the burning of biomass fuels results in exposure to high levels of indoor air pollution, with consequent health effects. Possible interventions to reduce the exposure include changing cooking practices and introduction of smoke-free stoves supported by health education. Social, cultural and financial constraints are major challenges to implementation and success of interventions. The objective of this study is to determine awareness of women in Gondar, Ethiopia to the harmful health effects of cooking smoke and to assess their willingness to change cooking practices. METHODS: We used a single, administered questionnaire which included questions on household circumstances, general health, awareness of health impact of cooking smoke and willingness to change. We interviewed 15 women from each of rural, urban-traditional and middle class backgrounds. RESULTS: Eighty percent of rural women cooked indoors using biomass fuel with no ventilation. Rural women reported two to three times more respiratory disease in their children and in themselves compared to the other two groups. Although aware of the negative effect of smoke on their own health, only 20% of participants realised it caused problems in children, and 13% thought it was a cause for concern. Once aware of adverse effects, women were willing to change cooking practices but were unable to afford cleaner fuels or improved stoves. CONCLUSION: Increasing the awareness of the health-effects of indoor biomass cooking smoke may be the first step in implementing a programme to reduce exposure.
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Pitchforth E, Watson V, Tucker J, Ryan M, van Teijlingen E, Farmer J, Ireland J, Thomson E, Kiger A, Bryers H, et al (2008). Models of intrapartum care and women's trade-offs in remote and rural Scotland: a mixed-methods study.
BJOG,
115(5), 560-569.
Abstract:
Models of intrapartum care and women's trade-offs in remote and rural Scotland: a mixed-methods study.
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.
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Doshani A, Pitchforth E, Mayne CJ, Tincello DG (2007). Culturally sensitive continence care: a qualitative study among South Asian Indian women in Leicester.
Fam Pract,
24(6), 585-593.
Abstract:
Culturally sensitive continence care: a qualitative study among South Asian Indian women in Leicester.
BACKGROUND: Urinary incontinence is a significant health problem with potentially serious physical, psychological and social consequences. The true prevalence is difficult to ascertain, especially in hard to reach groups such as ethnic minority populations and research in this area is lacking. The UK has an increasingly diverse population, and ascertaining the needs for incontinence care among ethnic minority groups is crucial. OBJECTIVES: This study aimed to explore views and experiences of incontinence and perceptions of care among South Asian Indian women in Leicester, UK. METHODS: a qualitative focus group study involving four focus groups, each of six women, was undertaken. Focus groups were conducted in the participants' chosen language and facilitated by a bilingual moderator. Groups were tape-recorded, transcribed and analysed in a systematic and iterative way based on the constant comparative method. RESULTS: Women commonly normalized symptoms of urinary incontinence, attributing them to the ageing process or consequences of childbirth. Help-seeking behaviour was hindered not only by feelings of embarrassment in discussing sensitive problems, especially with male health professionals, but also the perceived embarrassment felt by doctors. Women reported a lack of available information in culturally sensitive media. Talk-based media were more highly valued than text-based media. Generational differences in help-seeking behaviour were apparent. CONCLUSIONS: This exploratory study provides valuable understanding of the continence needs of South Asian Indian women. Common needs were identified, as were important generational differences. Suggestions offered by women for the existing service improvement seemed relatively modest in terms of resources required.
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Pitchforth E, van Teijlingen E, Graham W, Fitzmaurice A (2007). Development of a proxy wealth index for women utilizing emergency obstetric care in Bangladesh.
Health Policy Plan,
22(5), 311-319.
Abstract:
Development of a proxy wealth index for women utilizing emergency obstetric care in Bangladesh.
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.
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van Teijlingen E, Pitchforth E (2007). Focusing the group.
RCM Midwives,
10(2), 78-80.
Author URL.
Eboh WO, Pitchforth E, van Teijlingen E (2007). Lost words: research via translation.
RCM Midwives,
10(8), 374-377.
Author URL.
van Teijlingen E, Pitchforth E, Bishop C, Russell E (2006). Delphi method and nominal group technique in family planning and reproductive health research.
J Fam Plann Reprod Health Care,
32(4), 249-252.
Author URL.
van Teijlingen E, Pitchforth E (2006). Focus group research in family planning and reproductive health care.
J Fam Plann Reprod Health Care,
32(1), 30-32.
Author URL.
Pitchforth E, van Teijlingen E, Graham W, Dixon-Woods M, Chowdhury M (2006). Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh.
Qual Saf Health Care,
15(3), 214-219.
Abstract:
Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh.
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.
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Kenyon S, Dixon-Woods M, Jackson CJ, Windridge K, Pitchforth E (2006). Participating in a trial in a critical situation: a qualitative study in pregnancy.
Qual Saf Health Care,
15(2), 98-101.
Abstract:
Participating in a trial in a critical situation: a qualitative study in pregnancy.
BACKGROUND: Randomised controlled trials of interventions in critical situations are necessary to establish safety and evaluate outcomes. Pregnant women have been identified as a potentially vulnerable population. OBJECTIVE: to explore women's experiences of being recruited to ORACLE, a randomised controlled trial of antibiotics in pre-term labour. METHODS: Twenty qualitative interviews were conducted with women who had participated in ORACLE. Analysis was based on the constant comparative method. RESULTS: Women gave prominence to the socioemotional aspects of their interactions with healthcare professionals in making decisions on trial participation. Comments on the quality of written and spoken information were generally favourable, but women's accounts suggest that the stressful nature of the situation affected their ability to absorb the information. Women generally had poor understanding of trial design and practices. The main motivation for trial participation was the possibility of an improved outcome for the baby. The second and less prominent motivation was the opportunity to help others, but this was conditional on there being no risks associated with trial participation. In judging the risks of participation, women seemed to draw on "common sense" understandings including a perception that antibiotics were risk free. DISCUSSION: Recruitment to trials in critical situations raises important questions. Future studies should explore how rigorous governance arrangements for trials, particularly in critical situations, can protect participants rather than relying on ideals of informed consent that may be impossible to achieve. Future research should include a focus on interactions between research candidates and professionals involved in recruitment.
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Pitchforth E (2006). Risk and everyday life.
SOCIOLOGICAL RESEARCH ONLINE,
11(3).
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Pitchforth E, van Teijlingen E (2005). International public health research involving interpreters: a case study from Bangladesh.
BMC Public Health,
5Abstract:
International public health research involving interpreters: a case study from Bangladesh.
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.
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van Teijlingen E, Pitchforth E, Porter M, Keenan KF (2005). Range of qualitative research - Reply.
JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE,
31(2), 165-+.
Author URL.
Guest G, Van Teijlingen E, Pitchforth E, Porter M, Keenan KF (2005). Range of qualitative research [4] (multiple letters). Journal of Family Planning and Reproductive Health Care, 31(2), 165-167.
Forrest Keenan K, van Teijlingen E, Pitchforth E (2005). The analysis of qualitative research data in family planning and reproductive health care.
J Fam Plann Reprod Health Care,
31(1), 40-43.
Author URL.
Pitchforth E, Porter M, van Teijlingen E, Forrest Keenan K (2005). Writing up and presenting qualitative research in family planning and reproductive health care.
J Fam Plann Reprod Health Care,
31(2), 132-135.
Author URL.
Pitchforth E, Russell E, Van der Pol M (2002). Access to specialist cancer care: is it equitable?.
Br J Cancer,
87(11), 1221-1226.
Abstract:
Access to specialist cancer care: is it equitable?
The first principle of the Calman-Hine report's recommendations on cancer services was that all patients should have access to a uniformly high quality of care wherever they may live. This study aimed to assess whether the uptake of chemotherapy for colorectal cancer varied by hospital type in Scotland. Hospitals were classified according to cancer specialisation rather than volume of patients. To indicate cancer specialisation, hospitals were classified as 'cancer centres', 'cancer units' and 'non-cancer' hospitals. Colorectal cancer cases were obtained from cancer registrations linked to hospital discharge data for the period January 1992 to December 1996. Multilevel logistic regression was used to model the binary outcome, namely whether or not a patient received chemotherapy within 6 months of first admission to any hospital. The results showed that patients admitted first to a 'non-cancer' hospital were less than half as likely to go on to receive chemotherapy as those first admitted to a cancer unit or centre (OR=0.28). This result was not explained by distance between hospital of first admission and nearest cancer centre, nor by increasing age or severity of illness. The study covers the period immediately preceding the introduction of the Calman-Hine report in Scotland and should serve as a baseline for future monitoring of access to specialist care.
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