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1.  The swine flu vaccine, public attitudes, and researcher interpretations: a systematic review of qualitative research 
During pandemics, health authorities may be uncertain about the spread and severity of the disease and the effectiveness and safety of available interventions. This was the case during the swine flu (H1N1) pandemic of 2009–2010, and governments were forced to make decisions despite these uncertainties. While many countries chose to implement wide scale vaccination programmes, few accomplished their vaccination goals. Many research studies aiming to explore barriers and facilitators to vaccine uptake have been conducted in the aftermath of the pandemic, including several qualitative studies.
To explore public attitudes to the swine flu vaccine in different countries through a review of qualitative primary studies.To describe and discuss the implications drawn by the primary study authors.
Systematic review of qualitative research studies, using a broadly comparative cross case-study approach. Study quality was appraised using an adaptation of the Critical Appraisal Skills Programme (CASP) quality assessment tool.
The review indicates that the public had varying opinions about disease risk and prevalence and had concerns about vaccine safety. Most primary study authors concluded that participants were uninformed, and that more information about the disease and the vaccine would have led to an increase in vaccine uptake. We find these conclusions problematic. We suggest instead that people’s questions and concerns were legitimate given the uncertainties of the situation at the time and the fact that the authorities did not have the necessary information to convince the public. Our quality assessment of the included studies points to a lack of reflexivity and a lack of information about study context. We suggest that these study weaknesses are tied to primary study authors’ lack of acknowledgement of the uncertainties surrounding the disease and the vaccine.
While primary study authors suggest that authorities could increase vaccine uptake through increased information, we suggest instead that health authorities should be more transparent in their information and decision-making processes in future pandemic situations.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-016-1466-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4919843  PMID: 27338141
Pandemic; Swine flu; Vaccination; H1N1; Qualitative research; Systematic review; Reflexivity; Research context
2.  Using Qualitative Evidence in Decision Making for Health and Social Interventions: An Approach to Assess Confidence in Findings from Qualitative Evidence Syntheses (GRADE-CERQual) 
PLoS Medicine  2015;12(10):e1001895.
Simon Lewin and colleagues present a methodology for increasing transparency and confidence in qualitative research synthesis.
PMCID: PMC4624425  PMID: 26506244
3.  Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multi-perspective study 
In most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients.
Based on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.
The four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter.
Compared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes.
Trial Registration
Trial Registration number: NCT01374035
PMCID: PMC3751904  PMID: 23958371
Referral and consultation; Mental health; Health services; General practice; Group interview
4.  Scanning for satisfaction or digging for dismay? Comparing findings from a postal survey with those from a focus group-study 
Despite growing support for mixed methods approaches we still have little systematic knowledge about the consequences of combining surveys and focus groups. While the methodological aspects of questionnaire surveys have been researched extensively, the characteristics of focus group methodology are understudied. We suggest and discuss whether the focus group setting, as compared to questionnaire surveys, encourages participants to exaggerate views in a negative direction.
Based on an example from our own research, where we conducted a survey as a follow up of a focus group study, and with reference to theoretical approaches and empirical evidence from the literature concerning survey respondent behaviour and small group dynamics, we discuss the possibility that a discrepancy in findings between the focus groups and the questionnaire reflects characteristics of the two different research methods. In contrast to the survey, the focus group study indicated that doctors were generally negative to clinical guidelines. We were not convinced that this difference in results was due to methodological flaws in either of the studies, and discuss instead how this difference may have been the result of a general methodological phenomenon.
Based on studies of how survey questionnaires influence responses, it appears reasonable to claim that surveys are more likely to find exaggerated positive views. Conversely, there are some indications in the literature that focus groups may result in complaints and overly negative attitudes, but this is still an open question. We suggest that while problematic issues tend to be under-communicated in questionnaire surveys, they may be overstated in focus groups.
We argue for the importance of increasing our understanding of focus group methodology, for example by reporting interesting discrepancies in mixed methods studies. In addition, more experimental research on focus groups should be conducted to advance the methodology and to test our hypothesis.
PMCID: PMC3447657  PMID: 22943658
Research methodology; Focus groups; Qualitative; Surveys; Mixed methods; Primary care physicians; GPs
5.  General practitioners' experiences with sickness certification: a comparison of survey data from Sweden and Norway 
BMC Family Practice  2012;13:10.
In most countries with sickness insurance systems, general practitioners (GPs) play a key role in the sickness-absence process. Previous studies have indicated that GPs experience several tasks and situations related to sickness certification consultations as problematic. The fact that the organization of primary health care and social insurance systems differ between countries may influence both GPs' experiences and certification. The aim of the present study was to gain more knowledge of GPs' experiences of sickness certification, by comparing data from Sweden and Norway, regarding frequencies and aspects of sickness certification found to be problematic.
Statistical analyses of cross-sectional survey data of sickness certification by GPs in Sweden and Norway. In Sweden, all GPs were included, with 3949 (60.6%) responding. In Norway, a representative sample of GPs was included, with 221 (66.5%) responding.
Most GPs reported having consultations involving sickness certification at least once a week; 95% of the GPs in Sweden and 99% of the GPs in Norway. A majority found such tasks problematic; 60% of the GPs in Sweden and 53% in Norway. In a logistic regression, having a higher frequency of sickness certification consultations was associated with a higher risk of experiencing them as problematic, in both countries. A higher rate of GPs in Sweden than in Norway reported meeting patients wanting a sickness certification without a medical reason. GPs in Sweden found it more problematic to discuss the advantages and disadvantages of sick leave with patients and to issue a prolongation of a sick-leave period initiated by another physician. GPs in Norway more often worried that patients would go to another physician if they did not issue a certificate, and a higher proportion of Norwegian GPs found it problematic to handle situations where they and their patient disagreed on the need for sick leave.
The study confirms that many GPs experience sickness absence consultations as problematic. However, there were differences between the two countries in GPs' experiences, which may be linked to differences in social security regulations and the organization of GP services. Possible causes and consequences of national differences should be addressed in future studies.
PMCID: PMC3320536  PMID: 22375615
6.  Psychiatry out-of-hours: a focus group study of GPs' experiences in Norwegian casualty clinics 
For Norwegian general practitioners (GPs), acute treatment of mental illness and substance abuse are among the most commonly experienced emergency situations in out-of-hours primary healthcare. The largest share of acute referrals to emergency psychiatric wards occurs out-of-hours, and out-of-hours services are responsible for a disproportionately high share of compulsory referrals. Concerns exist regarding the quality of mental healthcare provided in the out-of-hours setting. The aim of this study was to explore which challenges GPs experience when providing emergency care out-of-hours to patients presenting problems related to mental illness or substance abuse.
We conducted a qualitative study based on two individual interviews and six focus groups with purposively sampled GPs (totally 45 participants). The interviews were analysed successively in an editing style, using a thematic approach based on methodological descriptions by Charmaz and Malterud.
Safety and uncertainty were the dominating themes in the discussions. The threat to personal safety due to unpredictable patient behaviour was a central concern, and present security precautions in the out-of-hours services were questioned. The GPs expressed high levels of uncertainty in their work with patients presenting problems related to mental illness or substance abuse. The complexity of the problems presented, shortage of time, limited access to reliable information and limited range of interventions available during out-of-hours contributed to this uncertainty. Perceived access to second opinion seemed to have a major impact on subjectively experienced work stress.
The GPs experienced out-of-hours psychiatry as a field with high levels of uncertainty and limited support to help them meet the experienced challenges. This might influence the quality of care provided. If the current organisation of emergency mental healthcare is to be kept, we need to provide GPs with a better support framework out-of-hours.
PMCID: PMC3127983  PMID: 21619608
7.  What about N? A methodological study of sample-size reporting in focus group studies 
Focus group studies are increasingly published in health related journals, but we know little about how researchers use this method, particularly how they determine the number of focus groups to conduct. The methodological literature commonly advises researchers to follow principles of data saturation, although practical advise on how to do this is lacking. Our objectives were firstly, to describe the current status of sample size in focus group studies reported in health journals. Secondly, to assess whether and how researchers explain the number of focus groups they carry out.
We searched PubMed for studies that had used focus groups and that had been published in open access journals during 2008, and extracted data on the number of focus groups and on any explanation authors gave for this number. We also did a qualitative assessment of the papers with regard to how number of groups was explained and discussed.
We identified 220 papers published in 117 journals. In these papers insufficient reporting of sample sizes was common. The number of focus groups conducted varied greatly (mean 8.4, median 5, range 1 to 96). Thirty seven (17%) studies attempted to explain the number of groups. Six studies referred to rules of thumb in the literature, three stated that they were unable to organize more groups for practical reasons, while 28 studies stated that they had reached a point of saturation. Among those stating that they had reached a point of saturation, several appeared not to have followed principles from grounded theory where data collection and analysis is an iterative process until saturation is reached. Studies with high numbers of focus groups did not offer explanations for number of groups. Too much data as a study weakness was not an issue discussed in any of the reviewed papers.
Based on these findings we suggest that journals adopt more stringent requirements for focus group method reporting. The often poor and inconsistent reporting seen in these studies may also reflect the lack of clear, evidence-based guidance about deciding on sample size. More empirical research is needed to develop focus group methodology.
PMCID: PMC3061958  PMID: 21396104
8.  Guidelines; from foe to friend? Comparative interviews with GPs in Norway and Denmark 
GPs follow clinical guidelines to varying degrees across practices, regions and countries, but a review study of GPs' attitudes to guidelines found no systematic variation in attitudes between studies from different countries. However, earlier qualitative studies on this topic are not necessarily comparable. Hence, there is a lack of empirical comparative studies of GP's attitudes to following clinical guidelines. In this study we reproduce a Norwegian focus group study of GPs' general attitudes to national clinical guidelines in Denmark and conduct a comparative analysis of the findings.
A strategic sample of GP's in Norway (27 GPs) and Denmark (18 GPs) was interviewed about their attitudes to guidelines, and the interviews coded and compared for common themes and differences.
Similarities dominated the comparative material, but the analysis also revealed notable differences in attitudes between Norwegian and the Danish GPs. The most important difference was related to GP's attitudes to clinical guidelines that incorporated economic evaluations. While the Norwegian GPs were sceptical to guidelines that incorporated economic evaluation, the Danish GPs regarded these guidelines as important and legitimate. We suggest that the differences could be explained by the history of guideline development in Norway and Denmark respectively. Whereas government guidelines for rationing services were only newly introduced in Norway, they have been used in Denmark for many years.
Comparative qualitative studies of GPs attitudes to clinical guidelines may reveal cross-national differences relating to the varying histories of guideline development. Further studies are needed to explore this hypothesis.
PMCID: PMC2827473  PMID: 20078891
9.  Thou shalt versus thou shalt not: a meta-synthesis of GPs' attitudes to clinical practice guidelines 
GPs' adherence to clinical practice guidelines is variable. Barriers to guideline implementation have been identified but qualitative studies have not been synthesised to explore what underpins these attitudes.
To explore and synthesise qualitative research on GPs' attitudes to and experiences with clinical practice guidelines.
Design of study
Systematic review and meta-synthesis of qualitative studies.
PubMed, CINAHL, EMBASE, Social Science Citation Index, and Science Citation Index were used as data sources, and independent data extraction was carried out. Discrepancies were resolved by consensus. Initial thematic analysis was conducted, followed by interpretative synthesis.
Seventeen studies met the inclusion criteria. Five were excluded following quality appraisal. Twelve papers were synthesised which reported research in the UK, US, Canada, and the Netherlands, and covered different clinical guideline topics. Six themes were identified: questioning the guidelines, GPs' experience, preserving the doctor–patient relationship, professional responsibility, practical issues, and guideline format. Comparative analysis and synthesis revealed that GPs' reasons for not following guidelines differed according to whether the guideline in question was prescriptive, in that it encouraged a certain type of behaviour or treatment, or proscriptive, in that it discouraged certain treatments or behaviours.
Previous analyses of guidelines have focused on professional attitudes and organisational barriers to adherence. This synthesis suggests that the purpose of the guideline, whether its aims are prescriptive or proscriptive, may influence if and how guidelines are received and implemented.
PMCID: PMC2084137  PMID: 18252073
attitudes of health personnel; general practice; guideline adherence; guidelines; meta-synthesis; qualitative research
10.  "What lies beneath it all?" – an interview study of GPs' attitudes to the use of guidelines 
General practitioners (GPs) adopt clinical practice guidelines to varying degrees. Several factors have been found to influence application of guidelines in practice and the GP is apparently the key actor. Studies are needed to increase our understanding of how GPs' attitudes influence their use of guidelines. In this study we explored GPs' attitudes to guidelines.
In 2007 we conducted six semi-structured group interviews with a purposive sample of 27 Norwegian GPs. The participants were encouraged to discuss guidelines they were familiar with, the evidence base of guidelines, professional autonomy and doctor-patient relations. We used thematic content analysis to extract central themes and arguments.
When deciding whether tfollow guideline recommendations, GPs consider whether guidelines are trustworthy, whether they suit patients and whether the recommended action is feasible. There were two important findings. First, the GP's were concerned that guidelines may be more heavily influenced by economic considerations than clinical ones. Second, in contrast to earlier findings, changes in recommendations and disagreement between experts were mostly viewed positively.
This study underscores the need for transparency in the process of development and implementation of guidelines. To enhance the use of guidelines, primary care physicians should be involved in the process of developing guidelines and the process should be transparent and explicit regarding the evidence base and economic considerations.
PMCID: PMC2577651  PMID: 18945360
11.  Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction 
Objective  This study investigates general practitioners’ (GPs) and patients’ attitudes to shared decision making, and how these attitudes affect patient satisfaction.
Background  Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients’ attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking.
Design  Questionnaire survey distributed through GPs.
Setting and participants  The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway.
Main variables studied  The data were collected using a nine‐item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP.
Results and conclusions  The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients’ needs and therefore satisfy patients even when the patient's attitude differs from the GPs’ attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.
PMCID: PMC5060341  PMID: 16677194
doctor–patient congruence; general practice; patient involvement; patient satisfaction; shared decision making
12.  Lay perceptions of evidence-based information – a qualitative evaluation of a website for back pain sufferers 
In an evidence-informed patient choice the patient has access to research-based information about the effectiveness of health care options and is encouraged to use this information in treatment decisions. This concept has seen growing popularity in recent years. However, we still know relatively little about users' attitudes to the use of research-based information, possibly because people have been unexposed to this type of information. After developing the BackInfo website where the results of Cochrane systematic reviews on the effects of low back pain were adapted and presented to lay users we evaluated how users responded to this information.
Focus group meetings were held with 18 chronic back pain sufferers, after they had been sent a link to the website before the meetings.
The focus groups suggest that the most important challenges to the use of BackInfo's research-based information are not primarily tied to the comprehension or presentation of the information, but are mainly associated with participants' attitudes towards the credibility of research and researchers, and the applicability of research results to themselves as individuals. Possible explanations for participants' lack of trust in research and their apparent difficulties in applying this research to their own situations include aspects that may be typical for the general public including the media's presentation of research, and a lack of familiarity with and feelings of distance to research evidence. Other aspects may be typical for patient groups with chronic and unclear medical conditions, such as a lack of trust in the health care establishment in general.
In order to enhance the credibility and applicability of research evidence, providers of research-based information could explore a number of possibilities including the use of including personal stories to illustrate the research outcomes.
PMCID: PMC1459152  PMID: 16539697
13.  "Saying no is no easy matter" A qualitative study of competing concerns in rationing decisions in general practice 
The general practitioner in Norway is expected to ensure equity and effectiveness through fair rationing. At the same time, due to recent reforms of the Norwegian health care sector, both the role of economic incentives and patient autonomy have been strengthened. Studies indicate that modern general practitioners, both in Norway and in other countries are uncomfortable with the gatekeeper role, but there is little knowledge about how general practitioners experience rationing in practice.
Through focus group interviews with Norwegian general practitioners, we explore physicians' attitudes toward factors of influence on medical decision making and how rationing dilemmas are experienced in everyday practice.
Four major concerns appeared in the group discussions: The obligation to ration health care, professional autonomy, patient autonomy, and competition. A central finding was that the physicians find rationing difficult because saying no in face to face relations often is felt uncomfortable and in conflict with other important objectives for the general practitioner.
It is important to understand the association between using economic incentives in the management of health care, increasing patient autonomy, and the willingness among physicians to contribute to efficient, fair and legitimate resource allocation.
PMCID: PMC1291367  PMID: 16281967

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