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1.  Cost effectiveness of a web-based decision aid for parents deciding about MMR vaccination: a three-arm cluster randomised controlled trial in primary care 
The British Journal of General Practice  2014;64(625):e493-e499.
Levels of measles in England and Wales are at their highest for 18 years, and strategies targeting the different groups of parents who do not vaccinate their children continue to be needed. Decision aids for decisions regarding childhood immunisation appear to be effective in achieving an increase in vaccine uptake but their cost effectiveness is unknown.
To assess the cost effectiveness of a web-based decision aid to increase uptake of the MMR vaccine.
Design and setting
Economic evaluation conducted alongside a cluster randomised controlled trial using urban GP practices in the north of England.
Fifty GP practices in the north of England were randomised to one of three trial arms: decision aid, leaflet, usual practice. A total of 220 first-time parents (child aged 3–12 months) were recruited. Parents self-reported their contacts with the NHS and other previous/expected resource utilisation; associated costs were calculated. Vaccine-uptake data were collected from GP practices. A cost-effectiveness analysis was undertaken and provided the incremental cost per first-vaccine uptake. Multiple imputation was used to account for missing data and findings were adjusted for baseline differences in parents’ levels of decisional conflict regarding MMR vaccination.
Of the 220 first-time parents recruited to the study, 179 completed the baseline and post-intervention questionnaires. MMR uptake was highest for those receiving the decision aid (42 out of 42, 100%) versus usual practice (61 out of 62, 98%) and leaflet arm (69 out of 75, 92%), and was associated with lower cost (–£9.20 versus usual practice and –£7.17 versus leaflet).
The decision aid has a high chance of being cost effective, regardless of the value placed on obtaining additional vaccinations. It also appears to offer an efficient means of decision support for parents.
PMCID: PMC4111342  PMID: 25071062
cost effectiveness; decision aids; immunisation; MMR; vaccination
2.  UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): protocol for an exploratory, qualitative study 
BMJ Open  2015;5(6):e008564.
Gypsies, Travellers and Roma (referred to here as Travellers) experience significantly poorer health and have shorter life expectancy than the general population. They are also less likely to access health services including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. This study has two aims: (1) Investigate the barriers and facilitators to acceptability and uptake of immunisations among six Traveller communities in the UK; (2) Identify potential interventions to increase uptake in these Traveller communities.
Methods and analysis
A three-phase qualitative study with six Traveller communities. PHASE 1: In each community, we will explore up to 45 Travellers’ views about the influences on their immunisation behaviours and ideas for improving uptake in their community. PHASE 2: In each community, we will investigate 6–8 service providers’ perspectives on barriers and facilitators to childhood and adult immunisations for Traveller communities with whom they work, and ideas to improve uptake. Interview data will be analysed using the Framework approach. PHASE 3: The findings will be discussed and interventions prioritised in six workshops, each with 10–12 phase 1 and 3–4 phase 2 participants.
Ethics and dissemination
This research received approval from NRES Committee Yorkshire and The Humber-Leeds East (Ref. 13/YH/02). It will produce (1) findings on the barriers and facilitators to uptake of immunisations in six Traveller communities; (2) a prioritised list of potentially feasible and acceptable interventions for increasing uptake in these communities; and (3) methodological development in undertaking research with diverse Traveller communities. The study has the potential to inform new ways of delivering services to ensure high immunisation uptake. Findings will be disseminated to participants, relevant UK organisations with responsibility for the implementation of immunisation policy and Traveller health/welfare; and submitted for publication in academic journals.
Trial registration number
PMCID: PMC4466610  PMID: 26056124
gypsy; traveller; Roma; immunisation; vaccination
3.  Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial 
Trials  2014;15:509.
Urinary incontinence (UI) affects half of patients hospitalised after stroke and is often poorly managed. Cochrane systematic reviews have shown some positive impact of conservative interventions (such as bladder training) in reducing UI, but their effectiveness has not been demonstrated with stroke patients.
We conducted a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP) for the management of UI after stroke. Stroke services were randomised to receive SVP (n = 4), SVP plus supported implementation (SVP+, n = 4), or usual care (UC, n = 4).
Feasibility outcomes were participant recruitment and retention. The main effectiveness outcome was presence or absence of UI at six and 12 weeks post-stroke. Additional effectiveness outcomes included were the effect of the intervention on different types of UI, continence status at discharge, UI severity, functional ability, quality of life, and death.
It was possible to recruit patients (413; 164 SVP, 125 SVP+, and 124 UC) and participant retention was acceptable (85% and 88% at six and 12 weeks, respectively). There was no suggestion of a beneficial effect on the main outcome at six (SVP versus UC: odds ratio (OR) 0.94, 95% CI: 0.46 to 1.94; SVP+ versus UC: OR: 0.62, 95% CI: 0.28 to 1.37) or 12 weeks (SVP versus UC: OR: 1.02, 95% CI: 0.54 to 1.93; SVP+ versus UC: OR: 1.06, 95% CI: 0.54 to 2.09).
No secondary outcomes showed a strong suggestion of clinically meaningful improvement in SVP and/or SVP+ arms relative to UC at six or 12 weeks. However, at 12 weeks both intervention arms had higher estimated odds of continence than UC for patients with urge incontinence.
The trial has met feasibility outcomes of participant recruitment and retention. It was not powered to demonstrate effectiveness, but there is some evidence of a potential reduction in the odds of specific types of incontinence. A full trial should now be considered.
Trial registration
ISRCTN Registry, ISRCTN08609907, date of registration: 7 July 2010.
Electronic supplementary material
The online version of this article (doi:10.1186/1745-6215-15-509) contains supplementary material, which is available to authorized users.
PMCID: PMC4307223  PMID: 25539714
Cluster randomised controlled trial; Feasibility; Stroke; Urinary incontinence
4.  Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes 
In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain.
To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes.
Search methods
For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007. We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials.
Selection criteria
Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change.
Data collection and analysis
Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.
We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints.
Main results
We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.
Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions.
Authors’ conclusions
Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.
PMCID: PMC4164371  PMID: 20238340
Outcome and Process Assessment (Health Care) [*standards]; Professional Practice [*standards]; Randomized Controlled Trials as Topic; Humans
5.  The association between social capital and mental health and behavioural problems in children and adolescents: an integrative systematic review 
BMC psychology  2014;2(1):7.
Mental health is an important component of overall health and wellbeing and crucial for a happy and meaningful life. The prevalence of mental health problems amongst children and adolescent is high; with estimates suggesting 10-20% suffer from mental health problems at any given time. These mental health problems include internalising (e.g. depression and social anxiety) and externalising behavioural problems (e.g. aggression and anti-social behaviour). Although social capital has been shown to be associated with mental health/behavioural problems in young people, attempts to consolidate the evidence in the form of a review have been limited. This integrative systematic review identified and synthesised international research findings on the role and impact of family and community social capital on mental health/behavioural problems in children and adolescents to provide a consolidated evidence base to inform future research and policy development.
Nine electronic databases were searched for relevant studies and this was followed by hand searching. Identified literature was screened using review-specific inclusion/exclusion criteria, the data were extracted from the included studies and study quality was assessed. Heterogeneity in study design and outcomes precluded meta-analysis/meta-synthesis, the results are therefore presented in narrative form.
After screening, 55 studies were retained. The majority were cross-sectional surveys and were conducted in North America (n = 33); seven were conducted in the UK. Samples ranged in size from 29 to 98,340. The synthesised results demonstrate that family and community social capital are associated with mental health/behavioural problems in children and adolescents. Positive parent–child relations, extended family support, social support networks, religiosity, neighbourhood and school quality appear to be particularly important.
To date, this is the most comprehensive review of the evidence on the relationships that exist between social capital and mental health/behavioural problems in children and adolescents. It suggests that social capital generated and mobilised at the family and community level can influence mental health/problem behaviour outcomes in young people. In addition, it highlights key gaps in knowledge where future research could further illuminate the mechanisms through which social capital works to influence health and wellbeing and thus inform policy development.
Electronic supplementary material
The online version of this article (doi:10.1186/2050-7283-2-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4270040  PMID: 25566380
Family social capital; Community social capital; Children; Adolescents; Mental health; Wellbeing; Behavioural problems; Self-esteem; Internalising behaviours; Externalising behaviours
6.  Pilot trial of Stop Delirium! (PiTStop) - a complex intervention to prevent delirium in care homes for older people: study protocol for a cluster randomised controlled trial 
Trials  2014;15:47.
Delirium (or acute confusion) is a serious illness common in older people, in which a person’s thinking and perceptions may be affected. Reducing delirium is important because of the considerable distress it causes, and the poor outcomes associated with it, such as increased admissions to hospital, falls, mortality and costs to the National Health Service (NHS). Preventing delirium is possible using multicomponent interventions; successful interventions in hospitals have reduced it by one-third. However, there is little research to guide practice in care homes, where it is common because of the clustering of known risk factors (older age, frailty, and dementia). In previous work we developed a multicomponent intervention to prevent delirium in care homes, called Stop Delirium! The intervention was based upon evidence from the research literature relating to the prevention of delirium and on strategies to change professional practice. Before starting a large costly trial of Stop Delirium!, this pilot study will test and help improve the design and feasibility of the trial protocol.
We plan to conduct a cluster randomised pilot trial in 14 care homes (independent residential and nursing). Following recruitment of residents (over 60 years, consenting or with consultee agreement, able to communicate in English, and not in palliative care) participating homes will be randomised, stratified by size of home and proportion of residents with dementia. Stop Delirium! will be delivered to intervention homes over 16 months, with controls receiving usual care. The primary outcome measure will be the presence of delirium on any day during a one-month post-intervention period.
We will collect data to determine 1) recruitment and attrition rates, 2) feasibility of various outcomes measurements, and 3) feasibility of capturing health resource use (resident diaries and by examining health records). We will estimate the between-cluster variation for the primary outcome, delirium occurrence.
This pilot study will refine methods for the definitive trial. The lessons learnt will also contribute to implementing National Institute for Health and Clinical Excellence (NICE) delirium guidelines, which recommend multicomponent interventions for delirium prevention.
Trial registration
PMCID: PMC3923732  PMID: 24495514
Pilot; Feasibility; RCT; Complex intervention; Older people; Delirium; Care home
8.  The association between family and community social capital and health risk behaviours in young people: an integrative review 
BMC Public Health  2013;13:971.
Health risk behaviours known to result in poorer outcomes in adulthood are generally established in late childhood and adolescence. These ‘risky’ behaviours include smoking, alcohol and illicit drug use and sexual risk taking. While the role of social capital in the establishment of health risk behaviours in young people has been explored, to date, no attempt has been made to consolidate the evidence in the form of a review. Thus, this integrative review was undertaken to identify and synthesise research findings on the role and impact of family and community social capital on health risk behaviours in young people and provide a consolidated evidence base to inform multi-sectorial policy and practice.
Key electronic databases were searched (i.e. ASSIA, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Embase, Medline, PsycINFO, Sociological Abstracts) for relevant studies and this was complemented by hand searching. Inclusion/exclusion criteria were applied and data was extracted from the included studies. Heterogeneity in study design and the outcomes assessed precluded meta-analysis/meta-synthesis; the results are therefore presented in narrative form.
Thirty-four papers satisfied the review inclusion criteria; most were cross-sectional surveys. The majority of the studies were conducted in North America (n=25), with three being conducted in the UK. Sample sizes ranged from 61 to 98,340. The synthesised evidence demonstrates that social capital is an important construct for understanding the establishment of health risk behaviours in young people. The different elements of family and community social capital varied in terms of their saliency within each behavioural domain, with positive parent–child relations, parental monitoring, religiosity and school quality being particularly important in reducing risk.
This review is the first to systematically synthesise research findings about the association between social capital and health risk behaviours in young people. While providing evidence that may inform the development of interventions framed around social capital, the review also highlights key areas where further research is required to provide a fuller account of the nature and role of social capital in influencing the uptake of health risk behaviours.
PMCID: PMC4015354  PMID: 24138680
Family social capital; Community social capital; Children; Adolescents; Health risk behaviours; Wellbeing; Health
9.  Development of a theory-based instrument to identify barriers and levers to best hand hygiene practice among healthcare practitioners 
A theoretical approach to assessing the barriers and levers to evidence-based practice (EBP) with subsequent tailoring of theoretically informed strategies to address these may go some way to positively influencing the delay in implementing research findings into practice. Hand hygiene is one such example of EBP, chosen for this study due to its importance in preventing death through healthcare associated infections (HCAI). The development of an instrument to assess barriers and levers to hand hygiene and to allow the subsequent tailoring of theoretically informed implementation strategies is reported here.
A comprehensive list of barriers and levers to hand hygiene were categorised to the Theoretical Domains Framework (TDF) in a Delphi survey. These items formed the basis of an instrument that was tested to establish validity and reliability. The relationship between self-reported compliance with hand hygiene and barriers and levers to hand hygiene was also examined along with compliance according to where the barriers and levers fit within the domains of the TDF framework.
A 33-item instrument that tested well for internal consistency (α = 0.84) and construct validity (χ2/df = 1.9 [p < 0.01], RMSEA = 0.05 and CFA = 0.84) was developed. The relationship between self-reported compliance with hand hygiene moderately correlated with barriers identified by participants (total barrier score) (r = 0.41, n = 276, p <0.001). The greater the number of barriers reported, the lower the level of compliance. A one-way between groups multivariate analysis of variance was performed to investigate differences between those adopting high or low compliance with hand hygiene. Compliance was highest for this sample of participants among practitioners with high levels of motivation, strong beliefs about capabilities, when there were positive social influences, when hand hygiene was central to participants’ sense of professional identity and was easier to remember to do.
This study has produced encouraging findings suggesting the potential for improved hand hygiene and resulting effects on the human and financial costs of healthcare associated infection. This study identifies a further potential use for the TDF.
PMCID: PMC3850814  PMID: 24059289
Evidence-based practice; Implementation; Hand hygiene; Instrument; Barriers and levers; Psychological theory; Compliance
10.  Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study 
Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery.
We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data.
Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier.
Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices.
Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly.
Study registration
PMCID: PMC3766659  PMID: 24004917
Delirium; Prevention; Acute hospital care; Complex intervention; Implementation; Normalization process theory
11.  Factors influencing attendance at structured self-management education programs for diabetes 
There are several structured self-management education programs which are available nationally for patients with diabetes in the UK. This study was aimed to determine the factors influencing participation of patients with diabetes in the programs.
Patients and Methods:
A cross-sectional survey through semi-structured questionnaire distributed to 550 patients attending primary or secondary care diabetes services, as well to those in community venues, was conducted. The inclusion criteria were people ≥18 years with diabetes diagnosed for 1 year or longer.
There was a lack of awareness of the programs among the respondents. There were statistically significant differences between tendency to attend the programs with demographic variables, qualification, and self-efficacy. The results also indicated that an individual will be more likely to participate in the structured self-management education programs if she/he feels at risk of complications, that diabetes complications are serious, and believes that the programs may help to avoid these risks.
This study indicated the nature of multidimensionality of the factors influencing participation in the programs.
PMCID: PMC3730450  PMID: 23922593
Diabetes; participation; self-management education programs
12.  Communicating with parents about vaccination: a framework for health professionals 
BMC Pediatrics  2012;12:154.
A critical factor shaping parental attitudes to vaccination is the parent’s interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitant parent towards vaccine acceptance. Poor communication can contribute to rejection of vaccinations or dissatisfaction with care. We sought to provide a framework for health professionals when communicating with parents about vaccination.
Literature review to identify a spectrum of parent attitudes or ‘positions’ on childhood vaccination with estimates of the proportion of each group based on population studies. Development of a framework related to each parental position with determination of key indicators, goals and strategies based on communication science, motivational interviewing and valid consent principles.
Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%). The goals of the encounter with each group will vary, depending on the parents’ readiness to vaccinate. In all encounters, health professionals should build rapport, accept questions and concerns, and facilitate valid consent. For the hesitant, late or selective vaccinators, or refusers, strategies should include use of a guiding style and eliciting the parent’s own motivations to vaccinate while, avoiding excessive persuasion and adversarial debates. It may be necessary to book another appointment or offer attendance at a specialised adverse events clinic. Good information resources should also be used.
Health professionals have a central role in maintaining public trust in vaccination, including addressing parents’ concerns. These recommendations are tailored to specific parental positions on vaccination and provide a structured approach to assist professionals. They advocate respectful interactions that aim to guide parents towards quality decisions.
PMCID: PMC3480952  PMID: 22998654
13.  How can continuing professional development better promote shared decision-making? Perspectives from an international collaboration 
Shared decision-making is not widely implemented in healthcare. We aimed to set a research agenda about promoting shared decision-making through continuing professional development.
Thirty-six participants met for two days.
Participants suggested ways to improve an environmental scan that had inventoried 53 shared decision-making training programs from 14 countries. Their proposed research agenda included reaching an international consensus on shared decision-making competencies and creating a framework for accrediting continuing professional development initiatives in shared decision-making.
Variability in shared decision-making training programs showcases the need for quality assurance frameworks.
PMCID: PMC3154854  PMID: 21729310
14.  Randomised cluster trial to support informed parental decision-making for the MMR vaccine 
BMC Public Health  2011;11:475.
In the UK public concern about the safety of the combined measles, mumps and rubella [MMR] vaccine continues to impact on MMR coverage. Whilst the sharp decline in uptake has begun to level out, first and second dose uptake rates remain short of that required for population immunity. Furthermore, international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children. Together, this work suggests that effective interventions are required to support parents to make informed decisions about MMR.
This trial assessed the impact of a parent-centred, multi-component intervention (balanced information, group discussion, coaching exercise) on informed parental decision-making for MMR.
This was a two arm, cluster randomised trial. One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations. The intervention arm received an MMR information leaflet and participated in the intervention (parent meeting). The control arm received the leaflet only. The primary outcome was decisional conflict. Secondary outcomes were actual and intended MMR choice, knowledge, attitude, concern and necessity beliefs about MMR and anxiety.
Decisional conflict decreased for both arms to a level where an 'effective' MMR decision could be made one-week (effect estimate = -0.54, p < 0.001) and three-months (effect estimate = -0.60, p < 0.001) post-intervention. There was no significant difference between arms (effect estimate = 0.07, p = 0.215). Heightened decisional conflict was evident for parents making the MMR decision for their first child (effect estimate = -0.25, p = 0.003), who were concerned (effect estimate = 0.07, p < 0.001), had less positive attitudes (effect estimate = -0.20, p < 0.001) yet stronger intentions (effect estimate = 0.09, p = 0.006). Significantly more parents in the intervention arm reported vaccinating their child (93% versus 73%, p = 0.04).
Whilst both the leaflet and the parent meeting reduced parents' decisional conflict, the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake.
PMCID: PMC3144460  PMID: 21679432
15.  Study protocol: ICONS: Identifying continence options after stroke: A randomised trial 
Trials  2011;12:131.
Urinary incontinence following acute stroke is common, affecting between 40%-60% of people in hospital after a stroke. Despite the availability of clinical guidelines for urinary incontinence and urinary incontinence after stroke, national audit data suggest incontinence is often poorly managed. Conservative interventions (e.g. bladder training, pelvic floor muscle training and prompted voiding) have been shown to have some effect with participants in Cochrane systematic reviews, but have not had their effectiveness demonstrated with stroke patients.
A cluster randomised controlled pilot trial designed to assess the feasibility of a full-scale cluster randomised trial and to provide preliminary evidence of the effectiveness and cost-effectiveness of a systematic voiding programme for the management of continence after stroke. Stroke services will be randomised to receive the systematic voiding programme, the systematic voiding programme plus supported implementation, or usual care. The trial aims to recruit at least 780 participants in 12 stroke services (4 per arm). The primary outcome is presence/absence of incontinence at six weeks post-stroke. Secondary outcomes include frequency and severity of incontinence, quality of life and cost-utility. Outcomes will be measured at six weeks, three months and (for participants recruited in the first three months) twelve months after stroke. Process data will include rates of recruitment and retention and fidelity of intervention delivery. An integrated qualitative evaluation will be conducted in order to describe implementation and assist in explaining the potential mediators and modifiers of the process.
Trial Registration
PMCID: PMC3113990  PMID: 21599945
16.  Effective continuing professional development for translating shared decision making in primary care: A study protocol 
Shared decision making (SDM) is a process by which a healthcare choice is made jointly by the healthcare professional and the patient. SDM is the essential element of patient-centered care, a core concept of primary care. However, SDM is seldom translated into primary practice. Continuing professional development (CPD) is the principal means by which healthcare professionals continue to gain, improve, and broaden the knowledge and skills required for patient-centered care. Our international collaboration seeks to improve the knowledge base of CPD that targets translating SDM into the clinical practice of primary care in diverse healthcare systems.
Funded by the Canadian Institutes of Health Research (CIHR), our project is to form an international, interdisciplinary research team composed of health services researchers, physicians, nurses, psychologists, dietitians, CPD decision makers and others who will study how CPD causes SDM to be practiced in primary care. We will perform an environmental scan to create an inventory of CPD programs and related activities for translating SDM into clinical practice. These programs will be critically assessed and compared according to their strengths and limitations. We will use the empirical data that results from the environmental scan and the critical appraisal to identify knowledge gaps and generate a research agenda during a two-day workshop to be held in Quebec City. We will ask CPD stakeholders to validate these knowledge gaps and the research agenda.
This project will analyse existing CPD programs and related activities for translating SDM into the practice of primary care. Because this international collaboration will develop and identify various factors influencing SDM, the project could shed new light on how SDM is implemented in primary care.
PMCID: PMC2988066  PMID: 20977774
17.  Managing controversy through consultation: a qualitative study of communication and trust around MMR vaccination decisions 
Background: Controversy over the measles, mumps, and rubella (MMR) vaccine has reduced uptake, raising concerns of a future disease epidemic.
Aims: To explore parents' accounts of decision making relating to the MMR vaccine controversy, identifying uptake determinants and education needs.
Design of study: Qualitative interviews analysed using the ‘framework’ approach.
Setting: Five general practices in the Leeds area, 2002–2003.
Method: Sixty-nine interviews conducted with parents of children aged between 4 and 5 years, and 12 interviews with primary care practitioners, managers and immunisation coordinators serving participating sites. Participants were interviewed one-to-one in a place of their choice.
Results: The vaccination decision is primarily a function of parental assessments of the relative acceptability and likelihood of possible outcomes. For most parents the evidence of science and medicine plays little role in the decision. Although local general practitioners and health visitors are trusted information sources, the influence of primary care providers on the vaccination decision is limited by concerns over consultation legitimacy, discussion opportunity, and perceptions of financial and political partiality. Parents and practitioners identify a need for new approaches to support decisions and learning when faced with this and similar healthcare controversies. These include new collaborative approaches to information exchange designed to transform rather than supplant existing parent knowledge as part of an ongoing learning process.
Conclusion: The study identified new ways in which parents and practitioners need to be supported in order to increase understanding of medical science and secure more informed decisions in the face of health controversy.
PMCID: PMC1324804  PMID: 15239914
health services; managed care; measles-mumps-rubella vaccine; MMR vaccine; trust; vaccination
18.  Qualitative study of pilot payment aimed at increasing general practitioners' antismoking advice to smokers 
BMJ : British Medical Journal  2001;323(7310):432.
To elicit general practitioners' and practice nurses' accounts of changes in their clinical practice or practice organisation made to claim a pilot health promotion payment. To describe attitudes towards the piloted and previous health promotion payments.
Qualitative, semistructured interview study.
13 general practices in Leicester.
18 general practitioners and 13 practice nurses.
Health professionals did not report substantially changing their clinical practice to claim the new payments and made only minimal changes in practice organisation. The new health promotion payment did not overcome general practitioners' resistance towards raising the issue of smoking when they felt that doing so could cause confrontation with patients. General practitioners who made the largest number of claims altered the way in which they recorded patients' smoking status rather than raising the topic of smoking more frequently with patients. Participants had strong negative views on the new payment, feeling it would also be viewed negatively by patients. They were, however, more positive about health promotion payments that rewarded “extra” effort—for example, setting up practice based smoking cessation clinics.
General practitioners and practice nurses were negative about a new health promotion payment, despite agreeing to pilot it. Health promotion payments do not automatically generate effective health promotion activity, and policymakers should consider careful piloting and evaluation of future changes in health promotion payments.
What is already known on this topicHealth promotion payments have been made to UK general practitioners since 1990, but their effectiveness is unknownWhat this study addsPrimary care staff held strong negative views about the pilot payments to promote smoking cessation and previous health promotion paymentsThe highest claiming practitioners altered their methods of recording smoking status rather than increasing the frequency with which they advised patients against smokingFuture changes in health promotion payments should be carefully piloted
PMCID: PMC37556  PMID: 11520844

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