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1.  Risk of cardiovascular disease? A qualitative study of risk interpretation among patients with high cholesterol 
BMC Family Practice  2013;14:137.
Previous studies have shown the importance of paying attention to lay peoples’ interpretations of risk of disease, in order to explain health-related behavior. However, risk interpretations interplay with social context in complex ways. The objective was to explore how asymptomatic patients with high cholesterol interpret risk of cardiovascular disease.
Fourteen patients with high cholesterol and risk of cardiovascular disease were interviewed, and patterns across patient accounts were identified and analysed from an ethnographic approach.
Information from the general practitioner about high cholesterol and risk of cardiovascular disease was reinterpreted in everyday social life. The risk associated with fatty foods was weighed against the pleasures of social and cultural events in which this type of food was common and cherished.
A positive mindset was applied as a strategy to lower the risk of having high cholesterol, but knowledge about risk was viewed as a cause of anxiety and self-absorption, and this anxiety made the body susceptible to disease, hampering the chances for healthy life.
Interpretations of high cholesterol and risk of cardiovascular disease are embedded in social relations and everyday life concerns. This should be addressed in general practice in preference-sensitive cases about risk-reducing medication.
Trial registration NCT01187056
PMCID: PMC3850715  PMID: 24040920
Risk perception; Cardiovascular disease; High cholesterol; Qualitative research
2.  What professional activities do general practitioners find most meaningful? Cross sectional survey of Norwegian general practitioners 
BMC Family Practice  2013;14:41.
Health reforms in many countries affect the scope and nature of primary care. General Practitioners (GPs) are expected to spend more time developing public health, preventive health care, coordination of care and teamwork. We aimed to explore which professional activities GPs consider to be meaningful and how they would like to prioritise tasks.
In a cross sectional online survey 3,270 GPs were invited to consider twenty different activities in general practice. They were asked to rate each of them on a Likert scale anchored from 1 (not meaningful) to 5 (very meaningful). They then selected three activities from the item list on which they would like to spend more time and three activities on which they would like to spend less time. We used multinomial logistic regression to explore associations between the GPs’ preferences for time spent on preventive health care activities and age, gender and practice characteristics.
Approximately 40% (n=1,308) responded. The most meaningful activities were handling common symptoms and complaints (94% scored 4 or 5), chronic somatic diseases (93%), terminal care (80%), chronic psychiatric diseases (77%), risk conditions (76%) and on call emergency services (70%). In terms of priority the same items prevailed except that GPs would like to spend less time on emergency services. Items with low priority were health certificates, practice administration, meetings with local health authorities, medically unexplained symptoms, addiction medicine, follow up of people certified unfit for work, psychosocial problems, preventive health clinics for children and school health services. In multivariate regression models physician and practice characteristics explained no more than 10% of the variability in the GPs’ preferences for time spent on preventive health care services.
The GPs found diagnosis and treatment of diseases most meaningful. Their priorities were partly at odds with those of the health authorities and policy makers.
PMCID: PMC3615944  PMID: 23522393
Health priorities; Health care reforms; General practice
3.  Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT): protocol for a general practice-based cluster randomised trial 
BMC Family Practice  2010;11:69.
Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world. Brief interventions in health care consultations can be effective in changing single health behaviours. General Practice holds considerable potential for primary prevention through modifying patients' multiple risk behaviours, but feasible, acceptable and effective interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modeling and exploratory trials, we have developed an intervention called Behaviour Change Counselling (BCC) derived from Motivational Interviewing (MI). This paper describes the protocol for an evaluation of a training intervention (the Talking Lifestyles Programme) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours.
This cluster randomised controlled efficacy trial (RCT) will evaluate the outcomes and costs of this training intervention for General Practitioners (GPs) and nurses. Training methods will include: a practice-based seminar, online self-directed learning, and reflecting on video recorded and simulated consultations. The intervention will be evaluated in 29 practices in Wales, UK; two clinicians will take part (one GP and one nurse) from each practice. In intervention practices both clinicians will receive training. The aim is to recruit 2000 patients into the study with an expected 30% drop out. The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months. Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians. Economic and process evaluations will also be conducted.
Opportunistic engagement by health professionals potentially represents a cost effective medical intervention. This study integrates an existing, innovative intervention method with an innovative training model to enable clinicians to routinely use BCC, providing them with new tools to encourage and support people to make healthier choices. This trial will evaluate effectiveness in primary care and determine costs of the intervention.
Trial Registration
PMCID: PMC2955601  PMID: 20858273
4.  Ambivalence related to potential lifestyle changes following preventive cardiovascular consultations in general practice: A qualitative study 
BMC Family Practice  2008;9:50.
Motivational interviewing approaches are currently recommended in primary prevention and treatment of cardiovascular disease (CVD) in general practice in Denmark, based on an empirical and multidisciplinary body of scientific knowledge about the importance of motivation for successful lifestyle change among patients at risk of lifestyle related diseases. This study aimed to explore and describe motivational aspects related to potential lifestyle changes among patients at increased risk of CVD following preventive consultations in general practice.
Individual interviews with 12 patients at increased risk of CVD within 2 weeks after the consultation. Grounded theory was used in the analysis.
Ambivalence related to potential lifestyle changes was the core motivational aspect in the interviews, even though the patients rarely verbalised this experience during the consultations. The patients experienced ambivalence in the form of conflicting feelings about lifestyle change. Analysis showed that these feelings interacted with their reflections in a concurrent process. Analysis generated a typology of five different ambivalence sub-types: perception, demand, information, priority and treatment ambivalence.
Ambivalence was a common experience in relation to motivation among patients at increased risk of CVD. Five different ambivalence sub-types were found, which clinicians may use to explore and resolve ambivalence in trying to aid patients to adopt lifestyle changes. Future research is needed to explore whether motivational interviewing and other cognitive approaches can be enhanced by exploring ambivalence in more depth, to ensure that lifestyle changes are made and sustained. Further studies with a wider range of patient characteristics are required to investigate the generalisability of the results.
PMCID: PMC2564947  PMID: 18789155
5.  A randomised controlled trial of the effects of a web-based PSA decision aid, Prosdex. Protocol 
BMC Family Practice  2007;8:58.
Informed decision making is the theoretical basis in the UK for men's decisions about Prostate Specific Antigen (PSA) testing for prostate cancer testing. The aim of this study is to evaluate the effect of a web-based PSA decision-aid, Prosdex, on informed decision making in men. The objective is to assess the effect of Prosdex on six specific outcomes: (i) knowledge of PSA and prostate cancer-related issues – the principal outcome of the study; (ii) attitudes to testing; (iii) decision conflict; (iv) anxiety; (v) intention to undergo PSA testing; (vi) uptake of PSA testing. In addition, a mathematical simulation model of the effects of Prosdex will be developed.
A randomised controlled trial with four groups: two intervention groups, one viewing Prosdex and the other receiving a paper version of the site; two control groups, the second controlling for the potential Hawthorn effect of the questionnaire used with the first control group. Men between the ages of 50 and 75, who have not previously had a PSA test, will be recruited from General Practitioners (GPs) in Wales, UK. The principal outcome, knowledge, and four other outcome measures – attitudes to testing, decision conflict, anxiety and intention to undergo testing – will be measured with an online questionnaire, used by men in three of the study groups. Six months later, PSA test uptake will be ascertained from GP records; the online questionnaire will then be repeated. These outcomes, and particularly PSA test uptake, will be used to develop a mathematical simulation model, specifically to consider the impact on health service resources.
Trial registration
Current Controlled Trial: ISRCTN48473735.
PMCID: PMC2075498  PMID: 17916259
6.  Developing a facilitation model to promote organisational development in primary care practices 
BMC Family Practice  2006;7:38.
The relationship between effective organisation of general practices and health improvement is widely accepted. The Maturity Matrix is an instrument designed to assess organisational development in general practice settings and to stimulate quality improvement. It is undertaken by a practice team with the aid of a facilitator. There is a tradition in the primary care systems in many countries of using practice visitors to educate practice teams about how to improve. However the role of practice visitors as facilitators who enable teams to plan practice-led organisational development using quality improvement instruments is less well understood. The objectives of the study were to develop and explore a facilitation model to support practice teams in stimulating organisational development using a quality improvement instrument called the Maturity Matrix. A qualitative study based on transcript analysis was adopted.
A model of facilitation was constructed based on a review of relevant literature. Audio tapes of Maturity Matrix assessment sessions with general practices were transcribed and facilitator skills were compared to the model. The sample consisted of two facilitators working with twelve general practices based in UK primary care.
The facilitation model suggested that four areas describing eighteen skills were important. The four areas are structuring the session, obtaining consensus, handling group dynamics and enabling team learning. Facilitators effectively employed skills associated with the first three areas, but less able to consistently stimulate team learning.
This study suggests that facilitators need careful preparation for their role and practices need protected time in order to make best use of practice-led quality improvement instruments. The role of practice visitor as a facilitator is becoming important as the need to engender ownership of the quality improvement process by practices increases.
PMCID: PMC1526440  PMID: 16784540
7.  PSA testing for prostate cancer: an online survey of the views and reported practice of General Practitioners in the UK 
BMC Family Practice  2005;6:24.
The role of Prostate Specific Antigen (PSA) testing in the early detection of prostate cancer is controversial. Current UK policy stipulates that any man who wishes to have a PSA test should have access to the test, provided he has been given full information about the benefits and limitations of testing. This study aimed to determine UK GPs' current reported practice regarding PSA testing, and their views towards informed decision-making and PSA testing.
Online questionnaire survey, with a sample of 421 GPs randomly selected from a database of GPs across the UK.
95% (400/421) of GPs responded. 76% of GPs reported having performed a PSA test for an asymptomatic man at least once in the previous three months, with 13% reported having tested more than five men in this period. A majority of GPs reported they would do a PSA test for men presenting with a family history and requesting a test, for asymptomatic men requesting a test and also for men presenting with lower urinary tract symptoms. Reported testing rates were highest for men with a family history. Amongst men with lower urinary tract symptoms and men with no symptoms, reported testing rates were significantly higher for older than younger men.
The majority of GPs expressed support for the current policy (67%), and favoured both the general practitioner and the man being involved in the decision making process (83%). 90% of GPs indicated that they would discuss the benefits and limitation of testing with the man, with most (61%) preferring to ask the man to make a further appointment if he decides to be tested.
This study indicates that PSA testing in asymptomatic men is a regular occurrence in the UK, and that there is general support from GPs for the current policy of making PSA tests available to 'informed' men who are concerned about prostate cancer. While most GPs indicated they would discuss the benefits and limitations prior to PSA testing, and most GPs favoured a shared approach to decision making, it is not known to what extent men are actually being informed. Research is needed to evaluate the most effective approach to assisting men in making an informed decision about whether or not to have a PSA test.
PMCID: PMC1180431  PMID: 15946386
8.  Identifying future models for delivering genetic services: a nominal group study in primary care 
BMC Family Practice  2005;6:14.
To enable primary care medical practitioners to generate a range of possible service delivery models for genetic counselling services and critically assess their suitability.
Modified nominal group technique using in primary care professional development workshops.
37 general practitioners in Wales, United Kingdom too part in the nominal group process. The practitioners who attended did not believe current systems were sufficient to meet anticipated demand for genetic services. A wide range of different service models was proposed, although no single option emerged as a clear preference. No argument was put forward for genetic assessment and counselling being central to family practice, neither was there a voice for the view that the family doctor should become skilled at advising patients about predictive genetic testing and be able to counsel patients about the wider implications of genetic testing for patients and their family members, even for areas such as common cancers. Nevertheless, all the preferred models put a high priority on providing the service in the community, and often co-located in primary care, by clinicians who had developed expertise.
There is a need for a wider debate about how healthcare systems address individual concerns about genetic concerns and risk, especially given the increasing commercial marketing of genetic tests.
PMCID: PMC1087483  PMID: 15831099
9.  Measuring access to primary care appointments: a review of methods 
Patient access to primary care appointments is not routinely measured despite the increasing interest in this aspect of practice activity. The generation of standardised data (or benchmarks) for access could inform developments within primary care organisations and act as a quality marker for clinical governance. Logically the setting of targets should be based on a sound system of measurement. The practicalities of developing appropriate measures need debate. Therefore we aimed to search for and compare methods that have been published or are being developed to measure patient access to primary care appointments, with particular focus on finding methods using appointment system data.
A search and review was made of the primary care literature from 1990 to 2001, which included an assessment of online resources (websites) and communication with recognised experts. The identified methods were assessed.
The published literature in this specific area was not extensive but revealed emerging interest in the late 1990s. Two broad approaches to the measurement of waiting times to GP appointments were identified. Firstly, appointment systems in primary care organisations were analysed in differing ways to provide numerical data and, secondly, patient perceptions (reports) of access were evaluated using survey techniques. Six different methods were found which were based on appointment systems data.
The two approaches of either using patient questionnaires or appointment system data are methods that represent entirely different aims. The latter method when used to represent patient waiting times for 'routine' elective appointments seems to hold promise as a useful tool and this avoids the definitional problems that surround 'urgent' appointments. The purpose for which the data is being collected needs to be borne in mind and will determine the chosen methods of data retrieval and representation.
PMCID: PMC169167  PMID: 12846934
access; primary care; measurement; appointments; waiting times.

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