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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Oral Sex, Young People, and Gendered Narratives of Reciprocity
Young people in many countries report gender differences in giving and receiving oral sex, yet examination of young people’s own perspectives on gender dynamics in oral heterosex are relatively rare. We explored the constructs and discourses 16- to 18-year-old men and women in England used in their accounts of oral sex during in-depth interviews. Two contrasting constructs were in circulation in the accounts: on one hand, oral sex on men and women was narrated as equivalent, while on the other, oral sex on women was seen as “a bigger deal” than oral sex on men. Young men and women used a “give and take” discourse, which constructed the mutual exchange of oral sex as “fair.” Appeals to an ethic of reciprocity in oral sex enabled women to present themselves as demanding equality in their sexual interactions, and men as supporting mutuality. However, we show how these ostensibly positive discourses about equality also worked in narratives to obscure women’s constrained agency and work with respect to giving oral sex.
Does the evidence support global promotion of the calendar-based Standard Days Method® of contraception?
Objectives: To scrutinise claims about the effectiveness of the Standard Days Method® (SDM). The SDM is a calendar method with similarities to the rhythm method that has now been reclassified and is marketed as a modern contraceptive method. As promoted, it requires users to avoid unprotected intercourse on days 8-19 of the menstrual cycle. It is used in at least 100 countries. SDM has been researched, developed, and is marketed by the Institute of Reproductive Health (IRH) at Georgetown University, USA, and a for-profit company Cycle Technologies. SDM proponents say it is a major advance on traditional periodic abstinence, claiming that it is 95% effective when used correctly - rivalling pills and condoms. The effectiveness claim is repeated in recent documents from the World Health Organization. Study design: Evaluation of evidence obtained via literature review of published and unpublished reports. Results: Claims made for SDM effectiveness appear to rely on a single efficacy study where "correct use" of SDM was defined as total abstinence from intercourse in cycle days 8-19. It may therefore be misleading to apply a 95% effectiveness figure from the study to SDM as promoted, where abstinence is not required. Moreover, "typical use" effectiveness figures, cited as 88%, are based on an unrepresentative sample of women using SDM in ways likely to vary from how SDM is used in practice. Conclusion: Existing evidence does not support claims that the effectiveness of SDM as promoted is comparable to the best short-acting modern contraceptive methods. SDM is promoted in ways that may mislead users, by quoting overestimates of effectiveness and providing efficacy comparisons only with selected methods of contraception. Users should be provided with full and accurate information to make contraceptive choices. Implications Use, delivery and promotion of SDM should be reevaluated. Meanwhile, SDM should only be offered to family planning clients as an adaptation of traditional periodic abstinence methods, requiring total abstinence in fertile days - reflecting "correct use" in the efficacy study - to achieve high effectiveness. Delivery of any form of SDM should include presentation of the full range of other contraceptive methods, including the most effective options.
Community participation for transformative action on women’s, children’s and adolescents’ health
The Global strategy for women’s, children’s and adolescents’ health (2016-2030) recognizes that people have a central role in improving their own health. We propose that community participation, particularly communities working together with health services (co-production in health care), will be central for achieving the objectives of the global strategy. Community participation specifically addresses the third of the key objectives: to transform societies so that women, children and adolescents can realize their rights to the highest attainable standards of health and well-being. In this paper, we examine what this implies in practice. We discuss three interdependent areas for action towards greater participation of the public in health: improving capabilities for individual and group participation; developing and sustaining people-centred health services; and social accountability. We outline challenges for implementation, and provide policy-makers, programme managers and practitioners with illustrative examples of the types of participatory approaches needed in each area to help achieve the health and development goals.
Developing patient-centred care: An ethnographic study of patient perceptions and influence on quality improvement
Background: Understanding quality improvement from a patient perspective is important for delivering patient-centred care. Yet the ways patients define quality improvement remains unexplored with patients often excluded from improvement work. We examine how patients construct ideas of 'quality improvement' when collaborating with healthcare professionals in improvement work, and how they use these understandings when attempting to improve the quality of their local services. Methods: We used in-depth interviews with 23 'patient participants' (patients involved in quality improvement work) and observations in several sites in London as part of a four-year ethnographic study of patient and public involvement (PPI) activities run by Collaborations for Leadership in Applied Health Research and Care for Northwest London. We took an iterative, thematic and discursive analytical approach. Results: When patient participants tried to influence quality improvement or discussed different dimensions of quality improvement their accounts and actions frequently started with talk about improvement as dependent on collective action (e.g. multidisciplinary healthcare professionals and the public), but usually quickly shifted away from that towards a neoliberal discourse emphasising the role of individual patients. Neoliberal ideals about individual responsibility were taken up in their accounts moving them away from the idea of state and healthcare providers being held accountable for upholding patients' rights to quality care, and towards the idea of citizens needing to work on self-improvement. Participants portrayed themselves as governed by self-discipline and personal effort in their PPI work, and in doing so provided examples of how neoliberal appeals for self-regulation and self-determination also permeated their own identity positions. Conclusions: When including patient voices in measuring and defining 'quality', governments and public health practitioners should be aware of how neoliberal rationalities at the heart of policy and services may discourage consumers from claiming rights to quality care by contributing to public unwillingness to challenge the status quo in service provision. If the democratic potential of patient and public involvement initiatives is to be realised, it will be crucial to help citizens to engage critically with how neoliberal rationalities can undermine their abilities to demand quality care.
Patient and Public Involvement in Healthcare Quality Improvement: How organizations can help patients and professionals to collaborate
Abstract: Citizens across the world are increasingly called upon to participate in healthcare improvement. It is often unclear how this can be made to work in practice. This 4-year ethnography of a UK healthcare improvement initiative showed that patients used elements of organizational culture as resources to help them collaborate with healthcare professionals. The four elements were: (1) organizational emphasis on non-hierarchical, multidisciplinary collaboration; (2) organizational staff ability to model desired behaviours of recognition and respect; (3) commitment to rapid action, including quick translation of research into practice; and (4) the constant data collection and reflection process facilitated by improvement methods.
Anal heterosex among young people and implications for health promotion: A qualitative study in the UK
Objective: To explore expectations, experiences and circumstances of anal sex among young people. Design: Qualitative, longitudinal study using individual and group interviews. Participants: 130 men and women aged 16-18 from diverse social backgrounds. Setting: 3 contrasting sites in England (London, a northern industrial city, rural southwest). Results: Anal heterosex often appeared to be painful, risky and coercive, particularly for women. Interviewees frequently cited pornography as the 'explanation' for anal sex, yet their accounts revealed a complex context with availability of pornography being only one element. Other key elements included competition between men; the claim that ' people must like it if they do it' (made alongside the seemingly contradictory expectation that it will be painful for women); and, crucially, normalisation of coercion and 'accidental' penetration. It seemed that men were expected to persuade or coerce reluctant partners. Conclusions: Young people' s narratives normalised coercive, painful and unsafe anal heterosex. This study suggests an urgent need for harm reduction efforts targeting anal sex to help encourage discussion about mutuality and consent, reduce risky and painful techniques and challenge views that normalise coercion.
Bases, stages and 'working your way up': Young people's talk about non-coital practices and 'normal' sexual trajectories
While the symbolic importance of 'losing your virginity' has been described in many settings, meanings of non-coital sexual experiences, such as oral sex and hand-genital contact, are often missing from theorisation of sexual transitions. Drawing on data from a qualitative mixed methods study with young people aged 16-18 in England (the 'sixteen18 project'), we explore normative expectations about non-coital sex and sexual trajectories. Our study demonstrates how gendered talk about a 'normal order' of non-coital sexual activities 'leading to' vaginal intercourse contributes to a heteronormative discourse shaping sexual narratives and experiences long before first vaginal intercourse. Pre-coital sexual experiences were accounted for in terms of providing an opportunity for young men to develop and demonstrate sexual skill, for young women to be prepared for penetration by a penis and to learn to enjoy partnered sexual encounters, and for both sexes to develop the emotional intimacy required for first vaginal intercourse in a relationship. Prior to 'having sex', young people's talk about, and experience of, non-coital sexual activities helps circulate ideas about what 'proper' sex is, which sexual practices are valued and why, which skills are required and by whom, and whose pleasure is prioritised. If sexual health programmes are to challenge gendered inequalities in dominant assumptions about sex, non-coital sexual activities should be viewed as a legitimate area for discussion.
Effects of Community Participation on Improving Uptake of Skilled Care for Maternal and Newborn Health: A Systematic Review
Background: Despite a broad consensus that communities should be actively involved in improving their own health, evidence for the effect of community participation on specific health outcomes is limited. We examine the effectiveness of community participation interventions in maternal and newborn health, asking: did participation improve outcomes? We also look at how the impact of community participation has been assessed, particularly through randomised controlled trials, and make recommendations for future research. We highlight the importance of qualitative investigation, suggesting key areas for qualitative data reporting alongside quantitative work. Methods and findings: Systematic review of published and 'grey' literature from 1990. We searched 11 databases, and followed up secondary references. Main outcome measures were the use of skilled care before/during/after birth and maternal/newborn mortality/morbidity. We included qualitative and quantitative studies from any country, and used a community participation theoretical framework to analyse the data. We found 10 interventions. Community participation had largely positive impacts on maternal/newborn health as part of a package of interventions, although not necessarily on uptake of skilled care. Interventions improving mortality or use of skilled care raised awareness, encouraged dialogue and involved communities in designing solutions-but so did those showing no effect. Discussion: There are few high-quality, quantitative studies. We also lack information about why participation interventions do/do not succeed - an area of obvious interest for programme designers. Qualitative investigation can help fill this information gap and should be at the heart of future quantitative research examining participation interventions - in maternal/newborn health, and more widely. This review illustrates the need for qualitative investigation alongside RCTs and other quantitative studies to understand complex interventions in context, describe predicted and unforeseen impacts, assess potential for generalisability, and capture the less easily measurable social/political effects of encouraging participation. © 2013 Marston et al.
Increasing the Use of Skilled Health Personnel Where Traditional Birth Attendants Were Providers of Childbirth Care: A Systematic Review
Background: Improved access to skilled health personnel for childbirth is a priority strategy to improve maternal health. This study investigates interventions to achieve this where traditional birth attendants were providers of childbirth care and asks what has been done and what has worked? Methods and Findings: We systematically reviewed published and unpublished literature, searching 26 databases and contacting experts to find relevant studies. We included references from all time periods and locations. 132 items from 41 countries met our inclusion criteria and are included in an inventory; six were intervention evaluations of high or moderate quality which we further analysed. Four studies report on interventions to deploy midwives closer to communities: two studies in Indonesia reported an increase in use of skilled health personnel; another Indonesian study showed increased uptake of caesarean sections as midwives per population increased; one study in Bangladesh reported decreased risk of maternal death. Two studies report on interventions to address financial barriers: one in Bangladesh reported an increase in use of skilled health personnel where financial barriers for users were addressed and incentives were given to skilled care providers; another in Peru reported that use of emergency obstetric care increased by subsidies for preventive and maternity care, but not by improved quality of care. Conclusions: The interventions had positive outcomes for relevant maternal health indicators. However, three of the studies evaluate the village midwife programme in Indonesia, which limits the generalizability of conclusions. Most studies report on a main intervention, despite other activities, such as community mobilization or partnerships with traditional birth attendants. Many authors note that multiple factors including distance, transport, family preferences/support also need to be addressed. Case studies of interventions in the inventory illustrate how different countries attempted to address these complexities. Few high quality studies that measure effectiveness of interventions exist. © 2012 Vieira et al.
Survey of patient and public perceptions of electronic health records for healthcare, policy and research: Study protocol
Background: Immediate access to patients complete health records via electronic databases could improve healthcare and facilitate health research. However, the possible benefits of a national electronic health records (EHR) system must be balanced against public concerns about data security and personal privacy. Successful development of EHR requires better understanding of the views of the public and those most affected by EHR: users of the National Health Service. This study aims to explore the correlation between personal healthcare experience (including number of healthcare contacts and number and type of longer term conditions) and views relating to development of EHR for healthcare, health services planning and policy and health research. Methods/design. A multi-site cross-sectional self-complete questionnaire designed and piloted for use in waiting rooms was administered to patients from randomly selected outpatients clinics at a university teaching hospital (431 beds) and general practice surgeries from the four primary care trusts within the catchment area of the hospital. All patients entering the selected outpatients clinics and general practice surgeries were invited to take part in the survey during August-September 2011. Statistical analyses will be conducted using descriptive techniques to present respondents overall views about electronic health records and logistic regression to explore associations between these views and participants personal circumstances, experiences, sociodemographics and more specific views about electronic health records. Discussion. The study design and implementation were successful, resulting in unusually high response rates and overall recruitment (85.5%, 5336 responses). Rates for face-to-face recruitment in previous work are variable, but typically lower (mean 76.7%, SD 20). We discuss details of how we collected the data to provide insight into how we obtained this unusually high response rate. © 2012 Luchenski et al.; licensee BioMed Central Ltd.
Healthcare professionals' representations of 'patient and public involvement' and creation of 'public participant' identities: Implications for the development of inclusive and bottom-up community participation initiatives
Community participation is widely thought to be important in the improvement of healthcare delivery and in health equity. Yet there is little agreement about what 'participation' means in practice, or when it might be necessary. Drawing on the case of healthcare delivery in the UK, we examine key socio-psychological elements at the heart of community engagement with participatory processes. We explore the link between public participant identities and social representations of patient and public involvement (PPI) among healthcare professionals, and examine the role they play in supporting or undermining inclusive and bottom-up forms of PPI. The study is ethnographic, using in-depth interviews with public participants and healthcare professionals involved in PPI, and observation of PPI activities in London. We show that it is crucial to take account of more than individual participants' capacities in order to understand and improve PPI. Professionals' talk about PPI contains contradictory discourses about participant identity. These contradictions are reflected in involvees' self-understanding and experience as public participants, constraining their subjectivities and forms of knowledge, and crystallizing in their participatory practices. Involvees must negotiate professionals' negative discourses to develop self-images that reflect their own interests and projects, and that empower them to produce an effect in the public sphere. These processes can hinder successful participation even where there is an institutional infrastructure to promote civic engagement with healthcare. Understanding how involvees construct their own identities through engagement with professional discourses will help develop processes that are positive and enabling rather than negative and limiting. © 2011 John Wiley & Sons, Ltd..
Evaluating social and behavioural impacts of english smoke-free legislation in different ethnic and age groups: Implications for reducing smoking-related health inequalities
Objective To explore social and behavioural impacts of English smoke-free legislation (SFL) in different ethnic groups. Design A longitudinal, qualitative panel study of smokers using in-depth interviews conducted before and after introduction of SFL. Participants A purposive sample of 32 smokers selected from three ethnic groups in deprived London neighbourhoods with approximately equal numbers of younger and older, male and female respondents. Results SFL has had positive impacts with half smoking less and three quitting. Although there were no apparent differences in smoking and quitting behaviours between groups, there were notable differences in the social impacts of SFL. The greatest negative impacts were in smokers over 60 years, potentially increasing their social isolation, and on young Somali women whose smoking was driven more underground. In contrast, most other young adult smokers felt relatively unaffected by SFL, describing unexpected social benefits. Although there was high compliance, reports of illegal smoking were more frequent among young, ethnic minority smokers, with descriptions of venues involved suggesting they are ethnically distinct and well hidden. Half of respondents reported stopping smoking in their own homes after SFL, but almost all were Somali or Turkish. White respondents tended to report increases in home smoking. Discussion Although our study suggests that SFL can lead to reductions in tobacco consumption, it also shows that impacts vary by ethnicity, age and sex. This study highlights the importance of understanding the meaning of smoking in different social contexts so future tobacco control interventions can be developed to reduce health and social inequalities.
Factors associated with sexual risk behaviour among young people in ukraine
We used data from a behavioural survey of Ukrainian men and women aged 14-24 to examine the relationship between nine potential risk factors and two HIV risk outcomes: non-use of condom at last sex, and multiple sexual partnerships. Younger age at first sex was positively associated with both health risk outcomes, and condom non-use at first sex was associated with subsequent non-use of condoms at last sex. There were regional differences in frequencies of both HIV risk behaviours. Compared with those who reported living in the place they were born, not living permanently at the current place of residence was associated with a fivefold increase in the odds of multiple partnership for women but not for men. Alcohol and drug use were associated with higher odds of multiple partnership and the effect was greater among women than among men. The data analysed are cross-sectional so cannot establish causality. More studies are needed to confirm these results and investigate causal relationships between the possible risk factors and the two health risk behaviours.
Factors that shape young people's sexual behaviour: a systematic review
Background: Since nearly half of new HIV infections worldwide occur among young people aged 15-24 years, changing sexual behaviour in this group will be crucial in tackling the pandemic. Qualitative research is starting to reveal how social and cultural forces shape young people's sexual behaviour and can help explain why information campaigns and condom distribution programmes alone are often not enough to change it. We undertook a systematic review to identify key themes emerging from such research, to help inform policymakers developing sexual health programmes, and guide future research. Methods: We reviewed 268 qualitative studies of young people's sexual behaviour published between 1990 and 2004. We developed a method of comparative thematic analysis in which we coded each document according to themes they contained. We then identified relations between codes, grouping them accordingly into broader overall themes. Documents were classified as either primary or secondary depending on their quality and whether they contained empirical data. From the 5452 reports identified, we selected 246 journal articles and 22 books for analysis. Findings: Seven key themes emerged: young people assess potential sexual partners as "clean" or "unclean"; sexual partners have an important influence on behaviour in general; condoms are stigmatising and associated with lack of trust; gender stereotypes are crucial in determining social expectations and, in turn, behaviour; there are penalties and rewards for sex from society; reputations and social displays of sexual activity or inactivity are important; and social expectations hamper communication about sex. The themes do not seem to be exclusive to any particular country or cultural background, and all themes were present, in varying degrees, in all countries assessed. Interpretation: This study summarises key qualitative findings that help in understanding young people's sexual behaviour and why they might have unsafe sex; policymakers must take these into account when designing HIV programmes. Considerable overlap exists between current studies, which indicates the need to broaden the scope of future work. © 2006 Elsevier Ltd. All rights reserved.
Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: Repeated cross sectional surveys
Objective: To examine the impact on contraceptive practice of making emergency hormonal contraception available over the counter. Design: Analysis of data on contraceptive practice for women aged 16-49 years in the period 2000-2 from the Omnibus Survey, a multipurpose survey in which around 7600 adults living in private households are interviewed each year. Setting Private households in Great Britain. Main outcome measures: Use of different types of contraception and rates of unprotected sex. Results: After emergency hormonal contraception was made available over the counter, levels of use of different types of contraception by women aged 16-49 remained similar. No significant change occurred in the proportion of women using emergency hormonal contraception (8.4% in 2000,7.9% in 2001, 7.2% in 2002) or having unprotected sex. A change did, however, occur in where women obtained emergency hormonal contraception; a smaller proportion of women obtained emergency hormonal contraception from physicians and a greater proportion bought it over the counter. No significant change occurred in the proportion of women using more reliable methods of contraception, such as the oral contraceptive pill, or in the proportion of women using emergency hormonal contraception more than once during a year. Conclusions: Making emergency hormonal contraception available over the counter does not seem to have led to an increase in its use, to an increase in unprotected sex, or to a decrease in the use of more reliable methods of contraception.
What is heterosexual coercion? Interpreting narratives from young people in Mexico City
Freedom from sexual coercion is frequently cited as essential for good sexual health. Sexual experiences cannot usually be observed directly, and interpretation of interview data is therefore crucial in our understanding of sexual behaviour. This paper explores the ways in which narratives can be used to understand sexual experiences, using coercion as a specific example. The narratives examined are from interviews with young people in low-income areas of Mexico City. This study demonstrates that sexual coercion is impossible to define objectively. In addition, the concept of coercion is focused too much on women, excluding men's negative sexual experiences, and can include events that the 'victims' do not see as coercive. Coercion is a highly subjective and fluid concept, limiting its value as a defining element of sexual health. An alternative way of conceptualising coercive experiences is suggested. © Blackwell Publishing Ltd/Editorial Board 2005.