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Narrative Research in Health and Illness
This comprehensive book celebrates the coming of age of narrative in health care. It uses narrative to go beyond the patient's story and address social, cultural, ethical, psychological, organizational and linguistic issues. This book has been written to help health professionals and social scientists to use narrative more effectively in their everyday work and writing. The book is split into three, comprehensive sections; Narratives, Counter-narratives and Meta-narratives.
Understanding barriers to healthy lifestyles in a Bangladeshi community
This article summarises the findings from a large qualitative study in east London. In a series of focus groups involving 147 people, the team explored the perceptions of the Bangladeshi community towards diabetes prevention and healthy living, sought advice from religious leaders and Islamic scholars, and asked healthcare professionals about their experiences of giving lifestyle advice to this target audience. The authors highlight key findings that are particularly relevant to diabetes nurses, and suggest some practical changes that might be implemented by nurses working with people of Bangladeshi origin.
Community based yoga classes for type 2 diabetes: An exploratory randomised controlled trial
Background. Yoga is a popular therapy for diabetes but its efficacy is contested. The aim of this study was to explore the feasibility of researching community based yoga classes in Type 2 diabetes with a view to informing the design of a definitive, multi-centre trial. Methods. The study design was an exploratory randomised controlled trial with in-depth process evaluation. The setting was two multi-ethnic boroughs in London, UK; one with average and one with low mean socio-economic deprivation score. Classes were held at a sports centre or GP surgery. Participants were 59 people with Type 2 diabetes not taking insulin, recruited from general practice lists or opportunistically by general practice staff. The intervention group were offered 12 weeks of a twice-weekly 90-minute yoga class; the control group was a waiting list for the yoga classes. Both groups received advice and leaflets on healthy lifestyle and were encouraged to exercise. Primary outcome measure was HbA1c. Secondary outcome measures included attendance, weight, waist circumference, lipid levels, blood pressure, UKPDS cardiovascular risk score, diabetes-related quality of life (ADDQoL), and self-efficacy. Process measures were attendance at yoga sessions, self-reported frequency of practice between taught sessions, and qualitative data (interviews with patients and therapists, ethnographic observation of the yoga classes, and analysis of documents including minutes of meetings, correspondence, and exercise plans). Results. Despite broad inclusion criteria, around two-thirds of the patients on GP diabetic registers proved ineligible, and 90% of the remainder declined to participate. Mean age of participants was 60 +/- 10 years. Attendance at yoga classes was around 50%. Nobody did the exercises regularly at home. Yoga teachers felt that most participants were unsuitable for 'standard' yoga exercises because of limited flexibility, lack of basic fitness, co-morbidity, and lack of confidence. There was a small fall in HbA1c in the yoga group which was not statistically significant and which was not sustained six months later, and no significant change in other outcome measures. Conclusion. The benefits of yoga in type 2 diabetes suggested in some previous studies were not confirmed. Possible explanations (apart from lack of efficacy) include recruitment challenges; practical and motivational barriers to class attendance; physical and motivational barriers to engaging in the exercises; inadequate intensity and/or duration of yoga intervention; and insufficient personalisation of exercises to individual needs. All these factors should be considered when designing future trials. Trial registration. National Research Register (1410) and Current Controlled Trials (ISRCTN63637211).
Evidence-based policymaking: A critique
The idea that policy should be based on best research evidence might appear to be self-evident. But a closer analysis reveals a number of problems and paradoxes inherent in the concept of "evidence-based policymaking. "The current conflict over evidence-based policymaking parallels a long-standing "paradigm war" in social research between positivist, interpretivist, and critical approaches. This article draws from this debate in order to inform the discussions over the appropriateness of evidence-based policymaking and the related question of what is the nature of policymaking. The positivist, empiricist worldview that underpins the theory and practice of evidence-based medicine (EBM) fails to address key elements of the policymaking process. In particular, a narrowly "evidence-based" framing of policymaking is inherently unable to explore the complex, context-dependent, and value-laden way in which competing options are negotiated by individuals and interest groups. Sociolinguistic tools such as argumentation theory offer opportunities for developing richer theories about how policymaking happens. Such tools also have potential practical application in the policymaking process: by enhancing participants' awareness of their own values and those of others, the quality of the collective deliberation that lies at the heart of policymaking may itself improve. © 2009 by The Johns Hopkins University Press.
Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study.
OBJECTIVE: To explore ethnic stereotypes of UK medical students in the context of academic underachievement of medical students from ethnic minorities. DESIGN: Qualitative study using semistructured one to one interviews and focus groups. SETTING: A London medical school. PARTICIPANTS: 27 year 3 medical students and 25 clinical teachers, purposively sampled for ethnicity and sex. METHODS: Data were analysed using the theory of stereotype threat (a psychological phenomenon thought to negatively affect the performance of people from ethnic minorities in educational contexts) and the constant comparative method. RESULTS: Participants believed the student-teacher relationship was vital for clinical learning. Teachers had strong perceptions about "good" clinical students (interactive, keen, respectful), and some described being aggressive towards students whom they perceived as quiet, unmotivated, and unwilling. Students had equally strong perceptions about "good" clinical teachers (encouraging, interested, interactive, non-aggressive). Students and teachers had concordant and well developed perceptions of the "typical" Asian clinical medical student who was considered over-reliant on books, poor at communicating with patients, too quiet during clinical teaching sessions, and unmotivated owing to being pushed into studying medicine by ambitious parents. Stereotypes of the "typical" white student were less well developed: autonomous, confident, and outgoing team player. Direct discrimination was not reported. CONCLUSIONS: Asian clinical medical students may be more likely than white students to be perceived stereotypically and negatively, which may reduce their learning by jeopardising their relationships with teachers. The existence of a negative stereotype about their group also raises the possibility that underperformance of medical students from ethnic minorities may be partly due to stereotype threat. It is recommended that clinical teachers be given opportunities and training to encourage them to get to know their students as individuals and thus foster positive educational relationships with them.
Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: Qualitative study
Objective: To explore ethnic stereotypes of UK medical students in the context of academic underachievement of medical students from ethnic minorities. Design: Qualitative study using semistructured one to one interviews and focus groups. Setting A London medical school. Participants: 27 year 3 medical students and 25 clinical teachers, purposively sampled for ethnicity and sex. Methods: Data were analysed using the theory of stereotype threat (a psychological phenomenon thought to negatively affect the performance of people from ethnic minorities in educational contexts) and the constant comparative method. Results: Participants believed the student-teacher relationship was vital for clinical learning. Teachers had strong perceptions about "good" clinical students (interactive, keen, respectful), and some described being aggressive towards students whom they perceived as quiet, unmotivated, and unwilling. Students had equally strong perceptions about "good" clinical teachers (encouraging, interested, interactive, non-aggressive). Students and teachers had concordant and well developed perceptions of the "typical" Asian clinical medical student who was considered over-reliant on books, poor at communicating with patients, too quiet during clinical teaching sessions, and unmotivated owing to being pushed into studying medicine by ambitious parents. Stereotypes of the "typical" white student were less well developed: autonomous, confident, and outgoing team player. Conclusions: Asian clinical medical students may be more likely than white students to be perceived stereotypically and negatively, which may reduce their learning by jeopardising their relationships with teachers. The existence of a negative stereotype about their group also raises the possibility that underperformance of medical students from ethnic minorities may be partly due to stereotype threat. It is recommended that clinical teachers be given opportunities and training to encourage them to get to know their students as individuals and thus foster positive educational relationships with them.
Introduction of shared electronic records: multi-site case study using diffusion of innovation theory.
OBJECTIVE: To explore the introduction of a centrally stored, shared electronic patient record (the summary care record (SCR)) in England and draw wider lessons about the implementation of large scale information technology projects in health care. DESIGN: Multi-site, mixed method case study applying utilisation focused evaluation. SETTING: Four early adopter sites for the SCR in England-three in urban areas of relative socioeconomic deprivation and the fourth in a relatively affluent rural area. Data sources and analysis Data included 250 staff interviews, 1500 hours of ethnographic observation, interviews and focus groups with 170 patients and carers, 2500 pages of correspondence and documentary evidence, and incorporation of relevant surveys and statistics produced by others. These were analysed by using a thematic approach drawing on (and extending) a theoretical model of complex change developed in a previous systematic review. Main findings The mixed fortunes of the SCR programme in its first year were largely explained by eight interacting influences. The first was the SCR's material properties (especially technical immaturity and lack of interoperability) and attributes (especially the extent to which potential adopters believed the benefits outweighed the risks). The second was adopters' concerns (especially about workload and the ethicality of sharing "confidential" information on an implied consent model). The third influence was interpersonal influence (for example, opinion leaders, champions, facilitators), and the fourth was organisational antecedents for innovation (for example past experience with information technology projects, leadership and management capacity, effective data capture systems, slack resources). The fifth was organisational readiness for the SCR (for example, innovation-system fit, tension for change, power balances between supporters and opponents, baseline data quality). The sixth was the implementation process (including the nature of the change model and the extent to which new routines associated with the SCR aligned with existing organisational routines). The seventh influence was the nature and quality of links between different parts of the system, and the final one was the wider environment (especially the political context of the programme). CONCLUSION: Shared electronic records are not plug-in technologies. They are complex innovations that must be accepted by individual patients and staff and also embedded in organisational and inter-organisational routines. This process is heavily influenced at the micro-level by the material properties of the technology, individuals' attitudes and concerns, and interpersonal influence; at the meso-level by organisational antecedents, readiness, and operational aspects of implementation; and at the macro-level by institutional and socio-political forces. A case study approach and multi-level theoretical analysis can illuminate how contextual factors shape, enable, and constrain new, technology supported models of patient care.
Prevention of type 2 diabetes in British Bangladeshis: Qualitative study of community, religious, and professional perspectives
Objective: To understand lay beliefs and attitudes, religious teachings, and professional perceptions in relation to diabetes prevention in the Bangladeshi community. Design: Qualitative study (focus groups and semistructured interviews). Setting: Tower Hamlets, a socioeconomically deprived London borough, United Kingdom. Participants: Bangladeshi people without diabetes (phase 1), religious leaders and Islamic scholars (phase 2), and health professionals (phase 3). Methods: 17 focus groups were run using purposive sampling in three sequential phases. Thematic analysis was used iteratively to achieve progressive focusing and to develop theory. To explore tensions in preliminary data fictional vignettes were created, which were discussed by participants in subsequent phases. The PEN-3 multilevel theoretical framework was used to inform data analysis and synthesis. Results: Most lay participants accepted the concept of diabetes prevention and were more knowledgeable than expected. Practical and structural barriers to a healthy lifestyle were commonly reported. There was a strong desire to comply with cultural norms, particularly those relating to modesty. Religious leaders provided considerable support from Islamic teachings for messages about diabetes prevention. Some clinicians incorrectly perceived Bangladeshis to be poorly informed and fatalistic, although they also expressed concerns about their own limited cultural understanding. Conclusion: Contrary to the views of health professionals and earlier research, poor knowledge was not the main barrier to healthy lifestyle choices. The norms and expectations of Islam offer many opportunities for supporting diabetes prevention. Interventions designed for the white population, however, need adaptation before they will be meaningful to many Bangladeshis. Religion may have an important part to play in supporting health promotion in this community. The potential for collaborative working between health educators and religious leaders should be explored further and the low cultural understanding of health professionals addressed.
What Seems to be the Trouble? Stories in Illness and Healthcare
(The Nuffield Trust) University College London, UK. Adopts a narrative approach to medicine and supports the 'stories' with evidence-based theory by concentrating on the illness and healing process rather than the purely clinical aspects of ...
Using the online environment in assessment for learning: A case-study of a web-based course in primary care
The development of e-learning has opened up new opportunities for innovation in assessment practices in higher education. This descriptive case study draws upon staff and student experiences of teaching and learning on a web-based Masters programme in primary health care to explore how specific features of the online environment can be exploited to promote assessment as part of learning. It begins by identifying different ways of conceptualising assessment in order to highlight the fundamental value choices facing those developing and delivering assessment systems, and then describes our own approach to assessment. In the second part of the paper we explore two key ways in which the online learning environment enables assessment to contribute to learning-through its potential to support collaborative learning, and through facilitating high quality feedback between teachers and students. © 2006 Taylor & Francis.
Promoting the skills of knowledge translation in an online master of science course in primary health care.
We present 4 key arguments: (1) knowledge translation requires tacit and explicit knowledge that must be introduced into the organization as well as simply acquired by individuals; (2) educating for knowledge translation must go beyond conveying facts and developing capability; (3) a constructivist and collaborative approach to education can address the needs of learners for knowledge translation; and (4) the online environment, if appropriately used, has many useful features for supporting constructivist and collaborative learning. We illustrate these arguments with reference to a part-time online master of science course whose learners are mostly senior health care professionals engaged in knowledge translation.
"You have to cover up the words of the doctor": The mediation of trust in interpreted consultations in primary care
Purpose - This article explores issues of trust in narratives of interpreted consultations in primary health care. Design/methodology/approach - The paper is based on empirical data from a qualitative study of accounts of interpreted consultations in UK primary care, undertaken in three north London boroughs. In a total of 69 individual interviews and two focus groups, narratives of interpreted consultations were sought from 18 service users, 17 professional interpreters, nine family member interpreters, 13 general practitioners, 15 nurses, eight receptionists, and three practice managers. The study collected and analysed these using a grounded theory approach and taking the story as the main unit of analysis. It applies a theoretical model that draws on three key concepts: Greener's taxonomy of trust based on the different "faces" of power in medical consultations; Weber's notion of bureaucratic vs traditional social roles; and Habermas' distinction between communicative and strategic action. Findings - Trust was a prominent theme in almost all the narratives. The triadic nature of interpreted consultations creates six linked trust relationships (patient-interpreter, patient-clinician, interpreter-patient, interpreter-clinician, clinician-patient and clinician-interpreter). Three different types of trust are evident in these different relationships - voluntary trust (based on either kinship-like bonds and continuity of the interpersonal relationship over time, or on confidence in the institution and professional role that the individual represents), coercive trust (where one person effectively has no choice but to trust the other, as when a health problem requires expert knowledge that the patient does not have and cannot get) and hegemonic trust (where a person's propensity to trust, and awareness of alternatives, is shaped and constrained by the system so that people trust without knowing there is an alternative). These different types of trust had important implications for the nature of communication in the consultation and on patients' subsequent action. Research limitations/implications - The methodological and analytic approach, potentially, has wider applications in the study of other trust relationships in health and social care. Practical implications - Quality in the interpreted consultation cannot be judged purely in terms of accuracy of translation. The critical importance of voluntary trust for open and effective communication, and the dependence of the latter on a positive interpersonal relationship and continuity of care, should be acknowledged in the design and funding of interpreting services and in the training of both clinicians, interpreters and administrative staff. Originality/value - This is the first study in which interpreted consultations have been analysed from a perspective of critical sociology with a particular focus on trust and power relations. © Emerald Group Publishing Limited.
Involving service users in the evaluation and redesign of primary care services for depression: A qualitative study
Aim: To understand the experiences, expectations and needs of service users with mild to moderate depression, and to use these to inform the design and redesign of local services in primary care. Design of study: Needs assessment using in-depth semi-structured qualitative interviews. Setting: A single general practice in eastern England. Methods: Nine patients with depression were identified from the practice register using purposeful sampling and interviewed by a practice nurse who had not previously provided any care to them. Ritchie and Spencer's Framework approach was used to analyse the qualitative data. Results: Participants welcomed the opportunity to provide feedback on their experiences. They told many positive stories which affirmed the overall accessibility and acceptability of the existing service. They reported symptoms that were distressing and difficult to live with, even when their depression was classified by health professionals as 'mild'. Participants considered they had good access to care. Despite this, many participants identified gaps in the current service such as access to information and concerns about discontinuing medication in the future. Conclusion: In-depth interviews with patients with depression are a feasible and acceptable way of identifying service gaps and enabling users to contribute to service evaluation and redesign. © 2005 Librapharm Limited.