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NIHR
Soft networks for bridging the gap between research and practice: Illuminative evaluation of CHAIN
Objectives: To explore the process of knowledge exchange in an informal email network for evidence based health care, to illuminate the value of the service and its critical success factors, and to identify areas for improvement. Design: Illuminative evaluation. Setting: Targeted email and networking service for UK healthcare practitioners and researchers. Participants: 2800 members of a networking service. Main outcome measures: Tracking of email messages, interviews with core staff, and a qualitative analysis of messages, postings from focus groups, and invited and unsolicited feedback to the service. Results: The informal email network helped to bridge the gap between research and practice by serving as a rich source of information, providing access to members' experiences, suggestions, and ideas, facilitating cross boundary collaboration, and enabling participation in networking at a variety of levels. Ad hoc groupings and communities of practice emerged spontaneously as members discovered common areas of interest. Conclusion: This study illuminated how knowledge for evidence based health care can be targeted, personalised, and made meaningful through informal social processes. Critical success factors include a broad based membership from both the research and service communities; a loose and fluid network structure; tight targeting of messages based on members' interests; the presence of a strong network identity and culture of reciprocity; and the opportunity for new members to learn through passive participation.
Primary Health Care: Theory and Practice
General practitioners and other primary care professionals have a leading role in contemporary health care, which Trisha Greenhalgh explores in this highly praised new text. She provides perceptive and engaging insights into primary health care, focussing on: • its intellectual roots • its impact on the individual, the family and the community • the role of the multidisciplinary team • contemporary topics such as homelessness, ethnic health and electronic records. Concise summaries, highlighted boxes, extensive referencing and a dedicated section on effective learning make this essential reading for postgraduate students, tutors and researchers in primary care. From the foreword by Julian Tudor Hart "Trish Greenhalgh, in her frequent columns in the British Medical Journal...more than any other medical journalist spoke to her fellow GPs in the language of experience, but never without linking this to our expanding knowledge from the whole of human science. When I compare the outlines of primary care so lucidly presented in this wonderful book, obviously derived from rich experience of real teaching and learning, with the grand guignol theatre of London medical schools when I was a student 1947-52, the advance is stunning." "Trish Greenhalgh is one of the international stars of general practice and a very clever thinker. This new book is a wonderful resource for primary health care and general practice. Every general practice registrar should read this book and so should every general practice teacher and primary care researcher." Professor Michael Kidd, Head of the Department of General Practice, University of Sydney and Immediate Past President of The Royal Australian College of General Practitioners "This important new book by one of primary care's most accomplished authors sets out clearly the academic basis for further developments in primary health care. Health systems will only function effectively if they recognise the importance of high quality primary care so I strongly recommend this book to students, teachers, researchers, practitioners and policy makers." Professor Martin Marshall, Deputy Chief Medical Officer, Department of Health, UK. © 2007 Trisha Greenhalgh.
Effect on smoking quit rate of telling patients their lung age: The Step2quit randomised controlled trial
Objective: To evaluate the impact of telling patients their estimated spirometric lung age as an incentive to quit smoking. Design: Randomised controlled trial. Setting: Five general practices in Hertfordshire, England. Participants: 561 current smokers aged over 35. Intervention: All participants were offered spirometric assessment of lung function. Participants in intervention group received their results in terms of "lung age" (the age of the average healthy individual who would perform similarto them on spirometry). Those in the control group received a raw figure for forced expiratory volume at one second (FEV1). Both groups were advised to quit and offered referral to local NHS smoking cessation services. Main outcome measures: The primary outcome measure was verified cessation of smoking by salivary cotinine testing 12 months after recruitment. Secondary outcomes were reported changes in daily consumption of cigarettes and identification of new diagnoses of chronic obstructive lung disease. Results: Follow-up was 89%. Independently verified quit rates at 12 months in the intervention and control groups, respectively, were 13.6% and 6.4% (difference 7.2%, P=0.005, 95% confidence interval 2.2% to 12.1%; number needed to treat 14). People with worse spirometric lung age were no more likely to have quit than those with normal lung age in either group. Cost per successful quitter was estimated at £280 (€365, $556). A new diagnosis of obstructive lung disease was made in 17% in the intervention group and 14% in the control group; a total of 16% (89/561) of participants. Conclusion: Telling smokers their lung age significantly improves the likelihood of them quitting smoking, but the mechanism by which this intervention achieves its effect is unclear. Trial registration: National Research Register N0096173751.
Reaching beyond the white middle classes.
Apparently simple questions can easily be misunderstood or cause offence in disadvantaged groups. But such problems can be avoided by careful design, piloting, and administration
"Smart boys" and "sweet girls"-sex education needs in Thai teenagers: a mixed-method study
Background: In Thailand, rapid increases in economic prosperity have been accompanied by erosion of traditional cultural and religious values and by negative effects on sexual health of young people. We investigated knowledge, attitudes, norms, and values of teenagers, parents, teachers, and policymakers in relation to sex and sex education in Chiang Mai, Thailand, with a view to informing sex education policy. Methods: We selected six secondary schools for maximum variation in socioeconomic background, religious background, and location. Methods were: narrative interviews with key stakeholders, and analysis of key policy documents; questionnaire survey of 2301 teenagers; 20 focus groups of teenagers; questionnaire survey of 351 parents; and two focus groups of parents. Qualitative and quantitative data were assessed separately with thematic and statistical analysis, respectively, then combined. Findings: We noted five important influences on Thai teenagers' sexual attitudes and behaviour: ambiguous social roles leading to confused identity; heightened sexual awareness and curiosity; key gaps in knowledge and life skills; limited parental input; and impulsivity and risk-taking. Male teenagers aspire to be "smart boys", whose status depends on stories of sexual performance and conquests. Female teenagers, traditionally constrained and protected as "sweet girls", are managing a new concept of dating without their parents' support, and with few life skills to enable them to manage their desires or negotiate in potentially coercive situations. School-based sex education is biologically focused and inconsistently delivered. Interpretation: Results of this large exploratory study suggest five approaches that could be developed to improve sex education: targeted training and support for teachers; peer-led sex education by teenagers; story-based scenarios to promote applied learning; local development of educational materials; and use of trained sexual health professionals to address learning needs of pupils, teachers, and parents. © 2006 Elsevier Ltd. All rights reserved.
Narrative Based Medicine
Edited by two leading general practitioners and with contributions from over 20 authors, this book covers a wide range of topics to do with narrative in medicine.
Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine
Objective: To develop and validate an instrument for measuring knowledge and skills in evidence based medicine and to investigate whether short courses in evidence based medicine lead to a meaningful increase in knowledge and skills. Design: Development and validation of an assessment instrument and before and after study. Setting: Various postgraduate short courses in evidence based medicine in Germany. Participants: The instrument was validated with experts in evidence based medicine, postgraduate doctors, and medical students. The effect of courses was assessed by postgraduate doctors from medical and surgical backgrounds. Intervention: Intensive 3 day courses in evidence based medicine delivered through tutor facilitated small groups. Main outcome measure: Increase in knowledge and skills. Results: The questionnaire distinguished reliably between groups with different expertise in evidence based medicine. Experts attained a threefold higher average score than students. Postgraduates who had not attended a course performed better than students but significantly worse than experts. Knowledge and skills in evidence based medicine increased after the course by 57% (mean score before course 6.3 (SD 2.9) v 9.9 (SD 2.8), P < 0.001). No difference was found among experts or students in absence of an intervention. Conclusions: The instrument reliably assessed knowledge and skills in evidence based medicine. An intensive 3 day course in evidence based medicine led to a significant increase in knowledge and skills.
Patients' attitudes to the summary care record and HealthSpace: Qualitative study
Objective: To document the views of patients and the public towards the summary care record (SCR, a centrally stored medical record drawn from the general practice record) and HealthSpace (a personal health organiser accessible through the internet from which people can view their SCR), with a particular focus on those with low health literacy, potentially stigmatising conditions, or difficulties accessing health care. Design: 103 semistructured individual interviews and seven focus groups. Setting: Three early adopter primary care trusts in England where the SCR and HealthSpace are being piloted. All were in areas of relative socioeconomic deprivation. Participants: Individual participants were recruited from general practice surgeries, walk-in centres, out of hours centres, and accident and emergency departments. Participants in focus groups were recruited through voluntary sector organisations; they comprised advocates of vulnerable groups and advocates of people who speak limited English; people with HIV; users of mental health services; young adults; elderly people; and participants in a drug rehabilitation programme. Methods: Participants were asked if they had received information about the SCR and HealthSpace and about their views on shared electronic records in different circumstances. Results: Most people were not aware of the SCR or HealthSpace and did not recall receiving information about it. They saw both benefits and drawbacks to having an SCR and described a process of weighing the former against the latter when making their personal choice. Key factors influencing this choice included the nature of any illness (especially whether it was likely to lead to emergency care needs); past and present experience of healthcare and government surveillance; the person's level of engagement and health literacy; and their trust and confidence in the primary healthcare team and the wider NHS. Overall, people with stigmatising illness were more positive about the SCR than people who claimed to speak for "vulnerable groups." Misconceptions about the SCR were common, especially confusion about what data it contained and who would have access to it. Most people were not interested in recording their medical data or accessing their SCR via HealthSpace, but some saw the potential for this new technology to support self management and lay care for those with chronic illness. Conclusion: Despite an extensive information programme in early adopter sites, the public remains unclear about current policy on shared electronic records, though most people view these as a positive development. The "implied consent" model for creating and accessing a person's SCR should be revisited, perhaps in favour of "consent to view" at the point of access.