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Nasir Hamid
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.
Effectiveness and efficiency of search methods in systematic reviews of complex evidence: Audit of primary sources
Objective To describe where papers come from in a systematic review of complex evidence. Method Audit of how the 495 primary sources for the review were originally identified. Results Only 30% of sources were obtained from the protocol denned at the outset of the study (that is, from the database and hand searches). Fifty one per cent were identified by "snowballing" (such as pursuing references of references), and 24% by personal knowledge or personal contacts. Conclusion Systematic reviews of complex evidence cannot rely solely on protocol-driven search strategies.
Making decisions about benefits and harms of medicines
Even when good scientific data are available, people's interpretation of risks and benefits will differ.