The influence of children’s day care on antibiotic seeking: a mixed methods study

Background

Preschool-aged children are the highest consumers of antibiotics, but consult mainly for viral infections. Little is known about how day care, which is common in this age group, influences primary care consulting and treatment-seeking behaviours.

Aim

To investigate daycare providers’ approaches to excluding and/or readmitting children with infections, and the consequences for parents’ consulting and antibiotic-seeking behaviours.

Design and setting

Cross-sectional survey, document analysis, and qualitative interviews of daycare providers and parents in South East Wales, UK.

Method

A total of 328 daycare providers were asked to complete a survey about infection exclusion practices and to provide a copy of their sickness exclusion policy. Next, 52 semi-structured interviews were conducted with purposively selected questionnaire responders and parents using their services. Questionnaire responses underwent bivariate analysis, policies underwent document analysis, and interviews were thematically analysed using constant comparison methods.

Results

In total 217 out of 328 (66%) daycare providers responded; 82 out of 199 (41%) reported advising parents that their child may need antibiotics and 199 out of 214 (93%) reported advising general practice consultations. Interviews confirmed that such advice was routine, and beliefs about antibiotic indications often went against clinical guidelines: 24% (n = 136) of sickness exclusion policies mentioning infections made at least one non-evidence-based indication for ‘treatment’ or antibiotics. Parent interviews revealed that negotiating daycare requirements lowered thresholds for consulting and encouraged antibiotic seeking.

Conclusion

Daycare providers encourage parents to consult general practice and seek antibiotics through non-evidence-based policies and practices. Parents’ perceptions of daycare providers’ requirements override their own beliefs of when it is appropriate to consult and seek treatment.     

Haematology patients and the internet – The use of on-line health information and the impact on the patient–doctor relationship

Objective

Patients access on-line health information (OHI) to better understand their health. We aimed to determine which demographic factors influence OHI use. We also explored how OHI is used and subsequent implications to the patient–doctor relationship.

Methods

We distributed a self-administered questionnaire to 202 haematology out-patients.

Results

62.3% used the internet and 54.3% used OHI. Higher education, (P < 0.001, OR 34.62, 95% CI 5.20–230.66) and household incomes of £15 000–25 000 (P = 0.023 OR 4.8 95% CI 1.236–18.59) were positively associated with OHI use.Those reassured after reading OHI had improved trust in their specialist (P < 0.001, OR 52.1, 95% CI 12.3–221.1), improved confidence during consultations, (P < 0.001, OR 23.0, 95% CI 2.8–188.2) and were improved decisions makers (P = 0.008, OR 13.6, 95% CI 4.1–45.7). Those with increased trust in their haematologist also had improved confidence (P < 0.001, OR 6.2, 95% CI 2.2–17.3) and improved decision making ability (P < 0.001, OR 13.6, 95% CI 4.7–39.4). 74.6% of patients did not share OHI with their haematologist.

Conclusions

Two-thirds of participants were exposed directly or indirectly to OHI. OHI affects patients’ view of their health and influences behaviour during consultations.

Practice implications

Haematologists could facilitate patients using OHI by recommending high quality websites and act supportively when patients share OHI.     

Students’ perceptions on the use of a ubiquitous 360° learning environment in histotechnology: a pilot study

This study assessed students’ perceptions of a ubiquitous 360° learning environment (ULE) in histotechnology comparing ULE perceptions to conventional web-based learning environment (WLE). Based on pervasive, seamless ubiquitous technologies and computing, ULE combines an authentic learning environment, i.e. histotechnology laboratory, with digital learning resources, embedded functional objects, mobile devices and sensing technologies. A highly usable user interface was created using a 360° spherical panorama imaging technique. The ULE was developed and conducted by a research group. Students’ perceptions on 360° ULE use were assessed in a quasi-experimental pilot study. From a histotechnology course, 57 out of 100 students participated voluntarily. The 360° ULE experimental group (n = 29) and WLE control group (n = 28) studied for 8 wks in 2014–2105. Assessment focused on the main criteria for ULE, i.e. flexibility, personalization, context-awareness, interactivity subscales. The WLE control group was assessed as more valuable from flexibility, context-awareness, and interactivity perspectives. Only the personalization aspect was perceived as higher in ULE than WLE. WLE group numerical values were systematically higher than the ULE group values, though statistically significant differences were revealed between groups. Both ULE and WLE environments supported learning. All measured subscales were assessed as high. Personalization and context-awareness aspects were evaluated as highest in both ULE and WLE groups, while interactivity was perceived as lowest. This study has implications for those developing technology-enhanced learning environments. Our developed 360° ULE could be easily implemented for health, medical, or nursing education as either practical training or continuing education.     

‘A heartbeat moment’: qualitative study of GP views of patients bringing health information from the internet to a consultation

Background

Government policy is to encourage self-help among patients. The internet is increasingly being used for health information. The literature on the role of the internet in the doctor–patient consultation remains sparse.

Aim

To determine the perceived responses of GPs to internet-informed patients in consultations and the strategies GPs use for dealing with information from the internet being brought into consultations.

Design of study

A qualitative study design was used, with semi-structured interviews.

Setting

GPs based in North Central London.

Method

Analysis was conducted by a multidisciplinary team of researchers. Participants were 11 GPs: five partners, three locums, and three salaried doctors; seven were white, three were Asian, and one was of Chinese origin. The median year of General Medical Council (GMC) registration was 1989. There were six women and five men; five participants worked in training practices.

Results

GPs experienced considerable anxiety in response to patients bringing information from the internet to a consultation but were able to resolve this anxiety. The study participants learned to distance themselves from their emotional response, and used cognitive and behavioural techniques to assist them in responding appropriately to patients. These techniques included buying time in a consultation, learning from previous consultations, and using the internet as an ally, by directing patients to particular websites. The importance for doctors of feeling valued by patients was apparent, as was the effect of the prior doctor–patient relationship.

Conclusion

GPs interviewed used sophisticated mechanisms for dealing with their emotions. GPs struggling with internet-informed patients can use the mechanisms described to alleviate the difficulties.     

Understanding of family medicine in Africa: a qualitative study of leaders’ views

Background

The World Health Organization encourages comprehensive primary care within an ongoing personalised relationship, including family physicians in the primary healthcare team, but family medicine is new in Africa, with doctors mostly being hospital based. African family physicians are trying to define family medicine in Africa, however, there is little clarity on the views of African country leadership and their understanding of family medicine and its place in Africa.

Aim

To understand leaders’ views on family medicine in Africa.

Design and setting

Qualitative study with in-depth interviews in nine sub-Saharan African countries.

Method

Key academic and government leaders were purposively selected. In-depth interviews were conducted using an interview guide, and thematically analysed.

Results

Twenty-seven interviews were conducted with government and academic leaders. Responders saw considerable benefits but also had concerns regarding family medicine in Africa. The benefits mentioned were: having a clinically skilled all-rounder at the district hospital; mentoring team-based care in the community; a strong role in leadership and even management in the district healthcare system; and developing a holistic practice of medicine. The concerns were that family medicine is: unknown or poorly understood by broader leadership; poorly recognised by officials; and struggling with policy ambivalence, requiring policy advocacy championed by family medicine itself.

Conclusion

The strong district-level clinical and leadership expectations of family physicians are consistent with African research and consensus. However, leaders’ understanding of family medicine is couched in terms of specialties and hospital care. African family physicians should be concerned by high expectations without adequate human resource and implementation policies.     

Diagnosing dementia in Dutch general practice: a qualitative study of GPs’ practices and views

BackgroundGPs play an important role in recognising the symptoms of dementia; however, little is known about how they perceive their actual and future role in diagnosing dementia.AimTo explore Dutch GPs’ perceptions of their current position in diagnosing dementia, their reasons for referral to secondary care, and views on the future diagnostic role of GPs.MethodEighteen GPs participated in a semi-structured interview that ranged from 20 to 60 minutes. Interviews were transcribed verbatim and thematic analysis was performed.ResultsGPs reported that their role in the diagnostic phase of identifying people with suspected dementia is limited to recognising cognitive problems and deciding whether a patient needs to be referred for further investigation, or whether care could be organised without specialist diagnosis. GPs indicated that they were likely to refer patients if patients/caregivers or dementia case managers requested it, or if they thought it could have consequences for treatment. Typically, GPs do not see the need for referral when their patients are very old and declining slowly. GPs would welcome a more prominent role in diagnosing dementia in their own practice.ConclusionDiagnosing dementia involves a complex balance between patient and carer preferences, the consequences for treatment and care, and the burden of referral. Dutch GPs favour a stronger involvement in diagnosing dementia provided that both resources and diagnostic algorithms are improved.     

Faculty’s work engagement in patient care: impact on job crafting of the teacher tasks

Background

High levels of work engagement protect against burnout. This can be supported through the work environment and by faculty themselves when they try to improve their work environment. As a result, they can become more engaged and better performers. We studied the relationship between adaptations by physicians to improve their teaching work environment, known as job crafting, and their energy levels, or work engagement, in their work as care provider and teacher. Job crafting encompasses seeking social (i) and structural (ii) resources and challenges (iii) and avoiding hindrances (iv).

Methods

We established a cross-sectional questionnaire survey in a cohort of physicians participating in classroom and clinical teaching. Job crafting and work engagement were measured separately for physicians’ clinical and teaching activities. We analyzed our data using structural equation modelling controlling for age, gender, perceived levels of autonomy and participation in decision making.

Results

383 physicians were included. Physicians’ work engagement for patient care was negatively associated with two job crafting behaviors in the teaching roles: seeking structural resources (classroom teaching: ß?=???0.220 [95% CI: -0.319 to ??0.129]; clinical teaching: ß?=???0.148 [95% CI: -0.255 to ??0.042]); seeking challenges (classroom teaching: ß?=???0.215 [95% CI: -0.317 to ??0.113]; clinical teaching:, ß?=???0.190 [95% CI: -0.319 to ??0.061]). Seeking social resources and avoiding hindrances were unaffected by physicians’ work engagement for patient care.

Conclusions

High engagement for teaching leads to job crafting in teaching. High engagement for patient care does not lead to job crafting in teaching.

     

Respecting the ‘stages’ of depression: Considering depression severity and readiness to seek help

Objective

Despite knowing the value of message customization, empirical results have failed to provide clear indicators of what make a depression help-seeking message effective. The present research examines stages of depression in response to a prominent communication strategy, gain versus loss framing, to inform possibilities for effective message customization.

Paediatric palliative care: development and pilot study of a ‘Directory’ of life-limiting conditions

Background

Children’s palliative care services are developing. Rational service development requires sound epidemiological data that are difficult to obtain owing to ambiguity in the definitions both of the population who needs palliative care and of palliative care itself. Existing definitions are of trajectory archetypes. The aim of this study was to develop and pilot a directory of the commonest specific diagnoses that map on to those archetypes.

Methods

The diagnoses of patients under the care of five children hospices and a tertiary specialist palliative medicine service in the UK were recorded. Duplicates and diagnoses that were not life-limiting conditions according to the ACT/RCPCH criteria or were not primary were removed. The resulting Directory of life-limiting conditions was piloted by analysing Death Certificate data of children in Wales between 2002 and 2007.

Results

1590 diagnoses from children’s hospices and 105 from specialist palliative medicine were combined. After removals there were 376 diagnostic label. All ICD10 chapter headings were represented by at least one condition. The pilot study showed that 569 (54%) deaths in Wales were caused by LLC. Only four LLC resulted in ten or more deaths. Among deaths from LLC, the ten commonest diagnoses accounted for 32%, while the 136 diagnoses that caused one or two deaths accounted for 25%. The majority occurred from a small number of life-limiting conditions.

Conclusion

The Directory is a practical tool for identifying most life-limiting conditions using ICD10 codes that facilitates extraction and analysis of data from existing sources in respect of life-limiting conditions in children such as death certificate data, offering the potential for rapid and precise studies in paediatric palliative care.

     

The closer ‘We’ are,the stronger ‘I’ am: the impact of couple identity on cancer coping self-efficacy

The present study tested the supposition that greater levels of couple identity (or we-ness) increase a woman’s coping self-efficacy in relation to breast cancer, which, in turn, predicts better psychosocial adjustment. Women (N = 112) in committed relationships completed surveys assessing their levels of couple identity, cancer coping self-efficacy, and aspects of their psychosocial adjustment (specifically, depression, anxiety and functional well-being) during one of their outpatient visits to the cancer centre. As predicted, the more women identified with their relationships, the lower their levels of depression and anxiety were and the greater their functional well-being was. This relationship was mediated by coping self-efficacy: greater identification with one’s relationship predicted greater confidence in one’s ability to cope, which, in turn, predicted better adjustment. The role intimate relationships play in women’s adjustment to breast cancer, as well as directions for further research, are discussed.     

Childhood long-term conditions in primary care: a qualitative study of practitioners’ views

Background

Improving child health and wellbeing in England was the key focus of the Chief Medical Officer’s Annual Report 2012, which recommended that all children with long-term conditions (LTCs) have a named GP responsible for their care. Little is known, however, about practitioners’ views and experiences of supporting children with LTCs in primary care.

Aim

To explore practitioners’ views of supporting children with LTCs and their families in primary care.

Design and setting

Qualitative interview study in primary care settings in South Yorkshire, England.

Method

Interviews explored practitioners’ views and experiences of supporting children with asthma, cystic fibrosis, type 1 diabetes, and epilepsy. Interviews were audiotaped, transcribed verbatim, and analysed using the framework approach.

Results

Nineteen practitioners were interviewed: 10 GPs, five practice nurses, and four nurse practitioners. The GPs’ clinical roles included prescribing and concurrent illness management; nurse practitioners held minor illness clinics; and practice nurses conduct asthma clinics and administer immunisations. GPs were coordinators of care and provided a holistic service to the family. GPs were often unsure of their role with children with LTCs, and did not feel they had overall responsibility for these patients. Confidence was dependent on experience; however, knowledge of GPs’ own limits and accessing help were felt to be more important than knowledge of the condition.

Conclusion

Primary care has a valuable role in the care of children with LTCs and their families. This study suggests that improving communication between services would clarify roles and help improve the confidence of primary care practitioners.     

Australians’ perspectives on support around use of personal genomic testing: Findings from the Genioz study

Personal genomic testing using direct-to-consumer and consumer-directed models, with or without involvement of healthcare providers, is increasing internationally, including in Australia. This study forms a sub-set of the Genioz study – Genomics: National Insights of Australians. We aimed to explore Australians’ experiences with these types of tests, especially online DNA tests, and their views regarding whom they would seek support from around understanding test results. The study used a mixed methods approach, employing an exploratory quantitative online survey and follow-up qualitative semi-structured interviews. Between May 2016 and May 2017, 2841 Australians responded to the survey. Interviews were conducted with 63 purposively sampled respondents, including 45 who had a genetic test and 18 who had not. Of 571 respondents who had any type of genetic test, 322 had a personal genomic test using criteria defined by the researchers. Testing for ancestry/genealogy was the most common, reported by 267 participants, reflecting the increased advertising of these tests in Australia. Some respondents described downloading their raw data for further interpretation through third party websites for genealogical as well as health related information. Carrier testing, testing for serious and preventable conditions and nutrition and/or wellness were the most common health related tests reported by respondents. Participants generally preferred to seek support from general practitioners (GPs), medical specialists with relevant expertise and independent genetics specialists, although another important preference for non-health information was online forums and networks. There was less preference for seeking support from employees associated with the testing companies. Generally, of those who had a health related PGT, the most common actions were seeking medical advice or doing nothing with the information, while more of those who had a personal genomic test for nutrition and/or wellness sought advice from complementary/alternative health practitioners (eg naturopaths) and integrative GPs, and 60% reported they had changed their diet. As awareness of personal genomic testing increases, publicly funded clinical genetics services may be less inclined to discuss results from personal genomic testing. Genetic counsellors could play an important role in providing this support, both pre-test and post-test, through opportunities for private practice but independent from testing companies.     

Exploring the rewards and challenges of paediatric palliative care work – a qualitative study of a multi-disciplinary children’s hospice care team

Background

Children’s hospices are a key provider of palliative care for children and young people with life-limiting and life-threatening conditions. However, despite recent policy attention to the provision of paediatric palliative care, little is known about the role of children’s hospice staff and the factors that may impact on their wellbeing at work. This study explored the rewards and challenges of working in a children’s hospice with an aim to identify staff support and development needs.

Methods

We conducted an exploratory, qualitative study involving thematic analysis of semi-structured interviews with 34 staff and three focus groups with 17 staff working in a multi-disciplinary care team in a UK children’s hospice.

Results

Participants identified rewards and challenges related to the direct work of caring for children and their families; team dynamics and organisational structures; and individual resilience and job motivation. Participants described the work as emotionally intensive and multi-faceted; ‘getting it right’ for children was identified as a strong motivator and reward, but also a potential stressor as staff strived to maintain high standards of personalised and emotional care. Other factors were identified as both a reward and stressor, including team functioning, the allocation of work, meeting parent expectations, and the hospice environment. Many participants identified training needs for different aspects of the role to help them feel more confident and competent. Participants also expressed concerns about work-related stress, both for themselves and for colleagues, but felt unable to discuss this at work. Informal support from colleagues and group clinical reflection were identified as primary resources to reflect on and learn from work and for emotional support. However, opportunities for this were limited.

Conclusions

Providing regular, structured, and dedicated clinical reflection provides a mechanism through which children’s hospice staff can come together for support and learning, and demonstrates an organisational commitment to staff wellbeing and development. Being aware of children’s hospice specific rewards and challenges can help to ensure that staff feel supported and competent in their role. Breaking down barriers to discussing work-related stress and enhancing awareness about early signs of burnout is also important.

     

GPs’ views on managing advanced chronic kidney disease in primary care: a qualitative study

BackgroundChronic kidney disease (CKD) has become a significant part of the GP’s workload since the introduction of the National Institute for Health and Care Excellence guidelines in 2008. Patients with advanced CKD (stages G4 and G5) often have comorbidities, varied disease progression, and are likely to be older. GPs may experience difficulties with management decisions for patients with advanced CKD, including when to refer to nephrology.AimTo explore GPs’ views of managing patients with advanced CKD and referral to secondary care.MethodSemi-structured interviews with 19 GPs. Transcribed interviews were thematically analysed.ResultsGPs had little experience of managing patients with advanced CKD, including those on dialysis or having conservative care (treatment without dialysis or a transplant), and welcomed guidance. Some GPs referred patients based on renal function alone and some used wider criteria including age and multimorbidity. GPs reported a tension between national guidance and local advice, and some had learnt from experience that patients were discharged back to primary care. GPs with more experience of managing CKD referred patients later, or sometimes not at all, if there were no additional problems and if dialysis was seen as not in the patient’s interests.ConclusionGPs want guidance on managing older patients with advanced CKD and comorbidities, which better incorporates agreement between local and national recommendations to clarify referral criteria. GPs are not generally aware of conservative care programmes provided by renal units, however, they appear happy to contribute to such care or alternatively, lead conservative management with input from renal teams.