Storylines of research in diffusion of innovation: a meta-narrative approach to systematic review

Producing literature reviews of complex evidence for policymaking questions is a challenging methodological area. There are several established and emerging approaches to such reviews, but unanswered questions remain, especially around how to begin to make sense of large data sets drawn from heterogeneous sources. Drawing on Kuhn's notion of scientific paradigms, we developed a new method-meta-narrative review-for sorting and interpreting the 1024 sources identified in our exploratory searches. We took as our initial unit of analysis the unfolding 'storyline' of a research tradition over time. We mapped these storylines by using both electronic and manual tracking to trace the influence of seminal theoretical and empirical work on subsequent research within a tradition. We then drew variously on the different storylines to build up a rich picture of our field of study. We identified 13 key meta-narratives from literatures as disparate as rural sociology, clinical epidemiology, marketing and organisational studies. Researchers in different traditions had conceptualised, explained and investigated diffusion of innovations differently and had used different criteria for judging the quality of empirical work. Moreover, they told very different over-arching stories of the progress of their research. Within each tradition, accounts of research depicted human characters emplotted in a story of (in the early stages) pioneering endeavour and (later) systematic puzzle-solving, variously embellished with scientific dramas, surprises and 'twists in the plot'. By first separating out, and then drawing together, these different meta-narratives, we produced a synthesis that embraced the many complexities and ambiguities of 'diffusion of innovations' in an organisational setting. We were able to make sense of seemingly contradictory data by systematically exposing and exploring tensions between research paradigms as set out in their over-arching storylines. In some traditions, scientific revolutions were identifiable in which breakaway researchers had abandoned the prevailing paradigm and introduced a new set of concepts, theories and empirical methods. We concluded that meta-narrative review adds value to the synthesis of heterogeneous bodies of literature, in which different groups of scientists have conceptualised and investigated the 'same' problem in different ways and produced seemingly contradictory findings. Its contribution to the mixed economy of methods for the systematic review of complex evidence should be explored further.     

Maternal and Neonatal Factors Adversely Affecting Breastfeeding in the Perinatal Period

Background

Despite its known advantages, breastfeeding rates are low world over. Large number of factors affect breastfeeding. This study was designed to detect maternal and neonatal factors that adversely affect breastfeeding in the perinatal period.

Methods

A prospective, single-blinded study was conducted on randomly chosen mother-infant pairs in the maternity ward of a tertiary care service hospital. Only full term singletons born by normal vaginal delivery were studied. The B.R.E.A.S.T observation score and time spent by the infant at the mother''s breast were primary outcome variables. Maternal age, gravida, para status and education level were recorded. Birth weight, sex, gestation age of the infant and time interval from birth to observation were also recorded. Initial univariate analysis followed by multivariate analysis was performed using SPSS ver 7.5 software.

Results

A total of 54 mother-infant pairs formed the study group; 19(35.2%) were primigravidas. Primigravidas status of the mother led to significantly lower scores (p<0.04; 95% CI 0.10 to 3.62) as did maternal age < 26 years (p<0.04; 95% CI 0.2. to 3.46) on univariate analysis. Low birth weight (<2500 g) was the only neonatal factor that significantly lowered breastfeeding scores (p<0.02;95%Cl 0.56 to 6.31). On multivariate analysis only primigravida status was significantly associated with lower scores (p<0.02). The alpha value of the study was 5% and the power was 74%. Time spent by infant on breast was not significantly different between primigravida and non-primigravida mothers.

Conclusion

Primigravida status adversely affects breastfeeding scores; therefore counseling and support should be focused on this group. Extra care should also be taken to ensure adequate breastfeeding by younger mothers and in those with low birth weight infants. Larger studies with long-term follow up will be able to identify other factors and dertermine the effects of focused counseling and support in the perinatal period upon long-term breastfeeding rates.Key Words: Breastfeeding, Primigravida, Counseling     

Efficacy and Toxicity Profile of Methotrexate Chloroquine Combination in Treatment of Active Rheumatoid Arthritis

Background

The present study was conducted to study the efficacy and toxicity profile of methotrexate chloroquine combination in treatment of active rheumatoid arthritis.

Methods

24 patients of rheumatoid arthritis confirming to revised American Rheumatism Association (ARA) criteria were studied prospectively for twenty months. Clinical evaluation was made every 3 months. Clinical disease variables measured at each visit were number of joints with swelling, number of joints with tenderness and pain, duration of morning stiffness and physician and patient assessment of disease activity. Blood counts, liver function tests and other adverse effects due to drugs were monitored every 2 months.

Results

10 patients demonstrated more than 50% improvement. 4 patients withdrew from study, 2 because of excessive nausea and vomiting and 2 because of noncompliance. Other side effects noted were hyperpigmentation, photosensitivity, skin rashes, raised transaminases and stomatitis.

Conclusion

Methotrexate chloroquine combination has good efficacy and toxicity profile. Gastrointestinal side effects are most common and usually responsible for the discontinuation of the drugs.Key Words: Rheumatoid arthritis, Methotrexate, Chloroquine, Efficacy, Toxicity     

Decentralisation strategies and provider incentives in healthcare

Introduction

This article examines the incentive effects of delegating operational and financial decision making from central government to local healthcare providers. It addresses the economic consequences of a contemporary policy initiative in the English National Health Service (NHS)–earned autonomy. This policy entails awarding operational autonomy to ‘front-line’ organisations that are assessed to be meeting national performance targets. In doing so, it introduces new types of incentives into the healthcare system, changes the nature of established agency relationships and represents a novel approach to performance management.

Methods

Theoretical elements of a principal-agent model are used to examine the impact of decentralisation in the context of the results of an empirical study that elicited the perceptions of senior hospital managers regarding the incentive effects of earned autonomy. A multi-method approach was adopted. In order to capture the breadth of policy impact, we conducted a national postal questionnaire survey of all Chief Executives in acute-care hospital Trusts in England (n = 173). To provide added depth and richness to our understanding of the impact and incentive effects of earned autonomy at an organisational level, we interviewed senior managers in a purposeful sample of eight acute-care hospital Trusts.

Results

This theoretical framework and our empirical work suggest that some aspects of the earned autonomy as currently implemented in the NHS serve to weaken the potential incentive effect of decentralisation. In particular, the nature of the freedoms is such that many senior managers do not view autonomy as a particularly valuable prize. This suggests that incentives associated with the policy will be insufficiently powerful to motivate providers to deliver better performance. We also found that principal commitment may be a problem in the NHS. Some hospital managers reported that they already enjoyed a large degree of autonomy, regardless of their current performance ratings. We also found evidence that the objectives of providers may differ from those of both the central government and local purchasers. There is, therefore, a risk that granting greater autonomy will allow providers to pursue their own objectives which, whilst not self-serving, may still jeopardise the achievement of strategic goals.

Conclusion

It is apparent that the design and implementation features of decentralising policies such as earned autonomy require careful attention if an optimal balance is to be struck between central oversight and local autonomy in the delivery of healthcare.     

Ethics roundtable debate: Child with severe brain damage and an underlying brain tumour

A young person presents with a highly malignant brain tumour with hemiparesis and limited prognosis after resection. She then suffers an iatrogenic cardiac and respiratory arrest that results in profound anoxic encephalopathy. A difference in opinion between the treatment team and the parent is based on a question of futile therapy. Opinions from five intensivists from around the world explore the differences in ethical and legal issues. A Physician-ethicist comments on the various approaches.     

Diffusion of innovations in service organizations: systematic review and recommendations

This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.     

Hepatic injury and pancreatitis during treatment with serotonin reuptake inhibitors: data from the World Health Organization (WHO) database of adverse drug reactions

Severe hepatic adverse drug reactions have been occasionally reported in the literature for the selective serotonin reuptake inhibitors (SSRIs), venlafaxine and nefazodone. In addition, a few case reports have suggested a possible association between SSRI treatment and pancreatitis. To further investigate this issue, a Bayesian confidence propagation neural network (BCPNN) method was applied on the World Health Organization database of adverse drug reactions. This method identifies whether a drug/adverse drug reaction combination is reported more frequently to the database than expected on the basis of chance alone compared to general reporting in the database. A statistically significant unexpected high number of reports were found for nefazodone and hepatic injury, relative to the generality of the dataset but, for the other drug/adverse drug reaction combinations, no such association was found. The nefazodone finding is in accordance with data from other publications, suggesting that the risk of hepatic injury is increased. However, because of the nature of the BCPNN, the negative findings do not necessarily prove that there is no excess risk for hepatic injury/pancreatitis during treatment with drugs other than nefazodone. Further studies are required using alternative methodologies to demonstrate whether the selective serotonin reuptake inhibitors or venlafaxine may cause hepatic injury or pancreatitis.