Needles, Jabs and Jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers and Roma.

BACKGROUND: Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services including immunisation. To improve immunisation rates, it is necessary to understand what helps and hinders individuals in these communities in taking up immunisations. This study had two aims. 1. Investigate the views of Travellers in the UK on the barriers and facilitators to acceptability and uptake of immunisations and explore their ideas for improving immunisation uptake; 2. Examine whether and how these responses vary across and within communities, and for different vaccines (childhood and adult). METHODS: This was a qualitative, cross-sectional interview study informed by the Social Ecological Model. Semi-structured interviews were conducted with 174 Travellers from six communities: Romanian Roma, English Gypsy/Irish Travellers (Bristol), English Gypsy (York), Romanian/Slovakian Roma, Scottish Show people (Glasgow) and Irish Traveller (London). The focus was childhood and selected adult vaccines. Data were analysed using the Framework approach. RESULTS: Common accounts of barriers and facilitators were identified across all six Traveller communities, similar to those documented for the general population. All Roma communities experienced additional barriers of language and being in a new country. Men and women described similar barriers and facilitators although women spoke more of discrimination and low literacy. There was broad acceptance of childhood and adult immunisation across and within communities, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough and described barriers to booking and attending immunisation. Cultural concerns about antenatal vaccines and HPV vaccination were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified as barriers across different communities. Trustful relationships with health professionals were important and continuity of care valued. CONCLUSIONS: The experience of many Travellers in this study, and the context through which they make health decisions, is changing. This large study identified key issues that should be considered when taking action to improve uptake of immunisations in Traveller families and reduce the persistent inequalities in coverage. TRIAL REGISTRATION: Current Controlled Trials ISRCTN20019630 .

Client and clinical staff perceptions of barriers to and enablers of the uptake and delivery of behavioural interventions for urinary incontinence: qualitative evidence synthesis.

AIM: To evaluate factors influencing uptake and delivery of behavioural interventions for urinary incontinence from the perspective of clients and clinical staff. BACKGROUND: Behavioural interventions are recommended as first-line therapy for the management of urinary incontinence. Barriers to and enablers of uptake and delivery of behavioural interventions have not been reviewed. DESIGN: Qualitative evidence synthesis. DATA SOURCES: MEDLINE, EMBASE, CINAHL, PsychInfo, AMED (inception to May 2013); Proceedings of the International Continence Society (ICS) (2006-2013). REVIEW METHODS: Studies where data were collected from clients or staff about their experiences or perceptions of behavioural interventions were included. Two reviewers independently screened records on title and abstract. Full-text papers were obtained for records identified as potentially relevant by either reviewer. Two reviewers independently filtered all full-text papers for inclusion, extracted findings and critically appraised studies. We used an approach akin to Framework, using a matrix of pre-specified themes to classify the data and facilitate its presentation and synthesis. RESULTS: Seven studies involving 200 participants identified clients' views. Findings identified from at least one study of moderate quality included increased fear of accidents and convenience of treatment. Factors enabling participation included realistic goals and gaining control. Six studies involving 427 participants identified staff views. Findings identified from at least one study of moderate quality included staff education and perceptions of treatment effectiveness. Enabling factors included teamwork and experience of success. CONCLUSION: There is little detailed exploration of clients' experiences of, and responses to, behavioural interventions. Evidence for staff relates predominantly to prompted voiding in long-term residential care. Studies of the uptake and delivery of other behavioural interventions in other settings are warranted.

Implementing a Systematic Voiding Program for Patients With Urinary Incontinence After Stroke.

We explored health professionals' views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-2013. We conducted semi-structured group or individual interviews with 38 purposively selected nursing, managerial, and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory (NPT) as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups, patient fear of extending hospital stay, and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP, patient and relative involvement, extra staff, improved nursing skill and confidence, and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.

A systematic review of research into black and ethnic minority patients' views on self-management of type 2 diabetes.

CONTEXT: Eliciting patients' views of type 2 diabetes self-management provides insights on how policy and services might better support the needs of this population. OBJECTIVE: To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self-management of type 2 diabetes. SEARCH STRATEGY: A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free-text terms. Two relevant journals were also hand searched. INCLUSION CRITERIA: Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self-management. DATA EXTRACTION AND SYNTHESIS: Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis. MAIN RESULTS: Fifty-seven studies were included, of qualitative (n = 54), mixed-method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: 'Importance of identity'; 'Being understood by others' and 'Making sense of condition', all linked conceptually under the overarching theme 'Sense of self'. The quality of the studies varied. DISCUSSION AND CONCLUSIONS: The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self-management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient-centred care and policies.

British-Pakistani women's perspectives of diabetes self-management: the role of identity.

AIMS AND OBJECTIVES: To explore the effects of type 2 diabetes on British-Pakistani women's identity and its relationship with self-management. BACKGROUND: Type 2 diabetes is more prevalent and has worse outcomes among some ethnic minority groups. This may be due to poorer self-management and an inadequate match of health services to patient needs. The influence that type 2 diabetes has on British-Pakistani women's identity and subsequent self-management has received limited attention. DESIGN: An explorative qualitative study. METHODS: Face-to-face semi-structured English and Urdu language interviews were conducted with a purposively selected heterogeneous sample of 15 British-Pakistani women with type 2 diabetes. Transcripts were analysed thematically. RESULTS: Four themes emerged: Perceived change in self emphasised how British-Pakistani women underwent a conscious adaptation of identity following diagnosis; Familiarity with ill health reflected women's adjustment to their changed identity over time; Diagnosis improves social support enabled women to accept changes within themselves and Supporting family is a barrier to self-management demonstrated how family roles were an aspect of women's identities that was resilient to change. The over-arching theme Role re-alignment enables successful self-management encapsulated how self-management was a continuous process where achievements needed to be sustained. Inter-generational differences were also noted: first generation women talked about challenges associated with ageing and co-morbidities; second generation women talked about familial and work roles competing with self-management. CONCLUSIONS: The complex nature of British-Pakistani women's self-identification requires consideration when planning and delivering healthcare. RELEVANCE TO CLINICAL PRACTICE: Culturally competent practice should recognise how generational status influences self-identity and diabetes self-management in ethnically diverse women. Health professionals should remain mindful of effective self-management occurring alongside, and being influenced by, other aspects of life.

Undertaking qualitative health research in social virtual worlds.

AIMS: This paper discusses the methodological challenges of using the 3D social virtual world Second Life for research and offers some solutions on a range of research issues including research ethics committee approval, gaining consent, recruitment of sample, data collection and engagement with 'in - world culture'. BACKGROUND: The attraction of social virtual worlds to researchers is their ability to mimic the physical world, as they, are seen as 'places' where people have a feeling of presence (being there) and social presence (being there with others) through the use of a 'customisable' avatar (digital self-representation). Emerging research demonstrating the persuasive nature of avatars on health behaviours through virtual worlds, online games and the 3D web has increased the use of and interest in these areas for delivering health information, advice and support. However, conducting research can be challenging in a 3D world where people are represented as anonymous avatars in an environment unlike any other online media. DATA SOURCES: 25 semi-structured interviews were conducted in Second Life from September 2011-June 2012. IMPLICATIONS FOR NURSING: Nurses wishing to undertake research in social virtual worlds should spend time in-world to acquire technical skills and gain an understanding of the culture of the world. CONCLUSION: Our experience of an interview-based study in virtual worlds indicates that researchers require several virtual world technical skills to create innovative tools to recruit, gain consent and collect data and an understanding of in-world culture, language and social norms to increase the chances of successful research.

The association between family and community social capital and health risk behaviours in young people: an integrative review.

BACKGROUND: Health risk behaviours known to result in poorer outcomes in adulthood are generally established in late childhood and adolescence. These 'risky' behaviours include smoking, alcohol and illicit drug use and sexual risk taking. While the role of social capital in the establishment of health risk behaviours in young people has been explored, to date, no attempt has been made to consolidate the evidence in the form of a review. Thus, this integrative review was undertaken to identify and synthesise research findings on the role and impact of family and community social capital on health risk behaviours in young people and provide a consolidated evidence base to inform multi-sectorial policy and practice. METHODS: Key electronic databases were searched (i.e. ASSIA, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Embase, Medline, PsycINFO, Sociological Abstracts) for relevant studies and this was complemented by hand searching. Inclusion/exclusion criteria were applied and data was extracted from the included studies. Heterogeneity in study design and the outcomes assessed precluded meta-analysis/meta-synthesis; the results are therefore presented in narrative form. RESULTS: Thirty-four papers satisfied the review inclusion criteria; most were cross-sectional surveys. The majority of the studies were conducted in North America (n=25), with three being conducted in the UK. Sample sizes ranged from 61 to 98,340. The synthesised evidence demonstrates that social capital is an important construct for understanding the establishment of health risk behaviours in young people. The different elements of family and community social capital varied in terms of their saliency within each behavioural domain, with positive parent-child relations, parental monitoring, religiosity and school quality being particularly important in reducing risk. CONCLUSIONS: This review is the first to systematically synthesise research findings about the association between social capital and health risk behaviours in young people. While providing evidence that may inform the development of interventions framed around social capital, the review also highlights key areas where further research is required to provide a fuller account of the nature and role of social capital in influencing the uptake of health risk behaviours.

Randomised cluster trial to support informed parental decision-making for the MMR vaccine.

BACKGROUND: In the UK public concern about the safety of the combined measles, mumps and rubella [MMR] vaccine continues to impact on MMR coverage. Whilst the sharp decline in uptake has begun to level out, first and second dose uptake rates remain short of that required for population immunity. Furthermore, international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children. Together, this work suggests that effective interventions are required to support parents to make informed decisions about MMR. This trial assessed the impact of a parent-centred, multi-component intervention (balanced information, group discussion, coaching exercise) on informed parental decision-making for MMR. METHODS: This was a two arm, cluster randomised trial. One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations. The intervention arm received an MMR information leaflet and participated in the intervention (parent meeting). The control arm received the leaflet only. The primary outcome was decisional conflict. Secondary outcomes were actual and intended MMR choice, knowledge, attitude, concern and necessity beliefs about MMR and anxiety. RESULTS: Decisional conflict decreased for both arms to a level where an 'effective' MMR decision could be made one-week (effect estimate = -0.54, p < 0.001) and three-months (effect estimate = -0.60, p < 0.001) post-intervention. There was no significant difference between arms (effect estimate = 0.07, p = 0.215). Heightened decisional conflict was evident for parents making the MMR decision for their first child (effect estimate = -0.25, p = 0.003), who were concerned (effect estimate = 0.07, p < 0.001), had less positive attitudes (effect estimate = -0.20, p < 0.001) yet stronger intentions (effect estimate = 0.09, p = 0.006). Significantly more parents in the intervention arm reported vaccinating their child (93% versus 73%, p = 0.04). CONCLUSIONS: Whilst both the leaflet and the parent meeting reduced parents' decisional conflict, the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake.

Educating staff working in long-term care about delirium: the Trojan horse for improving quality of care?

OBJECTIVE: This study aimed to design a multicomponent intervention to improve delirium care in long-term care facilities for older people in the UK and to identify the levers and barriers to its implementation in practice. METHODS: The research incorporated the theoretical phase and Phase 1 of the Medical Research Council's framework. We designed a multicomponent intervention based on the evidence for effective interventions for delirium and for changing practice. We refined the intervention with input from care home staff and field visits to homes. Our intervention incorporated the following features: targeting risk factors for delirium, a 'delirium practitioner' functioning as a facilitator, an education package for care home staff, staff working groups at each home to identify barriers to improving delirium care and to produce tailored solutions, a local champion identified from the working groups, consultation, liaison with other professionals, and audit or feedback. The delirium practitioner recorded her experiences of delivering the intervention in a contemporaneous log. This was analysed using framework analysis to determine the levers and barriers to implementation. RESULTS: We introduced a multicomponent intervention for delirium in six care homes in Leeds. Levers to implementation included flexibility, tailoring training to staff needs, engendering pride and ownership amongst staff, and minimising extra work. Barriers included time constraints, poor organization, and communication problems. CONCLUSION: We were able to design and deliver an evidence-based multicomponent intervention for delirium that was acceptable to staff. The next steps are to establish its feasibility and effectiveness in modifying outcomes for residents of care homes.

A systematic review of decision support needs of parents making child health decisions.

OBJECTIVE: To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child. CONTEXT: The first step towards implementing patient decision support is to assess patients' information and decision-making needs. SEARCH STRATEGY: A systematic search of key bibliographic databases for decision support studies was performed in 2005. Reference lists of relevant review articles and key authors were searched. Three relevant journals were hand searched. INCLUSION CRITERIA: Non-intervention studies containing data on decision support needs of parents making child health decisions. DATA EXTRACTION AND SYNTHESIS: Data were extracted on study characteristics, decision focus and decision support needs. Studies were quality assessed using a pre-defined set of criteria. Data synthesis used the UK Evidence for Policy and Practice Information and Co-ordinating Centre approach. MAIN RESULTS: One-hundred and forty nine studies were included across various child health decisions, settings and study designs. Thematic analysis of decision support needs indicated three key issues: (i) information (including suggestions about the content, delivery, source, timing); (ii) talking to others (including concerns about pressure from others); and (iii) feeling a sense of control over the process that could be influenced by emotionally charged decisions, the consultation process, and structural or service barriers. These were consistent across decision type, study design and whether or not the study focused on informed decision making.

What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review.

OBJECTIVES: To review and draw together the existing research evidence to assess the impact of advanced primary care nursing roles, particularly first contact nursing roles, for patients, nurses themselves and their colleagues in order to highlight salient issues for policy, practice and research. BACKGROUND: Internationally, nurses' roles continue to expand in response to doctor shortages and policy drives to provide effective and efficient health services. A body of research exists from which to evaluate the impact of advanced nursing roles on various dimensions of healthcare delivery and organisation. DESIGN AND DATA SOURCES: Medline, CINAHL, Applied Social Sciences Index and Abstracts, British Nursing Index, Cochrane Library, EMBASE, National Research Register, and PsycINFO databases were searched, including relevant websites. Studies were included if published in English and relevant to the primary/community care setting. Of a total of 211 papers identified, 88 were of relevance and included in the review. RESULTS: Nurses working in many advanced primary care roles such as acute/minor illness, minor injury and long-term conditions provide safe and effective care, and patient satisfaction is generally high. Many factors influence patient satisfaction with, and access to, such services but are little understood. Evidence on cost-effectiveness, efficiency and impact on other health care professionals is inconclusive though research suggests the introduction of extended roles can create uncertainty and intra-/inter-professional tensions. CONCLUSIONS: Evidence is of variable quality, often ignoring potentially important effect mediators such as the experience and educational level of advanced nurses, the effect of service 'maturation', organisational characteristics and differing patient preferences. The complex range of factors that influence patient satisfaction, access and outcomes of care need further investigation. Recent UK developments in nurse prescribing and the introduction of a national post-registration competency framework may improve working relations and patient understanding and experience of advanced nursing roles in primary care.

The nature and impact of urinary incontinence experienced by patients receiving community nursing services: a cross-sectional cohort study.

BACKGROUND: Nurses have played a pivotal role in the delivery of continence services yet little is known about the nature or impact of urinary symptoms experienced by patients in receipt of such care. AIM: To define the nature and impact of urinary symptoms experienced by patients in receipt of community nursing services. METHOD: The Leicestershire Urinary Symptoms Questionnaire was administered to 1078 patients with incontinence identified from 176 community nurses' caseloads in 157 general practices in England. Information included type and severity of urinary symptoms, impact on quality of life, help with coping, use of continence products and health service resources. RESULTS: Nine hundred and ninety nine (92.7%) patients (median age 79.0 years) returned completed questionnaires. Most patients had incontinence between 1 and 5 years duration, women were more likely than men to have had long standing ( > 5 years) symptoms and more than half the sample reported severe leakage. Women were more likely than men to report symptoms of stress incontinence (71.7% and 46.8%, respectively, p < 0.001) and urge incontinence UI (86.3% vs. 74.8%, respectively, p < 0.01). Half of the men and most women also experienced leakage as a result of difficulty getting to, on or off, a toilet/commode. Men were more likely than women to report getting up three or more times a night to pass urine (53.6% vs. 37.0%, respectively, p < 0.05). Most patients reported that their symptoms had a significant impact on many aspects of quality of life, and 45.7% would be very dissatisfied to continue "the way they are now". Professional help appeared principally one of containment. CONCLUSION: Many people with incontinence receiving community nursing services experience two or more urinary symptoms which, in the majority, have a significant impact on quality of life. Many older patients were not satisfied to "put up" with their urinary symptoms. Current service provision appears to be failing those who are most in need of such care.

UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study.

BACKGROUND: Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services, including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. AIMS: (1) Investigate the barriers to and facilitators of acceptability and uptake of immunisations among six Traveller communities across four UK cities; and (2) identify possible interventions to increase uptake of immunisations in these Traveller communities that could be tested in a subsequent feasibility study. METHODS: Three-phase qualitative study underpinned by the social ecological model. Phase 1: interviews with 174 Travellers from six communities: Romanian Roma (Bristol); English Gypsy/Irish Traveller (Bristol); English Gypsy (York); Romanian/Slovakian Roma (Glasgow); Scottish Showpeople (Glasgow); and Irish Traveller (London). Focus on childhood and adult vaccines. Phase 2: interviews with 39 service providers. Data were analysed using the framework approach. Interventions were identified using a modified intervention mapping approach. Phase 3: 51 Travellers and 25 service providers attended workshops and produced a prioritised list of potentially acceptable and feasible interventions. RESULTS: There were many common accounts of barriers and facilitators across communities, particularly across the English-speaking communities. Scottish Showpeople were the most similar to the general population. Roma communities experienced additional barriers of language and being in a new country. Men, women and service providers described similar barriers and facilitators. There was widespread acceptance of childhood and adult immunisation, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough. Cultural concerns about vaccines offered during pregnancy and about human papillomavirus were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified by Travellers and service providers as barriers for some. Trustful relationships with health professionals were important and continuity of care was valued. A few English-speaking Travellers described problems of booking and attending for immunisation. Service providers tailored their approach to Travellers, particularly the Roma. Funding cuts, NHS reforms and poor monitoring challenged their work. Five 'top-priority' interventions were agreed across communities and service providers to improve the immunisation among Travellers who are housed or settled on an authorised site: (1) cultural competence training for health professionals and frontline staff; (2) identification of Travellers in health records to tailor support and monitor uptake; (3) provision of a named frontline person in general practitioner practices to provide respectful and supportive service; (4) flexible and diverse systems for booking appointments, recall and reminders; and (5) protected funding for health visitors specialising in Traveller health, including immunisation. LIMITATIONS: No Travellers living on the roadside or on unofficial encampments were interviewed. We should exert caution in generalising to these groups. FUTURE WORK: To include development, implementation and evaluation of a national policy plan (and practice guidance plan) to promote the uptake of immunisation among Traveller communities. STUDY REGISTRATION: Current Controlled Trials ISRCTN20019630 and UK Clinical Research Network Portfolio number 15182. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 72. See the NIHR Journals Library website for further project information.

Can a facilitated programme promote effective multidisciplinary audit in secondary care teams? An exploratory trial.

This 24-month exploratory study evaluated whether a 6-month programme supported by a trained external facilitator was feasible, acceptable and led to the adoption of a multidisciplinary approach to audit by secondary care staff. Undertaken in five acute hospital sites in the East Midlands UK, 22 multidisciplinary teams were randomised to either an intervention or control arm. Employing mixed methods, a range of outcomes, including collaborative behaviour, was measured. The intervention was feasible and acceptable to staff. Involvement in the facilitated programme had a positive impact on self-reported knowledge (P=0.000 post-intervention and at 4-months follow-up), skills (P=0.000 post-intervention and P=0.02 at 4-months follow-up) and attitudes (P<0.01 post-intervention), appeared to have some influence on improving self-reported (P<0.05 post-intervention) and observed collaborative behaviour (P=0.01) and led to better quality audit resulting in measurable improvements to care. Improved collaborative behaviour may have resulted from an increase in assertive behaviour by nurses. Research to test approaches to support teams to work effectively together is currently hampered by a lack of suitable research instruments and needs addressing before main (phase 111) trials are undertaken.

UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): protocol for an exploratory, qualitative study.

INTRODUCTION: Gypsies, Travellers and Roma (referred to here as Travellers) experience significantly poorer health and have shorter life expectancy than the general population. They are also less likely to access health services including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. This study has two aims: (1) Investigate the barriers and facilitators to acceptability and uptake of immunisations among six Traveller communities in the UK; (2) Identify potential interventions to increase uptake in these Traveller communities. METHODS AND ANALYSIS: A three-phase qualitative study with six Traveller communities. PHASE 1: In each community, we will explore up to 45 Travellers' views about the influences on their immunisation behaviours and ideas for improving uptake in their community. PHASE 2: In each community, we will investigate 6-8 service providers' perspectives on barriers and facilitators to childhood and adult immunisations for Traveller communities with whom they work, and ideas to improve uptake. Interview data will be analysed using the Framework approach. PHASE 3: The findings will be discussed and interventions prioritised in six workshops, each with 10-12 phase 1 and 3-4 phase 2 participants. ETHICS AND DISSEMINATION: This research received approval from NRES Committee Yorkshire and The Humber-Leeds East (Ref. 13/YH/02). It will produce (1) findings on the barriers and facilitators to uptake of immunisations in six Traveller communities; (2) a prioritised list of potentially feasible and acceptable interventions for increasing uptake in these communities; and (3) methodological development in undertaking research with diverse Traveller communities. The study has the potential to inform new ways of delivering services to ensure high immunisation uptake. Findings will be disseminated to participants, relevant UK organisations with responsibility for the implementation of immunisation policy and Traveller health/welfare; and submitted for publication in academic journals. TRIAL REGISTRATION NUMBER: ISRCTN20019630.

Managing controversy through consultation: a qualitative study of communication and trust around MMR vaccination decisions.

BACKGROUND: Controversy over the measles, mumps, and rubella (MMR) vaccine has reduced uptake, raising concerns of a future disease epidemic. AIMS: To explore parents' accounts of decision making relating to the MMR vaccine controversy, identifying uptake determinants and education needs. DESIGN OF STUDY: Qualitative interviews analysed using the 'framework' approach. SETTING: Five general practices in the Leeds area, 2002-2003. METHOD: Sixty-nine interviews conducted with parents of children aged between 4 and 5 years, and 12 interviews with primary care practitioners, managers and immunisation coordinators serving participating sites. Participants were interviewed one-to-one in a place of their choice. RESULTS: The vaccination decision is primarily a function of parental assessments of the relative acceptability and likelihood of possible outcomes. For most parents the evidence of science and medicine plays little role in the decision. Although local general practitioners and health visitors are trusted information sources, the influence of primary care providers on the vaccination decision is limited by concerns over consultation legitimacy, discussion opportunity, and perceptions of financial and political partiality. Parents and practitioners identify a need for new approaches to support decisions and learning when faced with this and similar healthcare controversies. These include new collaborative approaches to information exchange designed to transform rather than supplant existing parent knowledge as part of an ongoing learning process. CONCLUSION: The study identified new ways in which parents and practitioners need to be supported in order to increase understanding of medical science and secure more informed decisions in the face of health controversy.

Devising and establishing the face and content validity of explicit criteria of consultation competence in UK primary care nurses.

AIM: The aims of this study were (a) to devise a set of prioritised criteria of consultation competence which primary care nurses need to acquire and (b) to determine the face and content validity of these criteria. METHOD: The criteria of consultation competence as contained in the Leicester Assessment Package (LAP) were modified for use with primary care nurses and sent to a stratified sample of UK primary care nurses (n=1126) to determine their face and content validity. RESULTS: Support for the seven categories of consultation competence varied from 93-98% and for the 39 component competences from 88-98%. There was no consensus for alternative or additional categories or components. CONCLUSIONS; We have established the face and content validity of the derived competences. These are suitable for the teaching and assessment of consultation skills of primary care nurses, at all stages of their professional development, when incorporated within an educational package.

Self-management of urinary and fecal incontinence.

OVERVIEW: Widely used by patients to control symptoms of chronic conditions such as diabetes, asthma, and arthritis, self-management can also help patients with urinary or fecal incontinence. The authors discuss the principles of self-management, the behaviors and skills self-managing patients need to acquire, and the nurse's role in reinforcing their use. They then describe strategies that can be incorporated within the framework of self-management to control urinary, fecal, or dual incontinence.

Cost effectiveness of a web-based decision aid for parents deciding about MMR vaccination: a three-arm cluster randomised controlled trial in primary care.

BACKGROUND: Levels of measles in England and Wales are at their highest for 18 years, and strategies targeting the different groups of parents who do not vaccinate their children continue to be needed. Decision aids for decisions regarding childhood immunisation appear to be effective in achieving an increase in vaccine uptake but their cost effectiveness is unknown. AIM: To assess the cost effectiveness of a web-based decision aid to increase uptake of the MMR vaccine. DESIGN AND SETTING: Economic evaluation conducted alongside a cluster randomised controlled trial using urban GP practices in the north of England. METHOD: Fifty GP practices in the north of England were randomised to one of three trial arms: decision aid, leaflet, usual practice. A total of 220 first-time parents (child aged 3-12 months) were recruited. Parents self-reported their contacts with the NHS and other previous/expected resource utilisation; associated costs were calculated. Vaccine-uptake data were collected from GP practices. A cost-effectiveness analysis was undertaken and provided the incremental cost per first-vaccine uptake. Multiple imputation was used to account for missing data and findings were adjusted for baseline differences in parents' levels of decisional conflict regarding MMR vaccination. RESULTS: Of the 220 first-time parents recruited to the study, 179 completed the baseline and post-intervention questionnaires. MMR uptake was highest for those receiving the decision aid (42 out of 42, 100%) versus usual practice (61 out of 62, 98%) and leaflet arm (69 out of 75, 92%), and was associated with lower cost (-£9.20 versus usual practice and -£7.17 versus leaflet). CONCLUSION: The decision aid has a high chance of being cost effective, regardless of the value placed on obtaining additional vaccinations. It also appears to offer an efficient means of decision support for parents.