Acceptability of screening to prevent osteoporotic fractures: a qualitative study with older women.

BACKGROUND: Osteoporotic fractures have a detrimental impact on health and quality of life, are more common in older women and are costly to treat. Screening to identify older women at high risk of fracture has the potential to offer substantial benefits. Understanding women's and professionals' experiences of screening will inform the implementation of screening in routine care. OBJECTIVE: To explore the views of older women and GPs about the acceptability of screening to prevent fractures. METHODS: A qualitative study conducted within a multi-centre randomized controlled trial of the effectiveness and cost-effectiveness of screening women aged 70-85 years for the prevention of fractures; 30 women randomized to the trial screening group and 15 GPs were recruited from general practices in North Somerset and Norfolk, UK. All 30 women and 11 of the GPs participated in face-to-face semi-structured interviews. Four GPs participated in a focus group. Data were analysed thematically, using the Framework Approach. RESULTS: Women and GPs viewed screening positively, recognizing its potential to improve fracture prevention and future health. Attending screening was not found to result in anxiety or excessive activity restriction. Demonstrating cost-effectiveness was key to the acceptability of screening amongst GPs. Implementing similar screening in routine care would require consideration of access to bone density scans, information provision to participants and mode of administration. CONCLUSIONS: Our findings suggest an effective and cost-effective screening programme to reduce osteoporotic fractures could be implemented in routine care and would be well received by women and GPs.

Preferences for mode of delivery after previous caesarean section: what do women want, what do they get and how do they value outcomes?

BACKGROUND: Women with one previous caesarean section must decide which mode of delivery they would prefer in their next pregnancy. This involves a choice between attempted vaginal birth and elective caesarean section. OBJECTIVE: To explore women's mode of delivery preferences and the values placed on the outcomes of decision making. Greater insight into these issues could benefit both clinical care and future research. DESIGN: Observational study using longitudinal data collected within a randomized controlled trial. SETTING AND PARTICIPANTS: Seven hundred and forty-two women with one previous caesarean section recruited at four antenatal clinics in South West England and Scotland. MAIN OUTCOME MEASURES: Mode of delivery preference recorded at 19 and 37 weeks' gestation and visual analogue scale ratings of health and delivery outcomes. RESULTS: Comparison of mid and late pregnancy preferences and actual mode of delivery shows that 57% of women hold the same mode of delivery preferences at both times and 65% of women actually have the birth they prefer. The visual analogue scale ratings show variation in the way women value the outcomes of the decision. DISCUSSION AND CONCLUSIONS: Understanding the way women's mode of delivery preferences change, how these relate to actual mode of delivery and how women value the outcomes of their decision will be beneficial to health professionals who wish to support women both during pregnancy and after birth. In addition, the visual analogue scale ratings provide evidence that may improve the development of population-level and economic models of decision making.

Three-year follow-up of a factorial randomised controlled trial of two decision aids for newly diagnosed hypertensive patients.

This study is a 3-year follow-up of a factorial randomised controlled trial of two decision aids - decision analysis and information video plus leaflet - for newly diagnosed hypertensive patients. We found no evidence of differences for either of the two decision aids compared with controls for the primary outcome of blood pressure control at follow-up. There were also no differences in any of the secondary outcomes measured - the proportion taking blood pressure lowering drugs, self-reported medication adherence, or consulting behaviour. The randomised controlled trial cohort as a whole, irrespective of randomised group, demonstrated substantial reductions in blood pressure and 10-year cardiovascular risk over the follow-up period.

Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial.

OBJECTIVES: To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section. DESIGN: Randomised trial, conducted from May 2004 to August 2006. SETTING: Four maternity units in south west England, and Scotland. PARTICIPANTS: 742 pregnant women with one previous lower segment caesarean section and delivery expected at >or=37 weeks. Non-English speakers were excluded. INTERVENTIONS: Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher. MAIN OUTCOME MEASURES: Total score on decisional conflict scale, and mode of delivery. RESULTS: Women in the information programme (adjusted difference -6.2, 95% confidence interval -8.7 to -3.7) and the decision analysis (-4.0, -6.5 to -1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups. CONCLUSIONS: Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section. Trial Registration Current Controlled Trials ISRCTN84367722.

Decision-making about mode of delivery after previous caesarean section: development and piloting of two computer-based decision aids.

OBJECTIVE: To develop and pilot two computer-based decision aids to assist women with decision-making about mode of delivery after a previous caesarean section (CS), which could then be evaluated in a randomized-controlled trial. BACKGROUND: Women with a previous CS are faced with a decision between repeat elective CS and vaginal birth after caesarean. Research has shown that women may benefit from access to comprehensive information about the risks and benefits of the delivery options. DESIGN: A qualitative pilot study of two novel decision aids, an information program and a decision analysis program, which were developed by a multidisciplinary research team. PARTICIPANTS AND SETTING: 15 women who had recently given birth and had previously had a CS and 11 pregnant women with a previous CS, recruited from two UK hospitals. Women were interviewed and observed using the decision aids. RESULTS: Participants found both decision aids useful and informative. Most liked the computer-based format. Participants found the utility assessment of the decision analysis program acceptable although some had difficulty completing the tasks required. Following the pilot study improvements were made to expand the program content, the decision analysis program was accompanied by a training session and a website version of the information program was developed to allow repeat access. CONCLUSIONS: This pilot study was an essential step in the design of the decision aids and in establishing their acceptability and feasibility. In general, participating women viewed the decision aids as a welcome addition to routine antenatal care. A randomized trial has been conducted to establish the effectiveness and cost-effectiveness of the decision aids.