Point-of-care testing in UK primary care: a survey to establish clinical needs.

BACKGROUND: A number of point-of-care diagnostic tests are commercially available in the UK, however, not much is known regarding GPs' desire for these tests or the clinical areas of interest. OBJECTIVE: We sought to establish for which conditions point-of-care tests (POCTs) would be most helpful to UK GPs for diagnosis, reduction of referrals, and monitoring of chronic conditions. METHODS: A total of 1635 regionally representative GPs were invited to complete an online cross-sectional survey between 31 September and 16 October 2012. RESULTS: A total of 1109 (68%) GPs responded to the survey. The most frequently cited conditions were urinary tract infections for diagnosis (47% of respondents), pulmonary embolism/deep vein thrombosis for referral reduction (47%) and international normalized ratio/anticoagulation for monitoring (49%). CONCLUSIONS: This survey has identified the conditions for which UK GPs would find POCTs most helpful. Comments by respondents suggest that quite radical system-level adjustments will be required to allow primary care clinicians to capitalize on the potential benefits of POCTs.

Embedding new technologies in practice - a normalization process theory study of point of care testing.

BACKGROUND: Many point of care diagnostic technologies are available which produce results within minutes, and offer the opportunity to deliver acute care out of hospital settings. Increasing access to diagnostics at the point of care could increase the volume and scope of acute ambulatory care. Yet these technologies are not routinely used in many settings. We aimed to explore how point of care testing is used in a setting where it has become 'normalized' (embedded in everyday practice), in order to inform future adoption and implementation in other settings. We used normalization process theory to guide our case study approach. METHODS: We used a single case study design, choosing a community based ambulatory care unit where point of care testing is used routinely. A focused ethnographic approach was taken, including non-participant observation of all activities related to point of care testing, and semi-structured interviews, with all clinical staff involved in point of care testing at the unit. Data were analysed thematically, guided by normalization process theory. RESULTS: Fourteen days of observation and six interviews were completed. Staff had a shared understanding of the purpose, value and benefits of point of care testing, believing it to be integral to the running of the unit. They organised themselves as a team to ensure that point of care testing worked effectively; and one key individual led a change in practice to ensure more consistency and trust in procedures. Staff assessed point of care testing as worthwhile for the unit, their patients, and themselves in terms of job satisfaction and knowledge. Potential barriers to adoption of point of care testing were evident (including lack of trust in the accuracy of some results compared to laboratory testing; and lack of ease of use of some aspects of the equipment); but these did not prevent point of care testing from becoming embedded, because the importance and value attributed to it were so strong. CONCLUSIONS: This case study offers insights into successful adoption of new diagnostic technologies into every day practice. Such analyses may be critical to realising their potential to change processes of care.

Parent's information seeking in acute childhood illness: what helps and what hinders decision making?

CONTEXT: Acute illness is a universal experience in early childhood. Parents find it difficult to determine whether or not their child requires medical care and seek information to inform their decision making. Little is known about parents' information seeking behaviour and what helps or hinders their decision making. OBJECTIVE: This study aimed to explore parents' use of information resources during decision making in acute childhood illness at home. DESIGN/METHOD: This exploratory qualitative study used focus groups and interviews to collect data from parents of children under 5 years of age. SETTING AND PARTICIPANTS: Twenty-seven parents were recruited in the East Midlands, UK, in South Asian and Gypsy/Travelling communities, a Children's Centre and a private sector day nursery. FINDINGS: Parents' pre-consultation information seeking was dominated by the internet, albeit with limited success. Parents liked easy to access, professionally validated and simple messages with access to more detailed information. Some parents always sought information through personal contact, whilst others did so when independent information seeking failed. When consulting a healthcare professional, parents liked to be given information to refer to later, although the information received varied. Importantly, neither hard copy nor the internet was accessible for parents with low levels of literacy. DISCUSSION AND CONCLUSIONS: Although there is a wealth of information parents can access independently, our findings indicate a need for easy access to clearly signposted, professionally validated resources and available in a range of formats provided through different delivery systems. One size does not fit all.

Could parental rules play a role in the association between short sleep and obesity in young children?

Short sleep duration is associated with obesity in young children. This study develops the hypothesis that parental rules play a role in this association. Participants were 3-year-old children and their parents, recruited at nursery schools in socioeconomically deprived and non-deprived areas of a North-East England town. Parents were interviewed to assess their use of sleep, television-viewing and dietary rules, and given diaries to document their child's sleep for 4 days/5 nights. Children were measured for height, weight, waist circumference and triceps and subscapular skinfold thicknesses. One-hundred and eight families participated (84 with complete sleep data and 96 with complete body composition data). Parental rules were significantly associated together, were associated with longer night-time sleep and were more prevalent in the non-deprived-area compared with the deprived-area group. Television-viewing and dietary rules were associated with leaner body composition. Parental rules may in part confound the association between night-time sleep duration and obesity in young children, as rules cluster together across behavioural domains and are associated with both sleep duration and body composition. This hypothesis should be tested rigorously in large representative samples.

Exploring Socioeconomic Differences in Bedtime Behaviours and Sleep Duration in English Preschool Children.

Children's sleep is critical for optimal health and development; yet sleep duration has decreased in recent decades, and many children do not have adequate sleep. Certain sleep behaviours ('sleep hygiene') are commonly recommended, and there is some evidence that they are associated with longer nighttime sleep. Parents of 84 British 3-year-old children were interviewed about their children's sleep and completed five-night/four-day sleep diaries documenting their children's sleep, from which daily sleep duration was estimated. Diaries were validated by actigraphy in a subgroup of children. Sleep hygiene behaviours (regular bedtime, reading at bedtime, falling asleep in bed) were associated with each other, and were more common in the high socioeconomic status compared to the low socioeconomic status group. Parents' reasons for not practicing sleep hygiene included difficulty, inability or inconvenience. Sleep hygiene behaviours were associated with significantly longer child sleep at night but not over 24 h. Longer daytime napping compensated for shorter nighttime sleep in children whose parents did not implement sleep hygiene behaviours. Parents may need to be advised that certain behaviours are associated with longer nighttime sleep and given practical advice on how to implement these behaviours. © 2014 The Authors. Infant and Child Development published by John Wiley & Sons, Ltd.

The safety netting behaviour of first contact clinicians: a qualitative study.

BACKGROUND: Acute illness is common in childhood, and it is difficult for healthcare professionals to distinguish seriously ill children from the vast majority with minor or self-limiting illnesses. Safety netting provides parents with advice on when and where to return if their child deteriorates, and it is widely recommended that parents of acutely sick young children should be given safety netting advice. Yet little is known about how and when this is given. We aimed to understand what safety netting advice first contact clinicians give parents of acutely sick young children, how, when, and why. METHODS: This was a qualitative study. Interviews and focus groups were held with doctors and nurses in a general practice surgery, a District General Hospital emergency department, a paediatric emergency department, and an out-of-hours service. Data were analysed using the method of constant comparison. RESULTS: Sixteen clinicians participated. They described that safety netting advice includes advising parents what to look for, when and where to seek help. How safety netting was delivered and whether it was verbal or written was inconsistent, and no participants described being trained in this area. Safety netting appeared to be rarely documented, and was left to individual preference. Limitations of written materials, and structural barriers to the provision of safety netting, were perceived. Participants described that safety netting was influenced by clinicians' experience, confidence, time and knowledge; and perceived parental anxiety, experience, and competence. Participants noted several limitations to safety netting including not knowing if it has been understood by parents or been effective; parental difficulty interpreting information and desire for face-to-face reassurance; and potential over-reassurance. CONCLUSION: First contact clinicians employ a range of safety netting techniques, with inconsistencies within and between organisations. Structural changes, clinician training, and documentation in patient notes may improve safety netting provision. Research is needed into the optimal components of safety netting advice so that clinicians can consistently deliver the most effective advice for parents.

Primary care clinicians' attitudes towards point-of-care blood testing: a systematic review of qualitative studies.

BACKGROUND: Point-of-care blood tests are becoming increasingly available and could replace current venipuncture and laboratory testing for many commonly used tests. However, at present very few have been implemented in most primary care settings. Understanding the attitudes of primary care clinicians towards these tests may help to identify the barriers and facilitators to their wider adoption. We aimed to systematically review qualitative studies of primary care clinicians' attitudes to point-of-care blood tests. METHODS: We systematically searched Medline, Embase, ISI Web of Knowledge, PsycINFO and CINAHL for qualitative studies of primary care clinicians' attitudes towards point-of-care blood tests in high income countries. We conducted a thematic synthesis of included studies. RESULTS: Our search identified seven studies, including around two hundred participants from Europe and Australia. The synthesis generated three main themes: the impact of point-of-care testing on decision-making, diagnosis and treatment; impact on clinical practice more broadly; and impact on patient-clinician relationships and perceived patient experience. Primary care clinicians believed point-of-care testing improved diagnostic certainty, targeting of treatment, self-management of chronic conditions, and clinician-patient communication and relationships. There were concerns about test accuracy, over-reliance on tests, undermining of clinical skills, cost, and limited usefulness. CONCLUSIONS: We identified several perceived benefits and barriers regarding point-of-care tests in primary care. These imply that if point-of-care tests are to become more widely adopted, primary care clinicians require evidence of their accuracy, rigorous testing of the impact of introduction on patient pathways and clinical practice, and consideration of test funding.

Motivations for active commuting: a qualitative investigation of the period of home or work relocation.

BACKGROUND: Promoting walking or cycling to work (active commuting) could help to increase population physical activity levels. According to the habit discontinuity and residential self-selection hypotheses, moving home or workplace is a period when people (re)assess, and may be more likely to change, their travel behavior. Research in this area is dominated by the use of quantitative research methods, but qualitative approaches can provide in-depth insight into the experiences and processes of travel behavior change. This qualitative study aimed to explore experiences and motivations regarding travel behavior around the period of relocation, in an effort to understand how active commuting might be promoted more effectively. METHODS: Participants were recruited from the Commuting and Health in Cambridge study cohort in the UK. Commuters who had moved home, workplace or both between 2009 and 2010 were identified, and a purposive sample was invited to participate in semi-structured interviews regarding their experiences of, and travel behavior before and after, relocating. A grounded theory approach was taken to analysis. RESULTS: Twenty-six commuters participated. Participants were motivated by convenience, speed, cost and reliability when selecting modes of travel for commuting. Physical activity was not a primary motivation, but incidental increases in physical activity were described and valued in association with active commuting, the use of public transport and the use of park-and-ride facilities. CONCLUSIONS: Emphasizing and improving the relative convenience, cost, speed and reliability of active commuting may be a more promising approach to promoting its uptake than emphasizing the health benefits, at least around the time of relocation. Providing good quality public transport and free car parking within walking or cycling distance of major employment sites may encourage the inclusion of active travel in the journey to work, particularly for people who live too far from work to walk or cycle the entire journey. Contrary to a straightforward interpretation of the self-selection hypothesis, people do not necessarily decide how they prefer to travel, relocate, and then travel in their expected way; rather, there is constant negotiation, reassessment and adjustment of travel behavior following relocation which may offer an extended window of opportunity for travel behavior change.

Adiposity and blood pressure in 7- to 11-year-old children: comparison of British Pakistani and white British children, and of British Pakistani children of migrant and British-born mothers.

OBJECTIVES: This study tested hypotheses that: (1) levels of adiposity, as assessed by triceps and subscapular skinfold thicknesses (SFTs), and blood pressure would be higher in British Pakistani children than in white British children; and (2) British Pakistani children of mothers born in the UK would have smaller SFTs and lower blood pressure than children of mothers born in Pakistan. METHODS: Participants aged 7 to 11 years were recruited from five primary schools in a deprived urban area. BMI, waist circumference, triceps and subscapular SFT, and blood pressure were measured. RESULTS: Participants comprised 209 white British and 132 British Pakistani children, including 79 children born in the UK to migrant mothers and 49 children born to British-born mothers. In comparisons by ethnic group, triceps SFT was significantly higher in British Pakistani children only after controlling for BMI. Subscapular SFT was higher in British Pakistani children, a finding strengthened after controlling for BMI. Systolic blood pressure was significantly higher in British Pakistani children, but not after controlling for socioeconomic status (SES). There were no significant differences between British Pakistani children born to migrant or British-born mothers, except that systolic blood pressure was lower in children of British-born mothers after controlling for SES, a finding that was not significant after controlling for BMI. CONCLUSIONS: This study confirms previous findings of larger SFTs and higher blood pressure in British children of Pakistani origin than in children of white European origin. Further work with larger sample sizes is needed to investigate differences between generations.

Parents' help-seeking behaviours during acute childhood illness at home: A contribution to explanatory theory.

Uncertainty and anxiety surround parents' decisions to seek medical help for an acutely ill child. Consultation rates for children are rising, yet little is known about factors that influence parents' help-seeking behaviours. We used focus groups and interviews to examine how 27 parents of children under five years, from a range of socioeconomic groups in the East Midlands of England, use information to make decisions during acute childhood illness at home. This article reports findings elucidating factors that influence help-seeking behaviours. Parents reported that decision-making during acute childhood illness was influenced by a range of personal, social and health service factors. Principal among these was parents' concern to do the right thing for their child. Their ability to assess the severity of the illness was influenced by knowledge and experience of childhood illness. When parents were unable to access their general practitioner (GP), feared criticism from or had lost trust in their GP, some parents reported using services elsewhere such as Accident and Emergency. These findings contribute to explanatory theory concerning parents' help-seeking behaviours. Professional and political solutions have not reduced demand; therefore, collaborative approaches involving the public and professionals are now needed to improve parents' access to information.

Caregivers' Experiences of Pathways to Care for Seriously Ill Children in Cape Town, South Africa: A Qualitative Investigation.

PURPOSE: Understanding caregivers' experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers' experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement. METHODS: Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers' experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison. RESULTS: Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed 'tactics' to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism. CONCLUSIONS: Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers' use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.

Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

BACKGROUND: Because of the difficulties inherent in diagnosis in primary care, it is inevitable that diagnostic errors will occur. However, despite the important consequences associated with diagnostic errors and their estimated high prevalence, teaching and research on diagnostic error is a neglected area. AIM: To ascertain the key learning points from GPs' experiences of diagnostic errors and approaches to clinical decision making associated with these. DESIGN AND SETTING: Secondary analysis of 36 qualitative interviews with GPs in Oxfordshire, UK. METHOD: Two datasets of semi-structured interviews were combined. Questions focused on GPs' experiences of diagnosis and diagnostic errors (or near misses) in routine primary care and out of hours. Interviews were audiorecorded, transcribed verbatim, and analysed thematically. RESULTS: Learning points include GPs' reliance on 'pattern recognition' and the failure of this strategy to identify atypical presentations; the importance of considering all potentially serious conditions using a 'restricted rule out' approach; and identifying and acting on a sense of unease. Strategies to help manage uncertainty in primary care were also discussed. CONCLUSION: Learning from previous examples of diagnostic errors is essential if these events are to be reduced in the future and this should be incorporated into GP training. At a practice level, learning points from experiences of diagnostic errors should be discussed more frequently; and more should be done to integrate these lessons nationally to understand and characterise diagnostic errors.

Information resources to aid parental decision-making on when to seek medical care for their acutely sick child: a narrative systematic review.

OBJECTIVE: To identify the effectiveness of information resources to help parents decide when to seek medical care for an acutely sick child under 5 years of age, including the identification of factors influencing effectiveness, by systematically reviewing the literature. METHODS: 5 databases and 5 websites were systematically searched using a combination of terms on children, parents, education, acute childhood illness. A narrative approach, assessing quality via the Mixed Methods Appraisal Tool, was used due to non-comparable research designs. RESULTS: 22 studies met the inclusion criteria: 9 randomised control trials, 8 non-randomised intervention studies, 2 qualitative descriptive studies, 2 qualitative studies and 1 mixed method study. Consultation frequency (15 studies), knowledge (9 studies), anxiety/reassurance (7 studies), confidence (4 studies) satisfaction (4 studies) and antibiotic prescription (4 studies) were used as measures of effectiveness. Quality of the studies was variable but themes supported information needing to be relevant and comprehensive to enable parents to manage an episode of minor illness Interventions addressing a range of symptoms along with assessment and management of childhood illness, appeared to have the greatest impact on the reported measures. The majority of interventions had limited impact on consultation frequencies, No conclusive evidence can be drawn from studies measuring other outcomes. CONCLUSIONS: Findings confirm that information needs to be relevant and comprehensive to enable parents to manage an episode of minor illness. Incomplete information leaves parents still needing to seek help and irrelevant information appears to reduce parents' trust in the intervention. Interventions are more likely to be effective if they are also delivered in non-stressful environments such as the home and are coproduced with parents.

Information needs of parents for acute childhood illness: determining 'what, how, where and when' of safety netting using a qualitative exploration with parents and clinicians.

OBJECTIVE: To explore the views of parents and clinicians regarding the optimal content, format and delivery of safety netting information for acute childhood illness. DESIGN: Qualitative study including semistructured focus groups and interviews. SETTING: First contact care settings, community centres, children's centres and nurseries in the Midlands, UK. PARTICIPANTS: 27 parents from a travelling community, Asian British community and white British community. Sixteen clinicians including 10 doctors and 6 nurses from a general practice surgery, an out-of-hours service and two emergency departments (paediatric and combined adult and paediatric). RESULTS: Participants described a need for safety netting to contain information on signs and symptoms of serious and common illnesses, illness management and where and when to seek help. Resources should be basic, simple to use and contain simple symbols. A key criterion was professional endorsement of resources. Internet-based information was desired which is reliable, consistent and up-to-date. Participants described a need for different types of information: that which could be delivered during consultations, as well as more general information for parents to access before consulting a healthcare professional. Face-to-face education, written materials and digital media were suggested delivery mechanisms. Audiovisual material was preferred by families with low literacy. Participants commonly suggested internet-based and phone-based resources, but the travelling community was less comfortable with these approaches. CONCLUSIONS: A multifaceted and tailored approach to safety netting is needed so that effective resources are available for parents with varying information needs, literacy levels and ability to use information technology. We have identified key aspects of content, quality criteria, format and delivery mechanisms for safety netting information from the perspectives of clinicians and parents. Resources should be coproduced with parents and clinicians to ensure that they are valued and utilised by both groups.

Making sense of a new transport system: an ethnographic study of the Cambridgeshire Guided Busway.

An increase in public transport use has the potential to contribute to improving population health, and there is growing interest in innovative public transport systems. Yet how new public transport infrastructure is experienced and integrated (or not) into daily practice is little understood. We investigated how the Cambridgeshire Guided Busway, UK, was used and experienced in the weeks following its opening, using the method of participant observation (travelling on the busway and observing and talking to passengers) and drawing on Normalization Process Theory to interpret our data. Using excerpts of field notes to support our interpretations, we describe how the ease with which the new transport system could be integrated into existing daily routines was important in determining whether individuals would continue to use it. It emerged that there were two groups of passengers with different experiences and attitudes. Passengers who had previously travelled frequently on regular bus services did not perceive the new system to be an improvement; consequently, they were frustrated that it was differentiated from and not coherent with the regular system. In contrast, passengers who had previously travelled almost exclusively by car appraised the busway positively and perceived it to be a novel and superior form of travel. Our rich qualitative account highlights the varied and creative ways in which people learn to use new public transport and integrate it into their everyday lives. This has consequences for the introduction and promotion of future transport innovations. It is important to emphasise the novelty of new public transport, but also the ways in which its use can become ordinary and routine. Addressing these issues could help to promote uptake of other public transport interventions, which may contribute to increasing physical activity and improving population health.