Changes needed to reduce risk of musculoskeletal disorders.

Musculoskeletal disorders (MSDs) are the main contributor to disability levels, which are rising as populations age. Workplace hazard exposures are a major source of this problem, and current workplace risk management practices require substantial changes to tackle it more effectively. Most importantly, the current focus of risk management on "manual handling" tasks must broaden to encompass the whole job. This is necessary because a wide range of psychosocial hazards, most of which operate across the whole job rather than particular tasks, are significant contributors to risk. To ensure that risk-control actions are effective, a recurring risk management cycle that includes worker participation and addresses risk from both biomechanical and psychosocial hazards will be essential. Legislation that mandates workplace management of psychosocial hazards would be helpful. Amendment by regulatory bodies of MSD-related guidance and codes of practice so that they reflect current research evidence would also be helpful in communicating the need for change to workplace stakeholders.

The APHIRM toolkit: an evidence-based system for workplace MSD risk management.

Musculoskeletal disorders (MSDs) continue as one of the largest occupational health and safety problems worldwide. One reason for this situation is that current workplace risk management practices fail to meet some important evidence-based requirements for effective reduction of MSD risk. In particular: they largely fail to address risk arising from psychosocial hazards; do not allow sufficient participation by workers; and often fail to control risk at its sources.To address these deficiencies, A Participative Hazard Identification and Risk Management (APHIRM) toolkit has been formulated in accordance with both a framework developed by the World Health Organisation and implementation science principles. It comprises a set of online tools that include automated data analysis and reporting modules, and procedures to guide users through the five stages of the conventional risk management cycle. Importantly, it assesses both hazard and risk levels for groups of people doing a particular job, focusing on the job overall rather than only on tasks deemed to be hazardous. Its intended users are workplace managers and consultants responsible for occupational health and safety, with active participation from workers also. Resultant risk control interventions are customized to address the main physical and psychosocial hazards identified for the target job, and repetitions of the risk management cycle enables ongoing evaluation of outcomes in terms of both hazard and risk levels.

Requirements for more effective prevention of work-related musculoskeletal disorders.

BACKGROUND: Exposures to occupational hazards substantially increase workers' risk of developing musculoskeletal disorders (MSDs) and can exacerbate pre-existing disorders. The effects on MSD risk of the physical requirements of work performance are well recognised, but there is now ample evidence that work-related psychosocial hazards can also have substantial effects; further, some hazards may be additive or interactive. This evidence is not reflected in current workplace risk management practices. DISCUSSION: Barriers to more effective workplace management of MSD risk include: the widespread belief that risk arises largely or entirely from physical hazard exposures; regulatory and guidance documents targeting MSDs, most of which reflect this belief; risk assessment tools that focus narrowly on subsets of mainly physical hazards and yet generate outputs in the form of MSD risk indicators; and the conventional occupational health and safety (OHS) risk management paradigm, which is ill-suited to manage MSD risk. It is argued that improved workplace management of MSD risk requires a systems-based management framework and more holistic risk assessment and control procedures that address risk from all types of hazard together rather than in isolation from each other, and that support participation by workers themselves. New MSD risk management tools are needed to meet these requirements. Further, successful implementation of such changes is likely to require some restructuring of workplace responsibilities for MSD risk management. Line managers and supervisors often play key roles in generating hazards, both physical and psychosocial, so there is a need for their more active participation, along with OHS personnel and workers themselves, in routine risk assessment and control procedures. MSDs are one of our largest OHS problems, but workplace risk management procedures do not reflect current evidence concerning their work-related causes. Inadequate attention is given to assessing and controlling risk from psychosocial hazards, and the conventional risk management paradigm focuses too narrowly on risk from individual hazards rather than promoting the more holistic approach needed to manage the combined effects of all relevant hazards. Achievement of such changes requires new MSD risk management tools and better integration of the roles of OHS personnel with those of line managers.

Psychosocial hazards play a key role in differentiating MSD risk levels of workers in high-risk occupations.

OBJECTIVES: Workplace management practices targeting risk of musculoskeletal disorders (MSDs) fail to reflect evidence that risk is affected by psychosocial as well as physical hazards. To promote improved practices in occupations where MSD risk is highest, better information is needed on how psychosocial hazards, combined with physical hazards, affect risk of workers in these occupations. METHODS: Survey ratings of physical and psychosocial hazards by 2329 Australian workers in occupations with high MSD risk were subjected to Principal Components Analysis. Latent Profile Analysis of hazard factor scores identified different combinations of hazards to which latent subgroups of workers were typically exposed. Survey ratings of frequency and severity of musculoskeletal discomfort or pain (MSP) generated a pre-validated MSP score and its relationship with subgroup membership was analysed. Demographic variables associated with group membership were investigated using regression modelling and descriptive statistics. RESULTS: Analyses identified three physical and seven psychosocial hazard factors and three participant subgroups with differing hazard profiles. Profile group differences were greater for psychosocial than physical hazards, and MSP scores out of 60 ranged from 6.7 for the low hazard profile (29% of participants) to 17.5 for the high hazard profile (21%). Differences between occupations in hazard profiles were not large. CONCLUSIONS: Both physical and psychosocial hazards affect MSD risk of workers in high-risk occupations. In workplaces such as this large Australian sample where risk management has focused on physical hazards, actions targeting psychosocial hazards may now be the most effective way to reduce risk further.

Reinforcing outpatient medical student learning using brief computer tutorials: the Patient-Teacher-Tutorial sequence.

BACKGROUND: At present, what students read after an outpatient encounter is largely left up to them. Our objective was to evaluate the education efficacy of a clinical education model in which the student moves through a sequence that includes immediately reinforcing their learning using a specifically designed computer tutorial. METHODS: Prior to a 14-day Pediatric Emergency rotation, medical students completed pre-tests for two common pediatric topics: Oral Rehydration Solutions (ORS) and Fever Without Source (FWS). After encountering a patient with either FWS or a patient needing ORS, the student logged into a computer that randomly assigned them to either a) completing a relevant computer tutorial (e.g. FWS patient + FWS tutorial = "in sequence") or b) completing the non-relevant tutorial (e.g. FWS patient + ORS tutorial = "out of sequence"). At the end of their rotation, they were tested again on both topics. Our main outcome was post-test scores on a given tutorial topic, contrasted by whether done in- or out-of-sequence. RESULTS: Ninety-two students completed the study protocol with 41 in the 'in sequence' group. Pre-test scores did not differ significantly. Overall, doing a computer tutorial in sequence resulted in significantly greater post-test scores (z-score 1.1 (SD 0.70) in sequence vs. 0.52 (1.1) out-of-sequence; 95% CI for difference +0.16, +0.93). Students spent longer on the tutorials when they were done in sequence (12.1 min (SD 7.3) vs. 10.5 (6.5)) though the difference was not statistically significant (95% CI diff: -1.2 min, +4.5). CONCLUSIONS: Outpatient learning frameworks could be structured to take best advantage of the heightened learning potential created by patient encounters. We propose the Patient-Teacher-Tutorial sequence as a framework for organizing learning in outpatient clinical settings.

Design of occupational therapy on-road test routes and related validity issues.

BACKGROUND/AIM: Specialist Occupational Therapy Driver Assessors and driver licensing authorities require on-road assessment procedures that are both valid and reliable. Assessment validity may be influenced by both test route characteristics and driver characteristics. To address these issues, this study aimed to evaluate the characteristics of test routes used by Occupational Therapy Driver Assessors (including associated driving manoeuvres and traffic conditions) and to explore Occupational Therapy Driver Assessor views relating to on-road assessment procedures. METHODS: In-depth interviews of 22 Occupational Therapy Driver Assessors were conducted; seven of the routes examined were in rural or regional locations. Supplementary information was obtained by observation of routes and review of Occupational Therapy Driver Assessors' route documentation. RESULTS: All Occupational Therapy Driver Assessors reported using a standard test route for clients seeking an open (i.e. not geographically restricted) licence. Compliance with professional guidelines reassessment procedures was very high for test items designated as compulsory, but more variable for those designated only as desirable. Differences between rural/regional vs. urban routes were noted, with those in rural/regional areas being less cognitively demanding. CONCLUSIONS: This study highlighted variation in route complexity between urban and rural locations. Whereas compliance with current professional guidelines for compulsory route items was very high, more detailed specification of standard route requirements is needed to improve the construct and content validity of assessments.

The problem with "ergonomics injuries": What can ergonomists do?

Effects of psychosocial hazards on risk of musculoskeletal disorders (MSDs) are often very substantial, but workplace risk management practices focus largely on biomechanical hazards, as do the risk assessment methods used by ergonomists. Translation of research evidence into more effective workplace practices demands a more holistic risk management framework that encompasses both types of hazard. In this context, we evaluate the validity of different MSD risk assessment methods for different purposes, focusing particularly on requirements for routine workplace risk management. These include choice of fit-for-purpose assessment methods, prioritisation of hazards that are most affecting risk, and control actions as high as possible in the risk control hierarchy. Ergonomists could facilitate more effective workplace risk management by promoting: awareness of the need for change; improvements to guidance from OHS regulators; research on MSD-related workplace management issues; and professional development programs on this topic for ergonomists and other OHS practitioners.

Parent-mediated communication-focused treatment in children with autism (PACT): a randomised controlled trial.

BACKGROUND: Results of small trials suggest that early interventions for social communication are effective for the treatment of autism in children. We therefore investigated the efficacy of such an intervention in a larger trial. METHODS: Children with core autism (aged 2 years to 4 years and 11 months) were randomly assigned in a one-to-one ratio to a parent-mediated communication-focused (Preschool Autism Communication Trial [PACT]) intervention or treatment as usual at three specialist centres in the UK. Those assigned to PACT were also given treatment as usual. Randomisation was by use of minimisation of probability in the marginal distribution of treatment centre, age (42 months), and autism severity (Autism Diagnostic Observation Schedule-Generic [ADOS-G] algorithm score 12-17 or 18-24). Primary outcome was severity of autism symptoms (a total score of social communication algorithm items from ADOS-G, higher score indicating greater severity) at 13 months. Complementary secondary outcomes were measures of parent-child interaction, child language, and adaptive functioning in school. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN58133827. RESULTS: 152 children were recruited. 77 were assigned to PACT (London [n=26], Manchester [n=26], and Newcastle [n=25]); and 75 to treatment as usual (London [n=26], Manchester [n=26], and Newcastle [n=23]). At the 13-month endpoint, the severity of symptoms was reduced by 3.9 points (SD 4.7) on the ADOS-G algorithm in the group assigned to PACT, and 2.9 (3.9) in the group assigned to treatment as usual, representing a between-group effect size of -0.24 (95% CI -0.59 to 0.11), after adjustment for centre, sex, socioeconomic status, age, and verbal and non-verbal abilities. Treatment effect was positive for parental synchronous response to child (1.22, 0.85 to 1.59), child initiations with parent (0.41, 0.08 to 0.74), and for parent-child shared attention (0.33, -0.02 to 0.68). Effects on directly assessed language and adaptive functioning in school were small. INTERPRETATION: On the basis of our findings, we cannot recommend the addition of the PACT intervention to treatment as usual for the reduction of autism symptoms; however, a clear benefit was noted for parent-child dyadic social communication. FUNDING: UK Medical Research Council, and UK Department for Children, Schools and Families.

N-Acylhydrazones as inhibitors of PDE10A.

Cyclic nucleotide phosphodiesterases (PDEs) are represented by a large superfamily of enzymes. A series of hydrazone-based inhibitors was synthesized and shown to be novel, potent, and selective against PDE10A. Optimized compounds of this class were efficacious in animal models of schizophrenia and may be useful for the treatment of this disease.

Multimorbidity, service organization and clinical decision making in primary care: a qualitative study.

BACKGROUND: Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. OBJECTIVE: To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making. METHODS: A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K. Interviews were conducted with 15 GPs and 10 practice nurses. RESULTS: Primary care professionals identified tensions between delivering care to meet quality targets and fulfilling the patient's agenda, tensions which are exacerbated in multimorbidity. They were aware of the inconvenience suffered by patients through attendance at multiple clinic appointments when care was structured around individual conditions. They reported difficulties managing patients with multimorbidity in limited consultation time, which led to adoption of an 'additive-sequential' decision-making model which dealt with problems in priority order until consultation resources were exhausted, when further management was deferred. Other challenges included the need for patients to co-ordinate their care, the difficulties of self-management support in multimorbidity and problems of making sense of the relationships between physical and mental health. Doctor and nurse accounts included limited consideration of multimorbidity in terms of the interactions between conditions or synergies between management of different conditions. CONCLUSIONS: Primary care professionals identify a number of challenges in care for multimorbidity and adopt a particular model of decision making to deliver care for multiple individual conditions. However, they did not describe specific decision making around managing multimorbidity per se.

Australian occupational therapy driver assessors' opinions on improving on-road driver assessment procedures.

OBJECTIVE: We collected practitioner opinions to improve the validity and reliability of the on-road driver assessment procedures used in Australia. METHOD: We used focus groups to document the views of experienced occupational therapy driver assessors using a purposive sampling method. RESULTS: Eight focus groups were conducted with 55 clinicians practicing in urban and rural regions. There was strong support for greater standardization of procedures for all tests. For drivers seeking unrestricted (open) licenses, use of standard routes with predetermined assessment points was important where practicable. Where use of a nonstandard route for this purpose was unavoidable, it was important to specify a minimum set of requirements related to route characteristics and assessment items. CONCLUSION: Australian occupational therapy driver assessors support greater standardization of test routes and procedures to improve reliability and validity. However, the extent to which standardization can be achieved is limited by variable road traffic environments where assessments are conducted.

Young drivers' perceptions of risk and difficulty: Day versus night.

Inexperienced drivers have a higher crash risk than others, particularly at night when drivers of all ages are at increased risk, but there has been little if any research on day-night differences in drivers' perceptions of risk and difficulty. Also, previous research on determinants of risk and difficulty ratings has focused largely on effects of vehicle speed, and researchers have identified a need to look more broadly at how ratings are affected by the complexity of depicted road-traffic situations. This study addressed those issues, using an exploratory approach entailing both quantitative and qualitative analyses. The 62 participants (28 females, 34 males) were grouped according to level of driving experience and age (16-30 years). Determinants of ratings were investigated using 6 day-night pairs of video clips at 6 different locations, plus 2 night-only clips at 2 other locations (14 clips in all). Depicted driving situations varied naturalistically in complexity as well as speed. They were presented in random orders twice to each participant, who used a slider to rate each clip continuously, once for risk and once for difficulty in balanced order. Consistent with previous evidence, there were no significant differences in ratings between participant groups. Ratings of risk and difficulty were highly correlated, as expected, but Rasch analysis confirmed that they reflected empirically different constructs. Ratings were significantly higher for night than day. They also differed significantly between locations, with vehicle speed not being their main determinant. Further, there were significant differences between locations in the relationship between risk and difficulty ratings, suggesting that participants' interpretations of 'risk' and 'difficulty' varied between locations. Qualitative analysis of rating patterns in relation to video clip content utilised constructs drawn from information theory and research on human information processing. It was concluded that more systematic research is required to investigate effects on ratings of variables determining the amount of information drivers must process, such as numbers and types of other road users and the predictability of their actions, road types and configurations, visibility conditions, particularly day versus night - as well as effects of vehicle speed which determines the required rate of processing.

Parent perceptions of participation in a parent-mediated communication-focussed intervention with their young child with autism spectrum disorder.

LAY ABSTRACT: Paediatric Autism Communication Therapy is an intervention for young children with autism spectrum disorder that focuses on parent-child communication. In Paediatric Autism Communication Therapy, the therapist and parent watch videos of the parent and child playing together. The therapist coaches the parent to carefully observe the child's communication and to interact with their child in a more sensitive and responsive way. Parents are encouraged to use the strategies with their child at home. Paediatric Autism Communication Therapy has been shown to lead to long-term improvements in parent-child communication and family quality of life. This study aimed to explore parents' perceptions of their participation in Paediatric Autism Communication Therapy. Interviews were carried out by an independent researcher with 18 parents. Parents discussed the learning processes they went through when working with Paediatric Autism Communication Therapy therapists and carrying out home practice. Some parents described initial doubts about the approach and hesitations about being videoed and analysing video material. In time, most parents came to really value the therapy and their relationship with the therapist. They reported positive changes in their interaction and relationship with their child and improvements to their child's communication and interaction. Some also highlighted poignant realisations and emotional challenges associated with taking part in this post-diagnosis therapy. Practical difficulties were also emphasised, including the time commitment, accessibility of therapy venues and difficulties in occupying the child during therapist-parent discussion. Implications for the clinical practice of parent-mediated interventions are discussed.

What makes a successful volunteer Expert Patients Programme tutor? Factors predicting satisfaction, productivity and intention to continue tutoring of a new public health workforce in the United Kingdom.

OBJECTIVES: Better management of chronic conditions is a challenge for public health policy. The Expert Patients Programme was introduced into the United Kingdom to improve self-care in people with long-term conditions. To deliver self-care courses, the programme relies on the recruitment and continued commitment to delivering the courses of volunteer lay tutors who have long-term conditions. Ensuring the tutor workforce is productive, satisfied in their role and retained long-term is central to the viability of the programme. This exploratory study aimed to determine what factors predict productivity, intention to continue tutoring, and satisfaction in a sample of volunteer tutors from the Expert Patients Programme. METHODS: A cross-sectional survey of 895 tutors was carried out and 518 (58%) responded. The questionnaire was designed to describe the characteristics, productivity, intention to continue tutoring, and satisfaction of tutors. Multiple linear regression analyses were used to examine the determinants of productivity, intention to continue tutoring, and satisfaction, such as patient demographics, attitudes, physical and mental health, mastery and self-esteem. RESULTS: Attitudes relating to personal goals, and better health were significant predictors of satisfaction with the tutor role. Only a small proportion of the variance in productivity was accounted for, and tutors were more likely to be productive when they were single, homeowners, car owners, and had lower scores on the depression scale. Overall satisfaction and personal goals were predictors of intention to continue tutoring. CONCLUSION: Demographic factors, health measures and attitudes each predicted different aspects of the experience of work conducted by the volunteer tutors. The results should prove useful for planning interventions to enhance the success of this new workforce initiative. PRACTICE IMPLICATIONS: Attempts to increase participation in courses by people from deprived backgrounds are likely to be enhanced if tutors come from similar backgrounds. This study demonstrated that material advantage and attitudes that value personal goals were predictors of satisfaction and productivity in the tutor role. Specific incentives and strategies may be required to recruit and support tutors from more marginalised groups in order to ensure equitable access to effective self-care support for all.

Barriers to more effective prevention of work-related musculoskeletal and mental health disorders.

Work-related psychosocial hazards have substantial effects on risks of both musculoskeletal and mental health disorders (MSDs, MHDs). Recent Australian research on workplace risk management practices in 19 work organisations found that risks from work-related psychosocial hazards were poorly managed. This study identified factors impeding better management of MSD and MHD risks within those organisations. METHOD: Interviews were conducted with staff from residential aged care and logistics/transport organisations in Australia. Transcripts were analysed using a worker-centred systems framework. RESULTS AND CONCLUSIONS: Many barriers to more effective risk management were identified. Most fundamentally, few people knew of the need to manage MSD risk arising from work-related psychosocial hazards, and OHS-related skills of key managers were often reported as inadequate, particularly concerning management of risk from psychosocial hazards. Also, funding and staffing levels were often reported as problematic, and OHS issues were seen as lower priority than accreditation and commercial requirements.

Practice nurses and the facilitation of self-management in primary care.

AIM: This paper is a report of a study to explore practice nurse involvement in facilitation of self-management for long-term conditions. BACKGROUND: In the United Kingdom chronic disease services have shifted from secondary care to general practice and from general practitioners to practice nurses. A new United Kingdom General Practice contract requires adherence to chronic disease management protocols, and facilitating self-management is recognized as an important component. However, improving self-management is a relatively new focus and little is known about the ways in which nurses engage with patient self-management and how they view work with patients in chronic disease clinics. METHOD: Semi-structured interviews with 25 practice nurses were carried out in 2004-2005. Interviews were audio-taped and transcribed verbatim. Analysis was informed by the 'trajectory model' and 'personal construct' theories. FINDINGS: Main themes in the early stages of work with patients were: categorization of patients, diagnosis, and patient education. First impressions appeared to determine expectations of self-management abilities, although these were amenable to change. Intermediate stages were 'ways of working' (breaking the task down, cognitive restructuring and addressing dissonance, modelling 'good' behaviour, encouragement, listening, involving carers and referral) and maintaining relationships with patients. However, in the longer-term nurses seemed to lack resources beyond personal experience and intuitive ways of working for encouraging effective self-care. CONCLUSION: The ways of working identified are unlikely to be sufficient to support patients' self-management, pointing to a need for education to equip nurses with techniques to work effectively with patients dealing with longer-term effects of chronic illness.

Dependence and identity: nurses and chronic conditions in a primary care setting.

PURPOSE: This paper aims to explore the ways in which practice nurses engage in identity work in the context of chronic disease management in primary care and assess the extent to which this is compatible with the identities promoted in government policy. DESIGN/METHODOLOGY/APPROACH: The paper draws on qualitative interviews with nurses applying the concepts of "identity threat" and Hegel's Master-Slave dialectic to explore the implications of nurse-patient interdependence for identity in a policy context which aims to promote self-management and patient empowerment. FINDINGS: The nurses in the study showed little sign of adapting their identities in line with government policies intended to empower health care "consumers". Instead, various aspects of identity work were identified which can be seen as helping to defend against identity threat and maintain and reproduce the traditional order. PRACTICAL IMPLICATIONS: The paper provides information on barriers to self-management that are likely to inhibit the implementation of government policy. ORIGINALITY/VALUE: Whilst much has been written on the extent to which patients are dependent on health professionals, the issue of professional dependence on patients has received much less attention. The paper hightlights how viewing the nurse-patient relationship in the context of a struggle for mastery related to identity represents a departure from traditional approaches and sheds light on hitherto unexplored barriers to self-management.

The Autism Family Experience Questionnaire (AFEQ): An Ecologically-Valid, Parent-Nominated Measure of Family Experience, Quality of Life and Prioritised Outcomes for Early Intervention.

There is a lack of measures that reflect the intervention priorities of parents of children with autism spectrum disorder (ASD) and that assess the impact of interventions on family experience and quality of life. The Autism Family Experience Questionnaire (AFEQ) was developed through focus groups and online consultation with parents, and reflected parental priorities. It was then administered to the parents of children enrolled in the Pre-school Autism Communication Trial and its 6-year follow-up study. The AFEQ showed good convergent validity with well-established measures of child adaptive functioning, parental mental health and parental wellbeing. It was sensitive to change in response to a parent-mediated intervention for young children with autism, showing treatment effect at treatment endpoint which increased at six-year follow-up.

A qualitative study of patients' perceptions of a 'minimal' psychological therapy.

BACKGROUND: Access to psychological therapy is often difficult. Problems with access may be overcome through 'minimal interventions' (such as books and computer programs), which encourage self-help for mental health problems and are less dependent on the availability of specialist therapists. However, to be effective, such interventions must be acceptable to patients. AIMS: To use qualitative methods to explore patient attitudes, by examining patient expectancies of psychological therapy and their experiences with a 'minimal intervention' (guided self-help). METHODS: Qualitative interviews (N = 24) were conducted with patients after they had received guided self-help for depression as part of a randomised controlled trial. RESULTS: There were important gaps between patients' expectancies of psychological therapy and their experience of the guided self-help. These gaps related to the process of therapy (e.g. time, professional expertise) and outcomes. Particularly salient was a theme relating to explanatory models. Patients were often seeking insight into the 'cause' of their current difficulties, whereas the minimal intervention was largely focused on symptom resolution. CONCLUSIONS: The effective implementation of 'minimal interventions' requires an understanding of the expectancies of patients concerning psychological therapy, in order to provide a basis for effective communication and negotiation between professionals and patients.

A qualitative study of GPs' attitudes to self-management of chronic disease.

BACKGROUND: Improving the quality of care for patients living with a chronic illness is a key policy goal. Alongside systems to ensure care is delivered according to evidence-based guidelines, an essential component of these new models of care is the facilitation of self-management. However, changes to the way professionals deliver care is complex, and it is important to understand the key drivers and barriers that may operate in the primary care setting. AIM: To explore GPs' perspectives on their involvement in the facilitation of chronic disease self-management. DESIGN OF STUDY: Qualitative study. SETTING: General practices located in two primary care trusts in northern England. METHOD: Data were collected through in-depth, semi-structured interviews with a purposive sample of GPs. During analysis, categories of response were organised into themes that relate to Howie's theoretical model for understanding general practice consultations: content, values, context. RESULTS: The GPs' responses highlighted tensions and trade-offs regarding their role in facilitating self-management. Although GPs valued increased patient involvement in their health care, this was in conflict with other values concerning professional responsibility. Furthermore, contextual factors also limited the degree to which they could assist in encouraging self-management. CONCLUSIONS: Providing GPs with training in consultation skills is required in order to encourage the delivery of effective self-management. In addition, the context in which GPs work also needs to be modified for this to be achieved.