Practitioners' Views on Nicotine Replacement Therapy in Pregnancy during Lapse and for Harm Reduction: A Qualitative Study.

Many countries, including the UK, recommend nicotine replacement therapy (NRT) for smoking cessation during pregnancy. However, adherence to NRT is generally low, smoking lapse or relapse is common and using NRT to reduce the harm from the number of cigarettes smoked is only advocated in non-pregnant smokers. Two focus groups were conducted with 13 professionals involved in antenatal stop smoking services (SSS). The data were analysed thematically. Two themes were extracted that describe health professionals' attitudes towards using NRT either during lapses or to reduce smoking in women who cannot quit (harm reduction). These are presented around a social-ecological framework describing three hierarchical levels of influence within smoking cessation support: (1) Organizational: providing NRT during lapses could be expensive for SSS though harm reduction could result in services helping a wider range of clients. (2) Interpersonal: participants felt using NRT for harm reduction was not compatible with cessation-orientated messages practitioners conveyed to clients. (3) Individual: practitioners' advice regarding using NRT during smoking lapses varied; many were generally uncomfortable about concurrent smoking and NRT use and had strong reservations about recommending NRT when smoking during all but the briefest lapses. Further evidence is required to guide policy and practice.

Knowledge and Education as Barriers and Facilitators to Nicotine Replacement Therapy Use for Smoking Cessation in Pregnancy: A Qualitative Study with Health Care Professionals.

Smoking during pregnancy is a leading cause of negative pregnancy and perinatal outcomes. While UK guidelines recommend nicotine replacement therapy (NRT) for smoking cessation during pregnancy, adherence to NRT is generally low and may partially explain why NRT appears less effective in pregnancy compared to non-pregnant smokers. This study aimed to identify and describe factors associated with NRT adherence from a health professional's perspective. Two focus groups and one expert group were conducted with 26 professionals involved in antenatal stop smoking services and the data were analysed thematically using a template methodology. From our analyses, we extracted two main themes: (i) 'Barriers to NRT use in pregnancy' explores the issues of how misinformation and unrealistic expectations could discourage NRT use, while (ii) 'Facilitators to NRT use in pregnancy' describes the different information, and modes of delivery, that stop smoking professionals believe will encourage correct and sustained NRT use. Understanding the barriers and facilitators to improve NRT adherence may aid the development of educational interventions to encourage NRT use and improve outcomes for pregnant women wanting to stop smoking.

Improving Behavioral Support for Smoking Cessation in Pregnancy: What Are the Barriers to Stopping and Which Behavior Change Techniques Can Influence These? Application of Theoretical Domains Framework.

Behavioral support interventions are used to help pregnant smokers stop; however, of those tested, few are proven effective. Systematic research developing effective pregnancy-specific behavior change techniques (BCTs) is ongoing. This paper reports contributory work identifying potentially-effective BCTs relative to known important barriers and facilitators (B&Fs) to smoking cessation in pregnancy; to detect priority areas for BCTs development. A Nominal Group Technique with cessation experts (n = 12) elicited an expert consensus on B&Fs most influencing women's smoking cessation and those most modifiable through behavioral support. Effective cessation interventions in randomized trials from a recent Cochrane review were coded into component BCTs using existing taxonomies. B&Fs were categorized using Theoretical Domains Framework (TDF) domains. Matrices, mapping BCT taxonomies against TDF domains, were consulted to investigate the extent to which BCTs in existing interventions target key B&Fs. Experts ranked "smoking a social norm" and "quitting not a priority" as most important barriers and "desire to protect baby" an important facilitator to quitting. From 14 trials, 23 potentially-effective BCTs were identified (e.g., information about consequences). Most B&Fs fell into "Social Influences", "Knowledge", "Emotions" and "Intentions" TDF domains; few potentially-effective BCTs mapped onto every TDF domain. B&Fs identified by experts as important to cessation, are not sufficiently targeted by BCT's currently within interventions for smoking cessation in pregnancy.

Intervention fidelity in primary care complex intervention trials: qualitative study using telephone interviews of patients and practitioners.

BACKGROUND: Treatment fidelity has previously been defined as the degree to which a treatment or intervention is delivered to participants as intended. Underreporting of fidelity in primary care randomised controlled trials (RCTs) of complex interventions reduces our confidence that findings are due to the treatment or intervention being investigated, rather than unknown confounders. AIM: We aimed to investigate treatment fidelity (for the purpose of this paper, hereafter referred to as intervention fidelity), of an educational intervention delivered to general practice teams and designed to improve the primary care management of insomnia. METHOD: We conducted telephone interviews with patients and practitioners participating in the intervention arm of the trial to explore trial fidelity. Qualitative analysis was undertaken using constant comparison and a priori themes (categories): 'adherence to the delivery of the intervention', 'patients received and understood intervention' and 'patient enactment'. RESULTS: If the intervention protocol was not adhered to by the practitioner then patient receipt, understanding and enactment levels were reduced. Recruitment difficulties in terms of the gap between initially being recruited into the study and attending an intervention consultation also reduced the effectiveness of the intervention. Patient attributes such as motivation to learn and engage contributed to the success of the uptake of the intervention. CONCLUSION: Qualitative methods using brief telephone interviews are an effective way of collecting the depth of data required to assess intervention fidelity. Intervention fidelity monitoring should be an important element of definitive trial design. TRIAL REGISTRATION: ClinicalTrials. gov id isrctn 55001433 - www.controlled-trials.com/isrctn55001433.

Explaining the barriers to and tensions in delivering effective healthcare in UK care homes: a qualitative study.

OBJECTIVE: To explain the current delivery of healthcare to residents living in UK care homes. DESIGN: Qualitative interview study using a grounded theory approach. SETTING: 6 UK care homes and primary care professionals serving the homes. PARTICIPANTS: Of the 32 participants, there were 7 care home managers, 2 care home nurses, 9 care home assistants, 6 general practitioners (GPs), 3 dementia outreach nurses, 2 district nurses, 2 advanced nurse practitioners and 1 occupational therapist. RESULTS: 5 themes were identified: complex health needs and the intrinsic nature of residents' illness trajectories; a mismatch between healthcare requirements and GP time; reactive or anticipatory healthcare?; a dissonance in healthcare knowledge and ethos; and tensions in the responsibility for the healthcare of residents. Care home managers and staff were pivotal to healthcare delivery for residents despite their perceived role in social care provision. Formal healthcare for residents was primarily provided via one or more GPs, often organised to provide a reactive service that did not meet residents' complex needs. Deficiencies were identified in training required to meet residents' needs for both care home staff as well as GPs. Misunderstandings, ambiguities and boundaries around roles and responsibilities of health and social care staff limited the development of constructive relationships. CONCLUSIONS: Healthcare of care home residents is difficult because their needs are complex and unpredictable. Neither GPs nor care home staff have enough time to meet these needs and many lack the prerequisite skills and training. Anticipatory care is generally held to be preferable to reactive care. Attempts to structure care to make it more anticipatory are dependent on effective relationships between GPs and care home staff and their ability to establish common goals. Roles and responsibilities for many aspects of healthcare are not made explicit and this risks poor outcomes for residents.

General practitioners' preferences for managing insomnia and opportunities for reducing hypnotic prescribing.

RATIONALE, AIMS AND OBJECTIVES: Insomnia and sleep problems are common with many sufferers seeking medical help from general practitioners (GPs) whose clinical response is limited, often involving prescription of hypnotic drugs. The case for improving the quality of care for patients with insomnia is compelling but there is little evidence about how better care could be achieved in a primary care setting. The aim of this study was to investigate GPs' management preferences for sleep problems and their awareness and perception of opportunities for improving care as well as reducing the use of benzodiazepines and Z drugs. METHODS: Cross-sectional survey of GPs using a self-administered postal questionnaire in 2005 to all GPs in West Lincolnshire Primary Care Trust Lincolnshire, UK. RESULTS: A total of 84 of 107 (78.5%) questionnaires sent to GP principals were returned after one reminder. Respondents favoured Z drugs over benzodiazepines for the majority of indications. Respondent attitudes to benzodiazepines and Z drugs were generally negative whereas they were positive towards initiatives to reduce hypnotic prescribing through personal guidance, awareness-raising strategies and organizational interventions. CONCLUSIONS: GPs were negative in attitude towards hypnotics and positive towards reducing prescribing for sleep problems. They need to develop resources and better strategies for assessment and non-pharmacological management of patients presenting with insomnia for the first time as well as those on long-term hypnotics. The feasibility and effectiveness of psychosocial interventions tailored to patient and service needs in primary care setting should be evaluated systematically seeking to understand potential clinical benefits as well as potential undesirable effects of service changes.

Patients' and clinicians' experiences of consultations in primary care for sleep problems and insomnia: a focus group study.

BACKGROUND: Insomnia affects around one-third of adults in the UK. Many sufferers seek help from primary care. AIM: To explore patients' and primary care practitioners' expectations, experiences, and outcomes of consultations for sleep difficulties, as a basis for improving the treatment of insomnia in primary care. DESIGN OF STUDY: A qualitative phenomenological approach. METHOD: Separate focus groups for GPs and nurse prescribers and patients recruited from eight general practices that were in a quality improvement collaborative. Constant comparative analysis was used. RESULTS: Emergent themes from 14 focus groups comparing participating patients (n = 30) and practitioners (n = 15), provided insights on presentation, beliefs, expectations, and management of sleep problems. Patients initially tried to resolve insomnia themselves; consulting was often a last resort. Patients felt they needed to convince practitioners that their sleep difficulties were serious. They described insomnia in terms of the impact it was having on their life, whereas clinicians tended to focus on underlying causes. By the time patients consulted, many expected a prescription. Clinicians often assumed this was what patients wanted, and felt this would hamper patients' ability to take non-drug treatments seriously. Clinicians expected patients who were already on sleeping tablets to be resistant to stopping them, whereas patients were often open to alternatives. CONCLUSION: Better management of insomnia should take into account the perceptions and interactions of patients and practitioners. Practitioners need to empathise, listen, elicit patients' beliefs and expectations, assess sleep better, and offer a range of treatments, including cognitive and behavioural therapies, tailored to individual needs. Practitioner education should incorporate understanding of patients' decision-making processes, the clinicians' role during the consultation, and how to negotiate and deliver strategies for resolving sleep problems.

Strategies for improving patient recruitment to focus groups in primary care: a case study reflective paper using an analytical framework.

BACKGROUND: Recruiting to primary care studies is complex. With the current drive to increase numbers of patients involved in primary care studies, we need to know more about successful recruitment approaches. There is limited evidence on recruitment to focus group studies, particularly when no natural grouping exists and where participants do not regularly meet. The aim of this paper is to reflect on recruitment to a focus group study comparing the methods used with existing evidence using a resource for research recruitment, PROSPeR (Planning Recruitment Options: Strategies for Primary Care). METHODS: The focus group formed part of modelling a complex intervention in primary care in the Resources for Effective Sleep Treatment (REST) study. Despite a considered approach at the design stage, there were a number of difficulties with recruitment. The recruitment strategy and subsequent revisions are detailed. RESULTS: The researchers' modifications to recruitment, justifications and evidence from the literature in support of them are presented. Contrary evidence is used to analyse why some aspects were unsuccessful and evidence is used to suggest improvements. Recruitment to focus group studies should be considered in two distinct phases; getting potential participants to contact the researcher, and converting those contacts into attendance. The difficulty of recruitment in primary care is underemphasised in the literature especially where people do not regularly come together, typified by this case study of patients with sleep problems. CONCLUSION: We recommend training GPs and nurses to recruit patients during consultations. Multiple recruitment methods should be employed from the outset and the need to build topic related non-financial incentives into the group meeting should be considered. Recruitment should be monitored regularly with barriers addressed iteratively as a study progresses.

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial.

BACKGROUND: Sleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety. METHODS AND DESIGN: This will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 x 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing. DISCUSSION: Previous studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation.

An evaluation of the 'Designated Research Team' approach to building research capacity in primary care.

BACKGROUND: This paper describes an evaluation of an initiative to increase the research capability of clinical groups in primary and community care settings in a region of the United Kingdom. The 'designated research team' (DRT) approach was evaluated using indicators derived from a framework of six principles for research capacity building (RCB) which include: building skills and confidence, relevance to practice, dissemination, linkages and collaborations, sustainability and infrastructure development. METHODS: Information was collated on the context, activities, experiences, outputs and impacts of six clinical research teams supported by Trent Research Development Support Unit (RDSU) as DRTs. Process and outcome data from each of the teams was used to evaluate the extent to which the DRT approach was effective in building research capacity in each of the six principles (as evidenced by twenty possible indicators of research capacity development). RESULTS: The DRT approach was found to be well aligned to the principles of RCB and generally effective in developing research capabilities. It proved particularly effective in developing linkages, collaborations and skills. Where research capacity was slow to develop, this was reflected in poor alignment between the principles of RCB and the characteristics of the team, their activities or environment. One team was unable to develop a research project and the funding was withdrawn at an early stage. For at least one individual in each of the remaining five teams, research activity was sustained beyond the funding period through research partnerships and funding successes. An enabling infrastructure, including being freed from clinical duties to undertake research, and support from senior management were found to be important determinants of successful DRT development. Research questions of DRTs were derived from practice issues and several projects generated outputs with potential to change daily practice, including the use of research evidence in practice and in planning service changes. CONCLUSION: The DRT approach was effective at RCB in teams situated in a supportive organisation and in particular, where team members could be freed from clinical duties and management backing was strong. The developmental stage of the team and the research experience of constituent members also appeared to influence success. The six principles of RCB were shown to be useful as a framework for both developing and evaluating RCB initiatives.

Magic bullets for insomnia? Patients' use and experiences of newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems in primary care.

BACKGROUND: Little is known about patients' perceptions of newer hypnotics. AIM: To investigate use, experience, and perceptions of Z drug and benzodiazepine hypnotics in the community. DESIGN OF STUDY: Cross-sectional survey of general practice patients who had received at least one prescription for a Z drug or benzodiazepine in the previous 6 months. SETTING: Lincolnshire, UK. METHOD: Self-administered postal questionnaire. RESULTS: Of 1600 surveys posted, 935 (58.4%) responses were received, of which 705 (75.4%) were from patients taking drugs for insomnia. Of those 705 patients, 87.9% (n = 620) were first prescribed a hypnotic by their GP, and 94.9% (n = 669) had taken a sleeping tablet for 4 weeks or more. At least one side effect was reported in 41.8% (n = 295); 18.6% wished to come off hypnotic medication; and 48.5% had tried to stop treatment. Patients on Z drugs were more likely to express a wish to stop (22.7% versus 12.3%; odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.13 to 2.49), or to have attempted to come off medication, than those on benzodiazepines (52.4% versus 41.0%; OR = 1.54, 95% CI = 1.12 to 2.12). The two groups did not differ significantly in respect of benefits or adverse effects. CONCLUSION: There were no significant differences in patients' perceptions of efficacy or side-effects reported by those on Z drugs compared to patients taking benzodiazepines. Side-effects were commonly reported, which may have contributed to a high proportion of responders, particularly patients on Z drugs who were wishing to stop, or who had previously tried to stop taking this medication. Reported prescribing practices were often at variance with the licence for short-term use.

Confidentiality in the waiting room: an observational study in general practice.

An ethnographic study using overt non-participatory observation was used to investigate confidentiality breaches in 13 GP practice reception and/or waiting areas in Lincolnshire. Staff and patient behaviours were observed for 2 hours. Aspects of management systems and physical environment were also thematically analysed. Forty-four instances occurred where patient-identifiable information was overheard. Of these instances, 22 were initiated by staff, 22 by patients, 33 face-to-face, and 10 from telephone conversations. Breaches included name and address, symptoms, conditions, or test results. Interaction between systems and physical environment in relation to 'attention focus', 'sound' and 'layout', increased the likelihood of breach of confidentiality. Further research on the patient perspective is recommended.

Are they really refusing to travel? A qualitative study of prehospital records.

BACKGROUND: Refusal by the patient to travel after calling an emergency ambulance may lead to a preventable waste of scarce resources if it can be shown that an alternative more appropriate response could be employed. A greater understanding is required of the reasons behind 'refusal to travel' (RTT) in order to find appropriate solutions to address this issue. We sought to investigate the reasons why patients refuse to travel following emergency call-out in a rural county. METHODS: Written records made by ambulance crews for patients (n = 397) who were not transported to hospital following an emergency call-out during October 2004 were retrospectively analysed. RESULTS: Twelve main themes emerged for RTT which included non injury or minor injury, falls and recovery after treatment on scene; other themes included alternative supervision, follow-up and treatment arrangements or patients arranging their own transport. Importantly, only 8% of the sample was recorded by ambulance crews as truly refusing to travel against advice. CONCLUSION: A system that facilitates standardised recording of RTT information including social reasons for non-transportation needs to be designed. 'Refused to travel' disclaimers need to reflect instances when crew and patient are satisfied that not going to hospital is the right outcome. These recommendations should be considered within the context of the plans for widening the role of ambulance services.

Discovering the research priorities of people with diabetes in a multicultural community: a focus group study.

BACKGROUND: Usually experts decide on which research is worthwhile, yet it is government policy to involve service users in research. There has been a lack of published research about involving patients from minority ethnic groups and people from deprived areas in setting research agendas. In this study we wanted to hear the voices of patients that are not often heard. AIM: To find out the research priorities of people with diabetes from an inner city community and compare these with current expert-led research priorities in diabetes. DESIGN OF STUDY: A qualitative study using a participatory approach with consumer groups. SETTING: Primary care within inner city Nottingham, UK. METHOD: Thirty-nine adult patients with diabetes with varying ethnic backgrounds recruited from three general practices. Six focus groups carried out in participants' preferred language, analysed using the constant comparative method. RESULTS: Nine main themes equating to research priorities were identified. Within these themes, information and awareness, service delivery and primary prevention of diabetes emerged as the main factors. There were no science-based topics and there was more emphasis on culturally influenced research questions, which differed from recent Department of Health priorities. There were several themes about service delivery, patient self-management and screening and prevention of diabetes that overlapped. CONCLUSIONS: There is some divergence between expert-led and patient-led agendas in research about diabetes. Patient perspectives have a significant influence on research priorities, and there are likely to be several different patient perspectives.

Understanding of blood pressure by people with type 2 diabetes: a primary care focus group study.

BACKGROUND: For many people with type 2 diabetes most care is provided in primary care. While people with both diabetes and hypertension are at increased risk of complications, little is known about their understanding of blood pressure. AIM: To explore the understanding and beliefs about the importance of blood pressure held by people with type 2 diabetes. DESIGN OF STUDY: Framework analysis of qualitative research using focus groups. SETTING: Thirty-two participants were recruited from four general practices and a religious meeting group in Nottingham. Discussions took place in five community centres providing familiar surroundings for participants. METHOD: In order to get views expressed fully, white, Asian, and African-Caribbean participants met in five separate groups. Facilitators were fluent in the appropriate language and one member of the research team was present at all focus groups. RESULTS: Some participants, including those with raised blood pressure, were not aware of the increased importance of achieving good blood pressure control. No participants mentioned the increased risk of eye or kidney disease as a result of the combination of diabetes and raised blood pressure. Participants' perceptions regarding the control of blood sugar and blood pressure were different: blood sugar control was seen as their responsibility but blood pressure control was seen as the responsibility of the doctor. There was scepticism regarding the diagnosis of raised blood pressure, of targets and the management of blood pressure. There was also scepticism about the advice and education about diabetes given in primary care. CONCLUSIONS: People with type 2 diabetes require more knowledge of the increased risks they have from raised blood pressure, although this alone is unlikely to improve blood-pressure control. Strategies to increase the degree of control over and responsibility taken for the control of blood pressure need development and may require the specific development of participatory and negotiating skills among people with type 2 diabetes. Increasing the participation of these people in their own care will require doctors and nurses to work in a different way.

Does increased use of private health care reduce the demand for NHS care? A prospective survey of general practice referrals.

BACKGROUND: The use of the private sector for health care is increasing, but it is unclear whether this will reduce demand on the NHS. The aim of this study was to examine the relationship between private and NHS outpatient referral rates accounting for their association with deprivation. METHODS: This is a prospective survey of general practitioner referrals to private and NHS consultant-led services between 1 January and 31 December 2001 from 10 general practices in the Trent Focus Collaborative Research Network, United Kingdom. Patient referrals were aggregated to give private and NHS referral rates for each electoral ward in each practice. RESULTS: Of 17,137 referrals, 90.4 percent (15,495) were to the NHS and 9.6 percent (1642) to the private sector. Private referral rates were lower in patients from the most deprived fifth of wards compared with the least deprived fifth (rate ratio 0.25, 95 percent CI 0.15 to 0.41, p < 0.001), whereas NHS referral rates were slightly higher in patients in the most deprived fifth of wards (rate ratio 1.18, 95 percent CI 0.98 to 1.42, p = 0.08) both after age standardisation and adjustment for practice. The NHS referral rate was significantly higher (rate ratio 1.40, 95 percent CI 1.15 to 1.71, p = 0.001) in wards with private referral rates in the top fifth compared with the bottom fifth after adjustment for deprivation and practice. CONCLUSIONS: Increased private health care activity does not reduce the demand for NHS care: NHS and private referral rates were positively associated with each other after adjusting for age, deprivation and practice.

Building consensus in health care: a guide to using the nominal group technique.

The nominal group technique has been used in the health care sector in the development of guidelines and the identification of research priorities. The methodology suits research that includes both health professionals and consumers, since it allows for the free exchange of opinions and the generation of ideas within a structured and non-hierarchical discussion forum. This article describes the process of planning and running a nominal group and uses examples from a primary-care-based study to illustrate some of the advantages of using this method, and also the practical implications of using the technique in consensus development.

Minor illness in children: parents' views and use of health services.

Consultation rates in young children are high, and parents and carers of young children have reported feeling disempowered and anxious when their children display common symptoms. Parents have stated that more information would help them manage these symptoms appropriately. This focus group study explored how parents and carers of young children feel when their child displays common symptoms, what information they need to assist them in appropriate management, and to determine if they would value an educational intervention on the management of common symptoms. Findings showed that many parents sought help from families and friends following negative experiences of seeking advice from health professionals and many were wary of the information presented in health information leaflets produced by pharmaceutical companies. Parents and carers who took part in this study stated that they would value an educational intervention that would help them to appropriately manage common symptoms. They wanted to receive the information through interactive group sessions, led by a health visitor, with the inclusion of simple and non-product biased "take home" materials.