Two world views: Perspectives on autistic behaviours.

This article reports on a study, utilising phenomenological methodology, which used interview and video narratives to collect data from 10 young people with autism and their parents. Data analysis employed multistage, primarily ethnomethodological methods in order to interpret and understand experiences of autism. The study found that parents, arguably influenced by the medical and psychological perspectives through which 'autism' has evolved, problematise what children with autism do as pathological. This article juxtaposes parents' understandings against how children with autism, themselves, account for what they do, by exploring respective accounts of children's obsessions and ritualistic behaviours.

Stigma, abortion, and disclosure--findings from a qualitative study.

INTRODUCTION: This study qualitatively explores perceptions of women who have experienced abortion care. It explores women's journey through abortion from confirmation of pregnancy to post-abortion. AIM: The study seeks to understand the implications of these perceptions for policy and practice. MAIN OUTCOME MEASURES: A qualitative study involving in-depth semi-structured interviews with 17 women, aged between 22 and 57 years, who had undergone legal induced abortion in the UK when they were 16 years or older. Participants were not recruited under the age of 16 because of the ethical and legal complexities of interviewing minors. Additionally, 16 years was deemed to be the most appropriate age as this is the legal age of consent in the UK. METHODS: Participants were recruited from 12 community contraception and sexual health clinics in two NHS trusts, one in England and one in Wales. Participant recruitment was set at a minimum of 12 and participants were recruited on a "first come first served basis" (i.e., the first 12 who contacted the researcher). The number of participants was raised to seventeen as this was the number deemed to be the most suitable for data saturation in this particular qualitative research. RESULTS: Women in this study understood abortion as highly taboo and a potentially personally stigmatizing event. These perceptions continued to affect disclosure to others, long after the abortion, and affected women's perceptions of the response of others, including society in general, significant others, and health professionals. CONCLUSIONS: Women's experiences of abortion may be influenced by perceived negative social attitudes. Health professionals and abortion service providers might combat the perceived isolation of women undergoing abortion by attending not only to clinical/technical aspects of the procedure but also to women's psychological/emotional sensitivities surrounding the event.

Type 2 diabetes and dog walking: patients' longitudinal perspectives about implementing and sustaining physical activity.

BACKGROUND: Physical activity is particularly important for people with type 2 diabetes, as evidence suggests that any reduction in sedentary time is good for metabolic health. AIM: To explore type 2 diabetes patients' talk about implementing and sustaining physical activity. DESIGN OF STUDY: Longitudinal, qualitative study using repeat in-depth interviews with 20 patients over 4 years following clinical diagnosis. SETTING: Patients were recruited from 16 general practices and three hospitals across Lothian, Scotland. RESULTS: Discussion, and salience, of physical activity was marginal in patient accounts of their diabetes management. Patients claimed to have only received vague and non-specific guidance about physical activity from health professionals, and emphasised a perceived lack of interest and encouragement. Aside from walking, physical activities which were adopted tended to attenuate over time. Patients' accounts revealed how walking a dog assisted this kind of activity maintenance over time. Three main themes are highlighted in the analysis: 1) incidental walking; 2) incremental physical activity gains; and 3) augmenting physical activity maintenance. The problems arising from walking without a dog (for example, lack of motivation) are also examined. CONCLUSION: Asking patients about pet preferences might seem tangential to medical interactions. However, encouraging dog walking or identifying another interest that promotes a regular commitment to undertake physical activity may yield long-term health benefits.

UK smoke-free legislation: changes in PM2.5 concentrations in bars in Scotland, England, and Wales.

OBJECTIVE: Evaluate the effect of smoke-free legislation on fine particulate [particulate matter <2.5 microm in diameter (PM(2.5))] air pollution levels in bars in Scotland, England, and Wales. DESIGN: Air quality was measured in 106 randomly selected bars in Scotland, England, and Wales before and after the introduction of smoking restrictions. METHODS: PM(2.5) concentrations were measured covertly for 30-min periods before smoke-free legislation was introduced, again at 1-2 months post-ban (except Wales) and then at 12-months post-baseline (except Scotland). In Scotland and England, overt measurements were carried out to assess bar workers' full-shift personal exposures to PM(2.5). Postcode data were used to determine socio-economic status of the bar location. RESULTS: PM(2.5) levels prior to smoke-free legislation were highest in Scotland (median 197 microg m(-3)), followed by Wales (median 184 microg m(-3)) and England (median 92 microg m(-3)). All three countries experienced a substantial reduction in PM(2.5) concentrations following the introduction of the legislation with the median reduction ranging from 84 to 93%. Personal exposure reductions were also within this range. There was evidence that bars located in more deprived postcodes had higher PM(2.5) levels prior to the legislation. CONCLUSIONS: Prior to legislation PM(2.5) concentrations within bars across the UK were much higher than the 65 microg m(-3) 'unhealthy' threshold for outdoor air quality as set by the US Environmental Protection Agency. Concentrations in Scottish and Welsh bars were, on average, two or more times greater than in English bars for which seasonal influences may be responsible. Legislation in all three countries produced improvements in indoor air quality that are consistent with other international studies.

'People pull the rug from under your feet': barriers to successful public health programmes.

BACKGROUND: A community public health programme, 'Breathing Space', aimed to tackle smoking in a low income area in Scotland. This paper draws on the qualitative process evaluation of a community-based initiative 'Breathing Space', which set out to tackle smoking in a low income area of Scotland, in order to explore user perceptions of key factors affecting implementation, and in particular to explore the implications of participant knowledge and expertise for programme stability and continuity. METHODS: The overall evaluation of Breathing Space used a quasi-experimental design and incorporated a detailed process evaluation. The process evaluation aimed to document development and implementation of the programme using a range of qualitative methods, including observation, in-depth interviews, focus groups and documentary analysis. The paper draws upon 59 semi-structured in-depth interviews which were carried out as part of the process evaluation. FINDINGS: Staff numbers from the multi-agency partnership dwindled across the lifecouof the programme and respondents identified lack of continuity as a key issue. While staff changes are an anticipated problem in programme implementation, here we draw on concepts of technicality and indeterminacy to explore the different aspects of public health programmes which are forfeited when individuals leave. The paper argues that, while technical components of public health programmes (such as the importance of staff complement and continuity) are widely recognised, it is the more indeterminate aspects, including the loss of key theoretical understanding underpinning the programme, which most affect programme delivery. Indeed, the paper suggests that, where inadequate planning and resources threaten the continuity of indeterminate knowledge, the success of public health programmes may be especially jeopardised. CONCLUSION: Community-based programmes which rely strongly on partnership processes would benefit from early consideration of the potential risks associated with both expected and unexpected stakeholder change. Building in appropriate contingency plans is necessary for sustaining the theory and culture of the programme. Evaluations of innovative community development initiatives may benefit from a formative approach.

Shifting accountability: a longitudinal qualitative study of diabetes causation accounts.

We undertook a longitudinal qualitative study involving of 20 patients from Scotland who had type 2 diabetes. We looked at their perceptions and understandings of why they had developed diabetes and how, and why, their causation accounts had changed or remained stable over time. Respondents, all of whom were white, were interviewed four times over a 4-year period (at baseline, 6, 12 and 48 months). Their causation accounts often shifted, sometimes subtly, sometimes radically, over the 4 years. The experiential dimensions of living with, observing, and managing their disease over time were central to understanding the continuities and changes we observed. We also highlight how, through a process of removing, adding and/or de-emphasising explanatory factors, causation accounts could be used as "resources" to justify or enable present treatment choices. We use our work to support critiques of social cognition theories, with their emphasis upon beliefs being antecedent to behaviours. We also provide reflections upon the implications of our findings for qualitative research designs and sampling strategies.

'If I don't like it then I can choose what I want': Welsh school children's accounts of preference for and control over food choice.

The paper draws on qualitative data collected in focus groups with primary school pupils in years three and five (ages 7-11 years), carried out as part of a wider study evaluating the Primary School Free Breakfast Initiative in Wales. A total of 16 focus groups were carried out across eight schools to examine pupil's perceptions of food and food related behaviour. A key finding was the way in which control over choice of food and access to healthy/unhealthy food options differed between younger and older pupils across home, school and eating out settings. While older participants experienced and valued high levels of control over food choice in all three settings, this was not the case for younger participants. Pupils in year three had little choice, particularly at home and school, with other factors (such as security, structure and mealtime companionship) being more important to them than ability to choose what they ate. All participants in the study expressed a general preference for unhealthy as opposed to healthy food items, even when acknowledging health consequences and engaging in some compensatory strategies. The authors suggest that interventions should aim to educate and encourage food providers, such as parents/carers, schools, and food outlets, to produce a range of healthy options, and encourage informed food choice among children at a younger age.

"It's no skin off my nose": why people take part in qualitative research.

In this article, the authors analyze participants' accounts of why they took part in a repeat-interview study exploring newly diagnosed patients' perceptions of diabetes service provision in Lothian, Scotland. The study involved three semistructured in-depth interviews with each patient (N = 40), which spanned a year. The authors provide a thematic discursive analysis of responses to the question, Can I ask you what made you decide to part in the study and why you've stayed involved over the past year? The main themes are (a) recruitment within health contexts ("the nurse said it would help"), (b) altruism ("if it can help somebody"), (c) qualitative research being seen as inherently innocuous ("nothing to lose"), and (d) therapeutic aspects of interviewing ("getting it off my chest"). The analysis contributes both to the qualitative literature about generic research participation and to a germinal literature exploring qualitative health research participation.

Taking the biscuit? A discursive approach to managing diet in type 2 diabetes.

Adopting and maintaining a healthy diet is pivotal to diabetic regimens. Behavioural research has focused on strategies to modify/maintain healthy behaviours; thus 'compliance' and 'noncompliance' are operationalized by researchers. In contrast, discursive psychology focuses on the actions different accounts accomplish--in this case regarding diets. Using thematic discourse analysis, we examine dietary management talk in repeat-interviews with 40 newly diagnosed type 2 diabetes patients. Women in our study tended to construct dietary practices as an individual concern, while men presented food consumption as a family matter. Participants accounted for 'cheating' in complex ways that aim to accomplish, for instance, a compliant identity. Discursive psychology may facilitate fluidity in our understandings of dietary management, and challenge fixed notions of 'compliant' and 'non-compliant' diabetes patients.

Lay perceptions of type 2 diabetes in Scotland: bringing health services back in.

The growing prevalence of type 2 diabetes is placing Scottish health services under considerable strain. Consequently, diabetes services are undergoing a major process of reorganisation, including the devolvement of routine diabetes care/diabetic review from secondary to primary healthcare settings. This qualitative study was devised to explore newly diagnosed type 2 diabetes patients' perceptions of their disease and the health services they receive at a time when this restructuring of services is taking place. The sample comprised 40 patients resident in Lothian, Scotland, who had diverse experiences of services, some receiving GP-based care only, others having varying contact with hospital diabetes clinics. In-depth interviews were undertaken with patients, three times at six monthly intervals over 1 year, enabling their experiences to be tracked at critical junctures during the post-diagnostic period. Disease perceptions and health service delivery were found to be mutually informing and effecting. Not only did (different types of) health service delivery influence the ways in which patients thought about and self-managed their disease, over time patients' disease perceptions also informed their expectations of, and preferences for, diabetes services. We thus argue that there is a need for a reconceptualisation within the medical social sciences to take into account the context of healthcare and the economic/policy factors that inform health service delivery when looking at patients' disease perceptions. We also discuss the logistical and ethical challenges of drawing upon patients' perspectives, preferences and views in the design and delivery of future health services.

Diagnosis of type 2 diabetes: a qualitative analysis of patients' emotional reactions and views about information provision.

Research about diagnosis of chronic illness indicates this is an emotional time for patients. Information provision is especially salient for diabetes management. Yet current orthodoxy suggests that too much information at the time of diagnosis is unhelpful for patients. In this study, we used in-depth interviews with 40 newly diagnosed type 2 diabetic (T2DM) patients in Scotland, to explore their emotional reactions about diagnosis, and their views about information provision at the time of diagnosis. Data were analysed using a thematic approach. Our results showed three main 'routes' to diagnosis: 'suspected diabetes' route; 'illness' route; and 'routine' route. Those within the 'routine' route described the most varied emotional reactions to their diagnosis. We found that most patients, irrespective of their route to diagnosis, wanted more information about diabetes management at the time of diagnosis. We suggest that practitioners would benefit from being sensitive to the route patients follow to diagnosis, and prompt, simple but detailed advice about T2DM management would be helpful for newly diagnosed patients.

Blood glucose self-monitoring in non-insulin-treated type 2 diabetes: a qualitative study of patients' perspectives.

BACKGROUND: Self-monitoring of blood glucose is controversial in the management of type 2 diabetes. Some research suggests that self-monitoring improves glycaemic control, whereas other research is sceptical about its value for people with type 2 diabetes who are not on insulin. Although blood glucose meters are widely available and used by this group, patients' own views are absent from the debate. AIM: To explore the pros and cons of glucose monitoring from the patients' perspectives. DESIGN OF STUDY: Qualitative repeat-interview study. SETTING: Patients were recruited from 16 general practices and three hospital clinics within four local healthcare cooperatives in Lothian, Scotland. METHOD: Interview data from 40 patients diagnosed with type 2 diabetes within the previous 6 months were analysed using thematic analysis informed by grounded theory. We report findings from round 1 and round 2 interviews. RESULTS: Glucose monitoring can heighten patients' awareness of the impact of lifestyle; for example, dietary choices, on blood glucose levels. Glucose monitoring amplifies a sense of 'success' or 'failure' about self-management, often resulting in anxiety and self-blame if glucose readings remain consistently high. Moreover, monitoring can negatively effect patients' self-management when readings are counter-intuitive. CONCLUSION: Our analysis highlights the importance of understanding the meanings that newly diagnosed patients attach to glucose self-monitoring. To maximise the positive effects of self-monitoring, health professionals should ensure that patients understand the purpose of monitoring and should clarify with patients how readings should be interpreted.

Patients in waiting: a qualitative study of type 2 diabetes patients' perceptions of diagnosis.

OBJECTIVE: Our aim was to examine how diagnosis is perceived by a sample of newly diagnosed type 2 diabetes patients. METHODS: A qualitative study was carried out in the Lothian region of Scotland using in-depth interviews of 40 newly diagnosed type 2 diabetes patients recruited from 16 general practices in four Local Health Care Co-operatives and three hospital clinics. Purposive selection ensured that the sample's demographic characteristics were broadly representative of newly diagnosed type 2 diabetes patients in Lothian/Scotland. RESULTS: Clarity, timing and authority of the diagnosis delivery were highly salient for patients. Many patients perceived their GP as unwilling to deliver/confirm the diagnosis. Patients who were not referred to hospital were unclear why a referral had not taken place. Those referred perceived confirmation of diagnosis by the consultant as a central reason. Waiting for a hospital appointment could be problematic for patients. Most wanted the diagnosis confirmed before they felt confident making lifestyle changes. Input from health services during the period prior to the hospital visit was highly valued. Waiting was taken by some asymptomatic patients to indicate that they did not have the condition. Others used a lengthy period of waiting to confirm their view that they had a 'milder' or 'less serious' form of diabetes than other patients. CONCLUSIONS: Adequate input from practitioners is needed to ensure that diagnosis is fully exploited as a crucial period in which patients learn to adapt to their condition. Being explicit about the diagnosis at first contact may avoid the problem of patients feeling 'in limbo' or uncertain whether they have type 2 diabetes. Practitioners should convey to patients that post-diagnosis/initial care is a process, stages of this process should be clarified to avoid misunderstanding and services should be integrated during this interim period to best effect.

Issues of participation, ownership and empowerment in a community development programme: tackling smoking in a low-income area in Scotland.

Founded on community development principles and practice, the 'Breathing Space' initiative aimed to produce a significant shift in community norms towards non-toleration and non-practice of smoking in a low-income area in Edinburgh, Scotland. The effectiveness of Breathing Space was evaluated using a quasi-experimental design, which incorporated a process evaluation in order to provide a description of the development and implementation of the intervention. Drawing on qualitative data from the process evaluation, this paper explores the varied and sometimes competing understandings of the endeavour held by those implementing the intervention. The paper examines the principles that underpin health promotion in the community setting, particularly the concepts of ownership, empowerment and participation, and their differential interpretation and employment by participants. The data illustrate how these varied understandings had implications for the joint planning and implementation of Breathing Space objectives. In addition, the different understandings raise questions about the appropriateness and viability of utilizing community development approaches in this context.

'I came back here and started smoking again': perceptions and experiences of quitting among disadvantaged smokers.

This paper draws upon qualitative research with 100 smokers (50 male and 50 female) in two Scottish areas of disadvantage to investigate their perceptions and experiences of quitting. The fieldwork took place between 1999 and 2000, with data collected through in-depth individual interviews and the completion of a smoking day grid. While many interviewees wanted to quit, they drew on their understandings of habit and addiction to illustrate the difficulties which quitting posed. Addiction was referenced through accounts of actual and anticipated unpleasant withdrawal symptoms, while accounts of the difficulties associated with quitting drew primarily upon habitual usage and routine aspects of their lives. Interviewees reported interacting frequently with other smokers. They also highlighted how stressful aspects of their lives perpetuated habitual smoking and prompted relapse following periods of cessation. Although the contexts inhabited by the interviewees were crucial in inhibiting successful quitting attempts, these factors acted in conjunction with and exacerbated feelings of physiological dependence on tobacco. Interviewees were sceptical about the effectiveness of nicotine replacement therapy (NRT) other than in the immediate or short term. For the most part, interviewees felt that NRT could not address aspects of their lives that appeared to support and sustain smoking in the long term. The paper concludes that in order to facilitate and sustain smoking cessation, tobacco control interventions need to tackle both nicotine addiction and the material circumstances experienced by disadvantaged smokers.

"It's like an addiction first thing...afterwards it's like a habit": daily smoking behaviour among people living in areas of deprivation.

The paper draws on qualitative interviews with a sample of male and female smokers who live in areas of disadvantage in Edinburgh, Scotland, to examine their perceptions of habit and addiction and the implications for smoking behaviour. The paper shows how smokers have a sophisticated understanding of these concepts and the way in which they affected their smoking behaviour across the course of a 'typical' day. The paper argues that daily contexts which smokers inhabit either constrain or facilitate smoking and as such play a central role in the way in which they smoke. In contexts where smoking was constrained (by externally or self-imposed restrictions) smokers described how they employed various strategies to achieve and maintain what they perceived to be a desirable level of nicotine intake, such as by anticipatory smoking. Where restrictions on smoking were absent, men's and women's smoking appeared remarkably similar. However, for the most part, the contexts which men and women inhabited over the course of the day differed, with women assuming the largest share of domestic and child care responsibilities. Apparent gender differences in smoking behaviour appeared to be related to the different daily contexts which men and women inhabited. Crucially, the influences on smoking described by respondents in this study were closely related to circumstances of socio-economic deprivation.

Cultural context, older age and smoking in Scotland: qualitative interviews with older smokers with arterial disease.

This paper explores how smoking among older smokers with a smoking-related illness is influenced by the wider cultural context of smoking. The paper draws upon a Scottish qualitative interview study to explore lifecourse changes in smoking-related beliefs and behaviours, in current smokers between the ages of 65 and 84 years with arterial disease. The respondents' understanding of smoking, as a socially acceptable behaviour of their youth, had undergone dramatic change over the course of their lives. While some respondents continued to associate their current smoking with their, albeit reduced, participation in social activities, others now smoked at home alone and associated smoking with increasing levels of isolation in their lives. Through an examination of how social attitudes may contribute to smoking as a solitary activity, the paper highlights the implications of cultural context for the adaptive strategies that older people use to cope with the circumstances and conditions of later life. The paper concludes that the wider cultural context of smoking is influential in shaping smoking as either an isolated 'home' activity, or as a 'social' activity for those whose opportunities to smoke in the private sphere are limited by disapproval of significant others. Within the social context, however, these 'social' smokers experience further constraints which shape and reduce their smoking behaviour. The data suggest that in order to be successful with this group of smokers, further research is needed to identify aspects of the lives of older people that sustain smoking in later life. These data will be necessary to develop appropriate health promotion measures to successfully target aspects of lives that support smoking in later life.