Interpreting silence, documenting experience: an anthropological approach to the study of health service users' experience with HIV/AIDS care in Lothian, Scotland.

This paper presents a critique of "health service user satisfaction studies" as a forum for users' voice and influence in health services evaluation and development. The study of service user experience is discussed from a social anthropological perspective, which explicitly theorises the relationship between the theoretical/epistemological foundation of health services evaluation and its political effects. It is argued that "experience" and its articulation are products of a social and political process in which research is implicated. "Experience" is thus not a static and absolute entity which can be measured or described out of the context in which data on experience are elicited and recorded-a context of which the researcher is a part. Validating findings on service user experience proceeds from a consideration of the way power and authority structure the situations where statements of experience are elicited and includes a critical appraisal of the researcher's role and ways in which this influenced interaction with study participants. The challenge and responsibility of the researcher is to capture the expression of experience without removing it from the flow of time and the situation and context where people have some control over its articulation. Attention to silence is suggested as a part of this strategy. An action research project concerned with coordination of services for people with HIV in Lothian, Scotland, is introduced. Material on users' experience of services is presented and discussed. In conclusion, the effects of research on the organisation and content of communication in the service settings studied are considered.

From trial data to practical knowledge: qualitative study of how general practitioners have accessed and used evidence about statin drugs in their management of hypercholesterolaemia.

OBJECTIVES: To explore how general practitioners have accessed and evaluated evidence from trials on the use of statin lipid lowering drugs and incorporated this evidence into their practice. To draw out the practical implications of this study for strategies to integrate clinical evidence into general medical practice. DESIGN: Qualitative analysis of semistructured interviews. SETTING: General practices in Lothian. SUBJECTS: 24 general practitioners selected to obtain a heterogeneous sample. RESULTS: Respondents were generally aware of the evidence relating to the use of statins in secondary prevention of coronary heart disease, but they were less clear about the evidence in primary prevention. The benefits of statins in secondary prevention were clearer to them and the social and economic issues less complex than was the case for use in primary prevention. Respondents rarely said they appraised the methods and content of trials, rather they judged the trustworthiness of the source of trial evidence and interpreted it within the context of the economic and social factors which impinge on their practice. Moreover, trial data become relevant for routine practice only when underpinned by a consensus on these issues. CONCLUSION: Strategies to promote incorporation of evidence from clinical trials into everyday practice are likely to be effective if they tap into and build on the process of local consensus building. Strategies such as teaching critical appraisal skills and guideline development may have little effect if they are separated from this process.

General medical practice in a multicultural and multiracial environment: report from a multidisciplinary casework seminar.

The impact of culture and race on the doctor-patient relationship, and hence on management, treatment and outcome, is not yet part of medical training programmes. This is true for graduate and undergraduate levels. In order to explore the format for such training, a pilot inter professional seminar in transcultural casework was carried out in East London over two terms in 1987. The initiative for the course was taken by a small group of professionals in psychiatric, primary health care, probation and social services. Nafsiyat, an inter-cultural therapy centre based in London, was approached and asked to provide a facilitator for the seminar. Participation in the seminar and dissemination of the lessons learned formed part of the work of Community Roots Project, Department of General Practice, St Bartholomew's Hospital Medical College. The Project has worked, through development work, group work and training, to explore ways of strengthening relationships between primary health care facilities and the communities they serve. The paper outlines some of the issues discussed in the seminar.

A matter of methods: perspectives on the role of the British general practitioner in the care of people with HIV/AIDS.

This paper is a critique of, and a comment on, the debate about the role of British general practitioners (GPs) in HIV care. We argue that (1) this debate is conducted around arguments which leave significant aspects of GPs' contribution undocumented and unnoticed, and that (2) research has contributed to this omission. The paper reviews the history of the debate about GPs' involvement in HIV care and argues that social research using structured survey methods has reinforced the continuing negative image of GP care. The paper draws on an ethnographic research project in Lothian (Scotland) which found that many people with HIV strongly valued their ongoing personal relationship with their GP. People with HIV also valued the hospital-based outreach system which provided reliable and high quality care, but sometimes experienced the associated interprofessional information sharing and discussion as invasive and controlling. Their GP relationship was valued because it was outside this hospital-based system of care. The paper concludes by suggesting that future developments in GP care should build on this positive aspect of the GP-patient relationship.

The chief scientist reports ... co-ordination of care on discharge from hospital into the community for patients with HIV/AIDS in Lothian.

OBJECTIVE: To document service use by people living with HIV/AIDS discharged from hospital, to identify gaps and overlaps in service provision after discharge, and to evaluate liaison between hospital-based and community-based services. DESIGN: Four week follow-up diary and interview study of service users, and interview/questionnaire study of service providers. SETTING: Services used by people discharged from the wards of two units of two Lothian hospitals. SUBJECTS: All patients with HIV infection admitted to the wards of two units of two Lothian hospitals from October 1992 to February 1993, and their service providers. RESULTS AND CONCLUSION: General practitioners were the most contacted service post discharge, but general practitioners did not appear to play a co-ordination role in service provision. Liaison on discharge was found to be effective in terms of continuity of care in most cases; and from a service user perspective, liaison between hospital and primary care agencies did not appear a major concern. The majority of hospital discharges were organised in a setting with a large number of services, with complex communication patterns and informal procedures of discharge arrangements. This created uncertainty among service providers as to the arrangements which had been made, and fear and anxiety that they fall through. On the other hand, the informality of discharge procedures also ensured flexibility and responsiveness to unexpected events and changes in service users' circumstances and was a vital factor in continuity of care experienced by them. A more important issue for service users was the poor integration of services concerned with social/material support in the system of medical and emotional care.