Qualitative research and its place in health research in Nepal.

There has been a steady growth in recent decades in Nepal in health and health services research, much of it based on quantitative research methods. Over the same period international medical journals such as The Lancet, the British Medical Journal (BMJ), The Journal of the American Medical Association (JAMA) and the Journal of Family Planning and Reproductive Health Care and many more have published methods papers outlining and promoting qualitative methods. This paper argues in favour of more high-quality qualitative research in Nepal, either on its own or as part of a mixed-methods approach, to help strengthen the country's research capacity. After outlining the reasons for using qualitative methods, we discuss the strengths and weaknesses of the three main approaches: (a) observation; (b) in-depth interviews; and (c) focus groups. We also discuss issues around sampling, analysis, presentation of findings, reflexivity of the qualitative researcher and theory building, and highlight some misconceptions about qualitative research and mistakes commonly made.

Involving older people with multimorbidity in decision-making about their primary healthcare: A Cochrane systematic review of interventions (abridged).

OBJECTIVE: To assess the effects of interventions aimed at involving older people with multimorbidity in decision-making about their healthcare during primary care consultations. METHODS: Cochrane methodological procedures were applied. Searches covered all relevant trial registries and databases. Randomised controlled trials were identified where interventions had been compared with usual care/ control/ another intervention. A narrative synthesis is presented; meta-analysis was not appropriate. RESULTS: 8160 abstracts and 54 full-text articles were screened. Three studies were included, involving 1879 patient participants. Interventions utilised behaviour change theory; cognitive-behavioural therapy and motivational interviewing; multidisciplinary, holistic patient review and organisational changes. No studies reported the primary outcome 'patient involvement in decision-making about their healthcare'. Patient involvement was evident in the theory underpinning interventions. Certainty of evidence (assessed using GRADE) was limited by small studies and inconsistency in secondary outcomes measured. CONCLUSION: The evidence base is currently too limited to interpret with certainty. Transparency in design and consistency in evaluation, using validated measures, is required for future interventions involving older patients with multimorbidity in decisions about their healthcare. PRACTICE IMPLICATIONS: There is a large gap between clinical guidelines for multimorbidity and an evidence base for implementation of their recommendations during primary care consultations with older people.

Models of intrapartum care and women's trade-offs in remote and rural Scotland: a mixed-methods study.

OBJECTIVE: To explore women's preferences for, and trade-offs between, key attributes of intrapartum care models. DESIGN: Mixed-methods study using discrete choice experiments (DCEs) and focus groups. SETTING: The North of Scotland. POPULATION: Women from the catchment areas of eight rural maternity units in the North of Scotland. METHODS: Based on current policy, 'model of care' and 'time travelled' were selected as key attributes of intrapartum care in remote and rural settings. A DCE questionnaire explored women's preferences for and trade-offs between these attributes. Focus groups validated the DCE attributes and provided valuable information about the drivers of women's preferences for place of delivery. MAIN OUTCOME MEASURES: Preferences for attributes of intrapartum care. RESULTS: Eight focus groups were conducted, and 877 eligible women completed the questionnaire. Overall, the DCE results found women preferred delivery in a unit to home birth and consultant-led care (CLC) to midwife-managed care (MMC). Women preferring CLC associated it with covering every eventuality and increased safety. Although women preferred shorter travel times, trade-offs indicated a willingness to travel for approximately 2 hours to get one's preferred choice. Focus group findings and subgroup DCE analysis showed heterogeneity of preferences related to experience, risk status, geographic location, perception of care and family circumstances. CONCLUSIONS: In contrast to service redesign offering local midwife-managed intrapartum care, most rural women in our study expressed a preference to give birth in hospital and have CLC because they felt safer. Women were willing to travel for this but within limits. Qualitative results showed that women's preferences were influenced by their home and family context, beliefs and previous pregnancy experiences. Challenges for service redesign are to provide comprehensive obstetric services within acceptable travel time, while responding to the heterogeneity of women's preferences.

Awareness of health effects of cooking smoke among women in the Gondar Region of Ethiopia: a pilot survey.

BACKGROUND: The burning of biomass fuels results in exposure to high levels of indoor air pollution, with consequent health effects. Possible interventions to reduce the exposure include changing cooking practices and introduction of smoke-free stoves supported by health education. Social, cultural and financial constraints are major challenges to implementation and success of interventions. The objective of this study is to determine awareness of women in Gondar, Ethiopia to the harmful health effects of cooking smoke and to assess their willingness to change cooking practices. METHODS: We used a single, administered questionnaire which included questions on household circumstances, general health, awareness of health impact of cooking smoke and willingness to change. We interviewed 15 women from each of rural, urban-traditional and middle class backgrounds. RESULTS: Eighty percent of rural women cooked indoors using biomass fuel with no ventilation. Rural women reported two to three times more respiratory disease in their children and in themselves compared to the other two groups. Although aware of the negative effect of smoke on their own health, only 20% of participants realised it caused problems in children, and 13% thought it was a cause for concern. Once aware of adverse effects, women were willing to change cooking practices but were unable to afford cleaner fuels or improved stoves. CONCLUSION: Increasing the awareness of the health-effects of indoor biomass cooking smoke may be the first step in implementing a programme to reduce exposure.

Rural maternity care: can we learn from Wal-Mart?

In many countries rural maternity care is under threat. Consequently rural pregnant women will have to travel further to attend larger maternity units to receive care and deliver their babies. This trend is not dissimilar from the disappearance of other rural services, such as village shops, banks, post offices and bus services. We use a comparative approach to draw an analogy with large-scale supermarkets, such as the Wal-Mart and Tesco and their effect on the viability of smaller rural shops, depersonalisation of service and the wider community. The closure of a community-maternity unit leads to women attending a different type of hospital with a different approach to maternity care. Thus small community-midwifery units are being replaced, not by a very similar unit that happens to be further away, but by a larger obstetric unit that operates on different models, philosophy and notions of risk. Comparative analysis allows a fresh perspective on the provision of rural maternity services. We argue that previous discussions focusing on medicalisation and change in maternity services can be enhanced by drawing on experience in other sectors and taking a wider societal lens.

Maternity care models in a remote and rural network: assessing clinical appropriateness and outcome indicators.

BACKGROUND: Little is known about performance of small rural maternity units, including stand-alone midwife units. AIM: To describe the proportions of women delivering locally, clinical appropriateness of model of care at delivery and outcome indicators for three rural staffing models of care. DESIGN: Case note review. SETTING: Remote and rural maternity units in NHS North of Scotland Region. SUBJECTS AND METHODS: 1400 deliveries to women from the catchments of eight rural units (stratified by staffing model) included those in local rural units and in associated distant referral units. Descriptive analysis examined women's risk, clinical appropriateness of model of care at delivery and outcomes aggregated by local catchment unit type and delivery unit type. RESULTS: Local deliveries by staffing model were 31% (214/697) in midwife stand-alone units, 70% (236/336) in midwife units alongside non-obstetric medical support and 86% (317/367) in small obstetric-led units. Model of care at delivery was generally appropriate according to risk. Judged inappropriate were 3% (22/696) of women with complications delivering in midwife stand-alone units; and of referral unit deliveries, 6% (37/632) with suspected complications unconfirmed, plus 5% (31/633) discharged undelivered by referral hospital at >36 weeks' gestation. Risk profiles of catchment samples were similar, but caesarean section rates appeared lower and neonatal unit admissions higher for women from stand-alone midwife units. CONCLUSIONS: Rural women were generally referred appropriately for specialist care. These stand-alone midwife units provided intrapartum care for approximately one-third of rural women who remained without complications. Further evidence is needed about outcomes by staffing models of care.

"Choice" and place of delivery: a qualitative study of women in remote and rural Scotland.

OBJECTIVE: To explore women's perceptions of "choice" of place of delivery in remote and rural areas where different models of maternity services are available. SETTING AND METHODS: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. RESULTS: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from "acceptors" to "active choosers." The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in "choice." CONCLUSIONS: Provision of different models of maternity services may not be sufficient to convince women they have "choice." The paper raises fundamental questions about the meaning of "choice" within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh.

OBJECTIVE: To explore what happened to poor women in Bangladesh once they reached a hospital providing comprehensive emergency obstetric care (EmOC) and to identify support mechanisms. DESIGN: Mixed methods qualitative study. SETTING: Large government medical college hospital in Bangladesh. SAMPLE: Providers and users of EmOC. METHODS: Ethnographic observation in obstetrics unit including interviews with staff and women using the unit and their carers. RESULTS: Women had to mobilise significant financial and social resources to fund out of pocket expenses. Poorer women faced greater challenges in receiving treatment as relatives were less able to raise the necessary cash. The official financial support mechanism was bureaucratic and largely unsuitable in emergency situations. Doctors operated a less formal "poor fund" system to help the poorest women. There was no formal assessment of poverty; rather, doctors made "adjudications" of women's need for support based on severity of condition and presence of friends and relatives. Limited resources led to a "wait and see" policy that meant women's condition could deteriorate before help was provided. CONCLUSIONS: Greater consideration must be given to what happens at health facilities to ensure that (1) using EmOC does not further impoverish families; and (2) the ability to pay does not influence treatment. Developing alternative finance mechanisms to reduce the burden of out of pocket expenses is crucial but challenging. Increased investment in EmOC must be accompanied by an increased focus on equity.

Participating in a trial in a critical situation: a qualitative study in pregnancy.

BACKGROUND: Randomised controlled trials of interventions in critical situations are necessary to establish safety and evaluate outcomes. Pregnant women have been identified as a potentially vulnerable population. OBJECTIVE: To explore women's experiences of being recruited to ORACLE, a randomised controlled trial of antibiotics in pre-term labour. METHODS: Twenty qualitative interviews were conducted with women who had participated in ORACLE. Analysis was based on the constant comparative method. RESULTS: Women gave prominence to the socioemotional aspects of their interactions with healthcare professionals in making decisions on trial participation. Comments on the quality of written and spoken information were generally favourable, but women's accounts suggest that the stressful nature of the situation affected their ability to absorb the information. Women generally had poor understanding of trial design and practices. The main motivation for trial participation was the possibility of an improved outcome for the baby. The second and less prominent motivation was the opportunity to help others, but this was conditional on there being no risks associated with trial participation. In judging the risks of participation, women seemed to draw on "common sense" understandings including a perception that antibiotics were risk free. DISCUSSION: Recruitment to trials in critical situations raises important questions. Future studies should explore how rigorous governance arrangements for trials, particularly in critical situations, can protect participants rather than relying on ideals of informed consent that may be impossible to achieve. Future research should include a focus on interactions between research candidates and professionals involved in recruitment.

Access to specialist cancer care: is it equitable?

The first principle of the Calman-Hine report's recommendations on cancer services was that all patients should have access to a uniformly high quality of care wherever they may live. This study aimed to assess whether the uptake of chemotherapy for colorectal cancer varied by hospital type in Scotland. Hospitals were classified according to cancer specialisation rather than volume of patients. To indicate cancer specialisation, hospitals were classified as 'cancer centres', 'cancer units' and 'non-cancer' hospitals. Colorectal cancer cases were obtained from cancer registrations linked to hospital discharge data for the period January 1992 to December 1996. Multilevel logistic regression was used to model the binary outcome, namely whether or not a patient received chemotherapy within 6 months of first admission to any hospital. The results showed that patients admitted first to a 'non-cancer' hospital were less than half as likely to go on to receive chemotherapy as those first admitted to a cancer unit or centre (OR=0.28). This result was not explained by distance between hospital of first admission and nearest cancer centre, nor by increasing age or severity of illness. The study covers the period immediately preceding the introduction of the Calman-Hine report in Scotland and should serve as a baseline for future monitoring of access to specialist care.