Barriers and facilitators to uptake and retention of inner-city ethnically diverse women in a postnatal weight management intervention: a mixed-methods process evaluation within a feasibility trial in England.

OBJECTIVES: To understand the barriers and facilitators to uptake and retention of postnatal women randomised to a commercial group weight management intervention using the COM-B (capability, opportunity, motivation and behaviour) behaviour change model. DESIGN: Concurrent mixed-methods (qualitative dominant) process evaluation nested within a feasibility randomised controlled trial, comprising questionnaires and interviews at 6 and 12 months postbirth. SETTING: One National Health Service maternity unit in an inner city area in the south of England. PARTICIPANTS: 98 postnatal women with body mass indices>25 kg/m2 (overweight/obese) at pregnancy commencement. INTERVENTION: Twelve-week Slimming World (SW) commercial group weight management programme, commencing anytime from 8 to 16 weeks postnatally. PRIMARY AND SECONDARY OUTCOME MEASURES: Data regarding uptake and retention from questionnaires and interviews conducted 6 and 12 months postbirth analysed thematically and mapped to the COM-B model. RESULTS: Barriers to SW uptake mostly concerned opportunity issues (eg, lack of time or childcare support) though some women also lacked motivation, not feeling that weight reduction was a priority, and a few cited capability issues such as lacking confidence. Weight loss aspirations were also a key factor explaining retention, as were social opportunity issues, particularly in relation to factors such as the extent of group identity and relationship with the group consultant; and physical opportunity such as perceived support from and fit with family lifestyle. In addition, barriers relating to beliefs and expectations about the SW programme were identified, including concerns regarding compatibility with breastfeeding and importance of exercise. Women's understanding of the SW approach, and capability to implement into their lifestyles, appeared related to level of attendance (dose-response effect). CONCLUSIONS: Uptake and retention in commercial weight management programmes may be enhanced by applying behaviour change techniques to address the barriers impacting on women's perceived capability, motivation and opportunity to participate. TRIAL REGISTRATION NUMBER: ISRCTN39186148.

Protocol for a two-arm feasibility RCT to support postnatal maternal weight management and positive lifestyle behaviour in women from an ethnically diverse inner city population: the SWAN feasibility trial.

INTRODUCTION: A high BMI during and after pregnancy is linked to poor pregnancy outcomes and contributes to long-term maternal obesity, hypertension, and diabetes. Evidence of feasible, effective postnatal interventions is lacking. This randomised controlled trial will assess the feasibility of conducting a future definitive trial to determine effectiveness and cost-effectiveness of lifestyle information and access to Slimming World® (Alfreton, UK) groups for 12 weeks commencing from 8 to 16 weeks postnatally, in relation to supporting longer-term postnatal weight management in women in an ethnically diverse inner city population. METHODS/ANALYSIS: Women will be recruited from one maternity unit in London. To be eligible, women will be overweight (BMI 25-29.9 kg/m2) or obese (BMI ≥ 30 kg/m2) as identified at their first antenatal contact, or have a normal BMI (18.5-24.9 kg/m2) at booking but gain excessive gestational weight as assessed at 36 weeks gestation. Women will be aged 18 and over, can speak and read English, expecting a single baby, and will not have accessed weight management groups in this pregnancy. Women will be randomly allocated to standard care plus lifestyle information and access to Slimming World® (Alfreton, UK) groups or standard care only. A sample of 130 women is required.Feasibility trial objectives reflect those considered most important inform a decision about undertaking a definitive future trial. These include estimation of impact of lifestyle information and postnatal access to Slimming World® (Alfreton, UK) on maternal weight change between antenatal booking weight and weight at 12 months postbirth, recruitment rate and time to recruitment, retention rate, influence of lifestyle information and Slimming World® (Alfreton, UK) groups on weight management, diet, physical activity, breastfeeding, smoking cessation, alcohol intake, physical and mental health, infant health, and health-related quality of life 6 and 12 months postnatally. An embedded process evaluation will assess acceptability of study processes and procedures to women. ETHICS/DISSEMINATION: London-Camberwell St Giles Research Ethics Committee, reference: 16/LO/1422. Outcomes will be disseminated in peer-reviewed journals and presentations at national and international conferences. TRIAL REGISTRATION: Trial registration number: ISRCTN 39186148. Protocol version number: v7, 13 August 17. Trial sponsor: King's College London.

How patients use access to their electronic GP record--a quantitative study.

BACKGROUND: Record access is likely to become an integral part of routine care in the UK. While existing research suggests that record access improves self-care and improves relationships between patients and clinicians, little is known about how patients make use of their ability to access their records or the impact that this has on health behaviour. AIM: To explore patients' use of access to their electronic GP record and the impact of that process on their health behaviour. METHOD: Self-administered postal questionnaire mailed from three general practice surgeries to patients registered to use PAERS record access system. Data were analysed using SPSS. Content analysis was used to analyse free-text responses. RESULTS: Two hundred and thirty-one of 610 patients responded. Frequent users of Record Access were those in poor health. Record access was used to look at test results and to read letters from those involved in health care. Forty-two per cent reported a positive impact on following medication advice and 64% a positive impact on following lifestyle advice. Just over half the sample felt accessing records prior to appointments saved time and wanted to share records with other health care providers. Approximately a third reported difficulties with understanding their records. CONCLUSIONS: Record access appears to have a number of positive outcomes and very few negative ones, although further work is needed to confirm this. It is used by patients to help practices improve efficiency and to improve compliance. It has the potential to promote and reinforce collaborative relationships between clinicians and patients.

Health beliefs before and after participation on an exercised-based rehabilitation programme for chronic knee pain: doing is believing.

BACKGROUND: To explore the health beliefs, experiences, treatment and expectations of people with chronic knee pain, and investigate if, how and why these change after taking part on an integrated exercise-based rehabilitation programme--Enabling Self-management and Coping with Arthritis knee Pain through Exercise, ESCAPE-knee pain. METHODS: Semi-structured interviews were conducted with people with chronic knee pain, before (n=29) and after (n=23) participation on the programme. Thematic analysis was used to document people's baseline health beliefs, attitudes and cognitions, and to see if how and why these changed after completing the programme. RESULTS: Initially people had poor understanding and negative, fatalistic beliefs about the management or prognosis for knee pain. Following the programme the majority of participants had positive experiences describing improvement in pain, physical and psychosocial functioning, greater knowledge and understanding of their condition and treatment options, and in their ability to use exercise to control symptoms. Beliefs about the causation and prognosis of knee pain were unchanged, but their concerns about possible dangers of exercise had decreased, they appreciated how exercise could reduce symptoms (treatment beliefs) and their confidence in their ability to use exercise to effect improvements (exercise self-efficacy) increased. These improvements were attributed to the content and structure of the programme, and the care and guidance of the physiotherapist. Several expressed a need for on-going support. CONCLUSIONS: ESCAPE-knee pain appears to achieve improvements by increasing people's treatment belief in safety and the utility of exercise to control symptoms, rather than alteration in their beliefs about causation or prognosis. TRIAL REGISTRATION: Current Controlled Trials ISRCTN94658828.

Patient factors in the implementation of decision aids in general practice: a qualitative study.

BACKGROUND: Decision aids (DAs) have been developed to help patients make treatment decisions. Research shows that they are effective in increasing patients' knowledge of treatment options without raising anxiety or conflict. However, they have not been routinely adopted for use in general practice in the UK and there are few reports addressing strategies to introduce them. OBJECTIVE: To examine patients' views about a variety of DAs for different conditions (heart disease, osteoporosis, osteoarthritis and breast cancer) in order to inform a strategy to introduce them into general practice. SETTING AND PARTICIPANTS: General practice patients over the age of 18 years being or having been treated for one of the conditions above. METHODS: Qualitative study involving 12 focus groups with 77 patients evaluating decision aids relevant to their conditions. A semi-structured interview guide was used to generate discussions about the applicability of the DAs in routine general practice. RESULTS: Patients welcomed DAs for their educational and informational content. Reactions to the DAs were influenced by patients' own personal desires for involvement. The main concerns were that the use of DAs would potentially shift the onus of decision making responsibility on to the patient and about the practical challenges to implementation. CONCLUSIONS: Clinicians will need to make explicit to patients that DAs are an adjunct to routine care and not a replacement, and therefore do not represent a derogation of responsibility. DAs need to be used as an integral part of the communication and support process for patients who want them.

How patients use access to their full health records: a qualitative study of patients in general practice.

OBJECTIVE: To explore how patients use record access, its impact and the benefits and drawbacks of using it. DESIGN: Qualitative study using focus group interviews, individual interviews and telephone interviews. SETTING: General practice offering electronic access to full medical records using PAERS system. PARTICIPANTS: Forty-three patients aged between 20 and 71 years participated. Of these, nine were in the healthy group, eight had long-term health conditions, 10 were in the mental health group and 16 were pregnant. RESULTS: Three themes emerged as to how patients used record access - participation in care, quality of care and self-care strategies. Record access was used to help prepare patients for consultations, compensate for poor or complex communication during consultations and to reduce the fragmentation of care. Record access had a small impact on health behavior intentions. Overall patients felt that record access reinforced trust and confidence in doctors and helped them feel like partners in healthcare. CONCLUSION: This study suggests that record access improves shared management, with patients using their records to improve interactions with healthcare providers, make decisions about their health and improve the quality of the care they receive. These findings also suggest a possible long-term potential for record access to improve health outcomes.

Translators and mediators: bilingual young people's accounts of their interpreting work in health care.

The interpreting work bilingual young people do in health care settings has largely been seen as a social problem, indicating deficiencies either in parents' language skills or in the provision of professional interpreting services. Little research has addressed this contribution young people make to health care work from their perspectives. This study explored the accounts of bilingual young people from four linguistic groups in London, including those from established minority groups and those more recently arrived. Young people reported extensive experience of interpreting in a number of settings, and identified a range of benefits to themselves and their families arising from their contributions, as well as some problems faced in achieving successful encounters. Focusing on young people's own accounts enabled their work to be conceptualised not as merely 'inappropriate and inadequate interpreting' but as a varied contribution to the informal economy of health care that ranged from simple translation to complex mediation between families, the wider community and the health care system.

Women awaiting hysterectomy: a qualitative study of issues involved in decisions about oophorectomy.

OBJECTIVE: Women awaiting abdominal hysterectomy have a further decision to take--whether or not to undergo a prophylactic oophorectomy. Prophylactic oophorectomy (removal of healthy ovaries) is commonly undertaken as an adjunct to hysterectomy to prevent ovarian cancer in women who are already having a hysterectomy for menorrhagia, fibroids or severe menstrual pain. It causes an immediate 'surgical menopause'--women no longer produce endogenous oestrogens and they are advised to take hormone replacement therapy (HRT). This descriptive study was undertaken as part of a larger pilot study. DESIGN: Qualitative interviewing study. SETTING: Hospital outpatient departments in southern England. SAMPLE: Women on waiting lists for hysterectomy for benign conditions. METHODS: In-depth semi-structured interviews were undertaken with 16 women awaiting hysterectomy to examine their views of prophylactic oophorectomy, menopause and HRT use. Interviews were transcribed. Nud*ist was used to organise the data. Analysis was undertaken by two researchers working independently who then met to agree themes. RESULTS: Women held treatment preferences both about the removal or retention of their ovaries and about subsequent HRT use. Many of the women did not want oophorectomy because of a dislike of a sudden menopause. Those who were planning to have an oophorectomy tended to have more severe symptoms. Some women were fearful of ovarian cancer--one woman described it as a 'silent killer'. A further theme was apparent in the discussion of ovaries as 'redundant' with further discussion of healthy versus problematic ovaries. Many women felt inadequately informed about their treatment options and were unaware of important longer term outcomes of oophorectomy such as an increased risk of osteoporosis or of coronary heart disease. CONCLUSION: It appears that many women emphasise the 'natural' when considering oophorectomy and the use of HRT. Women were uneasy both about a sudden menopause and about the risks of ovarian cancer. And although these women were all about to undergo surgery, they had experienced an apparent serious lack of information especially about long term risks and benefits on which they might base their decision.

Women's views of two interventions designed to assist in the prophylactic oophorectomy decision: a qualitative pilot evaluation.

INTRODUCTION: A qualitative pilot evaluation of two different decision interventions for the prophylactic oophorectomy (PO) decision: a Decision Chart and a computerized clinical guidance programme (CGP) was undertaken. The Decision Chart, representing current practice in decision interventions, presents population-based information. The CGP elicits individual values to allow for quality-adjusted life years to be calculated and an explicit guidance statement is given. Prophylactic oophorectomy involves removal of the ovaries as an adjunct to hysterectomy to prevent ovarian cancer. The decision is complex because the operation can affect a number of long-term outcomes including breast cancer, coronary heart disease and osteoporosis. METHODS: Both interventions were based on the evidence and were administered by a facilitator. The Decision Chart is a file, which progressively reveals information in the form of bar charts. The CGP is a decision-analysis based program integrating the results from a cluster of Markov cycle trees. The research evidence is incorporated with woman's individual risk factors, values and preferences. A purposive sample of 19 women awaiting hysterectomy used the decision interventions (10 CGP, nine Decision Chart). In-depth semi-structured interviews were undertaken. Interviews were transcribed and analysed to derive themes. RESULTS: Reactions to the different decision interventions were mixed. Both were seen as clarifying the decision. Some women found some of the tasks difficult (e.g. rating health status). Some were surprised by the "individualized" guidance, which the CGP offered. The Decision Chart provided some with a sense of empowerment, although some found that it provided too much information. CONCLUSIONS: Women were able to use both decision interventions. Both provided decision clarification. Problems were evident with both interventions, which give useful pointers for future development. These included the possibility for women to see how their individual risks of different outcomes are affected in the Decision Chart and enhanced explanation of the CGP tasks. Future design and evaluation of decision aids, will need to accommodate differences between patients in the desire for amount and type of information and level of involvement in the decision-making process.