The influence of internship training experience on Kenyan and Ugandan doctors' career intentions and decisions: a qualitative study.

BACKGROUND: Medical internship is a key period for doctors' individual career planning and also a transition period for the broader labour market. OBJECTIVES: We aimed to understand the complex set of factors influencing the career intentions and decisions of junior doctors, post-internship in Kenya and Uganda. METHODS: We conducted semi-structured interviews with 54 junior medical officers and 14 consultants to understand doctors' internship experiences and subsequent employment experiences. We analysed the data using a mix of a direct content approach, informed by an internship experience and career intentions framework developed primarily from high-income country literature, alongside a more inductive thematic analysis. RESULTS: Echoing the internship experience and career intentions framework, we found that clinical exposure during internship, work-life balance, aspects of workplace culture such as relationships with consultants and other team members, and concerns over future job security and professional development all influenced Kenyan and Ugandan doctors' career preferences. Additionally, we added a new category to the framework to reflect our finding that interns might want to 'fill a health system gap' when they choose their future careers, based on what they witness as interns. However, often career intentions did not match career and employment decisions due to specific contextual factors, most importantly a shortage of job opportunities. CONCLUSION: We have shown how internship experiences shape medical doctors' career intentions in Kenya and Uganda and highlighted the importance of job availability and context in influencing doctors' career choices.

Protocol for the Pathways Study: a realist evaluation of staff social ties and communication in the delivery of neonatal care in Kenya.

INTRODUCTION: The informal social ties that health workers form with their colleagues influence knowledge, skills and individual and group behaviours and norms in the workplace. However, improved understanding of these 'software' aspects of the workforce (eg, relationships, norms, power) have been neglected in health systems research. In Kenya, neonatal mortality has lagged despite reductions in other age groups under 5 years. A rich understanding of workforce social ties is likely to be valuable to inform behavioural change initiatives seeking to improve quality of neonatal healthcare.This study aims to better understand the relational components among health workers in Kenyan neonatal care areas, and how such understanding might inform the design and implementation of quality improvement interventions targeting health workers' behaviours. METHODS AND ANALYSIS: We will collect data in two phases. In phase 1, we will conduct non-participant observation of hospital staff during patient care and hospital meetings, a social network questionnaire with staff, in-depth interviews, key informant interviews and focus group discussions at two large public hospitals in Kenya. Data will be collected purposively and analysed using realist evaluation, interim analyses including thematic analysis of qualitative data and quantitative analysis of social network metrics. In phase 2, a stakeholder workshop will be held to discuss and refine phase one findings.Study findings will help refine an evolving programme theory with recommendations used to develop theory-informed interventions targeted at enhancing quality improvement efforts in Kenyan hospitals. ETHICS AND DISSEMINATION: The study has been approved by Kenya Medical Research Institute (KEMRI/SERU/CGMR-C/241/4374) and Oxford Tropical Research Ethics Committee (OxTREC 519-22). Research findings will be shared with the sites, and disseminated in seminars, conferences and published in open-access scientific journals.

Social networks and skilled health worker migration in Nigeria: An ego network analysis.

BACKGROUND: Nigeria provides a good case study for researchers, activists, and governments seeking to understand how social networks can help mitigate the negative impact of skilled health worker (SHW) migration in low and middle-income countries. This study aimed to map the social networks of SHWs and explore how they influence migration intentions. METHODS: We combined semi-structured qualitative interviews with an ego-network analysis of 22 SHWs living in Nigeria, used R-Studio to display and visualise their networks, and NVivo for thematic analysis of transcribed interviews. RESULTS: The network size and frequency of interaction were smaller among SHWs seeking to remain in Nigeria, however when compared to SHWs seeking to migrate, they had ties with a diverse group of stakeholders interested in improving health services. The influence of social networks on SHW migration intentions was observed within the following themes: access to information on migration opportunities, modelling of migration behaviour, support for decision making, and opportunities for policy engagement. CONCLUSION: The social networks of SHWs can aid the diffusion of norms that are relevant for improving SHW migration governance. Through their social networks, SHWs can improve awareness of the challenges associated with SHW migration among state actors and the public.

How do foundation year and internship experience shape doctors' career intentions and decisions? A meta-ethnography.

PURPOSE: Foundation years or internships are an important period for junior doctors to apply their knowledge and gain clinical competency. Experiences gained during the foundation years or internships are likely to inform newly qualified doctors' opinions about how they want to continue their career. We aimed to understand how medical doctors' internship experiences influence their career intention/decision. METHODS: We conducted qualitative evidence synthesis using meta-ethnography. We searched six electronic bibliographic databases for papers published between 2000-2020 and included papers exploring how foundation years or internship experiences shape doctors' career intention/decisions, including in relation to migration, public/private/dual practice preference, rural/urban preference, and specialty choice. We used the GRADE-CERQual framework to rate confidence in review findings. RESULTS: We examined 23 papers out of 6085 citations screened. We abstracted three high-level inter-related themes across 14 conceptual categories: (1) Deciding the personal best fit both clinically and in general (which option is 'more me'?) through hands-on and real-life experiences (2) Exploring, experiencing and witnessing workplace norms; and (3) Worrying about the future in terms of job market policies, future training and professional development opportunities. Confidence in findings varied but was rated high in 8 conceptual categories. CONCLUSIONS: Our meta-ethnographic review revealed a range of ways in which internship experience shapes medical doctors' career intentions/decisions allowing us to produce a broad conceptual model of this phenomenon. The results highlight the importance of ensuring sufficient, positive and inspiring clinical exposure, improving workplace environment, relationship and culture, refraining from undermining specific specialities and communicating contractual and job market policies early on to young doctors, in order to attract doctors to less popular specialties or work locations where they are most needed. We propose our conceptual model should be further tested in new research across a range of contexts.

The social networks of hospital staff: A realist synthesis.

OBJECTIVES: The social ties people have with one another are known to influence behaviour, and how information is accessed and interpreted. It is unclear, however, how the social networks that exist in multi-professional health care workplaces might be used to improve quality in hospitals. This paper develops explanatory theory using realist synthesis to illuminate the details and significance of the social ties between health care workers. Specifically we ask: How, why, for whom, to what extent and in what context, do the social ties of staff within a hospital influence quality of service delivery, including quality improvement? METHODS: From a total of 75 included documents identified through an extensive systematic literature search, data were extracted and analysed to identify emergent explanatory statements. RESULTS: The synthesis found that within the hospital workforce, an individual's place in the social whole can be understood across four identified domains: (1) social group, (2) hierarchy, (3) bridging distance and (4) discourse. Thirty-five context-mechanism-outcome configurations were developed across these domains. CONCLUSIONS: The relative position of individual health care workers within the overall social network in hospitals is associated with influence and agency. As such, power to bring about change is inequitably and socially situated, and subject to specific contexts. The findings of this realist synthesis offer a lens through which to understand social ties in hospitals. The findings can help identify possible strategies for intervention to improve communication and distribution of power, for individual, team and wider multi-professional behavioural change in hospitals.

African Hospital Libraries: How Shane Godbolt inspired and shaped a seedling.

The co-founderof African Hospital Libraries (AHL) chronicles how this charity grew from a tiny pop-up library set up by two VSO volunteers and the hospital management team, to establishing health care library services in three provincial government referral hospitals (Makeni, Bo, Kenema) in Sierra Leone, and supporting link-ups with a shared maternity and paediatric hospital library service in Freetown and two libraries in healthcare training institutions. She reflects on the impact that Shane Godbolt had and continues to have on the work and growth of the organisation.

Delivering integrated child development care in Pakistan: protocol for a clustered randomised trial.

BACKGROUND: Early childhood developmental delay is associated with significant disadvantage in adult life. In Pakistan, high prevalence of developmental delay is associated with poverty, under-nutrition, and maternal depression. AIM: To assess the effectiveness of an early child development counselling intervention delivered at private GP clinics, in poor urban communities. DESIGN & SETTING: A clustered randomised trial in Pakistan. METHOD: The intervention was developed following a period of formative research, and in consultation with local experts. A total of 2112 mother-child pairs will be recruited at 32 clinics, from within the locality (cluster); 16 clinics per arm. A primary care counselling intervention (promoting child development, nutrition, and maternal mental health) will be delivered at 6 weeks, 3, 6, and 9 months of the child's age. Monitoring, assessment, and treatment will also be performed at quarterly visits in intervention clinics. Primary outcome is the developmental delay at 12 months (ASQ-3 scores). Secondary outcomes are stunting rate, and maternal depression (PHQ-9 score). In addition, a process evaluation and costing study will be conducted. DISCUSSION: This trial will be the first to assess an early child development intervention, delivered in private GP clinics for poor urban communities in Pakistan. If found to be effective, this public-private model may offer a more sustainable, and feasible option for populations in poor urban settings, where private GP clinics are the most accessible provider of primary health care. There is scope for scale-up at provincial level, should the intervention be effective. TRIAL REGISTRATION: The trial has been registered with the Current Controlled Trials ISRCTN48032200.

Process evaluation of integrated early child development care at private clinics in poor urban Pakistan: a mixed methods study.

BACKGROUND: In poor urban Pakistan, private GP clinics lack adequate services to promote early child development (ECD) care. A clinic-based contextualised ECD intervention was developed for quarterly tool-assisted counselling of mothers. AIM: To explore the experience and implementation of ECD intervention by the private care providers and clients, for further adaptation for scaling of quality ECD care, at primary level private healthcare facilities in Pakistan. DESIGN & SETTING: A mixed methods approach using quantitative records review and qualitative interviews at poor urban clinics in Rawalpindi and Lahore, Pakistan. METHOD: Quantitative data from study-specific records were reviewed for 1242 mother-child pairs registered in the intervention. A total of 18 semi-structured interviews with clinic staff, mothers, and research staff were conducted at four clinics. The interviews were audiorecorded and transcribed verbatim. RESULTS: District Health Office (DHO) support allowed transparent and effective selection and training of clinic providers. Public endorsement of ECD care at private clinics and the addition of community advocates promoted ECD care uptake. Clinic settings were found feasible for clinic assistants, and acceptable to mothers, for counselling sessions. Mothers found ECD counselling methods more engaging compared to the usual care provided. CONCLUSION: In poor urban settings where public health care is scarce, minimal programme investment on staff training and provision of minor equipment can engage private clinics effectively in delivering ECD care.

Paying for Performance to Improve the Delivery and Uptake of Family Planning in Low and Middle Income Countries: A Systematic Review.

Paying for performance is a strategy to meet the unmet need for family planning in low and middle income countries; however, rigorous evidence on effectiveness is lacking. Scientific databases and grey literature were searched from 1994 to May 2016. Thirteen studies were included. Payments were linked to units of targeted services, usually modified by quality indicators. Ancillary components and payment indicators differed between studies. Results were mixed for family planning outcome measures. Paying for performance was associated with improved modern family planning use in one study, and increased user and coverage rates in two more. Paying for performance with conditional cash transfers increased family planning use in another. One study found increased use in the upper wealth group only. However, eight studies reported no impact on modern family planning use or prevalence. Secondary outcomes of equity, financial risk protection, satisfaction, quality, and service organization were mixed. Available evidence is inconclusive and limited by the scarcity of studies and by variation in intervention, study design, and outcome measures. Further studies are warranted.

Protocol for a pragmatic cluster randomised controlled trial for reducing irrational antibiotic prescribing among children with upper respiratory infections in rural China.

INTRODUCTION: Irrational use of antibiotics is a serious issue within China and internationally. In 2012, the Chinese Ministry of Health issued a regulation for antibiotic prescriptions limiting them to <20% of all prescriptions for outpatients, but no operational details have been issued regarding policy implementation. This study aims to test the effectiveness of a multidimensional intervention designed to reduce the use of antibiotics among children (aged 2-14 years old) with acute upper respiratory infections in rural primary care settings in China, through changing doctors' prescribing behaviours and educating parents/caregivers. METHODS AND ANALYSIS: This is a pragmatic, parallel-group, controlled, cluster-randomised superiority trial, with blinded evaluation of outcomes and data analysis, and un-blinded treatment. From two counties in Guangxi Province, 12 township hospitals will be randomised to the intervention arm and 13 to the control arm. In the control arm, the management of antibiotics prescriptions will continue through usual care via clinical consultations. In the intervention arm, a provider and patient/caregiver focused intervention will be embedded within routine primary care practice. The provider intervention includes operational guidelines, systematic training, peer review of antibiotic prescribing and provision of health education to patient caregivers. We will also provide printed educational materials and educational videos to patients' caregivers. The primary outcome is the proportion of all prescriptions issued by providers for upper respiratory infections in children aged 2-14 years old, which include at least one antibiotic. ETHICS AND DISSEMINATION: The trial has received ethical approval from the Ethics Committee of Guangxi Provincial Centre for Disease Control and Prevention, China. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, local and international conferences. TRIAL REGISTRATION NUMBER: ISRCTN14340536; Pre-results.

Impact of Contextual Factors on the Effect of Interventions to Improve Health Worker Performance in Sub-Saharan Africa: Review of Randomised Clinical Trials.

BACKGROUND: Africa bears 24% of the global burden of disease but has only 3% of the world's health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness. METHODS AND FINDINGS: A systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions' components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover. CONCLUSIONS: Interventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.

African Female Physicians and Nurses in the Global Care Chain: Qualitative Explorations from Five Destination Countries.

Migration of health professionals is an important policy issue for both source and destination countries around the world. The majority of migrant care workers in industrialized countries today are women. However, the dimension of mobility of highly skilled females from countries of the global south has been almost entirely neglected for many years. This paper explores the experiences of high-skilled female African migrant health-workers (MHW) utilising the framework of Global Care Chain (GCC) research. In the frame of the EU-project HURAPRIM (Human Resources for Primary Health Care in Africa), the research team conducted 88 semi-structured interviews with female and male African MHWs in five countries (Botswana, South Africa, Belgium, Austria, UK) from July 2011 until April 2012. For this paper we analysed the 34 interviews with female physicians and nurses using the qualitative framework analysis approach and the software atlas.ti. In terms of the effect of the migration on their career, almost all of the respondents experienced short-term, long-term or permanent inability to work as health-care professionals; few however also reported a positive career development post-migration. Discrimination based on a foreign nationality, race or gender was reported by many of our respondents, physicians and nurses alike, whether they worked in an African or a European country. Our study shows that in addition to the phenomenon of deskilling often reported in GCC research, many female MHW are unable to work according to their qualifications due to the fact that their diplomas are not recognized in the country of destination. Policy strategies are needed regarding integration of migrants in the labour market and working against discrimination based on race and gender.

'You can't stay away from your family': a qualitative study of the ongoing ties and future plans of South African health workers in the United Kingdom.

BACKGROUND: Migration of African-trained health workers to countries with higher health care worker densities adds to the severe shortage of health personnel in many African countries. Policy initiatives to reduce migration levels are informed by many studies exploring the reasons for the original decision to migrate. In contrast, there is little evidence to inform policies designed to facilitate health workers returning home or providing other forms of support to the health system of their home country. OBJECTIVE: This study explores the links that South African-trained health workers who now live and work in the United Kingdom maintain with their country of training and what their future migration plans may be. DESIGN: Semi-structured interviews were conducted with South African trained health workers who are now living in the United Kingdom. Data extracts from the interviews relating to current links with South Africa and future migration plans were studied. RESULTS: All 16 participants reported strong ongoing ties with South Africa, particularly through active communication with family and friends, both face-to-face and remotely. Being South African was a significant part of their personal identity, and many made frequent visits to South Africa. These visits sometimes incorporated professional activities such as medical work, teaching, and charitable or business ventures in South Africa. The presence and location of family and spouse were of principal importance in helping South African-trained health care workers decide whether to return permanently to work in South Africa. Professional aspirations and sense of duty were also important motivators to both returning and to being involved in initiatives remotely from the United Kingdom. CONCLUSIONS: The main barrier to returning home was usually the development of stronger family ties in the United Kingdom than in South Africa. The issues that prompted the original migration decision, such as security and education, also remained important reasons to remain in the United Kingdom as long as they were perceived as unresolved at home. However, the strong residual feeling of identity and regular ongoing communication meant that most participants expressed a sense of duty to their home country, even if they were unlikely to return to live there full-time. This is a resource for training and short-term support that could be utilised to the benefit of African health care systems.

Characteristics and clinical management of patients admitted to cholera wards in a regional referral hospital during the 2012 epidemic in Sierra Leone.

BACKGROUND AND OBJECTIVES: In 2012, Sierra Leone suffered a nationwide cholera epidemic which affected the capital Freetown and also the provinces. This study aims to describe the characteristics and clinical management of patients admitted to cholera isolation wards of the main referral hospital in the Northern Province and compare management with standard guidelines. DESIGN: All available clinical records of patients from the cholera isolation wards were reviewed retrospectively. There was no active case finding. The following data were collected from the clinical records after patients had left the ward: date of admission, demographics, symptoms, dehydration status, diagnoses, tests and treatments given, length of stay, and outcomes. RESULTS: A total of 798 patients were admitted, of whom 443 (55.5%) were female. There were 18 deaths (2.3%). Assessment of dehydration status was recorded in 517 (64.8%) of clinical records. An alternative or additional diagnosis was made for 214 patients (26.8%). Intravenous (IV) fluids were prescribed to 767 patients (96.1%), including 95% of 141 patients who had documentation of being not severely dehydrated. A history of vomiting was documented in 92.1% of all patients. Oral rehydration solution (ORS) was given to 629 (78.8%) patients. Doxycycline was given to 380 (47.6%) patients, erythromycin to 34 (4.3%), and other antibiotics were used on 247 occasions. Zinc was given to 209 (26.2%). DISCUSSION: This retrospective study highlights the need for efforts to improve the quality of triage, adherence to clinical guidance, and record keeping. CONCLUSIONS: Data collection and analysis of clinical practices during an epidemic situation would enable faster identification of those areas requiring intervention and improvement.

Security and skills: the two key issues in health worker migration.

BACKGROUND: Migration of health workers from Africa continues to undermine the universal provision of quality health care. South Africa is an epicentre for migration--it exports more health workers to high-income countries than any other African country and imports health workers from its lower-income neighbours to fill the gap. Although an inter-governmental agreement in 2003 reduced the very high numbers migrating from South Africa to the United Kingdom, migration continues to other high-income English-speaking countries and few workers seem to return although the financial incentive to work abroad has lessened. A deeper understanding of reasons for migration from South Africa and post-migration experiences is therefore needed to underpin policy which is developed in order to improve retention within source countries and encourage return. METHODS: Semi-structured interviews were conducted with 16 South African doctors and nurses who had migrated to the United Kingdom. Interviews explored factors influencing the decision to migrate and post-migration experiences. RESULTS: Salary, career progression, and poor working conditions were not major push factors for migration. Many health workers reported that they had previously overcome these issues within the South African healthcare system by migrating to the private sector. Overwhelmingly, the major push factors were insecurity, high levels of crime, and racial tension. Although the wish to work and train in what was perceived to be a first-class care system was a pull factor to migrate to the United Kingdom, many were disappointed by the experience. Instead of obtaining new skills, many (particularly nurses) felt they had become 'de-skilled'. Many also felt that working conditions and opportunities for them in the UK National Health Service (NHS) compared unfavourably with the private sector in South Africa. CONCLUSIONS: Migration from South Africa seems unlikely to diminish until the major concerns over security, crime, and racial tensions are resolved. However, good working conditions in the private sector in South Africa provide an occupational incentive to return if security did improve. Potential migrants should be made more aware of the risks of losing skills while working abroad that might prejudice return. In addition, re-skilling initiatives should be encouraged.

Why sub-Saharan African health workers migrate to European countries that do not actively recruit: a qualitative study post-migration.

BACKGROUND: Many studies have investigated the migration intentions of sub-Saharan African medical students and health professionals within the context of a legacy of active international recruitment by receiving countries. However, many health workers migrate outside of this recruitment paradigm. This paper aims to explore the reasons for migration of health workers from sub-Saharan Africa to Belgium and Austria; European countries without a history of active recruitment in sub-Saharan Africa. METHODS: Data were collected using semistructured interviews. Twenty-seven health workers were interviewed about their migration experiences. Included participants were born in sub-Saharan Africa, had trained as health workers in sub-Saharan Africa, and were currently living in Belgium or Austria, though not necessarily currently working as a health professional. RESULTS: Both Austria and Belgium were shown not to be target countries for the health workers, who instead moved there by circumstance, rather than choice. Three principal reasons for migration were reported: 1) educational purposes; 2) political instability or insecurity in their country of origin; and 3) family reunification. In addition, two respondents mentioned medical reasons and, although less explicit, economic factors were also involved in several of the respondents' decision to migrate. CONCLUSION: These results highlight the importance of the broader economic, social, and political context within which migration decisions are made. Training opportunities proved to be an important factor for migration. A further development and upgrade of primary care might help to counter the common desire to specialize and improve domestic training opportunities.

Cardiovascular risk scores: qualitative study of how primary care practitioners understand and use them.

BACKGROUND: The National Institute for Health and Care Excellence guidelines and the Quality Outcomes Framework require practitioners to use cardiovascular risk scores in assessments for the primary prevention of cardiovascular disease. AIM: To explore GPs understanding and use of cardiovascular risk scores. DESIGN AND SETTING: Qualitative study with purposive maximum variation sampling of 20 GPs working in Oxfordshire, UK. Method Thematic analysis of transcriptions of face-to-face interviews with participants undertaken by two individuals (one clinical, one non-clinical). RESULTS: GPs use cardiovascular risk scores primarily to guide treatment decisions by estimating the risk of a vascular event if the patient remains untreated. They expressed considerable uncertainty about how and whether to take account of existing drug treatment or other types of prior risk modification. They were also unclear about the choice between the older scores, based on the Framingham study, and newer scores, such as QRISK. There was substantial variation in opinion about whether scores could legitimately be used to illustrate to patients the change in risk as a result of treatment. The overall impression was of considerable confusion. CONCLUSION: The drive to estimate risk more precisely by qualifying guidance and promoting new scores based on partially-treated populations appears to have created unnecessary confusion for little obvious benefit. National guidance needs to be simplified, and, to be fit for purpose, better reflect the ways in which cardiovascular risk scores are currently used in general practice. Patients may be better served by simple advice to use a Framingham score and exercise more clinical judgement, explaining to patients the necessary imprecision of any individual estimate of risk.

When and how do GPs record vital signs in children with acute infections? A cross-sectional study.

BACKGROUND: NICE recommendations and evidence from ambulatory settings promotes the use of vital signs in identifying serious infections in children. This appears to differ from usual clinical practice where GPs report measuring vital signs infrequently. AIM: To identify frequency of vital sign documentation by GPs, in the assessment of children with acute infections in primary care. DESIGN AND SETTING: Observational study in 15 general practice surgeries in Oxfordshire and Somerset, UK. METHOD: A standardised proforma was used to extract consultation details including documentation of numerical vital signs, and words or phrases used by the GP in assessing vital signs, for 850 children aged 1 month to 16 years presenting with acute infection. RESULTS: Of the children presenting with acute infections 31.6% had one or more numerical vital signs recorded (269, 31.6%), however GP recording rate improved if free text proxies were also considered: at least one vital sign was then recorded in over half (54.1%) of children. In those with recorded numerical values for vital signs, the most frequent was temperature (210, 24.7%), followed by heart rate (62, 7.3%), respiratory rate (58, 6.8%), and capillary refill time (36, 4.2%). Words or phrases for vital signs were documented infrequently (temperature 17.6%, respiratory rate 14.6%, capillary refill time 12.5%, and heart rate 0.5%), Text relating to global assessment was documented in 313/850 (36.8%) of consultations. CONCLUSION: GPs record vital signs using words and phrases as well as numerical methods, although overall documentation of vital signs is infrequent in children presenting with acute infections.