Gender, households, and decision-making for wildfire safety.

This paper considers the impact of gendered norms on decision-making for wildfire preparation and response at the household level. Focusing on Australia, it provides a theoretical thematic analysis of data acquired in 107 interviews with residents of nine different localities. It builds on existing research on gender and disaster, as well as on decision-making and wildfires, and analyses the narratives that centre on 'split' households plans (where a male partner plans to stay and a female partner plans to evacuate) and disagreements within heterosexual couples as to an appropriate wildfire safety plan. The study finds that gender inequality and differences in gendered expectations are likely to create difficult conditions for negotiation between members of a heterosexual couple when there is disagreement over a plan and that this may contribute to risky decision-making practices and outcomes. The paper reiterates, therefore, the importance of taking into account the social construction of gender in wildfire research and policy.

Involving patients in clinical research: the Telescot Patient Panel.

BACKGROUND: To date, patient involvement in the development of clinical research work has been limited. In 2011, the Telescot research team commenced work on a feasibility trial to investigate home telemonitoring of blood pressure for people who have experienced stroke or transient ischaemic attack (TIA). The team decided to involve patients in the development of the research. OBJECTIVES: To improve research design through patient involvement. METHOD OF PATIENT INVOLVEMENT: A modified form of the 'Scrutiny Panel' approach was used to involve people who had stroke in the research project. RESULTS: The Patient Panel supported the research in three key ways: it informed patient communication; it presented patient perspectives on the applicability and usability of the intervention; and it guided the development of the qualitative study. DISCUSSION: The initiative was considered a positive experience for all. However, challenges were identified in terms of the time and cost implications of undertaking patient involvement. IMPLICATION FOR RESEARCH PRACTICE: Importance is attached to adequate project planning and development, partnership working with community-based organizations and the necessity for clear role delineation between patients and professionals to enable effective collaborative working. CONCLUSIONS: The Telescot Patient Panel was beneficial in supporting the development of the feasibility trial. The Panel approach was considered transferable to other clinical research contexts.

Qualitative study of telemonitoring of blood glucose and blood pressure in type 2 diabetes.

OBJECTIVES: To explore the experiences of patients and professionals taking part in a randomised controlled trial (RCT) of blood glucose, blood pressure (BP) and weight telemonitoring in type 2 diabetes supported by primary care, and identify factors facilitating or hindering the effectiveness of the intervention and those likely to influence its potential translation to routine practice. DESIGN: Qualitative study adopting an interpretive descriptive approach. PARTICIPANTS: 23 patients, 6 nurses and 4 doctors who were participating in a RCT of blood glucose and BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and deprivation status of the practice was sought. SETTING: 12 primary care practices in Scotland and England. METHOD: Data were collected via recorded semistructured interviews. Analysis was inductive with themes presented within an overarching thematic framework. Multiple strategies were employed to ensure that the analysis was credible and trustworthy. RESULTS: Telemonitoring of blood glucose, BP and weight by people with type 2 diabetes was feasible. The data generated by telemonitoring supported self-care decisions and medical treatment decisions. Motivation to self-manage diet was increased by telemonitoring of blood glucose, and the 'benign policing' aspect of telemonitoring was considered by patients to be important. The convenience of home monitoring was very acceptable to patients although professionals had some concerns about telemonitoring increasing workload and costs. CONCLUSIONS: Telemonitoring of blood glucose, BP and weight in primary care is a promising way of improving diabetes management which would be highly acceptable to the type of patients who volunteered for this study. TRIAL REGISTRATION NUMBER: ISRCTN71674628; Pre-results.

Mixed methods feasibility study for a trial of blood pressure telemonitoring for people who have had stroke/transient ischaemic attack (TIA).

BACKGROUND: Good blood pressure (BP) control reduces the risk of recurrence of stroke/transient ischaemic attack (TIA). Although there is strong evidence that BP telemonitoring helps achieve good control, none of the major trials have considered the effectiveness in stroke/TIA survivors. We therefore conducted a feasibility study for a trial of BP telemonitoring for stroke/TIA survivors with uncontrolled BP in primary care. METHOD: Phase 1 was a pilot trial involving 55 patients stratified by stroke/TIA randomised 3:1 to BP telemonitoring for 6 months or usual care. Phase 2 was a qualitative evaluation and comprised semi-structured interviews with 16 trial participants who received telemonitoring and 3 focus groups with 23 members of stroke support groups and 7 carers. RESULTS: Overall, 125 patients (60 stroke patients, 65 TIA patients) were approached and 55 (44%) patients were randomised including 27 stroke patients and 28 TIA patients. Fifty-two participants (95%) attended the 6-month follow-up appointment, but one declined the second daytime ambulatory blood pressure monitoring (ABPM) measurement resulting in a 93% completion rate for ABPM - the proposed primary outcome measure for a full trial. Adherence to telemonitoring was good; of the 40 participants who were telemonitoring, 38 continued to provide readings throughout the 6 months. There was a mean reduction of 10.1 mmHg in systolic ABPM in the telemonitoring group compared with 3.8 mmHg in the control group, which suggested the potential for a substantial effect from telemonitoring. Our qualitative analysis found that many stroke patients were concerned about their BP and telemonitoring increased their engagement, was easy, convenient and reassuring. CONCLUSIONS: A full-scale trial is feasible, likely to recruit well and have good rates of compliance and follow-up. TRIAL REGISTRATION: ISRCTN61528726 15/12/2011.

Telemonitoring for chronic heart failure: the views of patients and healthcare professionals - a qualitative study.

AIMS AND OBJECTIVES: To understand the views of patients and professionals on the acceptability and perceived usefulness of telemonitoring in the management of chronic heart failure in the context of day-to-day care provision. BACKGROUND: There is an increasing interest in the potential for telemonitoring to support the home-based management of patients with chronic heart failure. However, little is known about the views of patients and professionals on the use of telemonitoring in this context. A chronic heart failure telemonitoring service was set-up by NHS Lothian, Scotland, to evaluate the intervention. DESIGN: A qualitative design was adopted to explore the views of patients and professionals participating in the service. METHODS: Semi-structured interviews were undertaken with 18 patients (61% male, mean age 75 years) and five professionals participating at different time points in this new service. Interviews were audio recorded, coded and thematically analysed using the Framework approach. RESULTS: Five main themes were identified: 'information, support and reassurance'; 'compliance and dependence'; 'changes and challenges'; 'determining the criteria for patient applicability to telemonitoring'; and 'continuity of care'. CONCLUSION: Patients and professionals considered telemonitoring useful in the management of chronic heart failure, although with some caveats. Telemonitoring was popular with patients because they felt reassurance arising from what was perceived as continuous practitioner surveillance. Professionals expressed concern regarding perceived patient dependence on practitioner support. Increased workload was also a concern. Both groups acknowledged the need for improved technology and changes to service provision in order to better meet the intended objectives of the service. RELEVANCE TO CLINICAL PRACTICE: Although popular with patients, professionals emphasised the importance of case selection and adequate training and support, both for patients and themselves, in order to maximise the expected benefits of the service, particularly with regard to enabling self-management.

Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: a qualitative study embedded in a randomized controlled trial.

OBJECTIVE: To explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD). METHODS: Semi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient-practitioner relationships. Transcribed data were analyzed using the Framework approach. RESULTS: 38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring. CONCLUSION: Telemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of 'compliant self-management' may paradoxically have promoted dependence on professionals. PRACTICE IMPLICATIONS: Patients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support.

Continuity, but at what cost? The impact of telemonitoring COPD on continuities of care: a qualitative study.

BACKGROUND: Continuity of care is widely regarded as an important marker of quality in the management of patients with long-term conditions. New services that integrate telemonitoring into care pathways have potential to change aspects of continuity in both positive and negative ways. AIMS: A telemonitoring service for patients with chronic obstructive pulmonary disease (COPD) was introduced in Lothian, Scotland, in 2009. A qualitative study, nested within the TELESCOT COPD randomised control trial, was undertaken to explore the views of patients and professionals on telemonitoring. The perceived impact of telemonitoring on continuity of care was investigated as part of the research. METHODS: Semi-structured interviews were undertaken with 38 patients (47% male, mean age 67.5 years). A maximum variation sample in relation to age, sex, socio-economic background, disease severity, and compliance with telemonitoring was recruited. Thirty-two stakeholders (healthcare professionals and managers) were interviewed. Transcribed coded data were analysed thematically using the framework approach. Interpretation was supported by multidisciplinary discussion. RESULTS: Patients and healthcare professionals considered that relationship-based continuity of care was important in the delivery of telemonitoring services. Managers placed emphasis on improved continuity of clinical management as a means of reducing healthcare costs. However, professionals described many operational challenges arising from the 'bolting-on' of telemonitoring provision to existing usual care provision which, they considered, resulted in the proliferation of additional managerial discontinuities. CONCLUSIONS: Managers and healthcare professionals face major challenges in meeting demands for both relationship continuity and continuity of clinical management in the development of telemonitoring services.