Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study.

OBJECTIVE: To explore reasons for increased risk of hospital admission among south Asian patients with asthma. DESIGN: Qualitative interview study using modified critical incident technique and framework analysis. SETTING: Newham, east London, a deprived area with a large mixed south Asian population. PARTICIPANTS: 58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse. MAIN OUTCOME MEASURES: Patients' and health professionals' views on influences on admission, events leading to admission, general practices' organisation and asthma strategies, doctor-patient relationship, and cultural attitudes to asthma. RESULTS: South Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission. CONCLUSIONS: The different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

Referral for minor mental illness: a qualitative study.

BACKGROUND: Mild depression and anxiety are common problems in general practice. They can be managed by the general practitioner (GP) alone or referred. Previous quantitative studies have shown a large variation between GPs in terms of referral behaviour. The reasons for this variation are not fully understood. AIM: To describe and analyse GP's decision-making processes when considering who should be treating patients with minor mental illness, using a qualitative method. DESIGN OF STUDY: A qualitative interview study. SETTING: Twenty-three GPs in east London and Essex. METHOD: Subjects were chosen using a purposive sampling strategy and participated in one-to-one semi-structured interviews. A grounded theory approach was used for analysis. RESULTS: Two distinct referral strategies were identified--the 'containment' and the 'conduit' approaches. In addition, referrals were found to be of two types--proactive 'referrals to' and reactive 'referrals away'; for minor mental illness the 'referrals away' were found to predominate. Emotive as well as rational responses informed GP decision making on referral. CONCLUSIONS: Explanations of the variation in referral rates need to recognise the emotive responses of individual GPs to minor mental illness. The contribution of guidelines, which assume consistently rational responses to illness, may therefore be limited.

Linking general practices to the medical schools: qualitative issues.

The University Linked Practices (ULP) programme links general practices involved in undergraduate medical education with computer services provided through the school of medicine and dentistry. In-depth interviews were conducted with 26 staff involved in teaching undergraduate medical students in 15 general practices across east London and Essex. The interview schedule focused on the use of the computer, IT experience and training needs and the use of the computer network as a resource in undergraduate teaching. It is important to work with curriculum planners to ensure that computers are fully integrated into new courses.

Influence on general practitioners of teaching undergraduates: qualitative study of London general practitioner teachers.

OBJECTIVE: To examine the perceived effect of teaching clinical skills and associated teacher training programmes on general practitioners' morale and clinical practice. DESIGN: Qualitative semistructured interview study. SETTING: General practices throughout north London. SUBJECTS: 30 general practitioners who taught clinical skills were asked about the effect of teaching and teacher training on their morale, confidence in clinical and teaching skills, and clinical practice. RESULTS: The main theme was a positive effect on morale. Within teacher training this was attributed to developing peer and professional support; improved teaching skills; and revision of clinical knowledge and skills. Within teaching this was attributed to a broadening of horizons; contact with enthusiastic students; increased time with patients; improved clinical practice; improved teaching skills; and an improved image of the practice. Problems with teaching were due to external factors such as lack of time and space and anxieties about adequacy of clinical cover while teaching. CONCLUSION: Teaching clinical skills can have a positive effect on the morale of general practitioner teachers as a result of contact with students and peers, as long as logistic and funding issues are adequately dealt with.

Tensions between policy makers and general practitioners in implementing new genetics: grounded theory interview study.

OBJECTIVE: To explore general practitioners' perceptions of their role in implementing genetic technology. DESIGN: Grounded theory interview study. SETTING: Primary care. SUBJECTS: Purposive sample of 30 general practitioners with a further theoretical sample of 14. RESULTS: Inconsistencies were identified between policy makers' and general practitioners' definitions of general practitioners' role in implementing the new genetics. General practitioners emphasised the need to build on current practice, whereas policy makers focused on transforming practice to include the new specialised roles and skills. Two core themes were identified: genetics in a generalist context, which included appropriate generalist intervention, the ethical dilemmas implicit in the "therapeutic gap," the familial-hereditary distinction in primary care, and the implications for generalist identity, including the potential marginalisation of generalism. CONCLUSION: New technologies such as genetics that require implementation in general practice should be integrated within existing generalist frameworks.

Management of deliberate self harm in general practice: a qualitative study.

BACKGROUND: It has been estimated that the incidence of deliberate self harm (DSH) is at least 10 times that of suicide. Accident and emergency discharge figures also point to an almost doubling of reported cases of DSH in the early 1990s. AIM: To assess general practitioners' (GPs') views on, and educational requirements for, managing patients following an episode of DSH. METHOD: A qualitative study with 14 GPs (seven male and seven female) from two outer-London boroughs, selected in order to provide a maximum variety sample. Interviews took place between February and April 1997, and data were analyzed using the principles of grounded theory. RESULTS: Most GPs felt that all patients presenting with DSH should be assessed by a psychiatrist. They expressed a preference for working with a community psychiatric nurse rather than a counsellor. Suggestions to improve their working relationship with community mental health teams included provision of one centralized point of referral and ease of access to the service in times of crisis. GPs were sceptical of guidelines, emphasizing that they needed joint ownership in writing them, but most importantly that they needed adequate resources to implement them. Specific changes to postgraduate education were suggested, such as individual educational portfolios. CONCLUSION: Improved working relationships between GPs and community mental health teams are needed in order to provide a more efficient and effective service for patients. Lifelong learning needs to be adapted in a style and approach to suit GPs' individual requirements.

Qualitative methods: beyond the cookbook.

BACKGROUND: Qualitative methods appear increasingly in vogue in health services research (HSR). Such research, however, has utilized, often uncritically, a 'cookbook' of methods for data collection, and common-sense principles for data analysis. RESULTS AND CONCLUSIONS: This paper argues that qualitative HSR benefits from recognizing and drawing upon theoretical principles underlying qualitative data collection and analysis. A distinction is drawn between problem-orientated and theory-orientated research, in order to illustrate how problem-orientated research would benefit from the introduction of theoretical perspectives in order to develop the knowledge base of health services research.

Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics.

OBJECTIVE: To assess the medicalising effect of prescribing antibiotics for sore throat. SETTING: 11 general practices in England. DESIGN: Randomised trial of three approaches to sore throat: a 10 day prescription of antibiotics, no antibiotics, or a delayed prescription if the sore throat had not started to settle after three days. PATIENTS: 716 patients aged 4 and over with sore throat and an abnormal physical sign: 84% had tonsillitis or pharyngitis. OUTCOME MEASURES: Number and rate of patients making a first return with sore throat, pharyngitis, or tonsillitis. Early returns (within two weeks) and complications (otitis media, sinusitis, quinsy). Outcomes were documented in 675 subjects (94%). RESULTS: Mean follow up time was similar (antibiotic group 1.07 years, other two groups 1.03 years). More of those initially prescribed antibiotics initially returned to the surgery with sore throat (38% v 27%, adjusted hazard ratio for return 1.39%, 95% confidence interval 1.03 to 1.89). Antibiotics prescribed for sore throat during the previous year had an additional effect (hazard ratio 1.69, 1.20 to 2.37). Longer duration of illness (> 5 days) was associated with increased return within six weeks (hazard ratio 2.90, 1.70 to 4.92). Prior attendance with upper respiratory conditions was also associated with increased reattendance. There was no difference between groups in early return (13/238 (5.5%) v 27/437 (6%)), or complications (2/236 (0.8%) v 3/434 (0.7%)). CONCLUSIONS: Complications and early return resulting from no or delayed prescribing of antibiotics for sore throat are rare. Both current and previous prescribing for sore throat increase reattendance. To avoid medicalising a self limiting illness doctors should avoid antibiotics or offer a delayed prescription for most patients with sore throat.

Open randomised trial of prescribing strategies in managing sore throat.

OBJECTIVE: To assess three prescribing strategies for sore throat. DESIGN: Randomised follow up study. SETTING: 11 general practices in the South and West region. SUBJECTS: 716 patients aged 4 years and over with sore throat and an abnormal physical sign in the throat; 84% had tonsillitis or pharyngitis. Patients were randomised to three groups: prescription for antibiotics for 10 days (group 1,246 patients); no prescription (group 2,230 patients); or prescription for antibiotics if symptoms were not starting to settle after three days (group 3; 238 patients). MAIN OUTCOME MEASURES: Duration of symptoms; satisfaction and compliance with and perceived efficacy of antibiotics; time off school or work. Outcomes were documented in 582 subjects (81%). RESULTS: Median duration of antibiotic use differed significantly in the three groups (10 v 0 v 0 days, P < 0.001); 69% of patients in group 3 did not use their prescription. The proportion of patients better by day 3 did not differ significantly (37% v 35% v 30%, P = 0.28), nor did the duration of illness (median 4 v 5 v 5 days, P = 0.39), days off work or school (median 2 v 2 v 1, P = 0.13), or proportion of patients satisfied (96% v 90% v 93%, P = 0.09), although group 1 had fewer days of fever (median 1 v 2 v 2 days, P = 0.04). More patients in group 1 thought the antibiotics were effective (87% v 55% v 60%, P < 0.001) and intended coming to the doctor in future attacks (79% v 54% v 57%, P < 0.001). "Legitimation" of illness-to explain to work or school (60%) or family or friends (37%)-was an important reason for consultation. Patients who were more satisfied got better more quickly, and satisfaction related strongly to how well the doctor dealt with patient's concerns. CONCLUSION: Prescribing antibiotics for sore throat only marginally affects the resolution of symptoms but enhances belief in antibiotics and intention to consult in future when compared with the acceptable strategies of no prescription or delayed prescription. Psychosocial factors are important in the decision to see a general practitioner and in predicting the duration of illness.

Ethnicity and the sudden infant death syndrome: anthropological perspectives.

Comparative data on infant caring practices among Bangladeshi and Welsh families in Cardiff, and among Maori and white families in New Zealand, reveal qualitative differences in the infant sensory environment. An anthropological perspective is adopted to place SIDS, lone infant sleeping and parent:infant co-sleeping in a broader cultural context.

Mothers' awareness of risk-reducing measures for the sudden infant death syndrome.

A questionnaire was given to 37 mothers of infants under 12 months admitted to a hospital paediatric ward in August 1992 to assess their awareness of current risk-reducing recommendations for the sudden infant death syndrome (SIDS) and the role of health professionals in providing this information. Three mothers had not heard of SIDS; all were Bangladeshi. Twenty-seven mentioned lateral or supine lying, 18 overheating and 15 smoking. Only one mother actually volunteered that, as a risk-reducing measure, medical advice should be promptly sought if the baby became unwell. About one half of the mothers could name three of the four 'official' risk-reducing recommendations. In only seven mothers could there be recalled any information being given by health workers (hospital and community midwives, health visitor, general practitioner, etc.). For the best possible benefit to be derived from current risk-reducing campaigns we need to improve our understanding of how parents obtain relevant information and what role health professionals should have in this.

Sudden infant death syndrome: links with infant care practices.

OBJECTIVES: To investigate infant care practices in a small ethnic minority population within Britain that might suggest possible factors contributing to the low incidence of the sudden infant death syndrome in Asian populations. DESIGN: Ethnographic interviewing, a qualitative comparative method drawn from social anthropology. SETTING: Central Cardiff. SUBJECTS: Non-random sample of 60 mothers of Bangladeshi or Welsh ethnic origin and working or middle class occupational status, who had infants under one year old. None of the families interviewed had experienced a sudden infant death. RESULTS: Broad cultural contrasts emerged as a series of themes from the interview data: living patterns, family networks, sleeping patterns, and concepts of time and dependence. CONCLUSION: Bangladeshi infants were cared for in a consistently rich sensory environment; Welsh infants, in contrast, were more likely to experience alternating periods of high and low sensory input. Long periods of lone quiet sleep may be one factor that contributes to a higher rate of sudden deaths in white than in Asian infants.