Experiences of non-UK-qualified doctors working within the UK regulatory framework: a qualitative study.

OBJECTIVE: To explore the experience of non-UK-qualified doctors in working within the regulatory framework of the General Medical Council (GMC) document Good Medical Practice. DESIGN: Individual interviews and focus groups. SETTING: United Kingdom. PARTICIPANTS: Non-UK-qualified doctors who had registered with the GMC between 1 April 2006 and 31 March 2008, doctors attending training/induction programmes for non-UK-qualified doctors, and key informants involved in training and support for non-UK-qualified doctors. MAIN OUTCOME MEASURES: Themes identified from analysis of interview and focus group transcripts. RESULTS: Information and support for non-UK qualified doctors who apply to register to work in the UK has little reference to the ethical and professional standards required of doctors working in the UK. Recognition of the ethical, legal and cultural context of UK healthcare occurs once doctors are working in practice. Non-UK qualified doctors reported clear differences in the ethical and legal framework for practising medicine between the UK and their country of qualification, particularly in the model of the doctor-patient relationship. The degree of support for non-UK-qualified doctors in dealing with ethical concerns is related to the type of post they work in. European doctors describe similar difficulties with working in an unfamiliar regulatory framework to their non-European colleagues. CONCLUSIONS: Non-UK-qualified doctors experience a number of difficulties related to practising within a different ethical and professional regulatory framework. Provision of information and educational resources before registration, together with in-practice support would help to develop a more effective understanding of GMP and its implications for practice in the UK.

Health services experiences of parents of recently diagnosed visually impaired children.

AIM: To investigate the health service experiences and needs of parents in the period around diagnosis of ophthalmic disorders in their children. METHODS: Parents of children newly diagnosed with visual impairment and/or ophthalmic disorders at a tertiary level hospital in London participated in a questionnaire survey, using standard instruments, followed by in-depth individual interviews, to elicit their views about the processes of care, their overall level of satisfaction, and their unmet needs. RESULTS: 67% (147) of eligible families (135 mothers, 76 fathers) participated. Overall satisfaction with care was high, being greater among parents of children with milder visual loss or isolated ophthalmic disorders than those with more severe visual loss or multiple impairments. Nevertheless, parents' reported greatest need was the provision of general information, including about their child's ophthalmic disorder and educational and social services and support. Mothers reported greater information needs than fathers, as did white parents compared to those from ethnic minorities. White parents also regarded the processes of care to be less comprehensive and coordinated, as well as less enabling, than did parents from ethnic minorities. CONCLUSIONS: Although parents reported high overall satisfaction with services, improving the medium, content, and scope of general information provided by professionals to parents of visually impaired children emerges as a priority. Equitable planning and provision of health services for families of children with visual impairment needs to take into account that informational and other needs vary by whether the parent is the primary carer or not and their ethnicity, as well as by the severity and complexity of their child's visual loss.

Secondary prevention of stroke--results from the Southern Africa Stroke Prevention Initiative (SASPI) study.

OBJECTIVE: To describe the prevalence of risk factors and experience of preventive interventions in stroke survivors, and identilfy barriers to secondary prevention in rural South Africa. METHODS: A clinician visited individuals in the Agincourt field site (in South Africa's rural north east) who were identified in a census as possible stroke victims to confirm the diagnosis of stroke. We explored the impact of stroke on the individual's family, and health-seeking behaviour following stroke by conducting in-depth interviews in the households of 35 stroke survivors. We held two workshops to understand the knowledge, experience, and views of primary care nurses, who provide the bulk of professional health care. FINDINGS: We identified 103 stroke survivors (37 men), 73 (71%) of whom had hypertension, but only 8 (8%) were taking anti-hypertensive treatment. Smoking was uncommon; 8 men and 1 woman smoked a maximum of ten cigarettes daily. 94 (91%) stroke survivors had sought help, which involved allopathic health care for most of them (81; 79%). 42 had also sought help from traditional healers and churches, while another 13 people had sought help only from those sources. Of the 35 survivors who were interviewed, 29 reported having been prescribed anti-hypertensive pills after their stroke. Barriers to secondary prevention included cost of treatment, reluctance to use pills, difficulties with access to drugs, and lack of equipment to measure blood pressure. A negative attitude to allopathic care was not an important factor. CONCLUSION: In this rural area hypertension is the most important modifiable risk factor in stroke survivors. Effective secondary prevention may reduce the incidence of recurrent strokes, but there is no system to deliver such care. New strategies for care are needed involving both allopathic and non-allopathic-health care providers.

Engaging families in health services research on childhood visual impairment: barriers to, and degree and nature of bias in, participation.

AIM: To investigate the barriers to, and degree and nature of bias in, participation in health services research by parents of children with visual impairment. METHODS: Parents of children newly diagnosed with ophthalmic disorders at Great Ormond Street Hospital, London, participated in a study to elicit their health service experiences and needs through a postal questionnaire survey followed by in-depth interviews. The participating and non-participating families were compared at different stages of recruitment, according to sociodemographic and clinical characteristics. RESULTS: 20% (55) of all eligible families could not be invited to participate because of out of date contact details for either the family and/or family doctor in the hospital and/or community record systems. Completed questionnaires were received from 67% (147/221) of contacted families, although only 6% actively declined to take part. Compared to non-participating parents, those who took part were more likely to be white British, from higher socioeconomic groups, have English as their main language, and have no other visually impaired family members. There were no significant differences according to the clinical characteristics of their affected children. CONCLUSIONS: Families from socioeconomically deprived and ethnic minority groups are likely to be less visible than others in health services research on childhood visual impairment. Geographical mobility in families of young children with visual disability poses a potentially important obstacle to engaging them in research on their experiences of health services. These findings indicate the importance of addressing potential biases in the design and interpretation of future studies, to ensure equity in recommendations for policy and practice, and in implementation of services.

Knowledge, action and resistance: the selective use of pre-natal screening among Bedouin women of the Negev, Israel.

The selective use of prenatal screening by Bedouin women attending Ministry of Health, maternal and child health clinics in Israel is examined. The data consist of a review of 537 prenatal care records, 16 in depth interviews with mothers, and four interviews with health personnel. These data are part of a larger study that took place between 1994-99 amongst Negev Bedouin women, part of the Palestinian Arab minority within Israel. The record review shows that the majority of women who attend prenatal care do not take up referrals for Maternal Serum Alpha Feto Protein (MSAFP) testing or for amniocentesis tests. Although many women interviewed talked about the value of prenatal screening, they also spoke of 'false alarms' that may result from testing. Similarly, women were aware that the socially preferred pattern of consanguinity in marriage amongst the Bedouin may cause medical problems, however test uptake was unrelated to consanguinity. There was a variety of views concerning the permissibility of terminating a pregnancy. This study shows that women use prenatal screening selectively in a way that helps them to balance social and medical risk.

Purchasing a quick fix from private pharmacies in the Gaza Strip.

Increasingly, it is recognised by health planners and social scientists that self medication with drugs bought over the counter in private pharmacies is extremely widespread. Some anthropologists see this trend as an aspect of the 'commodification of health'. In this study, group interviews with health service users and providers in Gaza revealed many health service users reporting an inadequate supply of drugs resulting in the purchasing of drugs in private pharmacies. As a result, a survey of the pattern of utilization of three private pharmacies in three contrasting urban areas within the Gaza Strip was undertaken. Using a questionnaire, data were collected from all customers buying drugs. The results show that variations in the patterns of health seeking behaviour were associated with socioeconomic status. Adult males were the most frequent customers of all three pharmacies. They were buying medicines for members of their nuclear family more often than for themselves. Overall, pain and influenza were the most commonly reported conditions. The drugs purchased most frequently for women were for reproductive health problems, particularly infertility. Customers of the pharmacy in the relatively prosperous area more commonly purchased drugs which were prescribed by a private doctor.

Addressing birth in Gaza: using qualitative methods to improve vital registration.

The use of anthropological qualitative methods to validate and improve health surveillance data is demonstrated through an examination of the process of birth registration in Gaza. Theoretically, the importance of understanding the link between historical events and microlevel decision-making is emphasized both in general terms and specifically in the context of the Gaza Strip today. In the course of interviewing a sample of mother/infant pairs selected from a register of births in the Gaza Strip it became evident that 100% of the addresses were incomplete. Using qualitative methods in the form of field visits and interviews with physicians, clerks and nurses, an understanding of the information pathway for birth registration data was developed. It was also established that there was some erroneous recording of birthweight. An intervention was designed which failed to improve the accuracy of addresses but did improve the recording of birthweight.

Factors influencing milk insufficiency and its long-term health effects: the Bedouin Infant Feeding Study.

Women who breastfeed have frequently reported milk insufficiency as the reason for introducing the bottle, but no one has addressed its potential long-term health effects. This paper described the factors associated with milk insufficiency versus another reason for introducing the bottle and its potential health effects based on an analysis of a prospective cohort study of 1005 Bedouin Arab women who delivered healthy newborns in 1981 and 1982. By two months postpartum, 72% introduced the infant to the bottle with 72% reporting milk insufficiency as the reason for introducing the bottle. The percentage of milk insufficiency declined with increasing age of the infant. Based on multiple logistic regression analyses, birth season was statistically significantly associated with the odds ratio (OR) of milk insufficiency versus another reason for introducing the bottle during the first two months. Women who delivered in the spring-summer had an increased OR = 1.65 of reported milk insufficiency compared with those who delivered during the rest of the year. Parity was directly related to the OR = 1.04 of milk insufficiency (but just missed significance) during one to two months and was statistically significantly associated with the OR = 1.12 of reported milk insufficiency during 3-18 months. The rates of stunting after the infant was introduced to the bottle and the duration of breastfeeding did not differ by reason for introducing the bottle. Thus the high frequency of reported milk insufficiency was not associated with adverse health effects.

PIP: 1005 Bedouin infants born in 1981-1982 at the Soroka Medical Center Hospital in the Negev, Israel were followed up determine those factors which influence milk insufficiency reporting compared with another reason and the possible effects of the reported reason for introducing the bottle on the rates of stunting and the duration of any breastfeeding. 72% of the mothers had already started bottle feeding their infants by 2 months as did those who claimed to have had insufficient milk. After 2 months, however, the rate of inadequate milk as a reason declined. For example, 50% gave milk insufficiency as a reason at 3-6 months postpartum and 28% at 7-18 months postpartum. Infants born in March-July were at significantly higher risk of being introduced to the bottle with milk insufficiency as the reason in the 1st 2 months of life than those born in other months (odds ratio [OR]=1.65). In early infancy, parity was just slightly related to milk insufficiency (OR=1.04). Yet multiparous women with a 3-18 month index child were more likely to state milk insufficiency as a reason to begin bottle feeding than primiparous mothers (OR=1.12). This was a result of a change from a seminomadic life style to a sedentary life style. Specifically, even though settling in urban areas brought them closer to family and the family visited more often during the traditional 40-day postpartum rest period, assistance during this period fell or was nonexistent. Further, household chores increased. Multiparous mothers needed a rest between breastfeeds and introducing the bottle allowed them this rest. Thus they gave milk insufficiency as justification for this behavior regardless of its occurrence or not. Neither the rates of stunting among infants introduced to the bottle nor duration of breastfeeding differed by reason for introducing the bottle. Thus the high rates of reported milk insufficiency did not adversely affect their health.

The Bedouin Infant Feeding Study: study design and factors influencing the duration of breast feeding.

A longitudinal study of infant feeding practices, growth and morbidity among Bedouin Arab infants residing in the Negev, Israel, was conducted during a 3-year period (1981-1983). Follow-up samples were restricted to healthy newborns. The majority of newborns are breast fed at birth but, by 2 months, 50% are also introduced to a milk supplement. Based on the bivariate analysis using the logrank test to examine the factors associated with exclusive versus partial breast feeding during the first 6 months, those born during the wet cool months are exclusively breast fed longer than those born during the dry season. More traditional women, living in tents rather than houses or huts, exclusively breast feed for at least 6 months. In a multiple logistic regression model, parity, house type and birth season are independently associated with the odds of exclusively breast feeding for the first 6 months of life. Factors influencing the duration of any breast feeding for the first 18 months include: house type, place of residence, birthweight, and whether the infant was stunted at 6 months.

PIP: Researchers followed healthy newborns of 945 Bedouin Arab mothers who delivered either at the hospital in Beer Sheva, Israel or at home during 1981-1982 to examine infant feeding practices. They interviewed the mothers shortly after delivery, at 6 months, and/or at 12 and 18 months. 90% of mothers exclusively breast fed their newborns, but by 2 months only 50% continued to exclusively breast feed. The proportion of infants born between January-May who were exclusively breast fed and those born between July-October was significantly different at around 4 months (29.4% vs. 19%; p.01). This trend was still significant at 6 months (17.7% vs. 7.2%; p.001). Further the log rank test showed a significant trend during the total 6 month period (p.05). In addition, during the total 6 month period, the more traditional Bedouin Arabs were more likely to exclusively breast feed than established women (p.01). Type of housing was the environmental factor which had the greatest influence on breast feeding. For example, at 6 months, 13.9% of mothers who lived in a tent exclusively breast fed compared to 9.1% who lived in a hut and 6.4 % who lived in a house (p.001). In addition, the more children a mother already had the less likely she would exclusively breast feed during the total 6 moth period (p.01). At 6 months, only 7.3% of mothers with 6 children compared to 13.4% with 0 children. The multiple logistic regression model of breast feeding for at least 6 months showed that parity, house type, and birth season were independently associated with exclusively breast feeding. The traditional Bedouin Arab lifestyle (living in tents or huts and in traditional or transitional encampments) contributed strongly to increased duration of breast feeding. Further birth weight and nutritional status at 6 months were independently associated with breast feeding at 18 months.

Perinatal factors influencing infant feeding practices at birth: the Bedouin Infant Feeding Study.

Bedouin Arab women delivering newborns at Soroka Medical Center, Israel, during 1 year were interviewed in hospital to determine the factors influencing infant feeding practices at birth. Eighty-six per cent breastfed, 11% breast and bottlefed, and 3% bottlefed at birth. Based on a multiple logistic regression analysis, the factors that significantly reduced the odds ratio (OR) of exclusive breastfeeding vs. breast and bottle feeding or bottle feeding at birth include: delivering during the high birth season (OR = 0.49); maternal recall of feeling unwell during pregnancy (OR = 0.59); delivering a low birthweight newborn (OR = 0.10); a newborn diagnosed with major malformations (OR = 0.30) or with major illnesses (OR = 0.32); and delivering by Caesarean section (OR = 0.09). In contrast, multiparae experienced an increased odds (OR = 1.67) of breastfeeding. Among primiparae, the factors that significantly reduced the odds of exclusive breastfeeding include: delivering during the high birth season (OR = 0.47); delivering a low birthweight newborn (OR = 0.12); and delivering by Caesarean section (OR = 0.18). Mothers of high-risk neonates and those who deliver by Caesarean section need to be educated about the benefits of exclusive breastfeeding. Young primiparae are a challenge and require qualitative and quantitative research into the reasons precluding exclusive breastfeeding.