Understanding how patients establish strategies for living with asthma: a qualitative study in UK primary care as part of IMP2ART.

BACKGROUND: In the context of a variable condition such as asthma, patient recognition of deteriorating control and knowing what prompt action to take is crucial. Yet, implementation of recommended self-management strategies remains poor. AIM: To explore how patients with asthma and parents/carers of children with asthma develop and establish recommended self-management strategies for living with asthma, and how clinicians can best support the process. DESIGN AND SETTING: A qualitative study in UK primary care. METHOD: Patients with asthma and parents/carers of children with asthma from 10 general practices were purposively sampled (using age, sex, and duration of asthma) to participate in focus groups or interviews between May 2016 and August 2016. Participants' experiences of health care, management of asthma, and views on supported self-management were explored. Interviews and focus group sessions were audio-recorded and transcribed verbatim. Iterative thematic analysis was conducted, guided by the research questions and drawing on habit theory in discussion with a multidisciplinary research team. RESULTS: A total of 49 participants (45 patients; 4 parents/carers) took part in 32 interviews and five focus groups. Of these, 11 reported using an action plan. Patients learnt how to self-manage over time, building knowledge from personal experience and other sources, such as the internet. Some regular actions, for example, taking medication, became habitual. Dealing with new or unexpected scenarios required reflective abilities, which may be supported by a tailored action plan. CONCLUSION: Patients reported learning intuitively how to self-manage. Some regular actions became habitual; dealing with the unexpected required more reflective cognitive skills. In order to support implementation of optimal asthma self- management, clinicians should consider both these aspects of self-management and support, and educate patients proactively.

IMP2ART systematic review of education for healthcare professionals implementing supported self-management for asthma.

Despite a robust evidence base for its effectiveness, implementation of supported self-management for asthma is suboptimal. Professional education is an implementation strategy with proven effectiveness, though the specific features linked with effectiveness are often unclear. We performed a systematic review of randomised controlled trials and controlled clinical trials (published from 1990 and updated to May 2017 using forward citation searching) to determine the effectiveness of professional education on asthma self-management support and identify features of effective initiatives. Primary outcomes reflected professional behaviour change (provision of asthma action plans) and patient outcomes (asthma control; unscheduled care). Data were coded using the Effective Practice and Organisation of Care Taxonomy, the Theoretical Domains Framework (TDF), and Bloom's Taxonomy and synthesised narratively. Of 15,637 articles identified, 18 (reporting 15 studies including 21 educational initiatives) met inclusion criteria. Risk of bias was high for five studies, and unclear for 10. Three of 6 initiatives improved action plan provision; 1/2 improved asthma control; and 2/7 reduced unscheduled care. Compared to ineffective initiatives, effective initiatives were more often coded as being guideline-based; involving local opinion leaders; including inter-professional education; and addressing the TDF domains 'social influences'; 'environmental context and resources'; 'behavioural regulation'; 'beliefs about consequences'; and 'social/professional role and identity'. Findings should be interpreted cautiously as many strategies were specified infrequently. However, identified features warrant further investigation as part of implementation strategies aiming to improve the provision of supported self-management for asthma.

A Grounded Theory of Sexual Minority Women and Transgender Individuals' Social Justice Activism.

Psychosocial benefits of activism include increased empowerment, social connectedness, and resilience. Yet sexual minority women (SMW) and transgender individuals with multiple oppressed statuses and identities are especially prone to oppression-based experiences, even within minority activist communities. This study sought to develop an empirical model to explain the diverse meanings of social justice activism situated in SMW and transgender individuals' social identities, values, and experiences of oppression and privilege. Using a grounded theory design, 20 SMW and transgender individuals participated in initial, follow-up, and feedback interviews. The most frequent demographic identities were queer or bisexual, White, middle-class women with advanced degrees. The results indicated that social justice activism was intensely relational, replete with multiple benefits, yet rife with experiences of oppression from within and outside of activist communities. The empirically derived model shows the complexity of SMW and transgender individuals' experiences, meanings, and benefits of social justice activism.

A pragmatic group sequential, placebo-controlled, randomised trial to determine the effectiveness of glyceryl trinitrate for retained placenta (GOT-IT): a study protocol.

INTRODUCTION: A retained placenta is diagnosed when the placenta is not delivered following delivery of the baby. It is a major cause of postpartum haemorrhage and treated by the operative procedure of manual removal of placenta (MROP). METHODS AND ANALYSIS: The aim of this pragmatic, randomised, placebo-controlled, double-blind UK-wide trial, with an internal pilot and nested qualitative research to adjust strategies to refine delivery of the main trial, is to determine whether sublingual glyceryl trinitrate (GTN) is (or is not) clinically and cost-effective for (medical) management of retained placenta. The primary clinical outcome is need for MROP, defined as the placenta remaining undelivered 15 min poststudy treatment and/or being required within 15 min of treatment due to safety concerns. The primary safety outcome is measured blood loss between administration of treatment and transfer to the postnatal ward or other clinical area. The primary patient-sided outcome is satisfaction with treatment and a side effect profile. The primary economic outcome is net incremental costs (or cost savings) to the National Health Service of using GTN versus standard practice. Secondary outcomes are being measured over a range of clinical and economic domains. The primary outcomes will be analysed using linear models appropriate to the distribution of each outcome. Health service costs will be compared with multiple trial outcomes in a cost-consequence analysis of GTN versus standard practice. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the North-East Newcastle & North Tyneside 2 Research Ethics Committee (13/NE/0339). Dissemination plans for the trial include the Health Technology Assessment Monograph, presentation at international scientific meetings and publication in high-impact, peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISCRTN88609453; Pre-results.

Exploring the perspectives of clinical professionals and support staff on implementing supported self-management for asthma in UK general practice: an IMP2ART qualitative study.

Despite an overwhelming evidence base, supported self-management of asthma is poorly implemented into routine practice. Strategies for implementation must address organisational routines, as well as provide resources for patients and training to improve professionals' skills. We aimed to explore the priority that primary care practices attach to asthma self-management, to describe their existing asthma management routines, and to generate innovative implementation strategies. We recruited 33 participants (23 general practitioners; seven nurses; three administrative staff) from 14 general practices. The 12 interviews and three focus groups were transcribed, coded and analysed thematically. Supported self-management was largely a nurse-led task within clinic-based annual reviews. Barriers included poor attendance at asthma clinics, lack of time, demarcation of roles, limited access to a range of tailored resources, and competing agendas in consultation, often due to multimorbidity. Suggestions for initiatives to improve the provision of supported self-management included emphasising the evidence for benefit (to influence prioritisation), improving teamwork (including team-based education), organisational strategies (including remote consulting) which need to fit within existing practice routines. Technology offers some potential solutions (e.g., improved templates, 'app'-based plans), but must be integrated with the practice information technology systems. Building on these insights, we will now develop a theoretically-based implementation strategy that will address patient, professional, and organisational buy-in, provide team-based education and offer a range of practical options and tools, which can be adapted and integrated within existing routines of individual practices.OVERCOMING THE ORGANISATIONAL BARRIERS TO IMPLEMENTING ASTHMA SELF-MANAGEMENT: Understanding the routines of primary care practices can suggest strategies to implement supported self-management in general practice. Supported self-management of asthma including provision of individual action plans improves patient health and reduces the burden on healthcare services, but is not well implemented in routine practice. As part of a large-scale programme to implement self-management into UK general practice, Hilary Pinnock at the University of Edinburgh and co-workers conducted interviews and focus groups with 33 participants from 14 general practices to explore the organisational routines that hinder or enable professionals to provide support asthma self-management. Poor attendance at asthma clinics, demarcation of roles, lack of time and limited access to tailored resources were identified as specific barriers. Improvements suggested included improved teamwork between doctors and other medical healthcare professionals, comprehensive training, and improvements to IT systems.

What Happened Next: Interviews With Mothers After a Finding of Child Maltreatment in the Household.

Child Protective Services (CPS) identifies over 700,000 victims of child maltreatment in the United States annually. Research shows that risk factors for these children may persist despite CPS intervention. Mothers have unique and often untapped perspectives on the experiences and consequences of CPS intervention that may inform future practice. We explored these perspectives through interviews with 24 mothers after a first-time CPS finding of maltreatment not resulting in out-of-home placement. Male partners were primary perpetrators in 21 cases, with mothers or sitters identified as perpetrators in remaining cases. Data were analyzed using grounded theory. Mothers described risk factors or Roots of maltreatment prior to CPS involvement and reported variable experiences with Recognition of and Response to maltreatment. Divergent Outcomes emerged: I Feel Stronger and We're No Better These findings provide an understanding of household experiences around child maltreatment that may support practice and policy changes to improve outcomes for vulnerable children.

The complexities of power in feminist multicultural psychotherapy supervision.

The goal of the present study was to understand how current feminist multicultural supervisors understand and implement their feminist multicultural principles into clinical supervision. We addressed this aim by answering the following research question: How do self-identified feminist multicultural psychotherapy supervisors conceptualize and practice feminist supervision that is explicitly multicultural? The perspectives of 14 participant supervisors were obtained by using semistructured initial interviews, follow-up interviews, and feedback interviews and were investigated via a feminist constructivist grounded theory design and analysis. Most participants identified as counseling psychologists (n = 12), women (n = 11) and temporarily able-bodied (n = 11); but they identified with diverse racial/ethnic, sexual, spiritual/religious, generational, and nationality statuses. A 7-category empirical framework emerged that explained how the participants anticipated and managed power in supervision. The core category, the complexities of power in supervision, explained how participants conceptualized power in supervisory relationships. The 6 remaining categories were bringing history into the supervision room, creating trust through openness and honesty, using a collaborative process, meeting shifting developmental (a)symmetries, cultivating critical reflexivity, and looking at and counterbalancing the impact of context. Limitations of the study, implications for research, and suggestions to use the theoretical framework to transform supervisory practice and training are discussed. (PsycINFO Database Record

Educating professionals to support self-management in people with asthma or diabetes: protocol for a systematic review and scoping exercise.

INTRODUCTION: Supported self-management for asthma helps people adjust their treatment in response to symptom changes. This improves day-to-day control and reduces the risk of asthma attacks and the need for emergency healthcare. However, implementation remains poor in routine clinical practice. This systematic review is part of a programme of work developing an intervention to help primary care practice teams embed self-management support into routine asthma care. The aim of the review is to synthesise the evidence regarding the effectiveness of educational interventions for professionals supporting self-management in people with asthma or diabetes (type 1 and type 2). These two conditions have the most robust evidence base for the effectiveness of implementing supported self-management. METHODS AND ANALYSIS: Electronic searches will be conducted in CENTRAL, MEDLINE, EMBASE, ISI Web of Science, CINAHL, PsycINFO, AMED, Global Health, WHO Global Health Library, ERIC, BNI, RDRB/CME and Google Scholar. Eligible studies are randomised controlled trials or controlled clinical trials published between 1990 and 2016 which evaluated professional education interventions facilitating asthma or diabetes supported self-management. Further relevant work will be identified from trial registries, citation searching and through contact with authors of included studies. This will be supplemented by scoping potentially relevant educational packages described in English language policy literature or health service websites. Screening, data extraction and risk of bias assessment (using the Cochrane Risk of Bias Tool) will be completed by two independent reviewers, with a third reviewer arbitrating where necessary. We plan a theoretically informed narrative synthesis of the aggregated data as heterogeneity is likely to preclude meta-analysis. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review. The results will be described in a paper submitted for peer-reviewed publication and will inform the development of an implementation intervention. STUDY REGISTRATION NUMBER: PROSPERO CRD42016032922.

The role of therapeutic optimism in recruitment to a clinical trial in a peripartum setting: balancing hope and uncertainty.

BACKGROUND: Hope has therapeutic value because it enables people to cope with uncertainty about their future health. Indeed, hope, or therapeutic optimism (TO), is seen as an essential aspect of the provision and experience of medical care. The role of TO in clinical research has been briefly discussed, but the concept, and whether it can be transferred from care to research and from patients to clinicians, has not been fully investigated. The role played by TO in research emerged during interviews with staff involved in a peripartum trial. This paper unpacks the concept of TO in this setting and considers the role it may play in the wider delivery of clinical trials. METHODS: The Got-it trial is a UK-based, randomised placebo-controlled trial that investigates the use of sublingual glyceryl trinitrate (GTN) spray to treat retained placenta. Qualitative data were collected in open-ended interviews with obstetricians, research and clinical midwives (n =27) involved in trial recruitment. Data were analysed using the method of constant comparison. RESULTS: TO influenced staff engagement with Got-it at different points in the trial and in different ways. Prior knowledge of, and familiarity with, GTN meant that from the outset staff perceived the trial as low risk. TO facilitated staff involvement in the trial; staff who already understood GTN's effects were optimistic that it would work, and staff collaborated because they hoped that the trial would address what they identified as an important clinical need. TO could fluctuate over the course of the trial, and was sustained or undermined by unofficial observation of clinical outcomes and speculations about treatment allocation. Thus, TO appeared to be influenced by key situational factors: prior knowledge and experience, clinical need and observed participant outcomes. CONCLUSIONS: Situational TO plays a role in facilitating staff engagement with clinical research. TO may affect trial recruitment by enabling staff to sustain the levels of uncertainty, or individual equipoise, necessary to collaborate with research while also responding to patients' clinical needs. Staff may benefit from training to deal with fluctuations in TO. TRIAL REGISTRATION: ISCRTN88609453 . Registered on 26 March 2014.

Recruiting and consenting into a peripartum trial in an emergency setting: a qualitative study of the experiences and views of women and healthcare professionals.

BACKGROUND: Recruiting and consenting women to peripartum trials can be challenging as the women concerned may be anxious, in pain, and exhausted; there may also be limited time for discussion and decision-making to occur. To address these potential difficulties, we undertook a qualitative evaluation of the internal pilot of a trial (Got-it) involving women who had a retained placenta (RP). We explored the experiences and views of women and staff about the information and consent pathway used within the pilot, in order to provide recommendations for use in future peripartum trials involving recruitment in emergency situations. METHODS: In-depth interviews were undertaken with staff (n = 27) and participating women (n = 22). Interviews were analysed thematically. The accounts of women and staff were compared to identify differences and similarities in their views about recruitment and consent procedures. RESULTS: Women and staff regarded recruitment as having been straightforward and facilitated by the use of simplified (verbal and written) summaries of trial information. Both parties, however, conveyed discordant views about whether fully informed consent had been obtained. These differences in perspectives appeared to arise from the different factors and considerations impinging on women and staff at the time of recruitment. While staff placed emphasis on promoting understanding in the emergency situation of RP by imparting information in clear and succinct ways, women highlighted the experiential realities of their pre- and post-birthing situations, and how these had led to quick decisions being made without full engagement with the potential risks of trial participation. To facilitate informed consent, women suggested that trial information should be given during the antenatal period, and, in doing so, articulated a rights-based discourse. Staff, however, voiced opposition to this approach by emphasising a duty of care to all pregnant women, and raising concerns about causing undue distress to the majority of individuals who would not subsequently develop a RP. CONCLUSIONS: By drawing upon the perspectives of women and staff involved in the same trial we have shown that they may operate within different experiential and ethical paradigms. In doing so, we argue for the potential benefits of drawing upon multiple perspectives when developing information and consent pathways used in future (peripartum) trials. TRIAL REGISTRATION: ISCRTN 88609453 .

Achieving trustworthiness in qualitative research: a pan-paradigmatic perspective.

In this article, as two researchers from different traditions in qualitative research (consensual qualitative research and grounded theory), the authors present their shared views on the critical elements of trustworthiness in qualitative data. In addition to making specific recommendations about the integrity of data, the balance between participant meaning and researcher interpretation, and clear communication and application of the findings, they identify ways in which these issues are difficult to negotiate within and across different qualitative approaches. The authors present examples from various qualitative studies, emphasize the need for a shared language to reduce confusion between qualitative traditions and with researchers from a more strictly quantitative orientation, and recommend particular approaches to establishing trustworthiness in qualitative research.

Prevalence of Helicobacter pylori in Indigenous Western Australians: comparison between urban and remote rural populations.

OBJECTIVES: To determine and compare the prevalence of Helicobacter pylori in an urban and a remote rural Western Australian Indigenous community. DESIGN: Cross-sectional study of Helicobacter pylori status determined by urea breath tests between mid-January 2003 and the end of June 2004. PARTICIPANTS: 520 self-selected fasting participants, comprising 270 members of the Martu community at Jigalong, Punmu and Parnngurr in the East Pilbara region (129 men, 141 women; age range, 2-90 years) and 250 people from the Perth Indigenous community (96 men, 154 women; age range, 3-75 years. RESULTS: The overall prevalence of H. pylori was 76%, but the prevalence in the remote rural community was 91%, compared with 60% in the urban community. The odds of having H. pylori were six times greater for rural than for urban participants (odds ratio [OR], 6.34; 95% CI, 3.89-10.33). Further, the overall odds of H. pylori infection in males (rural and urban combined) were greater than for females (OR, 1.61; 95% CI, 1.02-2.54). In both communities, the prevalence of infection remained relatively constant after the age of 10. CONCLUSIONS: The prevalence of H. pylori in the two Indigenous communities was two to three times higher than that in the non-Indigenous Australian population and higher than that shown in previous studies in Indigenous Australians.

A single dose of mifepristone (200 mg) in the immediate preovulatory phase offers contraceptive potential without cycle disruption.

A single dose of mifepristone is an effective emergency contraceptive and has potential as a regular "once-a-month" pill. If given in the early luteal phase, the formation of a secretory endometrium is inhibited or delayed and implantation of the embryo prevented. We have explored the effect of giving the mifepristone just prior to ovulation on the ovarian and endometrial cycle. Seven women with regular menstrual cycles were studied during a control cycle and then in a second cycle when 200 mg mifepristone was given within 24 h of ovulation, i.e., when luteinizing hormone (LH) in serum was >15 IU/L and the dominant follicle was >18 mm. Ovulation was confirmed within 48 h by ultrasound in five of the seven women. The remaining two women had luteinized unruptured follicle. Following mifepristone, menses occurred after a normal luteal phase compared to control cycle (13.7 +/- 0.7 vs. 13.7 +/- 0.9 days). In all subjects the endometrium on LH + 6 in the treatment cycle showed no, or very little, secretory changes, suggesting it was unlikely that pregnancy would have occurred. We conclude that mifepristone could be given as a "once-a-month" contraceptive pill without causing significant disruption in the menstrual cycle in the majority of women for a 4-day period from just prior to ovulation until LH + 3.

The acceptability of combined oral hormonal contraceptives in Shanghai, People's Republic of China.

Although combined oral hormonal contraceptives have been described as the most significant medical advance of the 20th century, the usage rate in the People's Republic of China is considerably lower than in developed countries. This survey aimed to explore the acceptability of combined oral hormonal contraceptives (COC) amongst women aged 18-35 years who attended the family planning clinic in the International Peace Maternity and Child Health Hospital in Shanghai, as well as amongst gynecologists who worked in the same hospital. In total, 500 clients and 89 gynecologists were recruited. Only 12% of the clients had ever used COC. Women with a lower educational level or parous women were more likely to use COC (p < 0.05). COC was the third most popular method recommended by the gynecologists (85.4%). Both groups were concerned about the risks and side effects of COC, especially younger doctors and doctors with fewer years of experience (p < 0.01). The results of the survey suggest that it is necessary to provide improved training about COC to reproductive-aged women and professionals to dispel misunderstandings of the pill.