Uptake of folic acid supplements before and during pregnancy: focus group analysis of women's views and experiences.

BACKGROUND: To reduce risk of neural tube defects, current guidance recommends that all women who could become pregnant should take a daily 400 µg folic acid supplement before conception and until the 12th week of pregnancy. It is recognised that compliance with this guidance is sub-optimal, although little is known about the reasons why. The present study aims to explore the rationale behind women's decision-making on folic acid supplement use to inform health communications. METHODS: Women attending routine health visitor led baby clinics completed a questionnaire to establish their folic acid use in their most recent pregnancy. Participants were then invited to join focus group discussions to explore motivators and barriers to folic acid supplement use before and during pregnancy. RESULTS: Of 292 women approached, 211 (70%) provided information on supplement use. Of these, 67 (31%) reported having taken folic acid supplements as recommended; 118 (56%) only during pregnancy [22 (18%) only intermittently]; and 26 (12%) had not taken folic acid at all. Eight focus group discussions were held comprising 24 participants. Discussions indicated the rationale behind current recommendations was known. Participants often linked folic acid use with morning sickness, and invoked busy lives, competing priorities for concern, and poor memory in accounting for intermittent use. Building a 'lay evidence base' from their own experiences, many cited healthy pregnancy outcomes without supplement use and expressed scepticism about its preventive action. CONCLUSIONS: The findings of the present study highlight the importance of guidance on the importance of daily folic acid supplement use, the severity of neural tube defects and the provision of evidence on risk reduction.

Senior health professional's perceptions of variations in medical practice: a qualitative and quantitative study.

Following the introduction of the UK General Medical Council's regulations on the handling of poor medical performance, an interview and survey study was carried out among senior health professionals in the National Health Service (NHS). The aims of the study were to explore the respondents' perceptions of poor medical performance and to seek their experience of handling poorly performing doctors. Sixteen interviews were held face to face, followed by 28 telephone interviews. Subsequently, using similar questions to those in the interview schedule, a survey was carried out among senior health professionals across the NHS. Interview results identified a number of barriers to resolving poor performance, such as the unwillingness of some doctors to seek advice and the protective culture which prevented complaints being made against doctors. Survey respondents had high standards by which they judged poor performance, but they were more hesitant about considering poor consultation skills as being of the same significance as poor technical skills. However, problems with communication skills were the most frequently reported type of poor performance. The new arrangements for handling NHS doctors whose performance is perceived to be poor have much to do to overcome the barriers to effective action expressed by the respondents in this study.

The role of qualitative research in broadening the 'evidence base' for clinical practice.

This paper presents the case for seeking to broaden the 'evidence base' of medicine and health care by the inclusion of qualitative research findings. In order for qualitative research to make a significant contribution, advocates of this approach must demonstrate its ability to address questions of relevance to practice and proponents of EBM must rethink their ideas as to what may constitute a research question. A definition of qualitative research is provided, highlighting the somewhat different assumptions which underpin this model. The potential contribution of qualitative findings is assessed and the paper examines the ways in which such insights can be utilized. Finally it addresses the question as to how qualitative findings can be incorporated in the 'evidence base'.

Acquiring qualitative skills for primary care research. Review and reflections on a three-stage workshop. Part 1: using interviews to generate data. Members of WoReN. Wolds Primary Care Research Network.

This paper reflects on one Primary Care Research Network's (WoReN's) experience of running a workshop on generating interview data, provided as the first of a three-part workshop concerned with acquiring qualitative interviewing skills. It discusses the aims and limitations of the short workshop format in meeting the needs of practitioners embarking on qualitative research, drawing upon and reviewing the relevant research methods literature, and makes suggestions with regard to designing and running research methods workshops within primary care.

Acquiring qualitative skills for primary care research. Review and reflections on a three-stage workshop. Part 2: analysing interview data. Members of WoReN. Primary Care Research Network.

This paper reflects on one Primary Care Research Network's (WoReN's) experience of running a workshop on analysing qualitative interview data, provided as the second of a three-part workshop concerned with acquiring qualitative interviewing skills. It discusses the aims and limitations of the short workshop format in meeting the needs of practitioners embarking on the process of analysing qualitative data, drawing upon and reviewing the relevant research methods literature. Particular attention is paid to the role of qualitative data analysis computer packages and the debate on 'grounded theory'. We conclude by making suggestions with regard to designing and running data analysis workshops within primary care.

NHS attitudes to good medical practice.

Perceptions of good medical practice among senior NHS staff were collected through a survey. There are differences between the perceived seriousness of poor communication skills and poor technical skills.

The case for combining qualitative and quantitative approaches in health services research.

A judicious combination of qualitative and quantitative methods can play a valuable role in health services research. This paper reviews the main reasons for combining methods: for different stages in a project; to compensate for the shortcomings of individual methods; and for the purpose of 'triangulation'. It examines the potential for qualitative approaches to contribute to quantitative work--by providing insights into the process of data construction, identifying relevant variables to be studied, furnishing explanations for unexpected or anomalous findings, and generating hypotheses or research questions for further investigation. Similarly, qualitative work can be enhanced by using quantitative techniques--albeit often in a modified form--in analysing data, developing sampling strategies, and amalgamating findings from separate qualitative studies. Although there is potential to develop multi-method approaches, there remains an important role for rigorous studies employing either qualitative or quantitative methods.

The use of focus groups to define patient needs.

Focus groups are enjoying unprecedented popularity. In this article, the advantages and disadvantages of the method are outlined with cautions against the uncritical adoption of focus groups designed according to the marketing research tradition. It is argued that focus groups require detailed planning, and some advice regarding the running of groups, and analysis of data is provided. Special attention is directed to the practical and ethical issues in using focus groups to define patient needs in the area of childhood inflammatory bowel disease. Finally, some suggestions for maximising the full potential of focus groups are presented. Focus groups, if used appropriately and judiciously, are an inherently flexible method. Ultimately, their use is constrained only by the research question and the imagination of the researcher.

Perceptions of good medical practice in the NHS: a survey of senior health professionals.

OBJECTIVES: To categorize senior health professionals' experience with poor medical practice in hospitals and in general practice, to describe perceptions which senior NHS staff have of good medical practice, and to describe how problems of poor medical practice are currently managed. DESIGN: A postal questionnaire survey. The questionnaire sought perceptions of good medical practice, asked participants to characterise deviations from good practice, and to describe experience with managing poor performance at the time of the introduction of the General Medical Council (GMC) performance procedures. SETTING: A range of NHS settings in the UK: hospital trusts, health authorities/boards, local medical committees, community health councils. SUBJECTS: Senior health professionals involved in the management of medical professional performance. MAIN MEASURES: Perceptions of what constitutes good medical practice. RESULTS: Most respondents considered that persistent problems related to clinical practice (diagnosis, management, and outcome and prescribing) would require local management and, possibly, referral to the GMC performance procedures. Informal mechanisms, including informal discussion, education, training, and work shifting, were the most usual means of handling a doctor whose performance was poor. Many took a less serious view of deficiencies in performance on manner and attitude and communication, although consultation skills rather than technical skills comprised the greatest number of complaints about doctors. CONCLUSIONS: Senior NHS professionals seem reluctant to consider persistently poor consultation skills in the same critical light as they do persistently poor technical practice. These attitudes may need to change with the implementation of clinical governance and updated guidance from the GMC on what constitutes good medical practice.

Mixing qualitative methods: quality assurance or qualitative quagmire?

Although the advisability of combining qualitative and quantitative approaches has been questioned on the grounds of incompatibility of epistemological assumptions that underpin the two paradigms, mixing methods within the qualitative paradigm has been viewed as a more straightforward enterprise. This article challenges this view, highlighting the existence of several qualitative traditions, each with its own distinctive set of assumptions about what constitutes appropriate research questions; theoretical frameworks; research settings; relationships with those whom we study; techniques for eliciting data; form and content of data; and approaches to analyzing, presenting, and disseminating data. Multimethod qualitative approaches can be seen to occupy a contested domain. Analytical rigor would be strengthened by acknowledging and addressing the potentially contradictory assumptions on which one draws when seeking to combine qualitative methods. As qualitative researchers, it is incumbent on us to pay attention to context--not just in terms of the data collected but in terms of our own methodological positions.

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

OBJECTIVE: To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. DESIGN: Multicentre randomised controlled trial. SETTING: 51 general practices linked to nine Scottish maternity hospitals. SUBJECTS: 1765 women at low risk of antenatal complications. INTERVENTION: Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. MAIN OUTCOME MEASURES: Comparisons of health service use, indicators of quality of care, and women's satisfaction. RESULTS: Continuity of care was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). CONCLUSION: Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.

Using focus groups in general practice research.

Recent years have seen a growing recognition of the appropriateness of qualitative methods in family practice. This has been paralleled by an upsurge of interest in focus group discussions as a method. Drawing on the experience of using focus groups with general practice teams as one component of a multi-method study this paper explores emergent orthodoxies regarding the use of focus groups and reviews the contribution which this method can make to research in general practice.

Responding to a challenge: nursing care and AIDS.

Those providing nursing services have been at the forefront in responding to the AIDS epidemic. This paper poses the question as to what extent AIDS work makes unique demands of nursing staff. It explores the implications of AIDS-related nursing work and considers these within the broader context of the role of nurses and their work environment. Although intense, many of the demands of AIDS-related work are also features of nursing in other contexts. There is thus potential to draw on already formulated training responses and to contribute significantly to ongoing debates about nursing and nurse education.

The implications of HIV/AIDS for a range of workers in the Scottish context.

Although there have been a great many surveys of staff members' attitudes to HIV/AIDS, there has been relatively little research which has focused on their actual responses to and experiences of AIDS-related work (Barbour, 1994a). In addition, much of the published work on AIDS workers assumes that the demands of this work are self-evident, contingent upon client contact, and unique to this area of work. The research findings presented here suggest that these assumptions may be unfounded and certainly do not provide a complete picture of what AIDS work involves for staff members. Although some of the stressors reported by workers related to concerns explored in existing literature they did not always experience these anticipated demands as being especially problematic. Workers also reported experiencing problems in responding to demands from more unexpected quarters, such as organizational aspects of the work, rather than those stemming from the nature of contact with clients. Moreover, many of the demands were not unique to HIV/AIDS, but are features of other types of work. In devising training programmes for AIDS workers educators need to be alert to the often overlooked potential of pre-existing training programmes in operation in other specialties. Many of the demands cited by workers as problematic related to the newness of such demands in the light of their own employment histories rather than to HIV/AIDS work itself, suggesting that individualized training packages might be more appropriate. In relation to the retention of staff, it is crucial that the many rewards which pertain to this area of work are acknowledged and capitalized upon.

The impact of working with people with HIV/AIDS: a review of the literature.

This review describes and discusses research on the experiences of professionals and volunteers who work face-to-face with people with HIV/AIDS. Although there is a rapidly growing body of research which examines the attitudes and experiences of staff involved in HIV/AIDS service provision, this work has, as yet, failed to produce a comprehensive picture of the ways in which the demands of HIV/AIDS-related work differ from those of other fields of work. Because studies have differed considerably, both in terms of focus and methods, few systematic comparisons between the experiences of different professional groups have been made. Research must have a comparative focus if we are to begin to distinguish those demands which are unique to HIV/AIDS from those to which satisfactory responses may have already been developed in parallel fields of work. Much of the work to date has assumed that the demands inherent in AIDS work are self-evident, but has failed to contextualize AIDS work in relation to other fields of service provision, the personal circumstances and career paths of workers, and the organizational structure within which work takes place. The studies have provided very little information about the process of adaptation to AIDS work and the rewards which may offset some of the stresses and demands of the work. This review attempts to provide a comprehensive overview of the research which has been carried out in relation to workers in different locations responding to different epidemic patterns and demands on services. It also attempts to contextualize the demands of HIV/AIDS-related work by comparing the demands and responses reported with regard to other types of work and makes recommendations for future research.

AIDS-related attitudes and knowledge among attenders at a Scottish family planning clinic.

AIDS-related attitudes and knowledge of 1,970 family planning clinic attenders were examined using a self-completion questionnaire. Attitudes towards testing varied depending on the sex, age and marital status of respondents. Knowledge of HIV transmission routes was generally good, although the fact that those most likely to be at risk of infection--the younger respondents and those not currently in steady relationships--were the least well-informed gives some cause for concern. Since family planning consultations are frequently the only contact these young sexually active individuals have with the health service the opportunities for health education on HIV/AIDS afforded by regular attendance at these clinics should be capitalized upon.

PIP: In Glasgow, Scotland, 1970 people responded to a survey about AIDS knowledge, attitudes, and practices at the main family planning clinic. Most favored AIDS services in family planning clinics. Responses concerning what groups should be tested for HIV varied(36% everyone; 56w all pregnant women; and 63% all homosexual men). Moreover, 77% felt intravenous drug users should be tested, yet this group do not represent the largest group of AIDS/HIV cases. Indeed respondents had a tendency to believe that testing programs should be directed at others and not themselves. Those 20 and those 30 tended to say everyone should be tested (p.0001). 25-29 respondents exhibited the least zeal for testing of all pregnant women (p.001), yet 51% felt pregnant women should be tested. 73% of men and 62% of women favored routine testing of homosexual men which may reflect homophobia (p.001). Married people and those in steady relationships also favored testing homosexual men (p.005). Only 26% of respondents believed they knew enough about AIDS whereas 54% believed they did not know enough. Those 20 and those not in a steady relationship were least likely to feel they were well informed (p.001 and p.005 respectively). Respondents basically knew how HIV is transmitted, but 16% thought that donating blood would transmit HIV and another 16% were not sure if it did or not. In fact, those 20 were most likely to believe they could get HIV through donating blood (p.0001). Only 83% knew that safe sex reduces risk. Those not in a steady relationship were least likely to know about safe sex (p.005) and that a mother can infect an unborn baby with HIV (p.05). Those 20 felt only homosexual men were at risk (p.05) and that one could tell if someone is HIV infected by looking at him/her (p.01). They also tended not to know about the risk of receiving blood transfusions in the past (p.0001).