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Biomedical subjects

Mary Dixon-Woods

Publications and source records attributed to Mary Dixon-Woods.

At least 19 recordsLinked to original sources
PubMed2006

Patients' perceptions of written consent: questionnaire study.

OBJECTIVE: To examine patients' understanding of the status, function, and remit of written consent to surgery. DESIGN: Prospective questionnaire study. Questionnaires were sent to patients within one month of surgery. Responses were analysed with frequencies and single variable analyses. SETTING: Large teaching hospital. PARTICIPANTS: 732 patients who had undergone surgery in obstetrics and gynaecology over a six month period. MAIN OUTCOME MEASURES: Patients' awareness of the legal implications of written consent and their views on the function and remit of the consent form. RESULTS: Patients had limited understanding of the legal standing of written consent. Nearly half (46%, 95% confidence interval 43% to 50%) of patients believed the primary function of consent forms was to protect hospitals and 68% (65% to 71%) thought consent forms allowed doctors to assume control. Only 41% (37% to 44%) of patients believed consent forms made their wishes known. CONCLUSIONS: Many patients seem to have limited awareness of the legal implications of signing or not signing consent forms, and they do not recognise written consent as primarily serving their interests. Current consent procedures seem inadequate as a means for the expression of autonomous choice, and their ethical standing and credibility can be called into question.

Consent Forms↗
PubMed2006

Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups.

BACKGROUND: Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK METHODS: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis. RESULTS: Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research. DISCUSSION: By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.

Health Services Accessibility↗
PubMed2006

Receiving a summary of the results of a trial: qualitative study of participants' views.

OBJECTIVE: To explore trial participants' responses to receiving a summary of the results of a trial in pregnancy. DESIGN: Qualitative study with semistructured interviews. PARTICIPANTS: 20 women who had when pregnant participated in the ORACLE trial of antibiotics for preterm labour and preterm rupture of the membranes and requested a copy of the trial results. RESULTS: Less than a fifth of women who participated in the ORACLE trial indicated that they wished to receive the trial results. Reactions to the leaflet summarising the trial results were generally positive or neutral, although some women had difficulty in understanding the leaflet, and there was evidence of possible negative implications for women who had adverse outcomes. Women requested the results because they were interested in being able to complete their own personal narrative. They wished to know to which arm of the trial they had been allocated and the implications for their own pregnancy, and they were disappointed with receiving a generic summary. Women's accounts indicated some confusion about the trial findings. CONCLUSIONS: Recommendations that research participants be routinely provided with the results of studies have been made without the benefit of research to show the consequences of doing this or how it should best be managed. Caution is needed, as is more evaluation of how feedback of results should be handled, and assessment of the risks, benefits, and costs.

Anti-Bacterial Agents↗
PubMed2006

Breaking the ceremonial order: patients' and doctors' accounts of removal from a general practitioner's list.

The removal of patients from general practitioners' (GPs) lists in the UK offers important sociological insights into what happens when the doctor-patient relationship 'goes wrong'. An interactionist analysis shows how removers (doctors) and removed (patients) strategically invoke 'rules of conduct' to account for difficulties in the doctor-patient relationship and for GPs' decisions to end their relationships with patients. In this paper we extend this analysis through recourse to Bourdieu's theory of practice, by juxtaposing 'paired' accounts of the same removal event by both remover and removed. Our analysis demonstrates the unthinking or non-reflective nature of people's understanding of the rules governing social interactions, but also demonstrates how apparent rule violations make the rules explicit and expose patterns of power distribution. We argue that removal of patients amounts to a strategic exercise of symbolic power by GPs, and that this is experienced as an overtly violent symbolic act by patients. A theoretical reconciliation of interactionist theories of the doctor-patient relationship with Bourdieu's theory of practice is both possible and profitable, providing a micro-macro link in which issues of capital and power within the health (care) field are brought to the fore.

Attitude to Health↗
PubMed2006

Researching chronic childhood illness: the example of childhood cancer.

OBJECTIVES: To provide an overview of issues raised by conducting research in the area of chronic childhood illness, using the example of childhood cancer. METHODS: This literature review used informal methods. RESULTS: Children with cancer and their families may participate in a wide variety of studies in different research traditions, including social science studies, epidemiological, biological and genetic research, and clinical trials. Different concerns about research participation have been raised in these different contexts. Sociological debate has tended to characterize exclusion from research as a manifestation of assumptions of poor competence on the part of children, and to see inclusion in research as a means of restoring proper balance in power relations and giving children a voice. The ethical imperative within clinical research, on the other hand, has been in favour of protection of individuals from risk or direct harm. Lack of consensus on issues such as the status of children's consent for research participation persists, in part because debates have taken place within rather than across disciplinary boundaries, and in part because of a tendency to debate issues as ethical principles in an empirical vacuum. The lack of research on the experiences and views of those asked to take part in childhood cancer research is striking. DISCUSSION: It is important that debates about the involvement of children in research are informed by high-quality social science research and by interdisciplinary dialogue.

Child↗
PubMed2005

Why do women consent to surgery, even when they do not want to? An interactionist and Bourdieusian analysis.

The 'informed consent' process has been placed at the centre of bioethical and policy discourses about how the autonomy and rights of patients can best be protected. Although there has been critical analysis of how the process functions in relation to participation in research and particular ethical 'dilemmas', there has been little examination of the routine business of consenting to medical procedures. Evidence is now beginning to emerge that people may consent to surgery even when reluctant to do so. In this paper, we develop an analysis informed by Bourdieusian and interactionist social theory of the accounts of 25 British women who consented to surgery in obstetrics and gynaecology. Of these, nine were ambivalent or opposed to having an operation. When faced with a consent form, women's accounts suggest that they rarely do anything other than obey professionals' requests for a signature. Women's capacity to act is reduced as they become enmeshed in the hospital structure of tacit, socially imposed rules of conduct. However, the interactionist account of power operating through the social rules of particular situated encounters, and the sanctions associated with rule-breaking, may not provide a sufficiently powerful explanation for why women submit to surgery they are opposed or ambivalent towards. Bourdieu's concepts of habitus, capital and symbolic power/violence offer a potentially more elaborated account, by showing how the practical logic that women apply in the field of surgery confers a 'sense of place' relative to professionals. Women experience deficits in capital, intensified by their physical vulnerability in critical situations, that severely constrain their ability to exercise choice. This work demonstrates the weakness of the consent process as a safeguard of autonomy. Far from reinforcing autonomy, the process may reinforce rather than disrupt passivity, but more generally our findings raise the question of the extent to which autonomy is an illusory goal.

Adult↗
PubMed2005

A qualitative study of choosing and using an NHS Walk-in Centre.

BACKGROUND: NHS Walk-in Centres have been introduced to improve access to healthcare in the UK. Little is understood about why people choose Walk-in Centres from among the range of options available to them. OBJECTIVES: To explore users' accounts of choosing and using an NHS Walk-in Centre. METHODS: Semi-structured interviews with 23 users who had recently attended an NHS Walk-in Centre were conducted. Analysis was based on the constant comparative method. RESULTS: Participants' accounts revealed two types of service use: those who knew what was wrong with them and had a clear idea of what treatment was required, and those seeking professional advice. Users reported "solidarity" with the NHS and other NHS users, and were highly sensitive to the demands on both Accident and Emergency and GP services in their choice of services. The Walk-in Centre appeared to function as a means of overcoming the barriers to healthcare associated with other healthcare services, although there was some lack of clarity about the purpose of the Walk-in Centre. CONCLUSIONS: Users' accounts suggest that NHS Walk-in Centres improve access to healthcare by opening up an alternative means of seeking a professional opinion or treatment. It is especially important in allowing people to use the NHS without feeling that they are increasing the burden on general practice and A&E facilities, and to feel that they are behaving responsibly while still meeting their own needs.

Adult↗
PubMed2005

Factors influencing repeat caesarean section: qualitative exploratory study of obstetricians' and midwives' accounts.

OBJECTIVE: To explore the views of health professionals on the factors influencing repeat caesarean section. DESIGN: Qualitative study involving semi-structured interviews with professionals who care for women in pregnancy and labour. SETTING: Acute hospital trust with two maternity units and community midwifery service, Leicestershire, UK. SAMPLE: Twenty-five midwives and doctors. METHODS: Interviews with professionals were undertaken using a prompt guide. All interviews were audiotaped and transcribed verbatim. Analysis was based on the constant comparative method, assisted by QSR N5 software. MAIN OUTCOME MEASURES: Identification of factors influencing professional decision making about repeat caesarean section. RESULTS: Decision making in relation to repeat caesarean is a complex process involving several parties. Professionals identify the relevance of evidence for decision making for repeat caesarean. However, professionals feel that following strict protocols is of limited value because of the perceived substandard quality of evidence in this area, other external pressures and the contingent, unique and often unanticipated features of each case. Professionals also perceive that the organisation of care plays an important role in rates of repeat caesarean. CONCLUSIONS: Decision making for repeat caesarean is a social practice where standardised protocols may have limited value. Attention needs to be given to the multiple parties involved in the decision-making process. Reflective practice, opinion leadership and role modelling may offer ways forward but will require evaluation.

Attitude of Health Personnel↗
PubMed2005

Synthesising qualitative and quantitative evidence: a review of possible methods.

BACKGROUND: The limitations of traditional forms of systematic review in making optimal use of all forms of evidence are increasingly evident, especially for policy-makers and practitioners. There is an urgent need for robust ways of incorporating qualitative evidence into systematic reviews. OBJECTIVES: In this paper we provide a brief overview and critique of a selection of strategies for synthesising qualitative and quantitative evidence, ranging from techniques that are largely qualitative and interpretive through to techniques that are largely quantitative and integrative. RESULTS: A range of methods is available for synthesising diverse forms of evidence. These include narrative summary, thematic analysis, grounded theory, meta-ethnography, meta-study, realist synthesis, Miles and Huberman's data analysis techniques, content analysis, case survey, qualitative comparative analysis and Bayesian meta-analysis. Methods vary in their strengths and weaknesses, ability to deal with qualitative and quantitative forms of evidence, and type of question for which they are most suitable. CONCLUSIONS: We identify a number of procedural, conceptual and theoretical issues that need to be addressed in moving forward with this area, and emphasise the need for existing techniques to be evaluated and modified, rather than inventing new approaches.

Bayes Theorem↗
PubMed2004

Finding qualitative research: an evaluation of search strategies.

BACKGROUND: Qualitative research makes an important contribution to our understanding of health and healthcare. However, qualitative evidence can be difficult to search for and identify, and the effectiveness of different types of search strategies is unknown. METHODS: Three search strategies for qualitative research in the example area of support for breast-feeding were evaluated using six electronic bibliographic databases. The strategies were based on using thesaurus terms, free-text terms and broad-based terms. These strategies were combined with recognised search terms for support for breast-feeding previously used in a Cochrane review. For each strategy, we evaluated the recall (potentially relevant records found) and precision (actually relevant records found). RESULTS: A total yield of 7420 potentially relevant records was retrieved by the three strategies combined. Of these, 262 were judged relevant. Using one strategy alone would miss relevant records. The broad-based strategy had the highest recall and the thesaurus strategy the highest precision. Precision was generally poor: 96% of records initially identified as potentially relevant were deemed irrelevant. Searching for qualitative research involves trade-offs between recall and precision. CONCLUSIONS: These findings confirm that strategies that attempt to maximise the number of potentially relevant records found are likely to result in a large number of false positives. The findings also suggest that a range of search terms is required to optimise searching for qualitative evidence. This underlines the problems of current methods for indexing qualitative research in bibliographic databases and indicates where improvements need to be made.

Breast Feeding↗
PubMed2004

Ending the doctor-patient relationship in general practice: a proposed model.

BACKGROUND: The doctor-patient relationship in general practice is often viewed by practitioner and patient alike as a long-term 'personal' relationship. Little, however, is known about how such relationships are ended in general practice. METHODS: This paper uses theoretical insights obtained from the sociology and social psychology of social relationships, together with the authors' own empirical work on the removal of patients from GPs' lists, to develop a theoretical model of ending the doctor-patient relationship in general practice. RESULTS: Ending the relationship involves 'breakdown' and 'termination'. 'Breakdown' in the relationship occurs when one party decides that the other has acted in such a way as to threaten that party's identity as a 'good' patient or doctor. 'Termination' may be patient initiated, doctor initiated or by mutual consent. CONCLUSIONS: It is proposed that further research is needed to delineate the rules and rituals governing entry into and maintenance of the doctor-patient relationship in general practice as well as those that govern its ending.

Attitude of Health Personnel↗
PubMed2004

Informed consent for elective and emergency surgery: questionnaire study.

OBJECTIVES: To evaluate women's experience of giving consent to obstetric and gynaecological surgery and to examine differences between those undergoing elective and emergency procedures. DESIGN: A prospective questionnaire study. SETTING: A large teaching hospital. POPULATION: 1006 consecutive patients undergoing elective or emergency surgery in obstetrics and gynaecology. METHODS: Questionnaires were administered to women who had given consent to surgery following the introduction of national guidelines and consent form. Differences in responses between elective and emergency patients were assessed using frequencies, single and multivariable analyses. MAIN OUTCOME MEASURES: Patients' experience and recall of the consent process, their overall satisfaction and their views on what is important for adequate consent. RESULTS: There were significant differences between patients undergoing elective or emergency surgery. Patients undergoing emergency surgery were less likely to have read (OR 0.22) or understood (OR 0.40) the consent form, and were more likely to report feeling frightened by signing it (OR 2.52). They were more likely to report they felt they had no choice about signing the consent form (OR 2.11), and that they would have signed regardless of its content (OR 3.14). Overall, significantly more patients undergoing elective (80%) or emergency (63%) surgery reported satisfaction with the consent process. Patients were more likely to report satisfaction if they read (OR 1.80) and agreed with (OR 3.49) the consent form, and if someone checked that they understood (OR 3.09). CONCLUSION: Patients' needs may not be adequately addressed by current guidelines for consent to treatment, particularly in emergency circumstances. The introduction of more complex forms and procedures appears to conflict with patients' need for personal communication and advocacy. The implications on the ethical and legal standing of consent are considerable.

Elective Surgical Procedures↗
PubMed2004

What do they know?: a content analysis of women's perceptions of trial information.

OBJECTIVE: To examine interpretations of study information by women participating in ORACLE, a trial of antibiotics in preterm labour. DESIGN: Questionnaire survey sent to women recruited to the ORACLE trial. SETTING: United Kingdom. POPULATION: A questionnaire was sent to 3074 ORACLE participants in a purposively selected sample of 55 collaborating maternity units, chosen to reflect a range of regions and of district general and teaching hospitals. METHODS: Content analysis was applied to verbatim text provided in response to an open question. Responses were also compared with a framework based on key points about the purpose of ORACLE. Closed questions were analysed using descriptive statistics. MAIN OUTCOME MEASURES: Participants' interpretations of the purpose of the study. RESULTS: A response rate of 61% was achieved, and 1462 participants provided written answers to a specific question on why the study was being carried out. Content analysis suggested that the information leaflet was highly valued as a source of information about the trial. There was evidence that women's interpretations of the purpose of the trial were not identical to those that the investigators intended. Of the five key points about the trial described in the information leaflet, 400 (27%) participants reported one key point, 550 (38%) two key points, 229 (16%) three key points and 23 (1.5%) four key points. None reported five key points and it was not possible to classify 46 responses (3%). Vague, confused understanding or poor recall were evident in 204 (14%) of responses. CONCLUSION: Although the ORACLE trial was run as a model of good practice at the time, this study suggests that it may not be possible to demonstrate full understanding of trial purpose and design by all participants. Emphasis should be on the provision of full information that involves consumers in its design and evaluation.

Anti-Bacterial Agents↗
PubMed2004

Organising services for influenza vaccination for older people.

OBJECTIVES: To follow up a trial of home-administered influenza vaccination of older people to explore reasons for their immunisation behaviour, including their views on the organisation of services. METHODS: Follow-up of original trial using analysis of records of 1865 older people and semi-structured interviews of 25 older people. RESULTS: A once-off home visit does not appear to result in sustained changes in immunisation behaviour. Older people's behaviour appears to be largely explained by their beliefs about immunisation; the organisation of services may exert only small effects. Older people can be characterised as belonging to one of four groups in their orientation towards influenza vaccination: the 'faithful', who are keen to have vaccination; the 'converts', who have been persuaded of the benefits of vaccination and are likely to self-initiate appointments for vaccination; the 'easy-going', who require prompting for vaccination; and the 'sceptics', who perceive influenza vaccination to be ineffective or to be irrelevant for them because of their perceived inherent resistance to influenza. The last group sees vaccination as a form of interference and may be resistant to home visits to administer the vaccine. CONCLUSIONS: Targets for immunising older people require more debate because of the delicate balance between achieving herd immunity and preserving autonomy and choice for older people.

Aged↗
PubMed2003

Patients' accounts of being removed from their general practitioner's list: qualitative study.

OBJECTIVE: To explore patients' accounts of being removed from a general practitioner's list. DESIGN: Qualitative analysis of semistructured interviews. SETTING: Patients' homes in Leicestershire. PARTICIPANTS: 28 patients who had recently been removed from a general practitioner's list. RESULTS: The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were "good" patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services "appropriately," were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These "bad" general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner's list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising. CONCLUSIONS: Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with "difficult" patients.

Adolescent↗
PubMed2003

Effect of NHS walk-in centre on local primary healthcare services: before and after observational study.

OBJECTIVE: To assess the effect of an NHS walk-in centre on local primary and emergency healthcare services. DESIGN: Before and after observational study. SETTING: Loughborough, which had an NHS walk-in centre, and Market Harborough, the control town. PARTICIPANTS: 12 general practices. MAIN OUTCOME MEASURES: Mean daily rate of emergency general practitioner consultations, mean number of half days to the sixth bookable routine appointment, and attendance rates at out of hours services, minor injuries units, and accident and emergency departments. RESULTS: The change between the before and after study periods was not significantly different in the two towns for daily rate of emergency general practice consultations (mean difference -0.02/1000 population, 95% confidence interval -0.75 to 0.71), the time to the sixth bookable routine appointment (-0.24 half-days, -1.85 to 1.37), and daily rate of attendances at out of hours services (0.07/1000 population, -0.06 to 0.19). However, attendance at the local minor injuries unit was significantly higher in Loughborough than Market Harborough (rate ratio 1.22, 1.12 to 1.33). Non-ambulance attendances at accident and emergency departments fell less in Loughborough than Market Harborough (rate ratio 1.17, 1.03 to 1.33). CONCLUSIONS: The NHS walk-in centre did not greatly affect the workload of local general practitioners. However, the workload of the local minor injuries unit increased significantly, probably because it was in the same building as the walk-in centre.

After-Hours Care↗