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Biomedical subjects

N Britten

Publications and source records attributed to N Britten.

At least 19 recordsLinked to original sources
PubMed2002

Pathways to HIV testing and care by black African and white patients in London.

OBJECTIVE: To examine factors associated with uptake of HIV clinic services by black African HIV positive people living in London. DESIGN: Questionnaire survey of patients attending study clinic. SETTING: HIV outpatient clinic in south London, UK. SUBJECTS: All HIV positive patients attending the clinic between July 1999 and March 2000. MAIN OUTCOME MEASURES: Use of health services, delay in seeking HIV test, pre-HIV test concerns, delay in uptake of HIV care, barriers to clinic use, disclosure, sources of support. RESULTS: 392 questionnaires were completed. Respondents were 64% white, 26% black African, and 10% from other ethnic groups. Twenty eight per cent of black Africans suspected they were HIV positive before diagnosis (white patients 45% (p<0.01)). Before testing 11% of black Africans had previously attended a genitourinary medicine clinic, 80% had consulted a GP. Twenty per cent of black Africans expressed concern over entitlement to care and where to get an HIV test. The majority of black Africans (66%) received HIV care within 1 month of their diagnosis. They were significantly (p<0.01) less likely than white patients to disclose their HIV status to family and friends. CONCLUSION: This study suggests that although black Africans are a high risk group for HIV infection they generally do not suspect their status. While they may delay testing, their uptake of HIV clinic care and use of statutory and voluntary support services after diagnosis is similar to their white counterparts. However, they lack informal support networks. This study highlights the continuing need for health promotion work among London's African communities, to reduce the stigma surrounding HIV/AIDS and to raise awareness of the benefits of testing.

Adult↗
PubMed2001

Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor-patient communication in general practice.

Mishler (The discourse of medicine. The dialectics of medical interviews. Norwood, NJ: Ablex), applying Habermas's theory of Communicative Action to medical encounters. showed how the struggle between the voice of medicine and the voice of the lifeworld fragmented and suppressed patients' multi-faceted, contextualised and meaningful accounts. This paper investigates and critiques Mishler's premise that this results in inhumane, ineffective medical care. Using a more complex data collection strategy, comprising patient interviews, doctor interviews and transcribed consultations we show more complex relations than emerged from Mishler's analysis. We found four communication patterns across 35 general practice case studies. When doctor and patient both used the voice of medicine exclusively (acute physical complaints) this worked for simple unitary problems (Strictly Medicine). When both doctor and patient engaged with the lifeworld, more of the agenda was voiced (Mutual Lifeworld) and patients were recognised as unique human beings (psychological plus physical problems). Poorest outcomes occurred where patients used the voice of the lifeworld but were ignored (Lifeworld Ignored) or blocked (Lifeworld Blocked) by doctors' use of voice of medicine (chronic physical complaints). The analysis supports the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings. Some doctors switched communication strategies in different consultations, which suggests that their behaviour might be open to change. If doctors could be sensitised to the importance of dealing with the concerns of the lifeworld for patients with chronic physical conditions as well as psychological conditions, it might be possible to obtain better care for patients. This would require attention to structural aspects of the healthcare system to enable doctors to work fully within the patient-centred model.

Adult↗
PubMed2001

Adherence to antibiotics prescribed in an accident and emergency department: the influence of consultation factors.

The objective of this study was to investigate the extent of non-adherence to prescribed antibiotics and the relationship of non-adherence to consultation and attitudinal factors. Self-completion postal questionnaires were sent to 202 consecutive adult attenders to an accident and emergency (A&E) department who had been given antibiotics to take home, within a week of the A&E attendance. The questionnaire included a detailed log of dosing, two sections of eight questions each on the patients' perceptions of the consultation and of their attitudes to medicines in general, which were marked on Likert scales; and questions inviting free text answers. Efforts were made to maximize the response rate, and to contact a random sample of 10 non-responders to assess any non-response bias. The response rate was 56%. The non-responders sampled reported similar non-adherence to that of the responders. Of the 113 responders, 10 (9%) indicated that they had taken none of their prescribed medicines, and 25 (22%) that they had taken less than 80%. The most common pattern of non-adherence was early cessation. Two aspects of the consultation (expectations about a prescription, and that there were too many tablets) were related to adherence. In conclusion, this study suggests that the effectiveness of some A&E consultations is reduced by inadequate exploration of patients' concerns and expectations.

Adolescent↗
PubMed2000

Patients' unvoiced agendas in general practice consultations: qualitative study.

OBJECTIVE: To investigate patients' agendas before consultation and to assess which aspects of agendas are voiced in the consultation and the effects of unvoiced agendas on outcomes. DESIGN: Qualitative study. SETTING: 20 general practices in south east England and the West Midlands. PARTICIPANTS: 35 patients consulting 20 general practitioners in appointment and emergency surgeries. RESULTS: Patients' agendas are complex and multifarious. Only four of 35 patients voiced all their agendas in consultation. Agenda items most commonly voiced were symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items were: worries about possible diagnosis and what the future holds; patients' ideas about what is wrong; side effects; not wanting a prescription; and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 14 consultations with problem outcomes at least one of the problems was related to an unvoiced agenda item. CONCLUSION: Patients have many needs and when these are not voiced they can not be addressed. Some of the poor outcomes in the case studies were related to unvoiced agenda items. This suggests that when patients and their needs are more fully articulated in the consultation better health care may be effected. Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agendas.

Adult↗
PubMed2000

Misunderstandings in prescribing decisions in general practice: qualitative study.

OBJECTIVES: To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice. DESIGN: Qualitative study. SETTING: 20 general practices in the West Midlands and south east England. PARTICIPANTS: 20 general practitioners and 35 consulting patients. MAIN OUTCOME MEASURES: Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine. RESULTS: 14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing. CONCLUSIONS: Patients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.

Adult↗
PubMed2000

Menorrhagia in general practice--disease or illness.

Menorrhagia is a common presentation in primary care. The gynaecological literature defines menorrhagia, as the loss of 80 ml or more of blood per period and guidelines for treatment are based on this definition. There is extensive evidence that the majority of women who complain of heavy bleeding do not fit the medical definition. We interviewed women presenting with menorrhagia to explore their perceptions and their initial interaction with the medical profession. A distinct illness model emerged. Women had a precise understanding of their complaint, so that a change in her cycle was indicative of a problem to many women, without reference to outside criteria. Women attached particular importance to how they felt and to their ability to function and they rejected the medical emphasis on blood loss evaluation. Many women were dissatisfied with the consultation and experienced doctors as being dismissive of their problem. They were seeking an explanation for why their periods had changed and had concerns that related to their understanding of menstrual bleeding. Interviewees were unsure whether period problems could be described as illness, and what range of disturbance was normal. It is suggested that the disease model of menorrhagia is not relevant to the majority of women with this complaint. It is proposed that the disease model be replaced with illness models.

Adult↗
PubMed2000

Doctor-patient communication about drugs: the evidence for shared decision making.

The traditional paternalistic model of medical decision-making, in which doctors make decisions on behalf of their patients, has increasingly come to be seen as outdated. Moreover, the role of the patient in the consultation has been emphasised, notably through the adoption of 'patient-centred' strategies. Models that promote patients' active involvement in the decision-making process about treatment have been developed. We examine one particular model of shared decision making [Charles, C., Gafni, A., Whelan, T, 1997. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine 44, 681-692.]. The model has four main characteristics. These are that (1) both the patient and the doctor are involved, (2) both parties share information, (3) both parties take steps to build a consensus about the preferred treatment and (4) an agreement is reached on the treatment to implement. Focusing on the first two of the four characteristics of the model, we use the findings from a study of 62 consultations, together with interviews conducted with patients and general practitioners, to consider participation in the consultation in terms of sharing information about, and views of, medicines. We found little evidence that doctors and patients both participate in the consultation in this way. As a consequence there was no basis upon which to build a consensus about the preferred treatment and reach an agreement on which treatment to implement. Thus even the first two of the four conditions said to be necessary for shared decision making were not generally present in the consultations we studied. These findings were presented in feedback sessions with participating GPs, who identified a number of barriers to shared decision making, as well as expressing an interest in developing strategies to overcome these barriers.

Decision Making↗
PubMed2000

'Strong medicine': an analysis of pharmacist consultations in primary care.

BACKGROUND: Patients often find it difficult to discuss their medications fully with their prescribing doctor. Little is known about what might be said about medications to another professional within the primary health care team (PHCT). Pharmacists are seeking to extend their role within primary care and are ideally placed to provide independent medication advice. OBJECTIVE: Our aim was to test the feasibility of using primary care pharmacists as medication counsellors, and to analyse the content of their consultations using qualitative methods. METHOD: Some patients were referred by their doctors, some self-referred and others were invited by the pharmacists for medication reviews. Pharmacist-patient consultations took place within GP surgeries and in patients' homes, and were audiotaped, transcribed and analysed qualitatively. The study sample consisted of 25 consultations with three primary care pharmacists conducted over a 3-month period. RESULTS: Referrals from the doctors were slow and there were no referrals from nurses. The pharmacists, who all had clinical backgrounds and were not dispensing pharmacists, experienced few problems with the consultations. Patients were willing to discuss their medications in detail with the pharmacists. A theme emerged regarding the perceived potency of medications, and this seemed to have an effect on the experience of side effects and the perceived efficacy of the medications. CONCLUSIONS: From this small study, it would seem that pharmacist consultations within primary care are a feasible extension of their current role as prescribing budget advisors. The richness of the consultations reflects the acceptability to patients. Feedback of information to other members of the PHCT, given patient consent, would be very useful for a better understanding of the patient's perspective, which in turn would facilitate concordance in the negotiation of the patient's management.

Feasibility Studies↗
PubMed2000

In pursuit of patient-centred outcomes: a qualitative evaluation of the 'Measure Yourself Medical Outcome Profile'.

OBJECTIVES: To ascertain the ability of a patient-generated outcome measure, the 'Measure Yourself Medical Outcome Profile' (MYMOP), to reflect the outcomes of consultations which patients consider are most important, as derived from qualitative interviews. METHODS: A qualitative study using a constant comparative method to analyse semistructured interviews which were then compared with the results of MYMOP questionnaires. A variable-orientated analysis was used to develop themes and a case-orientated analysis was used to develop narrative summaries called vignettes from the interviews. The MYMOP questionnaire was completed by the interviewees (n = 20), a minimum to twice and a maximum of nine times over a four-month period. The scores were displayed on individual MYMOP charts. For each individual, the outcome as measured by MYMOP was compared with the outcome data from the qualitative interviews. The interviewees were attending a variety of complementary practitioners in primary care. RESULTS: The treatment effects which people described were encompassed by five themes: reduction in symptoms; reduction in disability; reduction in, or avoidance of, medication; gaining control and improving coping skills; and securing support and hope through the patient-practitioner relationship. The vignettes demonstrated how individuals identified and valued these various effects and weighed them up in evaluating the overall benefit of the treatment. Their MYMOP charts were able to measure some effects better than others. CONCLUSIONS: The treatment effects, as quantified using MYMOP, accorded with those described by most patients at interview, but some important limitations were identified with MYMOP, particularly an underplaying of the importance of medication avoidance or medication reduction in this patient group. This dimension is lacking in most outcome questionnaires and has been included in a new version of MYMOP. This study also showed that qualitative interview data can help in evaluating the ability of outcome questionnaires to measure the treatment effects that particular patient groups consider most important.

Adolescent↗
PubMed2000

Organising primary health care for people with asthma: the patient's perspective.

BACKGROUND: The 1993 chronic disease management contract encourages United Kingdom general practices to implement a standardised package of care with an emphasis on regular visits to an asthma clinic. AIM: To explore the views of people with asthma about the organisation of asthma care in general practice. METHOD: Semi-structured interviews with 20 patients registered with one practice with a nurse-run asthma clinic. The sample was selected to provide people with a wide range of ages and disease severity, and included parents of children. RESULTS: The age range of the interviewees was five to 87 years (parents of children were interviewed) and half of the interviewees had attended the asthma clinic at some time. In describing how they managed their asthma, people identified their medical care alongside other important factors, such as avoiding smoking and pollution, and a decision to seek medical help was made in the context of all of life's other priorities. People expressed diverse views about the organisation of care, describing how their needs changed over time and how they balanced up several factors in deciding what was best for them. These factors were encompassed by four themes: the accessibility of care, severity of asthma and dealing with uncertainty, self-knowledge and self-management, and expert knowledge and therapeutic relationships. Interviewees were evenly split between wishing to be seen regularly in the clinic and wishing only to attend when needing help. CONCLUSION: Patients required asthma services that allow individual choice and flexibility, and eight service objectives were identified that would cover most people's needs.

Adolescent↗
PubMed1999

Doctors talking

Explore the source record for details and available documents.

Journal Article↗
PubMed1999

The United Medical and Dental School of Guy's and St Thomas' Hospitals' MSc in general practice: graduates' perspectives.

AIM: Higher degrees have been proposed as one means whereby general practitioners can continue their professional development and avoid a slow decline into professional isolation and burnout. The United Medical and Dental School of Guy's and St Thomas' Hospitals' MSc in general practice has been available to experienced general practitioners for over a decade. This study reports some of the outcomes of participation for the 76 graduates of the first nine cohorts. METHOD: As part of an ongoing programme of evaluation the graduates were sent a questionnaire which, in addition to seeking information about attainment of intended outcomes, gave respondents the opportunity to write freely about the contribution made by the course to their own professional and personal development. Seventy-one graduates completed the questionnaire, a response rate of 93%. RESULTS AND CONCLUSIONS: An increased confidence that arises not only from a broadened knowledge base and increased skills but also from a sense of having been enabled to explore more deeply into their discipline, is the most frequently and highly valued outcome of participation. Graduates appreciated having additional protected time and demonstrated an ability to use it productively. A further significant outcome was the ability of the course to confront those habitual assumptions of doctors which inform their practice in a manner that was both challenging and supportive. Tendencies to professional isolation and burnout appear to have been reversed with a greater sense of connectedness to their discipline. Doctors seeking to diversify their general practice careers beyond the task of providing medical services have found the MSc an important route for change.

Attitude of Health Personnel↗
PubMed1999

Using reflexivity to optimize teamwork in qualitative research.

Reflexivity is often described as an individual activity. The authors propose that reflexivity employed as a team activity, through the sharing of reflexive writing (accounts of personal agendas, hidden assumptions, and theoretical definitions) and group discussions about arising issues, can improve the productivity and functioning of qualitative teams and the rigor and quality of the research. The authors review the literature on teamwork, highlighting benefits and pitfalls, and define and discuss the role for reflexivity. They describe their own team and detail how they work together on a project investigating doctor-patient communication about prescribing. The authors present two reflexive tools they have used and show through examples how they have influenced the effectiveness of their team in terms of process, quality, and outcome.

Communication↗
PubMed1999

What do general practice receptionists think and feel about their work?

BACKGROUND: Although there is some published work acknowledging that the general practice receptionist's role is both important and difficult, receptionists' own views have rarely been sought. AIM: To explore general practice receptionists' ideas and feelings about their work. METHOD: A questionnaire was distributed to all 150 receptionists in a representative sample of 26 practices in the area covered by Leeds family health services authority. Semi-structured interviews were conducted with a representative group of 20 receptionists selected from the questionnaire sample. RESULTS: All responders were women, 60% were over 40 years old, and about half had been in the post for more than five years; four-fifths worked part-time. They had chosen the job because it dovetailed with the rest of their lives. Responders derived satisfaction from helping patients, meeting people, having good relationships with colleagues, and doing varied work. Sources of stress included difficult patients, work pressure, problems finding appointments for patients, and feeling caught between doctors' and patients' demands. Responders' experiences and views of training were diverse. Practice managers were important in making them feel consulted and supported. All had a sense of teamwork with colleagues, but many did not perceive the whole practice as a team. Many felt doctors failed to appreciate the pressure and complexity of their work. CONCLUSIONS: Receptionists' work is complex, demanding and intense, involving a high level of commitment to patients, colleagues, and the practice. Recommendations include improved appointment systems, a positive role for practice managers in relation to reception staff, and individual planning of receptionists' training. Effective teamwork among receptionists should be recognized and developed. General practitioners (GPs) are recommended to develop a greater understanding of receptionists' work.

Adult↗