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Biomedical subjects

Nicky Britten

Publications and source records attributed to Nicky Britten.

30 records · Page 2Linked to original sources
PubMed2003

Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study.

OBJECTIVES: To understand why general practitioners prescribe antibiotics for some cases of sore throat and to explore the factors that influence their prescribing. DESIGN: Grounded theory interview study. SETTING: General practice. PARTICIPANTS: 40 general practitioners: 25 in the maximum variety sample and 15 in the theoretical sample. RESULTS: General practitioners are uncertain which patients will benefit from antibiotics but prescribe for sicker patients and for patients from socioeconomically deprived backgrounds because of concerns about complications. They are also more likely to prescribe in pressured clinical contexts. Doctors are mostly comfortable with their prescribing decisions and are not prescribing to maintain the doctor-patient relationship. CONCLUSIONS: General practitioners have reduced prescribing for sore throat in response to research and policy initiatives. Further interventions to reduce prescribing would need to improve identification of patients at risk of complications and be workable in busy clinical situations.

Anti-Bacterial Agents↗
PubMed2003

Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care.

Interest in how qualitative health research might be used more widely to inform health policy and medical practice is growing. Synthesising findings from individual qualitative studies may be one method but application of conventional systematic review methodology to qualitative research presents significant philosophical and practical challenges. The aim here was to examine the feasibility of synthesising qualitative research using qualitative methodology including a formative evaluation of criteria for assessing the research to be synthesised. Ten qualitative studies of adult patients' perspectives of diabetes were purposefully selected and questions proposed by the critical appraisal skills programme (CASP) adapted and used to assess papers prior to synthesis. Each study was reviewed independently by two experienced social scientists. The level of agreement between reviewers was determined. Three papers were excluded: one because it turned out not to be qualitative research, one because the quality of the empirical work was poor and one because the qualitative findings reported were also recorded in another paper already included. The synthesis, which had two distinct elements, was conducted using the meta-ethnographic method. Firstly, four papers containing typologies of patient responses to diabetes were synthesised. Secondly, six key concepts were identified from all seven papers as being important in enabling a person with diabetes to achieve a balance in their lives and to attain a sense of well-being and control. These included: time and experience, trust in self, a less subservient approach to care providers, strategic non-compliance with medication, effective support from care providers and an acknowledgement that diabetes is serious. None of the studies included in the synthesis referenced any of the early papers nor did they appear to have taken account of or built upon previous findings. This evaluation confirmed that meta-ethnography can lead to a synthesis and extension of qualitative research in a defined field of study. In addition, from it a practical method of qualitative research assessment evolved. This process is promising but requires further testing and evaluation before it could be recommended for more widespread adoption.

Adult↗
PubMed2003

Self-treatment and its discussion in medical consultations: how is medical pluralism managed in practice?

Recent policy changes in the UK such as deregulation of prescribed medicines and the introduction of telephone helpline services are intended to promote self-treatment. Drawing on interviews with, and consultations between, 35 patients and 20 general practitioners, we use Kleinman's (Patients and Healers in the context of culture: an exploration of the Borderland between Anthropology, Medicine and Psychiatry, University of California Press Ltd., London) model of the three sectors of health care in order to examine the range of self-treatments people use and the discussion of these treatments in medical consultations. We argue that despite the availability of a range of treatment options and policy changes advocating greater use of self-treatment, patients are inhibited from disclosing prior self-treatment, and disclosure is affected by patients' perceptions of the legitimacy of self-treatment. The findings are in keeping with Cant and Sharma's (A New Medical Pluralism, Alternative Medicines, Doctors, Patients and the State, UCL Press, London) contention that although there has been a pluralisation of "legitimate" providers of health care and a restructuring of expertise, biomedicine itself remains dominant.

Attitude of Health Personnel↗
PubMed2003

Developing and using quantitative instruments for measuring doctor-patient communication about drugs.

Previous qualitative work has identified communication problems between doctors and patients in general practice consultations, particularly in relation to prescribing. This study aimed to develop quantitative measures to extend the research and provide instruments for both researchers and practitioners to use in monitoring communication and prescribing. Questionnaires were developed from existing instruments. When used with patients and doctors in a variety of general practices, the instruments appeared to be acceptable and had high response rates. While many consultations were satisfactory in terms of patients' expectations and their experiences with medicines, only 38% did not have any poor outcome. The results using quantitative instruments were similar to but less striking compared to our previous qualitative work. The research was developmental and findings suggest that unnecessary prescribing and problems in communication are more likely to lead to poor outcomes in terms of non-adherence and patients having barriers to using their medication.

Communication↗
PubMed2003

Acupuncture for people with chronic illness: combining qualitative and quantitative outcome assessment.

OBJECTIVES: Many people with chronic disease seek acupuncture treatment, despite it being largely excluded from Western state-funded health care systems. What benefits and problems do such people perceive and experience as important? To what extent do three subjective health questionnaires encompass and measure these treatment effects? DESIGN AND OUTCOME MEASURES: A longitudinal qualitative study, using a constant comparative method, informed by grounded theory. Each person was interviewed three times over 6 months and before each interview participants completed three health status questionnaires, EuroQol, COOP-WONCA charts, and MYMOP2. Semistructured interviews used open-ended questions to explore peoples' experiences of illness and treatment, and then used the cognitive interview technique to discuss their questionnaire responses. SUBJECTS AND SETTINGS: Eight professional acupuncturists in seven different settings publicized the study to their patients. We interviewed a maximum variation sample of 23 people with chronic illness, who were having acupuncture for the first time. RESULTS: In addition to changes in their presenting symptoms people experienced whole-person effects that were characterized by changes in strength and energy, and changes in personal and social identity. These effects were distinct but not divisible because of their interdependence and their complex and individual development over time. The health status questionnaires varied in their ability to reflect and measure these changes, and the whole person effects were often missed. After 6 months some people had changed their treatment goals and some individuals were still seeing health improvement. One person found that acupuncture exacerbated her symptoms. CONCLUSIONS: Knowledge of the range, individuality, and varied temporal patterns of treatment outcomes can guide potential patients, clinicians, health care providers, and researchers. Qualitative methods have highlighted the strengths and weaknesses of different outcome questionnaires, and the importance of long-term follow-up. We plan to do further work on appropriate outcome questionnaire selection and development.

Acupuncture Therapy↗
PubMed2003

"Fire away": the opening sequence in general practice consultations.

BACKGROUND: Proponents of recent models of the doctor-patient relationship, such as concordance and shared decision making, have emphasized mutuality rather than paternalism or consumerism. However, little attention has been paid so far to the ways in which this might actually be achieved. OBJECTIVES: The aims of this study were to establish whether there are any rules governing the opening sequence in general practice consultations, and to analyse the ways in which the observing or breaking of such rules contributes to the development of mutuality between patients and GPs. METHODS: The paper is based on a qualitative study of 62 patients consulting 20 GPs in 20 practices in the Midlands and Southeast of England. Consultations were audio recorded and transcribed; patients were interviewed before and after each consultation, and doctors were interviewed afterwards. Data were analysed using the sociological method of Conversation Analysis. The outcomes were participants' own understandings as demonstrated in their speech. RESULTS: A selection rule was identified whereby doctors choose between the questions "How are you?" and "What can I do for you?" to elicit patients' concerns. Deviations from this selection rule may be either repairable or strategic. Repairable deviance is based on misunderstanding between participants, and is resolved interactionally, usually by patients. Strategic deviance is the attempt by doctors to emphasize or de-emphasize certain aspects of their relationships with particular patients. Deviations from the rule which are not repaired lead to misalignment between participants. CONCLUSION: In relation to concordance, or shared decision making more generally, this analysis demonstrates that alignment or misalignment between participants will occur before any discussion about treatment options occurs. In cases of misalignment, concordance will be much harder to achieve. Mutuality is an achievement of both patients and doctors, and requires the active participation of patients.

Communication↗
PubMed2003

Who decides about prostate cancer treatment? A qualitative study.

BACKGROUND: Shared decision-making between patients and health professionals has been promoted as ethically and clinically desirable. Patients vary in their willingness to participate in decision-making, while clinicians identify practical barriers to greater participation, such as time and communication skills. A paternalistic approach to treatment decisions remains common even in an area of clinical uncertainty. The willingness of patients to participate in decision-making varies over time during the course of an illness but patients may not be given the opportunity to revisit clinical decisions with their specialists after the initial consultation. OBJECTIVES: To gain an in depth understanding of the perspectives of men recently diagnosed with localized prostate cancer, and to explore the value of decision-making models in the setting of NHS practice. METHODS: The study design was a qualitative analysis of semi-structured interviews. Nineteen men recently diagnosed with localized prostate cancer were included from patients attending a British District General Hospital. RESULTS: The interviews suggested that the respondents' treatment plans were mostly decided on their behalf by their clinicians. Whilst initially accepting this paternalistic approach, the interviewees over time wished to revisit the decisions. Patients' barriers to shared decision-making included fear of appearing disrespectful to their doctors and of taking responsibility for the outcome of treatment. The structure of patient follow-up did not afford the men an opportunity to discussion treatment decisions further. CONCLUSIONS: The paternalistic decision-making model remains the chosen approach in this situation. The patients' willingness to become actively involved in choosing their care varies over time. Barriers to shared decision-making can be identified both in the nature of the doctor-patient relationship and the structure of the clinical follow-up.

Aged↗
PubMed2002

Patients' decisions about whether or not to take antihypertensive drugs: qualitative study.

OBJECTIVE: To describe the ways in which patients taking antihypertensive drugs balance reservations against reasons for taking them. DESIGN: Qualitative study using detailed interviews. SETTING: Two urban general practices in the United Kingdom. PARTICIPANTS: Maximum variety sample of 38 interviewees receiving repeat prescriptions for antihypertensives. MAIN OUTCOME MEASURES: Interviewees' reservations about drugs and reasons for taking antihypertensives. RESULTS: Patients had reservations about drugs generally and reservations about antihypertensives specifically. Reasons for taking antihypertensive drugs comprised positive experiences with doctors, perceived benefits of medication, and pragmatic considerations. Patients weighed their reservations against reasons for taking antihypertensives in a way that made sense for them personally. Some individual patients weighed different reservations against different reasons for taking antihypertensives. CONCLUSIONS: Patients' ideas may derive from considerations unrelated to the drugs' pharmacology. Doctors who want their patients to make well informed choices about antihypertensives and to reach concordant decisions about prescribing should explore how individuals strike this balance, to personalise discussion of drug use.

Adult↗
PubMed2002

Patients' attitudes to medicines and expectations for prescriptions.

BACKGROUND: Recent research has shown that patients' expectations for prescriptions influence doctors' prescribing decisions, but little is known of the antecedents of these expectations. OBJECTIVES: To test earlier qualitative research about patients' views of medicines; to describe the demographic characteristics of those holding orthodox and unorthodox views of medicines; to investigate the relationship between patients' ideal and predicted expectations for prescriptions; and to determine the relative effects of attitudinal, demographic, organizational and illness variables on these expectations. DESIGN: Questionnaire survey of patients consulting general practitioners. SETTING AND PARTICIPANTS: A total of 544 patients and 15 doctors in four general practices. MAIN VARIABLES STUDIED: Patients' attitudes to medicines; patients' demographic characteristics; organizational variables; aspects of patients' presenting problems. OUTCOME MEASURES: Patients' ideal and predicted expectations for prescriptions. RESULTS: Orthodox and unorthodox attitudes to medicines can be measured quantitatively, and ethnicity was the only demographic variable associated with both. Ideal and predicted expectations for prescriptions were closely related to each other but differed in their antecedents. Both types of expectations were associated with attitudinal, demographic, organizational and illness variables. Ideal expectations were influenced by orthodox and unorthodox attitudes to medicines, while predicted expectations were only influenced by orthodox attitudes. CONCLUSIONS: Future studies of patients' expectations for health services should distinguish between ideal and predicted expectations, and should consider the range of possible influences on these expectations. In particular, the effect of the organization and context of health services should be investigated.

Adult↗
PubMed2002

Patients' understanding of risk: a qualitative study of decision-making about the menopause and hormone replacement therapy in general practice.

OBJECTIVE: To explore women's understanding of the risks associated with the menopause and hormone replacement therapy (HRT). METHODS: Two general practices in Cambridge participated in this qualitative study using focus groups and semi-structured interviews. Forty women aged between 50 and 55 years, known to be current users, ex-users, or never-users of HRT were included in the study. RESULTS: Participants viewed risk as a danger: coping with risk required an assessment to facilitate an informed decision. To understand risk and make a personal interpretation, patients used their own knowledge, the presentation and context of that risk, together with their individual belief system particularly relating to representations of womanhood, lay beliefs and fatalism, control and choice. Experience, age and emotions often modified the salience of risk, and participants then used this meaning to weigh up the risks and benefits of a particular threat. CONCLUSION: Participants gained understanding of risk by an active risk assessment process involving individual and complex interplay between knowledge and core beliefs, allowing the assessment of risks and benefits to facilitate an informed decision about the menopause and HRT.

Decision Making↗
PubMed2002

Using meta ethnography to synthesise qualitative research: a worked example.

OBJECTIVES: To demonstrate the benefits of applying meta ethnography to the synthesis of qualitative research, by means of a worked example. METHODS: Four papers about lay meanings of medicines were arbitrarily chosen. Noblit and Hare's seven-step process for conducting a meta ethnography was employed: getting started; deciding what is relevant to the initial interest; reading the studies; determining how the studies are related; translating the studies into one another; synthesising translations; and expressing the synthesis. RESULTS: Six key concepts were identified: adherence/compliance; self-regulation; aversion; alternative coping strategies; sanctions; and selective disclosure. Four second-order interpretations (derived from the chosen papers) were identified, on the basis of which four third-order interpretations (based on the key concepts and second-order interpretations) were constructed. These were all linked together in a line of argument that accounts for patients' medicine-taking behaviour and communication with health professionals in different settings. Third-order interpretations were developed which were not only consistent with the original results but also extended beyond them. CONCLUSIONS: It is possible to use meta ethnography to synthesise the results of qualitative research. The worked example has produced middle-range theories in the form of hypotheses that could be tested by other researchers.

Anthropology, Cultural↗