Frank Dobbs

A meta-synthesis of pregnant women's decision-making processes with regard to antenatal screening for Down syndrome

The diffusion of antenatal screening programmes for Down syndrome has triggered much discussion about their powerful potential to enhance pregnant womens autonomy and reproductive choices. Simultaneously, considerable debate has been engendered by concerns that such programmes may directly contribute to the emergence of new and complex ethical, legal and social dilemmas for women. Given such discussion and debate, an examination of womens decision-making within the context of antenatal screening for Down syndrome is timely. This paper aims to undertake a meta-synthesis of qualitative studies examining the factors influencing pregnant womens decisions to accept or decline antenatal screening for Down syndrome. The meta-synthesis aims to create more comprehensive understandings and to develop theory which might enable midwives and other healthcare professionals to better meet the needs of pregnant women as they make their screening decisions. Ten electronic health and social science databases were searched together with a hand-search of eleven journals for papers published in English between 1999 and 2008, using predefined search terms, inclusion and exclusion criteria, and a quality appraisal framework. Nine papers met the criteria for this meta-synthesis, providing an international perspective on pregnant womens decision-making. Twelve themes were identified by consensus and combined into five core concepts. These core concepts were: destination unknown; to choose or not to choose; risk is rarely pure and never simple; treading on dreams, and betwixt and between. A conceptual framework is proposed which incorporates these themes and core concepts, and provides a new insight into pregnant womens complex decision-making processes with regard to antenatal screening for Down syndrome. However, further research is necessary to determine whether or not the development of a model of decision-making may empower pregnant women in making choices about screening.

Sexual health promotion in primary care – activities and views of general practitioners and practice nurses

Background Sexual health in Northern Ireland (NI) is poor compared with the rest of Europe with increasing incidences of sexually transmitted infections and one of the highest rates of teenage pregnancy. Traditionally, sexual health services have been provided in a fragmented way by a wide range of different providers but recent sexual health strategies have flagged sexual health as a key activity within the primary care setting.Aim The main aim of the study was to assess the sexual health promotion activities within the primary care setting across one Health and Social Services Board in NI.Methods A series of semi-structured interviews with both general practitioners (GPs) and practice nurses (PNs) was conducted to assess their views on the key issues in relation to sexual health in primary care. A questionnaire survey was also conducted with these health professionals to elicit information about sexual health promotion activities within the primary care setting.Findings The results have shown that promoting sexual health within the primary care setting is often ad hoc and often does not target the ‘at-risk’ population. As such, GPs and PNs tend not to discuss sexual health with non-heterosexual clients or those with learning disabilities due to lack of awareness and training. Health professionals feel inadequately trained to engage in effective sexual health promotion and to provide enhanced sexual health services. Personal embarrassment and lack of time were also identified as barriers for providing effective sexual health care.Conclusion Health professionals within the primary care setting require additional training to deal with the sensitive and complex issues inherent in the area of sexual health.

Diabetes mellitus in Irish general practice: Level of care as reflected by HbA1c values

Objective: To assess the level of care given to people with diabetes by general practitioners and factors affecting it. Methods: A cross-sectional study of Irish general practitioners, looking at practice characteristics and patient care over the previous 2 years; a nationally representative sample of 27 general practitioners. A total of 1030 people with diabetes were studied, of whom 201 were type 1 and 829 were type 2. Results: The response rate was 27 out of 52 (52%). HbA1c values were not related to the patients socioeconomic status. The average HbA1c for type 1 people with diabetes was 7.81%, and for type 2 it was 7.1%. HbA1c values were measured 3.02 times for type 1 and 3.16 times for people with type 2 diabetes. This is a good standard of care, especially for type 2 disease. Computerized practices and those patients whose care was shared with the hospital achieved better control, even though HbA1c levels were checked less frequently with computerization. The use of a protocol in the practices also improved care. Those practices employing a nurse had increased frequency of measurement of HbA1c and better control on univariate but not on multivariate analysis. Possible reasons for this are discussed. Conclusion: Diabetes Mellitus is treated to a good standard in Irish general practice, especially type 2 disease. This standard appears to be independent of the patients socio-economic status, is improved by GPs being computerised, in group practices and by providing care according to a protocol. Shared care also improves control. Employing a practice nurse may also improve care.

An international comparative family medicine study of the Transition Project data from the Netherlands, Malta, Japan and Serbia. An analysis of diagnostic odds ratios aggregated across age bands, years of observation and individual practices

INTRODUCTION This is a study of the process of diagnosis in family medicine (FM) in four practice populations from the Netherlands, Malta, Serbia and Japan. Diagnostic odds ratios (ORs) for common reasons for encounter (RfEs) and episode titles are used to study the process of diagnosis in international FM and to test the assumption that data can be aggregated across different age bands, practices and years of observation. METHODOLOGY Participating family doctors (FDs) recorded details of all their patient contacts in an episode of care (EoC) structure using the International Classification of Primary Care (ICPC). RfEs presented by the patient and the diagnostic labels (EoC titles) recorded for each encounter were classified with ICPC. The relationships between RfEs and episode titles were expressed as ORs using Bayesian probability analysis to calculate the posterior (post-test) odds of an episode title given an RfE, at the start of a new EoC. RESULTS The distributions of diagnostic ORs from the four population databases are tabled across age groups, years of observation and practices. CONCLUSIONS There is a lot of congruence in diagnostic process and concepts between populations, across age groups, years of observation and FD practices, despite differences in the strength of such diagnostic associations. There is particularly little variability of diagnostic ORs across years of observation and between individual FD practices. Given our findings, it makes sense to aggregate diagnostic data from different FD practices and years of observation. Our findings support the existence of common core diagnostic concepts in international FM.

The development of research capacity in Europe through research workshops—the EGPRN perspective

The academic development of the domain of General Practice and family medicine (FM) has made notable progress recently, but one should never rest on one’s laurels. Continuing progress requires a strong research base for the discipline, which is still weak both in terms of evidence, with relatively few publications from primary care, and in the limited number of research institutes around the world. Ironically, even though the evidence for primary care in health care systems is rather strong and international political support has been repeatedly promised, the spirit of Alma Ata seems not to have been realized and governments seem to be more supportive of investment in secondary and tertiary care. The key to development as an independent specialist discipline is the development of an independent research base to define the characteristics of the domain, to support clinical work and to inform educational and professional development. Primary care researchers have to go beyond the agenda of public health and secondary care and carry out research into the content and delivery of primary care and into diagnosis in primary care. What does research in general practice/FM entail? The researcher may be a clinician with a special interest, a student who is preparing a dissertation for a University degree or a researcher from a field outside medicine. A research question is developed, and with some advice, an appropriate methodology is selected (such as a questionnaire to fellow clinicians, a study of patient records or an intervention to improve practice). The novice researcher will benefit enormously from expert advice at this stage since errors in research question development or methodology for data collection may make the project untenable at a later stage. Successful completion of the project may result in obtaining a degree, improving practice at a local or regional setting in a specific domain or national or international publication of a paper and the start of a new academic career in parallel or instead of a purely clinical one. Successful publication will make access to research grants and/or career posts, and further publication, more likely.