J. Clayton

Patients' action during their cardiac event: qualitative study exploring differences and modifiable factors

Abstract Objectives: To explore the circumstances and factors that explain variations in response to a cardiac event and to identify potentially modifiable factors. Design: Qualitative analysis of semistructured, face to face interviews with patients admitted to two district hospitals for a cardiac event and with other people present at the time of the event. Patients were divided into three groups according to the length of delay between onset of symptoms and calling for medical help. Subjects: 43 patients and 21 other people present at the time of the cardiac event. Patients were divided into three groups according to the length of time between onset of symptoms and seeking medical help: non-delayers (<4 h; n=21), delayers (4-12 h; n=12), and extended delayers (>12 h; n=10). Main outcome measures: Decision making process, strategies for dealing with symptoms, and perception of risk and of heart attacks before the event according to delay in seeking help. Results: The illness and help seeking behaviour of informants had several components, including warning, interpretation, preliminary action, re-evaluation, and final action stages. The length of each stage was variable and depended on the extent to which informants mobilised and integrated resources into a strategy to bring their symptoms under control. There were obvious differences in informants knowledge of the symptoms that they associated with a heart attack before the event. Non-delayers described a wider range of symptoms before their heart attack and twice as many (13) considered themselves to be potentially at risk of a heart attack compared with the other two groups. For most informants the heart attack differed considerably from their concept of a heart attack. Conclusion: The most critical factor influencing the time between onset of symptoms and calling for professional medical help is that patients and others recognise their symptoms as cardiac in origin. This study suggests that various points of intervention in the decision making process could assist symptom recognition and therefore faster access to effective treatment. Key messages Research using methods that can explain variations in response to cardiac events has been neglected Informants in this study thought of heart attacks as sudden dramatic events in which people collapse and probably die, rather than as the evolving event that they experienced Those who sought medical help within 4 hours were more likely to see themselves as potentially at risk, knew a wider range of symptoms of a heart attack, and were much less likely to use drugs to treat their symptoms compared with those who waited longer Intervention at various points in the decision making process could help recognition of symptoms and speed access to effective treatment

Coronary heart disease: Women's assessment of risk--a qualitative study

Coronary heart disease (CHD) kills over 135,000 people each year. The underlying premise of this study was that women might not assess themselves as at risk because CHD has generally been perceived within popular culture, medicine and research as a mans disease. Hayes ( Social Science and Medicine, 35, pp. 55-61, 1991) suggests that critical to the success of any risk assessment strategy is: the identification of risk markers that can accurately predict specific adverse health outcomes and the ability of the strategy users to measure risk factors and calibrate them appropriately. In-depth interviews were conducted with 83 women, 50 who had been admitted to hospital with a CHD-related cardiac event and 33 without manifest CHD. They were found to adopt risk assessment strategies that enabled them to conceptually distance themselves from risk of CHD by: attributing risky lifestyle behaviour to men; subjectively manipulating the potential threat posed by their own risk factors and by over-emphasising the importance of social position to risk. The outcome of these strategies can be summed up as--women are only at high risk of developing CHD if they adopt a mans way of life. This has important implications for the prevention of CHD in women.

Women's Interpretation of Cardiac Symptoms at the Time of Their Cardiac Event: The Effect of Co-Occurring Illness

Background: Women tend to access medical help for a myocardial infarction later than men and are at a disproportionate risk of dying or of suffering disability as a consequence. Co-morbidity is associated with delay but little is known how this affects decision making. Aim: To examine the effect of co-occurring chronic illness or infections on womens interpretation of their symptoms and action at the time of their cardiac event. Methods: Semi-structured interviews with 44 women admitted to 3 district hospitals following a cardiac event. For the purposes of analysis they were divided into those who arrived at the hospital within 12 h of onset of symptoms (< 12 hour group) and those who took more than 12 h (> 12 hour group). Findings: Women utilised their mental records of knowledge and experiences to make sense of their cardiac symptoms. The mental records of the < 12 hour group contained knowledge of symptoms and previous experiences relevant to cardiac problems. Those of the > 12 hour group contained knowledge and experience of recent and co-occurring chronic illnesses, this provided persuasive ‘evidence’ to suggest that their symptoms were normal or typical for their current state of health and resulted in delay. Conclusion: Womens decision making and timely access to medical help at the time of a cardiac event is influenced by their repertoire of knowledge and experience. Interventions need to be designed to capture the process of symptom recognition and the influence of co-morbidity.

People and Teams Matter in Organizational Change: Professionals’ and Managers’ Experiences of Changing Governance and Incentives in Primary Care

OBJECTIVESnTo explore the experiences of governance and incentives during organizational change for managers and clinical staff.nnnSTUDY SETTINGnThree primary care settings in England in 2006-2008.nnnSTUDY DESIGNnData collection involved three group interviews with 32 service users, individual interviews with 32 managers, and 56 frontline professionals in three sites. The Realistic Evaluation framework was used in analysis to examine the effects of new policies and their implementation.nnnPRINCIPAL FINDINGSnIntegrating new interprofessional teams to work effectively is a slow process, especially if structures in place do not acknowledge the painful feelings involved in change and do not support staff during periods of uncertainty.nnnCONCLUSIONSnEliciting multiple perspectives, often dependent on individual occupational positioning or place in new team configurations, illuminates the need to incorporate the emotional as well as technocratic and system factors when implementing change. Some suggestions are made for facilitating change in health care systems. These are discussed in the context of similar health care reform initiatives in the United States.

Financial and clinical risk in health care reform: a view from below

Objectives This paper examines how the interaction between financial and clinical risk at two critical phases of health care reform in England has been experienced by frontline staff caring for vulnerable patients with long term conditions. Methods The paper draws on contracting theory and two interdisciplinary and in-depth qualitative research studies undertaken in 1995 and 2007. Methods common to both studies included documentary analysis and interviews with managers and front line professionals. The 1995 study employed action-based research and included observation of community care; the 2007 study used realistic evaluation and included engagement with service user groups. Results In both reform processes, financial risk was increasingly devolved to frontline practitioners and smaller organizational units such as GP commissioning groups, with payment by unit of activity, aimed at changing professionals behaviour. This financing increased perceived clinical risk and fragmented the delivery of health and social care services requiring staff efforts to improve collaboration and integration, and created some perverse incentives and staff demoralisation. Conclusions Health services reform should only shift financial risk to frontline professionals to the extent that it can be efficiently borne. Where team work is required, contracts should reward collaborative multi-professional activity.

Encouraging and enabling low‐income owner‐occupiers to maintain their homes: An exploratory study

Purpose – The purpose of this paper is to show that owner occupation has become the prevailing tenure in the UK with owners increasingly being seen as holding primary responsibility for the condition of their properties. The UK has had a long tradition of public sector enforcement and grant‐led intervention to help preserve the nations private sector housing stock. Recent housing policy changes have subsumed earlier grant legislation and provided a general provision for “assistance” to help owner‐occupiers maintain and repair their own homes. Simultaneously, the role of local authorities continues to shift from provider to enabler of service, with greater discretion and an increased role for other agencies at local level.Design/methodology/approach – This paper shows the focus group discussions that were held in South London to explore what low‐income owner‐occupiers in an ethnically‐diverse area would find helpful from the local authority in carrying out maintenance and repair works to their homes.Findi...

Exercising for a healthy heart: A qualitative study of women's beliefs

Objective The aim of this study was to explore womens beliefs about exercise in relation to key messages about physical inactivity and coronary heart disease. Design This was a qualitative study using semi-structured interviews. Setting Cardiac and gynaecological units of three hospitals in different locations. Method Open-ended, semi-structured interviews were conducted with 50 women admitted with a cardiac related event or suspected cardiac event, and 33 women without manifest coronary heart disease who had been admitted to the same hospitals for routine elective surgery/procedures. Results Women related to exercise primarily in terms of losing weight, looking good, staying mobile and keeping fit generally. Moderate physical activity was considered best and there was a perception that activity inherent in womens domestic lives provided this. Women believed overexercise could be potentially harmful. Conclusion Key messages about physical activity and its importance in preventing coronary heart disease need to take into account womens ideas about the benefits and hazards of exercise.

Personal responsibility for private sector housing renewal: Issues in health improvement

Objective To investigate current policy in respect of resourcing private sector housing renewal to promote healthy housing and communities. Design A qualitative study using focus group research investigating what low-income home owners would find helpful in carrying out maintenance and repair to their homes. Setting The focus groups were held in the area office of a South London (private sector housing) Renewal Area. Method Exploratory focus groups were held in 2003 to 2004, to represent low-income ethnically diverse home-owners within the Renewal Area. Results Respondents were open to looking at new ways of maintaining and repairing their homes, although tended to focus around their own needs rather than the works a local authority may strategically wish to see carried out in private housing sector to meet legal housing standards and promote healthy housing. Conclusion Local authorities need to be able to find new, evidence-based ways of supporting home-owners to carry out maintenance and repairs to their homes as part of a wider public health agenda.

The Research Governance Framework for Health and Social Care: Implications for developing research in primary care

The Research Governance Framework for Health and Social Care is a framework of responsibilities and quality checks formulated by the English Department of Health for researchers and others. Primary care trusts were required to comply with the RGF by April 1, 2003. Implementing research governance within primary care trusts includes establishing systems for being notified of any research activity, peer review and scientific support. This paper discusses findings arising from research commissioned in south London in 2003 by one of the national pilot sites for research governance in primary care. Data were gathered by means of telephone interviews with 23 experienced academics within the four south London higher education institutions included in the project. In particular, the paper explores issues concerning the effects of the research government framework on student projects, and the implications of these for the development of research capacity in primary care. A key message from this paper is that primary care research is still quite fragile, and that a heavy-handed introduction of research governance may deter neophytes and hamper research capacity-building. In particular, the withdrawal of higher education institutions from requiring primary datagathering for MScs because of the increasing hurdles of bureaucracy could make it more difficult for experienced practitioners to develop research skills.