Louise M. Wallace

The training needs of doctors working in England and in Poland with breastfeeding women

In the US, HIV dementia occurs in 10–15% of HIV-positive individuals with advanced infection. The prevalence of HIV dementia in sub-Saharan countries, where the vast majority of individuals with HIV reside, is largely unknown. This Review will summarize our current understanding of HIV-associated cognitive impairment in resource-limited settings, focusing specifically on the countries of sub-Saharan Africa. We will describe the frequency of HIV dementia and HIV-associated cognitive impairment from several case series in the sub-Saharan region. We will then summarize recent studies from Uganda and Ethiopia that included detailed neuropsychological assessments. The potential influence of clade diversity on HIV-associated cognitive impairment will be discussed. Differences between the results of the studies in Uganda and in Ethiopia raise the possibility that HIV subtypes might have different biological properties with respect to their capacity to cause HIV-associated cognitive impairment. Further studies are needed to determine the true prevalence of HIV dementia in sub-Saharan Africa and to establish whether specific clade subtypes might influence the presentation of neurological complications.

Feedback from incident reporting: information and action to improve patient safety

Introduction: Effective feedback from incident reporting systems in healthcare is essential if organisations are to learn from failures in the delivery of care. Despite the wide-scale development and implementation of incident reporting in healthcare, studies in the UK suggest that information concerning system vulnerabilities could be better applied to improve operational safety within organisations. In this article, the findings and implications of research to identify forms of effective feedback from incident reporting are discussed, to promote best practices in this area. Methods: The research comprised a mixed methods review to investigate mechanisms of effective feedback for healthcare, drawing upon experience within established reporting programmes in high-risk industry and transport domains. Systematic searches of published literature were undertaken, and 23 case studies describing incident reporting programmes with feedback were identified for analysis from the international healthcare literature. Semistructured interviews were undertaken with 19 subject matter experts across a range of domains, including: civil aviation, maritime, energy, rail, offshore production and healthcare. Results: In analysis, qualitative information from several sources was synthesised into practical requirements for developing effective feedback in healthcare. Both action and information feedback mechanisms were identified, serving safety awareness, improvement and motivational functions. The provision of actionable feedback that visibly improved systems was highlighted as important in promoting future reporting. Fifteen requirements for the design of effective feedback systems were identified, concerning: the role of leadership, the credibility and content of information, effective dissemination channels, the capacity for rapid action and the need for feedback at all levels of the organisation, among others. Above all, the safety-feedback cycle must be closed by ensuring that reporting, analysis and investigation result in timely corrective actions that effectively address vulnerabilities in existing work systems. Conclusions: Limited research evidence exists concerning the issue of effective forms of safety feedback within healthcare. Much valuable operational knowledge resides in safety management communities within high-risk industries. Multiple means of feeding back recommended actions and safety information may be usefully employed to promote safety awareness, improve clinical processes and promote future reporting. Further work is needed to establish best practices for feedback systems in healthcare that effectively close the safety loop.

The most effective psychologically-based treatments to reduce anxiety and panic in patients with chronic obstructive pulmonary disease (COPD): a systematic review.

Chronic obstructive pulmonary disease (COPD) is irreversible and causes a progressive reduction in physical functioning. There is evidence that emotional distress contributes to loss of function and that improvements may be obtained via psychologically based interventions to alleviate anxiety and panic. This systematic review examined the most effective interventions to date. A literature search revealed 25 studies; these were assessed using standardised criteria for inclusion and quality. Six randomised, controlled trials fulfilled the criteria, but the variety of methods, interventions and measures prevented the use of a meta-analysis. Two studies were unpublished doctoral theses, four were published studies. All of the studies had one or more deficiencies; failure to measure or report lung function, large variation in attrition, lack of blinding in assessment of treatment outcome, lack of use of standardised anxiety measures. Description of the intervention was not always sufficient to allow replication. There were no trials of interventions aimed at reducing panic. No study was adequately designed to provide an assessment of psychological intervention aimed at anxiety in COPD. Secondary outcomes included impacts on breathlessness, disability and quality of life. It can be concluded that currently there is insufficient research of quality on which to base recommendations for effective interventions for anxiety and panic in COPD. Future research should tie the design of evaluation to interventions based on theories of the relationship between dyspnoea and anxiety.

Disability, Ethnicity and Childhood: A critical review of research

Whilst there is an increasing body of literature on the perspectives of carers of disabled children, there is little research giving the disabled childs perspective from either majority or minority populations. Indeed, the voices of black and Asian children in disability research have been almost silent. This literature review collates and analyses existing knowledge about the perceptions held by disabled and non-disabled children, and young people from black and Asian families concerning issues of disability and impairment. The Disability Movement has long proclaimed its belief in the full participation and self-representation of all disabled people. However, despite this laudable objective, the Disability Movement in Britain has mirrored society in general and for the most part been led by white, middle-class, heterosexual, articulate males. This review discusses the simultaneous oppression faced by black and Asian disabled children, and concludes that their experience is unique and different from that of white disabled children. Accordingly, it emphasises the need for further research about the subjective experience of black and Asian disabled children in order to meet their particular needs.

Rethinking research in breast-feeding: a critique of the evidence base identified in a systematic review of interventions to promote and support breast-feeding

OBJECTIVE To appraise critically the relevance and value of the evidence base to promote and support the duration of breast-feeding, with a specific focus on disadvantaged groups. DESIGN A systematic review was conducted of intervention studies relevant to enhancing the duration of breast-feeding; topics included public health, public policy, clinical issues, and education, training and practice change. A systematic search was conducted. Eighty studies met the inclusion criteria. Data were systematically extracted and analysed. Full results and recommendations are reported elsewhere. Here a critique of the evidence base--topics, quality and gaps--is reported. RESULTS Many studies were substantially methodologically flawed, with problems including small sample sizes, inconsistent definitions of breast-feeding and lack of appropriate outcomes. Few were based on relevant theory. Only a small number of included studies (10%) were conducted in the UK. Very few targeted disadvantaged subgroups of women. No studies of policy initiatives or of community interventions were identified. There were virtually no robust studies of interventions to prevent and treat common clinical problems, or of strategies related to womens health issues. Studies of health professional education and practice change were limited. Cost-effectiveness studies were rare. CONCLUSIONS Policy goals both in the UK and internationally support exclusive breast-feeding until 6 months of age. The evidence base to enable women to continue to breast-feed needs to be strengthened to include robust evaluations of policies and practices related to breast-feeding; a step change is needed in the quality and quantity of research funded.

An exploration of the psychological factors affecting remote e‐worker's job effectiveness, well‐being and work‐life balance

Purpose: The purpose of this paper is to explore the impact of remote e-working on the key research areas of work-life balance, job effectiveness and well-being. The study provides a set of generalisable themes drawn from the key research areas, including building trust, management style and the quality of work and non-working life. Design/methodology/approach: The paper is an exploratory study into the psychological factors affecting remote e-workers using qualitative thematic analysis of eleven in-depth interviews with e-workers, across five organisations and three sectors. All participants worked remotely using technology independent of time and location for several years and considered themselves to be experts. Findings: The paper provides insights into the diverse factors affecting remote e-workers and produces ten emerging themes. Differentiating factors between e-workers included access to technology, ability to work flexibly and individual competencies. Adverse impacts were found on well-being, due to over-working and a lack of time for recuperation. Trust and management style were found to be key influences on e-worker effectiveness. Research limitations/implications: Because of the exploratory nature of the research and approach the research requires further testing for generalisability. The emerging themes could be used to develop a wide-scale survey of e-workers, whereby the themes would be further validated. Practical implications: Practical working examples are provided by the e-workers and those who also manage e-workers based on the ten emerging themes. Originality/value: This paper identifies a number of generalisable themes that can be used to inform the psychological factors affecting remote e-worker effectiveness.

Increasing chlamydia screening tests in general practice: a modified Zelen prospective Cluster Randomised Controlled Trial evaluating a complex intervention based on the Theory of Planned Behaviour

Objective To determine if a structured complex intervention increases opportunistic chlamydia screening testing of patients aged 15–24 years attending English general practitioner (GP) practices. Methods A prospective, Cluster Randomised Controlled Trial with a modified Zelen design involving 160 practices in South West England in 2010. The intervention was based on the Theory of Planned Behaviour (TPB). It comprised of practice-based education with up to two additional contacts to increase the importance of screening to GP staff and their confidence to offer tests through skill development (including videos). Practical resources (targets, posters, invitation cards, computer reminders, newsletters including feedback) aimed to actively influence social cognitions of staff, increasing their testing intention. Results Data from 76 intervention and 81 control practices were analysed. In intervention practices, chlamydia screening test rates were 2.43/100 15–24-year-olds registered preintervention, 4.34 during intervention and 3.46 postintervention; controls testing rates were 2.61/100 registered patients prior intervention, 3.0 during intervention and 2.82 postintervention. During the intervention period, testing in intervention practices was 1.76 times as great (CI 1.24 to 2.48) as controls; this persisted for 9 months postintervention (1.57 times as great, CI 1.27 to 2.30). Chlamydia infections detected increased in intervention practices from 2.1/1000 registered 15–24-year-olds prior intervention to 2.5 during the intervention compared with 2.0 and 2.3/1000 in controls (Estimated Rate Ratio intervention versus controls 1.4 (CI 1.01 to 1.93). Conclusions This complex intervention doubled chlamydia screening tests in fully engaged practices. The modified Zelen design gave realistic measures of practice full engagement (63%) and efficacy of this educational intervention in general practice; it should be used more often. Trial registration The trial was registered on the UK Clinical Research Network Study Portfolio database. UKCRN number 9722.

‘Breast is not always best’: South Asian women's experiences of infant feeding in the UK within an acculturation framework

Acculturating to a host country has a negative impact on immigrant womens breastfeeding practices, particularly when coming from countries where breastfeeding rates are higher than Western countries. Whether this is true of those immigrating to the UK remains to be investigated. The study aimed to explore whether acculturating to the UK had detrimental effects on breastfeeding practices of South Asian women, and to provide explanations as to how acculturation may have exerted its influence. Twenty South Asian women completed semi-structured interviews exploring infant feeding experiences. Data were thematically analysed. A bidimensional measure assessed womens acculturation status. Women displaying low acculturation levels were aware of living in a formula-feeding culture but this had little influence on breastfeeding intentions/behaviours; drawing upon South Asian cultural teachings of the psychological benefits of breast milk. These women opted to formula-feed in response to their childs perceived demands or in a bid to resolve conflict; either when receiving information about the best feeding method or between their roles as a mother and daughter-in-law. Highly acculturated women also experienced such conflict; their awareness of the formula-feeding culture governed feeding choice. The findings provide a picture of how acculturation may affect South Asian womens breastfeeding intentions and behaviours; encouraging health service providers to meet the varying needs of an acculturating population. If breastfeeding is to be encouraged, it is necessary to understand factors influencing feeding choice; with particular attention to the acculturation pathways that may govern such decisions. This paper highlights ways to tailor information for South Asian women depending on levels of acculturation.

Improving patient safety incident reporting systems by focusing upon feedback - lessons from English and Welsh trusts.

This paper describes practical implications and learning from a multi-method study of feedback from patient safety incident reporting systems. The study was performed using the Safety Action and Information Feedback from Incident Reporting model, a model of the requirements of the feedback element of a patient safety incident reporting and learning system, derived from a scoping review of research and expert advice from world leaders in safety in high-risk industries. We present the key findings of the studies conducted in the National Health Services (NHS) trusts in England and Wales in 2006. These were a survey completed by risk managers for 351 trusts in England and Wales, three case studies including interviews with staff concerning an example of good practice feedback and an audit of 90 trusts clinical risk staff newsletters. We draw on an Expert Workshop that included 71 experts from the NHS, from regulatory bodies in health care, Royal Colleges, Health and Safety Executive and safety agencies in health care and high-risk industries (commercial aviation, rail and maritime industries). We draw recommendations of enduring relevance to the UK NHS that can be used by trust staff to improve their systems. The recommendations will be of relevance in general terms to health services worldwide.

Use of a time series design to test effectiveness of a theory-based intervention targeting adherence of health professionals to a clinical guideline

OBJECTIVES The aim of this study was to test the effectiveness of a theory of planned behaviour intervention to increase adherence of community mental health professionals to a national suicide prevention guideline. DESIGN Routinely collected audit adherence data from an intervention and control site were collected and analysed using time series analysis to test whether the intervention significantly increased adherence. The effects of a local and national event on adherence were also examined. METHOD A Theory of Planned Behaviour (TPB) questionnaire, developed from interview findings, was administered to the health professionals. Subjective norms were found to be the most significant predictor of intention to adhere to the guideline, and were targeted with an interactive educational intervention. Time series analysis applied to routinely collected audit adherence data was used to test intervention effectiveness. RESULTS The TPB accounted for 58% of the variance in intention to adhere, with subjective norms the only significant predictor. The intervention did not significantly increase adherence; however, the national and local events were found to have significantly increased adherence. CONCLUSIONS The TPB was a useful framework for exploring barriers to adherence; however, this did not translate into an effective intervention. Future research should seek collaboration with local experts, and use this information in combination with the TPB, to develop interventions. Collaborative research with experts in pedagogy may also help to develop more effective interventions, particularly education-based interventions that require adult learning.