Mary O’Reilly-de Brún

Using a Theory-Driven Conceptual Framework in Qualitative Health Research

The role and merits of highly inductive research designs in qualitative health research are well established, and there has been a powerful proliferation of grounded theory method in the field. However, tight qualitative research designs informed by social theory can be useful to sensitize researchers to concepts and processes that they might not necessarily identify through inductive processes. In this article, we provide a reflexive account of our experience of using a theory-driven conceptual framework, the Normalization Process Model, in a qualitative evaluation of general practitioners’ uptake of a free, pilot, language interpreting service in the Republic of Ireland. We reflect on our decisions about whether or not to use the Model, and describe our actual use of it to inform research questions, sampling, coding, and data analysis. We conclude with reflections on the added value that the Model and tight design brought to our research.

Communication in cross-cultural consultations in primary care in Europe: the case for improvement. The rationale for the RESTORE FP 7 project

The purpose of this paper is to substantiate the importance of research about barriers and levers to the implementation of supports for cross-cultural communication in primary care settings in Europe. After an overview of migrant health issues, with the focus on communication in cross-cultural consultations in primary care and the importance of language barriers, we highlight the fact that there are serious problems in routine practice that persist over time and across different European settings. Language and cultural barriers hamper communication in consultations between doctors and migrants, with a range of negative effects including poorer compliance and a greater propensity to access emergency services. It is well established that there is a need for skilled interpreters and for professionals who are culturally competent to address this problem. A range of professional guidelines and training initiatives exist that support the communication in cross-cultural consultations in primary care. However, these are commonly not implemented in daily practice. It is as yet unknown why professionals do not accept or implement these guidelines and interventions, or under what circumstances they would do so. A new study involving six European countries, RESTORE (REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings), aims to address these gaps in knowledge. It uses a unique combination of a contemporary social theory, normalisation process theory (NPT) and participatory learning and action (PLA) research. This should enhance understanding of the levers and barriers to implementation, as well as providing stakeholders, with the opportunity to generate creative solutions to problems experienced with the implementation of such interventions.

REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol

BackgroundThe implementation of guidelines and training initiatives to support communication in cross-cultural primary care consultations is ad hoc across a range of international settings with negative consequences particularly for migrants. This situation reflects a well-documented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization Process Theory and participatory research methodology—Participatory Learning and Action—to investigate and support implementation of such guidelines and training initiatives in routine practice.MethodsThis is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders—migrant service users, general practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory’s four constructs—coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting. We will prospectively investigate and support the implementation journeys for the five selected interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings.DiscussionThis research employs a unique combination of Normalization Process Theory and Participatory Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and methodological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes.

Using Participatory Learning & Action research to access and engage with 'hard to reach' migrants in primary healthcare research

BackgroundCommunication problems occur in general practice consultations when migrants and general practitioners do not share a common language and culture. Migrants’ perspectives have rarely been included in the development of guidelines designed to ameliorate this. Considered ‘hard-to-reach’ on the basis of inaccessibility, language discordance and cultural difference, migrants have been consistently excluded from participation in primary healthcare research. The purpose of this qualitative study was to address this gap.MethodsThe study was conducted in the Republic of Ireland, 2009 – 2011. We developed a multi-lingual community-university research team that included seven established migrants from local communities. They completed training in Participatory Learning & Action (PLA) - a qualitative research methodology. Then, as trained service-user peer researchers (SUPERs) they used their access routes, language skills, cultural knowledge and innovative PLA techniques to recruit and engage in research with fifty-one hard-to-reach migrant service-users (MSUs).Results & discussionIn terms of access, university researchers successfully accessed SUPERs, who, in turn, successfully accessed, recruited and retained MSUs in the study. In terms of meaningful engagement, SUPERs facilitated a complex PLA research process in a language-concordant manner, enabling inclusion and active participation by MSUs. This ensured that MSUs’ perspectives were included in the development of a guideline for improving communication between healthcare providers and MSUs in Ireland. SUPERs evaluated their experiences of capacity-building, training, research fieldwork and dissemination as positively meaningful for them. MSUs evaluated their experiences of engagement in PLA fieldwork and research as positively meaningful for them.ConclusionsGiven the need to build primary healthcare ‘from the ground up’, the perspectives of diverse groups, especially the hard-to-reach, must become a normative part of primary healthcare research. PLA is a powerful, practical ‘fit-for-purpose’ methodology for achieving this: enabling hard-to-reach groups to engage meaningfully and contribute with ease to academic research. PLA has significant potential to become a ‘standard’ or generic approach in building community-based primary health care. Community–university partnerships have a significant role to play in this, with capacity to radically influence the shape of healthcare research, expanding the research agenda to incorporate the views and needs of hard-to-reach and vulnerable populations.

Involving migrants in the development of guidelines for communication in cross-cultural general practice consultations: a participatory learning and action research project

Objective The aim of this research was to involve migrants and other key stakeholders in a participatory dialogue to develop a guideline for enhancing communication in cross-cultural general practice consultations. In this paper, we focus on findings about the use of formal versus informal interpreters because dialogues about these issues emerged as central to the identification of recommendations for best practice. Design This qualitative case study involved a Participatory Learning and Action (PLA) research methodology. Participants The sample comprised 80 stakeholders: 51 from migrant communities; 15 general practitioners (GPs) and general practice staff; 7 established migrants as peer researchers; 5 formal, trained interpreters; and 2 service planners from the national health authority. Setting Galway, Ireland. Results There was 100% consensus across stakeholder groups that while informal interpreters have uses for migrants and general practice staff, they are not considered acceptable as best practice. There was also 100% consensus that formal interpreters who are trained and working as per a professional code of practice are acceptable as best practice. Conclusions Policymakers and service planners need to work in partnership with service providers and migrants to progress the implementation of professional, trained interpreters as a routine way of working in general practice.

Healthcare for migrants, participatory health research and implementation science—better health policy and practice through inclusion. The RESTORE project

Abstract Background: This is a time of unprecedented mobility across the globe. Healthcare systems need to adapt to ensure that primary care is culturally and linguistically appropriate for migrants. Evidence-based guidelines and training interventions for cultural competence and the use of professional interpreters are available across European healthcare settings. However, in real-world practice migrants and their healthcare providers ‘get by’ with a range of informal and inadequate strategies. RESTORE is an EU FP7 funded project, which is designed to address this translational gap. Objectives: The objective of RESTORE is to investigate and support the implementation of guidelines and training initiatives to support communication in cross-cultural consultations in selected European primary care settings. Design: RESTORE is a qualitative, participatory health project running from 2011–2015. It uses a novel combination of normalization process theory and participatory learning and action research to follow and shape the implementation journeys of relevant guidelines and training initiatives. Research teams in Ireland, England, the Netherlands, Austria and Greece are conducting similar parallel qualitative case study fieldwork, with a complementary health policy analysis led by Scotland. In each setting, key stakeholders, including migrants, are involved in participatory data generation and analysis. Expected results: RESTORE will provide knowledge about the levers and barriers to the implementation of guidelines and training initiatives in European healthcare settings and about successful, transferrable strategies to overcome identified barriers. RESTORE will elucidate the role of policy in shaping these implementation journeys; generate recommendations for European policy driving the development of culturally and linguistically appropriate healthcare systems.

Learning from doing: the case for combining normalisation process theory and participatory learning and action research methodology for primary healthcare implementation research

BackgroundThe implementation of research findings is not a straightforward matter. There are substantive and recognised gaps in the process of translating research findings into practice and policy. In order to overcome some of these translational difficulties, a number of strategies have been proposed for researchers. These include greater use of theoretical approaches in research focused on implementation, and use of a wider range of research methods appropriate to policy questions and the wider social context in which they are placed. However, questions remain about how to combine theory and method in implementation research. In this paper, we respond to these proposals.DiscussionFocussing on a contemporary social theory, Normalisation Process Theory, and a participatory research methodology, Participatory Learning and Action, we discuss the potential of their combined use for implementation research. We note ways in which Normalisation Process Theory and Participatory Learning and Action are congruent and may therefore be used as heuristic devices to explore, better understand and support implementation. We also provide examples of their use in our own research programme about community involvement in primary healthcare.ConclusionsNormalisation Process Theory alone has, to date, offered useful explanations for the success or otherwise of implementation projects post-implementation. We argue that Normalisation Process Theory can also be used to prospectively support implementation journeys. Furthermore, Normalisation Process Theory and Participatory Learning and Action can be used together so that interventions to support implementation work are devised and enacted with the expertise of key stakeholders. We propose that the specific combination of this theory and methodology possesses the potential, because of their combined heuristic force, to offer a more effective means of supporting implementation projects than either one might do on its own, and of providing deeper understandings of implementation contexts, rather than merely describing change.

Exploring barriers to primary care for migrants in Greece in times of austerity: perspectives of service providers

Abstract Background: Migration in Europe is increasing at an unprecedented rate. There is an urgent need to develop ‘migrant-sensitive healthcare systems’. However, there are many barriers to healthcare for migrants. Despite Greece’s recent, significant experiences of inward migration during a period of economic austerity, little is known about Greek primary care service providers’ experiences of delivering care to migrants. Objectives: To identify service providers’ views on the barriers to migrant healthcare. Methods: Qualitative study involving six participatory learning and action (PLA) focus group sessions with nine service providers. Data generation was informed by normalization process theory (NPT). Thematic analysis was applied to identify barriers to efficient migrant healthcare. Results: Three main provider and system-related barriers emerged: (a) emphasis on major challenges in healthcare provision, (b) low perceived control and effectiveness to support migrant healthcare, and (c) attention to impoverished local population. Conclusion: The study identified major provider and system-related barriers in the provision of primary healthcare to migrants. It is important for the healthcare system in Greece to provide appropriate supports for communication in cross-cultural consultations for its diversifying population.

Participatory approach works

Fudge et al report that users were not involved in defining categories or criteria for their involvement in the stroke programme on which this published ethnography is based.1 In our experience, user involvement, and research about user involvement, requires and benefits from a participatory approach.2 This fosters congruence …

Supporting the use of theory in cross-country health services research: a participatory qualitative approach using Normalisation Process Theory as an example

Objectives To describe and reflect on the process of designing and delivering a training programme supporting the use of theory, in this case Normalisation Process Theory (NPT), in a multisite cross-country health services research study. Design Participatory research approach using qualitative methods. Setting Six European primary care settings involving research teams from Austria, England, Greece, Ireland, The Netherlands and Scotland. Participants RESTORE research team consisting of 8 project applicants, all senior primary care academics, and 10 researchers. Professional backgrounds included general practitioners/family doctors, social/cultural anthropologists, sociologists and health services/primary care researchers. Primary outcome measures Views of all research team members (n=18) were assessed using qualitative evaluation methods, analysed qualitatively by the trainers after each session. Results Most of the team had no experience of using NPT and many had not applied theory to prospective, qualitative research projects. Early training proved didactic and overloaded participants with information. Drawing on RESTORE’s methodological approach of Participatory Learning and Action, workshops using role play, experiential interactive exercises and light-hearted examples not directly related to the study subject matter were developed. Evaluation showed the study team quickly grew in knowledge and confidence in applying theory to fieldwork. Recommendations applicable to other studies include: accepting that theory application is not a linear process, that time is needed to address researcher concerns with the process, and that experiential, interactive learning is a key device in building conceptual and practical knowledge. An unanticipated benefit was the smooth transition to cross-country qualitative coding of study data. Conclusion A structured programme of training enhanced and supported the prospective application of a theory, NPT, to our work but raised challenges. These were not unique to NPT but could arise with the application of any theory, especially in large multisite, international projects. The lessons learnt are applicable to other theoretically informed studies.