Moira Kelly

The role of theory in qualitative health research

The role of theory in qualitative research is often underplayed but it is relevant to the quality of such research in three main ways. Theory influences research design, including decisions about what to research and the development of research questions. Theory underpins methodology and has implications for how data are analyzed and interpreted. Finally, theory about a particular health issue may be developed, contributing to what is already known about the topic that is the focus of the study. This paper will critically consider the role of theory in qualitative primary care research in relation to these three areas. Different approaches to qualitative research will be drawn upon in order to illustrate the ways in which theory might variably inform qualitative research, namely generic qualitative research, grounded theory and discourse analysis. The aim is to describe and discuss key issues and provide practical guidance so that researchers are more aware of the role theory has to play and the importance of being explicit about how theory affects design, analysis and the quality of qualitative research.

Corticosteroids and peptic ulceration

The relationship between corticosteroids and peptic ulceration, together with the major complications of gastrointestinal haemorrhage and perforation, remains an area of clinical concern. This paper reviews the literature regarding peptic ulceration and corticosteroids. Risk factors related to an increased incidence of peptic ulceration in patients prescribed corticosteroids are discussed. These include: total dose of corticosteroid, previous history of peptic ulceration, advanced malignant disease and concurrent prescribing of nonsteroidal anti-inflammatory drugs (NSAI Ds). It is suggested that prophylaxis should be considered for those patients with two or more risk factors. Choice and efficacy of prophylaxis is also considered.

A comparison of hospice and hospital care for the spouses of people who die

To compare the quality of care for spouses of dying people in St Christophers Hospice, London and nearby hospitals in 1994 and to make comparisons with earlier studies of the same setting, interviews were undertaken with spouses of people who had died from cancer in these settings, matched by the deceaseds age and sex. The subjects comprised 66 people whose spouses had died in 1994, 33 of whom had died in the hospice, 33 in local hospitals. The mean age was 69.3; 61 % were female. No significant differences between groups were found on the outcome measures (adjustment to bereavement, anxiety and psychosomatic symptoms at the time of the final admission), largely replicating earlier studies in the same setting. In various respects hospitals have moved closer to hospice practice: in contrast to earlier studies, there were no differences in visiting patterns or in spouses helping with inpatient care. Bereavement follow-up is now initiated in some cases by hospitals. Liberal visiting hours could be stressful, however, and spouses sometimes helped with care to remedy staff shortcomings. Regret at not being present at the death was more common in the hospital group. Bereavement interventions may have more effect on subsequent adjustment if targeted on high-risk individuals. Other benefits than adjustment, however, may be achievable. Steps to create a calm atmosphere on hospital wards where people can be with their relatives near the time of death are desirable.

Improving ethnic monitoring for telephone-based healthcare: a conversation analytic study

Objectives Medical and healthcare organisations—including the national cancer support and helpline organisation that is the subject of this study—are expected to collect and monitor information about the ethnicity of their client populations. Information about ethnicity is important for a variety of reasons, including monitoring need and targeting healthcare services appropriately. Previous survey and interview research has suggested that collecting ethnicity data from service users can be incomplete and of variable quality—pointing to a need for an improved understanding of the (interactional) difficulties involved when call-handlers ask callers about their ethnicity. Design This study analyses a corpus of real-life audio-recorded calls to a national cancer helpline in the UK, focusing on the way that call-handlers collect the ethnic monitoring data. Setting A major national cancer helpline in the UK. Participants A sample of 273 recorded calls were recorded, of which 267 were frontline calls in which call-handlers are expected to ask the ethnicity monitoring question. Results Findings suggest that caller uncertainty about how to answer the question, resistance to answering and call-handler presumption can compromise the effectiveness of ethnic monitoring. It is likely to be improved by changing how the ethnicity monitoring question is asked. Changes include avoiding open question formats to ease caller uncertainty; offering callers a rationale (account) for the question to minimise resistance and confirming the accuracy of the ethnic category recorded. Conclusions We recommend that telephone-based healthcare personnel avoid asking the ethnicity monitoring question in an ‘open’ format; instead, a question containing a (short) standardised list can assist callers in responding. A training tool has been developed that applies this and other findings, with a view to improving ethnic monitoring.

Teaching diversity to medical undergraduates: Curriculum development, delivery and assessment. AMEE GUIDE No. 103

Abstract The aim of this Guide is to support teacher with the responsibility of designing, delivering and/or assessing diversity education. Although, the focus is on medical education, the guidance is relevant to all healthcare professionals. The Guide begins by providing an overview of the definitions used and the principles that underpin the teaching of diversity as advocated by Diversity and Medicine in Health (DIMAH). Following an outline of these principles we highlight the difference between equality and diversity education. The Guide then covers diversity education throughout the educational process from the philosophical stance of educators and how this influences the approaches used through to curriculum development, delivery and assessment. Appendices contain practical examples from across the UK, covering lesson plans and specific exercises to deliver teaching. Although, diversity education remains variable and fragmented there is now some momentum to ensure that the principles of good educational practice are applied to diversity education. The nature of this topic means that there are a range of different professions and medical disciplines involved which leads to a great necessity for greater collaboration and sharing of effective practice.

Drawing the Line: How African, Caribbean and White British Women Live Out Psychologically Abusive Experiences

This study explores how African, Caribbean and White British women worked to hide psychological partner abuse as they experienced it, “do gender,” and appear competent in social roles. They prioritized negotiated competencies as “good partners,” actively setting socially and culturally embedded boundaries to their abuser’s behaviors: an inner boundary encompassing normal behaviors and an outer one of “acceptable” behaviors projected as normal through remedial work. Behaviors breaching the outer boundary (e.g., if the women narrowed the bounds of the “acceptable”) compromised the women’s competence. This sometimes led them to actively use support services. Appropriate advice and support may change the boundaries.

Tomorrow’s Doctors and diversity issues in medical education

Teaching ‘cultural diversity’ to medical students in the UK became a priority following the publication of Tomorrow’s Doctors (General Medical Council, [GMC] 1993). This was in the context of increasing recognition in the UK and North America of the need to acknowledge variation in patient needs related to their ethnic background and the influence that cultural perspectives have on health as well as increasing diversity within society and changing expectations of doctors (Dogra et al. 2010). Previously, medical schools included ethnicity more in the context of teaching about health inequalities rather than about how health practitioners, including doctors, could meet the needs of a diverse range of patients including those with different ethnicities (for example: University of Leicester 1993). Tomorrow’s Doctors (GMC 1993) contained the recommendations for undergraduate medical education issued by the Education Committee of the GMC. In developing their recommendations, the Education Committee concluded that the time for change had come and medical schools needed to ensure that future doctors treated patients from all backgrounds equitably (GMC 1993). In this commentary we critique each of the three iterations of Tomorrow’s Doctors (1993, 2003, 2009) with respect to diversity education and discuss how these documents may have both helped and hindered this. We conclude with some recommendations.

Moral mediation in interpreted health care consultations

This paper reports on the moral work done in routine diabetes review consultations in primary care with nurses. Consultations with fluent English speakers are compared with consultations where an interpreter was present, largely involving patients of Bangladeshi origin. The study setting was Tower Hamlets in London, where type 2 diabetes is particularly common. Existing research has shown some dissatisfaction with diabetes care amongst Bangladeshi patients, and studies of care providers in other locations suggest that they at times experience the care of this group as particularly challenging. Through analysis of video-recorded consultations recorded in 2010-2011 we shed light on possible reasons for these difficulties. The 12 non-English speakers often experienced difficulties in raising issues that concerned them, particularly if their interpreter did not translate their utterance because it was deemed to be unrelated to diabetes. These difficulties were not shared by the 24 fluent English speakers, who also found it easier to convey a positive moral reputation and to excuse behaviour that deviated from recommended self-management practices. Interpreters at times also acted as moral mediators. For example, where a participant in the consultation made statements that appeared to convey a negative moral judgement of an other participant, these would often go untranslated. Probably, neither health care providers nor patients are fully aware of the nature of their communication difficulties. Given this, interpreters possess considerable power to influence matters. Understanding the moral work of consultations is important in explaining the findings of other studies showing difficulties in the provision of diabetes care to people with limited English language skills.

Who sets the Agenda? Are opportunistic brief interventions for 'excessive drinkers' and patient centred care compatible?

Brief interventions are said to be `a crucial and permanent addition to the range of strategies used to combat alcohol-related harm’ (Heather, 2001, p. 605). A distinction is made between specialist `brief treatment’ and `opportunistic brief intervention’ (OBI). Brief treatment is aimed at people seeking help for an alcohol problem, whereas OBI is aimed at people who are identi®ed as `excessive’ [1] drinkers in settings where they have attended for reasons other than to seek help for an alcohol problem. OBI is seen as part of a public health approach to alcoholrelated harm. Although OBIs can be carried out by a range of professionals who have contact with patient and client populations, general practitioners (GPs) have been targeted as those best placed to reach the largest possible number of people because they see the majority of the population on a relatively regular basis. Routine screening of patients and OBI with those found to be drinking excessively (screening and brief intervention (SBI)), is predicted to produce the greatest reduction in alcohol-related harm compared with other methods, given that environmental and other control methods are still resisted by government (Heather, 2001). OBIs have proven ef®cacy in clinical trials (see for example, Babor and Grant, 1992; Fleming et al., 1997) although most research has been carried out in the more specialized area of brief treatment for people with recognized alcohol problems. Advocates of SBI have expressed frustration that, despite evidence that it works, efforts aimed at widespread implementation of SBI by doctors (and nurses) have been largely unsuccessful (Heather, 2001; Kaner et al., 1999). Here I should like to explore some problems I see with the implementation of SBI by GPs and a possible way forward. This involves looking at the problem from a different angle to see if there are insights to be gained. The literature on SBI tends to emphasize the intervention itself, and factors related to patient outcome and GP implementation. I shall argue that much greater attention should be paid to the social interactive context in which the intervention may take place, in particular the nature of the patient±GP consultation.

Unmasking quality: exploring meanings of health by doing art

BackgroundQuality in healthcare has many potential meanings and interpretations. The case has been made for conceptualisations of quality that place more emphasis on describing quality and less on measuring it through structured, vertically oriented metrics. Through discussion of an interdisciplinary community arts project we explore and challenge the dominant reductionist meanings of quality in healthcare.DiscussionThe model for structured participatory arts workshops such as ours is ‘art as conversation’. In creating textile art works, women involved in the sewing workshops engaged at a personal level, developing confidence through sharing ideas, experiences and humour. Group discussions built on the self-assurance gained from doing craft work together and talking in a relaxed way with a common purpose, exploring the health themes which were the focus of the art. For example, working on a textile about vitamin D created a framework which stimulated the emergence of a common discourse about different cultural practices around ‘going out in the sun’. These conversations have value as ‘bridging work’, between the culture of medicine, with its current emphasis on lifestyle change to prevent illness, and patients’ life worlds. Such bridges allow for innovation and flexibility to reflect local public health needs and community concerns. They also enable us to view care from a horizontally oriented perspective, so that the interface in which social worlds and the biomedical model meet and interpenetrate is made visible.SummaryThrough this interdisciplinary art project involving academics, health professionals and the local community we have become more sensitised to conceptualising one aspect of health care quality as ensuring a ‘space for the story’ in health care encounters. This space gives precedence to the patient narratives, but acknowledges the importance of enabling clinicians to have time to share stories about care.