Roisin Pill

Concepts of illness causation and responsibility-some preliminary data from a sample of working class mothers

In recent years official policy in the U.K. has been marked by a shift in emphasis from curative to preventive medicine, with increasing stress being laid on the role of the individual in maintaining his/her health. However, we lack empirical data on the extent to which the concept of individual responsibility for health is accepted by various groups in our society and such data is essential before effective strategies for health education can be implemented. It is argued that readiness to accept responsibility for ones health depends partly on the views held about the aetiology of illness, and this proposition is explored using material on causation and the circumstances where blame is attributed, derived from semi-structured interviews with a sample of 41 working class mothers (Socioeconomic Group 9). Roughly half the sample held fatalistic views on the aetiology of illness and thought they were only morally accountable in very restricted circumstances. These women tended to be less well-educated than the rest of the group and they were less likely to be buying their own homes. The results are discussed in relation to current health education policies, consultation behaviours in primary medical care and consumer attitudes to the services provided by their doctors.

Qualitative study of decisions about infant feeding among women in east end of London

Abstract Objective: To improve understanding of how first time mothers who belong to a socioeconomic group with particularly low rates of breast feeding decide whether or not to initiate breast feeding. Design: Qualitative semistructured interviews early in pregnancy and 6-10weeks after birth. Setting: Womens homes in east end of London. Subjects: 21 white, low income women expecting their first baby were interviewed mostly at home, often with their partner or a relative. Two focus groups were conducted. Results: Women who had regularly seen a relative or friend successfully breast feed and described this experience positively were more confident about and committed to breast feeding. They were also more likely to succeed. Exposure to breast feeding, however, could be either a positive or a negative influence on the decision to breast feed, depending on the context. Women who had seen breast feeding only by a stranger often described this as a negative influence, particularly if other people were present. All women knew that breast feeding has health benefits. Ownership of this knowledge, however, varied according to the womans experience of seeing breast feeding. Conclusions: The decision to initiate breast feeding is influenced more by embodied knowledge gained from seeing breast feeding than by theoretical knowledge about its benefits. Breast feeding involves performing a practical skill, often with others present. The knowledge, confidence, and commitment necessary to breast feed may be more effectively gained through antenatal apprenticeship to a breastfeeding mother than from advice given in consultations or from books.

The effectiveness of one-to-one risk-communication interventions in health care: a systematic review

Objectives. To assess whether risk-communication interventions are associated with changes in patient knowledge, attitudes, and behaviors, and to identify aspects of these interventions that modify these effects. Design. Systematic review. Data sources. 96 studies from the period 1985-1996 retrieved by electronic searching of eight databases, hand searching of four journals, contacting key authors, and reference list searching. Main outcome measures. The effect size of the principal outcome was identified from each study. Outcomes measuring behavioral change were preferred; if these were not available, knowledge, anxiety, or risk perceptions were used, according to the focus of the study. Data were available to calculate the principal effect sizes for 82 of the studies. Analysis. Meta-regression. Results. The methodologic qualities of the studies varied. Nevertheless, risk-communication interventions generally had positive (beneficial) effects. Interventions addressing treatment choices were associated with larger effects than were those in other contexts, such as prevention or screening. Interventions using individual risk estimates were associated with larger effects than were those using more general risk information. Two design variables were identified as effect modifiers: randomized controlled trials were associated with smaller effects than other designs, and dichotomous outcomes were associated with larger effects than continuous outcomes. Conclusions. Risk communication interventions may be most productive if they include individual risk estimates in the discussion between professional and patient. Patient decisions about treatment appear more amenable to change by these interventions than attendance for screening or modification of risky behavior. Key words: risk communication; prevention interventions; patient behavioral changes; systematic review. (Med Decis Making 2000;20:290-297)

A qualitative study of women’s views about how health professionals communicate about infant feeding

To look at how communication by health professionals about infant feeding is perceived by first time mothers.

Public attitudes towards the use of primary care patient record data in medical research without consent: a qualitative study

Objectives: Recent legislative changes within the United Kingdom have stimulated professional debate about access to patient data within research. However, there is currently little awareness of public views about such research. The authors sought to explore attitudes of the public, and their lay representatives, towards the use of primary care medical record data for research when patient consent was not being sought. Methods: 49 members of the public and four non-medical members of local community health councils in South Wales, UK gave their views on the value and acceptability of three current research scenarios, each describing access to data without patient consent. Results: Among focus group participants, awareness of research in primary care was low, and the appropriateness of general practitioners as researchers was questioned. There was general support for research but also concerns expressed about data collection without consent. These included lack of respect and patient control over the process. Unauthorised access to data by external agencies was a common fear. Current data collection practices, including population based disease registers elicited much anxiety. The key informants were equally critical of the scenarios and generally less accepting. Conclusions: This exploratory study has highlighted a number of areas of public concern when medical records are accessed for research without patient consent. Public acceptability regarding the use of medical records in research cannot simply be assumed. Further work is required to determine how widespread such views are and to inform those advising on confidentiality issues.

Professional responses to innovation in clinical method: diabetes care and negotiating skills.

OBJECTIVE To describe the responses of family doctors and nurses to applying an innovative clinical technique and technology in the context of a randomised controlled trial. DESIGN Multi-faceted descriptive analysis of professional responses in the experimental arm of the trial. SUBJECTS AND SETTING 29 family practices involving 30 doctors and 33 nurses over a 3-year time scale and 200 patients with type II diabetes. INTERVENTION A new visual agenda-setting technology and other visual aids applied using the techniques of negotiation and motivational interviewing. OUTCOME MEASURES Uptake of training, use of the method, group discussions, willingness to accept consultation recordings. RESULTS 100% of clinicians welcomed two or more formal training sessions. The agenda-setting technology was used frequently by 71% of clinicians and occasionally by a further 22%. High levels of engagement with the method occurred among nurses but many doctors also reported benefits. CONCLUSIONS Family doctors and nurses in Wales have found a new technology to facilitate negotiation in diabetes consultation acceptable and useful. Analysis of outcome is now awaited.

Choice or change: Further evidence on ideas of illness and responsibility for health

A study of 204 Welsh mothers using well validated research methods has demonstrated that better understanding of the antecedents to health behaviours contributes to a reorientation of stereotyped ideas about working class health beliefs and behaviour. Fatalism and an orientation to life-style choices for health are not necessarily contradictory concepts and this has important implications for those who are involved in education for health. The development of a Salience of Lifestyle Index (SLI) is described and studied in relation to concepts of blame for illness, education, house tenure, religious commitment, employment, health behaviours and social background.

Why do interventions work in some places and not others: A breastfeeding support group trial

In a cluster randomised controlled trial of a policy to provide community breastfeeding support groups in Scotland, breastfeeding rates declined in 3 of 7 intervention localities. From a preliminary study, we expected breastfeeding outcomes to vary and we prospectively used qualitative and quantitative methods to ask why. Ethnographic in-depth interviews, focus groups, observations and survey data were analysed to build seven embedded case studies. A pyramidal model of how primary health service organisations implemented the policy was constructed prior to knowing trial outcomes to minimise bias. Informed by a realist approach, the model explained variation in (a) policy implementation (b) the breastfeeding outcomes, whereas the quantity of intervention delivered did not. In the three localities where breastfeeding rates declined, negative aspects of place including deprivation, unsuitable premises and geographical barriers to inter-professional communication; personnel resources including staff shortages, high workload and low morale; and organisational change predominated (the base model tiers). Managers focused on solving these problems rather than delivering the policy and evidence of progress to the higher model tiers was weak. In contrast, where breastfeeding rates increased the base tiers of the model were less problematic, there was more evidence of leadership, focus on the policy, multi-disciplinary partnership working and reflective action cycles (the higher model tiers). We advocate an ethnographic approach to the design and evaluation of complex intervention trials and illustrate how this can assist in developing an explanatory model. More attention should be given to the complex systems within which policies and interventions occur, to identify and understand the favourable conditions necessary for a successful intervention.

Preventive procedures and practices among working class women: new data and fresh insights.

Using a sample of lower working class mothers from South Wales, U.K. data is presented on the extent to which procedures, (behaviours which involve health professionals and services) and practices (behaviours which involve the individuals in day to day lifestyle choices) are interrelated and likely to be practised by the same people. The socio-demographic variables associated with each category separately and with the whole range of preventive behaviour are also described. The British data is considered in the light of current research on preventive health behaviour (PHB) which has relied heavily for both empirical data and theoretical insight on studies conducted in U.S.A. No evidence is found to support the proposition that PHB is undimensional nor on the other hand is there convincing support for the existence of hypothesized independent dimensions. It is argued that the failure of present theory to predict more than a comparatively small part of the variance in PHB has positive implications for researchers and health educators alike.

Making changes — women, food and families

GIVEN the recognised importance of diet and health, much health education on nutrition has been directed at women who are assumed to control fam ily eating patterns since they generally carry out the bulk of shopping and food preparation. However, recent research on the sociological significance of food and eating, and family decision-making, suggests that mothers, particularly working class mothers, may face considerable constraints in ini tiating changes in dietary behaviour. Empirical data from a survey of Welsh mothers, classified as Social Class IV and V, are used to illustrate these issues, and it is argued that health educators need to be more aware of the context in which behavioural change is attempted and direct their efforts at other family members, particularly husbands, whose attitudes may be crucial.