Sabi Redwood

Using the framework method for the analysis of qualitative data in multi-disciplinary health research

BackgroundThe Framework Method is becoming an increasingly popular approach to the management and analysis of qualitative data in health research. However, there is confusion about its potential application and limitations.DiscussionThe article discusses when it is appropriate to adopt the Framework Method and explains the procedure for using it in multi-disciplinary health research teams, or those that involve clinicians, patients and lay people. The stages of the method are illustrated using examples from a published study.SummaryUsed effectively, with the leadership of an experienced qualitative researcher, the Framework Method is a systematic and flexible approach to analysing qualitative data and is appropriate for use in research teams even where not all members have previous experience of conducting qualitative research.

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents

BackgroundEven though electronic prescribing systems are widely advocated as one of the most effective means of improving patient safety, they may also introduce new risks that are not immediately obvious. Through the study of specific incidents related to the processes involved in the administration of medication, we sought to find out if the prescribing system had unintended consequences in creating new errors. The focus of this study was a large acute hospital in the Midlands in the United Kingdom, which implemented a Prescribing, Information and Communication System (PICS).MethodsThis exploratory study was based on a survey of routinely collected medication incidents over five months. Data were independently reviewed by two of the investigators with a clinical pharmacology and nursing background respectively, and grouped into broad types: sociotechnical incidents (related to human interactions with the system) and non-sociotechnical incidents. Sociotechnical incidents were distinguished from the others because they occurred at the point where the system and the professional intersected and would not have occurred in the absence of the system. The day of the week and time of day that an incident occurred were tested using univariable and multivariable analyses. We acknowledge the limitations of conducting analyses of data extracted from incident reports as it is widely recognised that most medication errors are not reported and may contain inaccurate data. Interpretation of results must therefore be tentative.ResultsOut of a total of 485 incidents, a modest 15% (n = 73) were distinguished as sociotechnical issues and thus may be unique to hospitals that have such systems in place. These incidents were further analysed and subdivided into categories in order to identify aspects of the context which gave rise to adverse situations and possible risks to patient safety. The analysis of sociotechnical incidents by time of day and day of week indicated a trend for increased proportions of these types of incidents occurring on Sundays.ConclusionIntroducing an electronic prescribing system has the potential to give rise to new types of risks to patient safety. Being aware of these types of errors is important to the clinical and technical implementers of such systems in order to, where possible, design out unintended problems, highlight training requirements, and revise clinical practice protocols.

Under-representation of minority ethnic groups in research — call for action

People have been coming to the UK since the beginning of recorded time.1 The latest Census shows that England and Wales have become more ethnically diverse with the majority of individuals still identifying themselves as white British (80.6%).2 Over the past two decades, as a result of economic and political changes, migration patterns into the UK have shifted from postcolonial migration particularly referring to relatively discreet communities from the Indian sub-continent and West Indies settling in the UK, to a new type of migration with many different people arriving from many different places. This shift in pattern has resulted in a new kind of diversity which Vertovec3 has coined ‘super-diversity’ characterised by overlapping variables including country of origin (ethnicity, language, religious tradition, regional and/or local identities), migration experience (influenced by sex, age, education, specific social networks, economic factors), and legal status (encompassing a variety of entitlements and restrictions). Thus ethnic and cultural diversity is becoming more complex. While diversity has many benefits for the economy, science, and culture, it also presents health services and research with the challenges of meeting the needs of a population that is super-diverse in terms of their health profiles and behaviour.4 …

The design of lower‐limb sports prostheses: fair inclusion in disability sport

Within lower‐limb disability running, the design of the prosthesis has shifted from being a tool for restoring function to one of enabling athletes to perform to near non‐disabled standards. This paper examines the background to this development. The authors argue that the impact of technology on the design of prostheses is likely to affect athletes’ abilities and unfairly advantage those who are able to access the most recent innovations. It is shown that historically in the case of lower‐limb sports prostheses, some variation in their performance is evident. The sports legislation does not allow for this difference. It is indicated that these observations are of concern to the sports stakeholders and therefore warrants further attention. It is suggested that the full understanding of the prostheses contribution may never be known. The authors propose a synthesis of quantitative performance data and a qualitatively obtained code of values to help police these concerns.

Health care professionals' views of paediatric outpatient non-attendance:implications for general practice

Background. Non-attendance at paediatric hospital outpatient appointments poses potential risks to children’s health and welfare. Prevention and management of missed appointments depends on the perceptions of clinicians and decision makers from both primary and secondary care, including general practitioners (GPs) who are integral to non-attendance follow-up. Objectives. To examine the views of clinical, managerial and executive health care staff regarding occurrence and management of non-attendance at general paediatric outpatient clinics. Methods. A qualitative study using individual semi-structured interviews was carried out at three English Primary Care Trusts and a nearby children’s hospital. Interviews were conducted with 37 staff, including GPs, hospital doctors, other health care professionals, managers, executives and commissioners. Participants were recruited through purposive and ‘snowball’ sampling methods. Data were analysed following a thematic framework approach. Results. GPs focused on situational difficulties for families, while hospital-based staff emphasized the influence of parents’ beliefs on attendance. Managers, executives and commissioners presented a broad overview of both factors, but with less detailed views. All groups discussed sociodemographic factors, with non-attendance thought to be more likely in ‘chaotic families’. Hospital interviewees emphasized child protection issues and the need for thorough follow-up of missed appointments. However, GPs were reluctant to interfere with parental responsibilities. Conclusion. Parental motivation and practical and social barriers should be considered. Responsibilities regarding missed appointments are not clear across health care sectors, but GPs are uniquely placed to address non-attendance issues and are central to child safeguarding. Primary care policies and strategies could be introduced to reduce non-attendance and ensure children receive the care they require.

Involving interpreters in research studies

It is important to include non English speakers in health services research to ensure not only the generalisability of findings but also to address health inequalities and promote social justice. One approach is to use interpreters but there is little guidance for working with an interpreter in interviews. Involving an interpreter presents challenges in the planning and conduct of research interviews which can be minimised by an awareness of various theoretical and practical implications and of potential pitfalls. Drawing both on our experiences of involving interpreters in research and on the literature, we raise some issues that researchers need to consider.

“It was like walking without knowing where I was going”: A Qualitative Study of Autism in a UK Somali Migrant Community

Increasing recognition of autism in Somali migrant communities means that appropriate support services are needed. Attitudes to autism and barriers related to help-seeking in these communities are poorly understood. We aimed to assess what families affected by autism need, and how health, education and social care services can support them. In partnership with the local Somali community the research team conducted 15 in-depth interviews with parents affected by autism. Two themes are reported; ‘Perceptions of Autism’ and ‘Navigating the System’. Our research shows the importance of understanding cultural views of autism and the need to raise awareness, reduce stigma and provide support to encourage families not to delay seeking help for their children.

Patients-people-place: developing a framework for researching organizational culture during health service redesign and change

BackgroundOrganizational culture is considered by policy-makers, clinicians, health service managers and researchers to be a crucial mediator in the success of implementing health service redesign. It is a challenge to find a method to capture cultural issues that is both theoretically robust and meaningful to those working in the organizations concerned. As part of a comparative study of service redesign in three acute hospital organizations in England, UK, a framework for collecting data reflective of culture was developed that was informed by previous work in the field and social and cultural theory.MethodsAs part of a larger mixed method comparative case study of hospital service redesign, informed by realist evaluation, the authors developed a framework for researching organisational culture during health service redesign and change. This article documents the development of the model, which involved an iterative process of data analysis, critical interdisciplinary discussion in the research team, and feedback from staff in the partner organisations. Data from semi-structured interviews with 77 key informants are used to illustrate the model.ResultsIn workshops with NHS partners to share and debate the early findings of the study, organizational culture was identified as a key concept to explore because it was perceived to underpin the whole redesign process. The Patients-People-Place framework for studying culture focuses on three thematic areas (‘domains’) and three levels of culture in which the data could be organised. The framework can be used to help explain the relationship between observable behaviours and cultural artefacts, the values and habits of social actors and the basic assumptions underpinning an organization’s culture in each domain.ConclusionsThis paper makes a methodological contribution to the study of culture in health care organizations. It offers guidance and a practical approach to investigating the inherently complex phenomenon of culture in hospital organizations. The Patients-People-Place framework could be applied in other settings as a means of ensuring the three domains and three levels that are important to an organization’s culture are addressed in future health service research.

Low Nutrient Intake and Frailty Among Overweight and Obese Migrant Women From Ethnically Diverse Backgrounds Ages 60 Years and Older: A Mixed-Methods Study

Objective: To examine associations between energy/nutrient intakes and frailty in older migrant women, and to explore perceptions of body weight, dietary intake, and physical function. Design: Cross‐sectional, mixed‐methods study. Setting: Birmingham, United Kingdom. Participants: Seventy‐six first‐generation migrant women ≥ 60 years of age. Main Outcome Measures: Energy/nutrient intakes (assessed by 24‐hour dietary recall), frailty (using the frailty phenotype), and links between perceptions of body weight, dietary intake, and physical function (via semi‐structured interviews). Analysis: Bivariate and logistic regression analyses examined associations between frailty and low energy/nutrient intakes. Interviews were analyzed using inductive thematic analysis. Results: Seventy‐six women completed a 24‐hour dietary recall; 46 participated in a semi‐structured interview. Low energy intake was associated with frailty (odds ratio [OR], 11.71; 95% confidence interval [CI], 2.36–57.97). After adjusting for energy and other confounders, a low intake of > 3 nutrients was associated with frailty (OR, 6.58; 95% CI, 1.01–43.08). Qualitative data suggest that dietary intake was influenced by concerns about body weight and perceptions that unhealthy foods reduce mobility. Conclusions and Implications: Among older migrant women with high prevalence of overweight/obesity, an inadequate dietary intake may be a stronger predictor of frailty than weight loss. Dietary interventions should focus on healthy weight maintenance and optimization of nutritional adequacy and physical function.

Recent migrants’ perspectives on antibiotic use and prescribing in primary care: a qualitative study

Background Currently there is great interest in antibiotic prescribing practices in the UK, but little is known about the experiences of the increasing numbers of recent migrants (those present in the UK for >1 year but <5 years) registered at GP practices. Qualitative research has suggested that reasons for not prescribing antibiotics may not be clearly communicated to migrants. Aim This study aimed to explore the factors that shape migrants’ experiences of and attitudes to antibiotics, and to suggest ways to improve effective communication around their use. Design and setting A qualitative study on recent migrants’ health beliefs, values, and experiences in a community setting in primary care. Method Twenty-three recent migrants were interviewed in their preferred language by trained community researchers. The research team conducted a thematic analysis, focusing on health beliefs, engaging with health services, transnational medicine, and concepts of fairness. Experiences around antibiotics were a strong emerging theme. Results Three reasons were identified for antibiotics seeking: first, holding an ‘infectious model’ of illness implying that antibiotics are required quickly to avoid illness becoming worse or spreading to others; second, reasoning that other medications will be less effective for people ‘used to’ antibiotics’; and third, perceiving antibiotic prescription as a sign of being taken seriously. Some participants obtained antibiotics from their country of origin or migrant networks in the UK; others changed their mind and accepted alternatives. Conclusion Primary care professionals should aim to understand migrants’ perspectives to improve communication with patients. Further research is needed to identify different strategies needed to respond to the varying understandings of antibiotics held by migrants.