Stephen Rogers

Designing trials of interventions to change professional practice in primary care: lessons from an exploratory study of two change strategies

Various strategies have been evaluated for their ability to support the adoption of clinical evidence into everyday practice.1 2 There is increasing interest in interventions aimed at groups of healthcare staff and promoting organisational change. Observational studies of these types of interventions have produced encouraging findings,3 4 but the results of randomised controlled trials have sometimes been disappointing.5–7 These differences may be due to the methodological and practical difficulties of evaluating such interventions in randomised trials rather than to lack of efficacy of the interventions.8 We carried out an exploratory trial to examine the independent and combined effects of teaching evidence based medicine and facilitated change management on the implementation of cardiovascular disease guidelines in primary care (box). The trial was accompanied by a formative evaluation, drawing on information collected by the evidence based medicine tutor, the change management facilitator, and a qualitative researcher who observed workshops and meetings and conducted a series of semistructured interviews with study participants.14 Progress was reviewed at monthly steering group meetings, and the thesis of this paper emerged from the deliberations and discussions of this group. #### Summary points When designing trials of interventions to change professional practice in primary care, choices have to be made about selection of appropriate practices, development and adaptation of interventions, and experimental design The different priorities of researchers, those developing the interventions, and those participating must be recognised when such choices are made The best design options may be those that are able to reconcile the interests of research, development, and practice Interventions requiring the participation of health professionals in organisational change require a high degree of motivation, and eligibility criteria should be developed and applied at recruitment Interventions must be adapted as far as possible to the needs of participants without compromising theoretical …

Work-disabling illness as a shock for livelihoods and poverty in Dhaka Slums, Bangladesh

Abstract This paper examines the impact of work days off due to illness on the financial status and livelihoods of poor slum dwellers in Dhaka, Bangladesh. Data on illness and socio-economic status were collected in a panel survey with monthly rounds. We contacted over 12 000 individuals during a 12-month period and 2682 adults had taken work days off due to illness. Where adults had taken time off work due to illness, coping responses included a deficit in their financial situation, reducing expenditure, taking loans or mortgages, selling assets, changing their work and begging. Particular households may be vulnerable to adult ill-health. When ill-health prevents an adult earner from working, the household financial situation deteriorates, and strategies are used to offset the effect. It is likely that adult illness is a major contributor to chronic poverty.

Livelihoods, nutrition and health in Dhaka slums

OBJECTIVES To identify groups within Dhaka slums that report similar patterns of livelihood, and to explore nutritional and health status. DESIGN A random sample of households participated in a longitudinal study in 1995-1997. Socio-economic and morbidity data were collected monthly by questionnaire and nutritional status was assessed. Cluster analysis was used to aggregate households into livelihood groups. SETTING Dhaka slums, Bangladesh. SUBJECTS Five-hundred and fifty-nine households. MAIN OUTCOME MEASURES Socio-economic and demographic variables, nutritional status, morbidity. RESULTS Four livelihood groups were identified. Cluster 1 was the richest cluster with land, animals, business assets and savings. Loans as well as income were higher, which shows that this group was credit-worthy. The group was mainly self-employed and worked more days per month than the other clusters. The cluster had the second highest body mass index (BMI) score, and the highest childrens nutrition status. Cluster 2 was a poor cluster and was mainly dependent self-employed. Savings and loans were lower. Cluster 3 was the most vulnerable cluster. Members of this group were mainly casual unskilled, and 40% were female-headed households. Total income and expenditure were lowest amongst the clusters. BMI and childrens nutritional status were lowest in the slum. Cluster 4 was the second richest cluster. This group comprised skilled workers. BMI was the highest in this cluster and childrens nutritional status was second highest. CONCLUSIONS Cluster analysis has identified four groups that differed in terms of socio-economic, demographic and nutritional status and morbidity. The technique could be a practically useful tool of relevance to the development, monitoring and targeting of vulnerable households by public policy in Bangladesh.

Factors affecting nutritional status in female adults in Dhaka slums, Bangladesh

Abstract This study looks at women from the slums in Mohammadpur, Dhaka, Bangladesh, where 54 percent of womens BMI was less than 18.5. Fifty percent of the Dhaka slum population lived below the poverty line. Logistic regression showed that women with income above 1,500 taka per capita were 1.78 times more likely to have a higher BMI (odds ratio 1.7863; CI = 0.671–3.639). Women with their own savings were 1.89 times more likely to have higher BMI (odds ratio 1.879; CI = 0.01163–1.6431). Women were 4.5 times more likely to have a higher BMI when food expenditure per capita above 559 taka per month (odds ratio 4.55; CI = 1.0302–8.0799). Women were 1.82 times more likely to have higher BMI when there was a break even situation in financial status (odds ratio 1.8212; CI = ‐015709–3.6285). Female headed households were 3.3 times more likely to have a higher BMI compared to women living in male headed households (odds ratio 3.2966; CI = 0.33711–6.25620). Women who work 15–23 days per month were 2.3 times more likely to have a higher BMI (odds ratio 2.33; CI = 0.1133–4.5600). Women who are the budget manager are 1.12 times more likely to have a higher BMI (odds ratio 1.125; CI = 0.29296–2.0966). Where as a husband who beats his wife is 1.83 more likely to have a poorer BMI (odds ratio 1.8312; CI = ‐3.72596–0.17508). Women who have no marriage documents and women who take days off due to illness less than 11 days per month were more likely to have a poorer BMI (odds ratio 0.5567; CI = ‐0.049339–2.8379; odds ratio 0.7569; CI = 0.183167–2.0002). Womens nutritional status and well being can influence their ability to provide for themselves and their families and the demonstration of a relationship between measures of womens autonomy and control in the household and womens nutritional status is an important indication of the importance of these sociological constructs. Womens participation in work outside the home may be a factor increasing their autonomy. The identification of relationships between womens autonomy and control and their physical well being should provide further leverage for policy change that will enable women to escape some traditional roles and to contribute as more equal partners with men in the future of Bangladeshi society.

Mortality among referrals to a community-based intermediate care team

Objectives Intermediate care services have been introduced to help mitigate unnecessary hospital demand and premature placement in long-term residential care. Many patients are elderly and/or with complex comorbidities, but little consideration has been given to the palliative care needs of patients referred to intermediate care services. The objective of this study is to determine the proportion of patients referred to a community-based intermediate care team who died during care and up to 24 months after discharge and so to help inform the development of supportive and palliative care in this setting. Methods A retrospective cohort study of all 4770 adult patients referred to Northamptonshire Intermediate Care Team (ICT) between 11 April 2010 and 10 April 2011. Results Of 4770 patients referred, 60% were 75 years or older and 32% were 85 years of age or older. 4.0% of patients died during their ICT stay and 11% within 30 days of discharge. At the end of 12 months, 25% of the patients had died, increasing to 32% before the end of the second year. About 34% of all deaths occurred during the ICT stay or within 30 days of discharge, and a further 46% by the end of the first year. Male gender and higher age were associated with greater likelihood of death. Conclusions It is important for ICT clinicians to consider immediate and longer-term palliative care needs among patients referred to ICTs. Care models involving ICTs and palliative care teams working together could enable more people with end-stage non-cancer illnesses to die at home.