In the UK public concern about the safety of the combined measles, mumps and rubella MMR vaccine continues to impact on MMR coverage. Whilst the sharp decline in uptake has begun to level out, first ...and second dose uptake rates remain short of that required for population immunity. Furthermore, international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children. Together, this work suggests that effective interventions are required to support parents to make informed decisions about MMR. This trial assessed the impact of a parent-centred, multi-component intervention (balanced information, group discussion, coaching exercise) on informed parental decision-making for MMR.
This was a two arm, cluster randomised trial. One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations. The intervention arm received an MMR information leaflet and participated in the intervention (parent meeting). The control arm received the leaflet only. The primary outcome was decisional conflict. Secondary outcomes were actual and intended MMR choice, knowledge, attitude, concern and necessity beliefs about MMR and anxiety.
Decisional conflict decreased for both arms to a level where an 'effective' MMR decision could be made one-week (effect estimate = -0.54, p < 0.001) and three-months (effect estimate = -0.60, p < 0.001) post-intervention. There was no significant difference between arms (effect estimate = 0.07, p = 0.215). Heightened decisional conflict was evident for parents making the MMR decision for their first child (effect estimate = -0.25, p = 0.003), who were concerned (effect estimate = 0.07, p < 0.001), had less positive attitudes (effect estimate = -0.20, p < 0.001) yet stronger intentions (effect estimate = 0.09, p = 0.006). Significantly more parents in the intervention arm reported vaccinating their child (93% versus 73%, p = 0.04).
Whilst both the leaflet and the parent meeting reduced parents' decisional conflict, the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
People seeking fertility treatment are exposed to numerous stressors and many professionals are involved in their care. This literature review focuses on the role of nurses and midwives in ...the promotion of patient's well-being. Key themes identified are the need for continuity of care and support at all stages of treatment, but particularly prior to pregnancy testing, during the ante-natal period and following unsuccessful treatment. Women who conceive through fertility treatment are often anxious about the risk of potential miscarriage. It is not unreasonable that nurses and midwives receive training in acquiring skills in the provision of such support to patients which, arguably, is consistent with the general requirement that their skills and knowledge are updated to ensure safe and effective practice, but this would have resource implications. The wider question of who should provide well-being and emotional support for patients is an area of reproductive medicine which requires further research.
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IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
The problems associated with twin and higher order pregnancies have assumed major importance, with international debate about multiple pregnancy; the single biggest risk with in vitro fertilisation ...(IVF). We have critically reviewed published papers on female patients' and their partners' views of single embryo transfer (SET) and twin or higher level pregnancies to identify the requirements needed to improve the acceptability of SET. Twenty relevant papers were identified and included in the review. Although the majority of IVF patients and their partners, in the more recent studies, exhibited a desire for twins rather than singletons, closer examination of the evidence revealed that elective SET (eSET) could become increasingly acceptable. As success rates of IVF have improved and the risks and consequences of multiple pregnancies are well-documented, patients have accepted the transfer of two rather than three embryos as standard practice. However, more would accept eSET if success rates approached those of double embryo transfer (DET). This emphasises the importance of improving success rates of eSET so that more patients can achieve a singleton birth with one IVF cycle. If patients were offered only SET, it is likely that this would be acceptable as the normal expectation of pregnancy is one baby. Measures to improve the acceptability of SET include: using eSET, especially with younger patients; including partners when providing risk information; improving eSET success rates; improving outcomes with cryopreserved embryos; changing reimbursement/free cycles to favour eSET; using legal enforcement.
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IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Randomised controlled trials (RCTs) are considered to be the gold standard in evaluating medical interventions; however, people from ethnic minorities are frequently under‐represented in such ...studies. The present paper addresses a previously neglected debate about the tensions which inform clinical trial participation amongst people from ethnic minorities, in particular, South Asians, the largest ethnic minority group in the UK. In a narrative review of the available literature, based mainly on US studies, the present authors aim to make sense of the issues around under‐representation by providing a theoretical reconciliation. In addition, they identify a number of potential barriers to ethnic minority participation in clinical trials. In so doing, the authors recognise that the recent history of eugenic racism, and more general views on clinical trials as a form of experimentation, means that clinical trial participation among people from ethnic minorities becomes more problematic. Lack of participation and the importance of representational sampling are also considered, and the authors argue that health professionals need to be better informed about the issues. The paper concludes by offering a number of strategies for improving ethnic minority accrual rates in clinical trials, together with priorities for future research.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Continuity of care is widely regarded as a core value of primary care. The objective of this article is to explore the literature about the concept of continuity of care focusing on factors that ...influence continuity; advantages and disadvantages of continuity and the effect of continuity on outcomes, hence on the quality of care. Electronic databases and other websites were searched for relevant literature. The results of this review showed that continuity of care is influenced by demographic factors, factors related to patients and healthcare professionals, patient-healthcare professional relationship, inter-professional factors, role of receptionists and organisational factors. Several advantages were found to be associated with most types of continuity in various medical disciplines preventive medicine, general health, maternity and child health, mental and psychosocial health, chronic diseases and costs of care.Various factors influenced different types of continuity. Most types of continuity were associated with good outcomes, hence indirectly affecting the quality of care. Health care professionals and policy makers should be aware of the effect of continuity on quality of care and of the factors that influence continuity if they wish to preserve it as a core value of primary care.
Title. Retention of nurses in the primary and community care workforce after theage of 50 years: database analysis and literature review.
Aim. This paper is a report of a study conducted to explore ...strategies for retaining nurses and their implications for the primary and community care nursing workforce.
Background. An ageing nursing workforce has forced the need for recruitment and retention of nurses to be an important feature of workforce planning in many countries. However, whilst there is a growing awareness of the factors that influence the retention of nurses within secondary care services, little is known about those that influence retention of nurses in primary and community care. Little is known about the age profile of such nurses or the impact of the ageing nursing workforce on individual nursing specialities in the England.
Methods. Nursing databases were analysed to explore the impact of age on nursing specialities in primary and community care. The nurse retention literature was reviewed from 1995 to 2006.
Findings. Workforce statistics reveal that primary and community care nurses have a higher age profile than the National Health Service nursing workforce as a whole. However, there are important gaps in the literature in relation to the factors influencing retention of older primary and community care nurses. Specific factors exist for older nurses within primary care that are unique. Implications for their retention are suggested.
Conclusion. Particular attention needs to be paid to factors influencing retention of older nurses in primary and community care. These factors need to be incorporated into local and national policy planning and development.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
Background
It is widely believed that the method of payment of physicians may affect their clinical behaviour. Although payment systems may be used to achieve policy objectives (e.g. cost containment ...or improved quality of care), little is known about the effects of different payment systems in achieving these objectives.
Objectives
To evaluate the impact of different methods of payment (capitation, salary, fee for service and mixed systems of payment) on the clinical behaviour of primary care physicians (PCPs).
Search methods
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register; the Cochrane Controlled Trials Register; MEDLINE (1966 to October 1997); BIDS EMBASE (1980 to October 1997); BIDS ISI (1981 to October 1997); EconLit (1969 to October 1997); HealthStar (1975 to October 1997) Helmis (1984 to October 1997); health economics discussion paper series of the Universities of York, Aberdeen, Sheffield, Bristol, Brunel, and McMaster; Swedish Institute of Health Economics; RAND corporation; and reference lists of articles.
Selection criteria
Randomised trials, controlled before and after studies and interrupted time series analyses of interventions comparing the impact of capitation, salary, fee for service (FFS) and mixed systems of payment on primary care physician satisfaction with working environment; cost and quantity of care; type and pattern of care; equity of care; and patient health status and satisfaction.
Data collection and analysis
Two reviewers independently extracted data and assessed study quality.
Main results
Four studies were included involving 640 primary care physicians and more than 6400 patients. There was considerable variation in study setting and the range of outcomes measured. FFS resulted in more primary care visits/contacts, visits to specialists and diagnostic and curative services but fewer hospital referrals and repeat prescriptions compared with capitation. Compliance with a recommended number of visits was higher under FFS compared with capitation payment. FFS resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but patients were less satisfied with access to their physician compared with salaried payment.
Authors' conclusions
It is noteworthy that so few studies met the inclusion criteria. There is some evidence to suggest that the method of payment of primary care physicians affects their behaviour, but the findings' generalisability is unknown. More evaluations of the effect of payment systems on PCP behaviour are needed, especially in terms of the relative impact of salary versus capitation payments.
Title. Retaining older nurses in primary care and the community.
Aim. This paper is a report of a study conducted to examine issues associated with the impact of age on the retention of female ...primary and community care nurses in the National Health Service in England.
Background. Little is known about why older nurses in the primary and community care workforce leave and what might encourage them to stay.
Methods. A cross‐sectional survey using a semi‐structured postal questionnaire was carried out during 2005. Responses were received from 485 (61%) district nurses, health visitors, school nurses and practice nurses in five primary care trusts in England. Data were analysed to test for associations.
Results. Older nurses were more likely than younger ones to report that their role had lived up to expectations (P = 0·001). Issues important for older nurses were feeling valued and being consulted when change was implemented. Important factors encouraging nurses to stay were pension considerations, reduced working hours near retirement, and reduced workload. For those with degree‐level qualifications, enhanced pay was a factor encouraging retention (P = 0·044). Nurses might leave in response to high administrative workloads, problems in combining work and family commitments (P ≤ 0·001), and lack of workplace support (P = 0·029). Retirement and pensions advice was not widely available.
Conclusion. Since two‐thirds of nurses were generally happy in their role, it is important that the conditions necessary to maintain this level of satisfaction are continued throughout a nurse’s working life. Nurses may all too easily consider leaving prematurely unless policy makers and managers ensure that their working environment reflects the issues nurses consider to be conducive to retention.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
There is little UK-based empirical research on South Asian participation in clinical trials. The predominantly US literature rarely engages with mainstream debates about ethnicity, diversity and ...difference. This study was prompted by a lack of knowledge about how South Asian people perceive trial involvement and the risks and benefits involved. Face to face interviews were conducted with 25 health professionals (consultants, GPs, nursing staff, academics, non-medically trained trial co-ordinators, LREC and MREC members) and 60 South Asian lay people (20 Indians, 20 Pakistanis and 20 Bangladeshis) who had not taken part in a trial. The study took place in the Leeds and Bradford areas of England. It was found that lay South Asian attitudes towards clinical trial participation focused on similarities rather than differences with the general UK population, suggesting that the relevance of ethnicity should be kept in perspective. There was no evidence of antipathy amongst South Asians to the concept of clinical trials, and awareness was a correlate of social class, education and younger age. Lay factors that might affect South Asian participation in clinical trials included: age; language, social class; feeling of not belonging/mistrust; culture and religion. Approachable patients (of the same gender, social class and fluent in English) tended to be ‘cherry picked’ to clinical trials. This practice was justified because of a lack of time, resources and inadequate support. South Asian patients might be systematically excluded from trials due to the increased cost and time associated with their inclusion, particularly in relation to the language barrier. Under-representation might also be due to passive exclusion associated with cultural stereotypes. The paper concludes by applying the theoretical framework of institutional racism as a means of making sense of policy and practice. At the same time, caution is advocated against using ethnicity as the only form of discrimination facing minority ethnic populations.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Very few studies have reported cancer outcomes of patients referred through different routes, despite the prominence of current UK cancer urgent referral guidance.
This study aimed to compare ...outcomes of cancer patients referred through the urgent referral guidance with those who were not, with respect to stage at diagnosis, survival, and delays in diagnosis.
Analysis of hospital records.
One hospital trust in England.
The records of 889 patients diagnosed in 2000-2001 with one of four types of cancer were analysed: 409 with lung cancer; 239 with colorectal cancer; 146 with prostate cancer; and 95 with ovarian cancer. Outcome measures were diagnostic stage, survival, referral and secondary care delays.
For lung cancer, urgent referrals had more advanced TNM (tumor, node, metastasis) stage than patients diagnosed through other routes (P = 0.035) and poorer survival (P = 0.020). There was no difference in stage or survival for the other cancers. For each cancer, a higher proportion of urgent referrals was seen within 2 weeks. Secondary care delays for lung and colorectal cancer were shorter for inter-specialty referrals.
For patients with lung cancer, the guidance appears to be prioritising those in the more advanced stages of disease. This was not the case for the other three cancers. Referral delays were shorter for patients urgently referred, as is the intention of the guidance. The avoidance of delays in outpatient diagnostics probably accounts for shorter secondary care delays for inter-specialty referrals.
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