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Objective: Although medication abortion has become more common in high-income countries, the procedure has not yet met early expectations for widening access to abortion. High-quality evidence can serve as a catalyst for changes in policy and practice. To direct research priorities, it is important to understand where quality evidence is concentrated and where gaps remain. High-income countries have developed a body of evidence that may have implications for the future of medication abortion. This literature review assesses the characteristics and quality of published studies on medication abortion conducted in the last 10 years in high-income countries and indicates future areas for research to advance policy and practice, and broaden access. Study design: A structured search for literature resulted in 207 included studies. A framework based upon the World Health Organization definition of sub-tasks for medication abortion was developed to categorize research by recognized stages of the medication abortion process. Using an iterative and inductive approach, additional sub-themes were created under each of these categories. Established quality assessment frameworks were drawn upon to gauge the internal and external validity of the included research. Results: Studies in the US and the UK have dominated research on MA in high-income countries. The political and social contexts of these countries will have shaped of this body of research. The past decade of research has focused largely on clinical aspects of medication abortion. Conclusion: Researchers should consider refocusing energies toward testing service delivery approaches demonstrating promise and prioritizing research that has broader generalizability and relevance outside of narrow clinical contexts. Plain English summary: Although medication abortion is more commonly available worldwide, it is not being used as often as people thought it would be, particularly in high income countries. In order to encourage changes in policy and practice that would allow greater use, we need good quality evidence. If we can understand where we do not have enough research and where we have good amounts of research, we can determine where to invest energies in further studies. Many high-income countries have produced research on medication abortion that could influence policy and practice in similarly resourced contexts. I conducted a literature review to be able to understand the type and quality of research on medication abortion conducted in high-income countries in the past 10 years. I conducted the review in an organized way to make sure that the papers reviewed discussed studies that I thought would be important for answering this question. The literature review found 207 papers. Each of these papers were reviewed and organized them by theme. I also used existing methods to determinine the quality of each study. Most of the research came from the US and the UK. Furthermore, most of the research conducted in the past 10 years was focused on clinical studies of medication abortion. In future studies, researchers should focus more on new ways of providing medication abortion to women that offers greater access. Also, the studies should be designed so that the results have meaning for a broader group of people or situations beyond where the study was done. [ABSTRACT FROM AUTHOR]

Background: There are many challenges in delivering and evaluating knowledge for healthcare, but the lack of clear routes from knowledge to practice is a root cause of failures in safety within healthcare. Various types and sources of knowledge are relevant at different levels within the healthcare system. These need to be delivered in a timely way that is useful and actionable for those providing services or developing policies. How knowledge is taken up and used through networks and relationships, and the difficulties in attributing change to knowledge-based interventions, present challenges to understanding how knowledge into action (K2A) work influences healthcare outcomes. This makes it difficult to demonstrate the importance of K2A work, and harness support for its development and resourcing. This paper presents the results from a project commissioned by NHS Education for Scotland (NES) and Healthcare Improvement Scotland (HIS) to create an evaluation framework to help understand the NHS Scotland Knowledge into Action model.Methods: The team took a developmental approach to creating an evaluation framework that would be useful and practical. This included a literature review to ensure the evaluation was evidence-based; adaptation of contribution analysis for K2A project; action research with K2A project leads to refine the work and develop suitable measures.Results: Principles for evaluation and an evaluation framework based on contribution analysis were developed and implemented on a trial project. An outcomes chain was developed for the K2A programme and specific projects. This was used to design, collect and collate evidence of the K2A intervention. Data collected routinely by the intervention was supplemented with specific feedback measures from K2A project users.Conclusions: The evaluation approach allowed for scrutiny of both processes and outcomes and was adaptable to projects on different scales. This framework has proved useful as a planning, reflecting and evaluation tool for K2A, and could be more widely used to evidence the ways in which knowledge to action work helps improve healthcare outcomes. [ABSTRACT FROM AUTHOR]

A key element of the United Kingdom (UK) health policy reform in relation to chronic disease management is the introduction of a national programme seeking to promote self-care from within the National Health Service (NHS). The mainstay of the Expert Patients Programme (EPP) is a sixweek training course that provides the opportunity for anyone with a long-term condition to develop new skills to manage their condition better on a day-to-day basis. The course forms part of the NHS self-care support programme, is administered by Primary Care Trusts (PCTs) and delivered by people who have personal experience of living with a long-term condition. The NHS' official Expert Patients Programme website presently states that, "Pilot EPP courses began at 26 NHS PCT sites across England in May 2002, and by May 2004 approximately 300 PCTs had either actively implemented pilot courses or had committed to joining. The majority of PCTs are now coming to the end of the pilot phase, with many implementing plans to make EPP sustainable for the long-term." The NHS website heralds the pilot "a success." A national, postal survey of PCT EPP Leads was undertaken in order to examine both the evolvement of EPP during its pilot stage and future plans for the programme. A questionnaire was sent out to the 299 PCTs known to have committed to the EPP pilot, and an excellent 100% response rate was obtained over a 3-month period (April-July 2005). One marker of success of the Expert Patients Programme implementation is the actual running of courses by the Primary Care Trusts. This paper explores the extent to which the implementation of the pilot can indeed be viewed as a "success," primarily in terms of the number of courses run, and considers the extent to which PCTs have carried out all that they were committed to do. Findings suggest that the more time an EPP Lead dedicates to the Programme, the more likely it is that EPP has run successfully in the past, and the more likely it is that it will continue to run successfully in the future. Other factors indicating future EPP success include collaborating across PCTs to share co-ordinators, tutors, and funding. [ABSTRACT FROM AUTHOR]

Background: This paper outlines the principal characteristics of a learning organisation and the organisational features that define it. It then compares these features with the organisational conditions that currently obtain, or are being created, within the British NHS. The contradictory development of recent British health policy, resulting in the NHS becoming both more marketised and more bureaucratised has correspondingly ambiguous implications for attempts to implement a 'learning organisation' model. Methods: Texts that define and debate the characteristics of a learning organisation were found by snowballing references from the founding learning organisation books and published papers, and then by searching a database specifically devised for a literature review on organisational structures and processes in health care. COPAC and ABI-Info databases for subsequent peer-reviewed publications that also appeared relevant to the present study were searched. Results: The outcomes of the above search are summarised and mapped onto the current constituent organisations of the NHS to identify the extent to which they achieve or approximate to a learning organisation status. Conclusion: Because of the complexity of the NHS and the contradictory processes of marketisation and bureaucratisation characterising it, it cannot, as a whole system, become a learning organisation. However, it is possible that its constituent organisations may achieve this status to varying degrees. Constraints upon NHS managers to speak their minds freely place an ultimate limit on learning organisation development. This limitation suggests that current British health service policy encourages organisational learning-but not too openly and not too much. [ABSTRACT FROM AUTHOR]

Focused ethnography is an applied and pragmatic form of ethnography that explores a specific social phenomenon as it occurs in everyday life. Based on the literature a problem-focused research question is formulated before the data collection. The data generation process targets key informants and situations so that relevant results on the pre-defined topic can be obtained within a relatively short time-span. As part of a theory based evaluation of alternative forms of consultation (such as video, phone and email) in primary care we used the focused ethnographic method in a multisite study in general practice across the UK. To date there is a gap in the literature on using focused ethnography in healthcare research.The aim of the paper is to build on the various methodological approaches in health services research by presenting the challenges and benefits we encountered whilst conducing a focused ethnography in British primary care. Our considerations are clustered under three headings: constructing a shared understanding, dividing the tasks within the team, and the functioning of the focused ethnographers within the broader multi-disciplinary team.As a result of using this approach we experienced several advantages, like the ability to collect focused data in several settings simultaneously within in a short time-span. Also, the sharing of experiences and interpretations between the researchers contributed to a more holistic understanding of the research topic. However, mechanisms need to be in place to facilitate and synthesise the observations, guide the analysis, and to ensure that all researchers feel engaged. Reflection, trust and flexibility among the team members were crucial to successfully adopt a team focused ethnographic approach. When used for policy focussed applied healthcare research a team-based multi-sited focused ethnography can uncover practices and understandings that would not be apparent through surveys or interviews alone. If conducted with care, it can provide timely findings within the fast moving context of healthcare policy and research. [ABSTRACT FROM AUTHOR]

Background: Biomedical Research Centres (BRCs) are partnerships between healthcare organisations and universities in England. Their mission is to generate novel treatments, technologies, diagnostics and other interventions that increase the country's international competitiveness, to rapidly translate these innovations into benefits for patients, and to improve efficiency and reduce waste in healthcare. As NIHR Oxford BRC (Oxford BRC) enters its third 5-year funding period, we seek to (1) apply the evidence base on how best to support the various partnerships in this large, multi-stakeholder research system and (2) research how these partnerships play out in a new, ambitious programme of translational research.Methods: Organisational case study, informed by the principles of action research. A cross-cutting theme, 'Partnerships for Health, Wealth and Innovation' has been established with multiple sub-themes (drug development, device development, business support and commercialisation, research methodology and statistics, health economics, bioethics, patient and public involvement and engagement, knowledge translation, and education and training) to support individual BRC research themes and generate cross-theme learning. The 'Partnerships' theme will support the BRC's goals by facilitating six types of partnership (with patients and citizens, clinical services, industry, across the NIHR infrastructure, across academic disciplines, and with policymakers and payers) through a range of engagement platforms and activities. We will develop a longitudinal progress narrative centred around exemplar case studies, and apply theoretical models from innovation studies (Triple Helix), sociology of science (Mode 2 knowledge production) and business studies (Value Co-creation). Data sources will be the empirical research studies within individual BRC research themes (who will apply separately for NHS ethics approval), plus documentary analysis and interviews and ethnography with research stakeholders. This study has received ethics clearance through the University of Oxford Central University Research Ethics Committee.Discussion: We anticipate that this work will add significant value to Oxford BRC. We predict accelerated knowledge translation; closer alignment of the innovation process with patient priorities and the principles of responsible, ethical research; reduction in research waste; new knowledge about the governance and activities of multi-stakeholder research partnerships and the contexts in which they operate; and capacity-building that reflects the future needs of a rapidly-evolving health research system. [ABSTRACT FROM AUTHOR]

Background: Complexity has been linked to health interventions in two ways: first as a property of the intervention, and secondly as a property of the system into which the intervention is implemented. The former recognizes that interventions may consist of multiple components that act both independently and interdependently, making it difficult to identify the components or combinations of components (and their contexts) that are important mechanisms of change. The latter recognizes that interventions are implemented in complex adaptive systems comprised of intelligent agents who modify their behaviour (including any actions required to implement the intervention) in an effort to improve outcomes relative to their own perspective and objectives. Although an intervention may be intended to take a particular form, its implementation and impact within the system may deviate from its original intentions as a result of adaptation. Complexity highlights the challenge in developing interventions as effective health solutions. The UK Medical Research Council provides guidelines on the development and evaluation of complex interventions. While mathematical modelling is included in the guidelines, there is potential for mathematical modeling to play a greater role.Discussion: The dynamic non-linear nature of complex adaptive systems makes mathematical modelling crucial. However, the tendency is for models of interventions to limit focus on the ecology of the system - the 'real-time' operation of the system and impacts of the intervention. These models are deficient by not modelling the way the system reacts to the intervention via agent adaptation. Complex intervention modelling needs to capture the consequences of adaptation through the inclusion of an evolutionary dynamic to describe the long-term emergent outcomes that result as agents respond to the ecological changes introduced by intervention in an effort to produce better outcomes for themselves. Mathematical approaches such as those found in economics in evolutionary game theory and mechanism design can inform the design and evaluation of health interventions. As an illustration, the introduction of a central screening clinic is modeled as an example of a health services delivery intervention. Complexity necessitates a greater role for mathematical models, especially those that capture the dynamics of human actions and interactions. [ABSTRACT FROM AUTHOR]

Background: The rationale for the English National Chlamydia Screening Programme (NCSP) has been questioned. There has been little analysis, however, of what drove the NCSP's establishment and how it was implemented. Such analysis will help inform the future development of the NCSP. This study used a qualitative, theory-driven approach to evaluate the rationale for the NCSP's establishment and implementation. Methods: Semi-structured interviews with 14 experts in chlamydia screening were undertaken. The interview data were analysed with policy documents and commentaries from peer-reviewed journals (published 1996-2010) using the Framework approach. Results: Two themes drove the NCSP's establishment and implementation. The first, chlamydia control, was prominently referenced in documents and interviews. The second theme concerned the potential for chlamydia screening to advance wider improvements in sexual health. In particular, screening was expected to promote sexual health services in primary care and encourage discussion of sexual health with young people. While this theme was only indirectly referenced in policy documents, it was cited by interviewees as a strong influence on implementation in the early years. However, by full rollout of the Programme, a focus on screening volume may have limited the NCSP's capacity to improve broader aspects of sexual health. Conclusions: A combination of explicit and implicit drivers underpinned the Programme's establishment. This combination may explain why there was widespread support for its introduction and why implementation of the NCSP was inconsistent. The potential to improve young people's sexual health more comprehensively should be made explicit in future planning of the NCSP. [ABSTRACT FROM AUTHOR]

Background: Health policy in the UK and elsewhere is prioritising patient empowerment and patient evaluations of healthcare. Patient reported outcome measures now take centre-stage in implementing strategies to increase patient empowerment. This article argues for consideration of patient empowerment itself as a directly measurable patient reported outcome for chronic conditions, highlights some issues in adopting this approach, and outlines a research agenda to enable healthcare evaluation on the basis of patient empowerment. Discussion: Patient empowerment is not a well-defined construct. A range of condition-specific and generic patient empowerment questionnaires have been developed; each captures a different construct e.g. personal control, self-efficacy/self-mastery, and each is informed by a different implicit or explicit theoretical framework. This makes it currently problematic to conduct comparative evaluations of healthcare services on the basis of patient empowerment. A case study (clinical genetics) is used to (1) illustrate that patient empowerment can be a valued healthcare outcome, even if patients do not obtain health status benefits, (2) provide a rationale for conducting work necessary to tighten up the patient empowerment construct (3) provide an exemplar to inform design of interventions to increase patient empowerment in chronic disease. Such initiatives could be evaluated on the basis of measurable changes in patient empowerment, if the construct were properly operationalised as a patient reported outcome measure. To facilitate this, research is needed to develop an appropriate and widely applicable generic theoretical framework of patient empowerment to inform (re)development of a generic measure. This research should include developing consensus between patients, clinicians and policymakers about the content and boundaries of the construct before operationalisation. This article also considers a number of issues for society and for healthcare providers raised by adopting the patient empowerment paradigm. Summary: Healthcare policy is driving the need to consider patient empowerment as a measurable patient outcome from healthcare services. Research is needed to (1) tighten up the construct (2) develop consensus about what is important to include (3) (re)develop a generic measure of patient empowerment for use in evaluating healthcare (4) understand if/how people make trade-offs between empowerment and gain in health status. [ABSTRACT FROM AUTHOR]

Background: Health service policy in the United Kingdom emphasises the importance of self-care by patients with chronic conditions. Written information for patients about their condition is seen as an important aid to help patients look after themselves. From a discourse analysis perspective written texts such as patient information leaflets do not simply describe the reality of a medical condition and its management but by drawing on some sorts of knowledge and evidence rather than others help construct the reality of that condition. This study explored patient information leaflets on osteoarthritis (OA) to see how OA was constructed and to consider the implications for self-care. Methods: Systematic and repeated readings of six patient information leaflets on osteoarthritis to look for similarities and differences across leaflets, contradictions within leaflets and the resources called on to make claims about the nature of OA and its management. Results: Biomedical discourse of OA as a joint disease dominated. Only one leaflet included an illness discourse albeit limited, and was also the only one to feature patient experiences of living with OA. The leaflets had different views on the causes of OA including the role of lifestyle and ageing. Most emphasised patient responsibility for preventing the progression of OA. Advice about changing behaviour such as diet and exercise was not grounded in lived experience. There were inconsistent messages about using painkillers, exercise and the need to involve professionals when making changes to lifestyle. Conclusion: The nature of the discourse impacted on how OA and the respective roles of patients and professionals were depicted. Limited discourse on illness meant that the complexity of living with OA and its consequences was underestimated. Written information needs to shift from joint biology to helping patients live with osteoarthritis. Written information should incorporate patient experience and value it alongside biomedical knowledge. [ABSTRACT FROM AUTHOR]

Background: Inequality in health and health care services is an important policy issue internationally as well as in the UK, and is closely linked to socio-economic deprivation, which in cotland is concentrated in and around Glasgow. Patients views on primary care in deprived areas are not well documented. In the present study we explore the views of patients living in a high deprivation area on the quality of consultations in general practice. Methods: Qualitative focus group study set in an area of high socio-economic deprivation in a large peripheral housing estate in Glasgow, Scotland. 11 focus groups were conducted; 8 with local community groups and 3 with other local residents. In total 72 patients took part. Grounded theory was used to analyse the data. Results: Patients' perceptions of the quality of the consultation with GPs consisted of two broad, inter-relating themes; (1) the GPs' competence, and (2) the GPs empathy or ' caring'. Competence was often assumed but many factors coloured this assumption, in particular whether patients had experienced (directly or indirectly with a close family member) 'successful' outcomes with that doctor previously or not. 'Caring' related to patients feeling (a) listened to by the doctor and being able to talk; (b) valued as an individual by the doctor (c) that the doctor understood 'the bigger picture', and (d) the doctors' explanations were clear and understandable. Relational continuity of care (being able to see the same GP and having a good relationship), and having sufficient time in the consultation were closely linked with perceptions of consultation quality. Conclusion: Patients from deprived areas want holistic GPs who understand the realities of life in such areas and whom they can trust as both competent and genuinely caring. Without this, they may judge doctors as socially distant and emotionally detached. Relational continuity, empathy and sufficient time in consultations are key factors in achieving this. [ABSTRACT FROM AUTHOR]

Background: The United Kingdom (UK) is experiencing a general practitioner (GP) workforce retention crisis. Research has focused on investigating why GPs intend to quit, but less is known about the acceptability and effectiveness of policies and strategies to improve GP retention. Using evidence from research and key stakeholder organisations, we generated a set of potential policies and strategies aimed at maximising GP retention and tested their appropriateness for implementation by systematically consulting with GPs. Methods: 28 GP Partners and GPs working in national stakeholder organisations from South West England and London were purposively sampled, and asked to take part in a RAND/UCLA Appropriateness Method panel. Panellists were asked to read an evidence briefing summary, and then complete an online survey on two occasions. During each round, participants rated the appropriateness of policies and strategies aimed at improving GP retention using a nine point scale (1 'extremely inappropriate' to 9 'extremely appropriate'). Fifty-four potential policies and strategies (equating to 100 statements) were tested, focusing on factors influencing job satisfaction (e.g. well-being, workload, incentives and remuneration, flexible working, human resources systems). Ratings were analysed for panel consensus and categorised based on appropriateness ('appropriate', 'uncertain', 'inappropriate'). Results: 12/28 GPs approached agreed to take part, 9/28 completed two rounds of the online survey between February and June 2018. Panellists identified 24/54 policy and strategy areas (41/100 statements) as 'appropriate'. Examples included providing GP practices 'at risk' of experiencing GP shortages with a toolkit for managing recruitment and retention, and interventions to facilitate peer support to enhance health and wellbeing, or support portfolio careers. Strategies to limit GP workload, and manage patient demand were also endorsed. Conclusions: The panel of experienced GPs identified a number of practical ways to improve GP retention through interventions that might enhance job satisfaction and work-life balance. Future research should evaluate the impact of implementing these recommendations. [ABSTRACT FROM AUTHOR]