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This study explored how health information accessed via a 3D social virtual world and the representation of ‘self’ through the use of an avatar impact physical world health behaviour. In-depth interviews were conducted in a sample of 25 people, across 10 countries, who accessed health information in a virtual world (VW): 12 females and 13 males. Interviews were audio-recorded via private in-world voice chat or via private instant message. Thematic analysis was used to analyse the data. The social skills and practices evidenced demonstrate how the collective knowledge and skills of communities in VWs can influence improvements in individual and community health literacy through a distributed model. The findings offer support for moving away from the idea of health literacy as a set of skills which reside within an individual to a sociocultural model of health literacy. Social VWs can offer a place where people can access health information in multiple formats through the use of an avatar, which can influence changes in behaviour in the physical world and the VW. This can lead to an improvement in social skills and health literacy practices and represents a social model of health literacy.

Background Delirium is a frequent complication of hospital admission among older people. Multicomponent interventions which can reduce incident delirium by ≈one-third are recommended by the National Institute of Health and Care Excellence. Currently, a standardised delirium prevention system of care suitable for adoption in the UK National Health Service does not exist. The Prevention of Delirium (POD) system of care is a theory informed, multicomponent intervention and systematic implementation process which includes a role for hospital volunteers. We report POD implementation and delivery processes in NHS hospital wards, as part of a feasibility study. Methods A comparative case study design and participatory, multi-method evaluation was performed with sequential six month preparatory and six month delivery stages. Six wards in five hospitals in Northern England were recruited. Methods included: facilitated workshops; observation of POD preparatory activities; qualitative interviews with staff; collection of ward organisational and patient profiles; and structured observation of staff workload. Results POD implementation and delivery was fully accomplished in four wards. On these wards, implementation strategies informed by Normalization Process Theory operated synergistically and cumulatively. An interactive staff training programme on delirium and practices that might prevent it among those at risk, facilitated purposeful POD engagement. Observation of practice juxtaposed to action on delirium preventive interventions created tension for change, legitimating new ways of organising work around it. Establishing systems, processes and documentation to make POD workable in the ward setting, enhanced staff ownership. ‘Negotiated experimentation’ to involve staff in creating, appraising and modifying systems and practices, helped integrate the POD care system in ward routines. Activating these change mechanisms required a particular form of leadership: pro-active ‘steer’, and senior ward ‘facilitator’ to extend ‘reach’ to the staff group. Organisational discontinuity (i.e. ward re-location and re-modelling) disrupted and extended POD implementation; staff shortages adversely affected staff capacity to invest in POD. Findings resulted in the development of ‘site readiness’ criteria without which implementation of this complex intervention was unlikely to occur. Conclusions POD implementation and delivery is feasible in NHS wards, but a necessary context for success is ‘site readiness.’

Objective To explore the factors that influence expectant parents' infant feeding decisions in the antenatal period. Design Mixed method systematic review focussing on participant views data. Data sources CINAHL, Medline, Embase and PsychInfo databases were interrogated using initial keywords and then refined terms to elicit relevant studies. Reference lists were checked and hand-searching was undertaken for 2 journals (‘Midwifery' and ‘Social Science and Medicine') covering a 3 year time period (January 2011–March 2014). Key inclusion criteria: studies reflecting expectant parents' views of the factors influencing their infant feeding decisions in the antenatal period; Studies in the English language published after 1990, from developed countries and of qualitative, quantitative or mixed method design. Review methods A narrative interpretive synthesis of the views data from studies of qualitative, quantitative and mixed method design. Data were extracted on study characteristics and parents' views, using the Social Ecological Model to support data extraction and thematic synthesis. Synthesis was influenced by the Evidence for Policy and Practice Information and Co-Ordinating Centre approach to mixed method reviews. Results Of the 409 studies identified through search methods, 17 studies met the inclusion criteria for the review. Thematic synthesis identified 9 themes: Bonding/Attachment; Body Image; Self Esteem/Confidence; Female Role Models; Family and Support Network; Lifestyle; Formal Information Sources; Knowledge; and Feeding in front of others/Public. The review identified a significant bias in the data towards negative factors relating to the breastfeeding decision, suggesting that infant feeding was not a choice between two feeding options, but rather a process of weighing reasons for and against breastfeeding. Findings reflected the perception of the maternal role as intrinsic to the expectant mothers' infant feeding decisions. Cultural perceptions permeated personal, familial and social influences on the decision-making process. Expectant mothers were sensitive to the way professionals attempted to support and inform them about infant feeding choices. Conclusions By taking a Social Ecological perspective, we were able to explore and demonstrate the multiple influences impacting on expectant parents in the decision-making process. A better understanding of expectant parents' views and experiences in making infant feeding decisions in the prenatal and antenatal periods will inform public health policy and the coordination of service provision to support infant feeding activities.

OBJECTIVETo evaluate the microbiologic effectiveness of the World Health Organization’s 6-step and the Centers for Disease Control and Prevention’s 3-step hand hygiene techniques using alcohol-based handrub.DESIGNA parallel group randomized controlled trial.SETTINGAn acute care inner-city teaching hospital (Glasgow).PARTICIPANTSDoctors (n=42) and nurses (n=78) undertaking direct patient care.INTERVENTIONRandom 1:1 allocation of the 6-step (n=60) or the 3-step (n=60) technique.RESULTSThe 6-step technique was microbiologically more effective at reducing the median log10 bacterial count. The 6-step technique reduced the count from 3.28 CFU/mL (95% CI, 3.11–3.38 CFU/mL) to 2.58 CFU/mL (2.08–2.93 CFU/mL), whereas the 3-step reduced it from 3.08 CFU/mL (2.977–3.27 CFU/mL) to 2.88 CFU/mL (−2.58 to 3.15 CFU/mL) (P=.02). However, the 6-step technique did not increase the total hand coverage area (98.8% vs 99.0%, P=.15) and required 15% (95% CI, 6%-24%) more time (42.50 seconds vs 35.0 seconds, P=.002). Total hand coverage was not related to the reduction in bacterial count.CONCLUSIONSTwo techniques for hand hygiene using alcohol-based handrub are promoted in international guidance, the 6-step by the World Health Organization and 3-step by the Centers for Disease Control and Prevention. The study provides the first evidence in a randomized controlled trial that the 6-step technique is superior, thus these international guidance documents should consider this evidence, as should healthcare organizations using the 3-step technique in practice.Infect Control Hosp Epidemiol 2016;37:661–666

Background Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services including immunisation. To improve immunisation rates, it is necessary to understand what helps and hinders individuals in these communities in taking up immunisations. This study had two aims.Investigate the views of Travellers in the UK on the barriers and facilitators to acceptability and uptake of immunisations and explore their ideas for improving immunisation uptake;Examine whether and how these responses vary across and within communities, and for different vaccines (childhood and adult). Methods This was a qualitative, cross-sectional interview study informed by the Social Ecological Model. Semi-structured interviews were conducted with 174 Travellers from six communities: Romanian Roma, English Gypsy/Irish Travellers (Bristol), English Gypsy (York), Romanian/Slovakian Roma, Scottish Show people (Glasgow) and Irish Traveller (London). The focus was childhood and selected adult vaccines. Data were analysed using the Framework approach. Results Common accounts of barriers and facilitators were identified across all six Traveller communities, similar to those documented for the general population. All Roma communities experienced additional barriers of language and being in a new country. Men and women described similar barriers and facilitators although women spoke more of discrimination and low literacy. There was broad acceptance of childhood and adult immunisation across and within communities, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough and described barriers to booking and attending immunisation. Cultural concerns about antenatal vaccines and HPV vaccination were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified as barriers across different communities. Trustful relationships with health professionals were important and continuity of care valued. Conclusions The experience of many Travellers in this study, and the context through which they make health decisions, is changing. This large study identified key issues that should be considered when taking action to improve uptake of immunisations in Traveller families and reduce the persistent inequalities in coverage. Trial registration Current Controlled Trials ISRCTN20019630. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4178-y) contains supplementary material, which is available to authorized users.

Levels of measles in England and Wales are at their highest for 18 years, and strategies targeting the different groups of parents who do not vaccinate their children continue to be needed. Decision aids for decisions regarding childhood immunisation appear to be effective in achieving an increase in vaccine uptake but their cost effectiveness is unknown.To assess the cost effectiveness of a web-based decision aid to increase uptake of the MMR vaccine.Economic evaluation conducted alongside a cluster randomised controlled trial using urban GP practices in the north of England.Fifty GP practices in the north of England were randomised to one of three trial arms: decision aid, leaflet, usual practice. A total of 220 first-time parents (child aged 3-12 months) were recruited. Parents self-reported their contacts with the NHS and other previous/expected resource utilisation; associated costs were calculated. Vaccine-uptake data were collected from GP practices. A cost-effectiveness analysis was undertaken and provided the incremental cost per first-vaccine uptake. Multiple imputation was used to account for missing data and findings were adjusted for baseline differences in parents' levels of decisional conflict regarding MMR vaccination.Of the 220 first-time parents recruited to the study, 179 completed the baseline and post-intervention questionnaires. MMR uptake was highest for those receiving the decision aid (42 out of 42, 100%) versus usual practice (61 out of 62, 98%) and leaflet arm (69 out of 75, 92%), and was associated with lower cost (-£9.20 versus usual practice and -£7.17 versus leaflet).The decision aid has a high chance of being cost effective, regardless of the value placed on obtaining additional vaccinations. It also appears to offer an efficient means of decision support for parents.

Overview: Widely used by patients to control symptoms of chronic conditions such as diabetes, asthma, and arthritis, self-management can also help patients with urinary or fecal incontinence. The authors discuss the principles of self-management, the behaviors and skills self-managing patients need to acquire, and the nurse's role in reinforcing their use. They then describe strategies that can be incorporated within the framework of self-management to control urinary, fecal, or dual incontinence.

Background\ud Shunts, the main treatment for hydrocephalus, are problematic because they frequently malfunction. Detecting shunt malfunction is challenging because symptoms are similar to those of common childhood illnesses, particularly viral infections. Parents are responsible for identifying shunt malfunction and responding accordingly. Understanding parents' experiences has the potential to improve parent–professional collaboration and the management of the child's condition.\ud \ud Aim\ud To explore parents' experiences of living with a child with hydrocephalus and their decisions when they suspect shunt malfunction.\ud \ud Design and methods\ud A cross-sectional interview-based survey using qualitative methods was undertaken. Twenty-five parents participated in the interviews. Framework approach underpinned data analysis.\ud \ud Findings\ud Three concepts, ‘uncertainty’, ‘developing expertise’, and ‘a normal life’, were identified. These concepts were dynamic in nature as parents learned through experience, adapted to changes in their child's health status and made decisions about their needs. Uncertainty because of the unpredictability and life-threatening nature of shunt malfunction dominated parents' accounts. Through experience, parents learned to differentiate between symptoms that suggested a shunt problem and those of other childhood illnesses, but perceived their expertise was not always valued by health professionals or used to inform clinical decisions. Decisions about where or when to seek advice related to prior experiences of health-care services and minimizing disruption for the whole family.\ud \ud Conclusion\ud Parents can recognize illness symptoms suggestive of shunt malfunction and want to collaborate with health professionals about the management of their child's condition. Collaboration with parents requires health professionals to listen to parents' concerns and value their experiences

Aim To evaluate factors influencing uptake and delivery of behavioural interventions for urinary incontinence from the perspective of clients and clinical staff. Background Behavioural interventions are recommended as first-line therapy for the management of urinary incontinence. Barriers to and enablers of uptake and delivery of behavioural interventions have not been reviewed. Design Qualitative evidence synthesis. Data sources MEDLINE, EMBASE, CINAHL, PsychInfo, AMED (inception to May 2013); Proceedings of the International Continence Society (ICS) (2006–2013). Review methods Studies where data were collected from clients or staff about their experiences or perceptions of behavioural interventions were included. Two reviewers independently screened records on title and abstract. Full-text papers were obtained for records identified as potentially relevant by either reviewer. Two reviewers independently filtered all full-text papers for inclusion, extracted findings and critically appraised studies. We used an approach akin to Framework, using a matrix of pre-specified themes to classify the data and facilitate its presentation and synthesis. Results Seven studies involving 200 participants identified clients’ views. Findings identified from at least one study of moderate quality included increased fear of accidents and convenience of treatment. Factors enabling participation included realistic goals and gaining control. Six studies involving 427 participants identified staff views. Findings identified from at least one study of moderate quality included staff education and perceptions of treatment effectiveness. Enabling factors included teamwork and experience of success. Conclusion There is little detailed exploration of clients’ experiences of, and responses to, behavioural interventions. Evidence for staff relates predominantly to prompted voiding in long-term residential care. Studies of the uptake and delivery of other behavioural interventions in other settings are warranted.

Highlights • The use of decision aids for immunisation decisions is under researched and controversial. • Parents receiving a decision aid or a leaflet had reduced decisional conflict for the MMR decision. • MMR uptake in the decision aid and control arms achieved levels required for population immunity. • Leaflet arm parents were less likely to vaccinate their child. • Childhood immunisation decision aids can achieve both informed decision-making and uptake., Objective To evaluate the effectiveness of a web based decision aid versus a leaflet versus, usual practice in reducing parents’ decisional conflict for the first dose MMR vaccination decision. The, impact on MMR vaccine uptake was also explored. Design Three-arm cluster randomised controlled trial. Setting: Fifty GP practices in the north of, England. Participants: 220 first time parents making a first dose MMR decision. Interventions: Web, based MMR decision aid plus usual practice, MMR leaflet plus usual practice versus usual practice only, (control). Main outcome measures: Decisional conflict was the primary outcome and used as the, measure of parents’ levels of informed decision-making. MMR uptake was a secondary outcome. Results Decisional conflict decreased post-intervention for both intervention arms to a level where, parents could make an informed MMR decision (decision aid: effect estimate = 1.09, 95% CI −1.36 to −0.82; information leaflet: effect estimate = −0.67, 95% CI −0.88 to −0.46). Trial arm was significantly, associated (p

We explored health professionals’ views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-2013. We conducted semi-structured group or individual interviews with 38 purposively selected nursing, managerial, and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory (NPT) as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups, patient fear of extending hospital stay, and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP, patient and relative involvement, extra staff, improved nursing skill and confidence, and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.

BACKGROUND AND OBJECTIVES: delirium is a distressing but potentially preventable condition common in older people in long-term care. It is associated with increased morbidity, mortality, functional decline, hospitalization and significant healthcare costs. Multicomponent interventions, addressing delirium risk factors, have been shown to reduce delirium by one-third in hospitals. It is not known whether this approach is also effective in long-term care. In previous work, we designed a bespoke delirium prevention intervention, called 'Stop Delirium!' In preparation for a definitive trial of Stop Delirium, we sought to address key aspects of trial design for the particular circumstances of care homes.DESIGN: a cluster randomized feasibility study with an embedded process evaluation.SETTING AND PARTICIPANTS: residents of 14 care homes for older people in one metropolitan district in the UK.INTERVENTION: Stop Delirium!: a 16-month-enhanced educational package to support care home staff to address key delirium risk factors. Control homes received usual care.MEASUREMENTS: we collected data to determine the following: recruitment and attrition; delirium rates and variability between homes; feasibility of measuring delirium, resource use, quality of life, hospital admissions and falls; and intervention implementation and adherence.RESULTS: two-thirds (215) of eligible care home residents were recruited. One-month delirium prevalence was 4.0% in intervention and 7.1% in control homes. Proposed outcome measurements were feasible, although our approach appeared to underestimate delirium. Health economic evaluation was feasible using routinely collected data.CONCLUSION: a definitive trial of delirium prevention in long-term care is needed but will require some further design modifications and pilot work.

Objectives Findings from national audits and enquiries continue to report that care for patients with continence problems is often substandard and inadequate education is often cited as one of the probable causes. These factors combined with the forecasted increase in the number of people with incontinence prompted us to undertake a survey of all UK Higher Education Institutes (HEIs) to establish the amount of undergraduate continence education within relevant healthcare programs—medical, adult nursing, mental health nursing, learning disabilities nursing, children's nursing, midwifery, physiotherapy, and occupational therapy. Design An on line questionnaire targeted course program leads (n = 362) in all 86 HEIs in which undergraduate professional healthcare programs were provided (n = 362). Main Outcome Measure Eighty-six HEIs were approached, 85 agreed to participate in the survey. A response rate of 81% (n = 294/362 programs) was obtained: 14% (n = 42) of respondents reported that there was no continence-related education within their undergraduate program. The mean number of hours was 4.7 (SD 4.3), and ranged from 2.5 (SD 3.5) hr (Occupational Therapy) to 7.3 (SD 4.8) hr (Adult Nursing). Conclusion The survey results indicate that the amount of undergraduate education has changed little. Further research is needed to identify the most appropriate methods of delivering continence education and translate knowledge into improved patient outcomes. Adequate undergraduate continence education directed by the General Medical Council, Royal Colleges and Health Professional Council is required. Neurourol. Urodynam. 32: 224–229, 2013. © 2012 Wiley Periodicals, Inc.

For many years, discussions of the relative merits of generic and theoretical approaches to qualitative research have divided researchers while overshadowing the need to focus on addressing clinical questions. Drawing on the challenges of designing a study that explored parents' experiences of living with children with hydrocephalus, the authors of this paper argue that over-adherence to, and deliberations about, the philosophical origins of qualitative methods is undermining the contributions qualitative research could make to evidence-based health care and suggest qualitative methods should stand alone.

Dementia is a debilitating condition characterised by global loss of cognitive and intellectual functioning, which gradually interferes with social and occupational performance. It is a common worldwide condition with a significant impact on society. There are currently 36 million people worldwide with Alzheimer's disease (AD) and other dementias [1]. This is expected to more than double by 2030 (65 million) and reach ∼115 million in 2050, unless a major breakthrough is made. The worldwide societal costs were estimated at USD 604 billion in 2010 and rising [2]. To date research on the specific physical healthcare needs of people with dementia has been neglected. Yet, physical comorbidities are reported as common in people with dementia [3] and have been shown to lead to increased disability and reduced quality of life for the affected person and their carer [4]. Dementia is most frequently associated with older people who often present with other medical conditions, known as co-morbidities. Such co-morbidities include diabetes, chronic obstructive pulmonary disorder, musculoskeletal disorders and chronic cardiac failure and are common, 61% of people with …

Background: Despite many strategies employed to improve hand hygiene, compliance remains low at around 50%. Two reasons have been identified for this. First, implementation strategies are rarely tailored according to assessed barriers and levers to best practice. Secondly there is a lack of explicit theoretical basis for the assessment of these barriers and levers to practice. Aim: This paper reports barriers and levers to hand hygiene and an evaluation of the use of theory in assessing barriers and levers to hand hygiene. Methods: Identification of barriers and levers occurred through interviews, questionnaires and focus groups. In each case two different question schedules were used, one based on psychological theory and the other with no explicit theoretical underpinning. Results: Although there was considerable overlap in the barriers and levers identified using the two schedules there were also marked differences. Conclusions: Identification of further barriers and levers may help us address lack of compliance with hand hygiene. Using a theoretical framework may prompt the identification of barriers that people may not ordinarily report but which have an important impact on behaviour, particularly emotion.

Objective: The objective of this feasibility study was to evaluate the acceptability and potential effectiveness of a web-based MMR decision aid in supporting informed decision-making for the MMR vaccine.Design: This was a prospective before-and-after evaluation.Setting: Thirty parents of children eligible for MMR vaccination were recruited from two childcare organizations in a moderately deprived community in a city in the north of England.Method: Parents completed postal questionnaires at recruitment, one week and three months after using the decision aid. Data on the acceptability of the decision aid, informed decision-making outcome measures and vaccine uptake were collected. Telephone interviews were conducted with five parents. Acceptability data were analysed using simple descriptive statistics. Repeated measures ANOVAs were undertaken for analysing the informed decision-making data. Content analysis of the qualitative data was undertaken.Results: Twenty six parents (87 per cent) completed all three study questionnaires. The decision aid was found to be acceptable to parents and was considered useful in supporting their informed decision-making. There was a statistically significant increase in parents’ knowledge over time and statistically significant decrease in decisional conflict for the MMR decision. Most parents (88 per cent) reported vaccinating their child.Conclusions: We cannot extrapolate from our data to infer that the decision aid has changed decision-making outcomes or influenced vaccination uptake. However, findings suggest that it may increase knowledge about MMR and reduce decisional conflict to a level where parents can make an informed decision. A randomized controlled trial is now underway to expand on these findings.

In spite of a growing body of evidence to show that urinary incontinence is treatable or symptoms can be significantly improved in the majority of older people significant shortfalls in the quality of continence care are highlighted consistently in the international literature. The key barriers to providing optimal continence care for older people points to a need to address change not only from an individual practitioner perspective but also at the levels of the multidisciplinary team and organization. Examples of some emerging implementation frameworks that incorporate the broader context in which change occurs in 'real world' practice are introduced which may serve as useful guides. It is argued that if national and international standards of good practice for continence care are to be achieved, implementation methods have to take account of the complex interplay of patient, practitioner, social and organizational factors that mediate change.

The objectives of this systematic review are: • to explore health professionals’ views about the universal childhood immunisation programme • to explore health professionals’ views about current provision of decision support (information and guidance on making an informed decision) for parents about universal childhood immunisation • to explore health professionals’ own beliefs and values regarding universal childhood vaccines (in particular MMR) Inclusion criteria Types of participants The review will consider published studies that include any health professional working in a on‐acute or ambulatory care setting and the universal childhood immunisation programme. This would include, but not be limited by, membership of the following groups: Community or Primary Care Paediatricians, General Practitioners (including Family Doctors or Family Physicians), Health Visitors (including Community Registered Nurses, Nursery Nurses and Health Care Assistants), Nurse Practitioners, Practice Nurses (including Family Practice Nurses), School Nurses and Midwives. Phenomena of interest The phenomena of interest are health professionals’ views about the universal childhood immunisation programme, views about updates and changes to the childhood immunisation programme, views about parental decision support needs (information needs and help in making an informed decision) in relation to any childhood immunisation; current decision support (information and guidance on making an informed decision) provision for parents and their beliefs and values in relation to the immunisations themselves. A range of terms will be used to capture pertinent data on “views”, “attitudes”, “beliefs”, “values”, “perceptions”, “perspectives” as these terms do not always appear in the title or abstract whilst useful data are present within the publication text (see search strategy for details of terms). Types of context The context of interest includes but is not restricted to the following: • Health professionals’ and the universal childhood immunisation programme • Health professionals’ and immunisations for children up to (and including) 7 years old • Health professionals’ and any type of immunisation • Health professionals’ and immunisation information

BackgroundGypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services, including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations.Aims(1) Investigate the barriers to and facilitators of acceptability and uptake of immunisations among six Traveller communities across four UK cities; and (2) identify possible interventions to increase uptake of immunisations in these Traveller communities that could be tested in a subsequent feasibility study.MethodsThree-phase qualitative study underpinned by the social ecological model. Phase 1: interviews with 174 Travellers from six communities: Romanian Roma (Bristol); English Gypsy/Irish Traveller (Bristol); English Gypsy (York); Romanian/Slovakian Roma (Glasgow); Scottish Showpeople (Glasgow); and Irish Traveller (London). Focus on childhood and adult vaccines. Phase 2: interviews with 39 service providers. Data were analysed using the framework approach. Interventions were identified using a modified intervention mapping approach. Phase 3: 51 Travellers and 25 service providers attended workshops and produced a prioritised list of potentially acceptable and feasible interventions.ResultsThere were many common accounts of barriers and facilitators across communities, particularly across the English-speaking communities. Scottish Showpeople were the most similar to the general population. Roma communities experienced additional barriers of language and being in a new country. Men, women and service providers described similar barriers and facilitators. There was widespread acceptance of childhood and adult immunisation, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough. Cultural concerns about vaccines offered during pregnancy and about human papillomavirus were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified by Travellers and service providers as barriers for some. Trustful relationships with health professionals were important and continuity of care was valued. A few English-speaking Travellers described problems of booking and attending for immunisation. Service providers tailored their approach to Travellers, particularly the Roma. Funding cuts, NHS reforms and poor monitoring challenged their work. Five ‘top-priority’ interventions were agreed across communities and service providers to improve the immunisation among Travellers who are housed or settled on an authorised site: (1) cultural competence training for health professionals and frontline staff; (2) identification of Travellers in health records to tailor support and monitor uptake; (3) provision of a named frontline person in general practitioner practices to provide respectful and supportive service; (4) flexible and diverse systems for booking appointments, recall and reminders; and (5) protected funding for health visitors specialising in Traveller health, including immunisation.LimitationsNo Travellers living on the roadside or on unofficial encampments were interviewed. We should exert caution in generalising to these groups.Future workTo include development, implementation and evaluation of a national policy plan (and practice guidance plan) to promote the uptake of immunisation among Traveller communities.Study registrationCurrent Controlled Trials ISRCTN20019630 and UK Clinical Research Network Portfolio number 15182.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 72. See the NIHR Journals Library website for further project information.

One third of the primary care nursing workforce is aged 50 years and over. Workforce planning is essential if primary care is to ensure that there are appropriate numbers of nurses available to replace the loss of experienced nurses as they approach retirement.As part of an ongoing study to explore the factors influencing retention of female nurses over the age of 50 years in the primary care nursing workforce, a questionnaire survey targeting all community nurses employed in five Primary Care Trusts was undertaken. Accurate statistics on the number and type of community nurse employed in the five Primary Care Trusts were sought to: (i) identify a denominator to accurately identify the response rates to questionnaires in the survey of Primary Care Trusts; and (ii) to compare the Primary Care Trust data with Department of Health statistics to investigate the accuracy of workforce data. A number of problems with locating accurate primary care nursing workforce statistics were identified.The purpose of this paper is to highlight the difficulties inherent in collating workforce data and the implications for future workforce planning, both locally and nationally. The impact on research is also highlighted.An ageing nursing workforce indicates that primary care nursing will experience significant reductions in its workforce. Local and National workforce statistics for primary care are flawed. There are significant gaps in primary care data for school and practice nurses. There needs to be clarification and a consensus for the term 'community nurse'. The expansion of the public health role for school nurses is seriously challenged because of limited availability of appropriately qualified nurses and an urgent need for an investigation into school nursing statistics. Future workforce planning and development needs to be based on accurate and reliable statistics, to plan for an ageing nursing workforce. The quality of research in primary care is compromised because of the lack of availability of accurate nursing workforce data.Effective delivery of the NHS Plan requires a thorough understanding of the composition of the primary care nursing workforce and targets need to be based on accurate and reliable workforce statistics.

Objectives: To explore how masculinity influences white, Indian and Pakistani men's interpretation of cardiac chest pain and the decision to seek or delay seeking medical help. Method: Semi-structured interviews were conducted with 36 men of white ethnicity (UK ancestry) and 20 men of South Asian ethnicity (Indian or Pakistani ancestry) who had a confirmed diagnosis of acute myocardial infarction or angina pectoris. The study setting was two coronary care units and eight cardiology wards situated in two teaching hospitals in the North of England. All interviews were tape-recorded, transcribed verbatim and analysed using a constant comparative method. Results: Displaying a high threshold for pain and discomfort was a masculine attribute valued by white men in the study but not by the Indian and Pakistani men. White men's fears of being seen to be weak contributed to delays in seeking medical treatment and led to reluctance to disclose symptoms to others. Indian and Pakistani men emphasized wisdom, education and responsibility for the family and their own health as more valued masculine attributes, and this contributed to a greater willingness to seek medical help. Conclusion: Masculinity had a differing role in white and South Asian men's decisions to seek or delay seeking medical help for chest pain. The study supports the development of coronary heart disease policy and practice that acknowledges men's gender as an important determinant of their health behaviour, but illustrates that there is no probable single appropriate approach to tackling the delay in how men seek treatment for chest pain.

Context: Eliciting patients' views of type 2 diabetes self‐management provides insights on how policy and services might better support the needs of this population. Objective: To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self‐management of type 2 diabetes. Search strategy: A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free‐text terms. Two relevant journals were also hand searched. Inclusion criteria: Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self‐management. Data extraction and synthesis: Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis. Main results: Fifty‐seven studies were included, of qualitative (n = 54), mixed‐method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: ‘Importance of identity’; ‘Being understood by others’ and ‘Making sense of condition’, all linked conceptually under the overarching theme ‘Sense of self’. The quality of the studies varied. Discussion and conclusions: The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self‐management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient‐centred care and policies.

Background\ud \ud Shunts, the main treatment for hydrocephalus, are problematic as they frequently malfunction. Identifying shunt malfunction requires parents to recognize its symptoms and health professionals to integrate parents' information about the child's symptoms within the clinical assessment to reach a diagnosis.\ud Aim\ud \ud To investigate parent–professional shared decision making during the diagnosis of suspected shunt malfunction in acute hospital admissions.\ud Design and methods\ud \ud A mixed method study involving audio recordings of admission consultations, a shared decision making questionnaire and interviews 1-week post-consultation, was undertaken. Twenty-eight family members and fourteen health professionals participated. The interactions were analysed using conversational analysis, framework approach for the interview data and descriptive statistics for questionnaire responses.\ud Findings\ud \ud Both parents and professionals focussed on establishing a diagnosis and ruling out shunt malfunction when a child with hydrocephalus was ill. Participants' perceived effective collaboration as central to this task: parents wanted to contribute to the process of diagnosis by providing information about the likely cause of symptoms. Professionals were satisfied with the level of involvement by parents, although parent satisfaction was more variable. The challenge for professionals was to integrate parents' expertise of their child's presenting symptoms within clinical decision making processes.\ud Conclusion\ud \ud In this context, both parents' and professionals' perceived their interactions to be about problem-solving, rather than making decisions about treatments. Although the shared decision-making model can help patients to make better decisions between treatment options, it is unclear how best to support collaboration between professionals and parents to ensure a good problem-solving process.

Aims and objectives. To explore the effects of type 2 diabetes on British-Pakistani women’s identity and its relationship with self-management. Background. Type 2 diabetes is more prevalent and has worse outcomes among some ethnic minority groups. This may be due to poorer self-management and an inadequate match of health services to patient needs. The influence that type 2 diabetes has on British-Pakistani women’s identity and subsequent self-management has received limited attention. Design. An explorative qualitative study. Methods. Face-to-face semi-structured English and Urdu language interviews were conducted with a purposively selected heterogeneous sample of 15 British-Pakistani women with type 2 diabetes. Transcripts were analysed thematically. Results. Four themes emerged: Perceived change in self emphasised how British-Pakistani women underwent a conscious adaptation of identity following diagnosis; Familiarity with ill health reflected women’s adjustment to their changed identity over time; Diagnosis improves social support enabled women to accept changes within themselves and Supporting family is a barrier to self-management demonstrated how family roles were an aspect of women’s identities that was resilient to change. The over-arching theme Role re-alignment enables successful self-management encapsulated how self-management was a continuous process where achievements needed to be sustained. Inter-generational differences were also noted: first generation women talked about challenges associated with ageing and co-morbidities; second generation women talked about familial and work roles competing with self-management. Conclusions. The complex nature of British-Pakistani women’s self-identification requires consideration when planning and delivering healthcare. Relevance to clinical practice. Culturally competent practice should recognise how generational status influences self-identity and diabetes self-management in ethnically diverse women. Health professionals should remain mindful of effective self-management occurring alongside, and being influenced by, other aspects of life.

Introduction Two hand hygiene techniques are promoted internationally: the World Health Organisation’s 6 step and the Centre for Disease Control’s 3 step techniques; both of which may be considered to have suboptimum levels of empirical evidence for use with alcohol based hand rub (ABHR). Objectives The aim of the study was to compare the effectiveness of the two techniques in clinical practice. Methods A prospective parallel group randomised controlled trial (RCT) was conducted with 1:1 allocation of 6 step versus the 3 step ABHR hand hygiene technique in a clinical setting. The primary outcome was residual microbiological load. Secondary outcomes were hand surface coverage and duration. The participants were medical and nursing participants (n=120) in a large teaching hospital. Results The 6 step technique was statistically more effective at reducing the bacterial count 1900cfu/ml (95% CI 1300, 2400cfu/ml) to 380cfu/ml (95% CI 150, 860 cfu/ml) than the 3 step 1200cfu/ml (95% CI 940, 1850cfu/ml) to 750cfu/ml (95% CI 380, 1400cfu/ml) (p=0.016) but even with direct observation by two researchers and use of an instruction card demonstrating the technique, compliance with the 6 step technique was only 65%, compared to 100% compliance with 3 step technique. Further those participants with 100% compliance with 6 step technique had a significantly greater log reduction in bacterial load with no additional time or difference in coverage compared to those with 65% compliance with 6 step technique (p=0.01). Conclusion To our knowledge this is the first published RCT to demonstrate the 6 step technique is superior to the 3 step technique in reducing the residual bacterial load after hand hygiene using alcohol based hand rub in clinical practice. What remains unknown is whether the residual bacterial load after the 3 step technique is low enough to reduce risk of transmission from the hands and whether the 6 step technique can be adapted to enhance compliance in order to maximise reduction in residual bacterial load and reduce duration.

Introduction: Gypsies, Travellers and Roma (referred to here as Travellers) experience significantly poorer health and have shorter life expectancy than the general population. They are also less likely to access health services including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. This study has two aims: (1) Investigate the barriers and facilitators to acceptability and uptake of immunisations among six Traveller communities in the UK; (2) Identify potential interventions to increase uptake in these Traveller communities. \ud \ud \ud Methods and analysis: A three-phase qualitative study with six Traveller communities. PHASE 1: In each community, we will explore up to 45 Travellers’ views about the influences on their immunisation behaviours and ideas for improving uptake in their community. PHASE 2: In each community, we will investigate 6–8 service providers’ perspectives on barriers and facilitators to childhood and adult immunisations for Traveller communities with whom they work, and ideas to improve uptake. Interview data will be analysed using the Framework approach. PHASE 3: The findings will be discussed and interventions prioritised in six workshops, each with 10–12 phase 1 and 3–4 phase 2 participants. \ud \ud \ud Ethics and dissemination: This research received approval from NRES Committee Yorkshire and The Humber-Leeds East (Ref. 13/YH/02). It will produce (1) findings on the barriers and facilitators to uptake of immunisations in six Traveller communities; (2) a prioritised list of potentially feasible and acceptable interventions for increasing uptake in these communities; and (3) methodological development in undertaking research with diverse Traveller communities. The study has the potential to inform new ways of delivering services to ensure high immunisation uptake. Findings will be disseminated to participants, relevant UK organisations with responsibility for the implementation of immunisation policy and Traveller health/welfare; and submitted for publication in academic journals. \ud \ud \ud Trial registration number ISRCTN20019630

Item does not contain fulltext BACKGROUND: Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants. OBJECTIVES: To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants. SEARCH METHODS: We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals. SELECTION CRITERIA: Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified. MAIN RESULTS: We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression. AUTHORS' CONCLUSIONS: Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.

BackgroundUrinary incontinence (UI) following acute stroke is common, affecting between 40% and 60% of people in hospital, but is often poorly managed.AimTo develop, implement and evaluate the preliminary effectiveness and potential cost-effectiveness of a systematic voiding programme (SVP), with or without supported implementation, for the management of UI after stroke in secondary care.DesignStructured in line with the Medical Research Council framework for the evaluation of complex interventions, the programme comprised two phases: Phase I, evidence synthesis of combined approaches to manage UI post stroke, case study of the introduction of the SVP in one stroke service; Phase II, cluster randomised controlled exploratory trial incorporating a process evaluation and testing of health economic data collection methods.SettingOne English stroke service (case study) and 12 stroke services in England and Wales (randomised trial).ParticipantsCase study, 43 patients; randomised trial, 413 patients admitted to hospital with stroke and UI.InterventionsA SVP comprising assessment, individualised conservative interventions and weekly review. In the supported implementation trial arm, facilitation was used as an implementation strategy to support and enable people to change their practice.Main outcome measuresParticipant incontinence (presence/absence) at 12 weeks post stroke. Secondary outcomes were quality of life, frequency and severity of incontinence, urinary symptoms, activities of daily living and death, at discharge, 6, 12 and 52 weeks post stroke.ResultsThere was no suggestion of a beneficial effect on outcome at 12 weeks post stroke [intervention vs. usual care: odds ratio (OR) 1.02, 95% confidence interval (CI) 0.54 to 1.93; supported implementation vs. usual care: OR 1.06, 95% CI 0.54 to 2.09]. There was weak evidence of better outcomes on the Incontinence Impact Questionnaire in supported implementation (OR 1.22, 95% CI 0.72 to 2.08) but the CI is wide and includes both clinically relevant benefit and harm. Both intervention arms had a higher estimated odds of continence for patients with urge incontinence than usual care (intervention: OR 1.58, 95% CI 0.83 to 2.99; supported implementation: OR 1.73, 95% CI 0.88 to 3.43). The process evaluation showed that the SVP increased the visibility of continence management through greater evaluation of patients’ trajectories and outcomes, and closer attention to workload. In-hospital resource use had to be based on estimates provided by staff. The response rates for the postal questionnaires were 73% and 56% of eligible patients at 12 and 52 weeks respectively. Completion of individual data items varied between 67% and 100%.ConclusionsThe trial was exploratory and did not set out to establish effectiveness; however, there are indications the intervention may be effective in patients with urge and stress incontinence. A definitive trial is now warranted.Study registrationThis study is registered as ISRCTN08609907.Funding detailsThe National Institute for Health Research Programme Grants for Applied Research programme. Excess treatment costs and research support costs were funded by participating NHS trusts and health boards, Lancashire and Cumbria and East Anglia Comprehensive Local Research Networks and the Welsh National Institute for Social Care and Health Research.

Aim. This paper reviews the key research literature regarding men's health-related help seeking behaviour. Background. There is a growing body of research in the United States to suggest that men are less likely than women to seek help from health professionals for problems as diverse as depression, substance abuse, physical disabilities and stressful life events. Previous research has revealed that the principle health related issue facing men in the UK is their reluctance to seek access to health services. Method. The investigation of men's health-related help seeking behaviour has great potential for improving both men and women's lives and reducing national health costs through the development of responsive and effective interventions. A search of the literature was conducted using CINAHL, MEDLINE, EMBASE, PsychINFO and the Cochrane Library databases. Results. Studies comparing men and women are inadequate in explaining the processes involved in men's help seeking behaviour. However, the growing body of gender-specific studies highlights a trend of delayed help seeking when they become ill. A prominent theme among white middle class men implicates ‘traditional masculine behaviour’ as an explanation for delays in seeking help among men who experience illness. The reasons and processes behind this issue, however, have received limited attention. Conclusions. Principally, the role of masculine beliefs and the similarities and differences between men of differing background requires further attention, particularly given the health inequalities that exist between men of differing socio-economic status and ethnicity. Further research using heterogeneous samples is required in order to gain a greater understanding of the triggers and barriers associated with the decision making process of help seeking behaviour in men who experience illness.

Aim To explore the opportunities and obstacles that impinge on attempts to advance public health nursing, paying particular attention to the role of, and implications for, nursing management. Background Nurses are to have a central role in the government's drive to re-invigorate the United Kingdom public health agenda. This paper explores the perceptions and support needs of the primary and community nurses, health visitors and midwives charged with meeting that goal. Method Focus group interviews were conducted separately with health visitors, school nurses, district nurses, community midwives and practice nurses from the a single health authority area in Yorkshire. Eight group interviews were conducted involving 31 practitioners in total. All interviews were audio recorded and transcribed in full. Data were analysed using the framework approach. Findings Workload, resource and time pressures limit the ability of community and primary care nurses to deliver public health work. Furthermore, nurses feel that the leadership required to guide service delivery and optimize deployment of under utilized public health skills at local level is missing, and that public health activity lacks legitimacy. Conclusion If the new public health agenda is to be delivered, nursing managers will have to be clear about what is meant by public health work and decide whether it is to remain a peripheral concern or core activity. Having made that decision they must communicate it to practitioners on the ground through word and deed – that is, by identifying capacity, restructuring workloads and re-prioritizing activity.

The aim of this work was to evaluate the impact of training in the use of the Consultation Assessment and Improvement Instrument for Nurses (CAIIN) in the context of expanding roles for primary care nurses. To achieve this, 10 experienced primary care nurses undertook a 3-day workshop in using the CAIIN to evaluate videotaped consultations between nurses and patients, and consultations between course participants and simulated patients. The impact of the workshop was assessed by questionnaire and semistructured interview. All participants found the CAIIN to be an acceptable approach to analyse and improve the consultation performance of themselves and others. They believed that it would further improve their existing skills, and provided a useful framework for learning those aspects of consultation competence in which they had less confidence. Several found role-play with simulated patients stressful. Concerns about the role of nurses in clinical problem-solving were reduced, but remained significant. The CAIIN was considered to have good potential as a learning tool as part of continuing professional development and clinical supervision. In conclusion, the rapidly expanding roles of primary care nurses requires serious consideration to be given to assessing and improving their consultation skills. The CAIIN provides an acceptable method of doing so. However, learning to use the instrument effectively requires expertise amongst teachers and significant protected learning time for nurses who become assessors or mentors of their peers.

Objective To examine the early implementation of the new National Health Service (NHS) smoking cessation services and assess implications for their future. Design Quantitative study. Setting NHS smoking cessation services in England, spring 2001. Method Postal survey of all smoking cessation coordinators (managers) in England. Results The response rate was 69 per cent. Three quarters of the coordinators reported that no prior smoking cessation services had existed in their area, 42 per cent had no experience of running clinical services for patients, and one in five reported employing very few or no smoking cessation advisors with previous clinical experience in smoking cessation or any other field. Some coordinators were experiencing difficulties in recruiting and retaining staff, the most common reasons being short-term funding or the lack of appropriate experience. Nevertheless, almost 60 per cent of the coordinators reported that the smoking cessation services were working at full capacity at the time of the survey. Services were offering a range of smoking cessation interventions that were mostly in line with the evidence base. Conclusion Evidence based smoking cessation services were set up across England within a short period of time. The majority of staff employed initially had little or no previous experience relevant to their posts and large numbers have been trained in smoking cessation skills. As ring- fenced funding of smoking cessation services came to an end in March 2003, it is important not to lose this substantive investment in skills and infrastructure and ensure that the services are incorporated into mainstream funding, with a proper career structure for smoking cessation service staff.

The Diana Children's Community Teams (DCCTs), a new nurse-led service funded by the Department of Health, were established to provide care in the community as an alternative to hospital for children with life-threatening/life-limiting illnesses and their families. This paper presents selected findings highlighting the professionals' experiences which formed part of the evaluation of the Diana, Princess of Wales Children's Community Service in Leicester, Leicestershire and Rutland. The Diana Service in Leicestershire attempts to encompass both parental empowerment and interagency collaboration. By working in partnership with the children and their families, the team provides an integrated and multiprofessional community-based service. This paper particularly concentrates on the perceptions and recommendations from the Diana team itself. Three independently managed Community Nursing Services existed in Leicestershire prior to the Diana teams; a Paediatric Macmillan Service, a Children's Community Nursing Service and a Respite Service. The Leicestershire DCCT integrated the three nursing services into a single team. This team has moved away from a traditional uniprofessional service structure by encompassing a wider team of multiprofessionals, including a cultural link worker, an occupational therapist, a physiotherapist, a play specialist and a team of trained counsellors, working in partnership to provide a quality service for families. * The evaluation, which used a longitudinal multimethod process analysis based on an action research framework, suggests that children with complex and life-limiting illnesses and their families benefit greatly from an effective seamless service. This paper recommends a framework of care that may be relevant to other teams of children's community services across the country. This service has been judged by the impact it has had on the families who use it and the professionals employed within it.

This paper aims to address three broad themes. An outline of the current UK primary/community health care research and development (R&D) agenda is presented and it is argued that in addressing this agenda greater diversity of research designs and methods to generate knowledge for policy and practice is needed. It is proposed that philosophical and disciplinary entrenchment, particularly within nursing, has led to over preoccupation with arguments about the epistemological basis of research approaches and methods as an end in itself and the research priorities and questions for health and health care that should drive such debates are often side lined or altogether ignored. The remainder of the paper addresses Meyer's proposition for the need for more participative practitioner-centred research within the context of community/primary health care. It is argued that while action research and other participative research methods have much to offer we need to understand and use the full range of research approaches and methods at our disposal, and where appropriate, develop new ones if we are to tackle the research priorities relevant to a large and diverse community/primary care R&D agenda.

Objectives: This study measured the extent to which a systematic approach was used to select criteria for audit, and identified problems in using such an approach with potential solutions. Design: A questionnaire survey using the Audit Criteria Questionnaire (ACQ), created, piloted, and validated for the purpose. Possible ACQ scores ranged from 0 to 1, indicating how systematically the criteria had been selected and how usable they were. Setting: A stratified random sample of 10 audit leads in each of 83 randomly selected NHS trusts and all practices in each of 11 randomly selected primary care audit group areas in England and Wales. Participants: Audit leads of ongoing audits in each organisation in which a first data collection had started less than 12 months earlier and a second data collection was not completed. Main outcome measures: ACQ scores, problems identified in the audit criteria selection process, and solutions found. Results: The mean ACQ score from all 83 NHS trusts and the 11 primary care audit groups was 0.52 (range 0.0–0.98). There was no difference between mean ACQ scores for criteria used in audits on clinical (0.51) and non-clinical (0.52) topics. The mean ACQ scores from nationally organised audits (0.59, n=33) was higher than for regional (0.51, n=21), local (0.53, n=77), or individual organisation (0.52, n=335) audits. The mean ACQ score for published audit protocols (0.56) was higher than for locally developed audits (0.49). There was no difference in ACQ scores for audits reported by general practices (0.49, n=83) or NHS trusts (0.53, n=383). Problems in criteria selection included difficulties in coordination of staff to undertake the task, lack of evidence, poor access to literature, poor access to high quality data, lack of time, and lack of motivation. Potential solutions include investment in training, protected time, improved access to literature, support staff and availability of published protocols. Conclusions: Methods of selecting review criteria were often less systematic than is desirable. Published usable audit protocols providing evidence based review criteria with information on their provenance enable appropriate review criteria to be selected, so that changes in practice based on these criteria lead to real improvement in quality rather than merely change. The availability and use of high quality audit protocols would be a valuable contribution to the evolution of clinical governance. The ACQ should be developed into a tool to help in selecting appropriate criteria to increase the effectiveness of audit.

Since 1997, Labour Governments have championed partnership working as part of a commitment to develop a new public health agenda. Multidisciplinary and multiagency working have been placed at the heart of attempts to tackle widening health inequalities, with Primary Care Trusts (PCT) being placed at the forefront of a corporate approach to delivering improvements in individual, community and population well-being. However, observed practice in relation to public health collaboration has rarely met the challenge of past policy prescriptions. Furthermore, we have limited understanding of who is best placed to meet the challenge of securing public health partnerships within a primary care led National Health Service (NHS). This paper reviews the need for PCT involvement in partnership working, assesses the potential contribution primary care nurses can make to the co-ordinated delivery of the new public health agenda, and identifies key issues for policy and practice. It concludes that nurses have the opportunity to play a key role in the development of partnerships for improved public health at the PCT level. However, it also notes that the development of such functions will require an expansion of existing nursing roles, a willingness to take on a more overtly political role, and a deeper consideration of the constituents of successful collaborative action for improved public health.

Background: Delirium is the most frequent complication among older people following hospitalisation. Delirium may be prevented in about one-third of patients using a multicomponent intervention. However, in the United Kingdom, the National Health Service has no routine delirium prevention care systems. We have developed the Prevention of Delirium Programme, a multicomponent delirium prevention intervention and implementation process. We have successfully carried out a pilot study to test the feasibility and acceptability of implementation of the programme. We are now undertaking preliminary testing of the programme. Methods/Design: The Prevention of Delirium Study is a multicentre, cluster randomised feasibility study designed to explore the potential effectiveness and cost-effectiveness of the Prevention of Delirium Programme. Sixteen elderly care medicine and orthopaedic/trauma wards in eight National Health Service acute hospitals will be randomised to receive the Prevention of Delirium Programme or usual care. Patients will be eligible for the trial if they have been admitted to a participating ward and are aged 65 years or over. The primary objectives of the study are to provide a preliminary estimate of the effectiveness of the Prevention of Delirium Programme as measured by the incidence of new onset delirium, assess the variability of the incidence of new-onset delirium, estimate the intracluster correlation coefficient and likely cluster size, assess barriers to the delivery of the Prevention of Delirium Programme system of care, assess compliance with the Prevention of Delirium Programme system of care, estimate recruitment and follow-up rates, assess the degree of contamination due to between-ward staff movements, and investigate differences in financial costs and benefits between the Prevention of Delirium Programme system of care and standard practice. Secondary objectives are to investigate differences in the number, severity and length of delirium episodes (including persistent delirium); length of stay in hospital; inhospital mortality; destination at discharge; health-related quality of life and health resource use; physical and social independence; anxiety and depression; and patient experience. Discussion: This feasibility study will be used to gather data to inform the design of a future definitive randomised controlled trial. Trial registration: ISRCTN01187372. Registered 13 March 2014.

Objectives: dementia is a debilitating condition characterised by global loss of cognitive and intellectual functioning, which reduces social and occupational performance. This population frequently presents with medical co-morbidities such as hypertension, cardiovascular disease and diabetes. The CONSORT statement outlines recommended guidance on reporting of participant characteristics in clinical trials. It is, however, unclear how much these are adhered to in trials assessing people with dementia. This paper assesses the reporting of medical co-morbidities and prescribed medications for people with dementia within randomised controlled trial (RCT) reports. Design: a systematic review of the published literature from the databases AMED, CINAHL, MEDLINE, EMBASE and the Cochrane Clinical Trial Registry from 1 January 1997 to 9 January 2014 was undertaken in order to identify RCTs detailing baseline medical co-morbidities and prescribed medications . Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) RCT appraisal tool, and descriptive statistical analyses were calculated to determine point prevalence. Results: nine trials, including 1474 people with dementia, were identified presenting medical co-morbidity data. These indicated neurological disorders (prevalence 91%), vascular disorders (prevalence 91%), cardiac disorders (prevalence 74%) and ischaemic cerebrovascular disease (prevalence 53%) were most frequently seen. Conclusions: published RCTs poorly report medical co-morbidities and medications for people with dementia. Future trials should include the report of these items to allow interpretation of whether the results are generalisable to frailer older populations. PROSPERO Registration: CRD42013006735.

The Data Protection Act (1998): implications for health researchers Aims. This paper reports on the methods used in two studies to obtain access to subjects to comply with the common law duty of confidence laid out in the Data Protection Act (1998) and discusses the researchers’ problems in interpreting the procedures. Rationale. The amendments to the United Kingdom (UK) Data Protection Act (1998) are causing confusion within the health service and academic institutions. There is a need to balance patient confidentiality with the requirement to conduct vital, unbiased research in which health service professionals are not subject to ethical dilemmas. This paper examines the recruitment methods used in two studies in which the researchers’ attempts to adhere to the requirements lengthened the study costs and may have produced less reliable results. Methods. The methodological difficulties in two studies are presented. In Study 1, the difficulties encountered when the Multicentre Research Ethics Committee refused permission for researchers to recruit patients directly to a multicentre randomized controlled trial are discussed. In Study 2, the method used to compile a sampling frame for a national questionnaire survey following the eight principles of the Act are described. Findings. Our experience has shown that health care professionals are increasingly required to recruit patients to intervention trials, and that researchers are not allowed access to the names of patients or other subjects to ask them for consent to participate in a study. The requirement for researchers to use ‘intermediaries’ to obtain consent from and recruit subjects to studies increases the risk of selection bias, may expose the practitioner to ethical difficulties and may compromise the external validity of trial results. There is also a danger that research costs will soar when the Data Protection Act (1998) is fully realized. Conclusion. The Data Protection Act (1998) is currently being interpreted in a number of different ways. We conclude there is an urgent need for consensus within the health service and academic communities.

Background - A growing number of new ways of organising services across the primary/secondary interface are being introduced and evaluated. The principal motive for such reorganisation is to improve the efficiency of health care. However, unless the impact of the new services on patients is investigated and taken into account, it is possible that patients' reactions could be negative, a factor that could lead to unexpected consequences in the use and costs of services. Objective - To develop a measure of patients' attitudes towards care across the interface between primary and secondary care. Design - Generation of questions to be included in the measure from a qualitative study of patients' experiences of care across the interface; administration of pilot versions of the measure to samples of patients referred to secondary care; refinement of questions guided by analysis of response patterns, principal components analysis and internal consistency; administration of the final version of the patient career diary in complete form retrospectively to patients referred to secondary care, and one section alone to patients attending outpatient departments for follow up appointments. Face validity was assessed by analysis of open comments in a sample of 50 diaries, and review of the diary by 34 health professionals. Construct validity was assessed by investigation of levels of correlation between components of each section of the diary and the components of the healthcare section overall. Setting - In the final field test, patients were attending various hospital services, including cardiology, dermatology, neurology, gynaecology, general surgery, general medicine, ophthalmology, trauma and orthopaedics, and gastroenterology. Results - The final version of the diary included 109 questions in seven sections: general practitioner (GP) visits and referral, other GP visits, first outpatient visit, other outpatient visits, inpatient stay and discharge, care after discharge, and care overall. Response rates were poor for retrospective completion of the entire diary, but excellent when a section was given separately. Principal components analysis confirmed that components relating to issues identified as important to patients in the qualitative study had been included in the diary. Levels of internal consistency were good, and comments of patients and health professionals supported validity. Conclusion - The patient career diary is a valid and reliable measure of patients' attitudes to care across the interface. It should be given in sections to ensure adequate response rates, and is suitable for use in the evaluation or quality of patterns of care across the interface. In future, the impact on patients of new ways of organising services across the interface should be investigated by use of measures such as the patient career diary.

There has been considerable confusion and unease within the nursing profession about the emphatic push for all healthcare to be 'evidence-based'. In particular, there has been anxiety that the emphasis on evidence ignores practitioners' skills and individual patient preferences. This paper attempts to clarify the main issues surrounding evidence-based nursing. These include its epidemiological origins and purpose, the meaning and limits of 'evidence', the need for individual skills and expertise in the use of evidence, and the strengths and weaknesses of different kinds of evidence. It aims to debunk the misconception that randomized controlled trials are synonymous with evidence, and to increase critical awareness of the nature of evidence in nursing.

This paper reports the development of a questionnaire designed to assess whether patients' experiences of cancer services meet agreed standards as part of the process of accrediting cancer centres and units. Based on issues that patients and carers consider important, questions covered all stages of a patient's journey through the health service. 446 patients from five hospitals in Trent Region (UK) were recruited, 66% ( n =298) returned completed questionnaires. Patients generally rated their experiences of care positively. Areas of care receiving 10% or more negative responses included the manner and surroundings in which the diagnosis was given; information about treatment implications and side-effects; recognizing how anxious the patient was feeling during treatment and follow-up; written information about the illness and its treatment; and involvement in decisions about treatment. The questionnaire demonstrated satisfactory internal consistency as well as sufficient discriminatory power to detect differences in perceptions of good and poor care between the three geographical study sites. Criterion validity was satisfactory as measured by the level of association between overall care scores and the combined scores of the eight subsections. Further work needs to be undertaken in testing for construct validity and sensitivity to change.

Clinical governance is the core component of the new quality programme for the NHS (see box on next page) announced in the consultation document A First Class Service .1 It is described as “a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” It will be the central focus for assuring the quality of care and addressing the issue of providing accountability through the Commission for Health Improvement.2 The activities of the commission will reflect national and local priorities as identified by the National Institute of Clinical Excellence and health improvement programmes respectively. Although A First Class Service included details about the structure and functioning of clinical governance in health service trusts, arrangements for primary care groups were not specified. In this paper, we suggest a possible model for clinical governance in primary care groups. Clinical governance is central to the NHS quality programme, but how it will operate in primary care groups remains unclear Although many activities included in the new concept of clinical governance are already being undertaken, these need to be coordinated A model of governance that addresses the core tasks of defining, accounting for, and improving quality and incorporates evidence on effective methods of changing performance is suggested This model can improve professional, practice, and primary care group performance It shows how groups can introduce and develop clinical governance and how health authorities and the Commission for Health Improvement can monitor progress The model is based on three underlying precepts

This paper discusses the methodological challenges of using the 3D social virtual world Second Life for research and offers some solutions on a range of research issues including research ethics committee approval, gaining consent, recruitment of sample, data collection and engagement with 'in - world culture'.The attraction of social virtual worlds to researchers is their ability to mimic the physical world, as they, are seen as 'places' where people have a feeling of presence (being there) and social presence (being there with others) through the use of a 'customisable' avatar (digital self-representation). Emerging research demonstrating the persuasive nature of avatars on health behaviours through virtual worlds, online games and the 3D web has increased the use of and interest in these areas for delivering health information, advice and support. However, conducting research can be challenging in a 3D world where people are represented as anonymous avatars in an environment unlike any other online media.25 semi-structured interviews were conducted in Second Life from September 2011-June 2012.Nurses wishing to undertake research in social virtual worlds should spend time in-world to acquire technical skills and gain an understanding of the culture of the world.Our experience of an interview-based study in virtual worlds indicates that researchers require several virtual world technical skills to create innovative tools to recruit, gain consent and collect data and an understanding of in-world culture, language and social norms to increase the chances of successful research.

Background:\ud Health risk behaviours known to result in poorer outcomes in adulthood are generally established in late childhood and adolescence. These ‘risky’ behaviours include smoking, alcohol and illicit drug use and sexual risk taking. While the role of social capital in the establishment of health risk behaviours in young people has been explored, to date, no attempt has been made to consolidate the evidence in the form of a review. Thus, this integrative review was undertaken to identify and synthesise research findings on the role and impact of family and community social capital on health risk behaviours in young people and provide a consolidated evidence base to inform multi-sectorial policy and practice.\ud \ud Methods:\ud Key electronic databases were searched (i.e. ASSIA, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Embase, Medline, PsycINFO, Sociological Abstracts) for relevant studies and this was complemented by hand searching. Inclusion/exclusion criteria were applied and data was extracted from the included studies. Heterogeneity in study design and the outcomes assessed precluded meta-analysis/meta-synthesis; the results are therefore presented in narrative form.\ud \ud Results:\ud Thirty-four papers satisfied the review inclusion criteria; most were cross-sectional surveys. The majority of the studies were conducted in North America (n=25), with three being conducted in the UK. Sample sizes ranged from 61 to 98,340. The synthesised evidence demonstrates that social capital is an important construct for understanding the establishment of health risk behaviours in young people. The different elements of family and community social capital varied in terms of their saliency within each behavioural domain, with positive parent–child relations, parental monitoring, religiosity and school quality being particularly important in reducing risk.\ud \ud Conclusions:\ud This review is the first to systematically synthesise research findings about the association between social capital and health risk behaviours in young people. While providing evidence that may inform the development of interventions framed around social capital, the review also highlights key areas where further research is required to provide a fuller account of the nature and role of social capital in influencing the uptake of health risk behaviours.

Objectives--To determine the role of medical audit advisory groups in audit activities in general practice. Design--Postal questionnaire survey. Subjects--All 104 advisory groups in England and Wales in 1994. Main measures--Monitoring audit: the methods used to classify audits, the methods used by the advisory group to collect data on audits from general practices, the proportion of practices undertaking audit. Directing and coordinating audits: topics and number of practices participating in multipractice audits. Results--The response rate was 86-5%. In 1993-4, 54% of the advisory groups used the Oxfordshire or Kirklees methods for classifying audits, or modifications of them. 99% of the advisory groups collected data on audit activities at least once between 1991-2 and 1993-4. Visits, questionnaires, and other methods were used to collect information from all or samples of practices in each of the advisory group's areas. Some advisory groups used different methods in different years. In 1991-2, 57% of all practices participated in some audit, in 1992-3, 78%, and in 1993-4, 86%. 428 multipractice audits were identified. The most popular topic was diabetes. Conclusions--Advisory groups have been active in monitoring audit in general practice. However, the methods used to classify and collect information about audits in general practices varied widely. The number of practices undertaking audit increased between 1991-2 and 1993 1. The large number of multipractice audits supports the view that the advisory groups have directed and coordinated audit activities. This example of a national audit programme for general practice may be helpful in other countries in which the introduction of quality assurance is being considered.