Development of a Complex Intervention for Secondary Prevention of Coronary Heart Disease in Primary Care Using the UK Medical Research Council Framework

Objective: To apply the UK Medical Research Council (MRC) framework for development and evaluation of trials of complex interventions to a primary healthcare intervention to promote secondary prevention of coronary heart disease. Study Design: Case report of intervention development. Methods: First, literature relating to secondary prevention and lifestyle change was reviewed. Second, a preliminary intervention was modeled, based on literature findings and focus group interviews with patients (n = 23) and staff (n = 29) from 4 general practices. Participants’ experiences of and attitudes toward key intervention components were explored. Third, the preliminary intervention was pilot-tested in 4 general practices. After delivery of the pilot intervention, practitioners evaluated the training sessions, and qualitative data relating to experiences of the intervention were collected using semistructured interviews with staff (n = 10) and patient focus groups (n = 17). Results: Literature review identified 3 intervention components: a structured recall system, practitioner training, and patient information. Initial qualitative data identified variations in recall system design, training requirements (medication prescribing, facilitating behavior change), and information appropriate to the prospective study participants. Identifying detailed structures within intervention components clarified how the intervention could be tailored to individual practice, practitioner, and patient needs while preserving the theoretical functions of the components. Findings from the pilot phase informed further modeling of the intervention, reducing administrative time, increasing practical content of training, and omitting unhelpful patient information. Conclusion: Application of the MRC framework helped to determine the feasibility and development of a complex intervention for primary care research.

The visual representation of the “indignados”. A visual analysis about the characterization of the participants of the 15-M movement.

The aim of this work is to show the type of media coverage done by the newspapers La Razón, El País and Público about the 15-M social movement during the time that the camping at Sol took place. Specifically, in terms of how the characterization of the “indignados” (outraged) got made. Based on our previous descriptive observations, we approached a visual analysis of the photographs published on the paper editions of those mainstream media from May 15-June 12 of the 2011. we started from a total sample of 379 items, developing:1) A content analysis of La Razón, El País, and Público; the most frequents words of each media, articles classifications from the reviews found on them (expositive, positive-evaluation, negative-evaluation).2) An analysis of the 408 images obtained from the total sample, which establishes a clear evolution of the “indignados” profile and how differently each media took the movement as such. That’s, when they stop naming them “indignados”, and recognize its nature as social movement by calling it: “Movimiento 15-M"...

De la cooperativa agroalimentaria a la "learning netchain". Hacia un planteamiento teorico interorganizativo e interpersonal

Se propone un planteamiento teórico/conceptual para determinar si las relaciones interorganizativas e interpersonales de la netchain de las cooperativas agroalimentarias evolucionan hacia una learning netchain. Las propuestas del trabajo muestran que el mayor grado de asociacionismo y la mayor cooperación/colaboración vertical a lo largo de la cadena están positivamente relacionados con la posición horizontal de la empresa focal más cercana del consumidor final. Esto requiere una planificación y una resolución de problemas de manera conjunta, lo que está positivamente relacionado con el mayor flujo y diversidad de la información/conocimiento obtenido y diseminado a lo largo de la netchain. Al mismo tiempo se necesita desarrollar un contexto social en el que fluya la información/conocimiento y las nuevas ideas de manera informal y esto se logra con redes personales y, principalmente, profesionales y con redes internas y, principalmente, externas. Todo esto permitirá una mayor satisfacción de los socios de la cooperativa agroalimentaria y de sus distribuidores y una mayor intensidad en I+D, convirtiéndose la netchain de la cooperativa agroalimentaria, así, en una learning netchain.

Validity, trustworthiness and rigour:reasserting realism in qualitative research

Aim The aim of this paper is to challenge recent sceptical approaches to the possibility of validating qualitative research and to underline the benefits of adopting a realist approach to validity. Background In recent discussion about the methodological bases for qualitative research it has been argued that, because different methodologies take different approaches to validity, attempts to develop a common set of validation criteria are futile. On the basis of this sceptical view, a number of strategies for judging qualitative research have been proposed. These include suggestions that: it should be judged according to aesthetic or rhetorical criteria, rather than epistemological validity; responsibility for appraisal should move from researchers to readers; each methodology should be assessed individually according to its own merits. Discussion None of these suggestions provide a viable alternative to validity, defined as the extent to which research reflects accurately that to which it refers. Because the form of research does not determine its content, replacement of epistemology by aesthetics is unsustainable. Because research reports mediate between writer and reader, a one-sided approach to this relationship constitutes a false dichotomy. If we accept the criterion of practitioner confidence as a means of judging methodological approaches, this involves rejection of judgement according to a methodology�s own merits. Conclusion If qualitative research is actually about something, and if it is required to provide beneficial information, then a realist approach to validity holds out greatest promise.

Using the opinions of coronary heart disease patients in designing a health education booklet for use in general practice consultations.

Objective This study explored how coronary heart disease (CHD) patients’ views would inform the design of an information booklet aimed at providing patients and practitioners with a resource to help influence positively patients’ health behaviour outcomes. Methods Opinions of patients (N=23) with CHD about their information needs, particularly lifestyle advice, were explored using a qualitative approach in four general practices. This information was used in designing a booklet for a pilot study intervention aimed at promoting healthy lifestyle behaviours and medication adherence among people with CHD. Subsequent focus groups explored patients’ (N=17) opinions about the booklet’s ‘fitness for purpose’; semi-structured interviews with practitioners (N=10) examined their views on the booklet’s usefulness. Results In initial focus groups patients identified gaps in their information provision regarding coping with stress, available local community support and medication purpose. A booklet, prepared on the basis of previous literature, was modified to address these gaps. Pilot study patients were satisfied with the re-designed booklet and practitioners reported that its use in consultations enabled change implementation and facilitated patients’ understanding of connections between lifestyle and health outcomes. Conclusion Acknowledging the opinions of CHD patients in producing health information booklets which emphasised a patient centred approach supported practitioner-patient partnerships for choosing healthy lifestyle choices.

The prevalence of nonadherence in difficult asthma

Rationale: With the advent of new and expensive therapies for severe refractory asthma, targeting the appropriate patients is important. An important issue is identifying nonadherence with current therapies. The extent of nonadherence in a population with difficult asthma has not been previously reported.

Objectives: To examine the prevalence of nonadherence to corticosteroid medication in a population with difficult asthma referred to a Specialist Clinic and to examine the relationship of poor adherence to asthma outcome.

Methods: General practitioner prescription refill records for the previous 6 months for inhaled combination therapy and short-acting ß-agonists were compared with initial prescriptions and expressed as a percentage. Blood plasma prednisolone and cortisol assay levels were used to examine the utility of these measures in assessing adherence to oral prednisolone. Patient demographics, hospital admissions, lung function, oral prednisolone courses, and quality of life data were analyzed to indentify the variables associated with reduced medication adherence.

Measurements and Main Results: A total of 182 patients were assessed. Sixty-three patients (35%) filled 50% or fewer inhaled medication prescriptions; 88% admitted poor adherence with inhaled therapy after initial denial. Twenty-one percent of patients filled more than 100% of presciptions, and 45% of subjects filled between 51 and 100% of prescriptions. Twenty-three of 51 patients (45%) prescribed oral steroids were found to be nonadherent.

Conclusions: A significant proportion of patients with difficult-to-control asthma remained nonadherent to corticosteroid therapy. Objective surrogate and direct measures of adherence should be performed as part of a difficult asthma assessment and are important before prescibing expensive novel biological therapies.

Relationships matter: The problems and prospects for social workers' relationships with young children in care

One of the key lessons learnt in the UK from the Laming Inquiry into the death of Victoria Climbié was the importance of social workers developing consistent and long-term relationships with young children in whose lives they are involved. This issue is now informing policy developments, including the proposed Social Work Practices which, based on a similar model to General Practitioner practices, aim to provide a lead professional to act as a parental figure and an advocate for every child in care. This paper begins by confirming the importance of developing relationships between social workers and young children, but questions the ability of the new policy developments to facilitate these. Drawing upon data from research involving interviews with social workers, the paper outlines the factors which hinder social workers' relationships with young children and argues that while the new proposals address some of the more surface structural and organizational factors, they do not address the deeper factors regarding attitudes, values and emotional competence which are crucial if social workers are to successfully build relationships with young children in care.

Where do parents go for feeding advice in the first year?

Health visiting services have been restructured from being universal for all children to targeting families in need. UK recommendations on infant feeding have also recently changed. With the many sources of information available on feeding babies, it is important to know where parents get feeding advice and which sources they find valuable. In this study, 215 mothers of one-year old infants were interviewed about where they had obtained feeding advice in the first year of their infant’s life and how useful they found this information. The health visitor was the most commonly cited source of information (70%) followed by grandparents (53%), while 10% of mothers relied solely on health visitor advice. This study highlights the importance placed by mothers on health visitors, which may have implications for the service in the midst of the reorganisation of the health visitor’s role.

An absorptive capacity interpretation of Six Sigma

Purpose – The Six Sigma approach to business improvement has emerged as a phenomenon in both the practitioner and academic literature with potential for achieving increased competitiveness and contributing. However, there is a lack of critical reviews covering both theory and practice. Therefore, the purpose of this paper is to critically review the literature of Six Sigma using a consistent theoretical perspective, namely absorptive capacity.

Design/methodology/approach – The literature from peer-reviewed journals has been critically reviewed using the absorptive capacity framework and dimensions of acquisition, assimilation, transformation, and exploitation.

Findings – There is evidence of emerging theoretical underpinning in relation to Six Sigma borrowing from an eclectic range of organisational theories. However, this theoretical development lags behind practice in the area. The development of Six Sigma in practice is expanding mainly through more rigorous studies and applications in service-based environments (profit and not for profit). The absorptive capacity framework is found to be a useful overarching framework within which to situate existing theoretical and practice studies.

Research limitations/implications – Agendas for further research from the critical review, in relation to both theory and practice, have been established in relation to each dimension of the absorptive capacity framework.

Practical implications – The paper shows that Six Sigma is both a strategic and operational issue and that focussing solely on define, measure, analyse, improve control-based projects can limit the strategic effectiveness of the approach within organisations.

Originality/value – Despite the increasing volume of Six Sigma literature and organisational applications, there is a paucity of critical reviews which cover both theory and practice and which suggest research agendas derived from such reviews.

Effect of pioglitazone on endothelial function in impaired glucose tolerance

Aim: Flow-mediated dilation (FMD) is a surrogate marker of endothelial function, which has been proposed as a barometer of vascular health. Impaired microvascular response to reactive hyperaemia is thought to be the mechanism behind reduced shear stress and subsequently impaired FMD, which has been associated with cardiovascular events. This study aims to assess the effect of pioglitazone on the vasculature of patients with impaired glucose tolerance (IGT).

Materials and Methods: Forty IGT patients with no cardiovascular disease were compared with 24 healthy age- and sex-matched controls. Endothelial function was assessed using FMD of the brachial artery. Adiponectin (ADN) levels were measured and insulin sensitivity was calculated using homeostasis model assessment of insulin resistance (HOMA-IR). A randomised double-blind placebo-controlled trial of the IGT subjects was then performed, with subjects receiving either pioglitazone 30 mg od or matched placebo for 12 weeks before the measurements were repeated.

Results: The IGT subjects had a significantly impaired FMD compared with the controls (p < 0.001). Diastolic shear stress (DSS) was also significantly reduced in IGT (p = 0.04). High molecular weight (HMW) ADN was significantly lower in the IGT group than in controls (p = 0.03). On analysis of the IGT group after 12 weeks treatment, FMD was significantly increased in the pioglitazone group compared with placebo (p = 0.03) as was endothelium-independent dilation (EID) (p = 0.03). A significant increase in total ADN (p < 0.001), HMW ADN (p < 0.001) and HMW/total ratio (p = 0.001) occurred in the pioglitazone group compared with placebo.

Conclusions: Pioglitazone improved endothelial function in IGT. Treatment with pioglitazone may reduce the risk of cardiovascular disease in this patient group.

Explicit argumentation as a supervisory tool for decision making in child protection cases involving human rights issues

This paper addresses the problems often faced by social workers and their supervisors in decision making where human rights considerations and child protection concerns collide. High profile court cases in the United Kingdom and Europe have consistently called for social workers to convey more clarity when justifying their reasons for interfering with human rights in child protection cases. The themes emerging from these case law decisions imply that social workers need to be better at giving reasons and evidence in more explicit ways to support any actions they propose which cause interference with Convention Rights. Toulmin (1958, 1985) offers a structured approach to argumentation which may have relevance to the supervision of child protection cases when social workers and managers are required to balance these human rights considerations. One of the key challenges in this balancing act is the need for decision makers to feel confident that any interventions resulting in the interference of human rights are both justified and proportionate. Toulmin’s work has already been shown to have relevance for assisting social workers navigate pathways through cases involving competing ethical and moral demands (Osmo and Landau, 2001) and more recently to human rights and decision making in child protection (Duffy et al, 2006). Toulmin’s model takes the practitioner through a series of stages where any argument or proposed recommendation (claim) is subjected to intense critical analysis involving exposition of its strengths and weaknesses. The author therefore proposes that explicit argumentation (Osmo and Landau, 2001) may help supervisors and practitioners towards safer and more confident decision making in child protection cases involving the interference of the human rights of children and parents. In addition to highlighting the broader context of human rights currently permeating child protection decision making, the paper will include case material to practically demonstrate the application of Toulmin’s model of argumentation to the supervision context. In this way the paper adopts a strong practice approach in helping to assist practitioners with the problems and dilemmas they may come up against in decision making in complex cases.

'Like walking on eggshells': Service user views and expectations of the child protection system

This paper reports on a study of service users' views on Irish child protection services. Qualitative interviews were conducted with 67 service users, including young people between 13 and 23. The findings showed that despite refocusing and public service management reforms, service users still experience involvement with the services as intimidating and stressful and while they acknowledged opportunities to participate in the child protection process, they found the experience to be very difficult. Their definition of ‘needs’ was somewhat at odds with that suggested in official documentation, and they viewed the execution of a child protection plan more as a coercive requirement to comply with ‘tasks’ set by workers than a conjoint effort to enhance their children's welfare. As in previous studies, the data showed how the development of good relationships between workers and service users could compensate for the harsher aspects of involvement with child protection. In addition, this study demonstrated a high level of discernment on the part of service users, highlighting their expectation of quality standards in respect of courtesy, respect, accountability, transparency and practitioner expertise.