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What is clinical governance?

delivering on the legal duty of NHS trusts to put in place systems for monitoring and ensuring that quality of care is provided. Represents a framework through which NHS organsiations are responsible 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


What is the health and social care act 2012?

This act has a duty to improve quality. It states that the Secretary of State must exercise the functions of the Secretary of State in relation to the health service, with a view to securing continuous improvement in the quality of services provided to individuals.
o Effectiveness of the services
o Safety of the services
o Quality of the experience undergone by patients
o In regard to the quality standards prepared by NICE


How has it been suggested that healthcare is inequitable?

by variations in healthcare, which suggest that not everyone is getting the best care- variations in who receives high quality of care, and access to care
e.g. twice as likely to have foot amputated due to diabetes in you live in SW, compared to SE. More thorough feet check may have meant preventability.


what is equity?

everyone with same need gets same care


what is an adverse event?

an injury caused by medical management rather than underlying disease, that prolongs hospitilisation, produces a disability, or both.


what is a preventable adverse event?

an adverse event that could be prevented given the current state of medical knowledge


examples of variations in healthcare?

5-fold variations in asthma admission rates to hospitalts with acute exacerbations across England

14-fold variation rate per 1000 people in provision of hip replacements


what is meant by care being inefficient?

the best value for money care is not being provided


example of an unavoidable adverse event?

a drug reaction in a patient prescribed drug for 1st time


examples of preventable adverse events?

operations on wrong side of body
wrong dose/type of drug
failure to rescue- patient may deteriorate and attention is not given in time
some kinds of infections


preventable adverse events in terms of surgery?

leaving behind a foreign object
wrong procedure
wrong site


example of a preventable adverse event where medication was given via the wrong site?

vincristine- chemotherapy drug that is administered IV, but between 1975 and 2001, 14 people dies in the UK as drug given intrathecally- as spinal injection


why does harm occur in the NHS?

over-reliance on individual responsibility:
all humans make errors, everyone is fallible
most of medicine complex and uncertain
most errors result of system- inadequate training, long hours, lack of checks, ampoules that look the same

personal effort is necessary but not sufficient to deliver safe care


how has the WHO said we can address human factors to ensure a systems based approach to promote quality in healthcare?

avoid reliance on memory
make things visible
review and simplify processes
standardise common processes and procedures
routinely use checklists
reduce reliance on vigilance


describe a model used to explain why patient safety problems occur

One human factors model is the Swiss
Cheese Model of organisational accidents.
The Swiss Cheese Model hypothesises that in any system there are many levels of defence. Examples of levels of defence would be checking of drugs before administration, a preoperative checklist or
marking a surgical site before an operation. Each of these levels little ‘holes’ in it which are caused by poor design, senior management decision-making,
procedures, lack of training, limited resources etc. These holes are known as ‘latent conditions’.
If latent conditions become aligned over successive levels of defence they create a
window of opportunity for a patient safety incident to occur. Latent conditions also increase the likelihood that healthcare professionals will make ‘active errors- lead directly to a patient being harmed whilst delivering patient care. When a combination of latent
conditions and active errors cause all levels of defences to be breached a patient safety
incident occurs.

Patient safety incident typically due to a series of seemingly minor events all happen consecutively and/or concurrently so on that one day, at that one time, all the ‘holes’ line up and a serious event results


types of error in administering healthcare?

1. Slips and lapses
 Error of action
 Person knows what they want to do but action does not turn out as intended
 E.g. wanted to give a baby 0.05mg of a drug but gave 0.5mg instead
2. Mistake
 Error of knowledge or planning
 Action goes as planned but fails to achieve intended outcome because the wrong action was taken
 E.g. perfect administration of migraine treatment, but problem was a brain tumour
3. Violation
 Intentional deviations from protocols, standards, safe operating procedures or other rules
 E.g. not using aseptic technique when inserting a catheter


why does violation occur in healthcare causing problems with safety?

There is a perceived benefit. Less trouble for the staff, saves time, reduces distractions while doing the round.
Assumed absent or minimal consequences. Do not consider it likely there will be negative
effects for the patient or consequences for themselves. The process or rule may not appear to have value


situation of Elaine Bromiley, 2005: human factors contributing to harm occuring with patient care?

Doctors failed to recognise a standard can't intubate can't ventilate crisis when Elaine Bromiley was admitted to hospital for routine sinus surgery and during the anaesthetic, she experienced breathing
problems and the anaesthetist was unable to insert a device to secure her airway
Loss of situational awareness – the stress of the situation meant that the consultants
involved became highly focussed on repeated attempts to insert the breathing tube. As
a result of this they lost sight of the bigger picture i.e. how long these attempts had
been taking. This ‘tunnel vision’ meant they had no sense of time passing or the
severity of the situation
• Perception and cognition - actions were not in line with the emergency protocol. In the
pressure of the moment many options were being considered but they were not
necessarily the options that made the most sense in hindsight
• Teamwork – there was no clear leader. The consultants in the room were all providing
help and support but no one person was seen to be in charge throughout. This led to a
breakdown in the decision making process and communication between the three
consultantswww.patientsafetyfirst.nhs.uk 5
• Culture – Nurses who sensed the urgency early on brought the emergency kit to the
room, and then alerted the intensive care unit. They stated that these were available
but did not raise their concerns aloud when they were not utilised. Other nurses who
were aware of what was happening did not know how to broach the subject. The
hierarchy of the team made assertiveness difficult despite the severity of the situation.


What is the NHS outcomes framework?

This is intended to provide a national level overview of how well the NHS is performing in order to monitor and improve quality and safety in the NHS.
It specifies national outcome goals and indicators in 5 domains:
preventing people from dying prematurely
enhancing QOL for people with LT conditions
helping people recover from episodes of ill health/injury
ensuring people have a +ve experience of care
treating and caring for people in a safe environment and protecting from avoidable harm

The NHS outcomes framework provides a national overview of how the NHS is performing, holds the Health Secretary and NHS comissioning board accountable for £95bn of public money and acts as a catalyst to change NHS culture and behaviour to drive up quality


what is NICE?

National Institute for Health and Care Excellence- sets quality standards based on best available evidence, aims to define what high quality care should look like.
In April 2013 they were established in primary legislation, becoming a Non Departmental Public Body (NDPB) and placing them on a solid statutory footing as set out in the Health and Social Care Act 2012. They then took on responsibility for developing guidance and quality standards in social care, and name changed to reflect this.


what is a NICE quality standard?

a set of statements that are:
markers of high quality, clinical and cost-effective patient care across a pathway or clinical area
derived from best available evidence e.g. NICE guidance or NHS evidence accredited sources
and produced collaboratively with NHS and social care, along with their partners and service users


example of a NICE quality standard for stoke

11 statements, including:
brain imaging within 1 hr of arrival if indicated
screen for swallowing within 4 hrs
urinary incontinence reassessed after 2 weeks


What are clinical comissioning groups?

groups that are authorised to comission healtcare services for their local populations
drive quality through contracts
Supported by Commissioning Support Units which work in partnership with healthcare commissioners, healthcare providers, local authorities and others, to enable excellence in the commissioning and delivery of healthcare services.
Successful comissioning- delivering right outcomes at the right cost


How are CCGs held accountable for their progress in delivering outcomes?

The Clinical Commissioning Group Outcomes Indicator Set (CCG OIS) is an integral part of the NHS Commissioning Board's systematic approach to quality improvement. Its primary aim is to support and enable clinical commissioning groups (CCGs) and health and wellbeing partners to plan for health improvement by providing information for measuring and benchmarking outcomes of services commissioned by CCGs to drive local improvement in quality and outcomes for patients


human factors indicated in patient safety incidents?

Cognition and mental workload
The physical environment
Physical demands


What is the QOF?

Introduced in 2004 as part of the General Medical Services Contract, the Quality and Outcomes Framework is a voluntary incentive scheme for GP practices in the UK, rewarding them for how well they care for patients. Practices aim to deliver high quality care across a range of areas, for which they score points
Sets national quality standards with indicators in primary care
General Practices score points according to how well they perform against the indicators
Practice payments calculated based on points achieved
Results published online annually so can make comparisons
Example of a financial incentive to reward quality in healthcare


What are Best Practice Tariffs?

Best practice tariffs (BPTs) help the NHS to improve quality by reducing unexplained variation and universalising best practice.
Standards must be met to get the max amount of money for that practice.


What are quality accounts?

way of disclosing information about performance, focus on safety, effectiveness and experience of patients, published annually and are publically available.
All trusts required to publish them, so increased info disclosure at organisational and individual level


Describe the CQC

Since 2009, all NHS trusts must be registered with the CQC. which can impose conditions of registration if it is not satisfied, can make unannounced visits, can issue warning notices, fines, prosecution, restrictions on activities, closure, and check quality accounts.
Independent regulator of all health and social care services in England


What is a clinical audit?

process of quality improvement that seeks to improve patient care and outcomes through sytematic review of care against criteria and implementation of change


Example of an audit cycle for hand hygiene

Topic: hand hygiene
Research evidence: NICE quality standards
Criteria and standards: washing hands on entering a ward
First evaluation: 50% of drs did this
Implement Change: put up a poster at the entry to a ward
Second evaluation: 75% of drs did this


Component parts of a clinical audit?

Setting standards
Measuring current practice- collecting data
Compare results with standards
Change practice
Re-audit to make sure practice has improved


Problems of getting evidence into practice?

Drs don't know about it- dissemination ineffective, drs not incentivised to keep up to date- lot of reading, systematic review help with this
Drs don't use the evidence- habit, organisational culture, professional judgement- decision made based on that individual pateint in a certain clinical situation
Organisational systems cannot support innovation e.g. managers lack clout to invoke changes
Commissioning decisions reflect different priorites e.g. if patients say they want something else
Resources not available to implement change- financial or human


why might an area exhibit inequality in healthcare, but not inequity in access to healthcare?

inequality- things are different, whereas inequity is when these differences are unfair and avoidable, or not accounted for by clinical need.
So inequality in areas may respond to the needs of the population e.g. more healthcare services for the elderly pop in 1 particular region compared to another, this wouldn't be inequitable because everyone with the same need is still getting the same care.


Describe how health is linked to socioeconomic status in Britain?

This represents the social and economic position of a person in relation to others in society, which can be classified as individual-based e.g. occupation, and geographical area-based. Life expectancy and disability-free life expectancy are both higher in those areas which are less deprived.
Age standardised mortality rates, hence accomodating for confounding factor of age, are also higher in lower socioeconomic groups.
Rate of still births, perinatal, neonatal and infant deaths are much higher for those people with lower income occupations


describe associations in Britain between health and ethnicity

CVD: highest prevalence in men of S.Asian origin, Bangladeshi=worst
Cancer: lower % prevalence in BME groups
Infant mortality: higher rates in women of Pakistani and Black Caribbean origin
Mental Health: people from BME (black and minority ethnicity) groups more likely to be diagnosed with mental illness), highest reported % poor mental health in women of pakistani and black caribbean origin, but smaller differences than diagnosis rates


what is health behaviour?

activity undertaken for purpose of maintaining health and preventing illness


what is illness behaviour?

activity of ill person to define illness and seek solution


what is sick role behaviour?

formal response to symtpoms, inc seeking formal help and action of person as patient


why might smoking be more prevalent among manual workers in comaprison to managerial and professional groupings?

higher social class- professional jobs, more likely to have +ve definition of health so incentives to give up smoking more evident for groups who could expect to remain healthy- focus on LT investments so quitting is rational choice

for lower social class- manual workers, incentives to quit are less clear as focus on ST- improving immediate environ, smoking=coping, so may be a normalised behaviour, so smoking would be rational choice


what can lay beliefs impact on?

health behaviour- difficulty accepting advice e.g. stopping smoking to prevet cervical cancer if contradicts their lay beleifs
illness behaviour
adherence/non-adherence to tment e.g. asthma:
deniers- say they don't have asthma
distancers- deny having proper asthma
pragmatists- use preventive medication only when bad asthma, so accepted they had asthma, but saw it as a mild acute illness- so not managed as an ongoing chronic condition
won't take medication if don't accept asthmatic identity- no drugs and no attendance to asthma clinics, or stigma associated with asthmatic identity


what are lay beliefs?

how people understand and make sense of health and illness, constructed with no specialised knowledge from the person but drawn from many different cources e.g. media, family, friends, own experience with a dr, and so they are not simply the result of having less medical knowledge
people reluctant to accept knowledge that contradicts their lay beliefs


why do we want to measure health?

want indication of need for healthcare- want to know service requirement so as to not waste resources
target resources where most needed
assess effectiveness of hcare interventions
evaluate quality of hcare services
use evaluations of effectiveness to get better value for money
monitor patients' progress


commonly used measures of health?

patient-based outcomes


pros and cons of mortality as measure of health

easily define
not always recorded accurately- reason died?
not good way of assessing outcomes and care quality, especially as most procedures are not life or death situations


pros and cons of morbidity as measure of health

routinely collected e.g. disease registers
collection not always reliable/accurate
tells us nothing about patient's experiences of condition when looking at clinical outcomes
not always easy to use in evaluation


what is a patient-based outcome to measure health?

want to assess patient's well-being from their point of view, e.g. HRQoL, health status
patient-reported outcome measures (PROMs) are measures of health that come directly from patients and can be used to measure patient-based outcomes, and work by comparing scores before and after tment or over longer-periods


why do we want to use patient-based outcomes?

increase in conditions where aim is managing rather than curing e.g. chronic diseases like RA
biomedical tests- just 1 part of picture
need to focus on patient's concerns- patient-centered care
need to pay attention to iatrogenic effects of care e.g. SEs of part. medication, doing more harm than good


what can patient-based outcomes be used to do?

clinically- montior progress of patient
assess benefits in relation to cost
clinical audit
measure health status of populations
compare interventions in clinical trial
measure of service quality


How has the NHS outcomes framework made use of PROMs?

identified them as a key source of info about outcomes of planned procedures
indicator 3.1 has been renamed and extended to total health gain as assessed by patients, so helping people to recover from episodes of ill health or following injury assessment isn't just based on biomedial tests and a drs opinion


why have PROMs been introduced?

improve clinical management of patients- informed, shared decision-making
comparison of providers (hospitals)- monitor performance, people not doing well are exposed so they can be made to improve or will not be contracted with to improve quality, so productivity can be increased through demand management, quality improved through patient choice.


what happens to data collected from PROMs?

published by health and social care info centre, and can be broken down by provider so can make trust comparisons
of interest to comissioners who will contract with an organisation that will carry out procedure to highest quality
and of interest to patients who can choose dr to do a part operation, so informs their decision-making


challenges of using PROMs?

minimising time and cost of collection, analysis, and date presentation
achieve high rates of patient participation
provide appropriate output to different audiences e.g. CCGs or patient
avoid misuse, must be appropr for situation
expand to other areas e.g. LT conditions, emergency conditions, mental health


HRQoL is an example of a patient-based outcome, what is its definition?

quality of life in clinical medicine represents the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient


what does HRQoL consider about the patient?

physical function- mobility, AODL
global judgements of health- look at QoL that could be expected if didn't have that condition
psychological well-being
social well-being
cognitive functioning
personal constructs- stigma, life satisfaction, satisfaction with bodily appearance
satisfaction with care


advantages of using qualitative methods to measure HRQoL?

gives access to parts other methods don't reach
very appropriate in some cases
good for initial look at dimensions of HRQoL- can be used as guidance for developing quantitative tool to measure HRQoL


disadvantages of using qualitative methods to measure HRQoL?

not easy to use in evaluation, esp RCTs, not part standardised
very resource hungry- need expert training, time


what do quantitative methods of measureing HRQoL rely upon?

use of questionnaires known as 'instruments' or 'scales'
should fulfil certain criteria


properties of instrument necessary for use of PROMs as quantitative approach to measuring HRQoL (patient based outcome)

Reliabiliy: instrument accurate over time and internally consistent- if patient has no change in health, they should get same score each time on the measure
Validity: does it measure what it is intended to measure- measure might be accessing only pain, and neglecting social aspects of illness


characteristics of published instruments used to measure HRQoL?

validated, developed in a scientific way ,easy to use, reliability and validity already established
can compare across different groups of patients using standardised measures
BUT can be used indiscriminately and inappropriately


what must be considered when selecting an instrument to measure HRQoL?

is there published work showing established reliability and validity
have there been other published studies that have used this instrument successfully
is it suitable for area of interest- is pop used appropriate
does it adequately reflect patient's concerns in this area
is instrument acceptable to patients
is it sensitive to change- must consider size of change expected
is it easy to administer and analyse


examples of generic measures of HRQoL?

short-form 36-item questionnaire
euroQol EQ-5D


how does the SF-36 work?

contains 36 items which can be grouped into 8 dimensions: physical functioning, social funcitoning, role functioning- physical and emotional, bodily pain, vitality, general health, mental health
responses to questions scored and scores for items within each dimension added together, this score then transformed to give each respondent's score for each dimension (0-100), but NOT allowed to add up dimensions to give overall score- interpretation can be difficult in some cases


positives of SF-36?

acceptable to people
5-10 mins for completion
good internal consistency
test retest high
responsive to change
pop date available so can compare to wider pop outcome


advantages of generic instruments?

use in broad range of health problems
can be used if no disease-specific instrument
enable comparisons across tment groups
can detect unexpected +ve/-ve effects of an intervention, specific too focused for this
can assess health of populations


disadvantages of generic instruments?

less detailed
loss of relevance- too general?
can be less sensitive to changes that occur as a result of an intervention, so change after intervention must be big
may be less acceptable to patients- may not know what/why being asked if vague qns


what types of specific instruments are there?

disease specific: asthma QOL questionnaire
site specific: oxford hip score, shoulder disability questionnaire
dimension specific: McGill pain questionnaire


advantages of specific instruments?

acceptable to patients- tunes in well to their experience
sensitive to change
very relevant content


disadvantages of specific instruments?

can't use with people that don't have disease
comparison is limited
may not detect unexpected effects


QOL can be measured with generic and specific instruments, what do each do?

Generic: can be used with nay pop, generally cover perceptions of overall health, also qns on social, emotional, physical functioning, pain, self-care
Specfic: evaluates a series of health dimensions specific to a disease, site of body or dimension


what is stigma?

a -vly defined condition, attribute, trait or behaviour conferring "deviant status"


what is discreditable stigma?

nothing seen, i.e. chronic illness not visible on exterior, but if found out.. acute awareness of patient that people would act differently towards them if they knew


examples of diseases with discreditable stigma?

mental illness


what is discredited stigma?

physically visible characteristic or well known stigma which sets them apart


examples of discredited stigma?

physical disability
known suicide attempt


why might epilepsy be considered as having both discreditable and discredited stigma?

condition may be unknown to others in daily life as no outward symptoms- discreditable, but then may undergo a seizure in a public place- epilepsy has become visible to people, patient then has discredited stigma as feel people are judging them because of what has just happened


what is enacted stigma?

real experience of prejudice, discrimination and disadvantage as consequence of condition


what is felt stigma?

fear of enacted stigma, pateint's concern about being treated differently, also encompasses a feeling of shame assoc with having condition
selective concealment


what is biological disruption?

key sociological concept which identifies chronic illness as a major disruptive experience as the pattern a patient though their life would follow is disrupted, so there is a new consciousness of the body and fragility of life, grief for a former life. Accepted more by older people


categories of work in chronic illness?

everyday life


what are illness narratives?

much sociological research based on people's narratives of their illness, which offer a way of making sense, perform certain functions and allow patient to create an understanding of their own condition


what is a narrative reconstruction?

process where shattered self is reconstructed in ways that explain illness appearance, so patient is made aware of how they can explain the illness to themselves, and have a desire to create a sense of coherence, stability and order in aftermath of biographical disruption


what is illness work?

symptom management, central to coping task is dealing with physical problems which has to occur prior to coping with social relationships, e.g. eating, bathing, interaction between body and identity, with bodily changes promoting changes in self conception


what is everyday life work?

coping and strategic management: coping- cognitive processes involved in dealing with illness
strategy- actions and processes involved in managing condition and impact
Decisions about mobilisation of resources and how to balance demands on others and remain independent, when does help need to be accepted by patient?
Must manage daily living: want to keep pre-illness lifestyle and indentity intact, so may pretend nothing is wrong, or may redesignate new life as normal life- so person may signal changes in identity rather than preserve old ones, creating a new identity


what is emotional work?

work done by patients to protect emotional well-being of others, so maintaining normal activities becomes deliberately conscious, may disrupt friendships and may strategically withdraw or restrict social terrain, may down play pain, and present as 'cheery self', making it difficult for self and family- know patient in pain and that they are trying to hide it- can't really help if patient won't admit their struggle
impact on role e.g. being head of family- breadwinner
dependency- feeling of uselessness to self and others, being a burden


what is biographical work?

loss of self, former self-image lost with difficulty constructing a new image, so constant struggle to lead valued lives and maintain +ve definitions of self, interaction between body and identity


what is identity work?

working to maintain an acceptable identity, illness can affect how people see themselves and how others see them, consequence of actual and imagined reaction of others, illness can become defining part of identity


what 4 dilemmas does loss of self give rise to?

scrutinise reactions of others for signs of discreditation
foster dependence on others
relationships harder to maintain as illness progresses, but increasing needs require more intimate contact
inability to 'do' leads to loss of social life


what is the medical model of conceptualising disability?

disability as deviation from medical norms, diasadvantages direct consequence of impairment and disabilities, needs medical intervention to cure or help, person responsible for needing to change, rather than society


what is the social model of conceptualising disability?

problems product of environment and failure of environment to adjust, disability form of social oppression, political action and social change needed, so society is wrong e.g. wheelchair users- stairs not adjusted for them


critiques of medical model for disability?

lack of recognition of social and psychological factors, stereotyping and stigmatizing language


critiques of social model for disability?

body left out
overly drawn view of society
failure to recognise body realities and extent to which these are solvable socially


what is evidence-based hcare?

hcare delivered on best available evidence, which is derived from findings of rigorously conducted research. We must do what we believe is likely to work, and our beliefs will be based on the evidence.


what is there evidence of in evidence-based hcare?

effectivenss- of drugs, practices or itnerventions, offering best tment for patient
cost-effectiveness- as finite resources, so money must be spent where can gain maximum utility.


what were practices previously influenced too much by before evidence-based practice introduced?

organsiational and social culture
historical practice and precendent
clinical fashion
professional opinion


practical criticisms of evidence-based practice

may be an impossible task to create and maintain sytsematic reviews across all specialities- need to keep up to date and include everything
may be challenging and expensive to disseminate and implement findings
RCTs seen as gold standard but not always feasible or even necessary/desirable e.g. due to ethical considerations
choice of outcomes often very biomedical- definition by pharmaceutical compaines who want to show their tment in best light, so this may limit interventions trialled, and so which are funded
required good faith on the part of the pharmaceutical companies


philosophical criticisms of evidence-based practice

does not align with (most) doctors' modes of reasoning
aggregate, pop-level outcomes don't mean that an intervention will work for an individual, not patient-centered
may create unreflective rule followers out of professionals, who just do what they're told irrespective of judgement of patient in front of them
might be understood as a means of legitimising rationing, with potential to undermine trust in dr-patient relationship, hcare expenditure cut which may not act in patient's best interest
professional responsibilty/autonomy


why are systematic reviews useful to clinicians?

offer quality control and increased certainty as appraise and integrate findings
up to date, authoritative and generalisable conclusions
save clinicians from having to locate and appraise studies for themselves
may reduce delay between research discoveries and implementation of tment in clinical practice
help prevent biased decisions
can be relatively easily converted into guidelines and recommendations


strengths of quantitative methods for social science research?

research produced is reliable and repeatable
good at describing
finding relationships between things
allowing comparisons


weaknesses of quantitative methods for social science research?

may not access all important info
may force people into inappropriate categories
don't allow people to express things in the way they want
may not be effective in establishing causality


what is quantitative research?

Quantitative research is a collection of numerical data, which begins as a hypothesis and conclusions can be drawn by deduction, about relationships between variables, sometimes causal.


when might questionnaires be used in quantitative research?

measure of exposure to RFs, effect of lifestyle and dietary factors on cancer
knowledge and attitudes e.g. sexual health
satisfaction with health services


what must a questionnaire design be?

VALID:measure what it is supposed to
RELIABLE: measure things consisitently, so differences in results come from differences between people, not from inconsistencies in how items understood or responses interpreted


Quantitative research designs?

experimental study designs-RCTs
cross-sectional surveys

secondary analysis:
official statistics- census
other national surveys e.g. by universities
local and regional surveys- e.g. by local councils


what are qualitative methods for social science research good for?

understand perspective of those in a situation
access info not revealed by quantitative approach, and people may be more willing to answer qns by talking than filling in a questionnaire
explaining relationships between variables e.g. why and how ethnicity promotes or discourages smoking cessation


what are weaknesses of qualitative methods for social science research?

finding consistent relationships between variables
generalisability- cannot infer propensity of those views from a small sample that may not be statistically representative


what does qualitative research achieve?

understand perspective
emphasises meaning, experience and views of responders
analysis emphasises researcher's interpretations, not measurement
can provide insight into people's behaviour
look at hows and whys of an association


4 research methods used in qualitative research?

observation and ethonography
focus groups


advantages of ethongraphy and observation?

can gain access to a person's behaviour, which they may provide a biased account of or be unaware of, and which may not be commented on by interviewees as they don't think it's worth it, and the context within which they occur- study human behaviour in natural context e.g. observing hospital


problems of observation?

labour intensive, can take a long period of time for research to occur
so commonly combined with formal interviews and other data sources in ethnographic studies


good points about focus groups?

can be quick method for establishing parameters, or for accessing group-based, collective understanding of an issue
may encourage people to participate


bad point about focus groups?

quieter people may not get involved
some topics may be too sensitive to discuss
not so useful for individual experience
need for good facilitator to manage group dynamics, can be difficult to arrange


what factors determine the approach and study design used in social science research methods?

topic under investigation and research qn
research team's preference/expertise
time and money
funders and/or audience


what is meant by a system's based approach of managing quality and safety in hcare?

Systems-based approaches to quality and safety suggest that when things go wrong in
complex systems such as healthcare, it is due to multiple errors occurring (the swiss
cheese model) rather than the fault of individuals. The errors committed by individuals
are the “active errors” but these are usually at the end of a long chain of other types of
errors. Latent errors are built into systems, and include such things as understaffing,
error-tolerant cultures, team conflict, poor management, etc, and these are the issues
that really demand to be tackled in a systems-based approach. Systems-based
approaches require learning from other high risk, low error industries, and having
organisational cultures that discourage latent errors, having reporting systems that
promote “no-blame” learning.


what is the social selection explanation for health inequality?

This explanation argues that the direction of causation is from health to social position,
rather than vice versa. Sick individuals move down the social hierarchy, while healthy
individuals move up. Therefore chronically ill and disabled people are more likely to be


what is the behavioural-cultural explanation for health inequality?

This explanation argues that ill health is due to people’s choices/decisions, knowledge
and goals. It would suggest that people from disadvantaged backgrounds tend to engage
in more health-damaging behaviours, while people from advantaged backgrounds tend to
engage in more health-promoting behaviours


Why might a woman with heavy menstrual bleeding not seek hcare advice based on her lay beliefs?

Some women may feel that their heavy menstrual bleeding is not interfering with their ability to carry out their normal roles or activities (functional definition of health).
They may not feel it constitutes
a medical problem and/or may not think there is anything a doctor could do to help.
It may be normalized as ‘just part of being a woman’.


Why can delay and decay make evaluating health promotion interventions difficult?

Decay and delay can cause problems in evaluating the effectiveness of health promotion
interventions. ‘Delay’ refers to when an intervention might take a long time to have an
effect, while ‘decay’ refers to when an intervention might have an initial effect but this
wears off rapidly. The timing of an evaluation can therefore influence the outcome.


What is the International Classification of Impairments, Disabilities or Handicaps (ICIDH)?

Attempts to classify consequences of disease. 3 concepts:
impairment- abnormality in structure or functioning of body
disability- performance of activities
handicap- broader social and psychological consequences of living with impairment and disability

1 state may or may not lead to another- not an inevitable progression
also no necessary relationship between severity of impairment and severity of resulting disability or handicap e.g. RA: very stiff joints, but good control, so can walk well.


problems with international classification of impairments, disabilities or handicaps?

many features of medical mode, not social of disability?
problematic use of word handicap- derogotory term
implies problems are intrinsic or inevitable


what is the international classification of functions, disability and health (ICF) ?

ICF is the WHO’s framework for measuring health and disability at both individual and population levels. It is endorsed for use as the international standard to describe and measure health and disability and attempts to integrate medical and social models., and recognise significance of wider environment.


key components of international classification of functions, disability and health?

body structures and functions, and impairments of/to
activities undertaken by individual, and difficulties in doing them
participation in life situations, which may become restricted

All, and relationships between, affected by personal and environmental contextual factors


why is optimum self-management in chronic disease difficult to achieve?

poor adhenerence rates to tment
reduced QOL
poor psychological well-being


what is the expert patient's programme?

provide courses to help patients living with LT conditions. Aims to reduce hosp admissions and is patient centered. Patients can share good coping techniques with others.
BUT responsibility for care placed on very ill patients, real agency and understanding, little evidence of efficiency savings