BMJ Open

Jolly, Kate; Ingram, Jenny; Clarke, Joanne; Johnson, Debbie; Trickey, Heather; Thomson, Gill; Dombrowski, Stephan U; Sitch, Alice; Dykes, Fiona; Feltham, Max G; Darwent, Kirsty; MacArthur, Christine; Roberts, Tracy; Hoddinott, Pat

doi: 10.1136/bmjopen-2017-019142pmid: 29362263

IntroductionBreast feeding improves the health of mothers and infants; the UK has low rates, with marked socioeconomic inequalities. While trials of peer support services have been effective in some settings, UK trials have not improved breast feeding rates. Qualitative research suggests that many women are alienated by the focus on breast feeding. We propose a change from breast feeding-focused interactions to respecting a woman’s feeding choices, inclusion of behaviour change theory and an increased intensity of contacts in the 2 weeks after birth when many women cease to breast feed. This will take place alongside an assets-based approach that focuses on the positive capability of individuals, their social networks and communities.We propose a feasibility study for a multicentre randomised controlled trial of the Assets feeding help Before and After birth (ABA) infant feeding service versus usual care.Methods and analysisA two-arm, non-blinded randomised feasibility study will be conducted in two UK localities. Women expecting their first baby will be eligible, regardless of feeding intention. The ABA infant feeding intervention will apply a proactive, assets-based, woman-centred, non-judgemental approach, delivered antenatally and postnatally tailored through face-to-face contacts, telephone and SMS texts. Outcomes will test the feasibility of delivering the intervention with recommended intensity and duration to disadvantaged women; acceptability to women, feeding helpers and professionals; and feasibility of a future randomised controlled trial (RCT), detailing recruitment rates, willingness to be randomised, follow-up rates at 3 days, 8 weeks and 6 months, and level of outcome completion. Outcomes of the proposed full trial will also be collected. Mixed methods will include qualitative interviews with women/partners, feeding helpers and health service staff; feeding helper logs; and review of audio-recorded helper–women interactions to assess intervention fidelity.Ethics and disseminationStudy results will inform the design of a larger multicentre RCT. The National Research Ethics Service Committee approved the study protocol.Trial registration number ISRCTN14760978; Pre-results.

Chow, Clara K; Thiagalingam, Aravinda; Santo, Karla; Kok, Cindy; Thakkar, Jay; Stepien, Sandrine; Billot, Laurent; Jan, Stephen; Joshi, Rohina; Hillis, Graham S; Brieger, David; Chew, Derek P; Rådholm, Karin; Atherton, John J; Bhindi, Ravinay; Collins, Nicholas; Coverdale, Steven; Hamilton-Craig, Christian; Kangaharan, Nadarajah;

King, Carina; Boyd, Nicholas; Walker, Isabeau; Zadutsa, Beatiwel; Baqui, Abdullah H; Ahmed, Salahuddin; Islam, Mazharul; Kainja, Esther; Nambiar, Bejoy; Wilson, Iain; McCollum, Eric D

doi: 10.1136/bmjopen-2017-019177pmid: 29382679

ObjectiveTo gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries.DesignFocus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach.SettingCommunity, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care.ParticipantsHealthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors.ResultsWe conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability.ConclusionsPulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations.Trial registration numberNCT02941237.

Sansom, Anna; Terry, Rohini; Fletcher, Emily; Salisbury, Chris; Long, Linda; Richards, Suzanne H; Aylward, Alex; Welsman, Jo; Sims, Laura; Campbell, John L; Dean, Sarah G

doi: 10.1136/bmjopen-2017-019849pmid: 29326195

ObjectiveTo identify factors influencing general practitioners' (GPs’) decisions about whether or not to remain in direct patient care in general practice and what might help to retain them in that role.DesignQualitative, in-depth, individual interviews exploring factors related to GPs leaving, remaining in and returning to direct patient care.SettingSouth West England, UK.Participants41 GPs: 7 retired; 8 intending to take early retirement; 11 who were on or intending to take a career break; 9 aged under 50 years who had left or were intending to leave direct patient care and 6 who were not intending to leave or to take a career break. Plus 19 stakeholders from a range of primary care-related professional organisations and roles.ResultsReasons for leaving direct patient care were complex and based on a range of job-related and individual factors. Three key themes underpinned the interviewed GPs’ thinking and rationale: issues relating to their personal and professional identity and the perceived value of general practice-based care within the healthcare system; concerns regarding fear and risk, for example, in respect of medical litigation and managing administrative challenges within the context of increasingly complex care pathways and environments; and issues around choice and volition in respect of personal social, financial, domestic and professional considerations. These themes provide increased understanding of the lived experiences of working in today’s National Health Service for this group of GPs.ConclusionFuture policies and strategies aimed at retaining GPs in direct patient care should clarify the role and expectations of general practice and align with GPs’ perception of their own roles and identity; demonstrate to GPs that they are valued and listened to in planning delivery of the UK healthcare; target GPs’ concerns regarding fear and risk, seeking to reduce these to manageable levels and give GPs viable options to support them to remain in direct patient care.

Kastor, Anshul; Mohanty, Sanjay K

doi: 10.1136/bmjopen-2017-016990pmid: 29371266

ObjectivesThe prime objective of this study is to examine the trends of disease and age pattern of hospitalisation and associated costs in India during 1995–2014.DesignPresent study used nationally representative data on morbidity and healthcare from the 52nd (1995) and 71st (2014) rounds of the National Sample Survey.SettingsA total of 120 942 and 65 932 households were surveyed in 1995 and 2014, respectively.MeasuresDescriptive statistics, logistic regression analyses and decomposition analyses were used in examining the changes in patterns of hospitalisation and associated costs. Hospitalisation rates and costs per hospitalisation (out-of-pocket expenditure) were estimated for selected diseases and in four broad categories: communicable diseases, non-communicable diseases (NCDs), injuries and others. All the costs are presented at 2014 prices in US$.ResultsHospitalisation rate in India has increased from 1661 in 1995 to 3699 in 2014 (per 100 000 population). It has more than doubled across all age groups. Hospitalisation among children was primarily because of communicable diseases, while NCDs were the leading cause of hospitalisation for the 40+ population. Costs per hospitalisation have increased from US$177 in 1995 to US$316 in 2014 (an increase of 79%). Costs per hospitalisation for NCDs in 2014 were US$471 compared with US$175 for communicable diseases. It was highest for cancer inpatients (US$942) followed by heart diseases (US$674). Age is the significant predictor of hospitalisation for all the selected diseases. Decomposition results showed that about three-fifth of the increase in unconditional costs per hospitalisation was due to increase in mean hospital costs, and the other two-fifth was due to increase in hospitalisation rates.ConclusionThere has been more than twofold increase in hospitalisation rates in India during the last two decades, and significantly higher rates were observed among infants and older adults. Increasing hospitalisation rates and costs per hospitalisation are contributing substantially to the rising healthcare costs in India.

doi: 10.1136/bmjopen-2017-016526corr1pmid: 29382684

Seijmonsbergen-Schermers, Anna; de Jonge, Ank; van den Akker, Thomas; Beeckman, Katrien; Bogaerts, Annick; Barros, Monalisa; Janssen, Patricia; Binfa, Lorena; Rydahl, Eva; Frith, Lucy; Gross, Mechthild; Hálfdánsdóttir, Berglind; Daly, Deirdre; Calleja-Agius, Jean; Gillen, Patricia; Vika Nilsen, Anne Britt; Declercq, Eugene

Maybury, Charlotte; Morgan, Matthew David; Smith, Russell; Harper, Lorraine

doi: 10.1136/bmjopen-2017-019630pmid: 29362273

ObjectivesThis study aimed to investigate the impact of research training funded via the National Health Service (NHS) on medical trainees compared with traditional clinical research training fellowships (CRTFs).Design, setting and participantsOnline survey of 221 clinical trainees who had completed a period of research during their clinical training between 2009 and 2015 in the West Midlands.Main outcome measuresResearch outcomes.ResultsOverall response rate was 59%, of whom 72 participants were funded by CRTFs and 51 funded by the NHS. Although participants with CRTFs were more likely to be awarded a higher degree compared with those on NHS-administered funding (66/72 CRTFs and 37/51 NHS, P=0.005), similar proportions of NHS-funded and CRTF-funded participants entered clinical lecturer posts on completing initial research training (8/51 NHS and 16/72 CRTF, P=0.37). 77% of participants had three or more publications (CRTF 57 and NHS 39, P=0.72). 57 participants had completed clinical training; similar proportions of CRTF-funded and NHS-funded trainees had research included in their consultant contract (12/22 NHS and 14/26 CRTF, P=0.96) or were appointed to academic posts (3 of 25 NHS funded and 6 of 32 CRTF, P>0.05). 95% of participants would recommend to colleagues and 82% of participants felt the research experience improved their provision of clinical care with no difference between CRTF-funded and NHS-funded participants (P=0.49). Continuing to participate in clinical work during the research reduced reports of trainee difficulty on returning to clinical work (23/108 continued clinical work vs 12/22 no clinical work, P=0.001).ConclusionResearch training funded by the NHS provides a quality experience and contributes to the clinical academic capacity within the UK. More needs to be done to support NHS participants to successfully achieve a higher degree.

Yepes-Nuñez, Juan José; Morgan, Rebecca L; Mbuagbaw, Lawrence; Carrasco-Labra, Alonso; Chang, Stephanie; Hempel, Susanne; Shekelle, Paul; Helfand, Mark; Baldeh, Tejan; Schünemann, Holger J

doi: 10.1136/bmjopen-2016-015623pmid: 29362242

ObjectiveSummary of findings (SoF) tables present results of systematic reviews in a concise and explicit format. Adopted by many review groups including the Cochrane Collaboration and the Agency for Healthcare Research and Quality (AHRQ), optimal understanding of SoF table may be influenced by the type of information being conveyed and objectives or preferences of the end user. This study aims to compare three SoF table formats in terms of understanding, accessibility, satisfaction and preference with systematic review users.MethodsThe primary objective of this three-arm randomised controlled non-inferiority trial is to investigate whether an alternative Grading of Recommendations Assessment, Development and Evaluation (GRADE) SoF table or Evidence-based Practice Center SoF table is non-inferior to the current GRADE SoF table in the understanding of the information presented to systematic review users, particularly for descriptive findings. Researchers, clinical practice guideline developers, policy-makers or knowledge transfer professionals will be recruited. Data will be collected electronically at baseline and after randomisation. Non-inferiority would be declared if the difference in the proportion of participants who understand the information displayed in the alternative SoF table is 10% or less.Ethics and disseminationThe Hamilton Integrated Research Ethics Board reviewed this protocol. The findings from this study will be disseminated through a publication in a peer-reviewed journal.Trial registration numberNCT02813941.

Buell, Danielle; Hemmelgarn, Brenda R; Straus, Sharon E

doi: 10.1136/bmjopen-2017-019796pmid: 29352021

ObjectiveTo assess the proportion of women who presented research or medical grand rounds at five major academic hospitals in Canada.DesignA cross-sectional study.SettingFive major university-affiliated hospitals in Toronto and Calgary.ResultsOverall, at all sites and types of academic rounds, there were an average of 17% fewer women presenting than men (P<0.001). There were an average of 32% and 21% more men presenting at the city-wide grand rounds in cities A and B, respectively (P<0.001, P=0.002). There were more male speakers at four out of five types of rounds. The proportion of women presenting on average was proportional to the Canadian workforce, but on average, below the proportion of female residents and medical students (median ratio 1.1, 0.7 and 0.8, respectively).ConclusionOur study demonstrated a lower proportion of females in an important outlet for academic recognition and role modelling. This provides a possible contributing factor to the under-representation of women in academic medicine and an area that can be systematically targeted to promote equity.