How professionals deal with clients' explicit objections to their advice

Previous literature on advice-resistance in medicine and welfare has tended to focus on patients' or callers' inexplicit resistance (minimal responses, silence and so on). But clients also raise explicit objections, which put up a firmer barrier against the advisor's efforts. In a novel look at resistance, we show that one important distinction among objections is their epistemic domain: whether the client's objection is in their own world (e.g. experiencing pain), or in the world of the practitioner (e.g. difficulties in making appointments). We show that the practitioner may try to manoeuvre the objection onto grounds where their own expertise will win the day, in five ways: conceding the objection's validity as a preface to moving on; proposing a 'work-around' that effectively repeats the original advice; selecting an aspect of it that could be remediated; correcting the client's understanding of the challenges of the advice; and stressing the urgency of the original course of action. We discuss the distinction between objections to solicited and unsolicited advice, and the role of objections in revealing, and affirming, a service-user's personal life-world contingencies

"It's a can of worms": understanding primary care practitioners' behaviours in relation to HPV using the Theoretical Domains Framework

Background: The relationship between infection with high-risk human papillomavirus (HPV) and cervical cancer is transforming cervical cancer prevention. HPV tests and vaccinations have recently become available. In Ireland, as elsewhere, primary care practitioners play a key role in prevention. ATHENS (A Trial of HPV Education and Support) aims to develop a theorybased intervention to support primary care practitioners in their HPV-related practice. This study, the first step in the intervention development process, aimed to: identify HPV-related clinical behaviours that the intervention will target; clarify general practitioners’ (GPs’) and practice nurses’ roles and responsibilities; and determine factors that potentially influence clinical behaviour. A secondary objective was to informally assess the utility of the Theoretical Domains Framework (TDF) in understanding clinical behaviours in an area with an evolving evidence-base. Methods: In-depth semi-structured telephone interviews were conducted with GPs and practice nurses. The topic guide, which contained open questions and HPV-related clinical scenarios, was developed through literature review and clinical experience. Interview transcripts were content-analysed using the TDF as the coding framework. Results: 19 GPs and 14 practice nurses were interviewed. The major HPV-related clinical behaviours were: initiating a discussion about HPV infection with female patients; offering/recommending HPV vaccination to appropriate patients; and answering patients’ questions about HPV testing. While the responsibility for taking smears was considered a female role, both male and female practitioners dealt with HPV-related issues. All 12 theoretical domains arose in relation to HPV infection; the domains judged to be most important were: knowledge, emotion, social influences, beliefs about capabilities and beliefs about consequences. Eleven domains emerged in relation to HPV vaccination, with beliefs about consequences, social influences, knowledge and environmental context and resources judged to be the most important. Nine domains were relevant to HPV testing, with knowledge and beliefs about capabilities judged to be the most important. Conclusions: The findings confirm the need for an intervention to support primary care practitioners around HPV and suggest it should target a range of theoretical domains. The TDF proved valuable in analysing qualitative data collected using a topic guide not specifically designed to capture TDF domains and understanding clinical behaviours in an area with an evolving evidence-base

Intervening with conversation analysis in telephone helpline services: strategies to improve effectiveness

This article overviews the way conversation analytic work on telephone helplines can make an impact in practical situations. It takes three illustrative themes in helpline research: (a) the giving, receiving, and resisting of advice; (b) the expression of strong emotion and its identification, management, and then coordination with helpline goals; and (c) how helplines' policies and practices shape the interactions between caller and call taker. For each of these themes, we show how conversation analysis research insights have been applied to improve helpline effectiveness. This has been done through a variety of practice-based reports, consultancy exercises, and training initiatives, including workshops where we aim to identify and facilitate good practice. Intervention studies of this type are at the forefront of interactional research on telephone helplines. Data are in Australian and British English

A fish stinks from the head: Ethnic diversity, segregation, and the collapse of Yugoslavia

Demographic analysis clarifies political issues in the collapse of Yugoslavia. In most regions, 1961-1991, ethnic diversity (estimated by informational entropy) increased and segregation (estimated by Theil’s H) decreased. In a few regions there was a reversal in 1991 as migration flows or presentations of self perhaps changed in anticipation of war. The analysis strengthens refutations of the view that long standing ethnic hatreds were the root cause of the Yugoslav collapse and supports analyses that attribute collapse to general economic crisis, economic competition between regions, and failures at the peak of government.collapse of Yugoslavia, diversity, ethnic politics, ethnicity, segregation, Yugoslavia

Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial

Background: Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services. Methods/Design: Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial. Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders. The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically. Discussion: Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services. In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen