Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland

Objectives: To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change. Design: Qualitative focus group study consisting of 11 focus groups with 67 participants. Setting: General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland. Sample: Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes. Results: General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They seemed to develop various operational strategies for its implementation. There appeared to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes. Conclusions: Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system, before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered

Targeting outcomes redux

"...There are sharply divergent views as to how much narrowly targeted interventions actually benefit the poor. These result from differing assessments of three issues: whether better targeting outcomes are likely to be achieved, whether such methods are cost-effective, and whether the living standards of the poor are improved by such targeted interventions. This paper focuses on the first issue. Using a newly constructed database of targeted interventions, it addresses three questions: (1) What targeting outcomes are observed? (2) Are there systematic differences in targeting performance by targeting methods and other factors? (3) What are the implications for such systematic differences for the design and implementation of targeted interventions?" from Authors' Abstract.Developing countries ,Poverty ,

Targeting outcomes redux

"...There are sharply divergent views as to how much narrowly targeted interventions actually benefit the poor. These result from differing assessments of three issues: whether better targeting outcomes are likely to be achieved, whether such methods are cost-effective, and whether the living standards of the poor are improved by such targeted interventions. This paper focuses on the first issue. Using a newly constructed database of targeted interventions, it addresses three questions: (1) What targeting outcomes are observed? (2) Are there systematic differences in targeting performance by targeting methods and other factors? (3) What are the implications for such systematic differences for the design and implementation of targeted interventions?" from Authors' Abstract.Developing countries ,Poverty ,

Incentives for breastfeeding and for smoking cessation in pregnancy: An exploration of types and meanings

Financial or tangible incentives are a strategy for improving health behaviours. The mechanisms of action of incentives are complex and debated. Using a multidisciplinary integrated mixed methods study, with service-user collaboration throughout, we developed a typology of incentives and their meanings for initiating and sustaining smoking cessation in pregnancy and breastfeeding. The ultimate aim was to inform incentive intervention design by providing insights into incentive acceptability and mechanisms of action. Systematic evidence syntheses of incentive intervention studies for smoking cessation in pregnancy or breastfeeding identified incentive characteristics, which were developed into initial categories. Little published qualitative data on user perspectives and acceptability was available. Qualitative interviews and focus groups conducted in three UK regions with a diverse socio-demographic sample of 88 women and significant others from the target population, 53 service providers, 24 experts/decision makers, and conference attendees identified new potential incentives and providers, with and without experience of incentives. Identified incentives (published and emergent) were classified into eight categories: cash and shopping vouchers, maternal wellbeing, baby and pregnancy-related, behaviour-related, health-related, general utility, awards and certificates, and experiences. A typology was refined iteratively through concurrent data collection and thematic analysis to explore participants' understandings of ‘incentives’ and to compare and contrast meanings across types. Our typology can be understood in three dimensions: the degree of restriction, the extent to which each is hedonic and/or utilitarian, and whether each has solely monetary value versus monetary with added social value. The layers of autonomy, meanings and the social value of incentive types influence their acceptability and interact with structural, social, and personal factors. Dimensions of incentive meaning that go beyond the simple incentive description should inform incentive programme design and are likely to influence outcomes

Group interventions to improve health outcomes : a framework for their design and delivery

Peer reviewedPublisher PD

Public acceptability of financial incentives for smoking cessation in pregnancy and breastfeeding

Objective To survey public attitudes about incentives for smoking cessation in pregnancy and for breast feeding to inform trial design. Design Cross-sectional survey. Setting and participants British general public. Methods Seven promising incentive strategies had been identified from evidence syntheses and qualitative interview data from service users and providers. These were shopping vouchers for: (1) validated smoking cessation in pregnancy and (2) after birth; (3) for a smoke-free home; (4) for proven breast feeding; (5) a free breast pump; (6) payments to health services for reaching smoking cessation in pregnancy targets and (7) breastfeeding targets. Ipsos MORI used area quota sampling and home-administered computer-assisted questionnaires, with randomised question order to assess agreement with different incentives (measured on a five-point scale). Demographic data and target behaviour experience were recorded. Analysis used multivariable ordered logit models. Results Agreement with incentives was mixed (ranging from 34% to 46%) among a representative sample of 1144 British adults. Mean agreement score was highest for a free breast pump, and lowest for incentives for smoking abstinence after birth. More women disagreed with shopping vouchers than men. Those with lower levels of education disagreed more with smoking cessation incentives and a breast pump. Those aged 44 or under agreed more with all incentive strategies compared with those aged 65 and over, particularly provider targets for smoking cessation. Non-white ethnic groups agreed particularly with breastfeeding incentives. Current smokers with previous stop attempts and respondents who had breast fed children agreed with providing vouchers for the respective behaviours. Up to £40/month vouchers for behaviour change were acceptable (>85%). Conclusions Women and the less educated were more likely to disagree, but men and women of childbearing age to agree, with incentives designed for their benefit. Trials evaluating reach, impact on health inequalities and ethnic groups are required prior to implementing incentive interventions

Perspectives on financial incentives to health service providers for increasing breast feeding and smoking quit rates during pregnancy: a mixed methods study

Objective: To explore the acceptability, mechanisms and consequences of provider incentives for smoking cessation and breast feeding as part of the Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS) study. Design: Cross-sectional survey and qualitative interviews. Setting: Scotland and North West England. Participants: Early years professionals: 497 survey respondents included 156 doctors; 197 health visitors/maternity staff; 144 other health staff. Qualitative interviews or focus groups were conducted with 68 pregnant/postnatal women/family members; 32 service providers; 22 experts/decision-makers; 63 conference attendees. Methods: Early years professionals were surveyed via email about the acceptability of payments to local health services for reaching smoking cessation in pregnancy and breastfeeding targets. Agreement was measured on a 5-point scale using multivariable ordered logit models. A framework approach was used to analyse free-text survey responses and qualitative data. Results: Health professional net agreement for provider incentives for smoking cessation targets was 52.9% (263/497); net disagreement was 28.6% (142/497). Health visitors/maternity staff were more likely than doctors to agree: OR 2.35 (95% CI 1.51 to 3.64; p<0.001). Net agreement for provider incentives for breastfeeding targets was 44.1% (219/497) and net disagreement was 38.6% (192/497). Agreement was more likely for women (compared with men): OR 1.81 (1.09 to 3.00; p=0.023) and health visitors/maternity staff (compared with doctors): OR 2.54 (95% CI 1.65 to 3.91; p<0.001). Key emergent themes were 'moral tensions around acceptability', 'need for incentives', 'goals', 'collective or divisive action' and 'monitoring and proof'. While provider incentives can focus action and resources, tensions around the impact on relationships raised concerns. Pressure, burden of proof, gaming, box-ticking bureaucracies and health inequalities were counterbalances to potential benefits. Conclusions: Provider incentives are favoured by non-medical staff. Solutions which increase trust and collaboration towards shared goals, without negatively impacting on relationships or increasing bureaucracy are required

Unintended Consequences of Incentive Provision for Behaviour Change and Maintenance around Childbirth

Financial (positive or negative) and non-financial incentives or rewards are increasingly used in attempts to influence health behaviours. While unintended consequences of incentive provision are discussed in the literature, evidence syntheses did not identify any primary research with the aim of investigating unintended consequences of incentive interventions for lifestyle behaviour change. Our objective was to investigate perceived positive and negative unintended consequences of incentive provision for a shortlist of seven promising incentive strategies for smoking cessation in pregnancy and breastfeeding. A multi-disciplinary, mixed-methods approach included involving two service-user mother and baby groups from disadvantaged areas with experience of the target behaviours as study co-investigators. Systematic reviews informed the shortlist of incentive strategies. Qualitative semi-structured interviews and a web-based survey of health professionals asked open questions on positive and negative consequences of incentives. The participants from three UK regions were a diverse sample with and without direct experience of incentive interventions: 88 pregnant women/recent mothers/partners/family members; 53 service providers; 24 experts/decision makers and interactive discussions with 63 conference attendees. Maternity and early years health professionals (n = 497) including doctors, midwives, health visitors, public health and related staff participated in the survey. Qualitative analysis identified ethical, political, cultural, social and psychological implications of incentive delivery at population and individual levels. Four key themes emerged: how incentives can address or create inequalities; enhance or diminish intrinsic motivation and wellbeing; have a positive or negative effect on relationships with others within personal networks or health providers; and can impact on health systems and resources by raising awareness and directing service delivery, but may be detrimental to other health care areas. Financial incentives are controversial and generated emotive and oppositional responses. The planning, design and delivery of future incentive interventions should evaluate unexpected consequences to inform the evidence for effectiveness, cost-effectiveness and future implementation

Tackling Male Obesity: the ROMEO (Review Of MEn Obesity) study

Background: Male obesity is particularly problematic in that men are less likely than women to realise they have a weight problem and are also less likely to engage in weight reduction programmes. Little is known about the most effective ways to engage obese men with obesity services in order to manage weight loss successfully. Aim: Funded by the National Institute of Health Research Health Technology Assessment Programme, theROMEO (Review Of MEn and Obesity) project is an on-going integrated series of five quantitative and qualitative systematic reviews of the evidence associated with management strategies for treating obesity in men, and how to engage men in these obesity services Methods: Studies included in the review are men 16 years or over, with no upper age limit. Ideally all groups of participants in studies must have a mean or median BMI of 30kg/m2. However, in most qualitative papers, BMI is not clearly stated. We are aiming to find out not only ‘what works’ for men in terms of weight management, but also ‘for which men, and under what circumstances’. Our pragmatic approach to this mixed methods evidence synthesis is informed by methods such as realist synthesis, thematic synthesis, framework synthesis, and analytical approaches developed from methods of inquiry such as grounded theory. Findings: We will present initial findings from the qualitative arm of the project. Conclusions: Our work will identify the existing evidence with which to develop guidance for the NHS onthe subject of men and obesity management. The individual reviews and integrated report will also provide guidance on whether further research is needed to develop better methods for engaging and retaining men in obesity interventions