Implementing guidelines and training initiatives to improve cross-cultural communication in primary care consultations: a qualitative participatory European study

Patient influence on general practice service improvement decision making: a participatory research mixed-methods intervention study

BACKGROUND

Health policy promotes patient participation in decision making about service organisation. In English general practice this happens through contractually required patient participation groups (PPGs). However, there are problems with the enactment of PPGs that have not been systematically addressed.

AIM

To observe how a co-designed theory-informed intervention can increase representational legitimacy and facilitate power sharing to support PPGs to influence decision making about general practice service improvement.

DESIGN AND SETTING

Participatory action research to implement the intervention in two general practices in the North of England was undertaken. The intervention combined two different participatory practices: partnership working involving externally facilitated meetings with PPG members and staff; and consultation with the wider patient population using a bespoke discrete choice experiment (DCE).

METHOD

To illustrate decision making in PPGs, qualitative data are presented from participant observation notes and photographed visual data generated through participatory methods. The DCE results are summarised to illustrate how wider population priorities contributed to overall decision making. Observational data were thematically analysed using normalisation process theory with support from a multi-stakeholder co-research group.

RESULTS

In both general practices, patients influenced decision making during PPG meetings and through the DCE, resulting in bespoke patient-centred action plans for service improvement. Power asymmetries were addressed through participatory methods, clarification of PPG roles in decision making, and addressing representational legitimacy through wider survey consultation.

CONCLUSION

Combining participatory practices and facilitated participatory methods enabled patients to influence decision making about general practice service improvement. The policy of mandatory PPGs needs updating to recognise the need to resource participation in a meaningful way.

Russian nurses' readiness for transcultural care of palliative patients

Palliative care involves an approach aimed at improving the quality of life of patients and their families, who are forced to cope with the problems associated with life-threatening diseases. This definition includes a growing group of patients around the world. It requires an extension of the definition of patients in need of palliative care in countries such as Russia and a significant improvement in the work of nursing personnel with these patients. This study aims to determine the level of preparedness of nursing personnel for specialized care (transcultural care) and the quality of care provided to palliative patients. The presented findings of the study demonstrate the relevance of developing transcultural competence, which enables significant improvement in the quality of life of palliative patients. The analysis of medical workers' assessment of the level of specific training and their intercultural preparedness was conducted based on hospices (Moscow). A survey was conducted among 113 medical workers of the middle level of education aged between 28 and 56 (average of 44.2 years) and experience in palliative care ranged from 3 to 18 years (average of 9.5 years). The Intercultural Readiness Check (IRC) test, widely used to assess nursing staff worldwide, was used for the survey to determine the level of readiness for transcultural care. A strong correlation was found between a number of the test scales and measures of participants' age and experience. The presented material demonstrates the realization of an interdisciplinary approach to the issues of specific training of nursing personnel in the field of "transcultural care" in providing palliative care to incurable patients.

Perimenopause and/or menopause help-seeking among women from ethnic minorities: a qualitative study of primary care practitioners' experiences

BACKGROUND

Each woman's experience of the perimenopause and/or menopause is individual and unique. Research shows women from ethnic minorities often have different experiences from their White peers, and these are not being considered in conversations about the menopause. Women from ethnic minorities already face barriers to help-seeking in primary care, and clinicians have expressed challenges in cross cultural communication including the risk that women from ethnic minorities' perimenopause and/or menopause health needs are not being met.

AIM

To explore primary care practitioners' experiences of perimenopause and/or menopause help-seeking among women from ethnic minorities.

DESIGN AND SETTING

A qualitative study of 46 primary care practitioners from 35 practices across 5 regions of England, with patient and public involvement (PPI) consultations with 14 women from three ethnic minority groups.

METHOD

Primary care practitioners were surveyed using an exploratory approach. Online and telephone interviews were conducted and the data were analysed thematically. The findings were presented to three groups of women from ethnic minorities to inform interpretation of the data.

RESULTS

Practitioners described a lack of awareness of perimenopause and/or menopause among many women from ethnic minorities, which they felt impacted their help-seeking and communication of symptoms. Cultural expressions of embodied experiences could offer challenges to practitioners to 'join the dots' and interpret experiences through a holistic menopause care lens. Feedback from the women from ethnic minorities provided context to practitioner findings through examples from their individual experiences.

CONCLUSION

There is a need for increased awareness and trustworthy information resources to help women from ethnic minorities prepare for the menopause, and clinicians to recognise their experiences and offer support. This could improve women's immediate quality of life and potentially reduce future disease risk.

Applying Structural Equation Modelling to Understand the Implementation of Social Distancing in the Professional Lives of Healthcare Workers

This study, based on the normalization process theory (NPT), explores the implementation of nonpharmaceutical interventions (NPIs)-specifically social distancing (SD)-in the professional lives of healthcare workers in three Pakistani hospitals. We collected and analysed health workers' data using partial least squares structural equation modelling (PLS-SEM) and assessed the policy implications of the results. Violations of normality assumptions in the quantitative data and the need for scores of independent variables for follow-up analysis guided the researchers to adopt a structural equation modelling process that involved a stepwise evaluation process for convergent validity, individual item validity, discriminant validity, the structural model relationship, and overall model fitness. Theoretical constructs coherence, cognitive participation, collective action, and reflexive monitoring were found to influence the normalization of SD. The results show that SD was normalized in the professional lives of healthcare workers through strong collective action (resources required) and reflexive monitoring (appraisal) but weak cognitive participation (actors' engagement) and coherence (sense-making). Low and middle-income countries (LMICs) should work more on actors' sense-making and engagement in dealing with healthcare crises that require SD. The research findings can aid policy institutions in better understanding the loopholes in the implementation process and making better policies.

Higher chronic stress and less satisfaction with GP communication in migrants with unemployment experience: data from the representative German DEGS1 and the GPCare-1 study

Background

The impact of unemployment on health is well studied. However, information on associations of unemployment, migration background and general practitioner-patient communication is scarce.

Methods

Data from the representative German Health Interview and Examination Survey for Adults (DEGS1) of individuals in working age (n = 5938) were analysed stratified by unemployment and migration background. Using official weighting factors, the prevalence of chronic stress, having ≥1 chronic disease, having a GP and GP visits in the last 12 months was determined. Multivariate regression models were analysed for associations between unemployment, migration background, and other socio-demographic characteristics with GP visits and chronic stress. Data from the General Practice Care-1 (GPCare-1) study (n = 813 patients) were analysed for differences in patient-physician communication between unemployed with and without migration background. Reverse proportional odds models were estimated for associations of unemployment and migration background with physician-patient communication.

Results

In the DEGS1, 21.5% had experienced unemployment (n = 1170). Of these, 31.6% had a migration background (n = 248). Compared to unemployed natives, unemployed with migration background had higher chronic stress (mean: 14.32 vs. 13.13, p = 0.02), while the prevalence of chronic disease was lower (21.7% vs. 30.2%, p = 0.03). They were less likely to have a GP (83.6% vs. 90%, p = 0.02), while GP visits were similar (mean: 3.7 vs. 3.3, p = 0.26). Migration background and unemployment experience were not associated with GP visits, while both factors were significantly associated with higher chronic stress (both: p < 0.01). In GPCare-1, 28.8% had ever experienced unemployment (n = 215). Of these, 60 had a migration background (28.6%). The unemployed with migration background reported less frequently that the GP gives them enough space to describe personal strains (46.5% vs. 58.2%; p = 0.03), and that their problems are taken very seriously by their GP (50.8% vs. 73.8%; p = 0.04). In multivariate analyses, migration background showed a lower probability of having enough space to describe personal strains and feeling that problems were taken very seriously.

Conclusion

Unemployment experience and migration background were associated with higher chronic stress. Only migration background was associated with less satisfaction regarding physician-patient communication.

Beyond challenges and enrichment: a qualitative account of cross-cultural experiences of nursing patients with an ethnic minority background in Norway

BACKGROUND

Substantial mass migrations to the Scandinavian countries have made them heterogeneous and multicultural societies. Migration has also influenced the workforce, especially the healthcare system that has had to accommodate a culturally diverse population. This qualitative study aimed to explore nurses' experiences in caring for patients with an ethnic minority background.

METHODS

Focus group interviews with a total of 21 nurses were conducted. Thematic analysis was performed on the transcribed and translated interviews.

RESULTS

The findings of this study revealed three major themes: various experiences concerning language barriers and the use of interpreters, the impact of religious and cultural values, and caring for patients with an ethnic minority background is professionally interesting but demanding.

CONCLUSIONS

Caring for culturally diverse patients offers both challenges and opportunities to enhance cultural competence and cultural sensitivity among nurses. Various culturally divergent needs of patients such as family visits, food preferences, expression of pain, and gender sensitivity are interlinked and depend on effective communication during encounters with nurses and the healthcare system at large.

An integrative review of the implementation of public health guidelines

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The evidence on public health guidelines implementation is scarce.

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Most implementation of public health guidelines centres on individuals’ behaviour.

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Most evaluations of public health guidelines focus on barriers to implementation.

Health guidelines are important tools to ensure that health practices are evidence-based. However, research on how these guidelines are implemented is scarce. This integrative review aimed to: identify the literature on evaluation of public health guidelines implementation to explore (a) the topics which public health guidelines being implemented and evaluated in their implementation process are targeting; (b) how public health guidelines are being translated into action and the potential barriers and facilitators to their implementation; and (c) which methods are being used to evaluate their implementation. A total of 2001 articles published since 2000 and related to both clinical and public health guidelines implementation was identified through searching four databases (PubMed, CINAHL, Web of Science, Scopus). After screening titles and abstracts, only 10 papers related to public health guidelines implementation, and after accessing full-text, 8 were included in the narrative synthesis. Data were extracted on: topic and context, implementation process, barriers and facilitators, and evaluation methods used, and were then synthesised in a narrative form using a thematic synthesis approach. Most of these studies focussed on individual behaviours and targeted specific settings. The evaluation of implementation processes included qualitative, quantitative and mixed-methods. The few articles retrieved suggest that evidence is still limited and highly context specific, and further research on translating public health guidelines into practice is needed.

Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches

Background

It has been widely acknowledged that refugees are at risk of poorer health outcomes, spanning mental health and general well‐being. A common point of access to health care for the migrant population is via the primary health care network in the country of resettlement. This review aims to synthesize the evidence of primary health care interventions to improve the quality of health care provided to refugees and asylum seekers.

Methods

A systematic review was undertaken, and 55 articles were included in the final review. The Preferred Reporting Items for Systematic Reviews was used to guide the reporting of the review, and articles were managed using a reference‐management software (Covidence). The findings were analysed using a narrative empirical synthesis. A quality assessment was conducted for all the studies included.

Results

The interventions within the broad primary care setting could be organized into four categories, that is, those that focused on developing the skills of individual refugees/asylum seekers and their families; skills of primary health care workers; system and/or service integration models and structures; and lastly, interventions enhancing communication services. Promoting effective health care delivery for refugees, asylum seekers and their families is a complex challenge faced by primary care professionals, the patients themselves and the communication between them.

Conclusion

This review highlights the innovative interventions in primary care promoting refugee health. Primary care interventions mostly focused on upskilling doctors, with a paucity of research exploring the involvement of other health care members. Further research can explore the involvement of interprofessional team members in providing effective refugee/migrant health.

Patient or Public Contribution

Patient and public involvement was explored in terms of interventions designed to improve health care delivery for the humanitarian migrant population, that is, specifically refugees and asylum seekers.

Perception and Experience of Transcultural Care of Stakeholders and Health Service Users with a Migrant Background: A Qualitative Study

INTRODUCTION

While European health policies do frequently take into consideration the ideas and experiences of their users, the voices of minority and marginalized communities are not often heard. European healthcare services must address this issue as the number of healthcare users with an MM background increases.

AIM

To explore the perspectives of key stakeholders and healthcare users with an MM background on transcultural care in four European countries.

DESIGN

Qualitative phenomenological study.

METHODS

Semi-structured, individual interviews were conducted with stakeholders and MM users. Interviews were translated and transcribed verbatim and were carried out from February to May 2021. Descriptive statistics was used to describe the characteristics of the sample; qualitative data were analyzed thematically following Braun and Clarke's phases, resulting in 6 themes and 18 subthemes.

RESULTS

For stakeholders and MM users with long-established residence in their respective countries, cultural differences involve different family and community norms, religious beliefs, lifestyles, and habits. These components are perceived as in tension with healthcare norms and values, and they mediate in two key and related aspects of the relationship between MM users and healthcare providers: accessibility and communication.

CONCLUSIONS

Communication and access to healthcare are key to MM health service users, and they are the most frequent sources of misunderstanding and conflict between them and healthcare professionals.

IMPACT

It is important to extend the investigation of cultural issues in healthcare to stakeholders and MM users. There is no doubt that healthcare professionals should be trained in cultural competence; however, cultural competence training is not the only area for improvement. There should be a change in paradigm in healthcare services across Europe: from individual to organizational integration of culture and diversity.

Appraisal of a Contact Tracing Training Program for COVID-19 in Greece Focusing on Vulnerable Populations

BACKGROUND

Contact tracing as an epidemiological strategy has repeatedly contributed to the containment of various past epidemics and succeeded in controlling the spread of disease in the community. Systematic training of contact tracers is crucial in ensuring the effectiveness of epidemic containment.

METHODS

An intensive training course was offered to 216 health and other professionals who work with vulnerable population groups, such as Roma, refugees, and migrants in Greece, by the scientific team of the postgraduate programme "Global Health-Disaster Medicine" of the Medical School, National and Kapodistrian University of Athens, with the support of the Swiss embassy in Greece. The course was delivered online due to the pandemic restriction measures and was comprised of 16 h over 2 days. The course curriculum was adapted in Greek using, upon agreement, a similar training course to what was developed by the Johns Hopkins University Bloomberg School of Public Health. Evaluation of the course was conducted in order to determine the short term satisfaction from participating in this training course.

RESULTS

A total of 70% of the course participants completed the evaluation questionnaires and all trainers gave feedback on the course. The training modules were ranked as extremely useful by the majority of the participants and over 50% of the participants specifically stated that the course content was directly related to their work with vulnerable groups. Content about the ethics of contact tracing and the effective communication skills presented were deemed most useful.

CONCLUSION

The course was well organised and provided the required skills for effective contact tracing. Many course participants intend to use some components in their work with vulnerable populations groups. Contact tracing efforts work best in a systematic and coordinated way and the provision of systematic and organised training can greatly increase its effectiveness.

Participatory co-design and normalisation process theory with staff and patients to implement digital ways of working into routine care: the example of electronic patient-reported outcomes in UK renal services

BACKGROUND

Successful implementation of digital health systems requires contextually sensitive solutions. Working directly with system users and drawing on implementation science frameworks are both recommended. We sought to combine Normalisation Process Theory (NPT) with participatory co-design methods, to work with healthcare stakeholders to generate implementation support recommendations for a new electronic patient reported outcome measure (ePRO) in renal services. ePROs collect data on patient-reported symptom burden and illness experience overtime, requiring sustained engagement and integration into existing systems.

METHODS

We identified co-design methods that could be mapped to NPT constructs to generate relevant qualitative data. Patients and staff from three renal units in England participated in empathy and process mapping activities to understand 'coherence' (why the ePRO should be completed) and 'cognitive participation' (who would be involved in collecting the ePRO). Observation of routine unit activity was completed to understand 'collective action' (how the collection of ePRO could integrate with service routines).

RESULTS

The mapping activities and observation enabled the research team to become more aware of the key needs of both staff and patients. Working within sites enabled us to consider local resources and barriers. This produced 'core and custom' recommendations specifying core needs that could be met with customised local solutions. We identified two over-arching themes which need to be considered when introducing new digital systems (1) That data collection is physical (electronic systems need to fit into physical spaces and routines), and (2) That data collection is intentional (system users must be convinced of the value of collecting the data).

CONCLUSIONS

We demonstrate that NPT constructs can be operationalised through participatory co-design to work with stakeholders and within settings to collaboratively produce implementation support recommendations. This enables production of contextually sensitive implementation recommendations, informed by qualitative evidence, theory, and stakeholder input. Further longitudinal evaluation is necessary to determine how successful the recommendations are in practice.

Involving migrants in the adaptation of primary care services in a 'newly' diverse urban area in Ireland: The tension between agency and structure

In line with World Health Organization policy (WHO, 2016; 2019), primary care services need to be adapted to effectively meet the needs of diverse patient populations. Drawing from a European participatory implementation study, we present an Irish case study. In a hybrid participatory space, migrants, general practice staff and service planners (n = 11) engaged in a project to implement the use of trained interpreters in primary care over 17 months. We used Normalisation Process Theory to analyse data from 15 Participatory Learning and Action research focus groups and related sources. While stakeholders' agency and expertise produced relevant positive results for the introduction of changes in a general practice setting, structural factors limited the range and scope for sustained changes in day-to-day practice.

Migrants' involvement in health policy, service development and research in the WHO European Region: A narrative review of policy and practice

OBJECTIVES

The involvement of individuals and communities in health decision-making is enshrined in WHO policies. However, migrant groups are under-represented in health decision-making processes. Our aim was to explore migrants' involvement in health policy, service development and research in the WHO European Region to identify levers for inclusive and meaningful practice.

METHODS

We conducted a narrative review of grey literature and peer-reviewed research on migrants' involvement in health decision-making across the 53 countries in WHO Europe. We searched for articles published in English between 2010 and the present in two electronic databases (PubMed, Scopus), IOM MIPEX Health Strand country reports, the EU SOPHIE project and using a Google advanced search. Findings were analysed descriptively and using Normalisation Process Theory to investigate levers and barriers to implementation of policy into practice.

RESULTS

Of 1,444 articles retrieved, 79 met the inclusion criteria. We identified 20 policies promoting migrants' involvement, but national-level policies were present in only two countries. We identified 59 examples of migrants' involvement in practice from half of the WHO Europe countries (n = 27). Our Normalisation Process Theory (NPT) analysis of 14 peer-reviewed empirical papers found that participatory research approaches are a lever to putting policy into practice in a meaningful way.

CONCLUSIONS

Migrants' involvement in health decision-making requires explicit national policies that are implemented evenly across policymaking, service provider and research activities in all countries in the WHO European Region. Participatory approaches to involvement activities are encouraged because they are a lever to perceived barriers to migrants' involvement.

Cultural competency and sensitivity in the curriculum for palliative care professionals: a survey in Switzerland

BACKGROUND

Cultural and linguistic diversity in patients and their relatives represents a challenge for clinical practice in palliative care around the world. Cross-cultural training for palliative care professionals is still scarce, and research can help determine and support the implementation of appropriate training. In Switzerland, health policies address diversity and equity issues, and there is a need for educational research on cross-cultural training in palliative care. The aim of this study was to investigate the clinical challenges faced by Swiss palliative care professionals when working with migrant patients and their relatives. We also documented professionals' interests in cross-cultural training.

METHODS

A web survey of professionals working in specialized palliative care in the French- and Italian-speaking areas of Switzerland investigated clinical challenges with migrant populations and interests in various training opportunities.

RESULTS

A total of 204 individuals responded to the survey, 48.5 % of whom were nurses. The major difficulties they reported were communication impediments associated with patients' linguistic and/or cultural backgrounds. In relation to educational needs, they expressed a particular interest in communication techniques that would allow them to deal with these issues autonomously. The professionals expressed less interest in training on collaborating with other professionals and examining one's own stereotypes.

CONCLUSIONS

Palliative care professionals' post-graduate and continuing education must address communication techniques for sensitive palliative and end-of-life topics in cross-cultural contexts. Beginning with their pre-graduate studies, health professionals should assimilate the importance of collaborating with other professionals in complex cross-cultural situations and learn to reflect on their stereotypes and pre-conceptions in clinical practice.

Migrant health and language barriers: Uncovering macro level influences on the implementation of trained interpreters in healthcare settings

There is a knowledge translation gap between policies promoting equitable access to healthcare and person-centred care, and the use of untrained interpreters in cross-cultural consultations leading to disparities in health outcomes. An 11 member inter-sectoral working group met at four workshops to discuss and agree on levers and barriers to the provision of trained interpreters in healthcare settings in Ireland. The process was informed by Participatory Learning and Action (PLA) research to support inter-stakeholder dialogue and learning. Normalisation Process Theory (NPT) was used as a conceptual framework to analyse levers and barriers. The NPT analysis explored sense-making, engagement and enactment and found challenges with sense-making and engagement in senior level service planners, managers and governmental offices. This had negative impacts on other key actors, including healthcare providers, medical students and interpreters. This also meant that the enactment of interpreted consultations in practice settings was replete with barriers, most notably a lack of resources, training and supportive organisational structures. The emergent action plan focused on improving sense-making and engagement through inter-sectoral awareness raising, designed to stimulate a series of complementary levers for implementation. Combining PLA and NPT provided new insights into macro level influences on implementation work at the level of a national healthcare system. The approaches used in this study are applicable in other fields.

Indicators of Quality Rehabilitation Services for Individuals with Limited English Proficiency: A 3-Round Delphi Study

OBJECTIVE

To obtain expert consensus on indicators of quality rehabilitation services for individuals with limited English proficiency (LEP).

DESIGN

Three-round Delphi study.

SETTING

Delphi survey conducted online with 30 experts. Most experts worked in adult physical rehabilitation settings and were from Illinois (n=16), and the remaining participants were from 8 other US states or Canadian provinces.

PARTICIPANTS

Experts (N=30) had a minimum of 2 publications on health care services for patients with LEP and/or a minimum of 5 years clinical experience in physical rehabilitation. Of 43 experts (11 researchers, 32 clinicians) who received the round 1 survey by e-mail, 30 returned complete responses (70% response rate). Of those, 25 completed round 2 and 24 completed round 3. Of round 1 participants, most (n =21) identified their primary professional activity as clinical, whereas the others worked in research (n =5) or education (n =4). Twenty-four were women. The median age was 43 years (range, 27-67y). Disciplines included occupational therapy (n =14), physical therapy (n =13), psychology (n=1), nursing (n=1), and medicine (n=1).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Indicators were rated on a 7-point Likert scale for importance and feasibility. Interquartile range (IQR) and 95% confidence intervals were calculated for importance and feasibility ratings. Indicators with an IQR <2 and a median importance score ≥6 were accepted as reaching consensus for importance.

RESULTS

Round 1 responses were categorized into 15 structural, 13 process, and 18 outcome indicators. All 15 structural indicators reached consensus for importance; 8 were rated as feasible. All 13 process indicators reached consensus, of which 8 were deemed feasible. Sixteen outcome indicators reached consensus, of which 7 were deemed feasible.

CONCLUSIONS

This Delphi study identified structural, process, and outcome indicators that can inform delivery and assessment of quality rehabilitation services for individuals with LEP. Future research should operationalize and measure these quality indicators in clinical practice.

'If relevant, yes; if not, no': General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory

Context

The use of ethnic identifiers in health systems is recommended in several European countries as a means to identify and address heath inequities. There are barriers to implementation that have not been researched.

Objective

This study examines whether and how ethnicity data can be collected in Irish general practices in a meaningful and acceptable way.

Methods

Qualitative case study data generation was informed by Normalization Process Theory (NPT) constructs about ‘sense’ making and ‘engagement’. It consisted of individual interviews and focus group discussions based on visual participatory techniques. There were 70 informants, including 62 general practitioner (GP) users of diverse ethnic backgrounds recruited through community organisations and eight GPs identified through an inter-agency steering group. Data were analysed according to principles of thematic analysis using NPT.

Results

The link between ethnicity and health was often considered relevant because GP users grasped connections with genetic (skin colour, lactose intolerance), geographic (prevalence of disease, early years exposure), behavioural (culture/food) and social determinant (housing) factors. The link was less clear with religion. There was some scepticism and questions about how the collection of data would benefit GP consultations and concerns regarding confidentiality and the actual uses of these data (e.g. risk of discrimination, social control). For GPs, the main theme discussed was relevance: what added value would it bring to their consultations and was it was their role to collect these data? Their biggest concern was about data protection issues in light of the European Union (EU) General Data Protection Regulation (GDPR). The difficulty in explaining a complex concept such as ‘ethnicity’ in the limited time available in consultations was also worrying.

Conclusions

Implementation of an ethnicity identifier in Irish general practices will require a strong rationale that makes sense to GP users, and specific measures to ensure that its benefits outweigh any potential harm. This is in line with both our participants’ views and the EU GDPR.

Participatory health research with migrants: Opportunities, challenges, and way forwards

CONTEXT

Migration is one of the most politically pressing issues of the 21st century but migrant health remains an under-researched area. The International Collaboration for Participatory Health Research (ICPHR) working group on migration developed this position statement to address opportunities and challenges in relation to migrant health. It aims to contribute to a shift from a deficit model that sees migrants as passively affected by policies to their reconceptualization as citizens who are engaged in the co-creation of solutions.

METHODS

This paper examines the opportunities and challenges posed by the use of PHR with migrants. It draws on a broad literature to provide examples of successful PHR with migrants and highlights critical issues for consideration.

FINDINGS

Successful initiatives illustrate the value of engaging migrants in the definition of the research agenda, the design and implementation of health interventions, the identification of health-protective factors and the operationalization and validation of indicators to monitor progress. Within increasingly super diverse contexts, fragmented community landscapes that are not necessarily constructed along ethnicity traits, inadequate structures of representation, local tensions and operational barriers can hamper meaningful PHR with migrants.

CONCLUSION

For each research context, it is essential to gauge the 'optimal' level and type of participation that is more likely to leverage migrants' empowerment. The development of Monitoring and Evaluation tools and methodological strategies to manage inter-stakeholder discrepancies and knowledge translation gaps are steps in this direction.

PATIENT OR PUBLIC CONTRIBUTION

This paper draws from contributions of migrant populations and other stakeholders to policymaking.

The views of New Zealand general practitioners and patients on a proposed risk assessment and communication tool: a qualitative study using Normalisation Process Theory

BACKGROUND

Communicating risks of medication harm and obtaining informed consent is difficult due to structural barriers, language and cultural practices, bias and a lack of resources appropriately tailored for the health literacy of most patients. A decision support tool was proposed to alert prescribers of risk and provide tailored information for patients to facilitate informed decision-making with patients and their whānau (family) around medication use. Patient and prescriber co-design was used to ensure the tool was designed to best meet the needs of end-users and avoid increasing health inequity. This paper describes the first stage of the co-design process.

METHOD

Normalisation Process Theory (NPT) was used to prospectively evaluate the tool. Semi-structured interviews were held with fifteen patients (five Māori, five Pasifika and five NZ European) and nine general practitioners (two Māori and seven European).

RESULTS

Three themes were identified, which related to the three NPT concepts most relevant to developing the tool. Theme 1 (coherence: meaning and sense making by participants) explored participants' understanding of prescribing safety, medication harm and risk, which is based on experience. Patients want as much information as possible about their medications and risk, but doctors find it difficult to communicate that information. Theme 2 related to the NPT concept of cognitive participation (commitment and engagement by participants) explored what participants thought about a prescribing decision support tool. Participants were cautiously optimistic, but worried about potential harm arising from its use. They also identified requirements for the tool and features to avoid. Theme 3 describes the collective action required for successful implementation of the tool; namely, culturally safe and trustworthy doctor-patient relationships.

CONCLUSION

Patients and general practitioners provided different perspectives when prospectively evaluating the proposed risk assessment and communication tool. This co-design research identified important pre-requisites for the tool and features to avoid and novel ideas for the proposed tool. Overall participants supported the development of the proposed risk assessment and communication tool, but identified the important role that doctor-patient relationships would play to ensure successful implementation. The use of Māori and Pacific languages in the proposed tool may enhance engagement and understanding.

Barriers to the use of trained interpreters in consultations with refugees in four resettlement countries: a qualitative analysis using normalisation process theory

Background

Increasing numbers of primary care practitioners in refugee resettlement countries are providing care to refugees. Access to trained interpreters is a priority for these practitioners, but there are many barriers to the implementation of interpreted consultations in routine care. There is a lack of international, theoretically informed research. The purpose of this paper is to understand barriers to interpreter use in primary care consultations in four resettlement countries using Normalisation Process Theory.

Method

We conducted a cross-sectional online survey with networks of primary care practitioners (PCPs) who care for refugees in Australia, Canada, Ireland and the US (n = 314). We analysed qualitative data from the survey about barriers to interpreter use (n = 178). We completed an inductive thematic analysis, iteratively developed a Normalisation Process Theory (NPT)-informed coding frame and then mapped the emergent findings onto the theory’s construct about enacting interpreted consultations.

Results

In all four countries, the use of an interpreter presented communication and interaction challenges between providers and patients, which can impede the goals of primary care consultations. Primary care practitioners did not always have confidence in interpreted consultations and described poor professional practice by some interpreters. There was variation across countries, and inconsistency within countries, in the availability of trained interpreters and funding sources.

Conclusion

There are shared and differential barriers to implementation of interpreted consultations in a consistent and sustained way in the four countries studied. These findings can be used to inform country-specific and international level policies and interventions focusing on improving skills and resources for interpreted consultations to improve implementation of interpreted primary care consultations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01314-7.

Introducing cross-cultural education in palliative care: focus groups with experts on practical strategies

BACKGROUND

The linguistic and cultural diversity found in European societies creates specific challenges to palliative care clinicians. Patients' heterogeneous habits, beliefs and social situations, and in many cases language barriers, add complexity to clinicians' work. Cross-cultural teaching helps palliative care specialists deal with issues that arise from such diversity. This study aimed to provide interested educators and decision makers with ideas for how to implement cross-cultural training in palliative care.

METHODS

We conducted four focus groups in French- and Italian-speaking Switzerland. All groups consisted of a mix of experts in palliative care and/or cross-cultural teaching. The interdisciplinary research team submitted the data for thematic content analysis.

RESULTS

Focus-group participants saw a clear need for courses addressing cross-cultural issues in end-of-life care, including in medical disciplines outside of palliative care (e.g. geriatrics, oncology, intensive care). We found that these courses should be embedded in existing training offerings and should appear at all stages of curricula for end-of-life specialists. Two trends emerged related to course content. One focuses on clinicians' acquisition of cultural expertise and tools allowing them to deal with complex situations on their own; the other stresses the importance of clinicians' reflections and learning to collaborate with other professionals in complex situations. These trends evoke recent debates in the literature: the quest for expertise and tools is related to traditional twentieth century work on cross-cultural competence, whereas reflection and collaboration are central to more recent research that promotes cultural sensitivity and humility in clinicians.

CONCLUSION

This study offers new insights into cross-cultural courses in palliative and end-of-life care. Basic knowledge on culture in medicine, variable practices related to death and dying, communication techniques, self-reflection on cultural references and aptitude for interprofessional collaboration are central to preparing clinicians in end-of-life settings to work with linguistically and culturally diverse patients.

Challenges to effective and autonomous genetic testing and counseling for ethno-cultural minorities: a qualitative study

Background

The Arab population in Israel is a minority ethnic group with its own distinct cultural subgroups. Minority populations are known to underutilize genetic tests and counseling services, thereby undermining the effectiveness of these services among such populations. However, the general and culture-specific reasons for this underutilization are not well defined. Moreover, Arab populations and their key cultural-religious subsets (Muslims, Christians, and Druze) do not reside exclusively in Israel, but are rather found as a minority group in many European and North American countries. Therefore, focusing on the Arab population in Israel allows for the examination of attitudes regarding genetic testing and counseling among this globally important ethnic minority population.

Methods

We used a qualitative research method, employing individual interviews with 18 women of childbearing age from three religious subgroups (i.e., Druze, Muslim, and Christian) who reside in the Acre district, along with focus group discussions with healthcare providers (HCPs; 9 nurses and 7 genetic counselors) working in the same geographical district.

Results

A general lack of knowledge regarding the goals and practice of genetic counseling resulting in negative preconceptions of genetic testing was identified amongst all counselees. Counselors’ objective of respecting patient autonomy in decision-making, together with counselees’ misunderstanding of genetic risk data, caused uncertainty, frustration, and distrust. In addition, certain interesting variations were found between the different religious subgroups regarding their attitudes to genetic counseling.

Conclusions

The study highlights the miscommunications between HCPs, particularly counselors from the majority ethno-cultural group, and counselees from a minority ethno-cultural group. The need for nuanced understanding of the complex perspectives of minority ethno-cultural groups is also emphasized. Such an understanding may enhance the effectiveness of genetic testing and counseling among the Arab minority group while also genuinely empowering the personal autonomy of counselees from this minority group in Israel and other countries.

Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review

Background

Normalisation Process Theory (NPT) provides a framework to understand how interventions are implemented, embedded, and integrated in healthcare settings. Previous reviews of published literature have examined the application of NPT across international healthcare and reports its benefits. However, given the distinctive clinical function, organisational arrangements and the increasing management of people with a wide variety of conditions in primary care settings in the United Kingdom, it is important to understand how and why authors utilise and reflect on NPT in such settings to inform and evaluate implementation processes.

Methods

A systematic review of peer-reviewed literature using NPT in primary care settings in the United Kingdom (UK) was conducted. Eight electronic databases were searched using replicable methods to identify articles published between January 2012 and April 2018. Data were analysed using a framework approach.

Results

Thirty-one articles met the inclusion criteria. Researchers utilised NPT to explore the implementation of interventions, targeting a wide range of health services and conditions, within primary care settings in the UK. NPT was mostly applied qualitatively; however, a small number of researchers have moved towards mixed and quantitative methods. Some variation was observed in the use of NPT constructs and sub-constructs, and whether and how researchers undertook modification to make them more relevant to the implementation process and multiple stakeholder perspectives.

Conclusion

NPT provides a flexible framework for the development and evaluation of complex healthcare interventions in UK primary care settings. This review updates the literature on NPT use and indicates that its application is well suited to these environments, particularly in supporting patients with long-term conditions and co-morbidities. We recommend future research explores the receipt of interventions by multiple stakeholders and suggest that authors reflect on justifications for using NPT in their reporting.

Participatory implementation research in the field of migrant health: Sustainable changes and ripple effects over time

Objective

This study aimed to explore whether positive impacts were sustained and unanticipated ripple effects had occurred four years after the implementation of interventions to improve cross‐cultural communication in primary care.

Background

Sustaining the implementation of change using complex interventions is challenging. The EU‐funded “RESTORE” study implemented guidelines and training on cross‐cultural communication in five Primary Care sites in Europe, combining implementation theory (Normalisation Process Theory) with participatory methodology (participatory learning and action—PLA). There were positive impacts on knowledge, skills and clinical routines.

Design, setting and participants

Four of the five original sites (England, Ireland, Greece, The Netherlands) were available for this qualitative follow‐up study. The study population (N = 44) was primary healthcare staff and migrants, most of whom had participated in RESTORE.

Intervention; main outcome measures

PLA‐style focus groups and interviews explored routine practice during consultations with migrants. Etic cards based on the effects of RESTORE stimulated the discussion. Deductive framework analysis was performed in each country followed by comparative data analysis and synthesis.

Results

Changes in knowledge, attitudes and behaviour with regard to consultations with migrants were sustained and migrants felt empowered by their participation in RESTORE. There were ongoing concerns about macro level factors, like the political climate and financial policies, negatively affecting migrant healthcare.

Conclusion

There were sustained effects in clinical settings, and additional unanticipated positive ripple effects, due in part, from the participatory approach employed.

Ethnic and gender differences in the management of type 2 diabetes: a cross-sectional study from Norwegian general practice

Background

Ethnic minority groups from Asia and Africa living in Western countries have a higher prevalence of type 2 diabetes (T2DM) than the general population. We aimed to assess ethnic differences in diabetes care by gender.

Methods

Population-based, cross-sectional study identified 10,161 individuals with T2DM cared for by 282 General Practitioners (GP) in Norway. Ethnicity was based on country of birth. Multilevel regression models adjusted for individual and GP factors were applied to evaluate ethnic differences by gender.

Results

Diabetes was diagnosed at a younger mean age in all other ethnic groups compared with Westerners (men: 45.9–51.6 years vs. 56.4 years, women: 44.9–53.8 years vs. 59.1 years). Among Westerners mean age at diagnosis was 2.7 years higher in women compared with men, while no gender difference in age at diagnosis was found in any minority group. Daily smoking was most common among Eastern European, South Asian and Middle East/North African men. In both genders, we found no ethnic differences in processes of care (GPs’ measurement of HbA1c, blood pressure, LDL-cholesterol, creatinine). The proportion who achieved the HbA1c treatment target was higher in Westerners (men: 62.3%; women: 66.1%), than in ethnic minorities (men 48.2%; women 53.5%). Compared with Western men, the odds ratio (OR) for achieving the target was 0.45 (95% CI 0.27 to 0.73) in Eastern European; 0.67 (0.51 to 0.87) in South Asian and 0.62 (0.43 to 0.88) in Middle Eastern/North African men. Compared with Western women, OR was 0.49 (0.28 to 0.87) in Eastern European and 0.64 (0.47 to 0.86) South Asian women.

Compared with Westerners, the blood pressure target was more often achieved in South Asians and Middle Easterners/North Africans in both genders. Small ethnic differences in achieving the LDL-cholesterol treatment target by gender were found.

Conclusion

Diabetes was diagnosed at a considerably earlier age in both minority men and minority women compared with Westerners. Several minority groups had worse glycaemic control compared with Westerners in both genders, which implies that it is necessary to improve glucose lowering treatment for the minority groups. Smoking cessation advice should particularly be offered to men in most minority groups.

Communication and patient safety in gynecology and obstetrics - study protocol of an intervention study

Background

Patient safety is a key target in public health, health services and medicine. Communication between all parties involved in gynecology and obstetrics (clinical staff/professionals, expectant mothers/patients and their partners, close relatives or friends providing social support) should be improved to ensure patient safety, including the avoidance of preventable adverse events (pAEs). Therefore, interventions including an app will be developed in this project through a participatory approach integrating two theoretical models. The interventions will be designed to support participants in their communication with each other and to overcome difficulties in everyday hospital life. The aim is to foster effective communication in order to reduce the frequency of pAEs. If communication is improved, clinical staff should show an increase in work satisfaction and patients should show an increase in patient satisfaction.

Methods

The study will take place in two maternity clinics in Germany. In line with previous studies of complex interventions, it is divided into three interdependent phases. Each phase provides its own methods and data. Phase 1: Needs assessment and a training for staff (n = 140) tested in a pre-experimental study with a pre/post-design. Phase 2: Assessment of communication training for patients and their social support providers (n = 423) in a randomized controlled study. Phase 3: Assessment of an app supporting the communication between staff, patients, and their social support providers (n = 423) in a case-control study. The primary outcome is improvement of communication competencies. A range of other implementation outcomes will also be assessed (i.e. pAEs, patient/treatment satisfaction, work satisfaction, safety culture, training-related outcomes).

Discussion

This is the first large intervention study on communication and patient safety in gynecology and obstetrics integrating two theoretical models that have not been applied to this setting. It is expected that the interventions, including the app, will improve communication practice which is linked to a lower probability of pAEs. The app will offer an effective and inexpensive way to promote effective communication independent of users’ motivation. Insights gained from this study can inform other patient safety interventions and health policy developments.

Trial registration

ClinicalTrials.gov Identifier: NCT03855735; date of registration: February 27, 2019.

Reprogenetics, reproductive risks and cultural awareness: what may we learn from Israeli and Croatian medical students?

Background

Past studies emphasized the possible cultural influence on attitudes regarding reprogenetics and reproductive risks among medical students who are taken to be “future physicians.” These studies were crafted in order to enhance the knowledge and expand the boundaries of cultural competence. Yet such studies were focused on MS from relatively marginalized cultures, namely either from non-Western developing countries or minority groups in developed countries. The current study sheds light on possible cultural influences of the dominant culture on medical students in two developed countries, potentially with different dominant cultures regarding reprogenetics and reproductive risks: Israel and Croatia.

Methods

Quantitative-statistical analyses were employed, based on anonymous questionnaires completed by 150 first year medical students in Israel and Croatia. The questionnaires pertained to the knowledge and attitudes regarding genetics, reproduction and reproductive risks. These questionnaires were completed before the students were engaged in learning about these topics as part of the curriculum in their medical school.

Results

Substantial differences were revealed between the two groups of medical students. Israeli medical students were less tolerant regarding reproductive risks and more knowledgeable about genetics and reproductive risks than Croatian medical students. For example, while nearly all Israeli medical students (96%) disagreed with the idea that “Screening for reproductive risks in prospective parents is wrong,” less than 40% of their Croatian counterparts shared a similar stance. Similarly, all (100%) Israeli medical students correctly observed that “A carrier of a recessive genetic disease actually has the disease” was wrong, as opposed to only 82% of Croatian students.

Conclusions

By linking applicable theoretical literature to these findings, we suggest that they may reflect the hidden influence of the dominant culture in each country, disguised as part of the “culture of medicine.” Acknowledging and learning about such influence of the dominant culture, may be an important addition to the training of medical students in cultural competence, and specifically their cultural awareness. Such an acknowledgement may also pave the road to drawing the attention of existing physicians regarding a less known yet an important aspect of their cultural competence, insofar as the cultural awareness component is concerned.

Increasing cultural awareness: qualitative study of nurses' perceptions about cultural competence training

Background

Nowadays, healthcare professionals worldwide deliver care for increasing numbers of culturally and linguistically diverse patients. The importance of cultural competence is evident in terms of the quality of healthcare, and more knowledge is needed about different educational models and approaches that aim to increase cultural competence. This study examines the perceptions of nurses about the content and utility of cultural competence training that focuses on increasing awareness of one’s own cultural features.

Methods

The training was conducted at one primary care hospital in southern Finland. Participants were registered nurses (n = 14) and practical nurses (n = 6) from different hospital units. Four 4-h training sessions—including lectures, discussions and short web-based learning tasks—were arranged during a four-week period. Semi-structured, small group interviews were conducted with 10 participants to examine their perceptions about the content and utility of the training. Qualitative content analysis with a conventional approach was used to analyse the data.

Results

Perceptions about the training were divided into three main categories: general utility of the training, personal utility of the training, and utility of the training for patients. General utility pertains to the general approach that the training provided on cross-cultural care, the possibility to initiate an open discussion, and the opportunity to improve current practices. Personal utility pertains to the opportunity to become aware of one’s own cultural features, to change one’s way of thinking, to obtain a new perspective on one’s own communication practices and to receive justification for carrying out particular workable practices. Utility for patients pertains to fostering better awareness and acknowledgement of patients’ differing cultural features and an increased respect in healthcare delivery. Additionally, the quality of the training was highlighted, and suggestions for improvement were offered.

Conclusion

Training that increases healthcare professionals’ awareness of their own cultural features was perceived as useful and thought-provoking. Increased awareness might facilitate the communication between healthcare professionals and patients, which is a crucial component of quality healthcare. It seems that in the future, training opportunities that allow larger groups to participate are needed, regardless of the time and place, and utilising the potential of e-learning should be considered.

Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review

BACKGROUND

Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes.

METHODS

A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively.

RESULTS

Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus.

CONCLUSIONS

This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.

Informing physician strategies to overcome language barriers in encounters with pediatric patients

OBJECTIVES

To describe physician perceptions of differences in limited English proficient (LEP) pediatric encounters and the behavioral adaptations they make to provide quality care to LEP pediatric patients.

METHODS

We conducted 30min, semi-structured interviews with 6 family physicians and 5 pediatricians in one health system. Audiotapes from each interview were transcribed verbatim then coded using content analysis.

RESULTS

Multiple aspects of the LEP pediatric encounter were perceived by physicians as different from other encounters: trust and relationship between physician and LEP child/child's family, continuity of care, encounter's structure and flow, patient assessment, and communication barriers. Within each of these themes, physicians identified how they adapt their behavior to improve the quality of care provided to LEP children and families.

CONCLUSIONS

Physicians' made both positive and negative adaptations in LEP pediatric encounters that may impact the quality of care provided to these patients.

PRACTICE IMPLICATIONS

By identification of specific positive and negative behavioral adaptations, this study emphasizes intervention targets, such as demonstrating interest in an LEP pediatric patient's family story and individuality and using common niceties in conversations with LEP children.

Using Participatory Learning & Action (PLA) research techniques for inter-stakeholder dialogue in primary healthcare: an analysis of stakeholders' experiences

PLAIN ENGLISH SUMMARY

It is important for health care workers to know the needs and expectations of their patients. Therefore, service users have to be involved in research. To achieve a meaningful dialogue between service users, healthcare workers and researchers, participatory methods are needed. This paper describes how the application of a specific participatory methodology, Participatory Learning and Action (PLA) can lead to such a meaningful dialogue. In PLA all stakeholders are regarded as equal partners and collaborators in research.During 2011-2015, a European project called RESTORE used PLA in Austria, Greece, Ireland, The Netherlands and the UK to investigate how communication between primary health care workers and their migrant patients could be improved.Seventy eight migrants, interpreters, doctors, nurses and other key stakeholders (see Table 2) participated in 62 PLA sessions. These dialogues (involving discussions, activities, PLA techniques and evaluations) were generally 2-3 h long and were recorded and analysed by the researchers.Participants reported many positive experiences about their dialogues with other stakeholders. There was a positive, trusting atmosphere in which all stakeholders could express their views despite differences in social power. This made for better understanding within and across stakeholder groups. For instance a doctor changed her view on the use of interpreters after a migrant explained why this was important. Negative experiences were rare: some doctors and healthcare workers thought the PLA sessions took a lot of time; and despite the good dialogue, there was disappointment that very few migrants used the new interpreting service.

ABSTRACT

Background In order to be effective, primary healthcare must understand the health needs, values and expectations of the population it serves. Recent research has shown that the involvement of service users and other stakeholders and gathering information on their perspectives can contribute positively to many aspects of primary healthcare. Participatory methodologies have the potential to support engagement and dialogue between stakeholders from academic, migrant community and health service settings. This paper focuses on a specific participatory research methodology, Participatory Learning and Action (PLA) in which all stakeholders are regarded as equal partners and collaborators in research.Our research question for this paper was: "Does the application of PLA lead to meaningful engagement of all stakeholders, and if so, what elements contribute to a positive and productive inter-stakeholder dialogue?". Methods We explored the use of PLA in RESTORE, a European FP7-funded project, during 2011-2015 in 5 countries: Austria, Greece, Ireland, the Netherlands and the UK. The objective of RESTORE was to investigate and support the implementation of guidelines and training initiatives (G/TIs) to enhance communication in cross-cultural primary care consultations with migrants.Seventy eight stakeholders (migrants, interpreters, doctors, nurses and others - see Table 2) participated in a total of 62 PLA sessions (discussions, activities, evaluations) of approximately 2-3 h' duration across the five sites. During the fieldwork, qualitative data were generated about stakeholders' experiences of engagement in this dialogue, by means of various methods including participatory evaluations, researchers' fieldwork reports and researcher interviews. These were analysed following the principles of thematic analysis. Results Stakeholders involved in PLA inter-stakeholder dialogues reported a wide range of positive experiences of engagement, and very few negative experiences. A positive atmosphere during early research sessions helped to create a sense of safety and trust. This enabled stakeholders from very different backgrounds, with different social status and power, to offer their perspectives in a way that led to enhanced learning in the group - they learned with and from each other. This fostered shifts in understanding - for example, a doctor changed her view on interpreted consultations because of the input of the migrant service-users. Conclusion PLA successfully promoted stakeholder involvement in meaningful and productive inter-stakeholder dialogues. This makes it an attractive approach to enhance the further development of health research partnerships to advance primary healthcare.

Material practices for meaningful engagement: An analysis of participatory learning and action research techniques for data generation and analysis in a health research partnership

BACKGROUND

The material practices which researchers use in research partnerships may enable or constrain the nature of engagement with stakeholder groups. Participatory learning and action (PLA) research approaches show promise, but there has been no detailed analysis of stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis.

OBJECTIVES

To explore stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis.

DESIGN

The EU RESTORE implementation science project employed a participatory approach to investigate and support the implementation of guidelines and training initiatives (GTIs) to enhance communication in cross-cultural primary care consultations. We developed a purposeful sample of 78 stakeholders (migrants, general practice staff, community interpreters, service providers, service planners) from primary care settings in Austria, England, Greece, Ireland and The Netherlands. We used speed evaluations and participatory evaluations to explore their experiences of two PLA techniques-Commentary Charts and Direct Ranking-which were intended to generate data for co-analysis by stakeholders about the GTIs under analysis. We evaluated 16 RESTORE researchers' experiences using interviews. We conducted thematic and content analysis of all evaluation data.

RESULTS

PLA Commentary Charts and Direct Ranking techniques, with their visual, verbal and tangible nature and inherent analytical capabilities, were found to be powerful tools for involving stakeholders in a collaborative analysis of GTIs. Stakeholders had few negative experiences and numerous multifaceted positive experiences of meaningful engagement, which resonated with researchers' accounts.

CONCLUSION

PLA techniques and approaches are valuable as material practices in health research partnerships.

Supporting the use of theory in cross-country health services research: a participatory qualitative approach using Normalisation Process Theory as an example

OBJECTIVES

To describe and reflect on the process of designing and delivering a training programme supporting the use of theory, in this case Normalisation Process Theory (NPT), in a multisite cross-country health services research study.

DESIGN

Participatory research approach using qualitative methods.

SETTING

Six European primary care settings involving research teams from Austria, England, Greece, Ireland, The Netherlands and Scotland.

PARTICIPANTS

RESTORE research team consisting of 8 project applicants, all senior primary care academics, and 10 researchers. Professional backgrounds included general practitioners/family doctors, social/cultural anthropologists, sociologists and health services/primary care researchers.

PRIMARY OUTCOME MEASURES

Views of all research team members (n=18) were assessed using qualitative evaluation methods, analysed qualitatively by the trainers after each session.

RESULTS

Most of the team had no experience of using NPT and many had not applied theory to prospective, qualitative research projects. Early training proved didactic and overloaded participants with information. Drawing on RESTORE's methodological approach of Participatory Learning and Action, workshops using role play, experiential interactive exercises and light-hearted examples not directly related to the study subject matter were developed. Evaluation showed the study team quickly grew in knowledge and confidence in applying theory to fieldwork.Recommendations applicable to other studies include: accepting that theory application is not a linear process, that time is needed to address researcher concerns with the process, and that experiential, interactive learning is a key device in building conceptual and practical knowledge. An unanticipated benefit was the smooth transition to cross-country qualitative coding of study data.

CONCLUSION

A structured programme of training enhanced and supported the prospective application of a theory, NPT, to our work but raised challenges. These were not unique to NPT but could arise with the application of any theory, especially in large multisite, international projects. The lessons learnt are applicable to other theoretically informed studies.