‘It’s possibly made us feel a little more alienated’: How people from ethnic minority communities conceptualise COVID-19 and its influence on engagement with testing

Objectives The cultural beliefs, practices and experiences of ethnic minority groups, alongside structural inequalities and the political economy play a critical, but overlooked role in health promotion. This study aimed to understand how ethnic minority groups in the United Kingdom conceptualised COVID-19 and how this influenced engagement in testing. Method Black (African and Caribbean) and South Asian (Indian, Pakistani and Bangladeshi) community members were purposefully recruited from across the UK. Fifty-seven semi-structured interviews were conducted and analysed using principles of grounded theory. Results We found that people of Black and South Asian ethnicity conceptualised COVID-19 as a disease that makes them visible to others outside their community and was seen as having more severe risk and suffering worse consequences, resulting in fear, stigmatisation and alienation. Views about COVID-19 were embedded in cultural beliefs, relating to culturally specific ideas around disease, such as ill-health being God’s will. Challenges brought about by the pandemic were conceptualised as one of many struggles, with the saliency of the virus contextualised against life experiences. These themes and others influenced engagement with COVID-19 testing. Testing was less about accessing timely and effective treatment for themselves and more about acting to protect the family and community. Testing symbolised a loss of income, anxiety and isolation, accentuated by issues of mistrust of the system and not being valued, or being treated unfairly. Conclusion Health communications should focus on counterbalancing the mistrust, alienation and stigmatisation that act as barriers to testing, with trust built using local credible sources.

What counts as a voiceable concern in decisions about speaking out in hospitals: A qualitative study

Objectives Those who work in health care organisations are a potentially valuable source of information about safety concerns, yet failures of voice are persistent. We propose the concept of ‘voiceable concern’ and offer an empirical exploration. Methods We conducted a qualitative study involving 165 semi-structured interviews with a range of staff (clinical, non-clinical and at different hierarchical levels) in three hospitals in two countries. Analysis was based on the constant comparative method. Results Our analysis shows that identifying what counts as a concern, and what counts as a occasion for voice by a given individual, is not a straightforward matter of applying objective criteria. It instead often involves discretionary judgement, exercised in highly specific organisational and cultural contexts. We identified four influences that shape whether incidents, events and patterns were classified as voiceable concerns: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability and normalisation. Determining what counted as a voiceable concern is not a simple function of the features of the concern; also important is whether the person who noticed the concern felt it was voiceable by them. Conclusions Understanding how those who work in health care organisations come to recognise what counts as a voiceable concern is critical to understanding decisions and actions about speaking out. The concept of a voiceable concern may help to explain aspects of voice behaviour in organisations as well as informing interventions to improve voice.

Comparison of inpatient spending and readmission rates for patients treated by male versus female physicians in China: An observational study

Objective To determine whether there are significant differences in costs of treatment and readmission rates for hospital consultations undertaken by female versus male physicians in China. Methods Using data from the Urban Employee Basic Medical Insurance program from January 2018 through October 2019, we investigated spending patterns and clinical outcomes for patients at tertiary hospitals in one of the largest cities in China by the gender of the attending physician. Our sample included 79,085 hospitalizations treated by 3993 physicians in internal medicine departments. We examined the association between physician gender and visit cost using a multivariable linear model. We examined the association between physician gender and 30-days readmission rates using a multivariable probability model. We adjusted for a rich set of patient characteristics, primary diagnosis fixed effects, and hospital fixed effects. In addition, we used patient fixed effects in a robustness analysis. Results Adjusting for primary diagnosis fixed effects, spending per visit was 4.1% higher for patients treated by male physicians than for those treated by female physicians, a statistically significant difference (95% CI [1.5%, 6.7%]). This pattern persisted after further adjusting for hospital fixed effects (3.2% [1.2%, 5.2%]), patient characteristics (3.2% [1.2%, 5.1%]), and patient fixed effects (4.2% [1.8%, 6.7%]). The difference is mainly driven by higher spending on drugs (8.7% [3.9%, 13.6%]) and out-of-pocket costs (3.9% [1.7%, 6.0%]). No statistically significant differences were observed in the readmission rates of patients treated by male and female physicians in any of our three model specifications. Conclusions Spending per visit was significantly higher among patients treated by male physicians than among those treated by female physicians, with the difference mainly driven by spending on drugs and out-of-pocket costs. No significant difference was observed in the hospital readmission rates of patients treated by male and female physicians. These findings have important implications for gender equality in medicine and health care quality and efficiency in developing countries.

The contribution of professions to the governance of integrated care: Towards a conceptual framework based on case studies from Denmark

Objective Good governance of integrated care is key to better health care, but we know little about how professions can help make this happen. Our aim is to introduce a conceptual framework to analyse how professions contribute to the governance of integrated care, and to apply the framework to a secondary analysis of selected case studies from Denmark. Methods We developed a framework, which identified the what, how and why of the contribution professions make to the governance of integrated care. We included five qualitative Danish studies, using coordination as an indicator of integrated care. We adopted a thematic approach in our analysis, combining deductive and inductive elements. Results Health professions engage in highly diverse activities, which fall into closely connected clusters of more formal or more informal coordination. Professions apply many different adaptive mechanisms at different levels to fit coordination into local contexts. Professions are driven by interlocking rationales, where a common focus on patients connects organizational and professional concerns. Conclusions Our analytical framework emerges as a useful tool for analysis. The contribution of professions to the governance of integrated care needs greater attention in health policy implementation as it can promote more effective governance of integrated care.

Embedded trials within national clinical audit programmes: A qualitative interview study of enablers and barriers

Background Audit and feedback entails systematic documentation of clinical performance based on explicit criteria or standards which is then fed back to professionals in a structured manner. There are potential significant returns on investment from partnerships between existing clinical audit programmes in coordinated programmes of research to test ways of improving the effect of their feedback to drive greater improvements in health care delivery and population outcomes. We explored barriers to and enablers of embedding audit and feedback trials within clinical audit programmes. Methods We purposively recruited participants with varied experience in embedded trials in audit programmes. We conducted qualitative semi-structured interviews, guided by behavioural theory, with researchers, clinical audit programme staff and health care professionals. Recorded interviews were transcribed, and data coded and thematically analysed. Results We interviewed 31 participants (9 feedback researchers, 14 audit staff and 8 healthcare professionals, many having dual roles). We identified barriers and enablers for all 14 theoretical domains but no relationship between domains and participant role. We identified four optimal conditions for sustainable collaboration from the perspectives of stakeholders: resources, that is, recognition that audit programmes need to create capacity to participate in research, and research must be adapted to fit within each programme’s constraints; logistics, namely, that partnerships need to address data sharing and audit quality, while securing research funding to ensure operational success; leadership, that is, enthusiastic and engaged audit programme leaders must motivate their team and engage local stakeholders; and relationships, meaning that trust between researchers and audit programmes must be established over time by identifying shared priorities and meeting each partner’s needs. Conclusion Successfully embedding research within clinical audit programmes is likely to require compromise, logistical expertise, leadership and trusting relationships to overcome perceived risks and fully realise benefits.

Culturally safe health care practice for Indigenous Peoples in Australia: A systematic meta-ethnographic review

Objectives Culturally safe health care services contribute to improved health outcomes for Aboriginal and Torres Strait Islander Peoples in Australia. Yet there has been no comprehensive systematic review of the literature on what constitutes culturally safe health care practice. This gap in knowledge contributes to ongoing challenges providing culturally safe health services and policy. This review explores culturally safe health care practice from the perspective of Indigenous Peoples as recipients of health care in Western high-income countries, with a specific focus on Australian Aboriginal and Torres Strait Islander Peoples. Methods A systematic meta-ethnographic review of peer-reviewed literature was undertaken across five databases: Ovid MEDLINE, Scopus, PsychINFO, CINAHL Plus and Informit. Eligible studies included Aboriginal and Torres Strait Islander Peoples receiving health care in Australia, had a focus on exploring health care experiences, and a qualitative component to study design. Two authors independently determined study eligibility (5554 articles screened). Study characteristics and results were extracted and quality appraisal was conducted. Data synthesis was conducted using meta-ethnography methodology, contextualised by health care setting. Results Thirty-four eligible studies were identified. Elements of culturally safe health care identified were inter-related and included personable two-way communication, a well-resourced Indigenous health workforce, trusting relationships and supportive health care systems that are responsive to Indigenous Peoples’ cultural knowledge, beliefs and values. Conclusions These elements can form the basis of interventions and strategies to promote culturally safe health care practice and systems in Australia. Future cultural safety interventions need to be rigorously evaluated to explore their impact on Indigenous Peoples’ satisfaction with health care and improvements in health care outcomes.

Are advanced clinical practice roles in England’s National Health Service a remedy for workforce problems? A qualitative study of senior staff perspectives

Objective A major issue facing all health systems is improving population health while at the same time responding to both growing patient numbers and needs and developing and retaining the health care workforce. One policy response to workforce shortages has been the development of advanced clinical practice roles. In the context of an English national policy promoting such roles in the health service, we explored senior managers’ and senior clinicians’ perceptions of factors at the organization level that support or inhibit the introduction of advanced clinical practice roles. The investigation was framed by theories of the diffusion of innovation and the system of professions. Methods We conducted a qualitative interview study of 39 senior manager and clinicians in 19 National Health Service acute, community, mental health and ambulance organizations across a metropolitan area in 2019. Results Small numbers of advanced clinical practice roles were reported, often in single services. Four main influences were identified in the development of advanced clinical practice roles: staff shortages (particularly of doctors in training grades) combined with rising patient demand, the desire to retain individual experienced staff, external commissioners or purchasers of services looking to shape services in line with national policy, and commissioner-funded new roles in new ambulatory care services and primary care. Three factors were reported as enabling the roles: finance for substantive posts, evidence of value of the posts, and structural support within the organization. Three factors were perceived as inhibiting developing the roles: confusion and lack of knowledge amongst clinicians and managers, the availability of finance for the roles, and a nervousness (sometimes resistance) to introducing the new roles. Conclusions While the national policy was to promote advanced clinical practice roles, the evidence suggested there was and would continue to be limited implementation at the operational level. Development scenarios that introduced new monies for such roles reduced some of the inhibiting factors. However, where the introduction of roles required funding to move from one part of a service to another, and potentially from one staff group to another, the growth of these roles was and is likely to be contested. In such scenarios, research and business evidence of relative advantage will be important, as too will be supporters in powerful positions. The paucity of publicly available evidence on the effectiveness of advanced clinical practice roles across the specialties and professions in different contexts requires urgent attention.