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      Knowledge mobilisation: an ethnographic study of the influence of practitioner mindlines on atopic eczema self-management in primary care in the UK

      research-article
      BMJ Open
      BMJ Publishing Group
      atopic eczema, ethnography, knowledge mobilisation, mindlines, primary care, self-management

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          Abstract

          Objective

          To explore how atopic eczema specific mindlines are developed by primary care practitioners.

          Design

          Ethnographic study.

          Setting

          One large, urban general practice in central England.

          Participants

          In observation, all practitioners and support staff in the practice and in interviews a diverse group of practitioners (n=16).

          Results

          Observation of over 250 hours and interview data were combined and analysed using an ethnographic approach through the lenses of mindlines and self-management. Three themes were identified: beliefs about eczema, eczema knowledge and approaches to self-management. Eczema mindlines are set against a backdrop of it being a low priority and not managed as a long-term condition. Practitioners believed that eczema is simple to manage with little change in treatments available and prescribing limited by local formularies. Practice is largely based on tacit knowledge and experience. Self-management is expected but not often explicitly facilitated. Clinical decisions are made from knowledge accumulated over time. Societal and technological developments have altered the way in which practitioner mindlines are developed; in eczema, for most, they are relatively static.

          Conclusions

          The outstanding challenge is to find novel, profession and context-specific, simple, pragmatic strategies to revise or modify practitioner mindlines by adding reliable and useful knowledge and by erasing outdated or inaccurate information thus potentially improve quality of eczema care.

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          Most cited references27

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          Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer

          Background Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. Objective The objectives of this metareview were to (1) assess the impact of telehealth interventions to support self-management on disease control and health care utilization, and (2) identify components of telehealth support and their impact on disease control and the process of self-management. Our goal was to synthesise evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support. Methods We performed a metareview (a systematic review of systematic reviews) of randomized controlled trials (RCTs) of telehealth interventions to support self-management in 6 exemplar long-term conditions. We searched 7 databases for reviews published from January 2000 to May 2016 and screened identified studies against eligibility criteria. We weighted reviews by quality (revised A Measurement Tool to Assess Systematic Reviews), size, and relevance. We then combined our results in a narrative synthesis and using harvest plots. Results We included 53 systematic reviews, comprising 232 unique RCTs. Reviews concerned diabetes (type 1: n=6; type 2, n=11; mixed, n=19), heart failure (n=9), asthma (n=8), COPD (n=8), and cancer (n=3). Findings varied between and within disease areas. The highest-weighted reviews showed that blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycemic control in type 2, but not type 1, diabetes, and that telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure, but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multifaceted interventions were associated with greater improvements in diabetes, heart failure, and asthma. Conclusions While telehealth-mediated self-management was not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth is a safe option for delivery of self-management support, particularly in conditions such as heart failure and type 2 diabetes, where the evidence base is more developed. Larger-scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.
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            Language and meaning: Data collection in qualitative research.

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              Guidelines and mindlines: why do clinical staff over-diagnose malaria in Tanzania? A qualitative study

              Background Malaria over-diagnosis in Africa is widespread and costly both financially and in terms of morbidity and mortality from missed diagnoses. An understanding of the reasons behind malaria over-diagnosis is urgently needed to inform strategies for better targeting of antimalarials. Methods In an ethnographic study of clinical practice in two hospitals in Tanzania, 2,082 patient consultations with 34 clinicians were observed over a period of three months at each hospital. All clinicians were also interviewed individually as well as being observed during routine working activities with colleagues. Interviews with five tutors and 10 clinical officer students at a nearby clinical officer training college were subsequently conducted. Results Four, primarily social, spheres of influence on malaria over-diagnosis were identified. Firstly, the influence of initial training within a context where the importance of malaria is strongly promoted. Secondly, the influence of peers, conforming to perceived expectations from colleagues. Thirdly, pressure to conform with perceived patient preferences. Lastly, quality of diagnostic support, involving resource management, motivation and supervision. Rather than following national guidelines for the diagnosis of febrile illness, clinician behaviour appeared to follow 'mindlines': shared rationales constructed from these different spheres of influence. Three mindlines were identified in this setting: malaria is easier to diagnose than alternative diseases; malaria is a more acceptable diagnosis; and missing malaria is indefensible. These mindlines were apparent during the training stages as well as throughout clinical careers. Conclusion Clinicians were found to follow mindlines as well as or rather than guidelines, which incorporated multiple social influences operating in the immediate and the wider context of decision making. Interventions to move mindlines closer to guidelines need to take the variety of social influences into account.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2019
                26 July 2019
                : 9
                : 7
                : e025220
                Affiliations
                [1] departmentFaculty of Health Education and Life Sciences , Birmingham City University , Birmingham, UK
                Author notes
                [Correspondence to ] Professor Fiona Cowdell; fiona.cowdell@ 123456bcu.ac.uk
                Author information
                http://orcid.org/0000-0002-9355-8059
                Article
                bmjopen-2018-025220
                10.1136/bmjopen-2018-025220
                6661925
                31350238
                25a4a6b9-b405-4118-a5b5-d1f2f6b4affc
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

                History
                : 04 July 2018
                : 24 May 2019
                : 10 June 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000659, Research Trainees Coordinating Centre;
                Categories
                Dermatology
                Research
                1506
                1687
                Custom metadata
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                Medicine
                atopic eczema,ethnography,knowledge mobilisation,mindlines,primary care,self-management
                Medicine
                atopic eczema, ethnography, knowledge mobilisation, mindlines, primary care, self-management

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