Low value clinical practices from the citizenry’s perspective

13 Oct

During the fifth edition of the international Preventing Overdiagnosis Congress, strategies for implementing solutions to avoid overdiagnosis and overuse were addressed based on the available scientific evidence.

In this year’s edition, which was held in Barcelona last year, apart from the involvement of professionals and organisations, patients had the opportunity to actively participate.

Experiences in different healthcare areas were shown in the use of best practices to communicate and to empower patients to achieve a better understanding of shared decisions.

Different world initiatives addressed the best practices to empower citizens in subjects related to low value practices, overdiagnosis and overtreatment. Experiences were shared and a debate was initiated on fundamental subjects such as the communication and participation of patients.

In recent years, the Essencial Project has studied the perspective of health professionals on low value practices, their causes and possible solutions so as to avoid them.

Essencial Project team: Cari Almazán, Johanna Caro, Liliana Arroyo and Hortènsia Aguado

For example, in a previous post, we explained the results of a survey we carried out with professionals in the field of primary care. The results of this survey highlighted the need to involve and empower the population more. Patients are also important decision makers in relation to their needs and in the demand for certain health services. Hence, the project must be accompanied by a communications strategy aimed not only at patients but also at citizens in general.

That is why we, from the Essencial Project, have been interested in finding out the opinion of patients in addition to the perspective of professionals. In the international Preventing Overdiagnosis 2017 Congress we participated explaining how an exploratory first approach was made to identify the beliefs, attitudes and perceptions of patients regarding the most important elements in consultations, low value practices and the essential components of an effective dialogue between professionals and patients. The end purpose of this was to understand the position of people before initiating possible interventions in the citizenry and to determine the most effective communicative tools and channels.

In Catalonia, AQuAS carried out the first exploratory qualitative study at the end of 2016 using a focus group of parents and children assigned to a primary care team. Low value practices in paediatrics are frequently associated with an over-diagnosis regarding antibiotics, bronchodilatadors, antipyretics or imaging tests, among others. These scenarios have been transferred to the debate with patients themselves. In total, seven women, mothers and grandmother of 14 children participated.

The first point of discussion was the most important elements in a consultation with health professionals and it was found that the treatment (29%) and information received (28%) are the most important elements received by professionals (representing approximately 60% of those mentioned). The relationship with the professional comes next (15%, often related to the degree of trust), followed by the feeling that their wishes or needs are met (12%), information requested (9%) and the diagnosis (5%).

The participants did not know the concept of low value practice but did recognise situations of an excessive prescription of medication or the request of unnecessary tests, especially in emergency services and private consultations.

Regarding communication, the participants said they appreciated that professionals communicate in a simple and direct manner, explaining the reasons for decisions. Similarly, that they felt it was important to receive printed information from professionals which they could peruse later at home. They also said they would like more informative sessions or community groups where these types of subjects could be explained to them and so gain more knowledge about these types of practices.

In our context, this is the first exploratory study done to identify low value practices and the communicative strategies of the citizenry, being the start of a series of studies on the population. Nonetheless, one of the limitations with which we find ourselves was that the participation was lower than expected. Although the term ‘low value practices’ is not known, participants identify situations in which they have experienced them.

Similarly, it is important to underline how patients value the treatment and information received as well as the professional-patient relationship. In the same way, patients recognise the need for a professional’s communication skills and the need for tools to support an effective communicative exchange.

Post written by Johanna Caro Mendivelso (@jmcaro103).

Extra motivational bonus and… Let them have fun! Key elements for qualitative research with adolescents

1 Dec
Santi Gómez

There is no doubt that a qualitative methodology considerably enriches the development and assessment of public health interventions. It is often the ingredient which gives a dish that very special flavour or sometimes is even its main ingredient which, if of quality, makes the dish a real winner.

When both quantitative and qualitative methodologies are applied respectively to the same project, the necessary nutrients are provided to make the project work and can even produce compound molecules of a high nutritional value if applied in combination. The flavours of qualitative methodology acquire specially relevance in the dish when an innovative intervention  is being cooked up using new channels of communication to reach the target population. We are talking of the PEGASO Fit for future.

The chefs at the the Agency for Health Quality and Assessment of Catalonia (AQuAS) and those at the Catalan Agency of Public Health (ASPCAT), together with other European chefs, have the PEGASO platform brewing on the stove. Centred around the smartphone, it aims to be a new creative recipe for the promotion of healthy lifestyles among adolescents. Eating habits, physical activity and hours of sleep are the real protagonists of the signature dish which has begun to be served in different secondary education schools in Catalonia, Scotland, England and Italy in the way of different health apps, games and movement sensors.

The PEGASO project is using qualitative methodology in all phases to ensure that the “food” gets to the table successfully and that it be a well-received recipe which spreads out cheerfully and quickly to all kitchens. Thus, the focus groups held with adults and adolescents before the start of pre-pilot phase allowed us to draw up a clear shopping list to get the necessary ingredients before we donned our aprons. Subsequently, and during the 3 stages of the pre-pilot phase, adolescents in several focus groups carved up the different prototypes of the platform’s components after having appraised their quality to decide whether they should be included in the recipe or not.

But what are the key elements for qualitative research with adolescents? A focus group with adolescents is an intense activity which is worth doing. In fact, in the pre-pilot phase of the PEGASO project, we had the opportunity to lead teams in different schools; Nou Patufet school in Barcelona, Verge de la Salut de Sant Feliu de Llobregat and IES Ramón de la Torre in Torredembarra. These teams were made up of wonderful players that converted each match into a real show. To be able to see thrilling sporting events, we used the extra motivational bonus before each match. This is the first key element for qualitative research with adolescents.

The setting up of a group is essential for its later development and just like a pep talk in the locker room, the tactics of the game were explained in a simple way and the importance of each individual’s contribution to working as a team was highlighted. Additionally, and also prior to setting up groups, the importance given by the PEGASO project that participants choose their best skills while also enjoying the match was highlighted. In this way, the players gave their best at all times leaving the supporters dumbstruck from minute 1.

When dealing with highly motivated groups, the coach has no need to scream and shout from the sideline but rather just guide the team with a simple gesture so that it can progressively achieve the pre-established objectives. In this way, spectacular goals are scored which surprise everyone, including the coach and technical staff. This is pretty much what happened to the PEGASO team where good communication and the initial extra motivational bonus helped great sporting events of two or more hours to take place.

In the focus groups of the PEGASO project, the dribbling and passing between participants has been constant and at an individual level, enjoyment was apparent. This is the second key element in qualitative research with adolescents: that they enjoy themselves. If this is achieved, a group of adolescents can get to wherever they want with endless energy. In this way, attributes which collective imagination often assigns to the adolescent population such as passiveness or a lack of interest have been totally ousted and annulled by freshness, creativity and the urge to participate. Undoubtedly, as Jaume Funes would say, the adolescents who have participated in the PEGASO project have been unbearably charming; and I would add, extremely funny and insatiable players.

And after a hard workout, to bed ….! All the information provided by adolescent genius must be given the chance to rest. Rest after an activity is also a nutritious element. A calm demeanour after the adequate hours of sleep enables one to carry out a qualitative in-depth analysis. It is under these conditions that an outcomes report can be written which gives value to the development of the intervention that, as we have already commented, aims to  promote a healthy diet, physical activity and rest. The PEGASO project aspires to be a useful tool in promoting these healthy habits among adolescents. Have a good day, a good match and good night!

Post written by Santi Gómez, AQuAS-APSCAT.

This text are part of a series of posts about qualitative research started at the Ibero-American Congress of Qualitative Health Research which was held in Barcelona several months ago. The other posts in the series are: Utilities and challenges of applying qualitative methodology in community health projects written by Dolors Rodríguez-Arjona and Broadening perspectives in health service assessment written by Vicky Serra-Sutton.

Utilities and challenges of applying qualitative methodology in community health projects

13 Oct

This is a follow up of the previous post regarding health-applied qualitative methodology. It is linked to the VII Ibero-American Congress of Qualitative Health Research but today’s approach is focused on the application of this methodology in community health projects.

During the process of construction and implementation of community health programs, dynamics of participation and networking are promoted in all its phases: from the analysis and identification of needs, to prioritizing initiatives and subsequent implementation. Such processes involve the corresponding allocation of actions, according to technical areas, which should enable for planning the specific programs required for each population centre, and the initiatives proposed to tackle health inequalities.

In this sense, the Catalan Agency of Public Health (ASPCAT) is making a significant commitment to community health. PINSAP (Interdepartmental Public Health Plan) is concrete evidence of this fact and a government instrument which collects and promotes health actions from a global approach (health in all policies). The aim is to improve the health of the Catalan population by involving the entire community (from Primary Care, Public Health and municipal agents from all areas, to the community – cultural, social, sports, neighbourhood, youth, school associations, etc.).


One aspect which justifies this networking and cross-sector collaboration is one of the premises of PINSAP, that of determinants of health and the fight against social inequalities. As we all know, the health of the population depends not only on factors directly related to this element, but multiple factors in the immediate environment and the daily lives of people. For this reason, the objective is to develop a multidisciplinary type of project at a community level including health in all policies.

Within the context of PINSAP, community health projects called COMSalut (Health and Community) are being implemented in different municipalities throughout Catalonia. The community itself can, and does assist in providing health. The starting point for these community projects is the creation of a local steering committee or team (EML, as per the Catalan acronym) which includes members of the different areas mentioned above (primary care, public health, municipal services and members of the community fabric). The second step is the diagnosis of health, to be followed by the prioritization and proposals for action phases. The health diagnostic process begins with a quantitative diagnosis, in which different indicators of health and lifestyles and determinants of health are identified. This phase is then followed by a qualitative diagnosis.

One of the objectives of health diagnosis in a community process is to identify needs and resources/assets which influence the health of the population in a specific neighbourhood, district or town, by drawing on the opinion of the community, both from members of the public as well as professionals, within the framework of the community process. In order to do this, a qualitative diagnosis must be carried out using the specific techniques which this methodology entails given that the aim is to identify the individual opinions of informants resulting from shared experience in that particular environment, placing the health diagnosis in a specific socioeconomic and political context. It was decided to conduct two nominal groups in each local process, one professional and one made up of members of the public, during which participants were invited to discuss positive aspects of the community, areas for improvement and potential proposals for improvement, both in general terms, as well as issues that might directly affect health. The issues are presented from a general perspective so that informants take the broadest possible approach in the area of health, expanding their viewpoint to include all community resources which might contribute to or subtract from health.

This is precisely one of the challenges involved in these community processes, since during the course of these sessions, especially in the case of groups comprising members of the public, attendees tend to focus the discussion on issues regarding urban infrastructure and local organization, as well as airing political demands and discarding for example, aspects of habits and individual and shared group lifestyles (family, neighbours, close friends, etc.).

The experience of using qualitative tools adds value to the research process carried out by the Catalan Department of Health and this is exactly what we brought to the VII Ibero-American Congress of Qualitative Health Research, which took place in Barcelona from 5 to 7 September.

Carmen Cabezas (ASPCAT), Dolors Rodríguez Arjona (ASPCAT), Vicky Serra-Sutton (AQuAS), Santi Gómez Santos (AQuAS-ASPCAT)


Key ideas to take home:

  • It is very interesting to see how the same qualitative process is weaving a network of collaboration and participation at the professional as well as community level. Networking is a successful tool in the process, but at the same time is a result that remains within the community and becomes an asset. The first phase of the process requires the setting up of a Local Committee to carry out a community diagnosis and subsequent follow-up. The succession of meetings and interdisciplinary teamwork leads to networking.
  • At this point we encounter one of the greatest challenges, and that is to raise awareness within the community, through joint reflection, of the assets and resources of their immediate environment that affect their individual and collective health. This is presented as a driving force for change to achieve increased health.


On the other hand, these community processes present a number of challenges to be faced:

  • In the first place, appropriate sampling strategies should be used to ensure the participation of key members and those who are knowledgeable of the community to be researched. The latter can be achieved by involving the local team or committee in the process in order to reach vulnerable population groups or those with special needs, as would be the case for youth, elderly people living alone, women, long-term unemployed, immigrants, etc. The individuals who should contact potential informants must be those who know the community well and are appreciated by the community.
  • Secondly, this type of community process involves another challenge which is, how to translate the results into a credible technical report and one that is beneficial to local team members and the community at large.

As a reflection within the context of this conference and the development of local community processes, we can see that qualitative tools can provide opportunities for active participation. This leads to networking and motivation and the implication of the team and the community. The process itself achieves the ultimate goal of raising awareness within the community about the factors present in the immediate environment and this represents a potential driving force for change.

This result is achieved through interdisciplinary activities and motivation, values which are ever-present and very current. However, I believe that we should carefully rethink what is really involved in a multidisciplinary project. Is it simply the sum of forces or does it involve something else? I think we should undertake the task to put into practice networking operationally, through incorporating all those in the community and shouldering responsibility together. Interdisciplinary work implies cooperation between different agents, combining efforts towards a common goal and establishing synergies and talent-sharing.

Post written by Dolors Rodríguez Arjona, sociologist specializing in qualitative health research.