• Predicting mortality among a general practice-based sample of older people with heart failure

      Barnes, S.; Gott, M.; Payne, S.; Parker, C.; Seamark, D.; Gariballa, S.; Small, Neil A. (2008)
      Objective: To identify factors available to general practitioners (GPs) that are predictive of mortality within a general practice-based population of heart failure patients, and to report the sensitivity and specificity of prognostic information from GPs. Methods: Five hundred and forty-two heart failure patients aged >60 years were recruited from 16 UK GP surgeries. Patients completed quality-of-life and services use questionnaires every 3 months for 24 months or until death. Factors with independent significant association with survival were identified using Cox proportional hazards regression analysis. Results: Women had a 58% lower risk of death. Patients self-reporting New York Heart Association Classification III or IV had an 81% higher risk of death. Patients aged 85+ years had over a five-fold risk of death as compared with those aged <65 years. Patients with a co-morbidity of cancer had a 78% higher risk of death. Of the 14 patients who died in a 12-month period, the GPs identified 11 (sensitivity 79%). They identified 133 of the 217 who did not die (specificity 61%). Discussion: Predictors readily available to GPs, such as patient characteristics, are easy to adapt to use in general practice, where most heart failure patients are diagnosed and treated. Identifying factors likely to influence death is useful in primary care, as this can initiate discussion about end-of-life care.
    • Predictive accuracy of enhanced versions of the on-admission National Early Warning Score in estimating the risk of COVID-19 for unplanned admission to hospital: a retrospective development and validation study

      Faisal, Muhammad; Mohammed, A. Mohammed; Richardson, D.; Steyerberg, E.W.; Fiori, M.; Beatson, K. (2021-09-13)
      The novel coronavirus SARS-19 produces 'COVID-19' in patients with symptoms. COVID-19 patients admitted to the hospital require early assessment and care including isolation. The National Early Warning Score (NEWS) and its updated version NEWS2 is a simple physiological scoring system used in hospitals, which may be useful in the early identification of COVID-19 patients. We investigate the performance of multiple enhanced NEWS2 models in predicting the risk of COVID-19. Our cohort included unplanned adult medical admissions discharged over 3 months (11 March 2020 to 13 June 2020 ) from two hospitals (YH for model development; SH for external model validation). We used logistic regression to build multiple prediction models for the risk of COVID-19 using the first electronically recorded NEWS2 within ± 24 hours of admission. Model M0' included NEWS2; model M1' included NEWS2 + age + sex, and model M2' extends model M1' with subcomponents of NEWS2 (including diastolic blood pressure + oxygen flow rate + oxygen scale). Model performance was evaluated according to discrimination (c statistic), calibration (graphically), and clinical usefulness at NEWS2 ≥ 5. The prevalence of COVID-19 was higher in SH (11.0 %=277/2520) than YH (8.7 %=343/3924) with a higher first NEWS2 scores ( SH 3.2 vs YH 2.8) but similar in-hospital mortality (SH 8.4 % vs YH 8.2 %). The c-statistics for predicting the risk of COVID-19 for models M0',M1',M2' in the development dataset were: M0': 0.71 (95 %CI 0.68-0.74); M1': 0.67 (95 %CI 0.64-0.70) and M2': 0.78 (95 %CI 0.75-0.80)). For the validation datasets the c-statistics were: M0' 0.65 (95 %CI 0.61-0.68); M1': 0.67 (95 %CI 0.64-0.70) and M2': 0.72 (95 %CI 0.69-0.75) ). The calibration slope was similar across all models but Model M2' had the highest sensitivity (M0' 44 % (95 %CI 38-50 %); M1' 53 % (95 %CI 47-59 %) and M2': 57 % (95 %CI 51-63 %)) and specificity (M0' 75 % (95 %CI 73-77 %); M1' 72 % (95 %CI 70-74 %) and M2': 76 % (95 %CI 74-78 %)) for the validation dataset at NEWS2 ≥ 5. Model M2' appears to be reasonably accurate for predicting the risk of COVID-19. It may be clinically useful as an early warning system at the time of admission especially to triage large numbers of unplanned hospital admissions.
    • The predictive moment: reverie, connection and predictive processing

      McVey, Lynn; Nolan, G.; Lees, J. (2020-07)
      According to the theory of predictive processing, understanding in the present involves non-consciously representing the immediate future, based on probabilistic inference shaped by learning from the past. This paper suggests links between this neuroscientific theory and the psychoanalytic concept of reverie–an empathic, containing attentional state–and considers implications for the ways therapists intuit implicit material in their clients. Using findings from a study about therapists’ experiences of this state, we propose that reverie can offer practitioners from diverse theoretical backgrounds a means to enter the predictive moment deeply, making use of its subtle contents to connect with clients.
    • Predictors of awareness of functional ability in people with dementia: the contribution of personality, cognition, and neuropsychiatric symptoms. Findings from the IDEAL programme

      Martyr, A.; Gamble, L.D.; Nelis, S.M.; Collins, R.; Alexander, C.M.; Morris, R.G.; Quinn, Catherine; Pentecost, C.; Rusted, J.M.; Victor, C.; et al. (2022)
      Introduction: Discrepancy scores reflecting the difference between parallel ratings made by people living with dementia (PwD) in the mild-to-moderate stages and by their informants provide a way to investigate awareness of functional ability in relation to activities of daily living (ADL). Methods: Two measures of ADL (Functional Activities Questionnaire; Dependence Scale) were completed by 1,227 PwD and their informants in the IDEAL cohort study baseline assessment. Self-rated and informant-rated scores were used to calculate discrepancies, which were used as an indicator of awareness of functional ability. Smaller discrepancy scores were considered to reflect greater awareness on the part of PwD. PwD completed questionnaires on depression, personality, comorbidities, neuropsychiatric symptoms, and completed a measure of cognition. Informants provided ratings of stress. Univariable and multiple regressions were used to investigate factors related to ADL discrepancy. Results: A similar pattern of associations were found for both ADL discrepancy scores. Smaller discrepancy scores were associated with higher levels of depression, higher neuroticism, fewer neuropsychiatric symptoms, higher comorbidity, lower carer stress, and receipt of less than 1 hour of care per day from the informant. Discussion/Conclusion: There was a clear pattern of factors that were associated with greater awareness for both measures of functional ability. These factors associated with smaller discrepancy scores could be used to identify PwD who might benefit from targeted interventions to support their independence.
    • Predictors of self-reported adherence to antihypertensive medicines: A multinational, cross-sectional survey

      Morrison, V.L.; Holmes, E.A.F.; Parveen, Sahdia; Plumpton, C.O.; Clyne, W.; de Geest, S.; Dobbels, F.; Vrijens, B.; Kardas, P.; Hughes, D.A. (2015-03)
      Background Nonadherence to antihypertensive medicines limits their effectiveness, increases the risk of adverse health outcome, and is associated with significant health care costs. The multiple causes of nonadherence differ both within and between patients and are influenced by patients’ care settings. Objectives The objective of this article was to identify determinants of patient nonadherence to antihypertensive medicines, drawing from psychosocial and economic models of behavior. Methods Outpatients with hypertension from Austria, Belgium, England, Germany, Greece, Hungary, The Netherlands, Poland, and Wales were recruited to a cross-sectional online survey. Nonadherence to medicines was assessed using the Morisky Medication Adherence Scale (primary outcome) and the Medication Adherence Rating Scale. Associations with adherence and nonadherence were tested for demographic, clinical, and psychosocial factors. Results A total of 2595 patients completed the questionnaire. The percentage of patients classed as nonadherent ranged from 24% in The Netherlands to 70% in Hungary. Low age, low self-efficacy, and respondents’ perceptions of their illness and cost-related barriers were associated with nonadherence measured on the Morisky Medication Adherence Scale across several countries. In multilevel, multivariate analysis, low self-efficacy (odds ratio = 0.73; 95% confidence interval 0.70–0.77) and a high number of perceived barriers to taking medicines (odds ratio = 1.70; 95% confidence interval 1.38–2.09) were the main significant determinants of nonadherence. Country differences explained 11% of the variance in nonadherence. Conclusions Among the variables measured, patients’ adherence to antihypertensive medicines is influenced primarily by their self-efficacy, illness beliefs, and perceived barriers. These should be targets for interventions for improving adherence, as should an appreciation of differences among the countries in which they are being delivered.
    • Preference of non-pharmaceutical preoperative anxiety reduction intervention in patients undergoing elective surgery

      Dagona, Sabo S.; Archibong, Uduak E.; McClelland, Gabrielle T. (2018-12)
      For patients to be treated, decisions about their care must be made before treatment begins. In case of pre-operative anxiety, it is currently unknown how clinicians and patients discuss information about the issue, and it is also not known whether clinicians consider (or are ready to consider) their patients’ preferences of non-pharmaceutical pre-operative anxiety reduction interventions. At present no study has been conducted to find information on surgical patients’ preferences of, and their involvement in decisions about non-pharmaceutical interventions for reducing their pre-operative anxiety. This paper investigates elective surgical patients’ involvement in treatment decisions with the aim of finding out their preferred non-pharmaceutical pre-operative anxiety reduction interventions before they undergo elective surgery. Method: A survey method was used to collect data on patients’ preference of non-pharmaceutical preoperative anxiety reduction interventions at a tertiary health facility in Nigeria. Participants: A sample of 30 participants-17 male and 13 female, schedule to undergo surgical operations was selected using a convenient sampling method. Their ages range between 17 to 70 years (mean age = 41.03 and standard deviation = 16.09). Study design/procedure: To elicit preference of interventions, the study participants were presented with cards that contain picture of surgical patient receiving one of the non-pharmaceutical interventions used in reducing pre-operative anxiety. The pictures were presented one at a time for 30-40 seconds. The researcher then gives the participants a sheet of paper with the different interventions boldly written for the participants to rank order them according to the degree of their preferences. Through this process, data was collected from all the 30 participants. Results: The results obtained were entered into SPSS for analysis. Descriptive statistics, at 95 % confidence was calculated to estimate the percentage, mean, standard deviation and confidence intervals based on the participants’ preference of the interventions. Discussions: The findings were discussed alongside the existing literature and recommendations were offered for clinical practice and further research.
    • Pregnancy related telephone consultations to an out-of-hours provider: a retrospective database study

      Haith-Cooper, Melanie; Stacey, T.; Clements, E.; Mohammed, Mohammed A.; Edwards, E. (2015)
      There is a marked increase in the number of General Practitioner (GP) organisations across Europe providing out of hours (OOH) emergency primary care services whereby GPs and/or Nurse Practitioners (NPs), provide telephone consultations to patients (Giesen et al., 2007a, McKinstry et al., 2009, Derkx et al., 2009). This has been an important development to manage the rising demand for health care with increasingly scarce resources (Blank et al., 2012, Purc-Stephenson and Thrasher, 2010) and also reduces unnecessary attendance at accident and emergency departments or home visits by GPs (Bunn et al., 2005, Roberts et al., 2008)... In this study we describe the characteristics of telephone consultation calls made by pregnant women to an OOH service run by a GP co-operative and also to compare and contrast the differences between the way the calls were handled by GPs and Nurse Practitioners (NPs). The NPs were qualified and registered nurses experienced in primary care or emergency care settings and none were practicing.
    • Pregnant and seeking asylum; exploring experiences ‘from booking to baby’

      Lephard, E.; Haith-Cooper, Melanie (2016-02-02)
      Pregnant women seeking asylum in the UK may be particularly vulnerable with poor underlying health, more complex pregnancies and an increased risk of maternal and perinatal mortality. Studies have shown that some women seeking asylum have poor experiences of maternity care. This is despite the implementation of NICE guidelines to improve care for women with complex social factors. This article reports on a phenomenological study undertaken in West Yorkshire, aiming to explore the maternity care experiences of local pregnant asylum seeking women, to inform service development. Six women were interviewed over a three-month period. The findings focused more broadly on their experiences of living in the UK whilst being an asylum seeker and pregnant rather than focusing on maternity care, although this was included. Five key themes emerged: ‘pre-booking challenges’, ‘inappropriate accommodation’, ‘being pregnant and dispersed’, ‘being alone and pregnant’ and ‘not being asked or listened to’. These findings could be used as the basis for training midwives to understand how the difficulties women experience can impact on their health and social needs.
    • Prehension of a flanked target in individuals with amblyopia.

      Buckley, John G.; Pacey, Ian E.; Scally, Andy J.; Barrett, Brendan T.; Panesar, Gurvinder K. (2015-11)
      Purpose: Reduced binocularity is a prominent feature of amblyopia and binocular cues are thought to be important for prehension. We examine prehension in individuals with amblyopia when the target-object was flanked, thus mimicking everyday prehension. Methods: amblyopes (n=20, 36.4±11.7 years; 6 anisometropic, 3 strabismic, 11 mixed) and visually-normal controls (n=20, 27.5±6.3 years) reached forward, grasped and lifted a cylindrical target-object that was flanked with objects on either (lateral) side of the target, or in front and behind it in depth. Only 6 amblyopes (30%) had measurable stereoacuity. Trials were completed in binocular and monocular viewing, using the better eye in amblyopic participants. Results: Compared to visual normals, amblyopes displayed a longer overall movement time (p=0.031), lower average reach velocity (p=0.021), smaller maximum aperture (p=0.007) and longer durations between object contact and lift (p=0.003). Differences between groups were more apparent when the flankers were in front and behind, compared to either side, as evidenced by significant group-by-flanker configuration interactions for reach duration (p<0.001), size and timing of maximum aperture (p≤0.009), end-of-reach to object-contact (p<0.001), and between object contact and lift (p=0.044), suggesting that deficits are greatest when binocular cues are richest. Both groups demonstrated a significant binocular advantage, in that in both groups performance was worse for monocular compared to binocular viewing, but interestingly, amblyopic deficits in binocular viewing largely persisted during monocular viewing with the better eye. Conclusions: These results suggest that amblyopes either display considerable residual binocularity or that they have adapted to make good use of their abnormal binocularity.
    • The preparation and practice of disabled health care practitioners: exploring the issues.

      Hargreaves, J.; Dearnley, Christine A.; Walker, Stuart A.; Walker, L. (2014)
      Regulatory bodies governing health professions and professional education set clear expectations regarding fitness to practise. Within the UK, the Equality Act, 2010, poses a challenge to regulators, educators and employers to ensure that people are not excluded on the basis of disability and to facilitate inclusion. This research took a mixed methods approach to exploring the tensions between Higher Education providers and placement providers in the health sector. Disabled and nondisabled students and health professionals engaged in semistructured interviews and a survey in order to explore their beliefs and experiences. The findings suggest that applying equality legislation within health settings may be particularly difficult and that ¿disability¿ is an ambiguous and multifaceted concept. Whilst small in scale, the findings have given a voice to a professional group who are underrepresented in research and have raised a number of important issues that merit discussion and further scrutiny.
    • Presence of bias in radiographer plain film reading performance studies

      Brealey, S.; Scally, Andy J.; Thomas, N. (2002)
      Purpose To raise awareness of the frequency of bias that can affect the quality of radiographer plain film reading performance studies. Methods Studies that assessed radiographer(s) plain film reading performance were located by searching electronic databases and grey literature, hand-searching journals, personal communication and scanning reference lists. Thirty studies were judged eligible from all data sources. Results A one-way analysis of variance (ANOVA) demonstrates no statistically significant difference (P=0.25) in the mean proportion of biases present from diagnostic accuracy (0.37), performance (0.42) and outcome (0.44) study designs. Pearson¿s correlation coefficient showed no statistically significant linear association between the proportion of biases present for the three different study designs and the year that the study was performed. The frequency of biases in film and observer selection and application of the reference standard was quite low. In contrast, many biases were present concerning independence of film reporting and comparison of reports for concordance. Conclusions The findings indicate variation in the presence of bias in radiographer plain film reading performance studies. The careful consideration of bias is an essential component of study quality and hence the validity of the evidence-base used to underpin radiographic reporting policy.
    • Preservation of self in people with dementia living in residential care: A socio-biographical approach.

      Surr, Claire A. (2006)
      The maintenance of self in dementia is associated with socio-biographical factors. The theoretical literature suggests that interpersonal relationships, the social context, and the generation of stories are important in maintenance of self. Empirical research on self in dementia supports this but has been predominantly conducted with participants living in the community. Living in residential care brings additional threats to self. This paper presents a study examining the relevance of a socio-biographical theory of self to people with dementia living in residential care. Between 3 and 8 tape-recorded and transcribed unstructured interviews were conducted with 14 people with dementia who were living in 4 residential homes throughout England and Wales, over a 6-24-month period. They were analysed using an interpretive biographical methodology. The results provide evidence to support the relevance of a socio-biographical theory of self to this group. Relationships with family, other residents and care home staff were important for maintenance of self. Social roles related to work, being part of a family, caring for others and being cared for, were particularly significant for self in this group. The creation of a life story, stories of selected life events, and the telling of stories with possible metaphorical interpretations were also important for the maintenance of self. The results also suggest that psychological and embodied factors may be relevant to the self in dementia. The study suggests that staff working in residential homes should consider these elements if they are to provide care that supports maintenance of self for people with dementia. Implications for future research are discussed.
    • Pressure ulcer incidence: do patients retain information

      Vowden, Kath; Warner, V.; Collins, Jane B. (2016)
      Many service commissioners are demanding a reduction in pressure ulcer prevalence and regard pressure ulceration as a key indicator of care quality. Within our area of practice, local commissioners have indicated that all health care providers in the district should work together to reduce pressure ulceration across the local health care economy. Health care professionals clearly have a critical role to play in patient assessment, risk categorisation, care planning and equipment provision. However, this alone will not be sufficient to achieve the reduction targets which will involve effective patient engagement. National and International guidelines all recognise the importance of patient education in care and recognise the significance of patient involvement in personalised care planning and service provision. Hartigan et al have demonstrated the value of education leaflets in supporting pressure ulcer prevention in an elderly population. Patient support applications running on mobile phones and tablets are also available to assist in pressure ulcer prevention and patient education but are not widely used in a hospital setting. This study examines how effective standard verbal and written information is at delivering patient education for pressure ulcer prevention. Local hospital policy is that all patients identied as being at risk of developing pressure ulceration are provided with information on what a pressure ulcer is, what constitutes risk and how to assist staff in pressure ulcer prevention. The policy includes patient and carer involvement in care planning, and encouragement to report skin changes and pain to staff.
    • The prevalence and predictors of loneliness in caregivers of people with dementia: findings from the IDEAL programme

      Victor, C.R.; Rippon, I.; Quinn, Catherine; Nelis, S.M.; Martyr, A.; Hart, N.; Lamont, R.; Clare, L. (2021-07)
      Objectives: To establish the prevalence of loneliness among family caregivers of people with dementia and to identify potential risk factors for loneliness. Methods: Using data from the baseline wave of the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort study, we examined loneliness in 1283 family caregivers of people with mild-to-moderate dementia living in Great Britain. Multinomial regression was used to examine the relative influence of a series of risk factors for caregiver loneliness. Results: Almost half, 43.7%, of caregivers reported moderate loneliness and 17.7% reported severe loneliness. Greater social isolation and increased caregiving stress were linked with both moderate and severe loneliness. Better quality of relationship with the person with dementia along with increased levels of well-being and life satisfaction were associated with a lower relative risk of reporting both moderate and severe loneliness. Discussion: This study examines the prevalence and predictors of loneliness in a large sample of family caregivers of people with dementia. Notably over two-thirds of caregivers in our sample reported feeling lonely. Interventions aimed at reducing caregiving stress and supporting meaningful relationships may go some way towards helping to reduce loneliness.
    • Prevalence of bacterial vaginosis in lesbians and heterosexual women in a community setting.

      Evans, A.L.; Scally, Andy J.; Wellard, S.J.; Wilson, J.D. (2007)
      Objectives: High prevalence of bacterial vaginosis (BV) has been reported in lesbians but most studies were based in sexually transmitted infection clinic settings; therefore, we wished to determine the prevalence and risk factors of BV in lesbians and heterosexual women in a community setting in the UK. Methods: A cross-sectional study recruiting lesbian women volunteers from community groups, events, clubs and bars. Heterosexual women were recruited from a community family planning clinic. They self-swabbed to create a vaginal smear, which was Gram-stained and categorised as BV, intermediate or normal flora. They completed a questionnaire about age, ethnic group, smoking, genital hygiene practices and sexual history. Results: Of 189 heterosexuals and 171 lesbians recruited, 354 had gradeable flora. BV was identified in 43 (25.7%) lesbians and 27 (14.4%) heterosexuals (adjusted OR 2.45, 95% CI 1.25 to 4.82; p¿=¿0.009). Concordance of vaginal flora within lesbian partnerships was significantly greater than expected (27/31 (87%) couples, ¿¿=¿0.63; p<0.001). Smoking significantly increased the risk of BV regardless of sexuality (adjusted OR 2.65; p¿=¿0.001) and showed substantial concordance in lesbian partnerships but less than for concordance of flora. Conclusions: Women who identified as lesbians have a 2.5-fold increased likelihood of BV compared with heterosexual women. The prevalence is slightly lower than clinic-based studies and as volunteers were recruited in community settings, this figure may be more representative of lesbians who attend gay venues. Higher concordance of vaginal flora within lesbian partnerships may support the hypothesis of a sexually transmissible factor or reflect common risk factors such as smoking.
    • The prevalence of nonprescription cannabinoid-based medicines in British children's hospices: results of a national survey

      Tatterton, Michael J.; Walker, C. (2019-10)
      Background: Almost 50,000 children and young people are affected by life-limiting conditions in the United Kingdom, around a third of which use children's hospices. Anecdotal evidence suggests that cannabinoid-based medicines (CBMs), specifically cannabis oil (CO), are being used by families with increasing frequency to manage distressing symptoms. The use of most nonprescription CBMs in the United Kingdom remains illegal. Objective: The objective of the study was to identify the prevalence of CO use by families who use children's hospices in the United Kingdom, and the approaches taken by those services to manage it. Design: An electronic survey was sent to each of the 54 children's hospices in the United Kingdom between May and July 2018, comprising 10 questions. Results: Forty children's hospices from across the four countries of the United Kingdom responded to the survey, representing 74% of British children's hospices. About 87.5% of hospices knew of children who use CO therapeutically. Sixty-nine percent of those hospices have received requests to administer CO during an episode of care. Approaches by organizations around CO management varied across the sectors, including arrangements for storage, administration, and recording of its use. Hospices highlighted how the lack of available guidance made decision making more challenging. Only a third of responding organizations routinely questioned families about the use of cannabis when prescribing medicines. Conclusion: CO is used extensively by children who use children's hospices. Despite recognizing the use of CO, many hospices are unable to support it. There is a need for clear guidelines on how hospices should approach the care needs of children, allowing hospices to meet the needs of children who use CO, and families in a safe, consistent, and relevant way, safeguarding all children, families, and professionals within the organization.
    • A preventative lifestyle intervention for older adults (Lifestyle Matters): a randomised controlled trial

      Mountain, Gail; Windle, G.; Hind, D.; Walters, S.; Keertharuth, A.; Chatters, R.; Sprange, K.; Craig, C.; Cook, S.; Lee, E.; et al. (2017-07)
      Objectives To test whether an occupation based lifestyle intervention can sustain and improve the mental wellbeing of adults aged 65 years or over compared to usual care, using an individually randomised controlled trial. Participants 288 independently living adults aged 65 years or over, with normal cognition were recruited from two UK sites between December 2011 and November 2015. Interventions Lifestyle Matters is a NICE recommended multi-component preventive intervention designed to improve the mental wellbeing of community living older people at risk of decline. It involves weekly group sessions over four months and one to one sessions. Main outcome measures The primary outcome was mental wellbeing at 6 months (mental health dimension of the SF-36).Secondary outcomes included physical health dimensions of the SF-36, extent of depression (PHQ-9), quality of life (EQ-5D) and loneliness(de Jong Gierveld Loneliness Scale),assessed at 6 and 24 months. Results Data on 262 (intervention =136; usual care =126) participants were analysed using intention to treat analysis. Mean SF-36 mental health scores at six months differed by 2·3 points (95 CI -1·3 to 5·9; P=0·209) after adjustments. Conclusions Analysis shows little evidence of clinical or cost effectiveness in the recruited population with analysis of the primary outcome revealing that the study participants were mentally well at baseline. The results pose questions regarding how preventive interventions to promote wellbeing in older adults can be effectively targeted in the absence of proactive mechanisms to identify those who at risk of decline.
    • Princípios e práticas de formação de policiais para o atendimento às mulheres em situação de violência

      Macaulay, Fiona; Martins, J. (Brazilian Forum on Public Safety, 2020-10)
      This training manual on gender-based violence is intended for use by all those who train the police and other actors in the local protection networks. It outlines the principles of effective training based on the integrated competencies of knowledge, attitudes and skills, and emphasises the use of appreciative inquiry, group learning and dynamic techniques such as dramatisation and case-based learning
    • Problem Based Learning in a Women-centred Midwifery Curriculum

      Haith-Cooper, Melanie; MacVane Phipps, Fiona E.; Pansini-Murrell, J.; Ball, D. (1999)