Filming Patient Interviews to Demonstrate the Value of Welfare Advice in General Practice: A Strategy for the Dissemination of Project Outcomes

Abstract

The Health Plus Project funded six qualified advice workers to provide welfare advice for patients in 30 general medical practices throughout the inner city of Bradford, England. The advice workers assisted patients with a range of welfare issues particularly relating to disability benefits and housing. When patient interviews were conducted to evaluate the service, they were also videotaped for presentation at a national conference on welfare advice in primary care. Filming the interviews raised a number of issues relating to the recruitment of patients, obtaining consent, and managing the communicative dynamics of the interviews. The video was, however, perceived as a very effective means to demonstrate the impact of the service on patients, and is recommended as a potential strategy for the dissemination of project outcomes.

Introduction

There is a large body of literature on the use of video in health and social science research. Video has been particularly useful for the analysis of interpersonal communication, for example, to analyse the quality of communication between doctor and patient (Coleman & Murphy, 1999; Elderkin‐Thompson & Waitzkin, 1999). In many cases video has been used for educational or training purposes to assess the performance of teachers or doctors (Coleman, 2000; Heath & Hindmarsh, 2002; Rosenstein, 2002) or to instruct patients in the control of chronic diseases (Marshall, Rothenberger & Bunnell, 1984). Video has also been used to evaluate the delivery of health care services, for example, in the observation of hospital emergency room practices (Morse & Pooler, 2002), or by means of video diary to assess patients' experiences of living with and managing chronic medical conditions (Rich & Patashnick, 2002).

There is, however, a further potential use of video as a medium for the dissemination of research findings. A study by Brannen (2002) used questionnaires and interviews to gain the views of 10–12 year old children about their experiences of growing up in different types of families (two‐parent, lone mother and step‐family). Several conferences were organized to disseminate the findings of the study to policymakers and practitioners in childcare. However, ‘instead of continuing to rely on the typical mechanisms used by qualitative researchers, namely to illustrate the research results with quotations drawn from transcripts’, it was decided to complement this with a video enabling children to speak for themselves about the issues raised in the research. (Although Brannen's initial idea had been to video children in order to illustrate the study's research findings, this actually evolved into a ‘rather different exercise’ of video‐recording reflective discussions amongst groups of children who were asked to comment on the research findings.)

It was similar sentiments that led to our use of video to film interviews with patients for a national conference on advice work in primary care, that is, to illustrate the benefits of welfare advice through a video of patients speaking for themselves. It is argued that this can be a very effective medium for demonstrating the impact of a service on patients and, as such, that it should be considered as a strategy for the dissemination of project outcomes. Filming patient interviews does, however, raise a number of technical and ethical issues and these are discussed.

The Health Plus Project

The Health Plus Project, funded by a Health Action Zone Innovations grant for three years, placed six qualified advice workers in 30 general practices throughout the inner city of Bradford. Typically, they conduct a three‐hour advice session for patients in the surgery each week, dealing with the whole range of welfare issues, including disability benefits, housing, employment rights, debt, etc. Patients may be referred by primary health care staff or may self‐refer. The project was initiated by two practice managers who recognized that their patients' health problems, particularly anxiety and depression, often appeared to be related to, or exacerbated by, social and economic factors.

The Department of Community and Primary Care at the University of Bradford evaluated the project using a combination of quantitative and qualitative methods (Greasley & Small, 2002a, 2002b, 2005b; Greasley, 2005). Table 1 provides an overview of the evaluation methodology. Interviews with advice workers and primary care professionals highlighted advantages of the service for patients in terms of providing easier access to welfare advice (especially for older patients and those from minority ethnic origins), and benefits for practices in terms of providing a resource to refer patients for help. The advice workers assisted patients with a variety of welfare issues and raised over £2 million in benefits for patients over a two‐year period (Greasley & Small, 2005a).

Table 1 Overview of Health Plus Evaluation

Service users	Service providers
Database created for the advice workers to record personal details for all clients seen as well as referral information, advice issues raised and any income generated through benefit claims.	Focus group with six advice workers to obtain their views about the benefits and problems encountered in providing the advice service in general practices.
Cohort of patients (all those attending for advice in first six months of project) invited to complete questionnaires at referral and six months follow‐up asking them to comment on the service and outcomes of advice.	Views of primary care staff obtained through a questionnaire to all practices and interviews at 14 practices 12 months into the project.

In May 2002 the Health Plus Project hosted a national conference on advice work in primary care to an audience of advice and health professionals. The aim was to highlight the relevance of welfare advice for patients in the context of primary care and to present outcomes of the project. It was important that the views of patients who had benefited from the service should be incorporated into the conference. This could have been accomplished by presenting comments from questionnaires completed by patients about the service they had received. Ideally, however, it was felt that the presence of patients at the conference, explaining their situation and how the advice had affected their lives, would have more impact. Since personal appearances at the conferences would have been a daunting experience for most patients, it was decided that the closest alternative would be to film patient interviews for presentation at the conference. A 20‐minute slot was thus allocated in the conference schedule to show interviews with patients talking about how the service had helped them.

Filming Patient Interviews: Issues Raised

Although the evaluation had obtained the views of service users through questionnaires, we also wanted to interview a small sample of patients who had used the service. This would enable us to present case studies illustrating the impact of the service on patients based upon the following questions:

• What were the problems that led you to seek advice?

• Were these problems affecting your health and quality of life?

• How did you find out about the service?

• What did the advisor do to help?

• Has this made any difference to your health and quality of life?

When the idea of filming patient interviews for the conference was raised, it was felt that the interviews and filming could be combined, with relatively brief edited versions being produced for the conference audience. The additional task of filming the interviews did, however, raise a number of issues relating to the recruitment of patients, obtaining consent, and managing the communicative dynamics of the interview.

Filming May Deter or Exclude Some Patients

The advice workers were asked to identify patients who had benefited from the service and who would be willing to be interviewed about their experience. Since we only had a 20‐minute slot at the conference we were aiming to show interviews with between five and eight patients. Ideally, we wanted a cross‐section of patients in terms of the type of help they had received (benefits, housing, debt, etc.) and ethnicity; we were particularly keen to obtain the views of south Asian women who constituted the largest category of service users.

The advice workers did, however, experience some difficulty in identifying patients who were willing to be interviewed. This is partly due to an understandable reluctance in disclosing information publicly about personal health (and social) problems, and welfare benefits help. However, some patients were enthusiastic about being interviewed: they had benefited from the project and since the evaluation might influence subsequent funding of the project they were willing to help. The advice workers identified seven patients who indicated that they would be willing to participate in the interviews (see Table 2).

Table 2 Patients Identified for Interview

White female in her 70s, living alone. As well as undergoing chemotherapy, she had broken her hip and leg, and so had mobility problems when she came out of hospital. The nurse at her general practice referred her to the advice worker for help to get a disabled ‘badge’ for her car so that her family and friends could take her out and use disabled parking. It was also discovered that she was due income support and council tax benefit, but had not been aware of this.

South Asian male, mid 40s. Illness and marital problems had led to stress and depression. He wanted re‐housing. The advice worker managed to get him re‐housed and also referred him to a counsellor to help him with his depression.

Black male, mid 40s, living with wife. Having retired due to breathing problems from working with industrial materials, his disability living allowance had been stopped and he had problems with debt. The advice worker helped to re‐negotiate his debt and managed to get his disability living allowance reinstated.

White female in her 70s, living alone, and undergoing periodic stays in hospital for tests and blood transfusions related to angina. The advice worker assisted her claim for attendance allowance.

White male, mid 70s, living with wife suffering from Alzheimer's disease. The advice worker helped them claim for attendance allowance, council tax benefit, and a discounted gas and electric scheme.

South Asian male in his mid 20s, suffered from severe haemorrhoids and received help with welfare benefits (withdrew prior to filming).

White male, 50s, suffered a stroke and received help with welfare benefits (withdrew prior to filming).

It was disappointing to note, however, that the advice workers had not identified any south Asian women who were willing to be interviewed. One factor that had restricted the number of south Asian women who were approached was the large proportion not able to understand and speak English. Although interviewing using an interpreter was feasible, it would have been an additional complication in the short time available to conduct the interviews before the conference. Alternatively, it might have been possible to superimpose an audio translation on the video. This highlights the need to cater for groups who may otherwise be excluded from interviews, for example, due to language or disability issues.

Filming Raises Issues of Consent

Qualitative researchers, according to Boschma, Yonge and Mychajlunow (2003, p. 129), ‘are concerned with privacy, which means protecting the individual; with confidentiality, which refers to protecting data; and with anonymity, which refers to hiding any information that could identify the participants’. Filming interviews for presentation at a national conference infringes each of these principles and therefore the issue of patient consent is critical.

The researcher visited each patient, with their advice worker, to outline the interview process and the nature of consent. It was emphasized that patients were under no obligation to partake in the interviews but, if they were interested, that they should talk it over with family or friends. It was further stressed that they could change their mind at any time. The researcher felt that it was especially important to stress these points since patients may have felt obliged to give interviews having received a great deal of help from the advice workers, including, in most cases, additional income through benefit claims. In this respect it was interesting to note that the researcher's insistence on fully explaining the nature of consent to patients, and the option to ‘change your mind at any time’, was perceived by one advice worker as ‘trying to put the client off’.

After the researcher had discussed the interviews with patients, all seven contacted their advice worker and agreed to participate. However, two later contacted their advice workers to say that they had decided not to take part. One was a man who had suffered a stroke which affected his speech, and who felt, after discussion with his wife, that speaking under filming conditions might prove too stressful. The other was a young man from the south Asian community whose health issue was haemorrhoids, which he may have felt some embarrassment talking about. Coleman (2000) notes that the number of patients who consent to video‐recording of their consultations with GPs reduces as the number of opportunities to ‘opt out’ increases. The fact that these two patients changed their minds and decided not to participate may reflect the researcher's insistence in fully outlining the interview process and the nature of consent.

It may have been possible to disguise the identity of participants by masking facial features and speech patterns. However, aside from the technical difficulties in achieving this, it was felt that such processing would have detracted from the impact of the video.

Filming Distorts the Communicative Process

Conducting patient interviews in the presence of a cameraman, with the aim of presenting the results at a conference, places a number of limitations on the interviewing process. First, there are time constraints, which may limit exploration of certain issues. Second, there may be issues of style as well as content: the interviewer is not only seeking answers to questions but is also conscious of the communicative impact of the recorded answers—will it be clear on the video? Thus there is a conscious effort not only to obtain the information, but also to deliver it in the right way for the video presentation.

From a technical point of view the communicative process is also distorted by the need to avoid speaking over the interviewee, since this would be viewed as interruptions from an unidentified off‐camera presence. The technique should be to allow the interviewee to speak, and ask questions or comment at the close of their speech. This meant that the interviews had a very formal structure of question–answer–question–answer format. It called for restraint upon the interviewer not to ask questions or make comments as they arise but to wait until the interviewee had finished speaking. This made it difficult to pick up on points as they arose, and inevitably some points were lost.

Brannen (2002) notes similar constraints in her video‐recordings of discussion groups with children for presentation at conferences. In contrast to an earlier phase of research focus groups (not video‐recorded) which were ‘interactive’ and ‘wide ranging’, the recorded discussions were much more focused and formal with less social interaction, more like structured interviews with little follow‐up probing as might have been done in a research interview.

From the interviewees' perspective, the presence of a camera, and the fact that what they say is neither confidential nor anonymous, may of course inhibit communication of critical or negative comments. This issue was, however, of less concern in our context since we were interviewing patients who had benefited from the service.

Presenting the Interviews

The edited interviews with five patients were presented sequentially, and introduced simply as ‘Client 1’, ‘Client 2’, etc. The whole screening lasted approximately 15 minutes. Each interview revealed a person whose health and quality of life had been improved through help with welfare issues. Their stories, a few examples from over 2,000 who attended for advice, provided first‐person accounts of how the service helped change lives for the better. How, for example, an older woman undergoing chemotherapy, who had broken her hip, received help to get a disabled ‘badge’ for her car—so that her family and friends could take her out and use disabled parking:

… now I can go shopping with the badges in the car and I can go to other places … [Family/friends] can even take me into town, shop in town you know like the Arndale in the one place. I can stay there and wander about or I can go somewhere else, anywhere, whereas I was just tied in before … It has given me a bit more freedom. Other friends that have cars can collect me you see. Like next Tuesday three other ladies I used to work with who are now retired—we go out for a meal every so often. One lady has a car so she picks me up, takes us out for a meal and we're doing that next Tuesday again. So yes, it's helped a lot.

Another older woman undergoing periodic stays in hospital for tests and blood transfusions related to angina admitted that she ‘wasn't eating right. I was just making do’. She went on to explain how the extra welfare benefits she received had made the ‘difference between going and looking at things and being able to buy them …’, and reflected, ‘I could have claimed years since but I didn't. I didn't know about it, did I’. An older man who had been looking after his wife who had severe Alzheimer's made this same point: ‘We never got anything for years. If Dr […] hadn't put us on to the advice worker we would never have known anything about it …’

The primary advantage of advice workers operating within the context of general practices is that they provide relatively easy access to welfare advice, facilitating the identification of cases like these that are so often overlooked. (Take‐up of benefit entitlements by pensioners in the UK is lower than the population as a whole, with estimates of up £1.86 billion unclaimed during 1999–2000; National Audit Office, 2002.) Being able to see these patients and hear them talking about how the service has impacted on their lives provides the most powerful illustration of project outcomes.

Reception at the Conference

The conference attracted a great deal of interest with 236 health and advice professionals in attendance. It was a good opportunity to sell the idea of providing welfare advice in general practice to health staff in particular—including our own Primary Care Trust—which had yet to commit further funding. A total of 140 people returned evaluation sheets rating the various sessions throughout the day. From Table 3 we can see that the video of patients received the most positive evaluation of all the sessions with 46% rating it as ‘excellent’ and 48% as ‘good’. Its impact, especially on potential funders, is illustrated in the following comments:

Table 3 Evaluation of Conference Sessions by Attendees (N = 140)

	Ratings %
Session	Excellent	Good	Satisfactory	Poor	Total
Morning presentations by service providers	31	60	8	1	100
Afternoon presentations by service providers	23	63	13	1	100
Video of patients	46	48	5	1	100
Panel discussion & questions	12	68	20	0	100

Very useful especially for PCT [Primary Care Trust] staff. I hope it will be made widely available.

Should be compulsory viewing for funders.

Much more useful—a good way to showcase success.

This last comment presumably means it is more useful (effective) than just listening to service providers talking about the project.

When the two practice managers who initiated the project were later interviewed about the project, they commented that the video had provided the most powerful feedback for them about the impact of the project.

Conclusion

An essential part of research is dissemination. Filming interviews can provide a very accessible and effective means to illustrate the impact of a project on service users, especially stakeholders and other interested parties who may wish to initiate similar projects. It shows the real people behind the statistics and is recommended as an excellent way to communicate qualitative data. It does, however, place a number of limitations on the interviewing process and for these reasons cannot be simply superimposed upon a schedule of interviews with service users. In our case it was best used as a discrete means by which to showcase success.

The video has since been used for other reasons (with the written consent of patients): for training advice workers, teaching health professionals, and for presentation at an international conference. Additionally, when the project was short‐listed for two national awards the video was shown to delegations from the awarding bodies and some of the patients interviewed for the video were available to discuss the project. In this respect, the video not only proved an excellent means of communicating the views of service users, but also functioned to further involve them in the dissemination process (cf. Brannen, 2002). The involvement of service users is central to health services in the UK (Department of Health, 2000).

In the past, access to video technology has been limited and the costs prohibitive. Our video was produced for under £300. Perhaps in future, especially with digital technology, more and more researchers will consider the use of video to illustrate the impact of projects on service users and to disseminate this information in this most accessible and effective way.

Acknowledgements

The author would like to acknowledge the role of Nick Hodgkinson (welfare rights specialist and conference organizer) for suggesting the video of patient interviews, and also for helping to edit the mass of footage for the conference. Thanks also to the advice workers and patients involved in the interviews, George Scully (Project Coordinator), and Wendy Calvert for comments on an earlier draft.

Additional information

Notes on contributors

Peter Greasley

Peter Greasley is a Lecturer in the Division of Health Care Studies, and the Graduate School, at the University of Bradford.