ࡱ> U@ :bjbj "2NNNNNNNb8"d$b~L$ʐRٍNٍNNHNN ~8NN  P'nzXW\6H~zL ,bbNNNNN7 ٍٍbb&bb&  Policy Briefing Social and Organisational Implications of One Stop First Trimester Prenatal Screening ESRC Award reference Number L218252042 Sandall,J.1 Lewando-Hundt,G.2 Spencer,K.3 Williams,C.1 Heyman,B.4 1 Kings College, London, 2 University of TV, 3 Barking, Havering and Redbridge NHS Trust, 4 City University Introduction UK policy guidelines state that the offer of screening for Downs syndrome is to become a routine part of antenatal care. There may also be a shift to first trimester combined screening technologies, which achieve the greater level of accuracy required in the guidelines. This is accompanied by the move to first trimester combined screening technologies, which achieve a greater level of accuracy. This study of the only NHS site in England offering combined first trimester screening in a one stop clinic has provided the opportunity to look at implications prior to the possibility of wider scale implementation in the UK. The findings of this project are relevant for those using and delivering prenatal screening services, and those responsible for maternal health policy. What is the Innovative Health Technology ? Innovative health technologies (IHTs) such as new drugs, devices, procedures, hospital delivery systems and wider organisational and socio-technical change present policymakers and the public with major new concerns. The study took place in two district hospitals, one offering innovative first trimester screening (combined Nuchal Translucency and Maternal Serum Screening within a one-stop clinic) and the other, standard second trimester Maternal Serum Sscreening (with results within 1 week). In the one stop clinic, women were screened earlier in pregnancy, and got results back faster, and with greater accuracy. Uptake in the innovative site was higher (95% vs 63%), and screening was integrated with routine antenatal care of booking bloods and the 11-13 week scan,care , thus avoiding a second separate screening visit. Aim, Design and Methods We aimed to explore and compare the risks and benefits of innovative and established models of prenatal screening primarily for Downs syndrome. Specifically the: impact of new screening technologies on the social management of pregnancy, service delivery and professional roles ; participants broader responses to new technologies, and views about the routinisation of screening ; perceptions of self, the fetus, and the management of reproductive risk ; and lay and professional understanding of complex information, and influences on decision-making. A mixed method research design was used to separate out issues generic to all prenatal screening programmes as compared to those specific to the innovative technology. Findings are based on data collected from 2001 to 2004: prospective antenatal and postnatal surveys of 993 and 656 women respectively;; observation of 45 clinic/ultrasound sessions in hospital and the community;; interviews with 24 health professionals and a prospective cohort of 27 women and some partners on a range of screening pathways; and 90 audio-taped consultations. Key Findings Like all healthcare interventions, innovative health technologies offer benefits and harms and often have unintended consequences. These are as follows: What do women value ? * Over 90% of Most women in both sites valued said fast results, and , early screeningknowing results early in pregnancy were very important and having an early scan. In the standard site, 64% of those women who had screeningscreened paid for private screening (compared to 2% in the innovative site). P and payment was associated with social advantage. In addition, 75% of all women were prepared to pay for 1st trimester screening in a future pregnancy if it was not available free. * When women were asked what screening method they would prefer, if they got pregnant again, 79% of women said that combined screening at about 12 weeks was the their option. However, 19% of women in the standard site said none compared to 3% in the innovative site. * The NHS one-stop clinic offering first trimester screening provided what a large percentage of pregnant women in this study valued and wanted, and reduced inequities of access to first trimester screening for those women who wished to have it. Informed decision making Generic issues * Overall, 19% of women said prenatal screening was not fully discussed at booking, with significantly more women who were booked by healthcare assistants or GPs reporting this. * Overall, 30% of women reported that they would have liked more information than they were given, with significantly more women who: were under 21, having their first baby, or those who had no educationalwere either poorly educated qualifications or educated to degree level education reportinging this. Overall, 39% of women said that options after the test were not discussed and 84% of women also reported that discussions of what it is like to have a child with Downs Syndrome never happened. * Overall, 39% of women said that options after the test were not discussed and 84% of women reported that discussions of what it is like to have a child with Downs Syndrome never took place. * When asked if they felt under pressure to have screening, 6% of all women said yes , and this was associated with processes factors such as: not having as much time to decide;, not being able to discuss tests as much as they wanted;, and and with a positive attitude towards screening expressed by the health professional. Issues associated with Innovativeinnovative sitetechnology Uptake in the innovative site was 95% compared to 63% in the standard site, and screening was tightly integrated into the routine antenatal care of booking bloods and the 11-13 week dating scan. * In the innovative site, The routine and integrated nature of screening in the innovative site was reflected in 27% of women reporteding that they never really made up their mind, but went along with what was offered, compared to 4 % in the standard site. Furthermore, 45% of women in the innovative site answered that they had been offered a screening test as part of routine care and it was assumed I would be having it compared to 6% in the standard site. This suggests a tendency to go with the flow in a service where screening is integrated into routine antenatal care. * A total of 67% of women in the innovative site, compared to 357% in the standard site reported professionals to be positive encouraging about screening. These positive views were reflected by women and their partners in the innovative site, andpartners reflected this pattern. Fewer women (32%) in the innovative site perceived health professionals as neutral compared to 62% in the standard site. Implications for women * There is little knowledge about the short and long term effects and implications of raised anxiety in women who are screened, and specifically in women who screen positive. * There is little known about how the experience of screening earlier pregnancy affects the ways women feel about pregnancy, birth and parenting, and whether this affects the decisions they make. * It is not known whether the increased routinisation and high uptake of screening makes it harder to opt out of, and whether women who choose not to accept may feel stigmatised. Practice Implications * The introduction of the one stop clinic had a significant impact on the social and organisational management of care, requiring a reorganisation of antenatal care involving GPs, the hospital, sonographers, laboratory staff and midwives. * The overall impact on women of multiple screening provision needs to be taken into account as new screening systems are implemented. * The information needs of specific groups of women need greater attention, and will require different strategies. This includes a greater understanding of sources of information that women use apart from that provided by the NHS. * More attention needs to be given to the communication of risk information to women. * If the ideal of informed decision making is to be achieved, attention must be paid as to who should provide information, and the training needs of health professionals. Particularly GPs and health care assistants. * Additionally the timing of information giving needs to be reviewed in the light of how antenatal services are staffed and delivered. Wider Policy Implications * In the innovative site, fFirst trimester screening was popular with staff and women, and uptake was very high. However, shifting antenatal , making screening a routineto an opt out rather than opt in service. This raises issues for informed choice and non-directive counselling. Staff attitudes are an important influence on uptake of screening tests. In such settings, non-directive information giving may be harder to achieve. * If an ethical screening policy is built on the concepts of informed choice and non-directiveness, then the implementation of routine first trimester screening will may further erode such practices, which are already often more rhetoric than reality. The pace at which first trimester screening is being introduced and the potential consequences of the resulting routinisation for an ethical screening policy need wider debate. * The pace at which first trimester screening is being introduced and the potential consequences of the resulting routinisation for an ethical screening policy need wider debate. * The current debates are dominated by ideals of technical accuracy and individual choice. Further research is needed on the range of social relations that shape how, and what policies are put forward and the social shaping of womens choices. Practice Implications The information needs of some specific groups of women need greater attention and will require different strategies including a greater understanding of other sources of information that women use apart from that provided by the NHS. The overall impact on women of multiple screening system provision in pregnancy needs to be taken into account as new screening systems are implemented. More attention needs to be given to the communication of risk information to women. It should be considered who should provide information, and to the training of health professionals who provide advice if the ideal of informed consent is to be achieved. In particular, the role of GPs and healthcare assistants needs consideration. Additionally the timing of information giving needs to be reviewed. Implications for service users It is unknown whether there are any short or long term effects of wide scale routine screening in early pregnancy. The wider short and long term effects of raised anxiety are unknown on all women who are screened, and those who screen positive. It is unknown whether screening in early pregnancy affects how women feel about pregnancy, childbirth and parenting and the decisions they make. It is unknown whether the routinisation of screening may stigmatise women who prefer not to accept. Is it worth mentioning here that in terms of anxiety birth is a bigger worry than screening and that many felt relieved after screening.. Contacting the project team The final report and further publications will be available on the ESRC and project project team websites.  HYPERLINK "http://www.york.ac.uk/res/iht/introduction.htm" http://www.york.ac.uk/res/iht/introduction.htm  HYPERLINK "http://www.regard.ac.uk/regard/home/index_html" http://www.regard.ac.uk/regard/home/index_html? Project leads Gillian Lewando-Hundt  HYPERLINK "mailto:gillian.hundt@warwick.ac.uk" gillian.hundt@warwick.ac.uk, 024765 23543  HYPERLINK "http://www2.warwick.ac.uk/fac/cross_fac/healthatwarwick/" http://www2.warwick.ac.uk/fac/cross_fac/healthatwarwick/ HYPERLINK ""  Jane Sandall,  HYPERLINK "mailto:jane.sandall@kcl.ac.uk" jane.sandall@kcl.ac.uk, Clare Williams,  HYPERLINK "mailto:clare.2.williams@kcl.ac.uk" clare.2.williams@kcl.ac.uk 0207 848 3023  HYPERLINK "http://www.kcl.ac.uk/nursing/research/women.html" http://www.kcl.ac.uk/nursing/research/women.html Kevin Spencer,  HYPERLINK "mailto:KevinSpencer1@aol.com" KevinSpencer1@aol.com 01708 708031Bob Heyman,  HYPERLINK "mailto:b.heyman@city.ac.uk" b.heyman@city.ac.uk 0207 040 5727  HYPERLINK "http://www.city.ac.uk/sonm/hcru/index.html" http://www.city.ac.uk/sonm/hcru/index.html  Gillian Lewando-Hundt  HYPERLINK "mailto:gillian.hundt@warwick.ac.uk" gillian.hundt@warwick.ac.uk, 024765 23543 http://www2.warwick.ac.uk/fac/cross_fac/healthatwarwick/ Jane Sandall,  HYPERLINK "mailto:jane.sandall@kcl.ac.uk" jane.sandall@kcl.ac.uk, 0207 848 3023.  HYPERLINK "http://www.kcl.ac.uk/nursing/research/women.html" http://www.kcl.ac.uk/nursing/research/women.html 21st January 2005 :;=MNx    ' ( @ A m n ¼vvvvvrhrhrhraWh)CJ OJQJ h)5\HhXfh)h)h)H*OJQJh)OJQJh)5CJOJQJ\h)CJaJ h)CJHhzfh)CJ h)CJ$h)CJ$aJ h)aJh)CJ(aJ%j"h)5CJOJQJU\aJh)5CJOJQJ\aJ%jh)5CJOJQJU\aJ"<=MN $a$$a$DC$Eƀzf$a$ ]`::  f i  1 >  fؿoeaWIHhyfh)OJQJh)CJ OJQJh)h)OJQJaJ /h)OJQJcHdhdhdh^fmH sH 'h)OJQJcHdhdhdh^f#Hh_fh)OJQJmH sH #Hh^fh)OJQJmH sH Hh^fh)OJQJh)6OJQJ]h)OJQJ&h)6OJQJ]mH sH ^fh)OJQJmH sH fg4;Ro}Ϲ߫ߝ}iiU'h)OJQJcHdhdhdhzf'h)OJQJcHdhdhdhafHhufh)OJQJaJHhafh)OJQJaJHhafh)OJQJHh`fh)OJQJ+h)OJQJaJ cHdhdhdh`fHh`fh)OJQJaJ h)OJQJh)OJQJaJ Hhtfh)OJQJ+568CD}Īz_J5z_J(Hhfh)B*OJQJaJph(Hhvfh)B*OJQJaJph5Hhfh)B*OJQJaJo(phf5Hhfh)<B*OJQJaJ phf(Hhufh)B*OJQJaJph2Hhfh)B*OJQJaJphfHhfh)OJQJh)OJQJaJh)5CJ OJQJ\h)OJQJHhzfh)OJQJ6JKLppDC$EƀfG$C$Eƀfa$HKLMt˰lXND4D&h)B*OJQJ^JphHhwfh)OJQJaJ h)OJQJaJ h)OJQJaJ'Hhfh)<B*OJQJph2Hhfh)9<B*CJ OJQJaJ ph(Hhfh)B*OJQJaJph(Hhfh)B*OJQJaJph5Hhfh)B*OJQJaJo(phf5Hhfh)<B*OJQJaJ phf2Hhfh)B*OJQJaJphf LMnopup+DC$Eƀf$a$DC$EƀfDC$Eƀf+WXY\z{|lmnopq裈裈seQ=/Hhfh)OJQJ'h)OJQJcHdhdhdhXf'h)OJQJcHdhdhdhfHhfh)OJQJ(Hhfh)B*OJQJ^Jph4h)B*OJQJ^JcHdhdhdhxfph(Hhxfh)B*OJQJ^Jph(Hhbfh)B*OJQJ^Jph4h)B*OJQJ^JcHdhdhdhyfphh)B*OJQJ^Jphh)OJQJ^Jpq~.`S$ vC$Eƀǜf^v`a$DC$EƀÜfq~ .01=BV⯥ycG7h)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdhfmH sH +Hhfh)OJPJQJaJ mH sH +Hh͜fh)OJPJQJaJ mH sH +Hh˜fh)OJPJQJaJ mH sH h)CJOJQJh)5OJQJ\'h)OJQJcHdhdhdhzf'h)OJQJcHdhdhdhcf'h)OJQJcHdhdhdhfh)CJ OJQJ V]bnotvͽuͧ_uS;/h)OJPJQJaJ cHdhdhdhfh)OJPJQJaJ +HhȜfh)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdhfmH sH +Hhfh)OJPJQJaJ mH sH +Hh{fh)OJPJQJaJ mH sH h)OJPJQJaJ mH sH +Hhfh)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdhfmH sH \^_`de÷{c{Q?&?0Hhfh)H*OJPJQJaJ f#Hhfh)OJPJQJaJ #Hhfh)OJPJQJaJ /h)OJPJQJaJ cHdhdhdhcf/h)OJPJQJaJ cHdhdhdhf#Hhfh)OJPJQJaJ #Hhcfh)OJPJQJaJ h)OJPJQJaJ /h)OJPJQJaJ cHdhdhdh{f#Hh{fh)OJPJQJaJ #Hhfh)OJPJQJaJ Ͻ᫒waQ48Hh˜fh)B*OJPJQJ^JaJ mH phsH HhĜfh)OJQJaJ+h)OJQJaJcHdhdhdhĜf5h)OJQJaJcHdhdhdhĜff1Hhfh)<B*OJQJphf#Hhfh)OJPJQJaJ #Hhfh)OJPJQJaJ #Hhfh)OJPJQJaJ h)OJPJQJaJ #Hhfh)OJPJQJaJ RO$vC$EƀĜf^v`a$ $v^v`a$O$vC$Eƀf^v`a$&'8gdb`C$O$0C$Eƀf^`0a$G$C$EƀĜfa$')Ad89HJ㹯vlh`PF6Hhfh)OJQJaJ h)OJQJaJ Hh˜fh)OJQJaJ h)OJQJh)h)CJOJQJh)5OJQJ\,HhĜfh)cHdhdhdhf,HhĜfh)cHdhdhdhjfHhĜfh)Hh˜fh)>HhĜfh)6B*OJPJQJ]^JaJ mH phsH 8HhĜfh)B*OJPJQJ^JaJ mH phsH 89Hkb$h^ha$L0C$Eƀf^`0DC$EƀƜfNOP_`߻u_O?/?Hh˛fh)OJQJaJHhћfh)OJQJaJHhfh)OJQJaJ+h)OJQJaJcHdhdhdhlfHhlfh)OJQJaJHhkfh)OJQJaJ+h)OJQJaJcHdhdhdhfHhfh)OJQJaJh)OJQJaJHh˜fh)OJQJaJ h)OJQJaJh)OJQJaJ +h)OJQJaJ cHdhdhdhf#&)/0ӽwaQQa;+h)OJQJaJcHdhdhdhfHh̛fh)OJQJaJ+h)OJQJaJcHdhdhdh̛f+h)OJQJaJcHdhdhdhmfHhћfh)OJQJaJh)OJQJaJ+h)OJQJaJcHdhdhdh˛f+h)OJQJaJcHdhdhdhlf+h)OJQJaJcHdhdhdhf+h)OJQJaJcHdhdhdhkf01]S$ *C$Eƀf^*`a$N$0Eƀf^`0a$012;Sj}ʯʏtR3+h)OJQJaJ cHdhdhdhf<h)5<CJOJQJ\cHdhdhdhfmH sH BHhfh)5CJOJQJ\aJ cHdhdhdhf5h)5CJOJQJ\aJ cHdhdhdhf?h)56CJOJQJ\]cHdhdhdhfmH sH 5h)5CJOJQJ\aJcHdhdhdhf9h)5CJOJQJ\cHdhdhdhfmH sH /h)OJQJcHdhdhdhfmH sH  12m#I$ & FEƀfa$I$ & FEƀfa$G$C$Eƀfa$ Ǩnjv`J5 )Hhfh)5CJOJQJ\aJ)HhΜfh)5CJOJQJ\aJ+Hhfh)OJPJQJaJ mH sH +h)OJQJaJcHdhdhdhf+h)OJQJaJ cHdhdhdhf7h)OJPJQJaJ cHdhdhdhfmH sH =h)6OJPJQJ]aJ cHdhdhdhfmH sH 7h)OJPJQJaJ cHdhdhdhfmH sH 7h)OJPJQJaJ cHdhdhdhmfmH sH  QiG$C$EƀŜfa$G$C$Eƀfa$h^h !8KPQXek%蹠jQjj;+h)OJPJQJaJ mH sH +HhΜfh)OJPJQJaJ mH sH 1Hhfh)6OJPJQJ]aJ mH sH +Hhfh)OJPJQJaJ mH sH HhΜfh)OJQJaJ Hhfh)OJQJaJ 0Hhfh)5<CJOJQJ\mH sH )Hhfh)5CJOJQJ\aJ 3Hhfh)56CJOJQJ\]mH sH -Hhfh)5CJOJQJ\mH sH QdG$C$Eƀfa$S$ & F&C$EƀŜf^`a$%()+HRZnq̶t^B^B,+Hhfh)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdhfmH sH +Hhfh)OJPJQJaJ mH sH +Hhfh)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdhfmH sH h)OJPJQJaJ mH sH +Hhmfh)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdhmfmH sH .h)6OJPJQJ]aJ mH sH mf245?IJӷy]D1$h)OJQJf%Hhfh)OJQJf1h)OJQJcHdhdhdhff7h)5OJQJ\cHdhdhdhff-h)CJcHdhdhdhff!Hhfh)CJf+Hhfh)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdhfmH sH h)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdhfmH sH  gG$C$Eƀfa$G$C$Eƀfa$O$0C$EƀYf^`0a$45Ymd$h^ha$F$Eƀfa$H & FC$EƀfJNXY!9:írW=#3h)OJQJaJ cHdhdhdhfmH sH 3h)OJQJaJ cHdhdhdhܛfmH sH 4Hhfh)B*OJQJ^JaJ mH phsH 4HhΜfh)B*OJQJ^JaJ mH phsH h)OJQJaJ +h)OJQJaJ cHdhdhdhnf+h)OJQJaJcHdhdhdhnfh)cHdhdhdhnf%Hhfh)OJQJf1h)OJQJcHdhdhdhff  . o ˽~~jPF8h)OJQJaJmH sH h)OJQJaJ 3h)OJQJaJ cHdhdhdhofmH sH 'Hhofh)OJQJaJ mH sH  h)6OJQJ]aJ mH sH 3h)OJQJaJ cHdhdhdhfmH sH 'Hhfh)OJQJaJ mH sH h)OJQJaJ mH sH 3h)OJQJaJ cHdhdhdhfmH sH 3h)OJQJaJ cHdhdhdhߛfmH sH o !/!J!L!e!f!g!i!!!!!ͽ}mW;m7h)OJPJQJaJ cHdhdhdh*fmH sH +Hh*fh)OJPJQJaJ mH sH h)OJPJQJaJ mH sH +HhϜfh)OJPJQJaJ mH sH h)OJQJaJ Hhfh)aJ mH sH Hhfh)aJ mH sH Hhfh)aJ mH sH 'Hh⛑fh)OJQJaJmH sH h)OJQJaJmH sH  h)6OJQJ]aJmH sH f!g!""ZXO$0C$Eƀ[f ^`0a$$a$O$0C$Eƀf^`0a$!!!"""(")"3"9"X"|"""" ###ͽͧͧucSC3CHh%fh)OJQJaJHhfh)OJQJaJHhfh)OJQJaJ#h)aJcHdhdhdhf7h)OJPJQJaJ cHdhdhdhךfmH sH +Hhfh)OJPJQJaJ mH sH +Hhךfh)OJPJQJaJ mH sH h)OJPJQJaJ mH sH +Hh.fh)OJPJQJaJ mH sH 7h)OJPJQJaJ cHdhdhdh.fmH sH ""##oO$0C$Eƀf^`0a$G$C$Eƀfa$G$C$Eƀfa$##K#W########$)$S$T$f$m$$$$$$$$$ڱq_O?OHhfh)OJQJaJHhfh)OJQJaJ"Hhf *h)OJQJaJHhfh)OJQJaJHhfh)OJQJaJHhfh)OJQJaJHhfh)OJQJaJ1Hhfh)<B*OJQJphfHhfh)OJQJaJ)Hhfh)OJQJaJfHhϜfh)OJQJaJ###$$u(uL0C$Eƀf^`0DC$EƀfDC$Eƀf$$$$$$$$$$%%%%'%;%<%=%R%S%߿m[M?Hhfh)OJQJHhfh)OJQJ"Hhf *h)OJQJaJ"Hhf *h)OJQJaJHhfh)OJQJaJHhfh)OJQJaJHhfh)OJQJaJHhfh)OJQJaJHhfh)OJQJaJHhfh)OJQJaJHhfh)OJQJaJHhלfh)OJQJaJ$<%=%S%m(DC$EƀfDC$EƀfL0C$Eƀf^`0S%U%X%%%&/&5&C&D&E&F&H&&ҶҶoZJ<.Hhfh)OJQJHhϜfh)OJQJHhfh)OJQJaJ)Hh,fh)OJQJaJf1Hh,fh)<B*OJQJphf,Hhfh)B*OJQJ^JaJ ph,Hhfh)B*OJQJ^JaJ ph6Hh,fh)B*OJQJ^JaJ phf,Hhfh)B*OJQJ^JaJ ph,HhϜfh)B*OJQJ^JaJ ph S%D&E&F&gG$C$Eƀfa$G$C$Eƀfa$O$0C$Eƀf^`0a$F&&&gG$C$Eƀfa$O$0C$Eƀf^`0a$&&&'''' ((( (8(L(i(((((((((ŹseWssGHhfh)OJQJaJHhfh)OJQJHhfh)OJQJHhfh)OJQJHhfh)OJQJHhМfh)OJQJHhfh)OJQJaJHhfh)aJHhϜfh)aJHhϜfh)OJQJHhfh)Hhfh)HhϜfh)Hhfh)OJQJ&'' (f_ vC$K$C$EƀϜf^a$L0C$Eƀf^`0 ((((gG$C$Eƀfa$O$0C$Eƀf^`0a$G$C$Eƀfa$((=)n)o)p))))))))))***!*+*4*9*W*X*`*߼|n|nn`L|Ln|`|'h)OJQJcHdhdhdhfHhfh)OJQJHhfh)OJQJh)OJQJ'h)OJQJcHdhdhdhpfHhpfh)OJQJHhМfh)OJQJh)OJQJ%Hhfh)5OJQJ\aJHhfh)OJQJaJHhfh)OJQJaJHhМfh)OJQJaJ(o)p))jgC$DC$EƀfO$0C$Eƀf^`0a$`*a*b*c*h**?+@+B+++++,,,ötaH:Hhfh)OJQJ1h)OJQJcHdhdhdhfqf%Hhfh)OJQJqfHhfh)OJQJ1h)OJQJcHdhdhdhfqfh)OJQJqfHhМfh)OJQJh)5CJOJQJ\h)OJPJQJaJ h)OJQJ'h)OJQJcHdhdhdhf'h)OJQJcHdhdhdhf)?+@+=,XN$0Eƀqf^`0a$$ va$O$0C$Eƀf^`0a$, ,<,=,>,?,@,,,,,,,,ó}eMeMC3%HhМfh)OJQJHhœfh)OJQJaJ h)OJQJaJ /h)OJPJQJaJ cHdhdhdhf/h)OJPJQJaJ cHdhdhdhf8h)5<CJOJQJ\aJ cHdhdhdhf1h)5CJOJQJ\cHdhdhdhfh)cHdhdhdhf7h)5OJQJ\cHdhdhdhqfrfh)OJQJqf%Hhfh)OJQJqf =,>,?,@,kkK$ C$Eƀfa$G$C$Eƀfa$@,,,,_V$ va$G$C$Eƀœfa$X$ & F vC$Eƀf^`a$,,9------------ǽoT?)Hhfh)5CJOJQJ\aJ5h)5CJOJQJ\aJcHdhdhdhf)Hhfh)5CJOJQJ\aJh)5CJOJQJ\aJ)HhМfh)5CJOJQJ\aJ)Hhœfh)5CJOJQJ\aJHhœfh)#Hhœfh)OJPJQJaJ #Hhœfh)OJPJQJaJ 'h)OJQJcHdhdhdhœf ,--fK$ vC$Eƀœfa$LvC$Eƀœf^v`--.....0/3////+0,00000111&1I1v1µoYYYCY+h)CJ OJQJcHdhdhdhvf+h)CJ OJQJcHdhdhdhuf/h)CJ OJQJaJcHdhdhdhsf/h)CJ OJQJaJcHdhdhdhf+h)CJ OJQJcHdhdhdhfh)5CJOJQJ\%Hhfh)5CJOJQJ\h)5CJOJQJ\aJ5h)5CJOJQJ\aJcHdhdhdhf-....a\Z$a$K$ vC$Eƀfa$R$ vvEƀf^v`a$./900k!I$ & FEƀf a$I$ & FEƀf a$I$ & FEƀf a$v1w1111222^2233^4ϰϖ|\<?Hh6f *h)CJ OJQJaJcHdhdhdhf?Hh6f *h)CJ OJQJaJcHdhdhdhyf2 *h)CJ OJQJaJcHdhdhdhyf2 *h)CJ OJQJaJcHdhdhdhwf<Hh5fh)CJ OJQJaJcHdhdhdhf/h)CJ OJQJaJcHdhdhdhf/h)CJ OJQJaJcHdhdhdhvf 0111c4d444[555_ZXXXXX$a$H & FC$Eƀf$a$$h^ha$I$ & FEƀf a$ ^4a4b4c4d44444444)5*5+5Y5ūwo[MoAo2A(h)0JOJQJjHh)OJQJUjh)OJQJUHhfh)OJQJ'h)OJQJcHdhdhdhfh)OJQJh)5OJQJ\aJh)5CJ OJQJ\aJ/h)CJ OJQJaJcHdhdhdhf2 *h)CJ OJQJaJcHdhdhdhf2 *h)CJ OJQJaJcHdhdhdh6f?Hh7f *h)CJ OJQJaJcHdhdhdh\fY5Z5[5\555555555555555말yeWI;Hhfh)OJQJHhМfh)OJQJHhfh)OJQJ'h)OJQJcHdhdhdhf-h)5OJQJ\cHdhdhdhf-h)5OJQJ\cHdhdhdhf-h)5OJQJ\cHdhdhdhf'h)OJQJcHdhdhdhfh)0JOJQJjIh)OJQJUh)OJQJjh)OJQJU555R66nh$IfI$C$EƀfIfDC$EƀМfC$5555%6&6'6B6C6E6R6S6_666666۲ȢیzlXlCz-+HhҜfh)0JOJQJ^JmH sH )jKh)OJQJU^JmH sH 'HhҜfh)OJQJ^JmH sH h)OJQJ^JmH sH #jh)OJQJU^JmH sH +Hhfh)OJQJ^JaJmH sH Hhfh)0JOJQJ*j KHhfh)OJQJU$jHhfh)OJQJUHhfh)OJQJ+Hhfh)5OJQJ\f66666666666δ~hR4+Hhfh)OJQJ^JaJmH sH ;Hhfh)5OJQJ\^JaJmH sH f+Hhfh)CJOJQJ^JmH sH +Hhќfh)CJOJQJ^JmH sH 'HhҜfh)OJQJ^JmH sH BjVMh)OJQJU^JcHdhdhdhҜfmH sH 3h)OJQJ^JcHdhdhdhҜfmH sH <jh)OJQJU^JcHdhdhdhҜfmH sH #jh)OJQJU^JmH sH  666?7m$I$C$EƀfIfI$C$EƀfIfI$C$EƀҜfIf66#7$7%7;7<7>7?7@7N7P7Q7ϱσjL30jh)B*OJQJU^JaJmH phsH ;Hhfh)5OJQJ\^JaJmH sH f1HhҜfh)5OJQJ\^JaJmH sH +Hhfh)OJQJ^JaJmH sH /Hhfh)0JOJQJ^JaJmH sH :jNHhfh)OJQJU^JaJmH sH +Hhfh)OJQJ^JaJmH sH 4jHhfh)OJQJU^JaJmH sH  ?7@777m$I$C$EƀfIfI$C$EƀfIfI$C$EƀҜfIfQ7d7~77777777777봛mW"]\x> |Ymh4"D9n"]\x> |Ymh4PNG  IHDRdq+sRGB!IDATx^]XTWږPfEذ$hQƨIQcMQY&$5jLl)֬b6(EzA S/\gffsr)|wv6PWU/i`FvAt‚ >1TĵNƠ4͵܌[Ŵ)*znF#]6ʵ羳ɧ:9%:s;).󢨵%76yʹlZV[j8 kkFe7Z]K~qY3obMEJٹhF$w)-,MI3-~SS'͛1yOSI) j љch4ڈ3 #ٶ&On3Y"=6zKs #AEﯩY 1QE;pՁzziOOGVӽR&: {)9 ORRo^@Vvl~ vqIWRޓ?6XiB̚ ׼,@IOt64lT ˃?ܰWB!];;:?:"*|HE~O>f0凅 뛝 ?Й?6e} mKĵ(;yE>+S(+Cu$j}=մ;l:dݪťltR76{uEzwذ DGox@Ϗ@R(?†]NcV8F >c?*r,$\ëuE]ÿ {x3眂|^ &fG['&O݇N\MazEY/W'Wxb(f]cAT[*WEUΥ?>#ݣf,έÂO3K|'".i"LI|2fF. N}Se֖SgOgǎ7n ]Tt=ؚq&֨TURYst+VRvgmPu-:g#j0ZeҥjDŽ6Zm6.khM,C ,iqBÊzm(vsR(@i8xfKk`&8.L')?7x:si;OH0I6)X?o8 1zŲ`|ֵ+rxTh~C{8qTFh\G'Q~Q^\lܹ?J2х'LMvR3IuTI#,Ս;T<5k+4[o߸Kad}G"l~t]3=f^=ݕ~>=cBM)(ΊR;e)usWld[9yB6l^,4vΜ=;W l2Vٕ+6\أc+x<[ZiEH{>v<$7* R+3$RWk-bvTQ7فĕߺ$:{qmmrv )Kl6${/ËR`q U̲g  fĘ!j$q/^-u`}VVZh>%H5}ϭ]\ 4t7K!^uL ˎլKc<=Xr:֯xE r$ݥ)-T־3B dt0LLj. M56{,"vuJA)M5qT$ n|<9Oݬj};>̓Nj΢w'v9/LSX,' ,EY/֍)奍_*86~F07͌&5΃Gάpϔ[C\APBuȩz7{K'2RF1̜VC`t0DR&(k[$zR* wo~F 3}iߨ!v)t k@jRXȚiSx<1`&hF .l6D8$!ĭJmzѪvm]K?7n- ,w/ã>T5U) b>8ѵ~ղ=8x~ոu ~BD='XH}~;3Vm:UZ Ͳk[YlZˆ`qXF 3w m["!δMj]sCZ[o|||/#Kւ`#o;<~bv{ry!kjtٹ`:2ڽQ@wLDڶfd8`#i.o) vմj fӞ`ŔhF*^u]ʺ ېæEVkݽ|*) 234x=˺JޱvM`!Qf3WV+W2 Ad=}s2z4¡FîT6@A&3ϑbvBWgLF5M(q'm&V"X<;i ܜTu&or9l^$Z4.Kmk5P ƐJ砥m\*} ˾ V rsⶪ+:V$0xna\a)'[քI5` Jh6ܗbycBI 5\XNGC(\]̖4l$L3"@Y 6Nz$Ds `QZ ƌ'xAQ/eշPϙ 5Ru67<ĉXЏU@ ((+$$] rI.x,-aC\ R.YP'ۖaZ )?%sd5V\6ŝ 1 Qת'6q1z)i+'6$Hy *n9ˑC)Zk[#c`77jǰZtV-AͭYh x6Č )ffn!>v4lc;wRʕkk/F6k @v74̂у*as̢2+Di@mTz!P`%hyl#ШV6YB5uMfpH s``JʴVF¸ꚆzwCK2@Va~kZ:(KoE$jdR*6CBP}0?XX)7p rXy*eaa\v`qz^mWc T:`[o{,L|ljIͅ\XHxƒJ|؅vN|̅r9pTXB`XSV${'Rz591v'WfWHժ!A@.lRpn{Da86uwLPo}Yăޅآ?Vf^HAE|b3u"dָ"Mprm۽f "Hh͡,I Z0 Cwd@\ _& TP* Cw,`,_s%HaWVL {r R.WԥBSFJWU[sXmuMǏ fn,=JTqo™B>iP_Z݂GyL9 ^/]H9aVV^d7c+#PP*1X99y؅ɓJ\l:Zұ )%jD3W!щ#8$,(FpllxF ){jy.]z-L P][Shc<$T @)(UݑV۬b"zE -lʂh]XiQ`7W#3ǦK_vIz#ndI] v|8sm@A0==y3XP\( .`aBa”t?mX݄F甏1,+רv Dx~衃 yEe>)dƍxG6G+w~72Yuzsi g]G[>0&3&6)*EhvğW[V_D'ߓLh 9PBÃ1!N1->ƈ>%3> R-g&À)Haߐ'__~ ^C=B"J^ځI q 5w4z0>B#E^)qp߭D|{ݚfXgij"cOC >x7;N'쬹sL@뛩n~V15ulYBQ* t.(dX!giotzN i؊ ZzLE T)g^g_$ȔaU3c̕ci2fdxpⓓ遨iĀށJ*fy0X_3R}U0kˤʂW|3&m_yB %}D6ƪL@hBpꄌ#6WX|ÇzU])xn̠ǒ]ۿ8t]" Z @E u!(aH$vO_AlvQٲ R?KF 3AxgFEj"tt6 {YHzm<0o4鏠{x}v\/( ͟XuO#h>HW,[_>=|2Tʤ-Hqa#4K1 i\?I;IMy,_|{xP^kj-޴+RPWժl]ch8d΢cP [D8xe`q:#`3TMNE- Ev)jF#e(%{[Ka@ ~b+米>ٰ޺CXN]p,tA[8)¨UZQ4HB[`P3Bt**v˫M0?>NVq>~t81)9Sg}&Q;-x.IJ8 @KU+Va 5.zh|LvxZf pݏ67*,H寎kVLe6T"BW/v[Zކv uuR. R^ǴG5(3, Y覯+{ X "=Hed!M;1!VՍGb&}C # xb7ӻ+05v܆B-3aTQX_# mXG%طHA 1g΂c*",[;>z79#I; o`~bzvyQ  bX%z'+_ؼBȱsz#C>2?2㻘^YV& I݇+5؜GenXag4"rr+ۅHШ/z*֞a#)^;cwbn4m;mجJIW.d6wT+)[o?x?`PN5X Px,X]@??Kׇ`]g澶l>ܞp0ꅳ~[?T߽@V8ST"" n> ޔ±Yުɰ츿ΉtN~8ܼ5*G% Y.=4IENDB`%Dd 0  # Abb%ZZu!]zETC>%#9n6%ZZu!]zETCPNG  IHDR^MD sRGB$IDATx^wTևA9tD Fbn"Qc$5&WM1EM%W&(bJPgx8k}k?2kke;sKCB_o}7vv#(3{p4J{.Z Xuv:4\f)i*d IS\|o1#] y R6䟏jO|[[+[޵9}n.򫛳$'Y_vvAnOpq}դsWm=z[we Ÿ+<+aQ=֮;nʿ֭ӯ^E+cc)Y=„%  { sx AQaeqPN-~ҍ^fHɬ:mXZXHIWnٺ,+Gkt}$edG0Iú]\ )$pFK_g1յBij,еc3Xy/^i#0a"b۷ԶId S;/t'utg#ґP϶#QUm FacNv: e.ZCuGO~},pn&T`e4(/S{83L+(|L \=3X}thkoUc"&ۡ}դ'ԯa"ZG qm\>l^-Lu5jҷ~ +ӇѠs-|xzl3k횿h; ږA4XMԮ ap˓ /k%ͪ&MΡf {iFWg <AaޗvPB4SVp3)_zZ_Q? ӝBiԤAy8;y/c 6k*ȼ͚2He2Вgg;)Dv`Z5]ٰ;Gc$WD,'L4rhwL^`&{>*ްԗ?|mЏMTq뎮̱YY~xeg/9=#+>*\8UnUs "G4|dէ8 b;#mVJ&'-2̶Qu.\pF'`\fNU{< Wؘt3DGSb k_ء#+s Z֠됣|5Uથ43 Ы&Ngl!'@Tzg!rt+]Zn.)ݽ=cZsx,iunaQ6Gvjժ9mOp/&ׯWyۅ XYu?xoVNէ*kriWgδâ?{N2/ Yڸ'c SxSc {^vSƽ2sGuZPXUyqtdYP!X8&_W1gͿ4}yO۝3,H;e}~瞣8mhIaM$4P4p?_ q{B5իpc?$hK|qKC1&8O.xF8p4cF o^u,~k>^+\ ' C.ssC NA.AxђuwR3p֭h򌡄 轼Ҟ^M d>Zgc|Kǥ cX:9l ߹,FhJG@O^A!{%SdPTX]ŁJt)ر{tm9p٠qo- ,6O4j#8r]i0›&K5lR8>WY>?=wBQ+.B`ݾ^M*k&\ؗ>*X! [ G˯78<ÿ%0,[c.ߒ_+$ \& Jɓ8yas$`^Q&-Kb\dr6_~2GQd򋬈4ơ@k?:GʏO U48^AWe7C޶T$~*.Cs9y䂓WIfU^u;v:^5q)ɣg{"LM7$tFCҘ@rT>]h|qU̓u@1XqUo lGXͿC4Л.[9:N[KmdK 4~1maΌ( fIcb z } t4F1~=%$y<γY>'5,$t%7 5̓^ѳ}`@}-ZۈܗsR3m໹"C&okkc?29٣]׈V@,sk֛3-m˦S2Ys zzޓq폜8T#6L FOAgpLQóDsj8Tp (<+R#bY<!u%Ҹ2GAINO놉VD UoVU6SǔA.՝)(TUIi$:+kKګo0s } J?e2Ё~(HB!hMKJCUi4?Ɏ؏f1_ yR7RmإdJ~:gL içhWȝ;@35@ˤVd&3fUj;n͊ ߚq0qU 8v4H@CWo#51=.z">qDRBx+52k3'x'==/voý"XLU9y! e[V{S\4-cY(n瞽'`-!gdN35Te2jS*4%2xx'ZIaA&~e(YAD=7{DŽfoH`W93P-1pÉ@UPBE]h|m[5u.D,9%CK3K_#T'"¤f|(\KoٯO5vx*v0Q:DO.!U&;+:M`:{_z liPсpwlf>[u;7obc\1}{G66e%mTZZx9~q[u9)슊u.$] :ܡl5kճa_֢ʲľR&D:g^n֚>ُ @,nFıPɼWRbo'|8^DY H:#Q ڗ}AJG4S.^#Y4'T48D=Z*ԞRP^ P+-Iv.@ \FIu(1[җ[m^U6@6dj  $J^ MO|yKJYQFe -@c3 yyЋoҳnN?ChҼ7^|n@Drr&?m`+OuVVBƜ0o3f!u=&\66G (ty>:dBjyU׫œt9/=ĩ iN/,ٵ ܾsCzyzTHpݿ@Z \|3y`QͿyzj\5<(S=n8%!qknvf9slX _ɖyW6kg9:j'&Qp:آlIV۽JpԹD5\RԿsM ;̗hK!#ٲ)y^?B #:Xzs$^N8xƭ;'ㆎp%-KK]ϟנNAc'K> hS͊qy(SїRjT=K)i 2Pt`JđlA^9jRz uCKLf :ˆ,- .@YĘN3*>9 +a8(>J.EBj$h܉dk B `+s/KW93B,V|G%r N4}ʘN!ʘj:T۷,;zN R:ۅ]@> Q>c6Sˇ P|?qdqTR!_MaÕ I,5 ?eU<)<_CsS@+WFƙ*2/_85]l@tXP{bXn4(W$:.("~ U]jY JtFֶdV7UNm"ɂ5V倮a1U^S;vr9)ˁ=OBO$LLUSm[b_ҳ#;8^7.w?()-)) i4 Èq#"Za]sNi!;@Va-5?"5i*BI/FF%^y6>1sƍSY$tqR2 IƊ6A}{r n3eZ4 f D`a.Gk9!*u(z߹(, Kp8&F3BDc? th*TzP\8{.)րf&5Ih@)#jM 2QR~aqHԚ)`@M)%PJjt.D ȤNzzD>lo̴HHeR%.R$ bIdVʪe`GV, abRAz1/7MMh_E b'p\BD]:u;=Nю;&6yu;+k+:T vx\K˗N{62FL(S,}ޡϴ;-ؑp3tA ygDvUI]@_Y?0}!8h80 a/OZzR\E),-J R$Y7 C[w[l*R acIKSLɟD;F:(fA`\~SԏN@f%p dl&b=05u!4 , /P~&6&0f# R~#(l>@x=p>7Jqaep ^"jr,l+X@qHW @50P l S  )᫠ Ha0 & w2 c.xs-\t#8*F0ƔZG/`^e+7`ehuuS$3PSl!ڸ s[0~a|daAn"`D FgP.n;btW"ǣ'Jo͠SpWX ^<+B@a("|%Aꋊّ6Q Xy>.qDTAiIN5+#?y566Y9Gkղɐ@W^Ek@X3+ppu曦Vm.C1,a)_`zϛ3£ثť#t;V &(:E 9ZZZPq_nE=|dHN`|IBPҿORT;˯|v@U}>T/`Y=|k18P,9X@6)_5CUD'% ͅJvDTDͨ 9AalT}#a ~U'R $ #H|,jA"ڌ 7lݫKDjI-~Ҏ"-7J6Y=l$[bEe0zB]QKLڨ'و<#LOf?Zt/*ۘ]V'L&6*UaoN$mpJf1 '}MZVMT4͓2\m'K ~͢z`!ݧ\.7B@_uY_.0\*"}sIENDB`1DyK /http://www.york.ac.uk/res/iht/introduction.htmyK ^http://www.york.ac.uk/res/iht/introduction.htm1DyK /http://www.regard.ac.uk/regard/home/index_htmlyK ^http://www.regard.ac.uk/regard/home/index_htmlDyK gillian.hundt@warwick.ac.ukyK Fmailto:gillian.hundt@warwick.ac.ukYDyK 9http://www2.warwick.ac.uk/fac/cross_fac/healthatwarwick/yK rhttp://www2.warwick.ac.uk/fac/cross_fac/healthatwarwick/1DyK /http://www2.warwick.ac.uk/fac/cross_fac/healthyK ^http://www2.warwick.ac.uk/fac/cross_fac/healthDyK jane.sandall@kcl.ac.ukyK <mailto:jane.sandall@kcl.ac.ukDyK clare.2.williams@kcl.ac.ukyK Dmailto:clare.2.williams@kcl.ac.uk9DyK 1http://www.kcl.ac.uk/nursing/research/women.htmlyK bhttp://www.kcl.ac.uk/nursing/research/women.html$$If!vh55e#v#ve:V l065L4DyK KevinSpencer1@aol.comyK :mailto:KevinSpencer1@aol.comDyK b.heyman@city.ac.ukyK 6mailto:b.heyman@city.ac.uk!DyK +http://www.city.ac.uk/sonm/hcru/index.htmlyK Vhttp://www.city.ac.uk/sonm/hcru/index.html$$If!vh55e#v#ve:V l065L4DyK gillian.hundt@warwick.ac.ukyK Fmailto:gillian.hundt@warwick.ac.ukDyK jane.sandall@kcl.ac.ukyK <mailto:jane.sandall@kcl.ac.uk9DyK 1http://www.kcl.ac.uk/nursing/research/women.htmlyK bhttp://www.kcl.ac.uk/nursing/research/women.html@@@ NormalCJ_HaJmH sH tH P@P Heading 1$$@&a$5CJ OJQJ\aJTT Heading 2$$@&a$B*CJOJQJaJphB@B Heading 3$@&5OJQJ\H@H Heading 4$$@&a$5OJQJ\F@F Heading 5$@&5CJOJQJ\v@v Heading 6$$ & F0@&`0a$,5CJOJPJQJWf\aJ mH sH DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List B'B Comment ReferenceCJaJH@H  Comment TextCJOJQJ^JaJFB@F Body Text$a$5CJ OJQJ\<+"<  Endnote TextCJaJ>*1> Endnote ReferenceH*@P@B@ Body Text 2$a$OJQJ8Q@R8 Body Text 3$a$6U@a6 Hyperlink >*B*phHrH  Balloon TextCJOJQJ^JaJLjL Comment Subject5OJQJ\^JFVF FollowedHyperlink >*B* ph4@4 Header  !4 @4 Footer  !4/4 List^`:0: List Bullet  & F)fC@f Body Text Indent $ v0^`0a$ OJQJaJ2<=MN6 J K L M n o p q ~   . &'89H012Q45Yfg<=SDEF  o!p!!?#@#=$>$?$@$$$$%%&&&&'9(()))c,d,,,[-----R....?/@/// 0!0"0u0000D1E1F1G111X22222 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;00 ;0 ;0 ;000 ;0 ;00 ;0 ;0H00 ;0(00 ;0 ;0 ;000000(0(0(0000 ;0 ;0 ;0 ;0 ;0 ;000 ;0000 ;00 ;0 ;0 ;0 ;00000 ;0(00 ;000000800 ;000000000000(000 0 ;0 ;0 ;0 ;000 ;000 ;000 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;00000 ;000000000000000000000000000 ;0 ;0 ;0 ;0 ;0@0 0)>!0"0E1F122 ;0@` ;0@ ;0@ ;0@ ;0@ ;0X fqV0 %Jo !#$S%&(`*,,-v1^4Y5566Q77\88G9.:::!"#%')*+,/12468:;>?@BDFHKNPRUWZ\]_`bdegilmnLp81Q"#$S%F&& (()=,@,,-.056?77"88E9:$&(-.03579<=ACEGIJLMOQSTVXY[^acfhjk: ,*-Y-[----&.B.R.......$/;/P/////010]0s000001B1]1112/2F2X2222XXXXXXXXXXXXXXMUZcbd "##e%r%--R..002222R....?/@///22 Jane Sandall Jane Sandall Jane Sandall Jane Sandall Jane Sandall Jane Sandall Jane Sandall Jane Sandall Jane Sandall IT Services)zJ*kd{E  &wn8:R-<PyL(g$V 8[2M!$4B5$o<i'RU'hp)F6J B0RUU2ZF6n7T5T#8hYL9-9nl?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnoqrstuvwxyz{|}~Root Entry F@,nData pX1TableWordDocument"SummaryInformation(DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q