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• How to Write Recommendations in Research | Examples & Tips

How to Write Recommendations in Research | Examples & Tips

Published on September 15, 2022 by Tegan George . Revised on July 18, 2023.

Recommendations in research are a crucial component of your discussion section and the conclusion of your thesis , dissertation , or research paper .

As you conduct your research and analyze the data you collected , perhaps there are ideas or results that don’t quite fit the scope of your research topic. Or, maybe your results suggest that there are further implications of your results or the causal relationships between previously-studied variables than covered in extant research.

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Table of contents

What should recommendations look like, building your research recommendation, how should your recommendations be written, recommendation in research example, other interesting articles, frequently asked questions about recommendations.

Recommendations for future research should be:

• Concrete and specific
• Supported with a clear rationale
• Directly connected to your research

Overall, strive to highlight ways other researchers can reproduce or replicate your results to draw further conclusions, and suggest different directions that future research can take, if applicable.

Relatedly, when making these recommendations, avoid:

• Undermining your own work, but rather offer suggestions on how future studies can build upon it
• Suggesting recommendations actually needed to complete your argument, but rather ensure that your research stands alone on its own merits
• Using recommendations as a place for self-criticism, but rather as a natural extension point for your work

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There are many different ways to frame recommendations, but the easiest is perhaps to follow the formula of research question   conclusion  recommendation. Here’s an example.

Conclusion An important condition for controlling many social skills is mastering language. If children have a better command of language, they can express themselves better and are better able to understand their peers. Opportunities to practice social skills are thus dependent on the development of language skills.

As a rule of thumb, try to limit yourself to only the most relevant future recommendations: ones that stem directly from your work. While you can have multiple recommendations for each research conclusion, it is also acceptable to have one recommendation that is connected to more than one conclusion.

These recommendations should be targeted at your audience, specifically toward peers or colleagues in your field that work on similar subjects to your paper or dissertation topic . They can flow directly from any limitations you found while conducting your work, offering concrete and actionable possibilities for how future research can build on anything that your own work was unable to address at the time of your writing.

See below for a full research recommendation example that you can use as a template to write your own.

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While it may be tempting to present new arguments or evidence in your thesis or disseration conclusion , especially if you have a particularly striking argument you’d like to finish your analysis with, you shouldn’t. Theses and dissertations follow a more formal structure than this.

All your findings and arguments should be presented in the body of the text (more specifically in the discussion section and results section .) The conclusion is meant to summarize and reflect on the evidence and arguments you have already presented, not introduce new ones.

The conclusion of your thesis or dissertation should include the following:

• A restatement of your research question
• A summary of your key arguments and/or results
• A short discussion of the implications of your research

For a stronger dissertation conclusion , avoid including:

• Important evidence or analysis that wasn’t mentioned in the discussion section and results section
• Generic concluding phrases (e.g. “In conclusion …”)
• Weak statements that undermine your argument (e.g., “There are good points on both sides of this issue.”)

Your conclusion should leave the reader with a strong, decisive impression of your work.

In a thesis or dissertation, the discussion is an in-depth exploration of the results, going into detail about the meaning of your findings and citing relevant sources to put them in context.

The conclusion is more shorter and more general: it concisely answers your main research question and makes recommendations based on your overall findings.

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George, T. (2023, July 18). How to Write Recommendations in Research | Examples & Tips. Scribbr. Retrieved April 5, 2024, from https://www.scribbr.com/dissertation/recommendations-in-research/

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Home » Research Recommendations – Examples and Writing Guide

Research Recommendations – Examples and Writing Guide

Table of Contents

Research Recommendations

Definition:

Research recommendations refer to suggestions or advice given to someone who is looking to conduct research on a specific topic or area. These recommendations may include suggestions for research methods, data collection techniques, sources of information, and other factors that can help to ensure that the research is conducted in a rigorous and effective manner. Research recommendations may be provided by experts in the field, such as professors, researchers, or consultants, and are intended to help guide the researcher towards the most appropriate and effective approach to their research project.

Parts of Research Recommendations

Research recommendations can vary depending on the specific project or area of research, but typically they will include some or all of the following parts:

• Research question or objective : This is the overarching goal or purpose of the research project.
• Research methods : This includes the specific techniques and strategies that will be used to collect and analyze data. The methods will depend on the research question and the type of data being collected.
• Data collection: This refers to the process of gathering information or data that will be used to answer the research question. This can involve a range of different methods, including surveys, interviews, observations, or experiments.
• Data analysis : This involves the process of examining and interpreting the data that has been collected. This can involve statistical analysis, qualitative analysis, or a combination of both.
• Results and conclusions: This section summarizes the findings of the research and presents any conclusions or recommendations based on those findings.
• Limitations and future research: This section discusses any limitations of the study and suggests areas for future research that could build on the findings of the current project.

How to Write Research Recommendations

Writing research recommendations involves providing specific suggestions or advice to a researcher on how to conduct their study. Here are some steps to consider when writing research recommendations:

• Understand the research question: Before writing research recommendations, it is important to have a clear understanding of the research question and the objectives of the study. This will help to ensure that the recommendations are relevant and appropriate.
• Consider the research methods: Consider the most appropriate research methods that could be used to collect and analyze data that will address the research question. Identify the strengths and weaknesses of the different methods and how they might apply to the specific research question.
• Provide specific recommendations: Provide specific and actionable recommendations that the researcher can implement in their study. This can include recommendations related to sample size, data collection techniques, research instruments, data analysis methods, or other relevant factors.
• Justify recommendations : Justify why each recommendation is being made and how it will help to address the research question or objective. It is important to provide a clear rationale for each recommendation to help the researcher understand why it is important.
• Consider limitations and ethical considerations : Consider any limitations or potential ethical considerations that may arise in conducting the research. Provide recommendations for addressing these issues or mitigating their impact.
• Summarize recommendations: Provide a summary of the recommendations at the end of the report or document, highlighting the most important points and emphasizing how the recommendations will contribute to the overall success of the research project.

Example of Research Recommendations

Example of Research Recommendations sample for students:

• Further investigate the effects of X on Y by conducting a larger-scale randomized controlled trial with a diverse population.
• Explore the relationship between A and B by conducting qualitative interviews with individuals who have experience with both.
• Investigate the long-term effects of intervention C by conducting a follow-up study with participants one year after completion.
• Examine the effectiveness of intervention D in a real-world setting by conducting a field study in a naturalistic environment.
• Compare and contrast the results of this study with those of previous research on the same topic to identify any discrepancies or inconsistencies in the findings.
• Expand upon the limitations of this study by addressing potential confounding variables and conducting further analyses to control for them.
• Investigate the relationship between E and F by conducting a meta-analysis of existing literature on the topic.
• Explore the potential moderating effects of variable G on the relationship between H and I by conducting subgroup analyses.
• Identify potential areas for future research based on the gaps in current literature and the findings of this study.
• Conduct a replication study to validate the results of this study and further establish the generalizability of the findings.

Applications of Research Recommendations

Research recommendations are important as they provide guidance on how to improve or solve a problem. The applications of research recommendations are numerous and can be used in various fields. Some of the applications of research recommendations include:

• Policy-making: Research recommendations can be used to develop policies that address specific issues. For example, recommendations from research on climate change can be used to develop policies that reduce carbon emissions and promote sustainability.
• Program development: Research recommendations can guide the development of programs that address specific issues. For example, recommendations from research on education can be used to develop programs that improve student achievement.
• Product development : Research recommendations can guide the development of products that meet specific needs. For example, recommendations from research on consumer behavior can be used to develop products that appeal to consumers.
• Marketing strategies: Research recommendations can be used to develop effective marketing strategies. For example, recommendations from research on target audiences can be used to develop marketing strategies that effectively reach specific demographic groups.
• Medical practice : Research recommendations can guide medical practitioners in providing the best possible care to patients. For example, recommendations from research on treatments for specific conditions can be used to improve patient outcomes.
• Scientific research: Research recommendations can guide future research in a specific field. For example, recommendations from research on a specific disease can be used to guide future research on treatments and cures for that disease.

Purpose of Research Recommendations

The purpose of research recommendations is to provide guidance on how to improve or solve a problem based on the findings of research. Research recommendations are typically made at the end of a research study and are based on the conclusions drawn from the research data. The purpose of research recommendations is to provide actionable advice to individuals or organizations that can help them make informed decisions, develop effective strategies, or implement changes that address the issues identified in the research.

The main purpose of research recommendations is to facilitate the transfer of knowledge from researchers to practitioners, policymakers, or other stakeholders who can benefit from the research findings. Recommendations can help bridge the gap between research and practice by providing specific actions that can be taken based on the research results. By providing clear and actionable recommendations, researchers can help ensure that their findings are put into practice, leading to improvements in various fields, such as healthcare, education, business, and public policy.

Characteristics of Research Recommendations

Research recommendations are a key component of research studies and are intended to provide practical guidance on how to apply research findings to real-world problems. The following are some of the key characteristics of research recommendations:

• Actionable : Research recommendations should be specific and actionable, providing clear guidance on what actions should be taken to address the problem identified in the research.
• Evidence-based: Research recommendations should be based on the findings of the research study, supported by the data collected and analyzed.
• Contextual: Research recommendations should be tailored to the specific context in which they will be implemented, taking into account the unique circumstances and constraints of the situation.
• Feasible : Research recommendations should be realistic and feasible, taking into account the available resources, time constraints, and other factors that may impact their implementation.
• Prioritized: Research recommendations should be prioritized based on their potential impact and feasibility, with the most important recommendations given the highest priority.
• Communicated effectively: Research recommendations should be communicated clearly and effectively, using language that is understandable to the target audience.
• Evaluated : Research recommendations should be evaluated to determine their effectiveness in addressing the problem identified in the research, and to identify opportunities for improvement.

Advantages of Research Recommendations

Research recommendations have several advantages, including:

• Providing practical guidance: Research recommendations provide practical guidance on how to apply research findings to real-world problems, helping to bridge the gap between research and practice.
• Improving decision-making: Research recommendations help decision-makers make informed decisions based on the findings of research, leading to better outcomes and improved performance.
• Enhancing accountability : Research recommendations can help enhance accountability by providing clear guidance on what actions should be taken, and by providing a basis for evaluating progress and outcomes.
• Informing policy development : Research recommendations can inform the development of policies that are evidence-based and tailored to the specific needs of a given situation.
• Enhancing knowledge transfer: Research recommendations help facilitate the transfer of knowledge from researchers to practitioners, policymakers, or other stakeholders who can benefit from the research findings.
• Encouraging further research : Research recommendations can help identify gaps in knowledge and areas for further research, encouraging continued exploration and discovery.
• Promoting innovation: Research recommendations can help identify innovative solutions to complex problems, leading to new ideas and approaches.

Limitations of Research Recommendations

While research recommendations have several advantages, there are also some limitations to consider. These limitations include:

• Context-specific: Research recommendations may be context-specific and may not be applicable in all situations. Recommendations developed in one context may not be suitable for another context, requiring adaptation or modification.
• I mplementation challenges: Implementation of research recommendations may face challenges, such as lack of resources, resistance to change, or lack of buy-in from stakeholders.
• Limited scope: Research recommendations may be limited in scope, focusing only on a specific issue or aspect of a problem, while other important factors may be overlooked.
• Uncertainty : Research recommendations may be uncertain, particularly when the research findings are inconclusive or when the recommendations are based on limited data.
• Bias : Research recommendations may be influenced by researcher bias or conflicts of interest, leading to recommendations that are not in the best interests of stakeholders.
• Timing : Research recommendations may be time-sensitive, requiring timely action to be effective. Delayed action may result in missed opportunities or reduced effectiveness.
• Lack of evaluation: Research recommendations may not be evaluated to determine their effectiveness or impact, making it difficult to assess whether they are successful or not.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Research Recommendations – Guiding policy-makers for evidence-based decision making

Research recommendations play a crucial role in guiding scholars and researchers toward fruitful avenues of exploration. In an era marked by rapid technological advancements and an ever-expanding knowledge base, refining the process of generating research recommendations becomes imperative.

But, what is a research recommendation?

Research recommendations are suggestions or advice provided to researchers to guide their study on a specific topic . They are typically given by experts in the field. Research recommendations are more action-oriented and provide specific guidance for decision-makers, unlike implications that are broader and focus on the broader significance and consequences of the research findings. However, both are crucial components of a research study.

Difference Between Research Recommendations and Implication

Although research recommendations and implications are distinct components of a research study, they are closely related. The differences between them are as follows:

Types of Research Recommendations

Recommendations in research can take various forms, which are as follows:

These recommendations aim to assist researchers in navigating the vast landscape of academic knowledge.

Let us dive deeper to know about its key components and the steps to write an impactful research recommendation.

Key Components of Research Recommendations

The key components of research recommendations include defining the research question or objective, specifying research methods, outlining data collection and analysis processes, presenting results and conclusions, addressing limitations, and suggesting areas for future research. Here are some characteristics of research recommendations:

Research recommendations offer various advantages and play a crucial role in ensuring that research findings contribute to positive outcomes in various fields. However, they also have few limitations which highlights the significance of a well-crafted research recommendation in offering the promised advantages.

The importance of research recommendations ranges in various fields, influencing policy-making, program development, product development, marketing strategies, medical practice, and scientific research. Their purpose is to transfer knowledge from researchers to practitioners, policymakers, or stakeholders, facilitating informed decision-making and improving outcomes in different domains.

How to Write Research Recommendations?

Research recommendations can be generated through various means, including algorithmic approaches, expert opinions, or collaborative filtering techniques. Here is a step-wise guide to build your understanding on the development of research recommendations.

1. Understand the Research Question:

Understand the research question and objectives before writing recommendations. Also, ensure that your recommendations are relevant and directly address the goals of the study.

2. Review Existing Literature:

Familiarize yourself with relevant existing literature to help you identify gaps , and offer informed recommendations that contribute to the existing body of research.

3. Consider Research Methods:

Evaluate the appropriateness of different research methods in addressing the research question. Also, consider the nature of the data, the study design, and the specific objectives.

4. Identify Data Collection Techniques:

Gather dataset from diverse authentic sources. Include information such as keywords, abstracts, authors, publication dates, and citation metrics to provide a rich foundation for analysis.

5. Propose Data Analysis Methods:

Suggest appropriate data analysis methods based on the type of data collected. Consider whether statistical analysis, qualitative analysis, or a mixed-methods approach is most suitable.

6. Consider Limitations and Ethical Considerations:

Acknowledge any limitations and potential ethical considerations of the study. Furthermore, address these limitations or mitigate ethical concerns to ensure responsible research.

7. Justify Recommendations:

Explain how your recommendation contributes to addressing the research question or objective. Provide a strong rationale to help researchers understand the importance of following your suggestions.

8. Summarize Recommendations:

Provide a concise summary at the end of the report to emphasize how following these recommendations will contribute to the overall success of the research project.

By following these steps, you can create research recommendations that are actionable and contribute meaningfully to the success of the research project.

Download now to unlock some tips to improve your journey of writing research recommendations.

Example of a Research Recommendation

Here is an example of a research recommendation based on a hypothetical research to improve your understanding.

Research Recommendation: Enhancing Student Learning through Integrated Learning Platforms

Background:

The research study investigated the impact of an integrated learning platform on student learning outcomes in high school mathematics classes. The findings revealed a statistically significant improvement in student performance and engagement when compared to traditional teaching methods.

Recommendation:

In light of the research findings, it is recommended that educational institutions consider adopting and integrating the identified learning platform into their mathematics curriculum. The following specific recommendations are provided:

• Implementation of the Integrated Learning Platform:

Schools are encouraged to adopt the integrated learning platform in mathematics classrooms, ensuring proper training for teachers on its effective utilization.

• Professional Development for Educators:

Develop and implement professional programs to train educators in the effective use of the integrated learning platform to address any challenges teachers may face during the transition.

• Monitoring and Evaluation:

Establish a monitoring and evaluation system to track the impact of the integrated learning platform on student performance over time.

• Resource Allocation:

Allocate sufficient resources, both financial and technical, to support the widespread implementation of the integrated learning platform.

By implementing these recommendations, educational institutions can harness the potential of the integrated learning platform and enhance student learning experiences and academic achievements in mathematics.

This example covers the components of a research recommendation, providing specific actions based on the research findings, identifying the target audience, and outlining practical steps for implementation.

Using AI in Research Recommendation Writing

Enhancing research recommendations is an ongoing endeavor that requires the integration of cutting-edge technologies, collaborative efforts, and ethical considerations. By embracing data-driven approaches and leveraging advanced technologies, the research community can create more effective and personalized recommendation systems. However, it is accompanied by several limitations. Therefore, it is essential to approach the use of AI in research with a critical mindset, and complement its capabilities with human expertise and judgment.

Here are some limitations of integrating AI in writing research recommendation and some ways on how to counter them.

1. Data Bias

AI systems rely heavily on data for training. If the training data is biased or incomplete, the AI model may produce biased results or recommendations.

How to tackle: Audit regularly the model’s performance to identify any discrepancies and adjust the training data and algorithms accordingly.

2. Lack of Understanding of Context:

AI models may struggle to understand the nuanced context of a particular research problem. They may misinterpret information, leading to inaccurate recommendations.

How to tackle: Use AI to characterize research articles and topics. Employ them to extract features like keywords, authorship patterns and content-based details.

3. Ethical Considerations:

AI models might stereotype certain concepts or generate recommendations that could have negative consequences for certain individuals or groups.

How to tackle: Incorporate user feedback mechanisms to reduce redundancies. Establish an ethics review process for AI models in research recommendation writing.

4. Lack of Creativity and Intuition:

AI may struggle with tasks that require a deep understanding of the underlying principles or the ability to think outside the box.

How to tackle: Hybrid approaches can be employed by integrating AI in data analysis and identifying patterns for accelerating the data interpretation process.

5. Interpretability:

Many AI models, especially complex deep learning models, lack transparency on how the model arrived at a particular recommendation.

How to tackle: Implement models like decision trees or linear models. Provide clear explanation of the model architecture, training process, and decision-making criteria.

6. Dynamic Nature of Research:

Research fields are dynamic, and new information is constantly emerging. AI models may struggle to keep up with the rapidly changing landscape and may not be able to adapt to new developments.

How to tackle: Establish a feedback loop for continuous improvement. Regularly update the recommendation system based on user feedback and emerging research trends.

The integration of AI in research recommendation writing holds great promise for advancing knowledge and streamlining the research process. However, navigating these concerns is pivotal in ensuring the responsible deployment of these technologies. Researchers need to understand the use of responsible use of AI in research and must be aware of the ethical considerations.

Exploring research recommendations plays a critical role in shaping the trajectory of scientific inquiry. It serves as a compass, guiding researchers toward more robust methodologies, collaborative endeavors, and innovative approaches. Embracing these suggestions not only enhances the quality of individual studies but also contributes to the collective advancement of human understanding.

Frequently Asked Questions

The purpose of recommendations in research is to provide practical and actionable suggestions based on the study's findings, guiding future actions, policies, or interventions in a specific field or context. Recommendations bridges the gap between research outcomes and their real-world application.

To make a research recommendation, analyze your findings, identify key insights, and propose specific, evidence-based actions. Include the relevance of the recommendations to the study's objectives and provide practical steps for implementation.

Begin a recommendation by succinctly summarizing the key findings of the research. Clearly state the purpose of the recommendation and its intended impact. Use a direct and actionable language to convey the suggested course of action.

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• Knowledge Base
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• How to Write Recommendations in Research | Examples & Tips

How to Write Recommendations in Research | Examples & Tips

Published on 15 September 2022 by Tegan George .

Recommendations in research are a crucial component of your discussion section and the conclusion of your thesis , dissertation , or research paper .

As you conduct your research and analyse the data you collected , perhaps there are ideas or results that don’t quite fit the scope of your research topic . Or, maybe your results suggest that there are further implications of your results or the causal relationships between previously-studied variables than covered in extant research.

Instantly correct all language mistakes in your text

Be assured that you'll submit flawless writing. Upload your document to correct all your mistakes.

Table of contents

What should recommendations look like, building your research recommendation, how should your recommendations be written, recommendation in research example, frequently asked questions about recommendations.

Recommendations for future research should be:

• Concrete and specific
• Supported with a clear rationale
• Directly connected to your research

Overall, strive to highlight ways other researchers can reproduce or replicate your results to draw further conclusions, and suggest different directions that future research can take, if applicable.

Relatedly, when making these recommendations, avoid:

• Undermining your own work, but rather offer suggestions on how future studies can build upon it
• Suggesting recommendations actually needed to complete your argument, but rather ensure that your research stands alone on its own merits
• Using recommendations as a place for self-criticism, but rather as a natural extension point for your work

Prevent plagiarism, run a free check.

There are many different ways to frame recommendations, but the easiest is perhaps to follow the formula of research question   conclusion  recommendation. Here’s an example.

Conclusion An important condition for controlling many social skills is mastering language. If children have a better command of language, they can express themselves better and are better able to understand their peers. Opportunities to practice social skills are thus dependent on the development of language skills.

As a rule of thumb, try to limit yourself to only the most relevant future recommendations: ones that stem directly from your work. While you can have multiple recommendations for each research conclusion, it is also acceptable to have one recommendation that is connected to more than one conclusion.

These recommendations should be targeted at your audience, specifically toward peers or colleagues in your field that work on similar topics to yours. They can flow directly from any limitations you found while conducting your work, offering concrete and actionable possibilities for how future research can build on anything that your own work was unable to address at the time of your writing.

See below for a full research recommendation example that you can use as a template to write your own.

The current study can be interpreted as a first step in the research on COPD speech characteristics. However, the results of this study should be treated with caution due to the small sample size and the lack of details regarding the participants’ characteristics.

Future research could further examine the differences in speech characteristics between exacerbated COPD patients, stable COPD patients, and healthy controls. It could also contribute to a deeper understanding of the acoustic measurements suitable for e-health measurements.

While it may be tempting to present new arguments or evidence in your thesis or disseration conclusion , especially if you have a particularly striking argument you’d like to finish your analysis with, you shouldn’t. Theses and dissertations follow a more formal structure than this.

All your findings and arguments should be presented in the body of the text (more specifically in the discussion section and results section .) The conclusion is meant to summarize and reflect on the evidence and arguments you have already presented, not introduce new ones.

The conclusion of your thesis or dissertation should include the following:

• A restatement of your research question
• A summary of your key arguments and/or results
• A short discussion of the implications of your research

For a stronger dissertation conclusion , avoid including:

• Generic concluding phrases (e.g. “In conclusion…”)
• Weak statements that undermine your argument (e.g. “There are good points on both sides of this issue.”)

Your conclusion should leave the reader with a strong, decisive impression of your work.

In a thesis or dissertation, the discussion is an in-depth exploration of the results, going into detail about the meaning of your findings and citing relevant sources to put them in context.

The conclusion is more shorter and more general: it concisely answers your main research question and makes recommendations based on your overall findings.

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the ‘Cite this Scribbr article’ button to automatically add the citation to our free Reference Generator.

George, T. (2022, September 15). How to Write Recommendations in Research | Examples & Tips. Scribbr. Retrieved 2 April 2024, from https://www.scribbr.co.uk/thesis-dissertation/research-recommendations/

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• Peer review
• Polly Brown ( pbrown{at}bmjgroup.com ) , publishing manager 1 ,
• Klara Brunnhuber , clinical editor 1 ,
• Kalipso Chalkidou , associate director, research and development 2 ,
• Iain Chalmers , director 3 ,
• Mike Clarke , director 4 ,
• Mark Fenton , editor 3 ,
• Carol Forbes , reviews manager 5 ,
• Julie Glanville , associate director/information service manager 5 ,
• Nicholas J Hicks , consultant in public health medicine 6 ,
• Janet Moody , identification and prioritisation manager 6 ,
• Sara Twaddle , director 7 ,
• Hazim Timimi , systems developer 8 ,
• Pamela Young , senior programme manager 6
• 1 BMJ Publishing Group, London WC1H 9JR,
• 2 National Institute for Health and Clinical Excellence, London WC1V 6NA,
• 3 Database of Uncertainties about the Effects of Treatments, James Lind Alliance Secretariat, James Lind Initiative, Oxford OX2 7LG,
• 4 UK Cochrane Centre, Oxford OX2 7LG,
• 5 Centre for Reviews and Dissemination, University of York, York YO10 5DD,
• 6 National Coordinating Centre for Health Technology Assessment, University of Southampton, Southampton SO16 7PX,
• 7 Scottish Intercollegiate Guidelines Network, Edinburgh EH2 1EN,
• 8 Update Software, Oxford OX2 7LG
• Correspondence to: PBrown
• Accepted 22 September 2006

“More research is needed” is a conclusion that fits most systematic reviews. But authors need to be more specific about what exactly is required

Long awaited reports of new research, systematic reviews, and clinical guidelines are too often a disappointing anticlimax for those wishing to use them to direct future research. After many months or years of effort and intellectual energy put into these projects, authors miss the opportunity to identify unanswered questions and outstanding gaps in the evidence. Most reports contain only a less than helpful, general research recommendation. This means that the potential value of these recommendations is lost.

Current recommendations

In 2005, representatives of organisations commissioning and summarising research, including the BMJ Publishing Group, the Centre for Reviews and Dissemination, the National Coordinating Centre for Health Technology Assessment, the National Institute for Health and Clinical Excellence, the Scottish Intercollegiate Guidelines Network, and the UK Cochrane Centre, met as members of the development group for the Database of Uncertainties about the Effects of Treatments (see bmj.com for details on all participating organisations). Our aim was to discuss the state of research recommendations within our organisations and to develop guidelines for improving the presentation of proposals for further research. All organisations had found weaknesses in the way researchers and authors of systematic reviews and clinical guidelines stated the need for further research. As part of the project, a member of the Centre for Reviews and Dissemination under-took a rapid literature search to identify information on research recommendation models, which found some individual methods but no group initiatives to attempt to standardise recommendations.

Suggested format for research recommendations on the effects of treatments

Core elements.

E Evidence (What is the current state of the evidence?)

P Population (What is the population of interest?)

I Intervention (What are the interventions of interest?)

C Comparison (What are the comparisons of interest?)

O Outcome (What are the outcomes of interest?)

T Time stamp (Date of recommendation)

Optional elements

d Disease burden or relevance

t Time aspect of core elements of EPICOT

s Appropriate study type according to local need

In January 2006, the National Coordinating Centre for Health Technology Assessment presented the findings of an initial comparative analysis of how different organisations currently structure their research recommendations. The National Institute for Health and Clinical Excellence and the National Coordinating Centre for Health Technology Assessment request authors to present recommendations in a four component format for formulating well built clinical questions around treatments: population, intervention, comparison, and outcomes (PICO). 1 In addition, the research recommendation is dated and authors are asked to provide the current state of the evidence to support the proposal.

Clinical Evidence , although not directly standardising its sections for research recommendations, presents gaps in the evidence using a slightly extended version of the PICO format: evidence, population, intervention, comparison, outcomes, and time (EPICOT). Clinical Evidence has used this inherent structure to feed research recommendations on interventions categorised as “unknown effectiveness” back to the National Coordinating Centre for Health Technology Assessment and for inclusion in the Database of Uncertainties about the Effects of Treatments ( http://www.duets.nhs.uk/ ).

We decided to propose the EPICOT format as the basis for its statement on formulating research recommendations and tested this proposal through discussion and example. We agreed that this set of components provided enough context for formulating research recommendations without limiting researchers. In order for the proposed framework to be flexible and more widely applicable, the group discussed using several optional components when they seemed relevant or were proposed by one or more of the group members. The final outcome of discussions resulted in the proposed EPICOT+ format (box).

A recent BMJ article highlighted how lack of research hinders the applicability of existing guidelines to patients in primary care who have had a stroke or transient ischaemic attack. 2 Most research in the area had been conducted in younger patients with a recent episode and in a hospital setting. The authors concluded that “further evidence should be collected on the efficacy and adverse effects of intensive blood pressure lowering in representative populations before we implement this guidance [from national and international guidelines] in primary care.” Table 1 outlines how their recommendations could be formulated using the EPICOT+ format. The decision on whether additional research is indeed clinically and ethically warranted will still lie with the organisation considering commissioning the research.

Research recommendation based on gap in the evidence identified by a cross sectional study of clinical guidelines for management of patients who have had a stroke

• View inline

Table 2 shows the use of EPICOT+ for an unanswered question on the effectiveness of compliance therapy in people with schizophrenia, identified by the Database of Uncertainties about the Effects of Treatments.

Research recommendation based on a gap in the evidence on treatment of schizophrenia identified by the Database of Uncertainties about the Effects of Treatments

Discussions around optional elements

Although the group agreed that the PICO elements should be core requirements for a research recommendation, intense discussion centred on the inclusion of factors defining a more detailed context, such as current state of evidence (E), appropriate study type (s), disease burden and relevance (d), and timeliness (t).

Initially, group members interpreted E differently. Some viewed it as the supporting evidence for a research recommendation and others as the suggested study type for a research recommendation. After discussion, we agreed that E should be used to refer to the amount and quality of research supporting the recommendation. However, the issue remained contentious as some of us thought that if a systematic review was available, its reference would sufficiently identify the strength of the existing evidence. Others thought that adding evidence to the set of core elements was important as it provided a summary of the supporting evidence, particularly as the recommendation was likely to be abstracted and used separately from the review or research that led to its formulation. In contrast, the suggested study type (s) was left as an optional element.

A research recommendation will rarely have an absolute value in itself. Its relative priority will be influenced by the burden of ill health (d), which is itself dependent on factors such as local prevalence, disease severity, relevant risk factors, and the priorities of the organisation considering commissioning the research.

Similarly, the issue of time (t) could be seen to be relevant to each of the core elements in varying ways—for example, duration of treatment, length of follow-up. The group therefore agreed that time had a subsidiary role within each core item; however, T as the date of the recommendation served to define its shelf life and therefore retained individual importance.

Applicability and usability

The proposed statement on research recommendations applies to uncertainties of the effects of any form of health intervention or treatment and is intended for research in humans rather than basic scientific research. Further investigation is required to assess the applicability of the format for questions around diagnosis, signs and symptoms, prognosis, investigations, and patient preference.

When the proposed format is applied to a specific research recommendation, the emphasis placed on the relevant part(s) of the EPICOT+ format may vary by author, audience, and intended purpose. For example, a recommendation for research into treatments for transient ischaemic attack may or may not define valid outcome measures to assess quality of life or gather data on adverse effects. Among many other factors, its implementation will also depend on the strength of current findings—that is, strong evidence may support a tightly focused recommendation whereas a lack of evidence would result in a more general recommendation.

The controversy within the group, especially around the optional components, reflects the different perspectives of the participating organisations—whether they were involved in commissioning, undertaking, or summarising research. Further issues will arise during the implementation of the proposed format, and we welcome feedback and discussion.

Summary points

No common guidelines exist for the formulation of recommendations for research on the effects of treatments

Major organisations involved in commissioning or summarising research compared their approaches and agreed on core questions

The essential items can be summarised as EPICOT+ (evidence, population, intervention, comparison, outcome, and time)

Further details, such as disease burden and appropriate study type, should be considered as required

We thank Patricia Atkinson and Jeremy Wyatt.

Contributors and sources All authors contributed to manuscript preparation and approved the final draft. NJH is the guarantor.

Competing interests None declared.

• Richardson WS ,
• Wilson MC ,
• Nishikawa J ,
• Hayward RSA
• McManus RJ ,
• Leonardi-Bee J ,
• PROGRESS Collaborative Group
• Warburton E
• Rothwell P ,
• McIntosh AM ,
• Lawrie SM ,
• Stanfield AC
• O'Donnell C ,
• Donohoe G ,
• Sharkey L ,
• Jablensky A ,
• Sartorius N ,
• Ernberg G ,

Writing the parts of scientific reports

22 Writing the conclusion & recommendations

There are probably some overlaps between the Conclusion and the Discussion section. Nevertheless, this section gives you the opportunity to highlight the most important points in your report, and is sometimes the only section read. Think about what your research/ study has achieved, and the most important findings and ideas you want the reader to know. As all studies have limitations also think about what you were not able to cover (this shows that you are able to evaluate your own work objectively).

Possible structure of this section:

Use present perfect to sum up/ evaluate:

This study has explored/ has attempted …

Use past tense to state what your aim was and to refer to actions you carried out:

• This study was intended to analyse …
• The aim of this study was to …

Use present tense to evaluate your study and to state the generalizations and implications that you draw from your findings.

• The results add to the knowledge of …
• These findings s uggest that …

You can either use present tense or past tense to summarize your results.

• The findings reveal …
• It was found that …

Achievements of this study (positive)

• This study provides evidence that …
• This work has contributed to a number of key issues in the field such as …

Limitations of the study (negative)

• Several limitations should be noted. First …

Combine positive and negative remarks to give a balanced assessment:

• Although this research is somewhat limited in scope, its findings can provide a basis for future studies.
• Despite the limitations, findings from the present study can help us understand …

Use more cautious language (modal verbs may, can, could)

• There are a number of possible extensions of this research …
• The findings suggest the possibility for future research on …
• These results may be important for future studies on …
• Examining a wider context could/ would lead …

Or indicate that future research is needed

• There is still a need for future research to determine …
• Further studies should be undertaken to discover…
• It would be worthwhile to investigate …

Academic Writing in a Swiss University Context Copyright © 2018 by Irene Dietrichs. All Rights Reserved.

How to write recommendations in a research paper

Many students put in a lot of effort and write a good report however they are not able to give proper recommendations. Recommendations in the research paper should be included in your research. As a researcher, you display a deep understanding of the topic of research. Therefore you should be able to give recommendations. Here are a few tips that will help you to give appropriate recommendations. 

Recommendations in the research paper should be the objective of the research. Therefore at least one of your objectives of the paper is to provide recommendations to the parties associated or the parties that will benefit from your research. For example, to encourage higher employee engagement HR department should make strategies that invest in the well-being of employees. Additionally, the HR department should also collect regular feedback through online surveys.

Recommendations in the research paper should come from your review and analysis For example It was observed that coaches interviewed were associated with the club were working with the club from the past 2-3 years only. This shows that the attrition rate of coaches is high and therefore clubs should work on reducing the turnover of coaches.

Recommendations in the research paper should also come from the data you have analysed. For example, the research found that people over 65 years of age are at greater risk of social isolation. Therefore, it is recommended that policies that are made for combating social isolation should target this specific group.

Recommendations in the research paper should also come from observation. For example, it is observed that Lenovo’s income is stable and gross revenue has displayed a negative turn. Therefore the company should analyse its marketing and branding strategy.

Recommendations in the research paper should be written in the order of priority. The most important recommendations for decision-makers should come first. However, if the recommendations are of equal importance then it should come in the sequence in which the topic is approached in the research. 

Recommendations in a research paper if associated with different categories then you should categorize them. For example, you have separate recommendations for policymakers, educators, and administrators then you can categorize the recommendations. 

Recommendations in the research paper should come purely from your research. For example, you have written research on the impact on HR strategies on motivation. However, nowhere you have discussed Reward and recognition. Then you should not give recommendations for using rewards and recognition measures to boost employee motivation.

The use of bullet points offers better clarity rather than using long paragraphs. For example this paragraph “ It is recommended  that Britannia Biscuit should launch and promote sugar-free options apart from the existing product range. Promotion efforts should be directed at creating a fresh and healthy image. A campaign that conveys a sense of health and vitality to the consumer while enjoying biscuit  is recommended” can be written as:

• The company should launch and promote sugar-free options
• The company should work towards creating s fresh and healthy image
• The company should run a campaign to convey its healthy image

The inclusion of an action plan along with recommendation adds more weightage to your recommendation. Recommendations should be clear and conscience and written using actionable words. Recommendations should display a solution-oriented approach and in some cases should highlight the scope for further research. 

15 Steps to Good Research

• Define and articulate a research question (formulate a research hypothesis). How to Write a Thesis Statement (Indiana University)
• Identify possible sources of information in many types and formats. Georgetown University Library's Research & Course Guides
• Judge the scope of the project.
• Reevaluate the research question based on the nature and extent of information available and the parameters of the research project.
• Select the most appropriate investigative methods (surveys, interviews, experiments) and research tools (periodical indexes, databases, websites).
• Plan the research project. Writing Anxiety (UNC-Chapel Hill) Strategies for Academic Writing (SUNY Empire State College)
• Retrieve information using a variety of methods (draw on a repertoire of skills).
• Refine the search strategy as necessary.
• Write and organize useful notes and keep track of sources. Taking Notes from Research Reading (University of Toronto) Use a citation manager: Zotero or Refworks
• Evaluate sources using appropriate criteria. Evaluating Internet Sources
• Synthesize, analyze and integrate information sources and prior knowledge. Georgetown University Writing Center
• Revise hypothesis as necessary.
• Use information effectively for a specific purpose.
• Understand such issues as plagiarism, ownership of information (implications of copyright to some extent), and costs of information. Georgetown University Honor Council Copyright Basics (Purdue University) How to Recognize Plagiarism: Tutorials and Tests from Indiana University
• Cite properly and give credit for sources of ideas. MLA Bibliographic Form (7th edition, 2009) MLA Bibliographic Form (8th edition, 2016) Turabian Bibliographic Form: Footnote/Endnote Turabian Bibliographic Form: Parenthetical Reference Use a citation manager: Zotero or Refworks

Adapted from the Association of Colleges and Research Libraries "Objectives for Information Literacy Instruction" , which are more complete and include outcomes. See also the broader "Information Literacy Competency Standards for Higher Education."

How to formulate research recommendations

Affiliation.

• 1 BMJ Publishing Group, London WC1H 9JR. [email protected]
• PMID: 17038740
• PMCID: PMC1602035
• DOI: 10.1136/bmj.38987.492014.94

“More research is needed” is a conclusion that fits most systematic reviews. But authors need to be more specific about what exactly is required

Publication types

• Biomedical Research / methods
• Biomedical Research / organization & administration*
• Biomedical Research / standards
• Diffusion of Innovation*
• Evidence-Based Medicine

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Turn your research insights into actionable recommendations

At the end of one presentation, my colleague approached me and asked what I recommended based on the research. I was a bit puzzled. I didn’t expect anyone to ask me this kind of question. By that point in my career, I wasn’t aware that I had to make recommendations based on the research insights. I could talk about the next steps regarding what other research we had to conduct. I could also relay the information that something wasn’t working in a prototype, but I had no idea what to suggest. 

How to move from qualitative data to actionable insights

Over time, more and more colleagues asked for these recommendations. Finally, I realized that one of the key pieces I was missing in my reports was the “so what?” The prototype isn’t working, so what do we do next? Because I didn’t include suggestions, my colleagues had a difficult time marrying actions to my insights. Sure, the team could see the noticeable changes, but the next steps were a struggle, especially for generative research. 

Without these suggestions, my insights started to fall flat. My colleagues were excited about them and loved seeing the video clips, but they weren’t working with the findings. With this, I set out to experiment on how to write recommendations within a user research report. 

.css-1nrevy2{position:relative;display:inline-block;} How to write recommendations 

For a while, I wasn’t sure how to write recommendations. And, even now, I believe there is no  one right way . When I first started looking into this, I started with two main questions:

What do recommendations mean to stakeholders?

How prescriptive should recommendations be?

When people asked me for recommendations, I had no idea what they were looking for. I was nervous I would step on people’s toes and give the impression I thought I knew more than I did. I wasn’t a designer and didn’t want to make whacky design recommendations or impractical suggestions that would get developers rolling their eyes. 

When in doubt, I dusted off my internal research cap and sat with stakeholders to understand what they meant by recommendations. I asked them for examples of what they expected and what made a suggestion “helpful” or “actionable.” I walked away with a list of “must-haves” for my recommendations. They had to be:

Flexible. Just because I made an initial recommendation did not mean it was the only path forward. Once I presented the recommendations, we could talk through other ideas and consider new information. There were a few times when I revised my recommendations based on conversations I had with colleagues.

Feasible.  At first, I started presenting my recommendations without any prior feedback. My worst nightmare came true. The designer and developer sat back, arms crossed, and said, “A lot of this is impossible.” I quickly learned to review some of my recommendations I was uncertain about with them beforehand. Alternatively, I came up with several recommendations for one solution to help combat this problem.

Prioritized (to my best abilities).  Since I am not entirely sure of the recommendation’s effort, I use a chart of impact and reach to prioritize suggestions. Then, once I present this list, it may get reprioritized depending on effort levels from the team (hey, flexibility!).

Detailed.  This point helped me a lot with my second question regarding how in-depth I should make my recommendations. Some of the best detail comes from photos, videos, or screenshots, and colleagues appreciated when I linked recommendations with this media. They also told me to put in as much detail as possible to avoid vagueness, misinterpretation, and endless debate. 

Think MVP. Think about the solution with the fewest changes instead of recommending complex changes to a feature or product. What are some minor changes that the team can make to improve the experience or product?

Justified.  This part was the hardest for me. When my research findings didn’t align with expectations or business goals, I had no idea what to say. When I receive results that highlight we are going in the wrong direction, my recommendations become even more critical. Instead of telling the team that the new product or feature sucks and we should stop working on it, I offer alternatives. I follow the concept of “no, but...” So, “no, this isn’t working, but we found that users value X and Y, which could lead to increased retention” (or whatever metric we were looking at.

Let’s look at some examples

Although this list was beneficial in guiding my recommendations, I still wasn’t well-versed in how to write them. So, after some time, I created a formula for writing recommendations:

Observed problem/pain point/unmet need + consequence + potential solution

Evaluative research

Let’s imagine we are testing a check-out page, and we found that users were having a hard time filling out the shipping and billing forms, especially when there were two different addresses.

A non-specific and unhelpful recommendation might look like :

Users get frustrated when filling out the shipping and billing form.

The reasons this recommendation is not ideal are :

It provides no context or detail of the problem 

There is no proposed solution 

It sounds a bit judgemental (focus on the problem!) 

There is no immediate movement forward with this

A redesign recommendation about the same problem might look like this :

Users overlook the mandatory fields in the shipping and billing form, causing them to go back and fill out the form again. With this, they become frustrated. Include markers of required fields and avoid deleting information when users submit if they haven’t filled out all required fields.

Let’s take another example :

We tested an entirely new concept for our travel company, allowing people to pay to become “prime” travel members. In our user base, no one found any value in having or paying for a membership. However, they did find value in several of the features, such as sharing trips with family members or splitting costs but could not justify paying for them.

A suboptimal recommendation could look like this :

Users would not sign-up or pay for a prime membership.

Again, there is a considerable lack of context and understanding here, as well as action. Instead, we could try something like:

Users do not find enough value in the prime membership to sign-up or pay for it. Therefore, they do not see themselves using the feature. However, they did find value in two features: sharing trips with friends and splitting the trip costs. Focusing, instead, on these features could bring more people to our platform and increase retention. 

Generative research

Generative research can look a bit trickier because there isn’t always an inherent problem you are solving. For example, you might not be able to point to a usability issue, so you have to look more broadly at pain points or unmet needs. 

For example, in our generative research, we found that people often forget to buy gifts for loved ones, making them feel guilty and rushed at the last minute to find something meaningful but quickly.

This finding is extremely broad and could go in so many directions. With suggestions, we don’t necessarily want to lead our teams down only one path (flexibility!), but we also don’t want to leave the recommendation too vague (detailed). I use  How Might We statements  to help me build generative research recommendations. 

Just reporting the above wouldn’t entirely be enough for a recommendation, so let’s try to put it in a more actionable format:

People struggled to remember to buy gifts for loved one’s birthdays or special days. By the time their calendar notified them, it was too late to get a gift, leaving them filled with guilt and rushing to purchase a meaningful gift to arrive on time. How might we help people remember birthdays early enough to find meaningful gifts for their loved ones?

A great follow-up to generative research recommendations can be  running an ideation workshop !

Researching the right thing versus researching the thing right

How to format recommendations in your report.

I always end with recommendations because people leave a presentation with their minds buzzing and next steps top of mind (hopefully!). My favorite way to format suggestions is in a chart. That way, I can link the recommendation back to the insight and priority. My recommendations look like this:

Overall, play around with the recommendations that you give to your teams. The best thing you can do is ask for what they expect and then ask for feedback. By catering and iterating to your colleagues’ needs, you will help them make better decisions based on your research insights!

Written by Nikki Anderson, User Research Lead & Instructor. Nikki is a User Research Lead and Instructor with over eight years of experience. She has worked in all different sizes of companies, ranging from a tiny start-up called ALICE to large corporation Zalando, and also as a freelancer. During this time, she has led a diverse range of end-to-end research projects across the world, specializing in generative user research. Nikki also owns her own company, User Research Academy, a community and education platform designed to help people get into the field of user research, or learn more about how user research impacts their current role. User Research Academy hosts online classes, content, as well as personalized mentorship opportunities with Nikki. She is extremely passionate about teaching and supporting others throughout their journey in user research. To spread the word of research and help others transition and grow in the field, she writes as a writer at dscout and Dovetail. Outside of the world of user research, you can find Nikki (happily) surrounded by animals, including her dog and two cats, reading on her Kindle, playing old-school video games like Pokemon and World of Warcraft, and writing fiction novels.

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The Global Guide to Research Impact

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• How to write actionable policy recommendations

By Nyasha Musandu 16/07/2013

When writing a policy brief, there are many things one has to consider: The language has to be just right, not too technical but professional. The length has to be brief yet informative and most of all it needs to speak to a pre-identified and targeted audience.

The policy brief has become the ‘go to’ tool in facilitating evidence based policies. The policy brief seeks to inform the decision maker of policy options that are evidence based, robust and will achieve the desired result in various scenarios. With the creation of each policy brief we hope that maybe, just maybe, we will get the right policy maker to read our compelling arguments, experience a eureka moment and spearhead the process of creating sound and effective policies with our research as their sword.  Unfortunately, policy influence rarely happens in this manner. What you have to try to do is identify your policy makers’ problems and give him/her actionable policy recommendations.

Here are some simple things to consider to ensure that your recommendations are practical and actionable.

1 .   Ensure that you have identified your target audience beforehand. Understanding who your audience is and what their job entails is crucial. What is their sphere of influence and what change can they implement?

2.   Be very clear about what the current policy you want to change is.

3.   Set the scene: Identify the shortfalls of the current policy. Where is this policy failing, why and how can your recommendations improve the status quo?

4.   Be aware of how policies are made: remember that government policy actors are interested in making decisions that are practical, cost-effective and socially acceptable.

5.   If you are suggesting change ask yourself: What specifically needs to be changed? How will this change come about? What resources will be needed? Where will these resources come from? What is the overall benefit to both the policy maker and society in general? If your recommendations include these components they are much more likely to garner the required change.

6.   The word actionable suggests that your recommendations should be active. Try using language that is active rather than passive. Words such as use, engage, incorporate etc.

7 .   Keep your policy recommendations short. Identify 3 recommendations and elaborate on these. Pick the three that are most practical and relevant for your target audience then focus on presenting these in the most actionable way.

8 .   Make sure your research supports your recommendations. This may sound very obvious but policy makers will want to know that the evidence supports your assertions. Where you are providing an opinion, not supported by research, make this very clear.

9.   Ask yourself, is my recommendation viable? Does the recommendation seem feasible?

References:

·       Global HIV/AIDS Initiatives Network, 2008. Policy Brief Guidelines.

·       Community – Based Monitoring System (CBMS) Network Coordinating Team. Guidelines for writing a policy brief.

·       FAO. Food Security Communications Toolkit .

·       MEASURE Evaluation, 2009. Making Research Findings Actionable: A quick reference to communicating health information for decision making .

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Contributors to this supplement of the  Publication of the American Dialect Society  examine past studies in North American language and dialects and make recommendations for future research, looking at aspects such as language regard and lexical, phonetic, phonological, and morphosyntactic variation. Authors cover various fields of interest to language scholars, including African American English, the history of North American English, language in Latinx communities, French heritage languages in North America, American Sign Language, and the Linguistic Atlas Projects.

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Managing Anger, Frustration, and Resentment on Your Team

• Nihar Chhaya

Four strategies to help managers respond with compassion.

Anger and resentment across your team can make an already stressful leadership job feel worse. But how you respond to your employees’ frustrations is critical to ensuring negative emotions don’t limit your effectiveness. The author offers four recommendations to try: 1) Balance your emotions first before reacting to your team’s frustration. 2) Lean into their anger with an intent to learn. 3) Redesign team goals together. 4) Build deeper trust by owning your part.

With so much instability in the workplace these days, you may feel untethered in your daily job responsibilities as well as your long-term career. And when insecurity leads to frustration, it can be hard to keep your temper. But when you are in a leadership role, you face an even more formidable challenge: managing your team’s moods without letting their episodes of anger impair your effectiveness.

• Nihar Chhaya  is an executive coach to senior leaders at global companies, including American Airlines, Coca-Cola, DraftKings and Wieden+Kennedy.    A former F500 corporate head of talent development, he is the President of  PartnerExec , helping leaders master influence for superior business and strategic outcomes. You can sign up for Enviable, his weekly newsletter .  

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• How opioid use disorder occurs

Opioid use — even short term — can lead to addiction and, too often, overdose. Find out how short-term pain relief leads to life-threatening problems.

People who take opioids are at risk of opioid use disorder, often called opioid addiction. Personal history and how long people use opioids play a role. But it's impossible to tell who could become dependent and misuse opioids. The misuse of opioids — legal, illegal, stolen or shared — is the reason 90 people die in the U.S. every day on average, according to the American Society of Anesthesiologists.

Addiction is a condition where something that started as pleasurable now feels like something you can't live without. Drug addiction is defined as an out-of-control feeling that you must use a medicine or drug and continue to use it even though it causes harm over and over again. Opioids are highly addictive, largely because they trigger powerful reward centers in your brain.

Opioids trigger the release of endorphins. They tell your brain that you feel good. Endorphins make it less likely that you'll feel pain. They also boost feelings of pleasure. This creates a sense of well-being that is powerful but lasts only a short time. When an opioid dose wears off, you may find yourself wanting those good feelings back as soon as possible. This is how opioid use disorder can begin.

Short-term versus long-term effects

When you take opioids again and again over time, your body doesn't make as many endorphins. The same dose of opioids doesn't make you feel as good. This is called tolerance. One reason opioid use disorder is so common is that people who build up tolerance may feel like they must raise their doses to keep feeling good. They also may start having cravings for opioids. If they don't raise their doses, they may start having withdrawal symptoms, including worsening pain, goosebumps, anxiety, yawning and diarrhea.

Because of the risk of opioid misuse, it's often hard to get your healthcare professional to raise your dose or renew your prescription. Some opioid users who believe they need a bigger supply find illegal ways to get opioids or start using heroin. Some street drugs are laced with contaminants or much more powerful opioids such as fentanyl. The number of deaths from using heroin has gone up since more heroin now contains fentanyl.

If you're taking opioids and you've built up a tolerance, ask your healthcare professional for help. Other safe choices are available to help you make a change and keep feeling well. Don't stop opioid medicines without help from a healthcare professional. Quitting these medicines suddenly can cause serious withdrawal symptoms, including pain that's worse than it was before you started taking opioids. Your healthcare team can help you gradually and safely reduce the amount of opioids you take.

Risk factors for opioid use disorder

Opioids are most addictive when you take them in a way other than how they were prescribed — for example, crushing a pill so that it can be snorted or injected. This life-threatening drug misuse is even more dangerous if the pill is effective for a longer period of time. Rapidly delivering all the medicine to your body can cause an accidental overdose. Taking more than your prescribed dose of opioid medicine, or taking a dose more often than prescribed, also increases your risk of opioid use disorder.

How long you use prescribed opioids also plays a role. Researchers have found that taking opioid medicines for more than a few days raises your risk of long-term use. This makes it more likely that opioids will become addictive. After only five days of taking an opioid medicine, the chances increase that you'll still be taking opioids a year after starting a short course of the medicine.

Genetic, psychological and environmental factors also play a role in addiction, which can happen quickly or after many years of opioid use.

Risk of opioid addiction is greater for people who:

• Are younger, specifically in their teens or early 20s.
• Have a personal or family history of substance misuse.
• Are living with stress, including being unemployed or living below the poverty line.
• Have a history of problems with work, family and friends.
• Have a history of taking part in crimes or having legal issues, including DUIs.
• Have serious depression, anxiety or post-traumatic stress disorder.
• Have a history of physical or sexual abuse.
• Take part in risky or thrill-seeking behavior.
• Perform poorly in school and do not value education.
• Use tobacco heavily.

In addition, women have a unique set of risk factors for opioid use disorder. Women are more likely than men to have long-term pain. Compared with men, women also are more likely to be prescribed opioid medicines, to be given higher doses and to use opioids for longer periods of time. Women also may be more likely than men to become dependent on prescription pain relievers.

Steps to prevent opioid use disorder

Opioids are safest when used for three or fewer days to manage serious pain, such as pain that follows surgery or a bone fracture. If you need opioids for severe pain, work with your healthcare professional to take the lowest dose possible, for the shortest time needed, exactly as prescribed. Also, be sure to ask if drugs other than opioids are available or if other types of treatment can be used instead. And don't share your opioid medicines or take other people's opioids.

If you're living with lifelong pain, opioids aren't likely to be a safe and effective long-term treatment option. Many other treatments are available, including less addictive pain medicines and therapies that don't involve medicines. If possible, aim for a treatment plan that allows you to enjoy your life without opioids.

Help prevent opioid misuse in your family and community by storing opioid medicines securely while you use them. Get rid of unused opioids properly. In the U.S., find the closest Controlled Substance Public Disposal Locations on a website the Drug Enforcement Administration (DEA) maintains. Or contact your local law enforcement agency or your trash and recycling service for information about local medicine takeback programs. If no takeback program is available in your area, ask your pharmacist for help.

Everyone plays an important role in breaking the grip that opioids have on communities and their residents.

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• Substance/medication-induced mental disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022; https://dsm.psychiatryonline.org. Accessed June 28, 2023.
• Warning signs of addiction. Recovered.org. https://recovered.org/addiction/warning-signs-of-addiction. Accessed June 28, 2023.
• Shah A, et al. Characteristics of initial prescription episodes and likelihood of long-term opioid use — United States, 2006-2015. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm?s_cid=mm6610a1_w. Accessed Nov. 10, 2023.
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“These are just finishing our medicines”: older persons’ perceptions and experiences of access to healthcare in public and private health facilities in Uganda

• Stephen Ojiambo Wandera 1 , 2 ,
• Valerie Golaz 3 ,
• Betty Kwagala 1 ,
• James P. M. Ntozi 1 &
• David Otundo Ayuku 2  

BMC Health Services Research volume  24 , Article number:  396 ( 2024 ) Cite this article

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There is limited research on the experiences of access to medicines for non-communicable diseases (NCDs) in health facilities among older persons in Uganda. This paper explores the perspectives of older persons and healthcare providers concerning older persons’ access to essential medicines in Uganda.

It is based on qualitative data from three districts of Hoima, Kiboga, and Busia in Uganda. Data collection methods included seven (07) focus group discussions (FGDs) and eighteen (18) in-depth interviews with older persons. Nine (9) key informant interviews with healthcare providers were conducted. Deductive and inductive thematic analysis (using Health Access Livelihood Framework) was used to analyze the barriers and facilitators of access to healthcare using QSR International NVivo software.

The key facilitators and barriers to access to healthcare included both health system and individual-level factors. The facilitators of access to essential medicines included family or social support, earning some income or Social Assistance Grants for Empowerment (SAGE) money, and knowing a healthcare provider at a health facility. The health system barriers included the unavailability of specialized personnel, equipment, and essential medicines for non-communicable diseases, frequent stock-outs, financial challenges, long waiting times, high costs for medicines for NCDs, and long distances to health facilities.

Access to essential medicines for NCDs is a critical challenge for older persons in Uganda. The Ministry of Health should make essential drugs for NCDS to be readily available and train geriatricians to provide specialized healthcare for older persons to reduce health inequities in old age. Social support systems need to be strengthened to enable older persons to access healthcare.

Peer Review reports

Globally, the demographic transition associated with increment in longevity is expected to increase the proportion of adults age 50 and older. Currently, the proportion of older persons (those age 60) and older is 11% and is expected to increase to 20% by 2050. The absolute number of older people increased from 205 million in 1950 to 810 million in 201. Projections for 2022 and 2050 are one billion and 2 billion respectively, outnumbering children age 0–14 years [ 1 , 2 ]. In sub-Saharan Africa (SSA), the absolute number of older persons (aged 60+) is 43 million, forming 5% of the population [ 3 ] and is projected to increase to 163 million (8.3% of the population) by 2050 [ 2 ]. In Uganda, the number of older persons has increased from 1.1 million in 2002 (4.5% of the population) to 1.3 million in 2010 [ 4 ] and shall increase to 5.5 million (5.7% of the population) by 2050 [ 2 ]. About 10% of the older persons were living alone by 2010 Uganda national household survey [ 5 ]. The average household size was 4.7 persons according to the Uganda Population and Housing Census of 2014 [ 6 ].

The World Health Organization (WHO) uses age 50 and older to define older persons in sub-Saharan African (SSA) countries due to lower life expectancy [ 7 ]. Several studies in SSA have used this definition [ 8 , 9 , 10 , 11 ]. On the other hand, the United Nations (UN) uses age 60 and older to define older persons [ 7 , 12 ]. Likewise, the Ministry of Gender, Labour and Social Development (MoGLSD) in Uganda uses the same definition [ 4 , 13 ]. Some reports on older people use this definition [ 1 ]. For this article, age 50 and older was used.

The prevalence of non-communicable diseases (NCDs) has been reported in some surveys in Uganda. Hypertension has been reported at 6.3% in the rural Uganda non-communicable disease (RUNCD) study [ 14 ]. A higher prevalence of hypertension (21%) has been reported among HIV patients [ 15 ]. A prevalence of hypertension of 21% has been reported in a sample of 611 people in a WHO STEPS tool study in Kasese [ 16 ]. Hypertension is the most reported NCD followed by obesity and diabetes in a scoping review for sub-Saharan Africa [ 17 ]. Among 2,382 older persons, about a quarter (23%) of the older persons reported an NCD in a 2010 national survey in Uganda [ 18 ]. Finally, in East Africa, 40% of deaths in 2015 were attributed to NCDs [ 19 ] and 53% were attributed to NCDs in eastern Uganda [ 20 ]. Therefore, NCDs are becoming an increasing health need in Uganda and are estimated at 26% [ 21 ].

In Uganda, the public healthcare system is hierarchically organized. At the top is the national referral hospitals: Mulago and Butabika. From Mulago national referral hospital, there are regional referral hospitals, health center (HC) from levels IV (district), III (sub-county), II (Parish) and I (village). Regional referral hospitals exist in each of the four regions of Uganda (central, eastern, western, and northern). At the lower levels, are health center IVs (district level) and IIIs (sub-county level). At the lowest levels namely parish and village are health center II and I, respectively [ 22 , 23 , 24 , 25 , 26 , 27 , 28 ].

Ageing is associated with several healthcare needs [ 29 ]. One of the critical needs of older persons is managing the worsening health outcomes [ 30 ] including non-communicable diseases (NCDs) and disabilities. NCDs increase the need for healthcare among older persons [ 31 , 32 ]. This has been observed in Hong Kong [ 31 ], Singapore [ 33 ] and in rural South Africa [ 34 ]. However, in some low- and middle-income countries (LMICs), older persons with NCDs have limited access to healthcare. Examples include in India [ 35 ], China [ 36 ] and Hong Kong [ 31 ]. Generally, older persons face barriers of access to healthcare due to increased vulnerability and deprivation in old age [ 3 , 30 , 37 , 38 ].

Studies on access to healthcare in general and access to essential medicines for NCDs and healthcare by older persons in Uganda are limited [ 39 , 40 , 41 , 42 ]. Available evidence on older people’s health have focused on HIV/AIDS [ 43 , 44 , 45 ]; caregiving roles of older persons [ 46 , 47 , 48 , 49 ] and various vulnerabilities [ 50 , 51 ]. Studies which have addressed access to healthcare used quantitative secondary data and focused on patient level factors [ 32 ]. Others have focused on specific interest groups like the diabetics and not necessarily the older population [ 38 , 52 , 53 ]. Therefore, the aim of this paper was to explore perceptions and experiences about the health system and individual barriers and facilitators of access to healthcare among older persons in health facilities in Uganda. In addition, the perspectives of healthcare providers and community workers are explored using key informant interviews.

Study design, setting and sampling

This study used a cross-sectional study design. This qualitative study was a follow up to the secondary data analysis of the factors which predicted access to healthcare using a nationally representative household survey whose results are published elsewhere [ 32 ].

Three districts were purposively selected as study sites namely: Hoima, Kiboga and Busia, taking geographical and regional variations into consideration. Hoima was selected in western, Kiboga for central and Busia for eastern region.

Purposive sampling was used to select the study participants. Local leaders at the local council level guided the identification of older persons’ households. To recruit more participants, snow ball sampling was also used.

Data sources

This paper primarily uses interviews from a qualitative study conducted in Busia, Kiboga and Hoima districts of Uganda in 2014 [ 54 ]. This study was part of a doctoral thesis for the the first author. Some of the survey data and findings are published in another paper [ 32 ]. In addition, preliminary interviews were conducted in 2012 in Hoima in a collaborative research framework on Poverty, Resource Accessibility and Spatial Mobility in East Africa [ 55 ]. Even though the data were collected in 2014, the findings are still relevant. First, there is limited evidence on the subject – experiences of older people with the public health system in Uganda. Some data which is yet to be published in other settings still points to the health system challenges for folder people. Recently, the Ministry of Health (MoH) in Uganda is in the process of developing a national healthcare strategy for older persons. Some of the findings have been used to inform this policy formulation process. Similarly, the Ministry of Gender, Labor and Social Development (MGLSD) is developing the national guidelines for mainstreaming ageing in Uganda.

Data collection

The interviews with older persons included 18 In-depth interviews (IDIs) and seven focus group discussions (FGDs) collectively comprising 52 participants. We aimed to balance the gender of the different participants among the IDIs and the FGDs. Also, we aimed to do the same number of interviews in each district. The IDIs focused on exploring the perceptions and experiences of older persons about the barriers and facilitators of access to essential medicines for non-communicable diseases in health facilities. In addition, 9 key informant interviews (KIIs) were conducted with healthcare providers at public or private health facilities to facilitate triangulation of data. Healthcare providers were from Hoima regional referral hospital (Hoima), Bukomero health centre (HC) IV (Kiboga), Lumino HC III and Friends of Christ Revival Ministries (FOCREV) clinic (Busia district). The KIIs focused on the barriers and facilitators of access to essential medicines among older persons in Uganda. All the interviews were audio recorded. Entry into community was sought through village local council (LCs) chairpersons, older person’s associations in Hoima and Busia, and SAGE coordinators in Kiboga district and health facility in charges.

Ethical considerations

The study was approved by the Research Ethics Committee / Institutional Review Board (IRB) of the Uganda National Council of Science and Technology (UNCST) (SS 3198). The multi-disciplinary study on Poverty, resource accessibility and spatial mobility in East Africa (MPRAM) research programme was also approved by the IRB of the UNCST (SS 2726).

All experiments / research processes were performed in accordance with relevant guidelines and regulations (such as the Declaration of Helsinki).

All the respondents gave their written and informed consent to participate in the study. During the informed consent process, we provided assurance of confidentiality, participation on voluntary basis, freedom to withdraw or to decline and to answer any question without negative consequences. Finally, during the reporting and publication phase, we anonymized the interviews to ensure confidentiality of the interviewees.

Inclusion and exclusion criteria

The inclusion criteria were being age 50 years and older, being in the right mind and the ability to comprehend. In addition, we aimed to interview older persons who were not ill by the time of the interview. Also, eligibility criteria included older persons who were in their right mind and could comprehend and were not ill by the time of the interview.

Data analysis

All recorded interviews were transcribed verbatim. All transcriptions were checked to ensure accuracy in transcription and translation from local languages (Lunyoro, Lusamia and Luganda for Hoima, Busia and Kiboga respectively) to English. Transcriptions were later, imported into QSR International NVivo software (version 9) for thematic and / or framework analysis [ 56 ].

Both deductive and inductive thematic analysis were used in the coding exercise [ 57 ]. Themes were developed following the Health Access Livelihood Framework (HALF model) related to access to healthcare [ 58 ]. The HALF model describes five dimensions of access to healthcare: availability, affordability, accessibility, adequacy and acceptability and five dimensions of livelihood assets [ 58 ]. The inductive thematic analysis involved adding themes or codes that were emerging from the transcriptions during the coding exercise.

This section presents the facilitators and barriers of access to healthcare among older persons. Perceptions and experiences are explored from the older persons and healthcare providers. We start with the facilitators and end with the barriers.

Facilitators of access to healthcare among older people

The facilitators of access to healthcare included availability of public health facilities, social support, support from NGOs, access to financial resources, transportation, access to village health teams, and having a healthcare provider who is a relative.

Availability of free services in public health facilities

Availability of public health facilities which are expected to provide free medical services was highlighted as a motivation for visiting health facilities. In addition, non-communicable diseases create demand for healthcare. Private health facilities are not easily afforded by older people. They prefer to visit public health facilities:

… we go there when we fail to get money to take us to private health facilities…When a person is very cold and you make a fire, you do not have to invite him. He will bring himself. We go there because we are sick… You wonder whether they will give you medicine or not… [Male FGD, Hoima]

Putting a special clinic day for older persons was considered as a facility for access to healthcare in Hoima. Older persons continued to access healthcare on all days. However, a special day was designated to provide extra care for older persons. After some time, this was removed. However, this was not standard practice across all the three districts. It was the best practice in Hoima only. This was being at the regional referral hospital. Conversely, older persons complained that “sickness does not wait for you on a special day”. As much they were happy with a special or clinic day for older persons, they expressed concerns about its effectiveness.

Family and social support

Family support includes the support of spouses, relatives, brothers and sisters, adult children, and grandchildren. The form of support could be material, financial, or physical/caretaking. Older persons with highly educated working children, and those with children working abroad tend to receive significant support. Relatives play a major role in patient attendance and interacting with health personnel. In kind /material support for instance includes purchase of food, eyeglasses, and transfer to better health facilities around the city. Older persons with relatives working in health facilities favour them by helping them to “jump” the queue. Many older persons receive support from family members in form of means of transportation to health facilities and payment of medical bills.

Some of us have educated our children like you [refers to moderator]. That is a real bank. When you educate a child and he gets a job, that is a bank [Male FGD, Hoima]

However, family, or social support dynamics are changing. Some older persons reported that family support is limited and is not reliable. Some older persons with relatives who can transport them to hospital and pay the bills are very few. This was stated in an FGD in Kiboga. Children whose resources are meagre are unable even though they would be willing to support their parents because they also must cater for their own children/families. Other children may not even help when they are able to. This was emphasized in one FGD:

… The health of old people is very poor. Some have children who do not care for them. Even those who have no children have nobody to care for them… [Male FGD, Hoima]

Support from non-governmental organizations (NGOs)

Some NGOs in Busia provided support to older persons including Compassion International. Compassion International in Busia provided some support to older persons as caregivers of children, when they have chronic illnesses such as TB, HIV, and cancer. In Hoima, the Uganda Reach the Aged Association (URAA), World Vision, Sans Frontiers, Sight Savers International, Infectious Diseases Institute (IDI) and Little Hospice Hoima provided health support. In Kiboga, Stearkey (based in Ntinda), provided support to older people.

When they have chronic illnesses, we intervene …like TB, we support like HIV groups for HIV positive…. umm they are mostly old people [Community Worker, Busia]

The URAA trained home-based care givers in Hoima who offered basic treatment to older persons from their homes. However, the program ceased due to lack of funding.

There was an NGO helping the elderly. They trained the home-based caregivers. They could bring drugs for the elderly… It was Uganda Reach the Aged Association, URAA… But they ran short of money and all that… [Female FGD, Hoima]

Little Hospice takes care of severe chronic illness such as stroke or cancer for older persons who are on HIV treatment. Infectious Diseases Institute (IDI) was supporting HIV ART in Hoima regional referral hospital where older persons were beneficiaries. Sight Savers and Sans Frontiers provide eye care, provision of eyeglasses inclusive and hearing aids respectively. STEARKEY from Ntinda, Kampala, Uganda, also supports older persons with hearing aids in Kiboga.

…with sight, we have got the Sight Savers… at least that one yes… umm sight savers and also hearing umm at least there there people Sans Frontiers, who usually come around. and then after checking… I think they give out spectacles… free free… Sans Frontiers they they cross check they check for the the the ears impairment [Traditional Minister, Bunyoro Kingdom, Hoima]

Some older people with disability received some transportation assistance from the National Union of Disabled Persons Uganda (NUDIPU).

Financial resources

Having financial resources / money helped older persons to access private health facilities, where the services / handling was perceived to be better than in public health facilities. Generally, poor older persons use public health facilities while the rich or the middle class use private health facilities. Financial resources are essential in purchasing essential medicines or drugs for NCDs and paying for extra charges at public facilities. A community worker noted:

…the haves go to private (facilities), the have-nots they stay in queues waiting for medicines [public health facilities] … and the have-nots, they have no choice they have to wait in the queues… when you have your money, why should you wait? [Community worker, Hoima]

Older persons in Kiboga, who received the monthly Social Assistance Grants for Empowerment (SAGE) funds, were able to use some of the resources to access healthcare. Older persons in Busia and Hoima were not receiving the SAGE grant by that time. These two districts were not yet included on the beneficiary list. A community worker in Kiboga asserted:

…the biggest challenge for the elderly is that they have been lacking money… now when you give them an opportunity to have cash [SAGE grant] … even if he falls sick, he still is able to … buy drugs [Community worker, Bukomero, Kiboga]

Availability of transport to access healthcare

Availability of transport to visit the health facilities was a key facilitator. The means of transport are usually provided by older persons’ relatives, children and sometimes, NGOs. A community worker in Hoima noted:

… those who have relatives who are able… to move them on boda bodas or even bicycles… or even vehicles…there are some rich people [Community worker, Hoima]

Some NGOs like World Vision and Bukomero Development Foundation in Kiboga provided transport to older persons in Kiboga to access better treatment in Kampala. A community worker in Kiboga stated that:

There are those older people especially those that are suffering from HIV and AIDS, … we have been able to give them transport to go for medication may be in Mulago … to be able to access better treatment from Kampala [Community worker, Kiboga]

Access to village health teams (VHTs)

The community health system in Uganda includes village health teams (VHTS), community health workers (CHWs), health assistants (HAs), expert clients and the AIDS community volunteers (ACVs). VHTs and CHWs identify, refer to health facilities, and give health education to older persons. This has helped TB and HIV patients to access treatment. This was the major outreach strategy in Lumino HC 3 (Busia) and Mparangasi HC 3 (Hoima district). Some older persons visit health facilities after such referrals. A healthcare provider in Busia reported:

… we have some patients in the village who are chronically sick…they do not go to hospitals … so the VHTs or the CHWs identifies them… visits them and they have referral notes, they do refer them to us… so some of them come … [Healthcare provider, Busia]

Those who do not turn up are followed by medical staff from the health facility, which is an outreach strategy to the community. The VHTs majorly deal with malaria treatment among children and pregnant women. One KII in Busia emphasized:

…at times those who are referred, and they do not come… So, we send our people now… we even send these nurses… to go and visit these patients in the village…. it is more active on TB and the ART clinics [Healthcare provider, Busia]

However, in Kiboga, some participants noted that VHTs focus on children and not older persons:

…We also have VHTs… they are dealing with treatment of children… specifically malaria but they do sensitization and mobilization… they are supposed to tell the old people, … to even advocate for them [Healthcare provider, Kiboga]

Knowing a healthcare provider at a health facility was a great motivator

Access to healthcare was much easier when an older person knew a healthcare provider - as a relative or a son or daughter of a friend. In such cases, he or she is helped to jump the queue. He or she is removed from the line and treated first irrespective of whether he or she came earlier or later than other patients. In some cases, relatives who can talk well to providers also help them jump the queue. In some other instances, providers offer direct assistance to older persons. An older woman in Busia asserted:

No, for me they make me jump the queue… Yes, there are those I know… There is Sam (Pesudo name), he just picks me… I don’t know the work he does but he comes that ‘elder come they work on you and you go’… They can complain about it when am not there…They finish complaining and for me, I am gone. It is upon them as a person who backbites you after you had left, can you hear? [Older woman, age about 70, Busia]

In Hoima, mention of such assistance also came up in the male FGD:

If you know some member of staff, someone’s child working there… I know the doctor. The relationship at that level. Someone can leave the health facility in Kasomoro and come to Booma because there is the child of the aunt working there [Male FGD, Hoima]

Barriers of access to healthcare

The barriers of access to healthcare for older people were numerous. They ranged from lack of essential medicines to ageism against older people, absence of geriatricians, treatment adherence issues, accessibility, affordability challenges, and acceptability issues. These are described as follows:

Availability of essential medicines for non-communicable diseases is a critical gap

This was the most frequently discussed theme in al the interviews. Both older persons and healthcare providers acknowledged unavailability or frequent stockouts of essential drugs for non-communicable diseases (NCDs) for older people in public health facilities. Public health facilities normally refer older people to private clinics to buy medicines, which is a huge barrier for them. Many older persons reported frequent drug stockouts at public health facilities due to large numbers of patients Footnote 1 . An older man in Busia witnessed a situation where the medicines, which were received at a health centre III in Busia district, only included septrin and paracetamol. In Busia, older persons reported challenges with the distribution of drugs:

When we go to VHTs, they tell us the drugs are for the young children; that we should go to the health facility to get ours. But when we go to health centres, we do not find the drugs there [Male FGD, Hoima district]

There was a belief that public health facilities receive medicines that do not match “older people’s” sicknesses (refers to NCDs) in health centre IIIs. According to one of the health providers in a health centre III, it is rare to find drugs for hypertension, diabetes, and typhoid at health centre IIIs Footnote 2 and lower levels.

Some older persons in Busia suspected drug pilferage by health providers - that the drugs are then sold in health providers’ private clinics. However, health providers in Busia attributed unavailability of some drugs to frequent stock outs because of the government push system , which predetermines which drugs are sent to HC III and II and the heavy client flow in public health facilities. In addition, absence of storage facilities for insulin explained the shortage of insulin for diabetes in one of the regional referral hospitals in Hoima Footnote 3 .

One of the health providers in a health centre III explained that health centres IIIs receive medicines from district hospitals because of the government “push system” (KII, Busia). Although medicines or drugs in public facilities are supposed to be free, patients are sometimes asked to pay some money to the dispensers to help them purchase the drugs which are not available from an outside private pharmacy. Participants perceived this to be a form of extortion as noted:

Dispensers tell you that the drug is out of stock. Once you give him the money, he just pockets it and then picks up the medicine and gives it to you…. assuming that he has just bought it from outside the clinic [Community worker, Hoima]

Absence of specialized health personnel including geriatricians

The second most pressing barrier was concerned with healthcare providers especially geriatricians. The unavailability of health personnel trained in geriatrics and gerontology makes it difficult to adequately addressing older persons’ health problems. A key informant referring to lower-level health facilities alluded to the need to have trained doctors in Hoima:

The health facilities exist but health providers cannot manage the complications of the diseases of the elderly… because most of these health centers are managed by nurses. A man may have problems associated with hypertension, or the heart; such health centers cannot handle even if they are near [Community worker, Hoima]

Ageism against older people by young healthcare providers

One of the key factors was ageist and negative attitudes against older people by young health providers in public health facilities. Older people in Busia reported ageism perpetrated by young health providers. Older persons were reprimanded for trying to access medicines instead of giving space and priority to younger persons. Female FGD participants in Busia cited a health provider’s statement as follows:

‘These (older persons) are just finishing our medicines; don’t they have grandchildren?’ With such observations from health providers, … we get tired of going to the hospital… They tell us that we finish medicines for our grandchildren…. Now they say we are useless to people [Female FGD, Busia district]

Poor handling of older people by healthcare providers was attributed to both the overwhelming workload and the intentional mistreatment by young nurses. The most vulnerable older persons are those that seek for care on their own (alone).

Affordability and financial challenges

Poverty or financial barriers was the fourth most reported problem in accessing healthcare. Older persons found challenges in paying for medical bills, drugs, transport costs and extra charges. In addition, specialized tests and services were unaffordable. Specialist services included eye care, surgical operations for appendicitis, tubal blockage, and hernia. Specialized tests like X-ray and CT scans were costly for older persons. An older woman in Busia, who was blind due to cataracts, had not gone to Mbale hospital, where she was referred because of money problems. In Hoima, older women in an FGD had this to say:

…You do not have money to buy medicine every time you go to the health facility. This disease … high blood pressure does not get healed. It is like AIDS or even more than AIDS… [Female FGD, Hoima district]

Referrals and prescription challenges

Most older people find it difficult to follow referrals to buy medicines or drugs from private clinics because of financial and literacy barriers. In addition, they were challenged to adhere to treatment prescriptions. On the other hand, private health facilities stock drugs for NCDs but at a fee, that is often very expensive for many older persons. A health provider in Busia described referral process for older persons as a “mountain climbing” experience:

Due to financial limitations, in some cases, older persons purchased incomplete dosage depending on their wallets Footnote 4 : An older person in Hoima district noted the following:

Health providers can prescribe a full dose that may cost 9000 shillings, but you cannot raise it at that time. You buy half dose for 4500 shillings which you can afford at that time [Older man, age 70+, Hoima]

Referrals to buy essential drugs for NCDs from private facilities, which are not available in public health facilities, were unaffordable to older persons. Besides, private clinics were found to be expensive.

Shortage of specialized equipment to screen and test for NCDs

Many public health facilities lacked some specialized equipment and health services for screening and diagnosing NCDs. For example, the computerised tomography scan (CT scan) and ultrasound scans. By the time of the interview (during the M-PRAM project in 2012), Hoima regional referral hospital (RRH) neither had a CT scan machine, nor an ultrasound scan. In private clinics, CT and ultrasound scans cost between 30,000 and 50,000 UGX, which is expensive for many older persons. In addition, X-ray cost 15,000 UGX even in Hoima RRH by the time of the study. Concerning health services, a key informant noted:

… Western medicine is not affordable. You must go to a clinic, pay money for checkup, and the medicine, because in the government facilities, the CT scan services are not available [Community worker, Hoima]

Accessibility challenges

Long distance to health facilities limited older persons’ access to healthcare. This challenge is compounded by physical disabilities and caretakers’ reluctance to take older people to health facilities. Consequently, older persons fail to keep appointments with health providers for instance, crucial ones like diabetes management.

In addition, a lack of means of transport was another barrier to accessing healthcare or visiting distant health facilities in the event of referral. Public transport is not readily accessible in remote areas. Ambulances in public health facilities are non-functional due to mechanical challenges or fuel shortages.

Transport costs are a serious challenge to older persons. Some older people do not have money to pay for transportation to a health facility. Means of transportation used ranged from a bicycle, boda boda (motorcycle) which is the most common, to a vehicle.

Physical disabilities among older people usually make it difficult to access health facilities. They may be unable to walk on their own when the illness is severe. Sometimes, they are unable to ride bicycles by themselves or they don’t even own one. They may not have funds to pay a boda-boda (motorcycle). Older people with disability could not walk to health facilities on their own. They depend on caretakers.

…with age, they come complaining … of painful legs, painful lower limbs …by the time they become real disabled, you can’t see them in hospital… they … stay home… they may fail to bring them to hospital [Health provider, Hoima hospital]

Social stigma also prevented many disabled older persons from being brought by their care takers to health facilities. A community worker narrated the ordeal:

… a totally blind HIV positive older person died alone in the house in Hoima and was buried on 26th July 2012 [Community worker, Hoima]

Adequacy and quality considerations in public health facilities

Some hospitals organized health services on specific days which made it difficult for older people to access care on the non-scheduled days. In addition, irregular or short working hours were reported as critical impediments to access to and utilization of health services. For example, older patients complained about late opening time (about 10 am) and early closing time (about 4 pm) except for special clinic days for children and expectant mothers.

In addition, mixing older persons with younger patients (especially children and women) who are stronger was reported as another barrier. Older persons reported that they had no strength to queue for services for long hours. This is a major impediment to their access to services in public health facilities, which are usually crowded with sick children and their mothers. Owing to long waiting hours in queues some older persons reported that fail to retain urine and as a result, they get ashamed in public. Apart from the heavy client flow in public facilities long queues and waiting time were attributed to staff shortages. For example, the doctor to patient ratio in Hoima regional referral hospital was about 1:100.

…One doctor can see over 100 patients… so they have to keep in the line, and when they come, you have to send them to the lab for a random blood sugar test… by the time she comes again she has to queue again … that becomes a problem [Health provider, Hoima]

Acceptability problems

Personal stigma limited-service acceptability by older persons. Some older persons expressed self-directed stigma - a feeling that they would not be cared for by health providers when they visited health facilities. In addition, some older persons reported not accessing care because of lack of presentable clothes to wear for health facility visits. Some who had bad experiences are health facilities indicated that they preferred death to discrimination and disgrace at public health facilities. According to them, death would mean rest from suffering. A community worker who interacts with older persons made the following observation.

…some older persons have given up accessing services at public health facilities. Even if you tell them to go to hospital, they say ‘no, don’t take me there’, because they know, the moment they are taken to hospital, they are mistreated… they are as rejects. Old people say ‘please leave me alone if am to die, let me just die peacefully at home other than being tossed about [Community worker, Hoima]

Traditional and religious beliefs in some communities promoted herbal medicine and discouraged western medicine. In Hoima district, some adherents of the religious sect called “Wobusobozi” [meaning he is able] led by “Bisaaka” do not believe in modern or western medicine:

The fear of Bishaaka himself he has made them believe that he knows whatever they do … or what they think. So, his word is final… health wise, it’s because he did not believe in modern medicine but when he saw that that it was putting him on a clash with government, he has changed [Community worker, Hoima]

The aim of this paper was to investigate the barriers and facilitators of access to healthcare among older persons in Uganda at both the health system and individual levels. Our findings indicated that barriers outweighed facilitators. The barriers and facilitators of access to healthcare tended to overlap. Key facilitators included availability of free services, social support, financial affordability, transportation, village health teams and knowing a healthcare provider. On the other hand, the barriers included unavailability of essential medicines for NCDs, specialized personnel and equipment, ageism among healthcare providers, financial challenges, poor quality and acceptability problems of public health facilities. The facilitators and barriers are either health system or patient factors.

A challenging health system

A series of challenges stemming from the health system itself, that is acknowledged by community workers, health sector workers as well as by the older persons, stem out from this study. From the health system side, absence of geriatricians, unavailability of essential medicines for NCDs, ageism, affordability limitations and acceptability challenges were critical gaps in Uganda.

The unavailability of essential drugs for NCDs in lower public health facilities (health center IIIs and lower) was a major barrier of access to healthcare for older people. The perceptions of the older persons and community workers generally were that “healthcare providers sell drugs through their clinics”. Conversely, healthcare providers explained that the government uses a push system which provides basic medicines to lower health facilities. The government pushes medical supplies and medicines to lower health facilities (health centers I to III). That is, “larger public health facilities express significantly greater facility-level autonomy in drug ordering compared with smaller facilities, which indicates ongoing changes in the Ugandan medical supply chain to a hybrid ‘push-pull’ system” [ 59 ]. Larger health facilities include national, regional and district health facilities. These make orders for their medicines depending on need of the people served. There is tension about these perceptions from older people and the explanation by healthcare providers. Some studies have reported this challenge, absence of essential medicines for NCDs in the Ugandan heath system [ 23 , 38 , 39 , 40 , 41 , 60 , 61 , 62 ]. The same shortage of supply of essential medicines for NCDs is reported in Kenya, Cameroon and the DRC [ 62 , 63 ].

In Uganda, the Ministry of Health (MoH) adopted the dual “pull and push” system in 2010 in the delivery of essential medicines and health supplies (EMHS) [ 42 , 64 ]. The pull system was maintained for HC IVs and hospitals while the push system was introduced for rural and hard to reach health facilities including HC III and IIs. Lower-level health facilities no longer request for drugs based on the diseases’ burden and the population served [ 42 , 65 , 66 , 67 ]. HC IIIs do not request for the drugs they need except for tuberculosis (TB) and antiretroviral drugs [ 42 , 64 ]. In lower public health facilities (HC I-III), older persons are given drugs that are available and referred with prescriptions to buy drugs from private clinics for those that are not available Footnote 5 . The implication is the unavailability of essential medicines for NCDs in HC IIIs and IIs, which are accessible to older persons, because they no longer request for drugs /medicines based on the diseases’ burden and the population served [ 65 , 66 , 67 ]. Older people who visit public health facilities cannot obtain treatment according to prescriptions in lower-level health facilities. Referrals to purchase medicines from private facilities is a nightmare to them. They end up with no treatment or accessing less than the required dosage. This has negative implications on older persons’ health outcomes including disease progression and drug resistance [ 40 , 63 ]. NCDs require long term adherence to treatment regimes. This is interrupted when availability of medicines and supplies ins interrupted [ 40 ]. In the absence of essential medicines, some older persons resort to herbal medicine. However, their preference would be essential medicines from health facilities.

Generally, there is an acute scarcity of skilled healthcare providers for handling NCDs among older people in Uganda, particularly geriatricians and gerontologists. This was a serious concern among healthcare providers, older persons, and other community workers. Older people also agreed with the situation as they indicated that most times, they were handled by nurses and clinical officers and few doctors. Older persons are handled by clinicians, physicians and nurses who sometimes have no clue about handling multi-morbidity and polypharmacy among older people. This was an issue of consensus across all interview types. Other studies also report the absence of skilled providers as major barrier [ 60 , 61 ]. Chronic non-communicable diseases create greater need for healthcare [ 31 ], in countries such as Hong Kong [ 31 ], Singapore [ 33 ], and in rural South Africa [ 34 ]. Older persons still report limited access to healthcare [ 35 ].

Ageism in healthcare delivery was reported among some young healthcare providers especially nurses. Sometimes, lower-level healthcare providers do not have training to handle NCDs and therefore, end up manifesting ageist attitudes to older people in their delivery of healthcare. Although some older people reported ageist attitudes by some healthcare providers, others reported good experiences with some especially when they knew them. The experiences vary from one individual to another. Ageism is reported as a critical impediment for older persons’ access to healthcare [ 29 ].

Health services were considered inadequate and of poor quality by both older persons and healthcare providers. Adequacy relates to how healthcare is organized and whether that meets patients’ expectations [ 53 ]. For example, opening hours and waiting times. In addition, it covers hygiene, and quality of care [ 58 , 68 ]. Irregular working hours have been reported as major barriers to access to healthcare in Uganda [ 58 , 60 , 68 ]. Long waiting times are documented as critical impediments to access to and utilization of health services in Uganda [ 60 , 68 ]. Generally, public health facilities were perceived as those which provide poor quality services [ 63 ]. Private health services were perceived as those with better quality but not affordable to older people.

Finally, acceptability challenges were reported in the health system. Acceptability refers to cultural access [ 69 ] or socio-cultural access [ 68 ]. It relates to providers’ and patients’ attitudes, beliefs and expectations of each other [ 69 ]. It also includes patients’ perceived quality of care [ 61 , 68 ] and satisfaction with care [ 68 ]. Obrist et al. (2007) argues that for effective healthcare access, the patients must feel welcome, cared for by service providers and must trust in the competence and personality of the healthcare providers” (Obrist et al., 2007). The consensus among older people was that public health facilities were not acceptable to them. The essential medicines were lacking, specialized equipment for diagnosis were either absent or if present, very costly for them and the providers were nurses who did not understand how to handle or manage NCDs. However, a special clinic day for older persons was a great facilitator. It was an effective intervention for older people.

Individual challenges

Physical disability and mobility limitations was a significant barrier of access to healthcare. Disability reduced physical accessibility to health facilities. Accessibility focuses on the geographic distance and travel time between users’ homes and the nearest health facilities (Obrist et al., 2007; Peters et al., 2008). It also includes (un)availability of public transport and ownership of a means of transport e.g. bicycle or motorcycle [ 58 ]. This finding was reported in the quantitative data as well [ 32 ]. The health access livelihood framework (HALF) posits that vulnerability context affects access to healthcare [ 58 ]. Disabled older persons are unable to move to health facilities on their own. They need a means of transport and a caretaker to assist them move to a health facility. Some care takers are either unwilling or lack the means to transport older persons to health facilities.

Family support and its absence have been mentioned as both a facilitator and a barrier when absent [ 41 ]. This is important in terms of financial means, support for transport but also care, responsibility. Children are call upon by older parents to take them through the difficulties they face – here specifically health issues, by swiftly making the right decisions. Yet, children are sometimes far away and not in a position to provide the expected support. Availability and absence of financial means affects affordability of healthcare for older people.

Affordability of specialized healthcare for NCDs is a major limitation for older persons. Most older persons lack health insurance in the absence of a national health insurance scheme in Uganda. Paying out of the pocket medical expenses is unattainable since most older persons do not have pensions in old age [ 13 , 40 , 70 ]. Olde age poverty is a big problem in Uganda [ 50 ]. In addition, most NCDs treatment is very costly even though it is readily available in private health facilities, but not public ones. Older persons end up leaving hospitals without medicines or with half dosages or resorting to non-medical alternatives [ 40 , 63 ]. Referral to purchase medicines in private facilities and pharmacies is a big problem [ 40 ]. In Uganda, health insurance schemes do not cover some or most NCDs [ 41 ]. Affordability refers to financial access [ 69 ] or financial accessibility [ 68 ]. The costs of healthcare services are expected to fit the clients’ resources or income and willingness and ability to pay (McIntyre et al., 2009; Obrist et al., 2007; Peters et al., 2008). Affordability relates to direct costs e.g. user fees, payment for drugs; indirect costs e.g. in terms of transport costs, lost time and income and other “unofficial charges” such as paying bribes (Obrist et al., 2007). Some study indicated the acute affordability challenge of medicines for NCDs in Congo DRC and Cameroon [ 62 ] and Kenya [ 63 ]. Finally, access to healthcare among older persons is affected by the individual’s confidence in the health system, the ability of the patient to afford care, the health system’s capacity to respond to individual needs with respect and dignity.

Strength and limitations

This study was a follow up of a quantitative study whose results have already been published [ 32 ]. Here, the triangulation of qualitative data collection methods (FGDs, IDIs and KIIs) improves the validity and reliability of the data. The integration of healthcare providers’ perspectives with those of the older persons, gives a consistent picture to the barriers and facilitators of access to healthcare among older persons in Uganda.

It would have been possible to go further in the analysis of factors and barriers in access to healthcare with follow up interviews and observation sessions of situations when older people access healthcare or would want to and of service delivery in healthcare facilities. This would call for participant observations, within villages and around some health facilities which handle older persons which wasn’t planed for in our overall project using an explanatory mixed methods research design. It however remains the major limitation of this qualitative study.

Finally, using the data when the interviews were conducted in 2012 and 2014 needs to be acknowledged. The timing is quite long. One would argue that times and seasons have changed regarding access to healthcare! However, the firs author has been involved in the policy formulation process for developing the national healthcare strategy for older persons in Uganda by the World Health Organization and the Ministry of Health. The findings are still relevant and the new evidence from the MOH officials tallies with some of the reported findings.

Conclusions & recommendations

Older persons face immense health system and patient level barriers when accessing healthcare in Uganda. Older persons have greater heath needs because of NCDs and functional limitations. However, the health system in Uganda is still unresponsive and insensitive to the health needs of older persons.

Major health system barriers include inadequate supply of essential drugs for NCDs, absence of geriatricians among healthcare personnel, low acceptability by younger healthcare providers, long waiting times, long queues, unaffordability of certain specialized services, inaccessibility of some facilities, and discrimination in the health services’ delivery.

At the patient level, there are social inequalities in access to healthcare among older people. The major barriers are financial, transport challenges, physical disability, and multi-morbidity because of NCDs.

Key recommendations to improve access to healthcare for older persons include the following: First, the health system needs strengthening to be able to respond to the health needs of older people in Uganda. Second, the tracking of the supply of essential medicines for NCDs for lower-level health facilities is critical. Third, training of geriatricians for the health system and social gerontologists, would be key interventions urgently needed to address this gap. Fourth, a national health insurance scheme to cover all vulnerable groups including older persons is warranted. Finally, developing a national policy and health strategy for addressing access to healthcare by older persons is urgently needed.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

IDI 15, older man age 70, Busia district. He visited HC thrice and missed drugs once when he was referred to buy and did not have the money. He also stated that the prescription was written in English which he could not understand.

KII_13, provider at HC III, Busia.

KII_05, Hoima regional referral hospital.

IDI 01, older man age 64, Hoima. Had high blood pressure but was better off economically.

IDI 13, older man age 56, Busia district. He also reported that he was once injected with an expired drug in one of the clinics by a nurse, who didn’t check the label/expiry date of the drug.

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Acknowledgements

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This research was partially supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Wellcome Trust (UK) (Grant No: 087547/Z/08/Z), the Department for International Development (DfID) under the Development Partnerships in Higher Education (DelPHE), the Carnegie Corporation of New York (Grant No: B 8606), the Ford Foundation (Grant No: 1100 − 0399), Google.Org (Grant No: 191994), SIDA (Grant No: 54100029), MacArthur Foundation (Grant No: 10-95915-000-INP), the Uppsala Monitoring Center, and the Norwegian Agency for Development Cooperation (NORAD). The qualitative data collection in 2014 was funded by the Carnegie Corporation of New York to Makerere University. The time to do the final write up of the manuscript was funded by the CARTA Postdoctoral Research Fellowship (2022–2023) at Moi University. In addition, preliminary interviews were conducted in 2012 in Hoima in a collaborative research framework on Poverty, Resource Accessibility and Spatial Mobility in East Africa [ 55 ]. The statements made and views expressed are solely the responsibility of the Fellow.

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Wandera, S.O., Golaz, V., Kwagala, B. et al. “These are just finishing our medicines”: older persons’ perceptions and experiences of access to healthcare in public and private health facilities in Uganda. BMC Health Serv Res 24 , 396 (2024). https://doi.org/10.1186/s12913-024-10741-6

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O’Hara R, Johnson M, Hirst E, et al. A qualitative study of decision-making and safety in ambulance service transitions. Southampton (UK): NIHR Journals Library; 2014 Dec. (Health Services and Delivery Research, No. 2.56.)

A qualitative study of decision-making and safety in ambulance service transitions.

Chapter 8 conclusions and recommendations.

The aim of this study was to explore the range and nature of influences on safety in decision-making by ambulance service staff (paramedics). A qualitative approach was adopted using a range of complementary methods. The study has provided insights on the types of decisions that staff engage in on a day-to-day basis. It has also identified a range of system risk factors influencing decisions about patient care. Although this was a relatively small-scale exploratory study, confidence in the generalisability of the headline findings is enhanced by the high level of consistency in the findings, obtained using multiple methods, and the notable consensus among participants.

The seven predominant system influences identified should not be considered discrete but as overlapping and complementary issues. They also embody a range of subthemes that represent topics for future research and/or intervention.

The apparently high level of consistency across the participating trusts suggests that the issues identified may be generic and relevant to other ambulance service trusts.

In view of the remit of this study, aspects relating to system weaknesses and potential threats to patient safety dominate in the account of findings. However, it should be noted that respondent accounts also provided examples of systems that were said to be working well, for example specific care management pathways, local roles and ways of working and technological initiatives such as IBIS and the ePRF.

• Implications for health care

The NHS system within which the ambulance service operates is characterised in our study as fragmented and inconsistent. For ambulance service staff the extent of variation across the geographical areas in which they work is problematic in terms of knowing what services are available and being able to access them. The lack of standardisation in practice guidelines, pathways and protocols across services and between areas makes it particularly challenging for staff to keep up to date with requirements in different parts of their own trust locations and when crossing trust boundaries. Although a degree of consistency across the network is likely to improve the situation, it is also desirable to have sufficient flexibility to accommodate the needs of specific local populations. There was some concern over the potential for further fragmentation with the increased number of CCGs.

Ambulance services are increasingly under pressure to focus on reducing conveyance rates to A&E; this arguably intensifies the need to ensure that crews are appropriately skilled to be able to make effective decisions over the need to convey or not to convey if associated risks to patients are to be minimised. Our findings highlight the challenges of developing staff and ensuring that their skills are utilised where they are most needed within the context of organisational resource constraints and operational demands. Decisions over non-conveyance to A&E are moderated by the availability of alternative care pathways and providers. There were widespread claims of local variability in this respect. Staff training and development, and access to alternatives to A&E, were identified as priorities for attention by workshop attendees.

One of the difficulties for ambulance services is that they operate as a 24/7 service within a wider urgent and emergency care network that, beyond A&E, operates a more restricted working day. The study findings identify this as problematic for two reasons. First, it fuels demand for ambulance service care as a route to timely treatment, when alternatives may involve delay. Second, it contributes to inappropriate conveyance to A&E because more appropriate options are unavailable or limited during out-of-hours periods. Ultimately, this restricts the scope for ensuring that patients are getting the right level of care at the right time and place. Study participants identified some patient populations as particularly poorly served in terms of alternatives to A&E (e.g. those with mental health issues, those at the end of life, older patients and those with chronic conditions).

The effectiveness of the paramedic role in facilitating access to appropriate care pathways hinges on relationships with other care providers (e.g. primary care, acute care, mental health care, community health care). An important element relates to the cultural profile of paramedics in the NHS, specifically, the extent to which other health professionals and care providers consider the clinical judgements/decisions made by paramedics as credible and actionable. Staff identified this as a barrier to access where the ambulance service is still viewed primarily as a transport service. Consideration could be given to ways of improving effective teamworking and communication across service and professional boundaries.

Although paramedics acknowledged the difficulties of telephone triage, they also identified how the limitations of this system impact on them. Over-triage at the initial call-handling stage places considerable demands on both staff and vehicle resources. A related concern is the limited information conveyed to crews following triage. Initial triage was suggested as an area that warrants attention to improve resource allocation.

The findings highlight the challenges faced by front-line ambulance service staff. It was apparent that the extent and nature of the demand for ambulance conveyance represents a notable source of strain and tension for individuals and at an organisational level. For example, there were widespread claims that meeting operational demands for ambulance services limits the time available for training and professional development, with this potentially representing a risk for patients and for staff. Staff perceptions of risk relating to patient safety extend to issues of secondary risk management, that is, personal and institutional liabilities, in particular risks associated with loss of professional registration. The belief that they are more likely to be blamed than supported by their organisation in the event of an incident was cited by staff as a source of additional anxiety when making more complex decisions. This perceived vulnerability can provoke excessively risk-averse decisions. These issues merit further attention to examine the workforce implication of service delivery changes, including how to ensure that staff are appropriately equipped and supported to deal effectively with the demands of their role.

Paramedics identified a degree of progress in relation to the profile of patient safety within their organisations but the apparent desire within trusts to prioritise safety improvement was felt to be constrained by service demands and available resources. Attempts to prioritise patient safety appear to focus on ensuring that formal systems are in place (e.g. reporting and communication). Concerns were expressed over how well these systems function to support improvement, for example how incident reports are responded to and whether lessons learned are communicated to ambulance staff within and between trusts. Consideration could be given to identifying ways of supporting ambulance service trusts to develop the safety culture within their organisation.

Service users attributed the increased demand for ambulance services to difficulties in identifying and accessing alternatives. They were receptive to non-conveyance options but felt that lack of awareness of staff roles and skills may cause concern when patients expect conveyance to A&E.

• Recommendations for research

The workshop attendees identified a range of areas for attention in relation to intervention and research, which are provided in Chapter 6 (see Suggestions for potential interventions and research ). The following recommendations for research are based on the study findings:

• Limited and variable access to services in the wider health and social care system is a significant barrier to reducing inappropriate conveyance to A&E. More research is needed to identify effective ways of improving the delivery of care across service boundaries, particularly for patients with limited options at present (e.g. those with mental health issues, those at the end of life and older patients). Research should address structural and attitudinal barriers and how these might be overcome.
• Ambulance services are increasingly focused on reducing conveyance to A&E and they need to ensure that there is an appropriately skilled workforce to minimise the potential risk. The evidence points to at least two issues: (1) training and skills and (2) the cultural profile of paramedics in the NHS, that is, whether others view their decisions as credible. Research could explore the impact of enhanced skills on patient care and on staff, for example the impact of increased training in urgent rather than emergency care. This would also need to address potential cultural barriers to the effective use of new skills.
• Research to explore the impact of different aspects of safety culture on ambulance service staff and the delivery of patient care (e.g. incident reporting, communication, teamworking, and training) could include comparisons across different staff groups and the identification of areas for improvement, as well as interventions that could potentially be tested.
• The increased breadth of decision-making by ambulance service crews with advanced skills includes more diagnostics; therefore, there is a need to look at the diagnostic process and potential causes of error in this environment.
• There is a need to explore whether there are efficient and safe ways of improving telephone triage decisions to reduce over-triage, particularly in relation to calls requiring an 8-minute response. This could include examining training and staffing levels, a higher level of clinician involvement or other forms of decision support.
• There is a need to explore public awareness of, attitudes towards, beliefs about and expectations of the ambulance service and the wider urgent and emergency care network and the scope for behaviour change interventions, for example communication of information about access to and use of services; empowering the public through equipping them with the skills to directly access the services that best meet their needs; and informing the public about the self-management of chronic conditions.
• A number of performance measures were identified engendering perverse motivations leading to suboptimal resource utilisation. An ongoing NIHR Programme Grant for Applied Research (RP-PG-0609–10195; ‘Pre-hospital Outcomes for Evidence-Based Evaluation’) aims to develop new ways of measuring ambulance service performance. It is important that evaluations of new performance metrics or other innovations (e.g. Make Ready ambulances, potential telehealth technologies or decision-support tools) address their potential impact on patient safety.

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