Advanced paramedic practitioners (APPs) are a fairly recent development in UK ambulance services (von Vopelius-Feldt and Benger, 2014) and were introduced into the London Ambulance Service (LAS) in the spring of 2014 (LAS, 2014). Advanced paramedic practitioners in critical care (APP(CC)s) were brought in to provide leadership and critical care for the most unwell and injured in the capital (LAS, 2014).
The professional body for paramedics in the UK, the College of Paramedics, has a postregistration career framework that states advanced practitioners are expected to be educated to master's degree level and have relevant clinical experience, research, education and leadership (College of Paramedics, 2018). APP(CC)s deliver scene leadership and enhanced clinical interventions such as the administration of strong analgesia, emergency front-of-neck access, endotracheal intubation, mechanical cardiopulmonary resuscitation, post-resuscitation care and ultrasound among many other interventions and skills (LAS, 2016).
In 2018, the LAS published its first gender pay gap study. This revealed a mean gender pay gap of 4.5%, with women in the LAS (in clinical and non-clinical roles) receiving lower pay on average than a man in the same organisation (LAS, 2018). It is relevant to this study as it reflects the fact that women are more likely to occupy lower-paid roles such as emergency medical technician and apprentice paramedic and are less likely to occupy senior, more highly paid roles (LAS, 2018).
In April 2018, the same year this study was conducted, there were 33 APPs specialising in critical care in the LAS, five of whom were women, accounting for 15.1% of the APP(CC) workforce; at the same time, women accounted for 49% of paramedics in the LAS.
The ‘lag’ of women entering APP(CC) roles (despite almost half of the LAS paramedic workforce being women) was mirrored in a systematic review examining 25 years of global literature that explored barriers to women doctors entering surgical careers (Singh et al, 2021). The review identified five broad themes including: education and recruitment, career development, impact of/on life around the globe and surgical subspecialties (Singh et al, 2021). The authors identified opportunities for overcoming these barriers, including creating mentorship systems, implementing policy that improves work/life balance and recognising the coincidental timing of surgical training and childbearing years (Singh et al, 2021).
While these findings are difficult to apply to the APP(CC) workforce as they originate from a different occupation, there is a similar theme of underrepresentation within a subspecialty of clinical training. Therefore the insights may be of benefit when trying to understand the APP(CC) gender imbalance.
Examining international literature specifically on emergency medical services (EMS) and career progression demonstrates that women have historically been underrepresented in EMS in the United States, most notably in management positions (Dunn, 1990; Zalar, 1990; Gonsoulin and Palmer, 1998; Honeycutt, 1999). The historical literature cites many reasons, including social expectations, sexual harassment and challenges with manual handling as reasons for fewer women in EMS (Gonsoulin and Palmer, 1998; Honeycutt, 1999). While this literature is not modern and there are many differences between American EMS systems and the UK ambulance service, both currently and historically, the representation of women in senior roles is mirrored within the LAS; in the absence of UK-based literature exploring why this may be the case, the United States literature can provide some insight.
It is well documented that a diverse workforce improves patient outcomes, reduces mortality and morbidity and is of utmost importance for fairness and social justice for all in society (Shannon et al, 2019).
This study explores female paramedics' attitudes as to why there are fewer women in APP(CC) roles to gain insight into this previously unresearched topic with the aim of improving patient outcomes.
Methods
The theoretical framework for this qualitative study aligns with a feminist pragmatic approach (McHugh, 2014), which offers a practical method for answering the research question. This was: ‘What are the perceived barriers to women becoming an advanced paramedic practitioner in critical care within the London Ambulance Service?’
Ethical approval was obtained from the University of Hertfordshire (protocol number: HSK/PGT/UH/03170) and research and development approvals were obtained from the LAS NHS Trust. This research was completed in partial fulfilment of an MSc by the lead author (AU), a female APP(CC) within the LAS. This was the first piece of primary research completed by the author, who has experience and training in clinical audit, research methods and literature review.
There were two phases to this study. Phase 1 was to generate broad lines of enquiry using a dominantly qualitative exploratory survey in which all female paramedics within the LAS were invited to participate. The exploratory survey asked participants to express their views on why there were so few female APP(CC)s and whether they felt there were any barriers to becoming an APP(CC) (Appendix 1).
Recruitment for the online survey, launched on International Women's Day on 8 March 2018, was done via the LAS's internal social media page and via a routine internal bulletin. It was an open invitation to all female paramedics within the LAS and women were not rewarded for taking part in any part of the study.
The online survey, which included a consent form and a participant information sheet, was open for 2 weeks. Once participants had completed the exploratory questions in the online survey, they were directed to a final question that asked them if they would be willing to give their consent to be contacted for a semi-structured interview (phase 2).
Participants had the option to remain anonymous. Some were known to the author before this study but some were not. They knew that the study aim was to identify reasons why there were fewer women in APP(CC) roles and that it was for the partial fulfilment of an MSc degree. Participants were unaware of any opinions or biases the author held about the subject area or any matters documented in the reflexive account held by the author.
The purpose of the survey was only to generate lines of enquiry to inform the interview questions (for phase 2) and to limit bias being introduced from the researcher's own assumptions about why there were so few women APP(CC)s. In the absence of relevant published literature that could have informed interview questions, primary descriptive thematic analysis (Braun and Clarke, 2006) of the survey responses was undertaken to generate broad lines of enquiry for the interview questions. Interview questions were based on the main themes identified from the primary descriptive thematic analysis of the survey responses and included questions relating to: working less than full time; confidence; emotional factors relating to the role; caregiving responsibilities; and the culture of the APP team.
To improve the transferability of this research, maximum variation sampling of the women who consented to be contacted for phase 2 was undertaken. To gather the views of a variety of women, participants were selected based upon their self-reported characteristics from the exploratory survey, which included age, clinical grade, experience, whether they worked full or less than full time and the number of children they had.
All of the sampled women agreed to attend a semi-structured interview (phase 2). The interview contained questions that had been informed by the exploratory survey responses.
Each woman was given a participation information sheet relating to this stage of the study and provided written consent to the interview. All were made aware that they had the option to withdraw from the study at any point and they were not to be rewarded for their contribution. The interviews were conducted alone with the author, at a time and private location in the ambulance trust of their convenience.
Six interviews were undertaken by the author over 10–20 April 2018. They were guided by an interview schedule (Appendix 2) that was informed by the survey responses. Before it was used, the interview schedule was reviewed by a non-participating APP(CC) colleague and the research supervisor as a pilot and no changes were made.
In the interview schedule, women were asked about how they believed working less than full time may influence career progression into an APP(CC) role, whether they believed there was a misogynistic culture within the APP(CC) team, the impact of being a caregiver on progression into an APP(CC) role, their level of confidence and how this might influence them as an APP(CC) and, finally, whether there were any emotional factors that would deter women from becoming an APP(CC).
Survey responses included two areas that were not included for the interview schedule; these related to the selection process and the fact that APP(CC) roles were not available earlier in their careers. As these related to how an individual would not meet the essential recruitment criteria for the role, they had not been included. Also, questions about shift work were not asked as shift work, was and remains inherent to the APP(CC) role. No specific questions surrounding an absence of barriers were posed; however, one participant was selected based on her survey responses that suggested there were no barriers to women becoming an APP(CC).
As the interviews were semi-structured, interviewees were asked to expand or give examples on points they had raised. The interviews were audio-recorded and transcribed verbatim by the author. Participants were invited to comment on the transcripts and analysis to ensure they accurately represented the interview and the researcher's interpretation of it. There were no repeated interviews and no field notes were made during the interviews. Interviews lasted for between 28 minutes 20 seconds and 14 minutes 58 seconds. The marker for data saturation was when no new ideas were generated; however, given the constraints of the academic schedule, this was not practical. It is hoped that the relatively varied sample of women, coupled with the probing nature of the interviews, generated an in-depth understanding of the challenges women face in this area.
Interpretive, inductive thematic analysis was then undertaken on the interview transcripts and was informed by knowledge gained throughout the literature review and background reading. The author was the only person to code and group themes and NVivo software was used to assist in this process.
Results
There were 94 qualitative survey responses from women within the LAS, which represented 9.6% of the LAS female paramedic workforce, including senior paramedics, paramedic managers, advanced paramedic practitioners and clinical team leaders (n=974) (email from LAS workforce information analyst Lola Beyioku, 16 April 2018). Thirty-seven of the responses were anonymous so these participants could not be contacted for an interview. Women who did consent to be approached for interview were contacted by email or telephone with the details they had provided.
The primary descriptive thematic analysis of the survey responses (phase 1) identified eight main themes. These were: selection process; emotional factors; shift work; part-time (less than full-time) work; no perceived barriers; family priorities; male-dominated culture; and, finally, confidence.
Five of these themes (emotional factors, male-dominated culture, confidence, working less than full time and family priorities) were selected to inform the interview questions because of their personal and intrinsic nature. As the aim of the exploratory survey was only to generate lines of enquiry to inform interview questions, full thematic analysis was not undertaken on this primary phase of the study and the interview questions are its only product.
Six women were interviewed for phase 2 of the research. Descriptive individual participant characteristics of the interviewed women are not published to maintain anonymity. However, the participants were aged from 27 to 45 years, had between 0 and 2 children, were working full and part time and had between <1 and more than 20 years of postregistration experience. One of the women was an APP(CC) and the remainder held roles ranging from newly qualified paramedic to paramedic managers. All said they were white British and all gave their express consent to be interviewed.
One main overarching theme was developed from the thematic analysis and was named ‘the social construction of female career progression within the ambulance service’. This manifested across three main subthemes: gender stereotypes; perceptions of self; and caregiving lifestyle. Examples from each subtheme are presented below.
Gender stereotypes
Women identified several ways in which they believed they were externally perceived and ways in which they internally view men.
It was perceived that a woman's assertiveness may be interpreted in a different way from that of a man:
‘I have had a discussion with a team that's quite close to my station. I had exactly the same discussion [with them] as I've later found out as did a colleague of mine that was a man. I got labelled as bossy, potentially bitchy—they all invited him down the pub.’
Paramedic manager, 6 years' postregistration experience
Women also described occasions where gender stereotypes had resulted in miscommunications:
‘Last week, I had an observer out with me; he wasn't in uniform and the fire brigade went to hand over to him instead of hand over to me, even though I had uniform on and a tabard on saying quite clearly what my role is.’
Paramedic manager, 6 years' postregistration experience
Women also hold gender stereotypes about men and perceive them to be more ambitious:
‘Maybe the men are more ambitious? Errm, I don't know why but, from, from a lot of the guys that I know, especially the guys from my course, they're like “yeah, we're gonna be APPs, we're gonna join HEMS [helicopter emergency medical services]”.’
Newly qualified paramedic, <1 year postregistration experience
A common theme from several participants was a perception that men had more confidence than women:
‘Males are kind of happy to sit at the lower level of confidence and take a chance at something whereas females like to be more comfortable with their confidence and then go for something.’
Paramedic educator, 6 years' postregistration experience
Another area was the notion of a ‘boys' club’ and this was defined by one of the participants:
‘Jobs for someone whose face is known, which historically has been men. Not that the jobs are only there for men. I don't think they are’.
Clinical team leader, 5 years' postregistration experience
This suggests a belief that there has been selective recruitment of men and women into specialist roles. Another comment relates this more specifically to gendered behaviour:
‘I've noticed that there are some managers, male managers who've got, who've picked out talent—but they all seem to be male talent that they pick out. There's a few guys that I know, say five or six of them, who have worked their way up into headquarters or wherever because they know certain male managers, but these certain male managers don't seem to do that with the women.’
Newly qualified paramedic, <1 year postregistration experience
Although this study is not concerned with establishing whether selective recruitment has been the case, the last comment suggests that it is present through the behaviours of men, both those in positions of power and those trying to advance their careers.
There is a perception that men network to advance in their career:
‘I think men are more flexible so they're putting themselves out there, doing different jobs, therefore their faces are known, their names are known, whereas I think most, more women, not all women but more women, are happy staying under the radar just coming to work and going home and aren't really up for traipsing across the city, going to headquarters or those sort of places where the people already recruited to these roles are based.’
Clinical team leader, 5 years' postregistration experience
Many of the perceptions women held about men were positive, such as ‘more confident’, ‘more ambitious’ and ‘more likely to advance their careers’. In contrast, beliefs about how women felt they were perceived were largely negative: ‘bitchy’, ‘less confident’ and ‘less likely to advance their careers’.
Women described gender stereotypes that related to the overarching theme of social constructs and female career progression within the ambulance service:
‘Errr… I think it's a social stigma. I think there is still sexism in the world with how a woman should behave and how a man should behave. Everyone wants to be mates with the bloke and impress the bloke, where we're still seen in a slightly different light.’
Paramedic manager, 6 years' postregistration experience
Perceptions of self
Perceptions of self concern how women describe their own qualities and experiences.
Confidence was a theme that appeared commonly and was directly linked to experience and exposure.
It was perceived that working part time could affect a woman's confidence:
‘I think that the more you do something, the more confident you become, and I just don't think I'm doing that any more.’
Paramedic with >20 years' experience
One full-time paramedic linked ability with exposure and experience:
‘You've got to be really doing sort of x amount of shifts a week to maintain that clinical skill, especially for the first few years.’
Paramedic manager, 6 years' postregistration experience
However, another participant felt working less than full time meant they had more time for study and, as a result, their confidence was not affected:
‘Working part-time has no impact on how confident or how good you are at doing the job because you're still going to every day be in touch and be disciplined in some way. Whether it's listening to a podcast or running through a debrief in your mind or talking to someone about it, or delivering a training session on it, you're always going to be in touch with that job, you're never going to walk away from it and be living two separate lives because it's something that means something to you.’
APP(CC), working less than full time
The majority of the women felt the emotional stresses of the APP(CC) role would not deter them, although one participant felt that women may be perceived to struggle with the emotional stresses of the role:
‘I am genuinely so surprised at how little I get emotionally affected. Not in a sadistic way but just … I'm quite good at detaching myself from a situation.’
‘I think we're probably seen as being more nervous and more timid by men; but I don't think that's true.’
Newly qualified paramedic, <1 year postregistration experience
It was perceived that women enjoyed and thrived on emotional stresses:
‘I think it is a very emotional role and the impression I'm under is that you could go home with a lot of burden from what you've seen during your shift, especially if you're tired and you've seen a lot of cases and maybe feeling burnt out or whatever. But I, err, my personality type is that I kind of thrive on that—as much as it exhausts me, it also inspires me. I like to be challenged; I like to feel pushed.’
APP(CC)
Lastly, women perceived themselves as having to behave a certain way to be considered a confident leader. The term ‘alpha female’ was used and described by a participant:
‘So, there's a stigma about what an alpha female is: they're decisive, they're bossy, errm… You know they're in charge, they're strong-willed women. Errm… and they might have all those capabilities but that doesn't mean that's the woman that they are.’
Paramedic manager, 6 years postregistration experience
It was perceived that social constructs regarding the behaviour of a leader affected the way women evolve their leadership style:
Researcher: ‘What do you think would happen if we undertook the role and leadership style in our own personalities rather than the sort of faking the alpha female type personality that you allude to?’
Paramedic manager, 6 years' postregistration experience: ‘I don't think people would have so much confidence in us.’
Caregiver role
Two of the women were mothers and provided insight into how being a mother had impacted their career.
Staff working part time could not access the same funding for education as those working full time:
‘I was looking into doing other courses but I think, from an ambulance service perspective, I think I'm right; you have to do a certain amount of hours before you can apply for funding as such. So, I think if I were to do anything at the minute… I'd have to fund myself, which would be quite tricky.’
Paramedic, mother, >20 years experience
It was perceived that working less than full-time (because of having children or caring for elderly parents) affected a woman's career and social life:
‘I think, yeah, having children limits your opportunities. I mean, it's brilliant, I love it! But it doesn't leave much time for anything else’
And:
‘It doesn't leave much time to be honest, even social or doing sports and things that I enjoy and then yeah, work on top.’
Paramedic, mother, >20 years' experience
Women also felt working less than full time was generally discouraged:
‘I would feel reluctant to go for that position if I were a part-time worker. I would expect, in the back of my mind, that they would say “yes, you can have this position, but only under full-time hours” and then you'd have to make a choice.’
Paramedic educator, 6 years' experience
‘I think, at the moment, it's not a job that's advertised as a part-time job. It's, errm, encouraged as a full-time job and, if you want to work part time, that's generally discouraged.’
APP(CC)
It was suggested that, with careful planning, a less than full-time APP(CC) role could be possible:
‘I think part-time working is very much dependent on the person, so it's a case-by-case basis. Because some people really excel when you let them work part time because they can make work their hobby. They've got time to really enjoy their work again and some people, if you let them work part time, they really fade away because nobody is driving them.’
APP(CC)
Women prioritised caregiving responsibilities over their professional career:
‘It would just feel like your primary focus, wouldn't it, if you're a caregiver to either of those groups of people. Um, you'd feel somewhat selfish pursuing a career development—it'd almost feel a little bit futile and a bit selfish to do that when you're having to care for someone.’
Paramedic educator, 6 years' postregistration experience
A further comment demonstrated how social constructs were perceived to impact a women's career progression:
‘I think men are better supported by women as in partners—men are better supported by their partners to go and do these jobs whereas I think if I went out and did a job where I was off late, had a high commitment level etc, I think that wouldn't work in our dynamic. I think he feels, he would feel that it's acceptable for him to be off late but not acceptable for me to be off late as I have priorities that are at home.’
Clinical team leader, 5 years' postregistration experience
Discussion
This is the first study that specifically explores the attitudes of female paramedics on why women are less likely to advance in their clinical careers in the same way as male paramedics.
It demonstrates that societal constructs have far-reaching implications for the development of female paramedics in terms of learning, earning and opportunity.
Workplace policy and culture that can be adapted to improve participation of women in these roles include the lack of opportunity to work less than full time at the point of recruitment into APP(CC) roles, the lack of access to higher education because of working part time and ambulance service culture in terms of expected behaviours.
A literature review revealed no studies that specifically explored participation in advanced practice roles in the ambulance service. Therefore, the wider literature was examined to inform the interpretation of the results.
The generation of the main theme of social constructs and their effects on career progression suggests that the position of men and women in society, and therefore the ambulance service, exists because of external social norms and behaviours. The social construction of reality, first described by Berger and Luckmann in 1966 and further explored by McDonald and Crandall in 2015, explains reality and knowledge as a construction of the society we live in. It is a theoretical perspective that suggests that prejudices map closely to social norms and individuals adapt their behaviours to align closely with those around them. When this theory is applied to this group of women, it demonstrates how women in the ambulance service behave in response to the cultural expectations around them, which in turn shapes their careers (Berger and Luckmann, 1966; McDonald and Crandall, 2015).
The subthemes of gender stereotypes, caregiving lifestyle and perceptions of self all relate to social constructs. In terms of personal perceptions and gender stereotyping, some women in this study felt that becoming an APP(CC) required an alpha leadership style and confidence. It may be that, because there are more male APP(CC) role models, women have encountered behavioural styles more traditionally expected of men, which they then believe are markers of success that they are unable to replicate authentically.
Behavioural expectations are a good example of how this can affect career progression as some women who deviate from social expectations, especially if their portrayed leadership style was unnatural to them, are penalised (Eagly and Karau, 2002; Hsaio, 2017; Lease, 2018).
Nonetheless, one study demonstrates that exposure to successful women before undertaking difficult leadership tasks improves women's performance (Latu et al, 2013) and, while there are fewer women APP(CC)s, there may be women within the LAS who have reaped the benefits of being exposed to successful female APP(CC)s.
It has been argued that assertiveness displayed by women can work to their detriment and training in this area can be a ‘double-edged sword’ (Lease, 2018). This is also the case for men who do not fulfil gendered male stereotypes and may be why societal expectations continue to endure which in turn may explain why men portray themselves as more confident and more ambitious in line with the perception within this study (Lease, 2018). This is perhaps why the paramedic manager was perceived as ‘bitchy’ as opposed to assertive.
Enduring gender stereotypes around women as leaders are more difficult to overcome in situations that have traditionally been dominated by the men, such as those in ambulance services (Eagly and Karau, 2002).
This gendered expectation also explains why men are more likely to reap the benefits of networking (Forret and Dougherty, 2004). It has been suggested that while networking can increase a man's social capital and further his career, it is less effective for women as historically there are fewer women in positions of power (Forret and Dougherty, 2004). Women who are in positions of power can be perceived as token—there to fulfil a quota—and, as a result, are excluded from the same social capital available to a man (Forret and Dougherty, 2004).
Often the impact of gender stereotyping remains unrecognised and the low prevalence of women in academic research and other professions has been attributed to unconscious bias (Easterly and Ricard, 2011). The boys' club phenomenon described in this study may be an example of unconscious bias, exacerbated by a lower networking yield for women as a result of a low prevalence of women in senior clinical roles.
Women are more likely to be the prime caregiver for children and suffer the biggest increase in gender pay disparity when they become mothers despite this narrowing of this gap for the millennial generation before motherhood (Equality and Human Rights Commission, 2017; Gardiner, 2017). Women are also more likely to take time away from work to start a family and are more likely to work part time because of societal norms and pressures (Equality and Human Rights Commission, 2017). Therefore, it is unsurprising that 61% of the workforce who work less than full time in the LAS are female (LAS, 2018) and that working less than full time was a key factor in the ‘caregiving’ and ‘perceptions of self’ themes in this study.
Throughout the data, there runs a continuous and enduring thread of this phenomenon. The subthemes overlap and the links between them remain, despite the themes being compressed throughout the thematic analysis (Braun and Clarke, 2006). It is for this reason that the overarching theme for this study is the social construction of female career progression within the ambulance service. All of the areas identified by the women as a reason for fewer female APP(CC)s can be related to the social constructs pertaining to the role of a woman and her career progression, making it more difficult for women to advance in their careers.
Some social constructs have logical roots in biological factors. Todd et al (2018) posed a counter argument in a systematic review that examined how gender and biology were linked to form social stereotypes in childhood, and therefore demonstrated that some beliefs may have roots in biological issues, such as childbearing.
Temperament theory also describes the way in which biological factors, such as the presence of different sex hormones during foetal and child development, shape one's personality, social interaction and reactivity (Shiner, et al, 2012). Arguably, these factors result in different abilities in men and women and, as a result, predict their careers (Shiner, et al, 2012). This theory, however, still does not explain why there are fewer women in APP(CC) roles when women are not deterred from standard paramedic roles despite these biological influences.
Notwithstanding this, in these modern times, while it is not currently possible nor perhaps ethical to interfere with these biological factors, it is possible to acknowledge the enduring effects they have for men and women and accommodate them equally.
Some of the issues seen in this study are different from those in the historical EMS literature. Women did not raise concerns over sexual harassment or sexual relations to gain promotion, nor did they raise concerns over manual handling or driving ability (Gonsoulin and Palmer, 1998; Honeycutt, 1999). This suggests, perhaps, that progress has been made in some areas in recent times.
Limitations
While the philosophical basis of qualitative research is not primarily concerned with sample size, this study represents the opinions of only a very small group of women within one UK ambulance service. Interview questions were based on survey responses that represented less than 10% of the service's female paramedic workforce. Replication of this research to a wider group of women may uncover new information.
One major limitation is the ethnically homogenous group of women sampled for interview. The majority (84.1%) of women who completed the exploratory survey anonymously or openly identified as white, 4.3% of declined to state their ethnicity and 8.5% of women responded with their nationality instead of their ethnic group. Just 3.1% of women identified as coming from either mixed or black and minority ethnic background (this was the term used in the survey in 2018 and has now been replaced as women from ethnic minority backgrounds). Unfortunately, these women were not included in the interviews despite giving their consent and this major oversight was not considered until the interviews had been concluded. Disappointingly, because of the constraints of the academic schedule, it was not possible to retrospectively interview these women.
Another limitation of this work is that only one author generated the analysis of both the exploratory surveys and the interviews. Ideally, two individuals would have independently analysed the responses and come to an agreement about how the responses should be interpreted. While bias may have been introduced because of this, a reflexive diary was kept to track how the perspectives of the author evolved throughout the study.
Repetition of this study by a different author or a male author may render different results, which would make for intriguing comparison.
Conclusion
Further research is needed to explore whether accommodating applications to APP(CC) positions at less than full-time hours would increase female participation. Likewise, it could be examined whether offering higher education funding for parents working part time may improve their academic attainment and therefore access to these senior clinical roles.
Improving awareness of gender biases and how APP(CC)s' behaviour as role models may influence future generations of advanced practitioners might serve to inspire talented people who would have otherwise been deterred. The profession should seek to find opportunities where APP(CC)s can inspire future generations.
Finally, further research should explore the views of women from ethnic minority backgrounds to understand their views as to why there are so few women APP(CC)s, especially as the interviews within this study were conducted with a homogenous group of white women. This work should be repeated with men from ethnic minority backgrounds who also remain underrepresented in APP(CC) roles. These will help the development of a strategy to improve participation and therefore the care delivered to patients.