Can you do a community assessment without talking to the community?

Conventionally, it has been accepted that an accurate understanding of community views on health topics can only come directly from community members. Yet, even as the need for this data has been increased by managed care, the methods of gathering it from community members remain costly and impractical for most busy practices or communities. This case study was conducted to determine whether well- informed health professionals can accurately and less expensively convey community views on health topics. In a low-income urban community, using a standard set of open-ended questions, focus groups and telephone and mail surveys were used to gather qualitative data from community residents and patients. Extended interviews and key informant surveys were used to gather similar data from health professionals. Data obtained from both sets of respondents were compared for content and logistics of collection. Overall, responses from the two groups had similar content but differing emphases. Community residents tended to emphasize socioeconomic determinants of health and everyday life concerns, while health care workers tended to emphasize the process of care. However, these perspectives were shared across the groups, as was an emphasis on the need for education with regard to community health concerns. The most striking difference between the groups was the community resources each group identified. As expected, costs for the health care worker approaches were less expensive. Findings from this case study suggest limited situations in which health care workers can adequately convey community views. In other situations, the different perspectives of each group can be complementary. Regardless of their role in qualitative data gathering, there remain important roles for community members in planning and decision-making regarding their health care.     

Hospice volunteers: bridging the gap to the community?

Current demographic, policy and management changes are a challenge to hospices to develop their volunteering practices. The study upon which this paper is based aimed to explore good practice in volunteer involvement and identify ways of improving care through developing volunteering. The project consisted of a narrative literature review; a survey of volunteer managers; and organisational case studies selected through purposive diversity sampling criteria. A total of 205 staff, volunteers, patients and relatives were interviewed across 11 sites in England in 2012. This article focuses on one of the findings – the place that volunteers occupy between the hospice and the community beyond its walls. External changes and pressures in society were impacting on volunteer management, but were viewed as requiring a careful balancing act to retain the ‘spirit’ of the hospice philosophy. Honouring the developmental history of the hospice was vital to many respondents, but viewed less positively by those who wished to modernise. Hospices tend to be somewhat secluded organisations in Britain, and external links and networks were mostly within the end‐of‐life care arena, with few referring to the wider volunteering and community fields. Volunteers were seen as an informal and symbolic ‘link’ to the local community, both in terms of their ‘normalising’ roles in the hospice and as providing a two‐way flow of information with the external environment where knowledge of hospice activities remains poor. The diversity of the community is not fully represented among hospice volunteers. A few hospices had deliberately tried to forge stronger interfaces with their localities, but these ventures were often controversial. The evidence suggests that there is substantial scope for hospices to develop the strategic aspects of volunteering through greater community engagement and involvement and by increasing diversity and exploiting volunteers' ‘boundary’ position more systematically to educate, recruit and raise awareness.     

Housing: the foundation of community care?

Until the late 1980s community care was traditionally the preserve of the health and social care agencies that dominated the planning and provision of care. Since then it has increasingly been recognized that housing should also play a major role in community care. This has been apparent in official guidance and statements, in some of the more innovative forms of community care provision, and in some of the academic literature. Yet the advancement of the housing dimension of community care in the 1980s has arguably become as much of a bland truism as the idea of community care itself has always been. What has remained largely absent from the debate is a considered and critical view of the meaning and potential role of housing in community care, or - more specifically - an agreed vision of the benefits a housing orientation can bring to the quality of community care. This article draws together many strands of the argument. It critically examines the emergence and development of the idea of housing as a 'key' component - even the 'foundation' - of community care, identifying some of the reasons why the housing dimension has risen from a seriously marginalized position to the central role which it is now often suggested it should occupy. The authors conclude by arguing that, whilst some progress has been made, a fundamental shift in thinking is still required at many levels. They suggest that community care users have consistently claimed that housing is the first essential component of effective community care. What is needed is for other participants in the community care process to endorse and develop an ordinary housing approach to community care, in which housing is genuinely accepted as the vital component and which can be translated into practice. This fuller recognition of the housing contribution must embrace meanings which can be agreed, understood and operationalized by the main participants in community care.     

More donation: through the community, the government or the market?

In previous research it has been established that the number of organ donors would increase if trained donation specialists were made available to assist families during the donation process. The amount to be gained would, however, not be sufficient to solve the problem of donation shortfall. Possibly the government needs to play a more active role, for example by means of a 'no objection, unless' system. The present political climate in The Netherlands does not appear for the time being to support such an initiative. Finally, the number of donors could be increased via the market by financial stimulus, but it is questionable whether this would be regarded as morally justified by the community.     

In health care reform, who cares for the community?

Health care reform has again focused the issues of ownership and mission of organizations in the health care field. Some believe that universal entitlement will eventually make both charitable patient care and the nonprofit form of organization obsolete. Others believe that special treatment of nonprofit organizations does not depend on charity at all; rather that the nonprofit form has social value in and of itself. The authors reflect a different point of view. They suggest that with reform, community benefit as the modern expression of a charitable mission will become ever more important in achieving the nation's health care goals. They believe that nonprofit organizations will continue to be entitled to special treatment only if their missions and programs extend beyond care of patients and entitled populations to focus also on care of communities. Any health organization's investment in disciplined community initiatives encompasses all the people in targeted communities, including those served by competing organizations. Without tax exemption, an organization committed to community care initiatives will be at a competitive disadvantage under the proposed community rated capitation payment system. Rather than abandoning the community benefit standard for tax exemption, health care reform calls for more systematic management of community care initiatives by nonprofit organizations and also of tax-exemption eligibility by the IRS.     

Patients and doctors: reformulating the UK health policy community?

The rise of the active health care consumer in the United Kingdom requires a reformulation not only of the traditional relationship between patients and doctors, but also of the macro-politics of health which reflect and service that relationship. Market and democratic themes have supplied an ideological impetus to the pressures for change. The well-publicised problems of medical self-regulation have given them practical political expression. However, the response from the policy community still reflects the dominant partners within it, medicine and the state. What neither partner has recognised is that the functionality of the policy community has been undermined by the different and issue-based challenges to the traditional patient-doctor relationship. As a result, the state is likely to remain the lead player in an increasingly unstable politics of health where consumerist issues are on the policy agenda, but patient groups are still excluded from the policy community.     

Competing risks and the clinical community: irrelevance or ignorance?

Life expectancy has dramatically increased in industrialized nations over the last 200 hundred years. The aging of populations carries over to clinical research and leads to an increasing representation of elderly and multimorbid individuals in study populations. Clinical research in these populations is complicated by the fact that individuals are likely to experience several potential disease endpoints that prevent some disease-specific endpoint of interest from occurrence. Large developments in competing risks methodology have been achieved over the last decades, but we assume that recognition of competing risks in the clinical community is still marginal. It is the aim of this article to address translational aspects of competing risks to the clinical community. We describe clinical populations where competing risks issues may arise. We then discuss the importance of agreement between the competing risks methodology and the study aim, in particular the distinction between etiologic and prognostic research questions. In a review of 50 clinical studies performed in individuals susceptible to competing risks published in high-impact clinical journals, we found competing risks issues in 70% of all articles. Better recognition of issues related to competing risks and of statistical methods that deal with competing risks in accordance with the aim of the study is needed.     

Osteoporosis detection in the community. Are patients adequately managed?

In conclusion, osteoporosis remains underdiagnosed in the South Eastern Sydney area. A public awareness campaign, highlighting the need for bone densitometry in men and women 45 years and older who sustain minimal trauma fractures in order to diagnose osteoporosis, is required. Proven therapies for patients presenting with osteoporotic fractures, including men, are now available and should be considered.     

Is the prevalence of successful weight loss and maintenance higher in the general community than the research clinic?

OBJECTIVE: The prevalence of successful weight loss remains unclear. In 1982, Schachter concluded that in the general population, the rate of "self-cured" obesity approached 63%-much higher than the rate from clinical trials. Several subsequent studies have addressed this issue. RESEARCH METHODS AND PROCEDURES: Our initial goal was to meta-analyze these studies to evaluate the validity of the original hypotheses and the extent to which additional investigations supported the findings. We began by restating Schachter's hypotheses in precise, testable terms. RESULTS: A systematic review of these studies found many methodological limitations and much heterogeneity among the samples studied, hypotheses addressed, and operational definitions. Some of these limitations appear to stem from the lack of clear, precise statements of the exact hypotheses tested. Differences among studies are delineated, and we outline why meta-analytic pooling of these data appears inappropriate. CONCLUSIONS: The current data are inadequate to draw any definite conclusions regarding the cure rate of obesity. Criteria for the adequate study of success rates with "self-cure" in the general population are proposed.     

How will family physicians care for the patient in the context of family and community?

Difficulties caring for patients in the context of family and community stem from problems of power and vulnerability. Patients are disempowered in relation to physicians and to the medical care system. Physicians are disempowered in their ability to provide comprehensive relationship-centered care to individuals and families because of economic constraints on medical care and limits on continuity of care. Individual patients are also vulnerable to abuses of power within their families because of physical and sexual abuse; the recognition of such abuses and appropriate interventions for them requires awareness of the gender ideology that underlies interpersonal abuses of power. Families and communities can be disempowered because of vulnerabilities related to race, ethnicity, poverty, and homelessness. The additive effects of these vulnerabilities have created health disparities that are a hallmark of inequities in our country's medical system. Opportunities to teach students to recognize and address these disparities abound within medical education. Participatory training and educational action projects can prepare learners to lead us toward a more just and egalitarian medical system with the potential to change the context of family and community in which we care for patients. However, systematic commitment from educational programs is necessary to produce activated clinicians, teachers, and researchers to achieve these changes.     

Should food or supplements be used in the community for the treatment of disease-related malnutrition?

Strategies are needed for community-based treatment of disease-related malnutrition (DRM), which is a common debilitating condition that in the UK is estimated to cost > 7 pounds x 10(9) annually. Whilst dietary fortification and counselling are often used as a first-line treatment for malnutrition, the numbers of dietitians available to undertake and oversee such practices are currently insufficient to address the extent of DRM in primary care. Although dietary fortification and counselling can improve nutritional (primarily energy) intake, the evidence base for this practice is weak and it needs addressing with well-designed trials that assess clinically-relevant outcome measures and costs. Liquid oral nutritional supplements (ONS) are increasingly used in the community, often in combination with dietary counselling. The larger evidence base of trials that have assessed ONS suggests that nutritional intake and some functional outcomes can be improved in some patient groups in the community. Although meta-analysis indicates significant reductions in mortality (odds ratio 0.59 (95% CI 0.48, 0.72), n 3258) and complication rates (odds ratio 0.41 (95% CI 0.31, 0.53), n 1710) with ONS v. routine care, few of these studies are community based. Thus, the impact of ONS on clinical outcome, healthcare use and costs requires further assessment. Similarly, the clinical and cost efficacy of other strategies (e.g. sensory enhancement, music, behavioural therapy), alone or in combination with other treatments, requires greater investigation in order to meet the challenge of treating DRM more effectively and cheaply in the future.     

Should the decisions of ethics committees be based on community values?

Medicine, Health Care and Philosophy -