A collaborative exploration of the reasons for lower satisfaction with services among Bangladeshi and Pakistani social care users

This study explored underlying reasons for the expression of dissatisfaction with services among Bangladeshi and Pakistani social care users in England and investigated, using a collaborative approach, how these could be addressed. In‐depth interviews were conducted in Birmingham, Leeds and London during 2012–2013 with 63 Bangladeshi, Pakistani and white British service users and 24 social care managers, social workers and care workers. A further 34 cognitive interviews were conducted within the same study. Following data analysis, three collaborative workshops involving service users and providers were held to validate the findings and to draw out policy and practice recommendations. Analysis of the cognitive interviews showed that higher dissatisfaction among Bangladeshi and Pakistani service users reported in social care surveys was not due to questionnaire design. Instead in‐depth interviews showed that dissatisfaction across all three groups was expressed along the social care journey, including accessing care, communication with social workers and the nature of care received. While many issues were common to all three groups, cultural differences also emerged as affecting experiences of social care. These included misunderstandings about family roles in care; gender issues, especially relating to women; language and communication barriers, alongside the need for a more nuanced approach to ethnic ‘matching’; and continuing limited cultural understanding among care workers. The collaborative workshops identified practical actions that could address some of the issues identified. These covered raising awareness of services within communities; improving support for informal carers; service user input to assessments; consistent and ongoing sharing of information; improving access; and more efforts to diversify and appropriately train the social care workforce. In conclusion, the paper presents the reality of dissatisfaction among these groups and argues for more action involving communities and service providers to address these persistent issues collaboratively.     

Accessibility and equity of health and social care services: exploring the views and experiences of Bangladeshi carers in South Wales, UK

There is a paucity of information regarding the extent and nature of caring provided by minority ethnic communities. The proportion of older people from these communities will dramatically increase in the next 20 years, which will be accompanied by increasing health and social care needs and an increased demand for carers. A qualitative, exploratory study was conducted to identify the health and social care needs of informal carers, who were caring for a dependent adult from a Bangladeshi community in South Wales, UK. This paper focuses on Bangladeshi carers' access to formal support services provided by the statutory, private and voluntary sectors to assist them with their caring responsibilities. The findings are based on data collected using face-to-face, focused interviews with 20 Bangladeshi carers. Purposive and snowball sampling were used to recruit the sample. The data were analysed using thematic content analysis. The dimensions of accessibility and equity of quality of care were drawn upon to aid understanding of the findings. Bangladeshi carers faced a number of barriers in accessing health and social service provision, which impeded uptake of these services. Additionally, there was evidence of inequity in service provision. Recommendations for improving the accessibility of health and social care services are proposed, which may assist in promoting more equitable services for carers from the Bangladeshi community.     

Changes in primary health care policy: the implications for joint commissioning with social services

Both the primary health care team (PHCT) and social services departments in the UK have undergone substantial changes to their organization and function since 1990. This paper looks at developments in primary health care policy that have affected the relationships between them regarding the commissioning of health and social care services. It focuses on evidence from seven initiatives designed to involve members of the PHCT in commissioning social care services. It examines some of the benefits and challenges of working together to commission services for health authority managers, GPs, district nurses, care managers and social work team managers in the light of impending changes to the PHCT, particularly the abolition of fundholding and the introduction of Primary Care Groups.     

Lay perspectives on lay health worker roles, boundaries and participation within three UK community-based health promotion projects

This paper examines lay interpretations of lay health worker roles within three UK community-based health promotion projects. It argues that understanding lay health worker roles requires critical analysis of the complex interrelationships between professionals, lay workers and the communities receiving a programme. Findings are presented that are drawn from a qualitative study of lay engagement in public health programme delivery where a key objective was to examine the perspectives of community members with the experience of receiving services delivered by lay health workers. Interviews and focus groups were conducted with 46 programme recipients from three case study projects; a breastfeeding peer support service, a walking for health scheme and a neighbourhood health project. The results show how participants interpreted the function and responsibilities of lay health workers and how those roles provided personalized support and facilitated engagement in group activities. Further insights into community participation processes are provided revealing the potential for active engagement in both formal and informal roles. The paper concludes that social relationships are core to understanding lay health worker programmes and therefore analysis needs to take account of the capacity for community members to move within a spectrum of participation defined by increasing responsibility for others.     

Primary health and social care services in the UK: progress towards partnership?

There has been a shift in the theoretical debates around the ways in which organisations deliver the state's objectives of providing health and social care services for its citizens, focusing on issues of welfare governance and the encouragement of partnership working between organisations. This article develops these theories by focusing on developments in primary health and social care policy in the UK, which have undergone a radical change recently. Responsibility for commissioning health care services now falls to primary care groups and trusts (PCG/Ts), run by general practitioners, other primary care practitioners, managers and lay members, and there is some pressure on primary care groups and primary care trusts to engage in partnership working with social services, for example, to cut hospital waiting lists or provide intermediate care services. One policy option is for these organisations to form Care Trusts, integrating the commissioning of health and social care for older people and ending the historical organisational divisions between health and social care in the UK. This paper examines evidence from the first stage of a 3-year longitudinal quantitative and qualitative study of the development of partnership working between PCG/Ts and social services departments in England. It examines whether the evidence suggests that the integration of health and social care is feasible or desirable in older people's services.     

Ethnic differences in women’s use of mental health services: do social networks play a role? Findings from a national survey

Objectives: The reasons for ethnic differences in women’s mental health service use in England remain unclear. The aims of this study were to ascertain: ethnic differences in women’s usage of mental health services, if social networks are independently associated with service use, and if the association between women’s social networks and service use varies between ethnic groups.

Design: Logistic regression modelling of nationally representative data from the Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) survey conducted in England. The analytic sample (2260 women, aged 16–74 years) was drawn from the representative subsample of 2340 women in EMPIRIC for whom data on mental health services, and social networks were available.

Results: Pakistani and Bangladeshi women were less likely than White women to have used mental health services (Pakistani OR?=?0.23, CI?=?0.08–0.65, p?=?.005; Bangladeshi OR?=?0.25, CI?=?0.07–0.86, p?=?.027). Frequent contact with relatives reduced mental health service use (OR?=?0.45, CI?=?0.23–0.89, p?=?.023). An increase in perceived inadequate support in women’s close networks was associated with increased odds of using mental health services (OR?=?1.91, CI?=?1.11–3.27, p?=?.019). The influence of social networks on mental health service use did not differ between ethnic groups.

Conclusions: The differential treatment of women from Pakistani and Bangladeshi ethnic groups in primary care settings could be a possible reason for the observed differences in mental health service use.     

Quitting smoking and experience of smoking cessation interventions among UK Bangladeshi and Pakistani adults: the views of community members and health professionals

OBJECTIVE: To explore attitudes to quitting smoking and experience of smoking cessation among Bangladeshi and Pakistani ethnic minority communities. DESIGN: Qualitative study using community participatory methods, purposeful sampling, interviews and focus groups, and a grounded approach to data generation and analysis. SETTING: Newcastle upon Tyne, UK, 2000-2002. PARTICIPANTS: 53 men and 20 women aged 18-80 years, including smokers, former smokers, and smokers' relatives, from the Bangladeshi and Pakistani communities; and eight health professionals working with these communities. RESULTS: Motivation to quit was high but most attempts had failed. "Willpower" was the most common approach to quitting. For some, the holy month of Ramadan was used as an incentive, however few had been successful in quitting. Perceived barriers to success included being tempted by others, everyday stresses, and withdrawal symptoms. Few participants had sought advice from health services, or received cessation aids, such as nicotine replacement therapy (NRT) or buproprion. Family doctors were not viewed as accessible sources of advice on quitting. Health professionals and community members identified common barriers to accessing effective smoking cessation, including: language, religion and culture; negative attitudes to services; and lack of time and resources for professionals to develop necessary skills. CONCLUSIONS: High levels of motivation do not seem to be matched by effective interventions or successful attempts to quit smoking among Bangladeshi and Pakistani adults in the UK. There is a need to adapt and test effective smoking cessation interventions to make them culturally acceptable to ethnic minority communities. UK tobacco control policies need to give special attention to the needs of ethnic minority groups.     

Empowerment and advocacy: reflections on action research with Bangladeshi and Pakistani families who have children with severe disabilities

The concepts of empowerment and advocacy, and how they impinge on power relationships for service providers working with black and Asian communities, are explored through the findings of a 20-month project carried out between 2000 and 2001 with 19 Pakistani and Bangladeshi families who have children with severe disabilities in Birmingham. This action research project evaluated an advocacy project designed to improve the quality of life for Pakistani and Bangladeshi families with at least one child with severe disabilities. The objectives included improving access to resources, services, information and support in ways which were non-stigmatising, and which were sensitive to the particular needs of the children and their carers. The present paper discusses four main themes: (1) advocacy and empowerment in practice; (2) issues of the efficacy of advocacy and of consultation within advocacy; (3) individual empowerment versus the families' needs; and (4) cultural and gender issues which emerged from the analysis of the study. The authors identify features of empowerment which must be addressed in advocacy services which are sensitive to ethnic differences. These issues must be addressed if services are to reap their potential to make a positive impact on the lives of the most vulnerable and powerless members of the community.     

医防融合背景下我国基层医疗卫生机构医防工作现状及认知调查

目的 通过调查我国5省基层卫生人员医防工作的参与情况与对开展医防融合工作的认知现状, 探讨目前基层医防融合工作存在的问题,为促进基层医疗卫生机构医防融合工作提供参考依据。方法 采用多阶段分层抽样,根据地域方位差异分别抽取四川、贵州、江西、江苏和广东5个省,再依据经济状况每省选取3个区县,共15个区县的乡镇卫生院和社区卫生服务中心(站)的卫生人员(6 439名)进行问卷调查与访谈, 对调查数据进行描述并对医防融合工作参与情况与认知现状进行检验。结果 从事公共卫生工作的958名卫生人员中,仅有292人(30.5%)同时参与公共卫生服务与医疗服务,有615人(64.2%)只参与公共卫生服务; 51.7%的公共卫生工作人员以独立公共卫生服务的方式参与基本卫生服务。从事公共卫生工作的卫生人员主要以护理学和临床医学专业为主,仅15.6%的人员具有预防医学专业背景。从事临床医疗工作的1 964名人员中,1 464人(74.5%)医疗服务与公卫服务均参与,但对基本公共卫生服务的投入时间相对较少。不同岗位的卫生人员参与医防工作的情况不同(=2 208.874,P<0.001)。结论 基层临床医疗工作与公共卫生工作机制相对独立。公共卫生工作人员因缺乏疾病诊断治疗能力或无处方权而不能很好地参与到临床医疗工作中; 临床医疗工作人员因缺乏公共卫生知识和技能对公共卫生服务的参与受限。 建议整合医防融合服务机制,打造基层整合型服务; 培养基层医防复合型人才,加大全科医生培养力度。     

How do health service managers respond to qualitative research?

During 1992 a qualitative evaluation of a government health service-run community health worker (CHW) project in South Africa found that project workers were doing good work despite serious structural shortcomings related to lack of community participation and inadequate integration of the project in the health district system. Recommendations were made to develop the project in order to enhance community involvement, to build closer integration between the project and the services offered at the health centre, and to collaborate with non-government CHW projects in neighbouring areas.The evaluation study was followed up one year later by interviews with health managers to determine their response to the evaluation. The managers reported that they had found the qualitative data valuable for understanding how clients perceived the health service, and for planning a more community-responsive service.Despite this, the recommendations from the evaluation were not implemented and political developments in the district resulted in the CHW project being closed down. It is concluded that qualitative evaluators need to carefully explore the political context of primary health care interventions in order that their research provides useful data for decision-making.     

African-Caribbean interactions with mental health services in the UK: experiences and expectations of exclusion as (re)productive of health inequalities

In the context of current concerns about health inequalities among minority ethnic groups in the UK, this paper addresses perceptions of mental health services among members of an African-Caribbean community in a South England town. Efforts to reduce health inequalities must take account of the views of local community members on the sources of those inequalities and on local health services. The statistical existence of inequalities in diagnosis and treatment of African-Caribbeans in the UK is well-established, supported by sociological explanations of these inequalities which centre on social exclusion in a variety of forms: institutional, cultural and socio-economic. However, detailed studies of the perspectives of local communities on mental health issues and services have received less attention. In this case study of community perceptions of mental health services, we find that social exclusion comprises an explanatory framework which is repeatedly invoked by community members in describing their interaction with mental health services. Interviewees assert that experience and expectation of racist mis-treatment by mental health services are key factors discouraging early accessing of mental health services, and thereby perpetuating mental health inequalities. We conclude that participation and partnership are vital means by which to generate both the objective and subjective inclusion that are requirements for an accessible and appropriate health service.     

‘Getting involved means making a difference?’ Insider views on the impact of a ‘healthy living’ community intervention

Addressing inequalities in health has featured strongly in UK health care policy over recent years, and efforts to consider inequalities at ‘ground level’ are increasingly evident. This includes enhancing primary care and other community-based services and emphasising consultation at community levels. The Healthy Living Approach to community development in Pembrokeshire, West Wales, was initiated and evaluated as part of the Welsh Assembly Government's Sustainable Health Action Research Programme (SHARP). As part of that programme an action research project was organised to respond to a context of funding and service delivery coloured by rural isolation, social exclusion and poor health. The project was adopted in three marginal communities and was evaluated using multiple methods to understand the effects of the initiative and how well it was seen to have worked. This paper reports on one aspect of that evaluation: focus groups with Project Steering Group members that examined the impact of the intervention from the perspective of those involved in the study's implementation. The paper highlights the perceived impact on community members and study organisers, the process of liaison between community and statutory body advisers and the appropriateness of the methodology. There was overwhelming support for the project and agreement that action research was the only feasible working methodology. The results offer insider views on the potential for ‘healthy living’ community interventions to enable communities to engage with locally defined health issues, but sets a note of caution about being able to achieve real and sustainable change.     

The impact of a quasi-market on sexually transmitted disease services in the UK.

This article reports the results of a study of the impact of quasi-market reforms on sexually transmitted disease (STD) services in one UK health region. An internal or quasi-market was introduced into UK health care in the 1991 reforms of the National Health Service (NHS). Health authorities (HAs) and general practitioner fundholders were given major new responsibilities for purchasing (later called commissioning) health services. The NHS quasi-market was designed to address recurrent difficulties in acute health services by promoting efficiency and consumer choice. The arrangements for commissioning STD services are important because these diseases are major threats to public health and HAs face a number of constraints in bringing about service changes through market mechanisms. In the UK, STD services are provided on a self-referral and confidential basis; patients experience STDs as stigmatizing and often have low expectations of service and little desire for involvement in commissioning decisions. HAs have only limited routine intelligence about STD services and little or no choice of local providers. This study adopted a qualitative case-study approach to examine HA commissioning of STD services. The study found that the introduction of the NHS quasi-market did not equip HAs with mechanisms for bringing about change in STD service provision or STD-related health outcomes. The findings are consistent with other recent studies of HA commissioning and provide further cumulative evidence of the limits to HA leverage in the NHS quasi-market. The study concludes that the commissioning of STD services is likely to remain a low priority in the new NHS structures based on primary care groups.     

Commissioning and equity in primary care in Australia: Views from Primary Health Networks

This paper reports findings from 55 stakeholder interviews undertaken in six Primary Health Networks (PHNs) in Australia as part of a study of the impact of population health planning in regional primary health organisations on service access and equity. Primary healthcare planning is currently undertaken by PHNs which were established in 2015 as commissioning organisations. This was a departure from the role of Medicare Locals, the previous regional primary health organisations which frequently provided services. This paper addresses perceptions of 23 senior staff, 11 board members and 21 members of clinical and community advisory councils or health priority groups from six case study PHNs on the impact of commissioning on equity. Participants view the collection of population health data as facilitating service access through redistributing services on the basis of need and through bringing objectivity to decision‐making about services. Conversely, participants question the impact of the political and geographical context and population profile on capacity to improve service access and equity through service commissioning. Service delivery was seen as fragmented, the model is at odds with the manner in which Aboriginal Community Controlled Health Organisations (ACCHOs) operate and rural regions lack services to commission. As a consequence, reliance upon commissioning of services may not be appropriate for the Australian primary healthcare context.     

Pakistani women's use of mental health services and the role of social networks: a systematic review of quantitative and qualitative research

Pakistani women in the UK are an at‐risk group with high levels of mental health problems, but low levels of mental health service use. However, the rates of service use for Pakistani women are unclear, partly because research with South Asian women has been incorrectly generalised to Pakistani women. Further, this research has been largely undertaken within an individualistic paradigm, with little consideration of patients’ social networks, and how these may drive decisions to seek help. This systematic review aimed to clarify usage rates, and describe the nature of Pakistani women's social networks and how they may influence mental health service use. Ten journal databases (ASSIA, CINAHL Plus, EMBASE, HMIC, IBSS, MEDLINE, PsycINFO, Social Sciences Abstracts, Social Science Citation Index and Sociological Abstracts) and six sources of grey literature were searched for studies published between 1960 and the end of March 2014. Twenty‐one studies met inclusion criteria. Ten studies (quantitative) reported on inpatient or outpatient service use between ethnic groups. Seven studies (four quantitative, three qualitative) investigated the nature of social networks, and four studies (qualitative) commented on how social networks were involved in accessing mental health services. Pakistani women were less likely than white (British) women to use most specialist mental health services. No difference was found between Pakistani and white women for the consultation of general practitioners for mental health problems. Pakistani women's networks displayed high levels of stigmatising attitudes towards mental health problems and mental health services, which acted as a deterrent to seeking help. No studies were found which compared stigma in networks between Pakistani women and women of other ethnic groups. Pakistani women are at a considerable disadvantage in gaining access to and using statutory mental health services, compared with white women; this, in part, is due to negative attitudes to mental health problems evident in social support networks.     

South Asian women,psychological distress and self-harm: lessons for primary care trusts

The present paper reports an investigation of the self-reported needs of South Asian women suffering distress and mental health problems which may lead to self-harm and suicide, and uses the data to define indicators of good practice for primary care. The design was a qualitative study using focus group discussion. Four focus groups of South Asian women (using existing women's groups in Manchester, UK) formed the setting for this study. Each focus group was facilitated by one of the authors, and the discussions occurred in Urdu, English and Punjabi. An interview guide was used, although the direction of the discussions followed the women's agenda. Notes were taken during the focus group discussions. Analysis of notes to define themes and emergence of framework was carried out. The data were analysed according to the principles of framework analysis. A range of systemic issues were described by respondents including: social, political and economic pressures; domestic violence; poverty; language problems; family and children's issues; and health. These experiences were reinforced by an extremely efficient community grapevine and were evident in described experiences such as: racism and stereotyping of Asian women; Asian communities and Islam; and the concept of izzat (honour) in Asian family life, which was seen as a major influence in the lives of Asian women. These experiences were thought to result in mental distress, which was described in a variety of ways by the women. The women saw self-harm as a usable coping strategy to deal with their distress. Perceived barriers to services were described by the women. Services tended to be accessed only at a point of desperation, rather than prior to crisis points. This indicated the need for services to be able to respond rapidly when Asian women did ask for help. Whilst the present paper describes a local study, thus limiting its generalisability, the use of such work in commissioning local health and social services is outlined. A number of indicators for good practice were drawn up in relation to addressing systemic issues in service provision using these findings. Such indicators will be of use by primary care trusts in developing, commissioning and monitoring services for this patient group.     

Social work at the Chinese Medicine system in Hong Kong: opportunities and challenges

Dealing with health and disease is an area of concern for social workers. The establishment of medical social service in a health setting has more than 100 years of history in the USA and more than 60 years in Hong Kong. Despite the increasing popularity of Chinese Medicine (CM) used by the Hong Kong people, there has been no medical social service presence in the CM system. A pilot project demonstrated a successful interdisciplinary collaboration model between social work and CM irrespective of different social work methods, that is, individual work, groupwork, and community-based services. In this article, we will relate the opportunities and difficulties that we encountered in setting up the first medical social service in the CM system. Drawing on our experience, we found that both professions benefited from the interdisciplinary collaboration. CM was able to expand its scope of service to increase the service quality and promote primary health care in the community with the support of social work. Conversely, social workers found that CM is a good resource for providing innovative services to meet the various needs of the people in the community. There was also a ripple effect of incorporating CM elements into social service. The interface between the disciplines of social work and CM can widen the scope of their contributions on health. Implications for CM social service in social work will also be examined.     

Health workers' community practices in primary health care models in South and Northeast Brazil

In order to verify the prevalence of health workers' participation in health practices in the community, a cross-sectional study was conducted with 3,743 primary care health workers in 41 municipalities with more than 100 thousand inhabitants each in South and Northeast Brazil. Overall prevalence of participation in the community was 62.7%, and was significantly higher in the Northeast and in the Family Health Program (FHP). The most common practice was health education on special holidays, in talks, and in groups. There was a positive association between participation and: female gender, training in the management of chronic diseases, use of protocols, satisfaction with community meetings, and academic health services. Differences in the prevalence of participation by region and health care model reaffirmed the inherent expectations in the historical context of reorganization of primary care. The results indicate that it is necessary to expand participation by health workers in the community, considering that primary care is the level of care that provides the best possibilities for promoting health practices with equity.     

Interorganisational cooperation and its effects on community rehabilitation for people with severe mental disorders in Beijing,China: A case study

A national comprehensive management pilot project for mental health has been implemented in China to provide integrated care for people with severe mental disorders through strengthened cooperation among government organisations and between government and other relevant social organisations. The promotion of community rehabilitation has been included as a key part of this pilot program. The present study took the AD district of Beijing as a case study to examine interorganisational cooperation and its effects on community rehabilitation in a real-world setting. Interviews were conducted with 14 frontline workers, including 7 mental health workers from community health centres and 3 staff and 4 social workers working in rehabilitation centres. Five officials from relevant health and social welfare departments and a social work organisation were also interviewed. Experiences in Beijing revealed that interorganisational cooperation helped to build a multiagency workforce furnished with basic mental health knowledge at the community level, which rendered it possible for frontline workers to provide fundamental follow-up services, pilot the case management model of service provision and increase the provision of psychosocial rehabilitation services within the poorly resourced context of Chinese mental healthcare. Moreover, the engagement of social organisations provided bottom-up pressure to innovate through the active bringing forward of new ideas concerning cooperation and service delivery. However, differences in professional authority and commitment were observed. Health department officials and health professionals seemed to exercise a dominant role as compared to social welfare department officials and social workers. Future policy making should motivate social welfare department officials to improve social care for people with severe mental disorders. Social workers require training to improve their knowledge of mental health matters, and social organisations need greater latitude to strengthen their influence over the development of community rehabilitation services for people with severe mental disorders.     

Tipping the balance: international collaboration in primary health care reorientation

This paper describes a multicountry initiative aimed at TippingThe Balance towards primary health care (TTB). The Alma Ata declaration was the inspiration for the projectwhich has three branches. This paper describes one of these:community participation and skills development. TTB is a collaboration involving primary health care and otherpublic sector workers, educators, researchers and people inlocal communities. Twelve linked projects in five differentcountries are described. Projects have been grouped into fouraction areas: community participation; protection and promotion;inter-sectoral collaboration; reorientation to primary healthcare. Striking similarities existed in relation to health issues inall countries in the TTB project. All project teams focusedon reduction of inequality in health experiences and expectations,and worked for social justice in health care. It is believed that, by all the efforts documented in this paper,TTB teams can make a significant contribution towards socialjustice in their own countries, and also internationally.