The 1996 Leicestershire Community Stroke & Ethnicity Study: differences and similarities between South Asian and white strokes

OBJECTIVE: To estimate the number of strokes in Leicestershire and investigate possible differences between South Asian and white patients. DESIGN: Prospective incidence sample survey. SETTING: Leicestershire. PARTICIPANTS: Acute stroke cases occurring in registered populations of 12 'high Asian' and 11 'low Asian' general practices. RESULTS: The age-specific incidence rates of stroke in Leicestershire were similar to those of the Oxford Community Stroke Project. South Asian patients were less likely to be living alone at home before their stroke and they tended to be younger than whites. However, only 12% of South Asian patients with a stroke were not admitted to hospital within 7 days of their stroke compared to 23% of white patients (chi2 = 3.24, d.f. = 1, P = 0.07). Only 21% of South Asian patients died within 28 days of their stroke compared to 33% of white patients (age-adjusted odds ratio = 0.37; 95% CI: 0.14-0.97). CONCLUSIONS: Overlapping case-finding was crucial to finding all 'possible' strokes and this required close collaborative working between general practices, community health services, hospitals and the health authority. Relatively fewer South Asian patients were managed in the community in the first 7 days. Interestingly, South Asian patients were less likely than white patients to die within 28 days. This is an area worthy of further research.     

Socioeconomic deprivation, coronary heart disease prevalence and quality of care: a practice-level analysis in Rotherham using data from the new UK general practitioner Quality and Outcomes Framework

BACKGROUND: The provision of coronary heart disease (CHD) health care has been shown to be inequitous, with those most in need having the least access to high-quality care. The new UK general practitioner (GP) Quality and Outcomes Framework (QOF) contract offers substantial financial rewards to general practices that combine maximal CHD case finding with high-quality CHD care. OBJECTIVE: To examine whether GP practice-level CHD prevalence and the measures of quality of care derived from the new QOF data are associated with area-level socioeconomic deprivation. METHODS: An ecological study of 38 GP practices contracting with Rotherham Primary Care Trust, United Kingdom, was carried out. We calculated Spearman rank correlation coefficients for practice-level age-sex-standardized QOF CHD prevalence against area deprivation score and for 11 QOF CHD indicator achievements against area deprivation score. RESULTS: Practice-level CHD prevalence showed a positive correlation with deprivation (r=0.64, p<0.001), as did one of the 11 quality-of-care indicators (recording of smoking status, r=0.34, p=0.04). The remaining 10 quality-of-care indicators showed no significant correlation with deprivation. CONCLUSION: Practice-level CHD prevalence is associated with deprivation, but we found no evidence of socioeconomic inequality in CHD care. This finding is in contrast to that from previous studies and the widely reported inverse care law.     

Community involvement and Primary Care Trusts: The case for social entrepreneurship

This article looks at the different and sometimes conflicting policy drivers for a move towards greater community involvement in primary health care. In this context, research findings focusing on community involvement initiatives that have taken place within general practices, Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) are explored and the key issues for implementation are appraised. Using an evaluation of a team set up to foster community involvement with the PCTs in Bradford, the utility of a social entrepreneurship approach is considered. It is argued that this form of approach can be employed as a means of utilizing the work of existing groups and operating in a ‘joined up’ way. It is further contended that an emphasis on process and on social entrepreneurship can foster the development of community involvement practices in Primary Care Trusts to meet the current and changing health needs of local communities.     

Perceptions of community participation and health gain in a community project for the South Asian population: a qualitative study

BACKGROUND: The new public health rejects old individualist attempts at improving health and embraces community-based approaches in reducing health inequalities. Primary Care Trusts in England face the challenge of converting community participation in health into reality. This study explores differences in perception of participation between lay and professional stakeholders of a community health project for a South Asian population in Greater Manchester. METHODS: In-depth interviews and focus groups were used to explore the views of professional and lay stakeholders. All data were audio-taped, transcribed and analysed for emerging themes using a qualitative framework. RESULTS: Professionals talked of working in partnership with the community but lay stakeholders did not feel that they had control over the project. There were problems in engaging the community and local health professionals in the project. Lack of cultural awareness hampered participation in the project. There was agreement that the project improved the self-confidence of participants and created a more informed population. However, there was little support for claims of improvements in social cohesion and changes in lifestyle directly as a result of the project. CONCLUSION: Converting the rhetoric of community participation in health into reality is a greater challenge than was envisaged by policy makers. Marginalized communities may not be willing participants and issues of language and cultural sensitivity are important. Project outcomes need to be agreed to ensure projects are evaluated appropriately. Projects with South Asian communities should not be seen to be dealing with all 'ethnic health' issues without addressing changes in statutory organizations and other wider social determinants of health.     

Development of the programme Mental Disorders in Primary Care as Internet-based distance education in South Africa

SETTING: This innovative educational programme was developed in the South African context for general practitioners (GPs). AIM: This short report describes the process of designing an Internet-based distance education programme Mental Disorders in Primary Care. LEARNING METHODS: The article discusses relevant educational principles and then describes four stages in the instructional design process: design, development, evaluation and revision. CONCLUSION: The design and development of an Internet-based distance education programme for GPs in South Africa was a potent learning experience for me as an academic family physician with no prior experience in this area. I hope that this short report will assist other people and contribute to an ongoing dialogue on this topic.     

Community development and HIV/STI-related vulnerability among female sex workers in Rio de Janeiro, Brazil

The Sonagachi Project of Kolkata, India has been recognized as a model community development and human immunodeficiency virus/sexually transmitted infection (HIV/STI) prevention intervention among female sex workers. Limited research has been conducted regarding its applicability outside the South Asian context. This study sought to document the process and effectiveness of integrating community development activities based on the Sonagachi model into an ongoing HIV/STI peer education program with female sex workers in Rio de Janeiro, Brazil. Structured cross-sectional surveys examining HIV/STI-related behaviors and community development measures were conducted among approximately 500 sex workers at pre- and post-intervention. We found that several community development components including social cohesion and mutual aid were significantly associated with consistent condom use among sex workers and their paying clients at pre-intervention. However, only a minority of women actively engaged in community-building activities over the 18-month study period. In turn, limited changes in community development components and no significant increases in the HIV/STI-related protective behaviors assessed were documented. Findings indicate that internalized stigma and socioeconomic pressures may have constrained the scope and pace of community mobilization in this setting during the study observation period.     

Development of the Volunteer Peer Educator Role in a Community Cardiovascular Health Awareness Program (CHAP): A Process Evaluation in Two Communities

Volunteers can support the delivery and sustainability of programs promoting chronic disease awareness to improve health at the community level. This paper describes the development of the peer education component of the Cardiovascular Health Awareness Program (CHAP) and assessment of the volunteer peer educator role in a community-wide demonstration project in two mid-sized Ontario communities. A case study approach was used incorporating process learning, a volunteer survey and debriefing discussions with volunteers. A post-program questionnaire was administered to 48 volunteers. Five debriefing discussions were conducted with 27 volunteers using a semi-structured interview guide. Discussions were audio-recorded and transcribed. Analysis used an editing approach to identify themes, taking into account the community-specific context. Volunteers reported an overall positive experience and identified rewarding aspects of their involvement. They felt well prepared but appreciated ongoing training and support and requested more refresher training. Understanding of program objectives increased volunteer satisfaction. Volunteers continued to develop their role during the program; however, organizational and logistical factors sometimes limited skill acquisition and contributions. The prospect of greater involvement in providing tailored health education resources addressing modifiable risk factors was acceptable to most volunteers. Continued refinement of strategies to recruit, train, retain and support volunteers strengthened the peer education component of CHAP. The experience and contributions of volunteers were influenced by the wider context of program delivery. Process evaluation allowed program planners to anticipate challenges, strengthen support for volunteer activities, and expand the peer educator role. This learning can inform similar peer-led health promotion initiatives. This study has been conducted by the authors for the CHAP Working Group.     

Management of diabetes in primary care: A structured-care approach

Background: In the Irish Midland Health Service Executive (HSE) Diabetes Structured Care Project, additional resources were targeted at general practice in the absence of a local hospital-based specialized diabetes unit. Objective: We assessed the performance of the Midland HSE Diabetes Structured Care programme in 2003, bench-marked against Primary Care Trust (PCT) data from the 2003/2004 National Diabetes Audit for England. Methods: Data on 947 patients (72% of eligible patients) from all 20 general practices participating in the structured-care programme were collected retrospectively over a 12-month period. The data included demographic and clinical variables as well as key process-of-care and intermediate outcome indicators used in the National Diabetes Audit for England. Results: The level of recording of process-of-care measures was near or above the upper quartile for PCTs in England. The proportion of patients with HbA_1c concentrations at target levels (<6.5%) in the Midlands HSE project (26.8%) was virtually identical to the upper quartile level for PCTs in England (27.4%). The proportion of patients reaching target total cholesterol levels (<5.0 mmol/l) (54.6%) was close to the mean for PCTs in England (56.6%), and performance with regard to target blood pressure levels was equally poor in both the Midlands HSE (18.0%) and in PCTs in England (20.8%).

Conclusion: Primary-care-led structured care, with relatively limited but well-focused investment, can achieve quality of care for patients with diabetes, comparable to international best practice.     

Peer education,gender and the development of critical consciousness: participatory HIV prevention by South African youth

Despite the growing popularity of participatory peer education as an HIV-prevention strategy worldwide, our understandings of the processes underlying its impact on sexual norms are still in their infancy. Starting from the assumption that gender inequalities play a key role in driving the epidemic amongst young people, we outline a framework for conceptualizing the processes underlying successful peer education. We draw on the inter-locking concepts of social identity, empowerment (with particular emphasis on Freire's account of critical consciousness) and social capital. Thereafter we provide a critical case study of a school-based peer education programme in a South African township school, drawing on a longitudinal case study of the programme, and interviews and focus groups with young people in the township. Our research highlights a number of features of the programme itself, as well as the broader context within which it was implemented, which are likely to undermine'the development of the critical thinking and empowerment which we argue are key preconditions for programme success. In relation to the programme itself, these include peer educators' preference for didactic methods and biomedical frameworks, unequal gender dynamics amongst the peer educators, the highly regulated and teacher-driven nature of the school environment and negative learner attitudes to the programme. In relation to the broader context of the programme, we point to factors such as limited opportunities for communication about sex outside of the peer educational setting, poor adult role models of sexual relationships, poverty and unemployment, low levels of social capital and poor community facilities. We discuss the implications of our findings for the design of peer educational activities, and point to a number of broader social and community development initiatives that would maximize the likelihood of programme success.     

Dissemination of information to General Practitioners: a questionnaire survey

Background  

Early identification of permanent hearing impairment in children enables appropriate intervention which reduces adverse developmental outcomes. The UK Government has introduced a universal hearing screening programme for neonates. All involved health professionals, including those in Primary Care, need to be aware of the service to enable them to offer appropriate support to their patients. A programme of information dissemination within Primary Care was therefore undertaken. The aim of the current study was to determine the extent to which the information had reached General Practitioners (GPs), the GPs' preferred mode of dissemination and the sources from which GPs accessed information     

Sustained benefits of a community dietetics intervention designed to improve oral nutritional supplement prescribing practices

Background: Healthcare professionals working in the community do not always prescribe oral nutritional supplements (ONS) according to best practice guidelines for the management of malnutrition. The present study aimed to determine the impact of a community dietetics intervention on ONS prescribing practices and expenditure 1 year later. Methods: The intervention involved general practitioners (GPs), practice nurses, nurses in local nursing homes and community nurses. It comprised an education programme together with the provision of a new community dietetics service. Changes in health care professionals’ nutrition care practices were determined by examining community dietetics records. ONS prescribing volume and expenditure on ONS were assessed using data from the Primary Care Reimbursement Service of the Irish Health Service Executive. Results: Seven out of 10 principal GPs participated in the nutrition education programme. One year later, screening for malnutrition risk was better, dietary advice was provided more often, referral to the community dietetics service improved and ONS were prescribed for a greater proportion of patients at ‘high risk’ of malnutrition than before (88% versus 37%; P < 0.001). There was a trend towards fewer patients being prescribed ONS (18% reduction; P = 0.074) and there was no significant change in expenditure on ONS by participating GPs (3% reduction; P = 0.499), despite a 28% increase nationally by GPs on ONS. Conclusions: The community dietetics intervention improved ONS prescribing practices by GPs and nurses, in accordance with best practice guidelines, without increasing expenditure on ONS during the year after intervention.     

广东省社区卫生服务的理论与实践研究

本文对广东省1989年以来开展的社区卫生服务理论与实践探索进行总结,我们在全省6个市的17个社区建立了社区卫生服务中心,制定了开展社区卫生服务工作程序,总服务人群为18万多人。通过理论与实践探索,作者认为要做好社区卫生服务必须重视:高校参与,教育先行,加强全科医学教育;开展社区卫生服务的科学研究;发展信息管理与信息服务,开发《社区卫生服务管理与评价系统(软件)》;理顺社区卫生服务与初级卫生保健、全科医疗的关系;应用健康多维评价技术进行社区卫生服务的规划、实施与评价。     

Community-based early intervention: the Coimbra project (Portugal)

The Coimbra Early Intervention Project was undertaken to develop the first co-ordinated, multidisciplinary, interagency programme involving health care, education and social services, using existing resources in the community. The programme operates region wide and supports annually about 160 families and children with disabilities or at risk. Thirty-three per cent of the 601 children served so far had developmental delay, 22% belonged to high-risk families and 45% had risk factors and disabilities. In spite of difficulties, the programme success has increased awareness of the need to integrate and co-ordinate multiple community services and to develop legislation for the provision of early intervention services.     

Peer audit and community dental health services

Dentists and patients are becoming increasingly aware of the need to ensure highstandards of care. This awareness is just as true of practitioners working within community dental services as in general dental practice. The paper discusses peer review as a form of audit and then goes on to describe such a programme of clinical evaluation in one particular community dental health service.     

Leg ulceration and ethnicity: a study in west London

Little is known of the influence race has on the development of leg ulceration, with most studies being performed in almost exclusively white populations. As part of a wider audit of leg ulcer services, health care professionals were contacted to give details of age, sex and ethnic background of all patients who attended for treatment of leg ulceration over a one year period in an area of west London. West London Health Care Trust provides services to a population of 275000 of whom 53000 have an ethnic background from the Indian subcontinent (South Asian).In all, 280 patients were identified, of whom 264 (94%) had details of age and sex. This gave a crude ascertainment rate of 1.02 per 1000 population. Of the 264 patients, five were classified as South Asians, with one patient classified as Afro-caribbean. The Mantel Haenzsel test demonstrated a significantly higher proportion of whites suffering from leg ulceration than South Asians, giving an odds ratio of 4.43, with 95% confidence intervals between 1.94 and 10.13 (P=0.0004). The expected frequency of South Asian patients should be 23, based on rates from the white population, of which 13 would be women and 10 men. Only five South Asian men were identified, and no Asian women with leg ulceration.Reasons for this low ascertainment are two-fold. Either there is a real difference between the white and South Asian populations, or South Asian patients are not presenting for treatment. Further work must be performed to determine whether this is an effect of low prevalence, or unmet need in the community.     

Community mobilization as an HIV prevention strategy: challenges and obstacles (South Africa)

This paper explores on the challenges and obstacles confronting the Mothusimpilo Project, a program designed to develop ways of responding to HIV/AIDS in a gold mining community in South Africa. The project utilized participatory approaches to promote active involvement of local groups and the community in designing and implementing the program. It employs 3 full-time workers who were recruited locally. The 2 major components of the program include improved prevention of sexually transmitted diseases and community-based condom distribution and peer education, whose particular targets involve migrant mine workers, commercial sex workers and the young people. It seeks to maximize community involvement through stakeholder management of the program and through grassroots involvement in program implementation. Despite the number of accesses in mobilizing the different components of the community, enormous obstacles, and challenges still remains. Some of these obstacles include poverty, women's lack of background of a male-dominated culture, and their sense of fatalism, which reduces their motivation to protect their sexual health.     

Volunteers’ Experiences Delivering a Community-University Chronic Disease Health Awareness Program for South Asian Older Adults

Volunteers and voluntary organizations can connect preventative health care programs to communities and may play an important role in addressing the health needs of older adults. Despite this, tensions may exist in the structures that drive volunteers and voluntary organizations representing immigrant communities to provide unpaid labour to augment and supplement health care services. Furthermore, organizational challenges may exist for community agencies relying on volunteers to sustain a health screening and education program. The intervention program was led by one voluntary agency specifically for South Asian communities in partnership with the university and five local organizations. This paper draws on volunteer surveys (n?=?22) and key informant interviews (n?=?12) to detail volunteer experiences providing this intervention. Volunteers were university students and other community volunteers. A total of 810 adults participated in the intervention within the Greater Toronto Area, Ontario, Canada between October 2014 and June 2016. We found that volunteers often used their experience as a ‘stepping stone’ position to other education or work. They also gained from the knowledge and used it to educate themselves and their family members and friends. This paper provides a critical reflection on the role of volunteers in a preventative and educational healthcare intervention program for older adults from the South Asian community. Tensions exist when relying on volunteer labour for the implementation of preventative community health care programming and must be explored to ensure program sustainability as well as equity within the health care system.     

Promoting screening for cervical cancer: realising the potential for recruitment by general practitioners

This paper explores the potential for general practitionersto promote screening for cervical cancer and describes one exampleof an effective general practitioner-based (GP-based) programmeto improve community screening rates. The GP-based programmewas designed to improve general practitioners' involvement inrecruiting women in their communities to have Pap smears. Theaim was to raise doctors' awareness of the fact that many womenare not adequately screened, to encourage them to consider whythese women are not being recruited, to assist them to developstrategies to overcome these problems, and to support them inthe use of these strategies by providing information and resources,feedback on performance, and peer support. The effectivenessof the GP-based programme was assessed as part of a multi-centretrial to compare the differential effectiveness of three community-basedstrategies to promote screening for cervical cancer: a televisioncampaign, a television campaign combined with personally addressedletters sent to all women in the community, and a televisioncampaign combined with the GP-based programme. Each interventionwas delivered to three postal regions in New South Wales, Australia,and time-series data on Pap smear rates were obtained. Threecontrol regions were included for comparison. Of all three strategies,the combined television campaign and GP-based programme hadthe most potential, with up to an additional 8% of previouslyunscreened women being screened during each quarter of the combinedtelevision campaign and GP-based programme. This compares withscreening of 2–4% of previously unscreened women in associationwith television combined with letters, and only 1–3% ofpreviously unscreened women when television was used alone.However, the impact of the GP-based programme was highly variable.This variation in effectiveness points to a need for furtherresearch to determine the general practitioner, community andprogramme factors associated with programme success.     

'Holding it lightly': the co-operative inquiry group: a method for developing educational materials

SETTING: The purpose of this research was to adapt the World Health Organization's educational programme Mental Disorders in Primary Care for South African general practitioners. AIM: This paper describes how to organise and facilitate a co-operative inquiry group as a form of participatory action research aimed at developing or adapting educational materials. Specific quality criteria for this type of action research are defined. The experience of our own co-operative inquiry and the lessons learnt are discussed. CONCLUSION: In the field of medical education participatory action research methodology is relatively new. This article shows how the co-operative inquiry group can be used effectively to develop educational materials. It is intended to encourage and support others in using similar methods of action research in their own settings.     

社区180例冠心病患者危险因素调查分析

目的调查分析社区内冠心病的各种危险因素,提高认知率,为控制和预防冠心病提供一定的科学依据。方法利用天津市红桥区社区医院下社区健康普查及临床病例随访收集资料;依据冠心病的诊断标准,确定180例社区冠心病患者为研究对象。结果社区冠心病患者男性占56.7%,女性占43.3%。高血压(60.0%)、高血脂(57.8%)、高盐饮食(78.9%)、糖尿病(36.7%)、肥胖(32.2%)、吸烟(28.9%)、饮酒(25.0%)、缺乏运动(28.3%)、心理因素(29.4%)、家族史(27.8%)为冠心病的危险因素。结论社区冠心病患者多有不健康生活饮食方式,高血压、高血脂、高盐饮食及糖尿病、肥胖是该社区居民冠心病的最主要危险因素,应实施有针对性的干预措施。