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In recent years several factors have affected the public’s relationship with health care research: increased data protection legislation and the resultant consent requirements; access to unforeseen levels of both information and misinformation through mass media; and a growing culture of personal choice which may have eroded the perceived importance of activities whose benefits are societal rather than personal. This article considers these factors and their implications and highlights the need for health care researchers to engage more effectively with the public in order to ensure its continued support.
To evaluate an approach to multidisciplinary case management that is embedded in primary health care.
Case management has been advocated in order to coordinate health and social care for vulnerable elderly people and avoid unnecessary hospital admissions. However, it is unclear who should undertake this.
This case study reports on an approach developed in a semi-rural general practice in Cambridgeshire, UK, and later adopted locally. Data evaluated included practice records, minutes of project meetings over a three-year period and comments from members of the primary care team.
Key elements of the approach were a register of vulnerable people, regular inter-disciplinary meetings and administrative support to follow-up decisions. Practitioners from a range of health and social services participated. Of the 937 people aged 75 and over, 54 (5.8%) were registered as vulnerable, along with five who were younger. After initial efforts to identify those at risk, new registrations fell. Of these 59 patients, 39 (66%) were admitted to hospital over the three years and practitioners believed that the project had prevented admissions. The monthly meetings also enabled professionals from different services to share information, coordinate their work and learn about local services.
By adopting a systematic approach to sharing intelligence about those at risk, extended primary care teams are able to provide case management for the vulnerable elderly. This integrated approach also provides a forum for practitioners to learn about local services. However it involves a significant time commitment. There is a need for further research to assess the cost-effectiveness of the approach in preventing avoidable admissions and improving health and quality of life for older people.
This paper presents findings from an ethnographic study that examined how qualified district nurses’ conceptualized their role in relation to family carers and how they performed this aspect of their role.
A participant observational study involving fieldwork and in-depth interviews with six district nursing teams was undertaken over a 12-month period. Interview transcripts and fieldnotes were analysed by drawing upon the principles of dimensional analysis.
District nurses acted on the assumption that family carers would, by choice or default, provide care. Family carer support was conceptualized as a means of promoting self-care and the patient’s independence from nursing services. The rationale for providing family carer support was based largely on service capacity rather than on carer needs and preferences. Six characteristics of district nursing support for carers were identified: enabling, supporting, mediating, care substitution, crisis prevention and crisis intervention. Family carers were not recipients of district nursing support in their own right but were dependent upon the cared-for person receiving nursing care. This in turn was conditional upon others (general practitioners and hospitals) making appropriate patient referrals. Family carer support was also conditional upon effective communication and family carer receptiveness.
As the scope of home-based nursing continues to increase, district nurses need to take a more active stance in providing family carer support and adopt a family rather than patient-focused approach in order that family carers might be supported more effectively.
The chronic care model (CCM) has been widely used in a variety of health care settings to guide system improvement for chronic illness care, including diabetes care. However, the evidence base for the specific components of the model has not been systematically reviewed. This review aimed at examining the extent to which interventions featuring the CCM components improve diabetes care and determining the relative effectiveness of different CCM components.
We systematically searched MEDLINE (1966 to December 2004), the Cochrane Effective Practice and Organisation of Care and the Cochrane Controlled Trials Register to identify interventions featuring one or more system components of the CCM for diabetes care. Outcome measures included HbA1c, blood pressure and blood lipid control. We used random-effects meta-analysis and meta-regression for quantitative synthesis of data.
In all, 69 studies (43 randomized controlled trials and 26 controlled before–after studies) met inclusion criteria and were included in this review. Overall, included studies reported a mean reduction of 0.46% (95% CI 0.38, 0.54) in HbA1c, mean reduction of 2.2 (95% CI 0.9, 3.5) mmHg in systolic blood pressure, mean reduction of 1.3 (95% CI 0.6, 2.1) mmHg in diastolic blood pressure and mean reduction of 0.24 (95% CI 0.06, 0.41) mmol/L in total cholesterol. For specific CCM components, interventions that addressed delivery system design reported the largest improvements in patient outcomes, followed by those employing a self-management support component. Interventions involving decision support or clinical information systems reported relatively smaller effect sizes.
Interventions featuring CCM components for diabetes care produced small-to-moderate improvements in a range of patient intermediate outcomes. The findings support the concept of the CCM in which the state of development of various aspects of primary care service systems defined in this model appear to be important factors in the quality of care provided to people with diabetes.
To identify and quantify clinical features associated with a future diagnosis of type 2 diabetes, and to record pathways to the diagnosis of diabetes.
The risk of type 2 diabetes posed by particular symptoms is largely unknown, especially in unselected populations like primary care. The current mode and setting of diagnosis in the UK are undescribed.
This was a population-based case–control study in seven general practices in Bristol, UK. In this study, 105 cases with newly diagnosed diabetes, and 105 age- and sex-matched controls were studied. Their primary care records for two years before diagnosis were examined for symptoms previously reported to be associated with diabetes and for abnormal investigations. Differences between cases and controls were analysed by conditional logistic regression. In cases, the pathways to the diagnosis of diabetes were categorised.
In all, 42 (40%) adults with newly diagnosed diabetes were asymptomatic at diagnosis and 84 (80%) were first detected in primary care. Five clinical features were independently associated with diabetes in multivariable analyses. Likelihood ratios for these were: thirst 36 (95% confidence interval 3.0, 440), P = 0.005; weight loss 5.7 (1.3, 26), P = 0.022; skin infections 4.6 (1.7, 12), P = 0.002; fasting glucose >5.6 mmol/L 38 (2.2, 640), P = 0.012; and random glucose >5.6 mmol/L 15 (2.5, 94), P = 0.003. The median time period between the onset of symptoms and diagnosis was short (8 days) in patients presenting with thirst, but much longer for those with weight loss (294 days) and skin infections (463 days). Over a quarter of patients had raised blood glucose readings, which were not followed up in the two years before diagnosis was made.
Most patients with type 2 diabetes are diagnosed in primary care. Many are asymptomatic at diagnosis. Earlier diagnosis of diabetes may be possible by considering diabetes in patients with weight loss and skin infections, and ensuring that borderline abnormal tests are adequately followed up.
Knowledge is recognized as a crucial organizational resource, which it has been suggested, increases in value through use. However, tensions exist between applying generalized scientific and academic knowledge to practice and incorporating local, experiential and tacit understanding in our knowledge base for practice. Knowledge management and transfer are frequently advocated as the means to increase service capacity within existing resource levels. In the NHS knowledge management and transfer tends to adopt a social constructivist approach, which favours the application of scientific evidence to practice, consequently the tacit and experiential knowledge of practitioners and service users is often excluded from formal knowledge-transfer processes.
This paper describes a systematic process that was used to formalize tacit nursing knowledge in child and adolescent mental health (CAMH) and link it into the pre-existing scientific and academic literature.
The paper goes on to describe how this process was modified and transferred to work with parents of children referred to CAMH services.
The paper illustrates the differing strands of pre-existing scientific and academic knowledge valued by nurses and parents. It highlights how involving service users in identifying scientific and academic knowledge that they find useful can focus attention on strands of pre-existing knowledge previously overlooked by professionals and service providers and thus enhance the value of this knowledge as an organizational resource. The paper also demonstrates how the tacit and experiential knowledge of nurses and services users can be transformed into more formalized knowledge, which can then be incorporated into organizational knowledge-transfer processes.
As part of a replication study after the randomized controlled trial (RCTs) in the Netherlands, the impact was assessed on health services utilization and expenditure of two self-management programmes for older adults with osteoarthritis (OA) of the knee and hip.
Evidence-based patient education and exercise programmes, developed and tested in RCTs, are often insufficiently diffused among practitioners and primary healthcare providers and tend to have a modest reach in the population. Large-scale adoption in primary healthcare can be improved if programmes are feasible and effective in real life.
The programmes were conducted in real-life conditions by primary healthcare providers (local health centres, home-care providers, physical therapy centres). Pre-test/post-test data were collected for consultation of the general practitioner (GP), medical specialist, physical therapist, and for the use of OA medication, as well as for the expenditure for physical therapy and OA medication.
In total, 20 Knee and 20 Hip programmes were carried out by 18 providers. The Knee programmes were attended by 204 participants and the Hip programmes by 169 participants. Physical therapy and use of OA medication for both programmes and consultation of the medical specialist for the Hip programme decreased. No effect was observed for consultations of the GP. Expenditure for physical therapy and use of OA medication could not be assessed, due to difficulties to obtain sufficient reliable data from participating health insurers. Both programmes produced similar outcomes in real-life conditions compared to their RCTs. The implications are discussed as to accurate data collection on OA expenditure, future cost-utility and cost-effectiveness studies, and the large-scale implementation of the programmes in the Dutch primary healthcare system.
The aim of this paper is to explore school nurses’ experiences of teaching Sex and Relationships Education (SRE) as part of the primary school curriculum. In particular, it focuses on the questions that the children ask during the lessons and the strategies the nurses employ in managing those questions.
School-based SRE is an important aspect of children’s education. However, it is a highly politicised and controversial area, which is a matter of concern to a number of stakeholders. In the primary school setting, school nurses are commonly involved in delivery of the programme. Their input is particularly valued, because they are ‘specialist outsiders’ who create an environment that is conducive to discussion of sensitive topics. To date, there is little understanding of the skills that they employ in managing the educational needs of primary school children within the confines of a pre-agreed school curriculum.
Semistructured focus group interviews were conducted with small groups of school nurses from a single geographical location in the Midlands region of England. Data were analysed using a thematic analysis approach.
Data identified the ways in which the nurses viewed and responded to the children’s agenda, which was realised in the form of questions. In particular, it focuses on what they deemed to be inappropriate questions and the basis on which this label was applied. Five strategies for managing these inappropriate questions were identifiable from the data. Their deployment is explored in relation to the tensions implicit in the realisation of sexualised realities in a classroom setting.
To describe the research project component of the BSc in Primary Health Care and to discuss the issues faced by students and faculty in attempting to complete a student-led research project.
Medical schools increasingly expect medical students to undertake research as part of intercalated BSc’s or in self-selected study modules. This research has historically been laboratory based, ‘piggybacking’ onto existing projects. Projects initiated by students themselves and studies in primary care or community settings are more unusual.
A qualitative study, based on interviews with students and examiners, triangulated with data from the peer review process and personal observations on the running of the course.
A London medical school, running an intercalated BSc in Primary Health Care.
We interviewed 24 of 26 students and two external examiners during the interview period of the study. Students successfully undertook research, from initial question through to publication. Overall, 90 dissertations were completed since 1997, of which half used a qualitative methodology (45/90). Ten projects have subsequently been published; there were also 16 conference presentations and 6 research letters. Themes from the interview data include: the students’ strong sense of project ownership, the difficulties of being a novice researcher, the difficulties posed by the research governance hurdles, the beneficial and for some students adverse impact (stress and coping with unsuccessful projects) and finally, the impact on their careers.
Students gain considerably from this learning process, not only by undertaking their own research, but they also gain in terms of acquisition of transferable skills such as critical appraisal and improved self-directedness. Project completion and publication rates suggest that programmes developing undergraduate initiated research projects can be as successful as those for other novice researchers. The student-led project is a fragile endeavour, but currently is sustainable.
This study was part of a major project studying the metabolic syndrome in Finnish men. The final sample composed of 273 (39%) men who voluntarily completed the Health Behaviour Questionnaire.
To identify key determinants of health behaviour and health beliefs in middle-aged men, and to analyse how they are associated with underlying health covariates.
A stepwise logistic regression model was used to estimate the adjusted odds of the outcome by socio-demographic, health-behaviour, health-belief and clinical factors.
Five models were developed: (1) use of medications, (2) alcohol consumption, (3) self-rated health status, (4) burnout, and (5) motivation to change unhealthy behaviours. Existing illness or injury and occupation had the strongest associations with medication use, in which industrial workers were more likely to use medications than office personnel. A positive association was found between alcohol counselling by family members and less use of alcohol. Lack of illness or injury, good dental health, and normal waist circumference had the strongest associations with perceived good health. Depression and insomnia were the most significant predictors for burnout. Men who exercised 4–7 times a week, or who used alcohol infrequently or not at all, were over two times more likely to be motivated than inactive men.
Many relevant predictors that were significantly associated with the selected key determinants of health behaviour and health beliefs of middle-aged men were found in this study. The promotion of regular physical activity and healthy lifestyles among middle-aged men is currently one of the most important priorities of preventive work in primary health care. More gender-specific studies are needed to obtain a deeper understanding regarding men’s health issues.