To describe conceptions of daily life in men living with a woman suffering from chronic obstructive pulmonary disease (COPD) in different stages of the disease.

A chronic disease like COPD affects not only the person living with the illness, but also the spouse. Significant tasks and demands are placed on husbands. COPD has for a long time been considered more a man's disease than a woman's disease, but according to new evidence COPD is a vast problem in women, which requires support from their spouses. The literature review did not reveal any previous studies concerning conceptions of daily life in men living with women suffering from COPD in different stages.

A phenomenographic study was conducted. Data were collected from October 2008 to October 2009 through semi-structured interviews with 19 men living with a woman suffering from COPD.

Two main descriptive categories were found: (1) unchanged life situation where no support was needed; (2) changed life situation related to severity of COPD, where support was needed. The categories were described from the perspective ‘ME and my spouse’. Even in their caregiving situation, the men continued with their own life and activities and did not put themselves in second place. No support was needed from healthcare or municipality when the women had mild COPD, but this changed when the COPD progressed. The men felt that daily life was burdened, restricted and the partner relationship was affected, even if the disease had not reached the final stage. The COPD forced them gradually into a caregiving role, and their daily life changed. They become more of a caregiver than a spouse. The men experienced lack of knowledge and support, and they felt that health professionals and municipality did not care about them.

Rural Health Clinics (RHCs) are primary care clinics certified through Medicare and Medicaid to provide health care to the medically underserved in rural areas of the United States. The purpose of this paper is to describe how the characteristics of RHCs have either changed or remained stable over a 10-year period in the past: from the late 1990s to 2007. In addition, it is also to describe some of the outstanding needs of RHCs as they navigate the transitions of U.S. health care reform.

Using a panel of RHCs continuously in existence from 2006 through 2007, we calculated and compared statistics with corresponding statistics from the literature. We described the geographic distribution of RHCs, demographics of their counties of location, and characteristics of RHC structure and staffing. We also explored the implications of the recently enacted health reform law (the Patient Protection and Affordable Care Act or ACA) for RHCs, and the improvements that RHCs need as it is implemented.

By the end of the study period, the highest percentages of RHCs were in the South and Midwest, the percentage of RHCs in the West had grown, and that in the South had declined. RHCs served counties with increasing proportions of individuals below poverty and Hispanics/Latinos. The percentage of independent clinics had grown, as had the percentage of for-profit clinics. Finally, the percentage of nurse practitioner full-time equivalents had grown as a proportion of the total for three providers.

In investigating the performance of RHCs, many managerial and operational factors are not well understood. It is imperative that RHCs gather the information that could help them maximize the elements of their performance that would keep them financially stable. In addition, a broader awareness of the unique challenges that RHCs face in this era of health care reform is needed.

Patients with obesity are at risk for treatment avoidance and nonadherence. Factors that contribute to engagement in primary health care for patients with obesity are not fully understood.

The purpose of this pilot study was to identify issues associated with engagement in primary health care for patients with obesity.

Using qualitative methodology, 11 patients with a mean body mass index of 40.8 kg/m2 registered with a primary health care practice were interviewed. Conventional content analysis was used to identify factors that contribute to engagement in primary health care.

Barriers and facilitators to engagement in primary health care were categorized into the following themes: availability of resources, importance of the relationship, meaningful communication, feeling judged, lack of privacy, poor communication and limited provider knowledge about obesity.

Obesity was identified as a health condition that requires additional considerations for patient engagement in their health care.

This study aimed at exploring the experiences of primary health-care providers of their encounters with patients with type 2 diabetes, and their preferences and suggestions for future improvement of diabetes care.

Barriers to good diabetes care could be related to problems from health-care providers’ side, patients’ side or the health-care system of the country. Treatment of patients with type 2 diabetes has become a huge challenge in Oman, where the prevalence has increased to high levels.

Semi-structured interviews were conducted with 26 health-care professionals, 19 doctors and seven nurses, who worked in primary health care in Oman. Qualitative content analysis was applied.

Organizational barriers and barriers related to patients and health-care providers were identified. These included workload and lack of teamwork approach. Poor patients’ management adherence and influence of culture on their attitudes towards illness were identified. From the providers’ side, language barriers, providers’ frustration and aggressive attitudes towards the patients were reflected. Decreasing the workload, availability of competent teams with diabetes specialist nurses and continuity of care were suggested. Furthermore, changing professional behaviours towards a more patient-centred approach and need for health education to the patients, especially on self-management, were addressed. Appropriate training for health-care providers in communication skills with emphasis on self-care education and individualization of care according to each patient's needs are important for improvement of diabetes care in Oman.

Primary care patients are commonly worried about their complaints when consulting their doctor. Knowing the reasons behind patients’ worries would enhance consultation practices. The aim of this study was to find out the reasons patients themselves give for their worries before a consultation and for possible relief or persistent worry after the consultation.

Our previous study using quantitative methods suggested that worried patients were uncertain about what was wrong with them and they perceived their complaints as serious. These results left some aspects unanswered; for instance, why did the patients consider their complaints severe.

We conducted semi-structured interviews of patients, aged 18–39 years, with somatic complaints other than a common cold (n = 40), both before and after a consultation, and the patients described their reasons for worry in their own words. These qualitative data were analysed using thematic content analysis.

The patients gave as reasons for their worries uncertainty, consequences of their complaints (eg, inability to work), insufficient control (eg, inadequate treatment) and prognosis. The patients were relieved when their uncertainty was diminished by getting an explanation for their complaint or when they achieved more control by getting treatment for their complaint. After a consultation, their reasons for worry, except for concern about the ability to function, tended to be replaced by other reasons. Psychological consequences and mistrust in health care also played a role in persistent worry. Our findings offer support to the patient-centred clinical method in primary care. To address the patients’ worries properly, the GP should bring them up for discussion. Special attention should be given to worries about the ability to function, as they tend to persist even after a consultation.

The aim of this paper is to identify and descriptively map the key characteristics of the model of service delivery in operation, and to explore the user, carer and professional experience of service provision. This included an exploration of congruity and mismatch between the different stakeholder groups.

In the United Kingdom (UK), 15% of the children under five years of age and 20% of the 5 to 15-year age group are reported to have a complex long-term condition, with the likelihood of having a condition increasing according to socio-economic circumstances. An increasing number of young people with complex needs are now surviving into late adolescence and early adulthood. However, service provision for children with complex needs is an area that, nationally, has been underdeveloped.

An exploratory single-site case study was undertaken across one Primary Care Trust in the UK. Documentary and policy review were undertaken along with in-depth qualitative exploration. Eighteen in-depth interviews were undertaken with relevant stakeholders and professionals across the multidisciplinary teams. Families with children between 12 months and 16 years of age who have continuing complex care needs were invited to take part in an interview to give their views about the care they receive. Interviews focused on the family experience and understanding of the child's condition, transition between secondary and primary care, effectiveness of admission and discharge planning and the overall contribution of different professionals. Professionals were also asked about their experiences of delivering care.

This study highlighted issues of communication between professionals and with parents and children as a major factor in determining the quality of service provision. Key aspects relating to the model of service provision, namely, paucity of communication, interagency collaboration and the parent as health worker, are highlighted.

Parents experienced both health and social service communication challenges when seeking care for their child. These challenges can be located within a general systems theory and hierarchy approaches to understand the complexity of service provision.

This study aims to evaluate changes in the durations of English National Health Service prescriptions, as indicated by the volumes of unit doses supplied between 1998 and 2009, and consider relevant policy implications.

Around the world, countries are seeking to manage the increase in medicines prescribing. In England, many primary care organisations, using limited supporting evidence of cost-effectiveness and clinical improvement, have sought to restrict the number of dosage units on a prescription to 28 days supply. This is based on a conviction that this reduces wastage costs.

Prescription Cost Analysis (PCA) statistics for England for the period January 1998 to December 2009 were used to analyse trends in the average number of unit doses (tablets or capsules) supplied per prescription for 11 drugs supplied in 34 different presentations.

The changes in prescription lengths observed between 1999 and 2009 ranged from +4.2% in the case of Amoxicillin 500 mg capsules to −41.3% in the case of Levothyroxine 50 μg tablets. All but four of the medicines selected showed statistically significant negative correlations (r > 0.8, P < 0.001) between the year of prescribing and the prescription length. If prescription lengths had been the same in 2009 as they were in 1999, then 33 million fewer prescription items would have been written for the preparations in this analysis. This shift across a range of medications suggests a generalised change in prescribing behaviour. The full balance of benefits and costs associated with this trend, as expressed via drug wastage avoided, patient (in)convenience experienced, professional time costs incurred or saved and positive or negative health outcome impacts, is not known. Although this study does not provide a definitive answer favouring prescription duration individualisation as opposed to standardisation, the available evidence indicates that policies that rigidly favour 28-day standard periods may require review.

In this paper, we assess the degree to which the observed consistency in maternal health-care utilization can be accounted for by social and economic demand determinants at individual and household level on the one hand and community access to health services in terms of health, road and education facilities on the other.

Data from the three rounds of national family health survey of India (NFHS-1, -2 and -3) conducted in 1992–93, 1998–99 and 2005–06 are used in this analysis. The results of the analysis are presented in two sections. First, statewise profiles of maternal health-care utilization from NFHS-1, -2 and -3 are presented to compare the trends. Second, the influence of demand and access factors estimated from multi-level logistic regression models are presented for selected states of India.

Results reveal that inequalities in maternal health-care utilization by socio-economic status have narrowed because of the impact of complementing factors of greater community access, and social and economical advancement in the south Indian states, where overall maternal health-care coverage is at the top end of the scale. In contrast, in the demographically lagging northern states of India, which are at the bottom end of the health coverage scale, both access and socio-economic demand determinants indicate greater inequalities in maternal health-care utilization.

Lack of access to health care, slow progress in socio-economic conditions and cultural constraints are major determinants of poor maternal health-care coverage among Indian states.

The overall purpose was to develop, test and evaluate an educational package to help people with diabetes self-manage their risk of developing chronic kidney disease (CKD), one of the main complications of diabetes.

Management of people in primary care who have both CKD and diabetes can be controlled by strict blood pressure (BP) and blood sugar control and advice on lifestyle changes, such as smoking cessation. However, there is little evidence to support the assertion that self-management can slow the rate of kidney disease progression.

A mixed-method longitudinal study. Development of the self-management package was informed by the findings of a case study in six GP Practices and also through interviews with 15 patients.

Testing of the self-management package was undertaken in the same six Practices, with one additional control Practice. Patients with Type 1 or Type 2 diabetes at risk of kidney disease were included. Outcomes in patients in the participating surgeries who did receive a pack (n = 116) were compared with patients in the control group (n = 60) over 6 time points.

At the end of the study (time point 6), the intervention group had a mean systolic BP of 4.1 mmHg lower and mean diastolic BP of 2.7 mmHg lower than in the control group.

Self-management techniques such as understanding of, and subsequent concordance with, prescribed BP medication may contribute to a reduction in BP, which in turn will reduce cardiovascular risk.

Relevance to clinical practice: This study contributes to the evidence base for self-management of early kidney disease. Although the exact reason for reduced BP in the intervention group is unclear, the importance of practitioner understanding of kidney disease management and patient understanding of BP medication are likely to be the contributing factors.

This case study describes how broker organizations supported a network of community-based services to work together to address the primary healthcare needs of recent immigrant families with young children.

In parts of Canada with low levels of immigration compared with large urban centres, service providers may need to collaborate more closely with one another so that cultural competencies and resources are shared. Providers within Atlantic Canada, with its relatively small immigrant population, were faced with such a challenge.

Social network analysis and qualitative inquiry were the methods used within this case study. Twenty-seven organizations and four proxy organizations representing other organization types were identified as part of the network serving a geographically bounded neighbourhood within a mid-sized urban centre in Atlantic Canada in 2009. Twenty-one of the 27 organizations participated in the network survey and 14 key informants from the service community were interviewed.

Broker organizations were identified as pivotal for ensuring connections among network members, for supporting immigrant family access to services through their involvement with multiple providers, and for developing cultural competence capacities in the system overall. Network cohesiveness differed depending on the type of need being addressed, as did the organizations playing the role of broker. Service providers were able to extend their reach through the co-location of services in local centres and schools attended by immigrant families and their children. The study demonstrates the value of ties across service sectors facilitated by broker organizations to ensure the delivery of comprehensive services to young immigrant families challenged by an unfamiliar system of care.

This paper aims to explore and analyse mental healthcare staff's (MHCS) knowledge and experiences of diabetes care for persons with psychosis.

There are a range of studies concerning the increased risk of type 2 diabetes mellitus among persons with psychosis, and the need for healthy lifestyle interventions to prevent the illness. MHCS are often trusted and have regular follow-ups with the patients, and their attitudes and actions often play an important role for the person's care behaviour. There is still little documentation of their experiences of diabetes care.

A qualitative, explorative design was used, collecting data through semi-structured interviews with 12 MHCS working in psychosis outpatient care in Sweden. Data were analysed with qualitative content analysis.

Three categories emerged and provide a deeper understanding of how staff were aware of the risks of type 2 diabetes among their patients and therefore performed lifestyle interventions to promote these. Nevertheless, they lacked knowledge of diabetes care and simultaneously felt a lack of training among diabetes nurses to adapt diabetes care to suit persons with cognitive dysfunctions. Patients who were overconfident in their ability to manage diabetes care reported to have experienced most difficulties. Cooperation among those involved in these persons’ health was considered necessary.

Diabetes care for persons with psychosis could improve if knowledge of type 2 diabetes was increased among MHCS and training in how to adapt diabetes care to persons with cognitive dysfunctions was enlarged among diabetes nurses. A challenge for nurses is to see how the care of different illnesses and support given by the family and others affect the persons total life situation and health. Healthcare plans and cooperation among all those involved in these persons’ health is necessary for this.

Subclinical hypothyroidism (SCHo) is a common biochemical diagnosis in older age. Evidence of impact is inconclusive and guidelines are inconsistent. With increasing numbers of thyroid function tests (TFTs) performed, GPs frequently have to make management decisions regarding this diagnosis. However, little is known about how SCHo is currently being managed in primary care.

To explore management of SCHo in primary care and GP reported rationale for treatment of SCHo in older individuals.

Descriptive study using retrospective case note review and GP survey.

Nineteen General Practices, Central England, UK.

Follow-up of a large cohort with subsequent detailed review of individuals for whom therapy had been initiated following diagnosis of SCHo. Data on practice policies, and rationale behind treatment were collected via GP questionnaire.

Forty-two individuals were treated following identification of SCHo. Factors regarded as supporting instigation of therapy recorded by practitioners included symptoms, a positive antithyroid antibody test and history of radioiodine therapy. In all, 55% were registered at 3/19 practices suggesting significant between practice variation. Reasons for testing included chronic disease check-up (n = 14), presenting ‘thyroid symptoms’ (n = 5) and presenting other symptoms (n = 9). Reasons for therapy initiation were only recorded in 26 cases and included presence of symptoms, persistently high or increasing serum thyroid stimulating hormone concentration and patient request. Only 2/15 GPs reported having practice guidelines on management.

Results suggest that GPs are uncertain how to interpret symptoms and TFT results in older individuals. There is considerable variation in management of SCHo between GPs with some GPs treating patients outside of all guideline recommendations.

To explore how an organization's trust in the cultural competency of other service providers (competence trust) can influence the effectiveness of a services network in meeting the needs of recent immigrant families.

Primary health care for recent immigrants arriving in Canada is delivered through a network of community-based services. To ensure the functioning of the network and its ability to facilitate access to needed services for new arrivals, network members need to be able to work together collaboratively. A case study involving services for an urban community in Atlantic Canada was undertaken in 2009 to explore how service organizations worked together to address the needs of recent immigrant families with young children. This paper focuses on provider perceptions of cultural competency among local service organizations and how this influenced trust and desire to work together for the benefit of families.

The case study utilized both social network analysis and qualitative inquiry methodology. Twenty-one of 27 selected organizations responded to the online social network survey, and 14 key informant interviews were conducted. Social network measures and network mapping were used to demonstrate trusting relationships and associated interactions, while interview data were used to explain the relationships observed.

Perceived cultural competency affected the degree of trust and collaboration within the services network when addressing the needs of recent immigrant families. Competence trust toward other providers increased the desire and commitment to work together, while lack of competence trust created avoidance. Non-government organizations were identified among the most culturally competent. The perceived positive and negative experiences of families with different providers influenced the level of trust among network members. The development of systemic cultural competences within a services network is needed in order to improve collaborations and access to services for immigrant families.

We investigated whether the risk estimates of General Practitioners (GPs) and their treatment decisions mutually influence each other and whether factors not related to the patient's risk, such as the gender and length in clinical practice, interact.

The quantitative assessment of the absolute risk of developing coronary heart disease (CHD) and the decision to start treatment with lipid-lowering drugs are crucial tasks in the primary prevention of CHD.

Nine clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to three groups of 90 randomly selected GPs in Stockholm. One group (R) was asked to estimate the risk of CHD within 10 years on a visual analogue scale. A second group (R + D) was asked to estimate the risk and to specify whether they would recommend a pharmacological lipid-lowering treatment. A third group (D) only to indicate whether they would recommend treatment.

Response rate ranged from 42.2% to 45.6%. The median risk estimates were higher in the R group than in the R + D group (difference not statistically significant). R + D group showed higher proportions of correct decisions to start treatment compared with the R group (86.2% versus 77.5%, P = 0.19). More correct decisions were made by female doctors (OR 1.77, 95% CI 1.19–2.61, P = 0.004) and by less experienced doctors (OR 0.97, 95% CI 0.95–0.99, P = 0.016).

The task of making CHD risk estimates and the task of making decisions whether to start lipid-lowering treatment do not seem to influence each other. The gender of physicians and the length of clinical experience seem to affect treatment decisions. Female GPs and less experienced GPs are more likely to make correct decisions. However, the relatively low response rate to the questionnaires may limit the generalizability of these results.

Seroprevalence study in Irula tribe of Marakkanam, Tamil Nadu State was carried out for certain bacterial (typhoid, syphilis and leptospirosis) and viral infection (hanta,hepatitis B and human immunodeficiency virus (HIV)).

Highest seroprevalence was observed for leptospirosis (61.1%) followed by, hepatitis B virus surface antigen (11.11%), syphilis (9.72%), typhoid (8.33%), hantavirus (6.9%) and HIV (2.77%).

The seroprevalence of leptospirosis and hantavirus may be attributed to their professional exposure to rodent that they catch in the open field and the syphilis, hepatitis B and HIV prevalence may be related to their sexual behavior and social customs.

To explore the views of individuals recently diagnosed with type 2 diabetes in relation to self-management of dietary intake and physical activity, and to compare these with the views of health professionals (HPs).

Diabetes education has become a priority area in primary and secondary care, and many education programmes are now embedded within a patient's care package. There are few contemporaneous explorations of patients’ views about lifestyle self-management. Such research is vital in order to identify areas that require further support, refinement or enhancement in terms of patient education.

Focus groups were held with patients recently diagnosed with type 2 diabetes (n = 16, 38% female, aged 45–73 years). In-depth semi-structured interviews were conducted with HPs (n = 7). Discussions focussed on self-management specifically in relation to making dietary and physical activity changes. All discussions were tape recorded, transcribed and analysed by emergent themes analysis using NVivo to manage the coded data.

Barriers were divided into six main categories: difficulty changing well-established habits, negative perception of the ‘new’ or recommended regimen, barriers relating to social circumstances, lack of knowledge and understanding, lack of motivation and barriers relating to the practicalities of making lifestyle changes. HPs generally echoed the views of patients. In conclusion, even against a background of diabetes education, recently diagnosed patients with type 2 diabetes discussed a wide range of barriers to self-management of diet and physical activity. The findings could help to provide HPs with a deeper understanding of the needs of recently diagnosed patients and may help refine current diabetes education activities and inform the development of educational resources.

To explore how well professional education and post-qualification clinical supervision support equips health visitors to deal with ethical tensions associated with implementing the public health agenda while also being responsive to individual clients.

Current health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This generates a number of public health-related ethical tensions.

Exploratory cross-sectional qualitative (interpretive) study using 29 semi-structured individual interviews with health visitors, practice teachers and university lecturers exploring how well health visitors’ professional education and post-qualification clinical supervision support equips them for dealing with these ethical tensions and whether they thought further ethics education was needed. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach.

Health visitors’ professional education did not always equip them to deal with ethical tensions, which arose from delivering public health interventions to their clients. However, the majority of participants thought that ethics could not be taught in a way that would equip health visitors for every situation and that ongoing post-qualification clinical supervision support was also needed, particularly in the first year after qualifying. The amount of post-qualification support available to practising health visitors was variable with some health visitors unable to access such support due to their working circumstances and pressures on staff time. Literature on the ethical tensions associated with evidence-based practice; public health ethics and ethics of care might be useful for health visitors in gaining greater understanding of the ethical tensions they face. This could be introduced as part of health visitors’ professional education or on post-qualification study days.

To identify the areas of daily function most affected by the introduction of Sativex, a cannabis-based medicine, and the impact on caregivers and people with multiple sclerosis (MS).

Cannabinoid medicines have recently become available on prescription in several parts of the world, principally for the treatment of spasticity in people with MS. Their efficacy and safety have been demonstrated in the setting of randomised controlled clinical trials. Results of such studies may not always reflect the wider effectiveness that a medicine shows when used in clinical practice.

A short questionnaire survey consisting mostly of multiple-choice questions, along with some free-text questions aimed at the patient and primary caregiver (ie, partner, mother, nurse or outside carer). The questionnaire was developed in consultation with a patient representative organisation, field tested, ethics approval gained, then distributed to prescribers in the United Kingdom, with the request that they in turn forward it to any patients who had received repeat prescriptions for Sativex within the previous 16 weeks. Patients were seen in both a primary care (general practice) and a secondary care (hospital) setting. There was no control group in this study. Most patients had MS, and the primary reasons for using Sativex were spasticity and pain.

The response rate was 57%, with 124 questionnaires returned. The majority of respondents and their caregivers reported improvements across a range of daily functional activities, alongside a reduction in the use of concomitant anti-spasticity medication and in the use of other healthcare resources.