The assessments of patients aged 75 years and over that were built into the 1990 contract for general practice have failed to enthuse primary care teams or to make a significant impact on the health of older people. The lack of an evidence base for these checks, and the absence of any training programme for practice staff involved in the assessment of older people, both appear to be important factors contributing to the failure of this approach. Alternative methods for improving the health of older people who are living at home are being sought. This paper describes the use of a model of community-oriented primary care (COPC) to initiate innovative care for older people in four exemplar practices in an inner-city area of London. Pump-priming funding was supplied for a 2-year period by one health authority, with the proviso that all innovation must be self-sustaining. The project was supported by an academic department of primary care, which promoted discussion about objectives and priorities, provided the evidence base for interventions considered by the practices, supported staff and created an evaluation framework, but avoided any prescriptive intervention in the process of innovation. All four practices have successfully identified different problems that need attention in their local populations of older people, and developed different projects focused on particular needs among older people. The effectiveness of the COPC method in promoting change in these practices was sufficient for the health authority to fund a second stage, extending the method to 40 practices over a 2-year period.

The aim of the study was to obtain information about factors that contribute to the maternal competence of first-time mothers when the child is 3 months old. Data collection was by structured questionnaires. The sample consisted of 271 first-time mothers, who completed the questionnaires when their infants were 3 months old. The multivariate method used was a stepwise regression analysis. According to multivariate analysis, seven predictors remained in the model to explain maternal competence. The better the mother felt about succeeding in child care, the more balanced was her state of mind, and the more cheerful and easy-going the child was, the greater was the mother's competence. Younger mothers, those who received more concrete support from members of their social network and those who were more attached to their child showed better competence. Those mothers who received more guidance on breastfeeding from public health nurses also showed greater maternal competence. The research findings suggest that important factors that contribute to the maternal competence of first-time mothers include maternal resources, social support received from those close to the mother, and guidance on breastfeeding from public health nurses.

This paper is concerned with how roles within one group general practice are perceived to have been affected by the introduction of the nurse practitioner into the primary health care team (PHCT) for a 2-year pilot period. The data presented are from data elicited during a single round of interviews with patients ( n = 30) and two rounds of interviews with all medical and nursing staff within the primary health care team on two occasions (40 interviews). The patient interviews were undertaken in the first year of the study, and interviews with staff were undertaken within 6 months of the commencement of the study and during the final 6 months. The overall aim was to evaluate the feasibility of the role and its possible future application to other primary health care settings. This paper will discuss the findings of that aspect of the study relating to the effects on role boundaries between doctors and nurses, and between nurse practitioner and nurses, midwives and health visitors in the practice as perceived by the patients, nurses and doctors involved. The nurse practitioner in this particular practice was a very experienced practice nurse with a wide range of knowledge and skills which she brought to the nurse practitioner role. This, together with well-organized teaching and supervision in the practice setting and a structured programme of formal education, resulted in a highly effective practitioner who was generally seen to have blurred the boundary lines between medical and nursing roles.

Exercise promotion schemes often fail to keep people exercising after the first few months. However, schemes that promote walking have been associated with longer-term adherence to exercise. Health Walks is a community-based exercise programme that emphasizes brisk walking activity. In the first year of an important new scheme in the Thames Valley, over 700 people took part. A survey was designed to determine the motivation of the participants and the benefits of the scheme. It was mailed to all of the participants in the scheme, of whom 48% replied. The evaluation found that 90% of participants said that they would continue walking on the scheme. In addition to physical fitness, the countryside and the social aspects of the walks were important motivating factors. The majority of the participants were women, in higher social classes and over 50 years of age, indicating the efficacy of this type of activity for older participants. The average number of walks taken each month was only three, yet participants perceived that there were health benefits. This may be due to the additional exercise which participants engaged in outside the organized scheme. Over half of the participants said that they were doing more walking, in addition to the Health Walks, and relied on their car less for short journeys. Primary care groups and trusts only need to provide minimal support to develop and co-ordinate walking schemes, in contrast to traditional exercise prescription schemes. Further research is needed to examine whether ‘walking for health’ schemes encourage people to adopt healthy lifestyles.

Employment initiatives for people who have experienced mental health problems offer development strategies that could be seen to match the philosophy and circumstances of mental health services in developing countries. Simple strategies to develop employment initiatives with a strong emphasis on self-reliance would appear to fit with current thinking on the promotion of mental health in developing countries (Üstün and Jenkins, 1998). The need for effective models to act as exemplars for programme development has been noted (Üstün and Jenkins, 1998). There are numerous models of employment rehabilitation detailed in the literature that might offer ideas for direction and development, but much of the research has been focused on Western European and North American models. Little attention has been paid to such schemes in developing countries, and therefore what is required is a project to identify emerging and innovative models of employment rehabilitation at a global level. The insights gained would assist in the development of guidelines for working with existing organizations in supporting and promoting good practice in developing countries. Development projects do not take place within a sociocultural vacuum, and indeed their success or failure is inextricably linked to social structures and social interaction. This paper sets out a research agenda for understanding and evaluating employment projects using the concept of ‘social capital’ as a framework.

This paper describes a pilot study to evaluate the effectiveness of a school-based parenting programme combining the use of both affective (related to feelings) and behavioural strategies. In this paper we describe the intervention, its evaluation and a summary of the quantitative information gathered. The three pre-eminent ways in which parents appeared to have benefited from this particular programme included (1) the support they received in their parenting role from other parents, including a mirroring of problems, (2) the regaining of a sense of control in the parental role, in part through an increase in their capacity to think about matters calmly, and also through the provision of new tools with which to do the job of parenting, and (3) an increased ability to empathize and identify with their children, and a better understanding of the factors which motivate children to behave in particular ways. The capacity to think about matters calmly and the ability to empathize and identify with children appeared to be important factors in the reduction of inappropriate and unhelpful parenting practices such as shouting and smacking. It is suggested that empathy in particular is central to effective parenting, and that these results support the suggestion that there is an important added benefit for parents from programmes which combine behavioural and affective strategies focusing on feelings, relationships within the family, and the parents' own experience of being parented. The limitations of the data are discussed with reference to its reliability and validity, and the need for further research using grounded theory with other groups of parents.