Links between homelessness and ill health are well established. However, homeless people are less likely to access traditional health care due to administrative barriers and hostility of professionals. For this reason more flexible modes of health care delivery, including nurse led care, have been explored. There has been a rapid increase in innovative nursing roles over the last two decades and the literature suggests that a clear role definition, good interprofessional working and supportive cultures are some of the features which ensure role effectiveness. A large study exploring new roles in nursing and midwifery in Northern Ireland identified an innovative nurse led approach in meeting the needs of single homeless people. The aim of this paper is to explore the effectiveness of this role using a public health framework. A case study design was used incorporating semi-structured interviews with analysis of secondary sources and a period of observation. Results demonstrated that the role fitted within a public health framework in that it involved assessment of need, skills to meet need, facilitation of access to care, partnership working, health promotion, health protection and influencing policy, and strategy development. The conclusion is that the role met the set criteria for innovative nursing roles. Furthermore, this practitioner meets the criteria for advanced nursing practice, providing evidence of effective nurse led care that meets the health agenda of targeting inequalities in health.

The aim of this article is to illuminate participants' access, utilization and perceptions of primary health care (PHC) services in two cities in England, including factors that militate against or enhance utilization of PHC services for African Caribbean people residing in England. Hypertension remains a major health issue amongst immigrant and UK born African Caribbean people. Current policy agendas are concerned with a reduction in cardiovascular disease and with addressing social exclusion, ameliorating health inequalities, and ensuring that individuals from black and minority ethnic groups receive fair and equitable access, care and treatment. The research conducted in two English cities investigates the meaning and consequences of hypertension and perceptions of PHC services. The research explored the decision making processes that lead to the presentation of individuals in PHC in England for early diagnosis and treatment. This qualitative study draws heavily on the focused ethnography methodological approach. Multiple methods were employed including two focus groups interviews, 21 semi-structured interviews and five vignette-based interviews. Participants numbered 36 in total. Data were analysed with the aid of Atlas/ti. using established principles for analysing ethnographic data. The findings map out the factors influencing early presentation for diagnosis in PHC and perspectives are gained on the quality of the participant/general practitioner (GP) relationship, as perceived by the participants. Participants' satisfaction and dissatisfaction with PHC services are also evidenced. It is relatively common in English communities of African Caribbean origin to use private PHC services. Motivations for this are evidenced, including historical antecedents. Participants used non-concordance (ie, non-compliance with prescribed medications) and traditional Caribbean herbal remedies as strategies of empowerment.

Excessive drinking is a global health problem which is responsible for a wide range of both chronic and acute illness, and which costs the UK National Health Service (NHS) £1.7 billion annually. Current health policy aims to reduce alcohol-related problems by promoting early identification of risk followed by brief intervention to facilitate positive changes in drinking level or patterns of consumption. However, practical and philosophical barriers concerning screening and brief alcohol intervention have so far impeded its uptake in routine primary care. This qualitative study aimed to simultaneously explore and compare health professionals’ and patients’ views on the acceptability and feasibility of screening and brief alcohol intervention in primary care. Focus groups were held with (a) four primary care teams, (b) two general practitioner (GP) and two nurse groups and (c) six patient groups in the north-east of England. A thematic framework approach was used to analyse audio-taped data via transcripts. Both health professionals and patients reported that raising and discussing alcohol-related risk was acceptable in primary care, when combined with other lifestyle issues or linked to relevant health conditions. Targeted rather than universal screening was the most acceptable method of identifying alcohol-related risk and would fit well with existing practice. However, there was uncertainty among health professionals about the effectiveness of brief alcohol interventions and some disagreement with patients concerning who was best placed to deliver them. Health professionals felt that nurses were best placed for such work whilst patients reported that they would initially raise the subject with GPs. There was broad acceptance of brief intervention approaches but a lack of support and specific incentives for this work impeded its delivery in routine practice.

This paper presents developments in evidence-based nursing practice in Botswana, Africa. Issues pertaining to evidence-based practice in community health such as the role of research, the digital divide between African countries and developing countries, and evidenced-based nursing curricula are discussed. The role of globalization in capacity building in evidence-based practice is emphasized. Recommendations for addressing challenges faced by some African countries, including Botswana in implementing evidence-based nursing practice are made.

This article reports on the implementation of community-based prevention of dementia among older adults in Japan. It is expected that the incidence of dementia will continue to increase as the population ages and thus care of those at risk of and with dementia is an important issue for nursing practice in the community. Community-based prevention of dementia comprises a comprehensive range of activities such as obtaining an understanding of community residents, early detection of dementia, fostering of volunteers, implementation of dementia prevention activities, provision of nursing care for older adults with dementia, as well as collaboration with local administrative institutions. We are working with a Japanese community (population of 65 years or more: about 2480 out of a total population of 10800) and in this article our activities are described. Among our activities we focus on itemizing the signs of dementia for early detection of the disease and on fostering volunteers. For early detection of dementia it is important to itemize the signs of dementia that close family members would notice in daily life. For fostering of volunteers it is necessary to enable them to develop skills to provide activities/clubs to interest the older adults and which are effective for prevention of dementia. We have started with clubs including a personal computer club, children's songs club and a picture mail club. Such activities are important strategies for a community-based intervention. The article concludes with reference to the need for verification studies to evaluate the impact of the community-based approach to the prevention of dementia outlined here which includes anticipatory education of the population concerning dementia, development of a method of early detection of dementia using a check-list and a means of secondary prevention via the activities of a group of volunteers (Ichigo Kai).

This paper reports on the contribution made by the first cohort of Primary Care Graduate Mental Health Workers (PCGMHW) employed in the Southwest of England. The PCGMHW is one of the new roles envisaged as part of the NHS plan. Aimed at enabling quick access to a range of time-limited therapies, while at the same time engaging in public health strategies to promote mental health in communities, the PCGMHW is at the cutting edge of modernizing primary care mental health. This study demonstrated that PCGMHWs trained in time-limited therapy approaches such as facilitated self-help moved quickly into situations were they were treating people with mild to moderate mental health problems, with evidence of clinical effectiveness. However, the community development aspect of the role was slower to develop, possibly as a reflection of the preference for one to one work in mental health or, alternatively, as an indication of the nebulous nature of public health work. The study identifies a number of key areas for consideration. First is the role of the PCGMHW in signposting people to services or resources. Second, the role of referral protocols in developing service models that profit from the presence of PCGMHWs. Third, the need to develop the role in relation to public health, stigma and social exclusion. However, to achieve this greater clarity over the role is required in Primary Care Trusts and urgent consideration of continuing professional development needs of PCGMHWs.

Partnership working, engagement and participation of service recipients and providers are issues at the core of UK and international health and social care policies. Although always considered desirable, recent legislation makes this practice a legal imperative in England. However, the operationalization of the concepts pose a number of challenges. This paper draws on evaluative data to examine how these concepts were addressed within one of the largest health action zones (HAZ) in England. The research took a generative perspective and was intended to promote learning, deepen understanding, model actions and consequences, and to provide a guide to decision making. Three approaches of theories of change, pluralistic evaluation and soft systems methodology were combined in the research design. Data was collected through 39 individual tape-recorded interviews with people involved with HAZ at both strategic and operational levels. The findings allowed partnership and engagement activity to be categorized into two domains, those that led to entrenchment in old practices and those that facilitated engaging with a partnership and community involvement ethos. By making the facilitating and inhibiting variables more explicit, the potential for working to a partnership philosophy is enhanced.

Eating disorders are a crippling and disabling condition. If they become chronic, the emotional, physical and social effects are substantial. The death rate is the highest of all psychiatric illnesses so the need to find prevention strategies is urgent. This research project has three aims, primary prevention of an eating disorder for the child, helping the mother recover and developing a protocol for a group to be used in primary care. Children of mothers with an eating disorder, are a proven ‘at risk’ group, because children model and internalize their experiences. This project was carried out in a community setting, targeting mothers with an eating disorder who had children under the age of 13. It was argued that if these mothers can be encouraged to change the dysfunctional behaviour they may be passing on to their children, an attempt can be made to break the cycle. This qualitative research pilot project utilized semi-structured interviews before and after 11 weeks of group therapy, with three- and six-month follow-ups. Although the sample was small, the results showed that a group allowed these mothers a safe space for reflection, enabling them to become aware of their behaviour. As a result the mothers implemented changes in response to their children's needs, encouraging healthier development. The pilot was a precursor for a larger study to be carried out and developed within the primary care network.

It is anecdotally reported that general practitioners (GPs) consider that some of their time is wasted by patients consulting with minor ailments. This study aimed to investigate patients’ definitions of minor ailments and explore the reasons behind their decision to seek a GP consultation about ailments that they perceive to be minor. Qualitative interviews were conducted with a purposive sample of 19 adult patients from two demographically and socially diverse general practices in England. Interviewees’ views on (i) the types of symptoms and illnesses they thought of as minor ailments and (ii) the precipitating factors that had influenced their decision to consult a GP about a minor ailment were explored. What interviewees considered as minor ailments depended not only upon factors relating to the current condition (such as severity), but also other issues (such as previous experience and knowledge).

Although a condition that could be self-managed was considered a minor ailment; a minor ailment was not necessarily synonymous with a condition that could be handled alone. It is therefore unhelpful to think of specific conditions as being minor or major or to dismiss all minor ailment consultations as a waste of GP time. From a patient perspective the decision to consult their GP about a minor ailment may be a rational and evaluated one. The importance of understanding why some patients consult with minor ailments, and allowing them to retain choice in the way they seek advice, should not be underestimated when considering ways of increasing access to health professionals.

The focus of this paper is on health inequalities at a local level and the implications for community-based practice. This paper describes the development of a small multiagency project supporting families in a disadvantaged urban neighbourhood within the UK. A baseline assessment enabled primary and secondary data to be collected to inform project development and identify priorities for action. Findings revealed the scale of health need and helped focus the direction of the project. Several issues affecting implementation were identified, including the importance of good liaison between services and adopting a community development approach. This paper discusses the wider implications for the planning, delivery and evaluation of community-based initiatives addressing health inequalities. Despite the scale of need, there appears to be good potential for practitioners working in disadvantaged neighbourhoods to achieve some positive changes. Key points of learning are identified.

The objectives of this study were to undertake a needs assessment of mental health services for asylum seekers and refugees in the London Borough of Haringey, to estimate accurate numbers of asylum seekers and refugees who need mental health services, and to understand their perspective on mental health needs and services. The mental health needs of asylum seekers and refugees in Haringey were determined through a needs assessment exercise, using epidemiological and corporate approaches. The representatives of the main asylum seeker communities in Haringey were interviewed to find out what the mental health needs of this group and their community are, and how best to provide services to them. Estimates of number of asylum seekers and refugees in Haringey ranged from 5000 to 35 000, with a current best-guess figure of 31000. The community representatives’ views suggested that the factors affecting mental health of asylum seekers and refugees were not directly under the remit of the National Health Service (NHS). They felt that practical issues like education, employment, and social inclusion should be addressed alongside provision of effective professional help like psychotherapy or pharmacotherapy. They also felt that language and cultural barriers were significant impediments to constructive engagement with mental health services for this group. Mental health needs of asylum seekers/refugees are broad based, with implications for public health, social services, primary care, and mental health services. Approaches to developing services for asylum seekers and refugees should be multidisciplinary, and community driven, addressing language and cultural barriers.

For the last 4 years we have implemented a model to mobilize rural health workers as leaders for HIV prevention in Malawi. We use a conceptual framework that integrates the World Health Organization's (WHO) primary health care (PHC) model, the social–cognitive model of behavioural change, and contextual tailoring of the intervention. Health workers are potential rural HIV prevention leaders because they have community trust and respect. However, their leadership potential has been limited by both health system barriers such as inadequate workers, supplies, and training and personal barriers such as risky occupational and personal behaviours. In the first phase of the project, we developed collaborative relationships and conducted qualitative research to adapt a peer group intervention for rural health workers and community members. In the ongoing second phase, we trained the health workers, who then volunteered and provided the intervention to adults in the communities their health centres serve. The intervention was adapted for young people through a community participatory process. Currently the adapted intervention is being offered to young people. As a guide to replication, we discuss barriers encountered in implementing this collaborative project and how we overcame them. This project demonstrates that health workers can be effective leaders for community AIDS prevention in African countries. The primary health care model offers a feasible, cost-effective and sustainable approach to maximizing health worker-community collaboration to reduce the spread of HIV.

There is a policy drive in the UK National Health Services (NHS) towards public involvement in service, education and research, with a number of national initiatives such as INVOLVE that have championed effective user input on research and development (R&D). The requisites of research governance include a balance of professional and public input, and the structures for this now exist at primary care level. There is a need for examples of how such policies can be implemented in Primary Care Trusts, and this article aims to show in detail the way in which a systematic approach to user involvement in R&D has been implemented. The PPIRes (Public and Patient Involvement in Research) project, whose progress over two years from 2003 to 2005 is reported, has been funded by NHS R&D monies allocated through a research consortium in Norfolk, and has been hosted in an NHS – academic partnership between Norwich Primary Care Trust and the Institute of Health at the University of East Anglia. The profile of volunteers, recommendations for good practice in public involvement, and the ‘facilitators and challenges’ to the programme are described.

The aim of this article is to report the results of a study examining salaried payment for general practitioners (GPs) in Scotland. The study examines ‘paragraph 52’ salaried payment, where GPs can employ a GP as a member of practice staff and claim reimbursement from the health board. The paper reports results of 18 semi-structured interviews with managers at two health boards, and at seven general practices who have a salaried GP. The paper also presents quantitative data about the nature of the salaried contracts and presents a comparison of practices with a salaried GP with other practices in Scotland. Seventeen practices employed a salaried GP 18 months after the scheme began. Ex-fundholders and training practices were more likely to have been selected by health boards to employ a salaried GP. The two health boards took different approaches to the scheme. The first selected those practices that were more likely to have identified specific service developments as part of their bid for a salaried GP. This approach might reward those practices that were already innovative, thus potentially increasing inequality in service provision between practices. The second health board used the scheme to maintain and support practices in rural areas, and was less concerned with service development, thus potentially reducing inequalities in access. Salaried GPs were ex-GP registrars and ex-locums who wanted more stability and less responsibility, and administration. Some were happy in their post, while others saw it as a stepping stone to a partnership. Most practices used the salaried GP to release the time of partners to engage in practice development. Some practices mentioned the financial benefits of the scheme and benefits in terms of enabling service development. Compared to using locums, it was suggested that referral rates of salaried GPs may be lower, and continuity of care higher. Participants felt strongly that the scheme should continue. The paragraph 52 scheme was used little, but was potentially valuable in introducing stability and experience for younger GPs who do not want a partnership. Health boards had different interpretations of the objectives and use of the scheme reflecting different local circumstances. The potential of the scheme to address inequalities in the distribution of GPs is uncertain.

In 1999 Hockey postulated the hypothesis that some older people experience a continual accumulation of small, individually minor events or difficulties that degrade their resilience until they ‘cannot cope with another thing’. She referred to this accumulation as cumulative trivia. The essence of cumulative trivia lies in their everyday nature, where regular occurrence and variety of challenge stack up to form perceived threats to an older person's ability to function independently. There is a strong overlap between this concept of cumulative trivia and an established concept in the health psychology literature called daily hassles. Consistent with the mainstream psychology approach, the vast majority of research into daily hassles has been quantitative. In the present article we adopt a critical stance to the knowledge produced from this research, questioning its foundations in the positivist epistemology. In particular the research is criticized for absenting the social context from our understanding of daily hassles, and for focusing too strongly upon the individual. The considerable lack of research into daily hassles in the lives of older people is also highlighted, indicating the need for work in this area. Using a social constructionist framework, we attempt to develop a holistic conceptualization of cumulative trivia, through which some key differences between the cumulative trivia and daily hassles concepts are indicated. We argue that cumulative trivia could be seen within the framework of the daily hassles literature but that this framework would require to be developed further and refined to accommodate the specific characteristics associated with Hockey's concept. We suggest that the social construction of ageing may serve to normalize experiences in ageing such that they become trivialized. Finally we examine how the social construction of independence as an ideal state may create or exacerbate the effects of cumulative trivia, and argue for its reconstruction to legitimize older people's experiences of minor difficulties. Through these arguments we relocate responsibility for cumulative trivia toward the social context.

The aim of the study was to investigate the experiences of professionals who treat asylum seekers and refugees, as well as those responsible for the planning, management and delivery of mental health services to this group in Haringey; and to identify and address key areas of difficulty to assist development of appropriate mental health services for this group in Haringey. Individual face to face interviews were conducted with the service providers using a semi-structured interview schedule. The results were triangulated with another study done in general practices in Haringey. Fourteen service providers – health professionals, service managers and commissioners who were involved in responding to the mental health needs of asylum seekers and refugees in Haringey. Findings from a previous study were used for primary care professionals’ views. The main issues faced by providers in dealing with mental health needs of asylum seekers and refugees were: increased demands placed on the time and resources of already stretched mental health services, language and cultural barriers, the difficulties in working through interpreters in delivering therapy, and the need for longer consultation time. Asylum seekers and refugees were felt to seek health professionals’ help with matters that were outside the professionals’ remit. Some providers were unsure of the appropriateness of the western model of treating mental illness for this group. Development of better information on these particular groups locally, and the use of appropriately trained health professionals from the asylum seeker and refugee community to both inform and provide mental health services, would be appropriate responses. A model of service provision addressing the wider influences on the mental health of this group is proposed, that would address the concerns raised by providers and users.

Jurisdictions around the world have articulated a need for development of an integrated health care system with increased emphasis on primary health care and incorporation of the principles and practices of health promotion. To date, the medical model has been the default model of care. Yet, treatment alone is unlikely to have marked effects on health inequities or health status. This article presents and discusses two foundational dimensions (values, structures) of a health promotion philosophy and approach in primary health care settings. We propose a strategy and framework to support practical and attainable action. Our article (the first of a series of two) is based on a literature review, validation by key experts and a national survey of Canadian primary health care settings. We argue that fundamental philosophical values provide a foundation for health promotion in primary health care. These values should be reflected in the structures that create a supportive environment for health promotion. Our remaining three domains (strategies, processes, outcomes) are presented in a second following article. Based on values and structures, we conclude that subsequent strategies (interventions), processes (client- and community-centred care), and desired health promotion outcomes (intended or unintended) may be achieved.

Increasingly, attention is shifting away from a focus on postnatal depression to the recognition that depression may be a recurrent experience in many women’s lives with the perinatal period constituting a time of particular vulnerability. This article reports on a study undertaken in one primary care trust which explored mothers’ and practitioners’ experience and awareness of antenatal depression and considered the service response offered by midwives and health visitors. The mothers who participated in focus groups felt ill prepared for the possibility that depression could occur during pregnancy. They identified social and role expectations as well as professional attitudes and service delivery models as barriers to disclosing feelings of depression during this period. The midwives and community nurses surveyed placed rather less emphasis than mothers on the value of continuity of care in pregnancy in promoting disclosure of mental health problems. Community midwives appeared less confident than health visitors in detecting and responding to antenatal depression but both groups of professionals had little knowledge of relevant community services. Co-ordination between midwives and health visitors appeared limited and contact with mental health services was lower than might have been anticipated; the general practitioner (GP) was still seen as the key resource in cases of antenatal depression. However, many of the mothers participating in the study found GPs unresponsive to expressions of negative feelings in pregnancy. The article considers approaches for increasing awareness and detection of antenatal depression and improving co-ordination between services.

International and UK National Health Service policy has focused attention on the need to develop research capacity in primary care, with the emphasis on collaboration between professional groups and across organizations including health and social care, and the academic context. The results of a survey of research activity, interest and skills in a health and social care community, in Northern England, are reported. The survey targeted primary care trust (PCT) staff, general practice staff and social services staff seconded to the PCT, and a response rate of 31% was achieved. Twelve per cent of respondents were involved in research, with research active professionals typically involved in between one and three projects. PCT staff reported a significantly higher level of research activity, research skills and research interest than general practice or social care staff. The holding of a master's degree was associated with a greater desire to lead or collaborate in research. All three groups expressed a preference for practice-based research training and other forms of research support were identified, including protected time, apprenticeship, mentoring and funding advice. The results of this survey have been valuable in terms of research governance, forming research strategy, and impact on capacity via training and support for the health and social care community within a newly formed research alliance between a district general hospital, a PCT and social services, including an academic advisory group. The paper concludes that a holistic approach to research capacity building should inform changing policy and research funding in the UK.

Trent Focus, a Research and Development Support Unit, have introduced the ‘Designated Research Team’ (DRT) approach to building research capacity. This approach funds protected time to develop research ideas and skills for a team with limited research experience. This paper uses the example of a successful team of podiatry researchers to illustrate the approach to, and outcomes of, a DRT. It draws on documentary analysis of meeting notes and annual reports, and team members' views collected during a recorded reflective session of the team at the end of the funding period. The DRT were successful in achieving agreed outcomes, including completing the project, submitting and publishing in peer reviewed journals, and presenting at conferences. They were also able to attract further funding, and engage with international collaborations and research activity. The unique contribution of this paper is that it focuses on facilitating factors to building research capacity based on a practice example. These include: enabling protected time, effective managerial support, applied and timely research training at relevant levels to expertise, immediate access to supervision and mentorship, a critical mass of research expertise within the team, and an encouraging workplace environment. Importantly, research undertaken was seen as a means to improve practice and the status of the professional group. ‘Accessible’ academic support including outreach work and attitudes of the team members and supervisors towards teaching and learning were important. Process factors enabling success include the use of project management techniques, clear delegation of tasks, effective lines of communication and accountability, and high levels of social capital and commitment between team members. The paper highlights ways forward to using these facilitating factors to build further research capacity, and to use this approach to highlight other areas of research capacity outcome measures.