Linkworkers in primary care

New beginnings: stakeholder perspectives on the role of health trainers

AIMS

First proposed in the 2004 White Paper Choosing Health, health trainers are a new addition to the public health workforce. Health trainers are recruited from local communities and provide support to enable individuals to adopt healthy lifestyles. The aim of this paper is to examine the emerging role of the health trainer in the context of one of the twelve early adopter programmes. The paper describes the support and signposting model developed in Bradford.

METHODS

An evaluation of the pilot scheme was undertaken using both quantitative and qualitative methods. The paper draws on two pieces of qualitative data from the evaluation. Two focus groups were held with 15 health trainers in their first months of practice. Telephone interviews were held with a sample of 16 key informants from community based placement organizations. Thematic analysis of the data was undertaken.

RESULTS

The new health trainers were very clear about their role in listening and giving support. Clients presented with a diverse range of needs and often had complex problems. The health trainers perceived that a client-centred approach was of value but there were some issues about the boundaries of appropriate advice. Outreach and networking were considered important skills. In the telephone interviews, interviewees understood the health trainer role and identified potential benefits for service users. The significance of health trainers having local knowledge was highlighted, although some organizations were able to assist with networking. The health trainer programme was seen as an additional and distinct resource complementing existing provision.

CONCLUSION

The new role of health trainer is a significant development for the public health workforce. Health trainers can offer something quite distinctive and separate from professional advice, and there is potential to help individuals to access support and services in local communities. More research is needed on the relative value of different models of health trainer.

Diabetes service provision: a qualitative study of the experiences and views of Pakistani and Indian patients with Type 2 diabetes

AIMS

To explore Pakistani and Indian patients' experiences of, and views about, diabetes services in order to inform the development of culturally sensitive services.

DESIGN

Qualitative, interview study involving 23 Pakistani and nine Indian patients with Type 2 diabetes recruited from general practices and the local community in Edinburgh, Scotland. Data collection and analysis occurred concurrently and recruitment continued until no new themes emerged from the interviews.

RESULTS

Respondents expressed gratitude for the availability of free diabetes services in Britain, as they were used to having to pay to access health care on the Indian subcontinent. Most looked to services for the prompt detection and treatment of complications, rather than the provision of advice about managing their condition. As respondents attached importance to receiving physical examinations, they could be disappointed when these were not offered by health-care professionals. They disliked relying on interpreters and identified a need for bilingual professionals with whom they could discuss their diabetes care directly.

CONCLUSIONS

Gratitude for free services in Britain may instil a sense of indebtedness which makes it difficult for Pakistanis and Indians to be critical of their diabetes care. Health-care professionals may need to describe their roles carefully, and explain how different diabetes services fit together, to avoid Pakistani and Indian patients perceiving treatment as unsatisfactory. Whilst linkworker schemes may meet patients' need to receive culturally sensitive information in their first language, work is needed to assess their effectiveness and sustainability.

Perceptions and experiences of taking oral hypoglycaemic agents among people of Pakistani and Indian origin: qualitative study

OBJECTIVE

To explore British Pakistani and British Indian patients' perceptions and experiences of taking oral hypoglycaemic agents (OHAs).

DESIGN

Observational cross sectional study using in-depth interviews in English or Punjabi.

SETTING AND PARTICIPANTS

32 patients of Pakistani and Indian origin with type 2 diabetes, recruited from primary care and community sources in Edinburgh, Scotland.

RESULTS

Respondents reported complex and ambivalent views about OHAs, which reflected their ambivalent attitudes towards Western drugs in general. Respondents considered OHAs to be an important part of the diabetic regimen because they perceived British healthcare professionals to be competent and trustworthy prescribers, and they considered the medicines available in Britain to be superior to those on the Indian subcontinent. Despite this, some respondents made deliberate efforts to reduce their tablet intake without being advised to do so. Reasons for this included perceptions that drugs worked by providing relief of symptoms and concerns that OHAs could be detrimental to health if taken for long periods, in conjunction with other drugs, or without traditional foods.

CONCLUSIONS

British Pakistani and Indian patients' perceptions of their OHAs may partly derive from popular ideas about drugs on the Indian subcontinent. Cultural factors need to be understood and taken into consideration to ensure that these patients are given appropriate advice and to avoid unnecessary changes to prescriptions.

Evaluation of delivery of enhanced diabetes care to patients of South Asian ethnicity: the United Kingdom Asian Diabetes Study (UKADS)

AIMS

We tested the hypothesis that enhanced care for diabetes, tailored to the needs of the South Asian community with Type 2 diabetes, would improve risk factors for diabetic vascular complications and ultimately reduce morbidity and mortality.

PATIENTS AND METHODS

The study was a cluster randomized controlled trial (RCT) with general practice the unit of randomization. Six West Midlands general practices with a high proportion of South Asian patients were randomized to 'enhanced care' using Asian link workers and extra community diabetes specialist nurse sessions (intervention) or continued standard practice care (control).

RESULTS

Of 401 patients recruited to the study, 361 (90%), comprising 178 from Coventry and 183 from Birmingham were eligible and included in the analyses. The mean age at baseline (standard deviation, SD) was 58.9 (11.7 years) with median (interquartile range; IQR) duration of diabetes 6.5 (3-11) years. At one year follow-up there was a significant difference in reduction of systolic (4.6 mmHg, P = 0.035) and diastolic blood pressure (3.4 mmHg, P = 0.003) and total cholesterol (0.4 mmol/l, P = 0.005), comparing the intervention and control groups. After adjusting for baseline measurement and age, only differential reduction in diastolic blood pressure remained significant. There was no significant change in HbA(1c) and no difference between the groups.

CONCLUSIONS

Using link workers and extra community diabetes specialist nurse input together with treatment protocols in primary care might prove a useful strategy in working towards NSF targets for diabetes management. In this study, small reductions in blood pressure and cholesterol were achieved. Improvement in glycaemic control may require longer and possibly different strategies. Further research is required to evaluate fully the effectiveness, including the costs and longer term sustainability of culturally sensitive initiatives.

Knowledge and attitudes in multicultural health care

Health professionals' knowledge of ethnic minority cultures and lifestyles was assessed to determine whether the respondents' cultural background and experience of working with ethnic minorities affected the health care delivered by them and to assess the need for training. Improving access to health services for ethnic minorities requires continuing education and training of all health professionals.