Diabetes healthcare strategies.

This article describes and contrasts two approaches to planning strategies for diabetes care. These are the 'epidemiologically based healthcare needs assessment' and 'marginal analysis'. Both have their advantages and disadvantages.

Banning the "A word": where's the evidence?

Background: It is argued that use of the term "accident" has a negative effect on prevention efforts as the term implies that such events are due to chance.

Aim: To test the hypothesis that use of "injury" in place of "accident" can influence professional attitudes towards "accident/injury" prevention.

Setting: Leeds Health Authority area serving the population (n=740,000) of the city of Leeds in the Yorkshire region of England.

Lifestyle factors affecting fruit and vegetable consumption in the UK Women's Cohort Study.

The UK Women's Cohort Study (UKWCS) was originally set up to look at morbidity and mortality data on subjects with a wide range of dietary intakes including vegans, lacto-ovo vegetarians, non-red meat eaters and red meat eaters. The aim of the present study was to investigate factors that affect fruit and vegetable consumption within this particular cohort of women. Females of ages 35-69 years, taking part in the UK Women's Cohort Study (N=35 367), provided health and lifestyle information including a 217-item food frequency questionnaire.

Prevention: developing a framework for conceptualizing and evaluating outcomes of preventive services for older people.

There is growing preoccupation among policy makers and commissioners in developing preventive strategies and services. There is simultaneous concern with evidence-based purchasing and provision, within health and social care. In social care the evidence base regarding prevention is neither extensive nor robust.

Social services and Primary Care Groups: a window of collaborative opportunity?

This paper reports on the findings of two investigations into the relationship between social services and Primary Care Groups (PCGs): a national postal questionnaire and a series of regional seminars. The key findings of both explorations are summarised and placed in the context of other available evidence on the development of PCGs. Issues covered include: the background and status of social services representatives; preparation and support for the board role; feedback and accountability, and early contributions.

Family care-giving and chronic illness: how parents cope with a child with a sickle cell disorder or thalassaemia.

There has been increasing interest in the way parents cope with childhood chronic illness and a shift away from merely describing the 'burdens' of care. An emphasis on coping by introducing ideas such as co-ordinated, accessible and appropriate service delivery as well as empowerment raises important policy and practice issues for public health. This paper, by drawing on qualitative material from a project evaluating service support to families caring for a child with a haemoglobinopathy, examines how parents cope with their caring responsibilities.

Dimensions of choice in the assessment and care management process: the views of older people, carers and care managers.

The aim of promoting the maximum possible choice for service users and carers is - together with the goal of greater independence - central to recent community care policies. This paper sets out a typology of those key choices which users and carers are expected to be able to make within each stage of the assessment and care management process: choices about what services, when to receive them (i.e.

Continuing health care: the local development of policies and eligibility criteria.

In 1995 the Department of Health issued guidance on continuing health care following the health service commissioner's finding against Leeds Health Authority for failing to provide long-term care. Under this guidance, health authorities were required to agree continuing health care policies and eligibility criteria with fundholders and local authorities. This study sought to investigate the extent to which the drafting of local policies and criteria, within the framework of national guidance, led to consistency between health authorities.

Joint commissioning across the primary health care-social care boundary: can it work?

General ideas about joint working have been commonplace in the UK for several decades and those more specifically about joint commissioning have been popular since the quasi-market reforms of the early 1990s. The Labour Government is now placing a heavy premium upon 'partnership working' and expects this to breathe new life into joint commissioning initiatives; especially those involving social care and primary health care. However, despite the relatively lengthy experience of joint commissioning, we still know very little about how it works in practice.

Simplified antiviral prophylaxis with or and without artificial feeding to reduce mother-to-child transmission of HIV in low and middle income countries: modelling positive and negative impact on child survival.

Background: Antiviral prophylaxis is recommended for HIV positive mothers to prevent mother-to-child transmission of HIV. To date UNAIDS and WHO policy has been based on a study in Thailand which showed a reduction in transmission by half with short course AZT (Zidovudine) treatment together with artificial feeding. We modelled the possible positive and negative effects on child deaths in low and middle resource developing country settings of two interventions to reduce mother to child transmission (MTCT) of HIV: antenatal testing, short-course antivirals (zidovudine or nevirapine), firstly with and then without artificial feeding.

Scaling-up HIV/AIDS and TB home-based care: lessons from Zambia.

Home-based care coverage in Africa is currently very low and likely to reduce drastically in the near future. This paper investigates the low coverage of home-based care programmes in Africa and uses two home-based care projects in Zambia as case studies. The very limited involvement of governments in the provision of home-based care services appears to be one of the main reasons behind the low coverage of home-based care in Africa.

The epidemiology of disability and occupation handicap resulting from major traumatic injury.

Purpose: To assess the prevalence of disability and handicap among survivors of major traumatic injury (injury severity score > 15) using a prospective population based cohort study design. The study was set in the former Yorkshire Health Region.

Subjects/methods: A cohort of 367 individuals identified as having received and survived major traumatic injury during the 12 month period October 1988-September 1989.

Integration of STI services into FP/MCH services: health service and social contexts in rural Ghana.

Ghana, like many countries, has taken up the call to integrate STI management with MCH/FP services. Since 1994 a range of policies has been developed on safe motherhood and family planning, as well as syndromic STI management guidelines for 'mid-level' staff and an all-encompassing 'reproductive health' policy. The success of these policy initiatives depends to a large extent on the processes and contexts of implementation, yet analysis of this has rarely been undertaken.

Using costing as a district planning and management tool in Balochistan, Pakistan.

This paper reports on two studies in the province of Balochistan, Pakistan, analyzing the costs of primary care facilities and district and divisional hospitals. There are no known previous cost studies within Balochistan and the information gained is a critical element in developing a more rational allocation of resources within the health sector. The results demonstrate both the high level of under-funding of primary care within the health sector and the current inefficiency of allocation towards primary care and, within budgets, between different line items.

Pharmacists' role in managing sexually transmitted infections: policy issues and options for Ghana.

The debate about extending the role of pharmacists in health care is growing in recognition of the ongoing difficulties experienced by many public sector services. The perceived accessibility and confidentiality of pharmacists makes them particularly attractive to patients for the management of health problems such as sexually transmitted infections (STI) that may lead to stigmatization. Despite growing interest in the subject, there are few documented analyses of the role of pharmacists in low-income countries.

Survival from adolescent cancer in Yorkshire, UK.

The aim of this study was to investigate survival rates for adolescents with cancer and identify factors associated with differential long-term prognosis in Yorkshire, UK. A survival analysis of a population-based cohort of young adults aged 15-24 years, diagnosed with a malignancy in the former Yorkshire Regional Health Authority between 1985 and 1994 was carried out. The main outcome was death from all causes.

Variation in clinical decision making is a partial explanation for geographical variation in lower extremity amputation rates.

Background: Rates of lower extremity amputation vary significantly both between and within countries. The variation does not appear to support differences in need as an explanation. This study set out to see if variations in clinical decision making might contribute to the explanation.

Investigating recovery from stroke: a qualitative study.

A recent randomized controlled trial evaluated the effects of specialist nurses providing information, advice and support to caregivers and patients at home during the first year after a stroke. Reported here are the results of a complementary study which used qualitative methods to examine the experience of patients and caregivers during the year of recovery after a stroke. We used semi-structured interviews with a purposively selected sample of 30 patients and 15 caregivers at the end of a randomized controlled trial (13-16 months post-stroke).

Effectiveness of the direct observation component of DOTS for tuberculosis: a randomised controlled trial in Pakistan.

Background: DOTS is the control strategy for tuberculosis promoted by WHO. Pakistan is currently developing its National Tuberculosis Programme, and requires guidance on types of direct observation of treatment appropriate for the local conditions. We did a randomised trial to assess the effectiveness of different packages for tuberculosis treatment under operational conditions in Pakistan.

Frequent attenders' consulting patterns with general practitioners.

Background: Despite the growing literature on frequent attendance, little is known about the consulting patterns of frequent attenders with different doctors. To develop appropriate intervention strategies and to improve the clinical care of frequent attenders, a full understanding of these consulting patterns is essential.

Aims: This paper has three aims: to determine whether frequent attenders consult more with some doctors than others; to determine how many different doctors frequent attenders consult with; and to determine whether frequent attenders exhibit greater continuity of care than non-frequent attenders.

Hospital managers of the future--what are their needs?

In the course of conducting a review of the international Hospital Management MA course at the Nuffield Institute for Health, Leeds University, the reviewers conducted a survey of international health care trends, especially in developing countries, and considered their implications for hospital and health managers. The demands on managers are becoming more complex and require new expertise in working autonomously, financial planning, organisation development, risk management in physical resource use, and quality of clinical care. The course has been restructured to take account of the identified needs.

A realistic theory of health sector management. The case for critical realism.

To date the practice of health sector management has not been sufficiently theorised. An adequate theory should be able to answer the pre-eminent critique of managerial rationality and ethics mounted by Alasdair MacIntyre in After Virtue and should also offer robust analytical and ethical resources to identify and engage with the social, political, economic and moral issues underlying health sector management. Critical realism with its ontology of generative mechanisms, agency-structure relationships, valorisation of activity and ideology critique offers such resources in an empirically orientated but adequately theorised realist framework.