Investigating the impact of London's ultra low emission zone on children's health: children's health in London and Luton (CHILL) protocol for a prospective parallel cohort study.

BACKGROUND: Air pollution harms health across the life course. Children are at particular risk of adverse effects during development, which may impact on health in later life. Interventions that improve air quality are urgently needed both to improve public health now, and prevent longer-term increased vulnerability to chronic disease. Low Emission Zones are a public health policy intervention aimed at reducing traffic-derived contributions to urban air pollution, but evidence that they deliver health benefits is lacking. We describe a natural experiment study (CHILL: Children's Health in London and Luton) to evaluate the impacts of the introduction of London's Ultra Low Emission Zone (ULEZ) on children's health. METHODS: CHILL is a prospective two-arm parallel longitudinal cohort study recruiting children at age 6-9 years from primary schools in Central London (the focus of the first phase of the ULEZ) and Luton (a comparator site), with the primary outcome being the impact of changes in annual air pollutant exposures (nitrogen oxides [NOx], nitrogen dioxide [NO2], particulate matter with a diameter of less than 2.5micrograms [PM2.5], and less than 10 micrograms [PM10]) across the two sites on lung function growth, measured as post-bronchodilator forced expiratory volume in one second (FEV1) over five years. Secondary outcomes include physical activity, cognitive development, mental health, quality of life, health inequalities, and a range of respiratory and health economic data. DISCUSSION: CHILL's prospective parallel cohort design will enable robust conclusions to be drawn on the effectiveness of the ULEZ at improving air quality and delivering improvements in children's respiratory health. With increasing proportions of the world's population now living in large urban areas exceeding World Health Organisation air pollution limit guidelines, our study findings will have important implications for the design and implementation of Low Emission and Clean Air Zones in the UK, and worldwide. CLINICALTRIALS: GOV: NCT04695093 (05/01/2021).

Taking a "Care Pathway/Whole Systems" Approach to Equality Diversity Inclusion (EDI) in Organ Donation and Transplantation in Relation to the Needs of "Ethnic/Racial/Migrant" Minority Communities: A Statement and a Call for Action.

International evidence shows variation in organ donation and transplantation (ODT) based upon a range of patient characteristics. What is less well understood is the impact of patient "ethnicity/race/immigration background," as these terms are defined and intended differently across countries. We also know that these characteristics do not operate in isolation but intersect with a range of factors. In this paper, we propose a framework that seeks to clarify the definition of the key terms "ethnicity/race/migrant" and to review how these communities are operationalized across European studies about inequities in ODT. Further, patients and the public wish to see Equality Diversity Inclusion (EDI) approaches in their everyday lives, not just in relation to ODT. We propose a 'care pathway/whole-systems' approach to ODT encompassing culturally competent public health interventions for a) the prevention and management of chronic diseases, b) improvements in public engagement for the promotion of the culture of ODT and enhancements in end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities. Our framework recognizes that if we truly wish to take an EDI approach to ODT, we need to adopt a more social, human and holistic approach to examining questions around patient ethnicity.

Examining the Role of the Health Belief Model Framework in Achieving Diversity and Equity in Organ Donation Among South Asians in the United Kingdom.

Organ donation continues to be low among ethnic minorities in the United Kingdom (UK), especially within the South Asian community, with a disproportionate number of patients of South Asian ethnicity awaiting organ transplants. In 2020/21, Minority Ethnic (ME) patients comprised almost a third of the national transplant waiting list, highlighting the continued imbalance between the need for transplants in South Asian communities and the availability of suitable organs. Median waiting times for transplants show that, generally, white patients wait less time than ME patients; Only 39.5% of ME families consented to proceed with deceased organ donation when approached compared to 69% of white families. How to increase awareness among the South Asian community on the scarcity of organ donors continues to be a growing challenge facing the healthcare system in the UK and globally. This article reflects on the education strategy implemented using the Health Belief Model. It provides a detailed framework with which to consider the rationale that led to a specific behaviour, in this case organ donation among the three major ethnicities (i.e., Indian, Pakistani, Bangladeshi) within the South Asian community as part of a single study.

Barriers towards deceased organ donation among Indians living globally: an integrative systematic review using narrative synthesis.

OBJECTIVES: To understand the barriers towards deceased organ donation among Indians living globally. DESIGN: Integrative systematic review using narrative synthesis. DATA SOURCES: CINAHL, Medline full-text, PsycInfo, Scopus, Global Health, Web of Science, and PubMed Central, Indian Journal of Transplantation and Google Scholar. TIME PERIOD: 1 January 1994 to 31 December 2021. PARTICIPANTS: Individuals of Indian origin living globally. RESULTS: Eighty-nine studies were included with more than 29 000 participants and quality of the studies were assessed using Joanna Briggs Institute's critical appraisal tool. Though majority of the participants had knowledge toward organ donation with a positive influence on willingness, the gap between knowledge and willingness was huge, with minimal registration influenced by the complex sociocultural constructs. Various sociocultural constructs such as family, fear and mistrust, religion, and bodily issues play a vital role. Differences were identified in willingness to donate and register between southern and other regions of India. Indian's organ donation behaviour in other geographical locations differed based on the socioreligious background of the country they lived in such as in Malaysia, Canada and the UK. However, they were collective in decision-making and had complex sociocultural interference irrespective of the country the individual lived which differed only in their next generations. CONCLUSION: Though this study showed the complex relationship, and its influences on organ donation behaviour, lacunae were identified to further understand how such complex interactions determine or inform the behaviour. Also, methodological issues were identified, where this particular population outside India were collectively studied with their neighbouring population which are not homogenous. Studies in India majorly addressed a similar aim using similar methods which produced repetition of studies leading to lack of diversified, wider and in-depth research. Therefore, while this systematic review addressed the barriers toward organ donation among Indians living globally, it also informs various gaps in research and also methodological issues. PROSPERO REGISTRATION NUMBER: CRD42019155274.

'They Are Kids, Let Them Eat': A Qualitative Investigation into the Parental Beliefs and Practices of Providing a Healthy Diet for Young Children among a Culturally Diverse and Deprived Population in the UK.

In the UK, ethnic minority children are at greater risk of obesity and weight-related ill health compared to the wider national population. The factors that influence the provision of a healthy diet among these populations remain less understood. An interpretive qualitative study with a phenomenological perspective comprised of 24 single sex semi-structured focus groups was conducted with 110 parents (63 mothers and 47 fathers) of young children (aged 0-5 years). The participants were recruited from deprived and ethnically diverse wards in Luton, UK and self-identified as being white British, Pakistani, Bangladeshi, black African-Caribbean or Polish. The findings highlighted a wide range of inter-relating psychological and sociocultural factors that underpin parental beliefs and practices in providing children with a healthy diet. Parents, whilst aware of the importance of providing children with a healthy diet, faced challenges such as lack of time and balancing competing responsibilities, which were clear barriers to providing children with a healthy diet. Access to and affordability of healthy food and the overexposure of cheap, convenient, and unhealthy processed foods made it increasingly difficult for parents to provide a healthy diet for their growing families. Household food practices were also found to be situated within the wider context of sociocultural and religious norms around cooking and eating, along with cultural identity and upbringing.

Improving support for breastfeeding mothers: a qualitative study on the experiences of breastfeeding among mothers who reside in a deprived and culturally diverse community.

BACKGROUND: The United Kingdom has one of the lowest breastfeeding rates in Europe, with the initiation and continuation of breastfeeding shown to be closely related to the mothers' age, ethnicity and social class. Whilst the barriers that influence a woman's decision to breastfeed are well documented, less is known how these barriers vary by the UK's diverse population. As such, this study aimed to explore mothers' experiences of breastfeeding and accessing breastfeeding services offered locally amongst a deprived and culturally diverse community. METHODS: A qualitative interpretive study comprising of 63 mothers (white British n = 8, Pakistani n = 13, Bangladeshi n = 10, black African n = 15 and Polish n = 17) who took part in single-sex focus groups, conducted in local community centres across the most deprived and ethnically diverse wards in Luton, UK. The focus groups were audio-recorded, transcribed and analysed thematically using Framework Analysis. RESULTS: The most common barriers to breastfeeding irrespective of ethnicity were perceptions surrounding pain and lack of milk. Confidence and motivation were found to be crucial facilitators of breastfeeding; whereby mothers felt that interventions should seek to reassure and support mothers not only during the early stages but throughout the breastfeeding journey. Mothers particularly valued the practical support provided by health care professions particularly surrounding positioning and attachment techniques. However, many mothers felt that the support from health care professionals was not always followed through. CONCLUSIONS: The findings presented inform important recommendations for the design and implementation of future programs and interventions targeted at reducing breastfeeding inequalities. Interventions should focus on providing mothers practical support and reassurance not only during the early stages but throughout their breastfeeding journey. The findings also highlight the need for tailoring services to support diverse communities which acknowledge different traditional and familial practices.

The impact of social prescribing services on service users: a systematic review of the evidence.

BACKGROUND: Social prescribing initiatives are widely implemented in the UK National Health Service to integrate health and social care. Social prescribing is a service in primary care that links patients with non-medical needs to sources of support provided by the community and voluntary sector to help improve their health and wellbeing. Such programmes usually include navigators, who work with referred patients and issue onward referrals to sources of non-medical support. This systematic review aimed to assess the evidence of service user outcomes of social prescribing programmes based on primary care and involving navigators. METHODS: We searched 11 databases, the grey literature, and the reference lists of relevant studies to identify the available evidence on the impact of social prescribing on service users. Searches were limited to literature written in English. No date restrictions were applied, and searches were conducted to June 2018. Findings were synthesized narratively, employing thematic analysis. The Mixed Methods Appraisal Tool Version 2011 was used to evaluate the methodological quality of included studies. RESULTS: Sixteen studies met the inclusion criteria. The evidence base is mixed, some studies found improvements in health and wellbeing, health-related behaviours, self-concepts, feelings, social contacts and day-to-day functioning post-social prescribing, whereas others have not. The review also shows that the evaluation methodologies utilized were variable in quality. CONCLUSION: In order to assess the success of social prescribing services, more high quality and comparable evaluations need to be conducted in the future.International Prospective Register of Systematic Reviews number: CRD42017079664.

Children's unmet palliative care needs: a scoping review of parents' perspectives.

BACKGROUND: Children with life-limiting conditions often have complex needs, making it challenging for services to provide satisfactory care. Few studies consider whether services actually meet families' needs by exploring and identifying the parents' perspectives of unmet needs. AIM: To identify what published evidence is available on the unmet needs of children with life-limiting conditions and their families, from the perspective of parents, internationally. ELIGIBILITY CRITERIA: Inclusion criteria: papers from the perspective of parents of children aged 0-19 years, who have a life-limiting condition and are receiving palliative care. Exclusion criteria: those papers not written in English, not reporting primary research and discussing children who died from stillbirth, accidental or unexpected circumstance. CHARTING METHODS: A scoping review was conducted in accordance with the methods of Arksey and O'Malley. SOURCES OF EVIDENCE: The electronic databases PubMed, MEDLINE, CINAHL and PsycINFO were searched. Key terms included: parent, needs, met/unmet/satisfaction, palliative/supportive/end of life care, life-limiting/life-threatening illness, infants/children/young people. RESULTS: Total hit indicated 5975 papers for screening. Fifty-five papers met the scoping review criteria. The majority used mixed-methods approaches inclusive of: questionnaires, self-report measures, in-depth interviews, focus groups, case record analysis and art-based workshops. Unmet needs included: respite care, coordination and organisation of care, psychological support and professional communication skills. CONCLUSIONS: The findings suggest many unmet needs from the parent's perspective, across several aspects of the Quality Standards and Children's Palliative Care Frameworks. Further research is needed which explores the parent's unmet needs in palliative care services.

The impact of the Luton social prescribing programme on energy expenditure: a quantitative before-and-after study.

OBJECTIVES: The objective of this study was to assess the change in energy expenditure levels of service users after participation in the Luton social prescribing programme. DESIGN: Uncontrolled before-and-after study. SETTING: This study was set in the East of England (Luton). PARTICIPANTS: Service users with complete covariate information and baseline measurements (n=146) were included in the analysis. INTERVENTION: Social prescribing, which is an initiative that aims to link patients in primary care with sources of support within the community sector to improve their health, well-being and care experience. Service users were referred to 12 sessions (free of charge), usually provided by third sector organisations. PRIMARY OUTCOME MEASURE: Energy expenditure measured as metabolic equivalent (MET) minutes per week. RESULTS: Using a Bayesian zero-inflated negative binomial model to account for a large number of observed zeros in the data, 95% posterior intervals show that energy expenditure from all levels of physical activities increased post intervention (walking 41.7% (40.31%, 43.11%); moderate 5.0% (2.94%, 7.09%); vigorous 107.3% (98.19%, 116.20%) and total 56.3% (54.77%, 57.69%)). The probability of engaging in physical activity post intervention increased, in three of four MET physical activity levels, for those individuals who were inactive at the start of the programme. Age has a negative effect on energy expenditure from any physical activity level. Similarly, working status has a negative effect on energy expenditure in all but one MET physical activity level. No consistent pattern was observed across physical activity levels in the association between gender and energy expenditure. CONCLUSION: This study shows that social prescribing may have the potential to increase the physical activity levels of service users and promote the uptake of physical activity in inactive patient groups. Results of this study can inform future research in the field, which could be of use for commissioners and policy makers.

Inequalities and outcomes: end stage kidney disease in ethnic minorities.

BACKGROUND: The international evidence about outcomes of End Stage Kidney Disease (ESKD) for ethnic minorities was reviewed to identify gaps and make recommendations for researchers and policy makers. METHODS: Nine databases were searched systematically with 112 studies from 14 different countries included and analysed to produce a thematic map of the literature. RESULTS: Reviews (n = 26) highlighted different mortality rates and specific causes between ethnic groups and by stage of kidney disease associated with individual, genetic, social and environmental factors. Primary studies focussing on uptake of treatment modalities (n = 19) found ethnic differences in access. Research evaluating intermediate outcomes and quality of care in different treatment phases (n = 35) e.g. dialysis adequacy, transplant evaluation and immunosuppression showed ethnic minorities were disadvantaged. This is despite a survival paradox for some ethnic minorities on dialysis seen in studies of longer term outcomes (n = 29) e.g. in survival time post-transplant and mortality. There were few studies which focussed on end of life care (n = 3) and ethnicity. Gaps identified were: limited evidence from all stages of the ESKD pathway, particularly end of life care; a lack of system oriented studies with a reliance on national routine datasets which are limited in scope; a dearth of qualitative studies; and a lack studies from many countries with limited cross country comparison and learning. CONCLUSIONS: Differences between ethnic groups occur at various points and in a variety of outcomes throughout the kidney care system. The combination of individual factors and system related variables affect ethnic groups differently indicating a need for culturally intelligent policy informed by research to prevent disadvantage.

Patient uptake and adherence to social prescribing: a qualitative study.

BACKGROUND: Social prescription is an initiative that aims to link patients in primary care with sources of support within the community and voluntary sector to improve their health, wellbeing, and care experience. Such programmes usually include navigators, who work with referred patients and issue onward referrals to sources of non-medical support. Most research on social prescribing (SP) has focused on outcome evaluations, resulting in a knowledge gap of factors affecting uptake and adherence. Understanding such factors enables the refinement of programmes, which has the potential to enhance uptake and adherence, reduce health inequalities, and optimise investment. AIM: To explore the experiences and views of service users, involved GPs, and navigators on factors influencing uptake and adherence to SP. DESIGN & SETTING: Qualitative interviews were conducted with stakeholders involved in an SP programme in the east of England (Luton). METHOD: Data were collected from semi-structured face-to-face interviews with service users, navigators, and GPs. Thematic analysis was used to analyse the data. RESULTS: Factors affecting uptake and adherence to SP were related to patients' trust in GPs, navigators' initial phone call, supportive navigators and service providers, free services, and perceived need and benefits. Reported barriers to uptake and adherence were fear of stigma of psychosocial problems, patient expectations, and the short-term nature of the programme. CONCLUSION: This study provides an insight into factors affecting patient uptake and adherence to SP programmes. More research in this field, including patients who refused to participate in SP, is needed.

Understanding the consumption of folic acid during preconception, among Pakistani, Bangladeshi and white British mothers in Luton, UK: a qualitative study.

BACKGROUND: To review the similarities and differences in Pakistani, Bangladeshi and White British mothers health beliefs (attitudes, knowledge and perceptions) and health behaviour regarding their consumption of folic acid pre-conception, to reduce the risk of neural tube defects. METHODS: Our study used a descriptive qualitative research approach, implementing face-to-face focus group discussions with Pakistani, Bangladeshi or White British mothers (normal birth outcomes and mothers with poor birth outcomes) and semi-structured interviews or focus groups with service providers using semi-structured topic guides. This method is well suited for under researched areas where in-depth information is sought. There were three sample groups: 1. Pakistani, Bangladeshi and White British mothers with normal birth outcomes (delivery after 37 weeks of gestation, in the preceding 6 to 24 months, weighing 2500 g and living within a specified postcode area in Luton, UK). 2. Pakistani Bangladeshi and white British bereaved mothers who had suffered a perinatal mortality (preceding 6 to 24 months, residing within a specificied postcode area). 3. Healthcare professionals working on the local maternity care pathway (i.e. services providing preconception, antenatal, antepartum and postpartum care). Transcribed discussions were analysed using the Framework Analysis approach. RESULTS: The majority of mothers in this sample did not understand the benefits or optimal time to take folic acid pre-conception. Conversely, healthcare professionals believed the majority of women did consume folic acid, prior to conception. CONCLUSIONS: There is a need to increase public health awareness of the optimal time and subsequent benefits for taking folic acid, to prevent neural tube defects.

Facilitators and barriers of implementing and delivering social prescribing services: a systematic review.

BACKGROUND: Social Prescribing is a service in primary care that involves the referral of patients with non-clinical needs to local services and activities provided by the third sector (community, voluntary, and social enterprise sector). Social Prescribing aims to promote partnership working between the health and the social sector to address the wider determinants of health. To date, there is a weak evidence base for Social Prescribing services. The objective of the review was to identify factors that facilitate and hinder the implementation and delivery of SP services based in general practice involving a navigator. METHODS: We searched eleven databases, the grey literature, and the reference lists of relevant studies to identify the barriers and facilitators to the implementation and delivery of Social Prescribing services in June and July 2016. Searches were limited to literature written in English. No date restrictions were applied. Findings were synthesised narratively, employing thematic analysis. The Mixed Methods Appraisal Tool Version 2011 was used to evaluate the methodological quality of included studies. RESULTS: Eight studies were included in the review. The synthesis identified a range of factors that facilitate and hinder the implementation and delivery of SP services. Facilitators and barriers were related to: the implementation approach, legal agreements, leadership, management and organisation, staff turnover, staff engagement, relationships and communication between partners and stakeholders, characteristics of general practices, and the local infrastructure. The quality of most included studies was poor and the review identified a lack of published literature on factors that facilitate and hinder the implementation and delivery of Social Prescribing services. CONCLUSION: The review identified a range of factors that facilitate and hinder the implementation and delivery of Social Prescribing services. Findings of this review provide an insight for commissioners, managers, and providers to guide the implementation and delivery of future Social Prescribing services. More high quality research and transparent reporting of findings is needed in this field.

Primary care interventions to encourage organ donation registration: A systematic review.

BACKGROUND: Previous research has proposed that primary care interventions to increase organ donation rates can help address the discrepancy between organ donation rates and the number of patients awaiting transplant. However, no systematic review has been conducted to examine interventions in this setting. OBJECTIVE: To synthesise evidence from previous organ donation interventions conducted in a primary care setting. METHODS: Six databases and grey literature were systematically searched between November 2016 and July 2017. Inclusion criteria included English language, studies published after the year 2000 and unpublished studies. A quality assessment and narrative synthesis was conducted. RESULTS: Ten studies met the inclusion criteria, nine of which examined actual organ donor registration as their primary outcome. Eight interventions increased registration to be an organ donor. Successful interventions utilised active methods of participant engagement that encouraged donation at the point of patient contact. DISCUSSION: Despite the small pool of studies that met the inclusion criteria, the results suggest that primary care interventions could produce promising results for increasing organ donation registration. However, additional higher quality studies are required before firm conclusions can be made. Barriers to implementation were also found and suggest that the feasibility of a primary care environment for organ donation intervention should be investigated.

Access and utilisation of primary health care services comparing urban and rural areas of Riyadh Providence, Kingdom of Saudi Arabia.

BACKGROUND: The Kingdom of Saudi Arabia (KSA) has seen an increase in chronic diseases. International evidence suggests that early intervention is the best approach to reduce the burden of chronic disease. However, the limited research available suggests that health care access remains unequal, with rural populations having the poorest access to and utilisation of primary health care centres and, consequently, the poorest health outcomes. This study aimed to examine the factors influencing the access to and utilisation of primary health care centres in urban and rural areas of Riyadh province of the KSA. METHODS: A questionnaire survey was carried out to identify the barriers and enablers to accessing PHCS in rural (n = 5) and urban (n = 5) areas of Riyadh province, selected on the classification of the population density of the governorates. An adapted version of the NHS National Survey Programme was administered that included 50 questions over 11 sections that assessed a wide range of factors related to respondent's access and experience of the PHCS. A total of 935 responses were obtained with 52.9% (n = 495) from urban areas and the remaining 47.1% (n = 440) from rural areas of Riyadh province. RESULTS: This study highlights that there are high levels of satisfaction among patients among all PHCS. In relation to differences between urban and rural respondents, the findings indicated that there were significant variations in relation to: education level, monthly income, medical investigations, receiving blood tests on time, extra opening hours, distance, cleanliness and health prevention. Core barriers for rural patients related to the distance to reach PHCS, cleanliness of the PHCS, receiving health prevention and promotion services, which should serve to improve health outcomes. CONCLUSIONS: This study highlighted important differences in access to and utilisation of PHCS between urban and rural populations in Riyadh province in the KSA. These findings have implications for policy and planning of PHCCs and reducing inequalities in health care between rural and urban populations and contributing to a reduction in the chronic disease burden in Riyadh province.

Meeting the Challenge of Diabetes in Ageing and Diverse Populations: A Review of the Literature from the UK.

The impact of type 2 diabetes on ageing societies is great and populations across the globe are becoming more diverse. Complications of diabetes unequally affect particular groups in the UK older people, and people with a South Asian background are two population groups with increased risk whose numbers will grow in the future. We explored the evidence about diabetes care for older people with South Asian ethnicity to understand the contexts and mechanisms behind interventions to reduce inequalities. We used a realist approach to review the literature, mapped the main areas where relevant evidence exists, and explored the concepts and mechanisms which underpinned interventions. From this we constructed a theoretical framework for a programme of research and put forward suggestions for what our analysis might mean to providers, researchers, and policy makers. Broad themes of cultural competency; comorbidities and stratification; and access emerged as mid-level mechanisms which have individualised, culturally intelligent, and ethical care at their heart and through which inequalities can be addressed. These provide a theoretical framework for future research to advance knowledge about concordance; culturally meaningful measures of depression and cognitive impairment; and care planning in different contexts which support effective diabetes care for aging and diverse populations.

Exploring access to end of life care for ethnic minorities with end stage kidney disease through recruitment in action research.

BACKGROUND: Variation in provision of palliative care in kidney services and practitioner concerns to provide equitable access led to the development of this study which focussed on the perspectives of South Asian patients and their care providers. As people with a South Asian background experience a higher risk of Type 2 Diabetes (T2DM) and end stage kidney failure (ESKF) compared to the majority population but wait longer for a transplant, there is a need for end of life care to be accessible for this group of patients. Furthermore because non English speakers and people at end of life are often excluded from research there is a dearth of research evidence with which to inform service improvement. This paper aims to explore issues relating to the process of recruitment of patients for a research project which contribute to our understanding of access to end of life care for ethnic minority patients in the kidney setting. METHODS: The study employed an action research methodology with interviews and focus groups to capture and reflect on the process of engaging with South Asian patients about end of life care. Researchers and kidney care clinicians on four NHS sites in the UK recruited South Asian patients with ESKF who were requiring end of life care to take part in individual interviews; and other clinicians who provided care to South Asian kidney patients at end of life to take part in focus groups exploring end of life care issues. In action research planning, action and evaluation are interlinked and data were analysed with emergent themes fed back to care providers through the research cycle. Reflections on the process of patient recruitment generated focus group discussions about access which were analysed thematically and reported here. RESULTS: Sixteen patients were recruited to interview and 45 different care providers took part in 14 focus groups across the sites. The process of recruiting patients to interview and subsequent focus group data highlighted some of the key issues concerning access to end of life care. These were: the identification of patients approaching end of life; and their awareness of end of life care; language barriers and informal carers' roles in mediating communication; and contrasting cultures in end of life kidney care. CONCLUSIONS: Reflection on the process of recruitment in this action research study provided insight into the complex scenario of end of life in kidney care. Some of the emerging issues such as the difficulty identifying patients are likely to be common across all patient groups, whilst others concerning language barriers and third party communication are more specific to ethnic minorities. A focus on South Asian ethnicity contributes to better understanding of patient perspectives and generic concepts as well as access to end of life kidney care for this group of patients in the UK. Action research was a useful methodology for achieving this and for informing future research to include informal carers and other ethnic groups.

Who uses NHS health checks? Investigating the impact of ethnicity and gender and method of invitation on uptake of NHS health checks.

BACKGROUND: NHS Health Checks is a national risk assessment prevention programme for all individuals aged 40-74 that reside in England. Through the systematic assessment of an individual's ten year disease risk, this programme aims to provide early identification and subsequent management of this risk. However, there is limited evidence on how socio-demographic factors impact on uptake and what influence the invitation method has on uptake to this programme. METHODS: NHS Health Check data from April 2013 to March 2014 was analysed (N = 50,485) for all 30 GP Practices in Luton, a culturally diverse town in England, UK. Data was collected for age, ethnicity, uptake (attendance and non attendance) and invitation method (letter written, verbal face-to-face, telephone). Actual usage of NHS Health Checks was determined for each ethnic group of the population and compared using Chi-square analysis. RESULTS: The overall uptake rate for Luton was 44 %, markedly lower that the set target of 50-75 %. The findings revealed a variation of uptake in relation to age, gender, level of deprivation. Ethnicity and gender variations were also found, with 'White British' 'Black Caribbean' and 'Indian' patients most likely to take up a NHS Health Check. However, patients from 'Any Other White Background' and 'Black African' were significantly less likely to uptake an NHS Health Check compared to all other ethnic groups. Ethnicity and gender differences were also noted in relation to invitation method. CONCLUSIONS: The findings revealed that different invitation methods were effective for different ethnic and gender groups. Therefore, it is suggested that established protocols of invitation are specifically designed for maximizing the response rate for each population group. Future research should now focus on uncovering the barriers to uptake in particular culturally diverse population groups to determine how public health teams can better engage with these communities.

Who uses NHS Direct? Investigating the impact of ethnicity on the uptake of telephone based healthcare.

INTRODUCTION: NHS Direct, a leading telephone healthcare provider worldwide, provided 24/7 health care advice and information to the public in England and Wales (1998-2014). The fundamental aim of this service was to increase accessibility, however, research has suggested a disparity in the utilisation of this service related to ethnicity. This research presents the first national study to determine how the diverse population in England have engaged with this service. METHODS: NHS Direct call data from the combined months of July, 2010 October, 2010, January 2011 and April, 2011 was analysed (N = 1,342, 245) for all 0845 4647 NHS Direct core service calls in England. Expected usage of NHS Direct was determined for each ethnic group of the population by age and gender and compared by actual usage using Chi-square analysis. A one-way analysis of variance (ANOVA) was used to determine variations of uptake by ethnic group and Index for Multiple Deprivation (IMD) 2010 rank. RESULTS: Results confirmed that all mixed ethnic groups (White and Black Caribbean, White and Black African, White and Asian) had a higher than expected uptake of NHS Direct which held consistent across all age groups. Lower than expected uptake was found for Black (African/Caribbean) and Asian (Bangladeshi/Indian/Chinese) ethnic group which held consistent by age and gender. For the Pakistani ethnic group usage was higher than expected in adults aged 40 years and older although was lower than expected in younger age groups (0-39). CONCLUSION: Findings support previous research suggesting a variation in usage of NHS Direct influenced by ethnicity, which is evidenced on a national level. Further research is now required to examine the underlying barriers that contribute to the ethnic variation in uptake of this service.

Barriers and facilitators to using NHS Direct: a qualitative study of 'users' and 'non-users'.

BACKGROUND: NHS Direct, introduced in 1998, has provided 24/7 telephone-based healthcare advice and information to the public in England and Wales. National studies have suggested variation in the uptake of this service amongst the UK's diverse population. This study provides the first exploration of the barriers and facilitators that impact upon the uptake of this service from the perspectives of both 'users' and 'non- users'. METHODS: Focus groups were held with NHS Direct 'users' (N = 2) from Bedfordshire alongside 'non-users' from Manchester (N = 3) and Mendip, Somerset (N = 4). Each focus group had between five to eight participants. A total of eighty one people aged between 21 and 94 years old (M: 58.90, SD: 22.70) took part in this research. Each focus group discussion lasted approximately 90 minutes and was audiotape-recorded with participants' permission. The recordings were transcribed verbatim. A framework approach was used to analyse the transcripts. RESULTS: The findings from this research uncovered a range of barriers and facilitators that impact upon the uptake of NHS Direct. 'Non-users' were unaware of the range of services that NHS Direct provided. Furthermore, 'non-users' highlighted a preference for face-to face communication, identifying a lack of confidence in discussing healthcare over the telephone. This was particularly evident among older people with cognitive difficulties. The cost to telephone a '0845' number from a mobile was also viewed to be a barrier to access NHS Direct, expressed more often by 'non-users' from deprived communities. NHS Direct 'users' identified that awareness, ease of use and convenience were facilitators which influenced their decision to use the service. CONCLUSIONS: An understanding of the barriers and facilitators which impact on the access and uptake of telephone-based healthcare is essential to move patients towards the self-care model. This research has highlighted the need for telephone-based healthcare services to increase public awareness; through the delivery of more targeted advertising to promote the service provision available.