Enacting person-centredness in integrated care: A qualitative study of practice and perspectives within multidisciplinary groups in the care of older people.

BACKGROUND: Person-centredness is important in delivering care for long-term conditions. New models of care aim to co-ordinate care through integration of health and social care which require new ways of working, often remotely from the patient. OBJECTIVE: To describe how person-centred care is enacted within multidisciplinary groups (MDGs) created as part of a new service, integrating health and social care for older people. METHODS: We followed the implementation of eight neighbourhood MDGs, observing and interviewing staff from three MDGs at different phases of programme implementation using semi-structured topic guides. RESULTS: Thirty-four MDG meetings were observed and 32 staff interviewed. Three core themes were identified which impacted on enactment of person-centred care: the structural context of MDGs enabling person-centred care; interaction of staff and knowledge sharing during the MDG meetings; and direct staff involvement of the person outside the MDG discussion. CONCLUSIONS: This study provides new insights into attempts to enact person-centred care within a new model of service delivery. Teams did what they could to enact person-centred care in the absence of the "real" patient within MDG meetings. They were successful in delivering and co-ordinating some aspects of care (eg prompting medication reviews, referring to social worker, health improvement and arranging further multidisciplinary team meetings for complex cases). This "absence of patients" and time pressures within the MDGs led to reliance on the "virtual" record, enhanced by additional "soft" knowledge provided by staff, rather than ensuring the patient's voice was included.

Standardized comparison of glucose intolerance in West African-origin populations of rural and urban Cameroon, Jamaica, and Caribbean migrants to Britain

OBJECTIVE: To compare the prevalence of glucose intolerance in genetically similar African-origin populations within Cameroon and from Jamaica and Britain. RESEARCH DESIGN AND METHODS: Subjects studied were from rural and urban Cameroon or from Jamaica, or were Caribbean migrants, mainly Jamaican, living in Manchester, England. Sampling bases included a local census of adults aged 25-74 years in Cameroon, districts statistically representative in Jamaica, and population registers in Manchester. African-Caribbean ethnicity required three grandparents of this ethnicity. Diabetes was defined by the World Health Organization (WHO) 1985 criteria using a 75-g oral glucose tolerance test (2-h > or = 11.1 mmol/l or hypoglycemic treatment) and by the new American Diabetes Association criteria (fasting glucose > or = 7.0 mmol/l or hypoglycemic treatment). RESULTS: For men, mean BMIs were greatest in urban Cameroon and Manchester (25-27 kg/m2); in women, these were similarly high in urban Cameroon and Jamaica and highest in Manchester (27-28 kg/m2). The age-standardized diabetes prevalence using WHO criteria was 0.8 percent in rural Cameroon, 2.0 percent in urban Cameroon, 8.5 percent in Jamaica, and 14.6 percent in Manchester, with no difference between sexes (men: 1.1 percent, 1.0 percent, 6.5 percent, 15.3 percent, women: 0.5 percent, 2.8 percent, 10.6 percent, 14.0 percent), all tests for trend P < 0.001. Impaired glucose tolerance was more frequent in Jamaica. CONCLUSIONS: The transition in glucose intolerance from Cameroon to Jamaica and Britain suggests that environment determines diabetes prevalence in these populations of similar genetic origin.(Au)

Standardised comparison of glucose tolerance and diabetes prevalence in four African/African-Caribbean populations in Britain, Jamaica and Cameroon

To study factors promoting the emergence of diabetes in African-Caribbean (AfC) as the second largest ethnic minority in Britain and how these compare with genetically similar populations in Jamaica (origin of 80 percent AfC) and Cameroon, using the same protocol we carried out 75g glucose tolerance tests in representative community samples aged 25-74 years, by WHO criteria. As results were similar by gender, sexes are combined here. [See table] Diabetes prevalence (age-standardised) increased from Africa to the Caribbean to Europe and was highest in Manchester men. Body mass index showed a striking increase from rural to younger urban Cameroonians. Increasing NIDDM prevalence is paralleled across site by changes in nutritional and lifestyle factors, also measured using standardised methods. Even in Cameroon, prevalence approaches rates in whites in Europe.(AU)

Prevelance of NIDDM among populations of the African diaspora

OBJECTIVES: Rates of non-insulin-dependent diabetes mellitus have risen sharply in recent years among blacks in the U.S. and the U.K. Increase in risk have likewise been observed in the island nations of the Caribbean and in urban West Africa. To date, however, no systematic comparison of the geographic variation of NIDDM among black populations have been undertaken. RESEARCH DESIGN AND METHODS: In the course of an international collaborative study on cardiovascular disease, we used a standardized protocol to determine the rates of NIDDM and associated risk factors in populations of the African diaspora. Representative samples were drawn from sites in Nigeria, St. Lucia, Barbados, Jamaica, the United States, and the United Kingdom. A total of 4,823 individuals aged 25-74 years were recruited, all sites combined. RESULTS: In sharp contrast to a prevalence of 2 percent in Nigeria, age-adjusted prevalences of self-reported NIDDM were 9 percent in the Caribbean and 11 percent in the U.S. and the U.K. Mean BMI ranged from 22 kg/m2 among men in West Africa to 31 kg/m2 in women in the U.S. Disease prevalence across sites was essentially collinear with obesity, pointing to site differences in the balance between energy intake and expenditure as the primary determinant of differential NIDDM risk among these populations. CONCLUSIONS: In ethnic groups sharing a common genetic ancestry, these comparative data demonstrate the determing influence of changes in living conditions on the population risk of NIDDM.(AU)

Nutritional influences on the emergence of diabetes mellitus and high blood pressure in Afro-origin populations in Cameroon, Jamaica, and Caribbean migrants to Europe - abstract

Our four nation study is establishing the role of nutrition in evolving diabetes mellitus (DM) and high blood pressure (BP) in these Afro-origin populations. Using highly standardized methods, we are testing whether increasing energy (particularly fat) and Na+ intakes, and decreased K+, Ca+ and antioxidant intakes, are associated with decreasing glucose tolerance (GT) and increasing BP within and between centres. Random community samples, aged 25 - 74 years, are stratified by sex up to 1,500/centre to generate sufficient index cases of impaired (I) GT and `high' BP (> 140 and/or 90 mm Hg but < 160 to 95 mm Hg) for an intervention trial and incident phase. During a 2-hr 759 glucose tolerance test (GTT), a food frequency questionnaire (FQQ), built up from food dairies and 24-hr recalls, and repeat 24-hr urines are supplying mean energy, fat, carbohydrate, fibre, protein and cation intakes. To date, 894 Jamaicans have been seen at the Spanish Town site, some 780 people (360 Afro-Caribbean) in Manchester, with 180 GT tested, 416 Cameroonians (246 urban) and a pilot study completed in Paris. Rates of IGT and DM run at approximately 8 percent and 14 percent in Jamaica, 15 percent of each in Manchester, and 4-8 percent in Cameroon through Jamaica to Manchester. Those at risk of hypertension (> 140 and/or 90 mm Hg) are similarly distributed. As baseline prevalence rates are established, the nutritionally-based intervention programme will be piloted as a randomized trial. Such efforts offer the chance for primary prevention of high BP, diabetes mellitus and their complications in these populations, before or as they face an epidemic from them (AU)

Stroke risk and prevention in Afro-Caribbean populations: improving the rule of halves in hypertension detection and control by primary care - abstract

The Rule of Halves suggests that detection, treatment and control rates of hypertension are only half what they could be, producing a particular burden in black communities because prevalence is high. In the UK with free access to health care, such a `rule' depends on initiatives and effort of primary care teams in blood pressure (BP) screening, case finding and management. As part of our international collaborative project, we assessed the status of the Rule of Halves in our biethnic population sample. Using the Family Health Service population listings (more accurate locally than the Census) as denominators, random samples aged 25 - 79 years were drawn to reflect Afro-Caribbean (AfC) and white European communities. With highly standardized methods and appropriate size cuff, the mean sitting BP is calculated from the 2nd and 3rd readings. With a 65 percent response so far, hypertension prevalence (> 160 and/or 95 mm Hg) is greater in AfCs at 115/311 (37 percent) than in whites at 88/414 (21 percent); while most in both communities knew of their hypertension (80 percent AfC; whites 70 percent), 68 percent AfCs but 48 percent whites were treated; and of these only 22 percent AfCs still had BPs >160/95 mmHg compared with 40 percent whites. However, again, only half of either group (52 percent AfC, 45 percent white) had their BP proper controlled to <150/90mmHg. From these results the Population Attributable Risk (PAR) of stroke was calculated to be 51 percent for AfCs and 37 percent for whites, with 29 percent and 22 percent respectively, of strokes due to poor BP control. Even if there is over-ascertainment here, assuming all non-responders were not hypertensive would only reduce the respective PAR to 48 percent and 28 percent. Thus, there is considerable awareness of hypertension in the AfC community and the Rule of Halves has improved, although little change is seen in whites (AU)

Low prevalence of rheumatoid arthritis in Black-Caribbeans compared with whites in inner city Manchester

OJECTIVES- to compare the prevalence of rheumatoid arthtitis (RA) in Black-Caribbeans and whites living in the same urban area. METHODS- cases of inflammatory joint disease were ascertained initially from a postal screening survey of 1851 blacks and 1829 age and sex-matched non-Blacks identified from general practices in the Moss Side and Hulme districts of Manchester. The ethnicity of the respondents was confirmed using data from a postal screening questionnaire. Those reporting joint swelling or a history of arthritis were reviewed by a rheumatologist at surgeries held in each practice. The clinical records of the questionnaire non-responders and questionnaire-positive non-attenders at surgery were reviewed. RESULTS- in an adjusted denominator population of 1046 Black-Caribbeans and 997 whites, the cumulative prevalence of RA was 2.9/1000 in Black-Caribbeans and 8/1000 in whites, representing a prevalence in Black Caribbeans of 0.36 times that found in whites (95 percent confidence interval 0.1-1.3). CONCLUSIONS- rheumatoid arthritis occurs less commonly in Black-Caribbeans than in Whites. The findings are consistent with published studies showing a low RA prevalence in rural black populations (AU)