A perspective of massive open online courses (MOOCs) and public health.

Massive open online courses (MOOCs) have emerged as an innovative educational technology relevant to and affecting higher education, professional development, and lifelong learning. This paper introduces the principles of MOOCs and reviews the development of these platforms over time. We reflect upon the considerable investment by institutions to develop, deliver and promote such courses, particularly in public health. While open to interpretation, the inherent power, influence, and effectiveness of MOOCs is unquestionable. The potential contribution of MOOCs to public health education is immense, with almost universal reach and access. However, apart from research into participant engagement and knowledge, MOOC-related research and evaluation continue to lag with the rapid proliferation of these courses in response to emerging challenges, as seen with the Coronavirus Disease 19 (COVID-19) pandemic. This makes analyzing the contribution of MOOCs to public health education, health promotion and community programs challenging. This perspective article provides a robust rationale for the necessity of MOOCs and their utility in upskilling health professionals and the general public. It builds on current knowledge to comprehensively explore the factors influencing the development, and application of MOOCs.

Independent effect of haemodialysis session frequency and duration on survival in non-indigenous Australians on haemodialysis.

BACKGROUND: End-stage kidney disease patients have increased mortality compared to the general population. Haemodialysis (HD) of more frequent and of longer duration has been proposed to improve survival but it remains unclear if this is attributed to increased frequency, duration, or both. We aimed to examine the independent effects of session frequency and duration on mortality in incident HD patients. METHODS: A retrospective cohort study was performed using data from the Australian and New Zealand Dialysis and Transplant Registry examining non-Indigenous patients aged ≥18 years who initiated HD of ≥3 sessions/week in Australia from 2001 to 2015. Initial dialysis prescription was categorized as session duration >5 h/session compared to ≤5 h/session and session frequency as >3 sessions/week compared to 3 sessions/week. Survival analysis was performed using Cox regression analysis, with multivariable analysis controlling for available covariates. RESULTS: We examined 16 944 patients of whom 757 (4.5%) received >3 sessions/week and 518 (3.1%) received >5 h/session. After controlling for frequency, patients initiated on HD sessions >5 h had a significantly reduced risk of mortality compared with patients with HD session ≤5 h (adjusted hazard ratio (HR) = 0.57; 95% confidence interval (CI) = 0.44-0.74). In contrast, patients initiated on >3 sessions/week of HD had a similar risk of death when compared with patients on 3 sessions/week of HD (adjusted HR = 0.97; 95% CI = 0.84-1.13), after controlling for duration. Limitations include potential residual confounding and changes in exposure over time. CONCLUSION: Longer duration rather than increased frequency of treatment appears to reduce mortality in HD patients. This has implications for management and requires further study.

Assessing risk of adverse drug reactions in the elderly: a feasibility study.

Background Adverse drug reactions are common in Australian general practice and can be a cause of, or contribute to, preventable hospital admissions. Developing practical tools to assist in identifying patients who are at high risk of serious adverse drug reactions is an important step in preventing these hospitalisations. Objective The aims of the study were to apply the Prediction of Hospitalisation due to Adverse Drug Reactions in Elderly Community-Dwelling Patients (PADR-EC) Score to assess the risk of medication-related hospitalisation among patients aged ≥ 65 years attending a rural general practice, and to investigate general practitioners' acceptance of the PADR-EC Score. Setting The project was based in a multicentre rural general practice in southern Tasmania, Australia. Method We conducted a cross-sectional study wherein the PADR-EC score was administered to patients aged ≥ 65 years attending a general practice. A focus group of general practice doctors was conducted and thematic analysis of the transcript used to explore their views regarding the utility of the PADR-EC score. Main Outcome Measures Successful application of the PADR-EC Score and an evaluation of general practitioners' acceptance of the PADR-EC Score are the two outcome measures of the project. Results The PADR-EC score was applied by the practice pharmacist and reported to GPs for 428 patients aged ≥ 65 years, with 24.8% classified as high-risk. The focus group found the PADR-EC score helped raise awareness of the risk of adverse drug reactions in the general practice setting. Doctors demonstrated good understanding of the PADR-EC Score and there were no negative reactions to the delivery model used. No changes to prescribing were implemented directly as a result of the PADR-EC Score, but more caution was used when doctors provided their usual clinical care. Conclusion Doctors used the PADR-EC score to complement their decision making. The PADR-EC Score was used as a reminder to review existing medication lists, follow-up on pathology results that may impact drug treatment and assess patients for prevalent ADRs. Further research is needed to validate the PADR-EC score in this setting.

HealthLit4Kids study protocol; crossing boundaries for positive health literacy outcomes.

BACKGROUND: Health attitudes and behaviours formed during childhood greatly influence adult health patterns. This paper describes the research and development protocol for a school-based health literacy program. The program, entitled HealthLit4Kids, provides teachers with the resources and supports them to explore the concept of health literacy within their school community, through classroom activities and family and community engagement. METHODS: HealthLit4Kids is a sequential mixed methods design involving convenience sampling and pre and post intervention measures from multiple sources. Data sources include individual teacher health literacy knowledge, skills and experience; health literacy responsiveness of the school environment (HeLLO Tas); focus groups (parents and teachers); teacher reflections; workshop data and evaluations; and children's health literacy artefacts and descriptions. The HealthLit4Kids protocol draws explicitly on the eight Ophelia principles: outcomes focused, equity driven, co-designed, needs-diagnostic, driven by local wisdom, sustainable, responsive, systematically applied. By influencing on two levels: (1) whole school community; and (2) individual classroom, the HealthLit4Kids program ensures a holistic approach to health literacy, raised awareness of its importance and provides a deeper exploration of health literacy in the school environment. The school-wide health literacy assessment and resultant action plan generates the annual health literacy targets for each participating school. DISCUSSION: Health promotion cannot be meaningfully achieved in isolation from health literacy. Whilst health promotion activities are common in the school environment, health literacy is not a familiar concept. HealthLit4Kids recognizes that a one-size fits all approach seldom works to address health literacy. Long-term health outcomes are reliant on embedded, locally owned and co-designed programs which respond to local health and health literacy needs.

Pokémon-Go: Why Augmented Reality Games Offer Insights for Enhancing Public Health Interventions on Obesity-Related Diseases.

Stimulating widespread interests of the population to participate in behavioural changes through information and technology has been an aim of much health informatics research. The recent widespread participation of the augmented reality game Pokémon Go which encourages exercises, provides significant insights into the potential of information technology to improve healthcare intervention on obesity-related disease. Does Pokémon Go point to another way of achieving health benefits using mobile devices? This paper analyses the features of Pokémon Go in relation to potential health benefits. This paper suggests from the perspective of a user on changes to the game that potentially could help with obesity, mental health cardiovascular health and vitamin D deficiencies. While the impact of augmented reality games on improving exercises might be substantial, the question of sustainability and likely long-term health outcomes remain debatable. The rapid uptake of Pokémon Go by the population around the world, however, should serve as a useful lesson for information and technological design to improve outcomes obesity-related diseases in the future.

Temporal trends and risk factors for readmission for infections, gastrointestinal and immobility complications after an incident hospitalisation for stroke in Scotland between 1997 and 2005.

BACKGROUND: Improvements in stroke management have led to increases in the numbers of stroke survivors over the last decade and there has been a corresponding increase of hospital readmissions after an initial stroke hospitalisation. The aim of this study was to examine the one year risk of having a readmission due to infective, gastrointestinal or immobility (IGI) complications and to identify temporal trends and any risk factors. METHODS: Using a cohort of first hospitalised for stroke patients who were discharged alive, time to first event (readmission for IGI complications or death) within 1 year was analysed in a competing risks framework using cumulative incidence methods. Regression on the cumulative incidence function was used to model the risks of having an outcome using the covariates age, sex, socioeconomic status, comorbidity, discharge destination and length of hospital stay. RESULTS: There were a total of 51,182 patients discharged alive after an incident stroke hospitalisation in Scotland between 1997-2005, and 7,747 (15.1%) were readmitted for IGI complications within a year of the discharge. Comparing incident stroke hospitalisations in 2005 with 1997, the adjusted risk of IGI readmission did not increase (HR = 1.00 95% CI (0.90, 1.11). However, there was a higher risk of IGI readmission with increasing levels of deprivation (most deprived fifth vs. least deprived fifth HR = 1.16 (1.08, 1.26). CONCLUSIONS: Approximately 15 in 100 patients discharged alive after an incident hospitalisation for stroke in Scotland between 1997 and 2005 went on to have an IGI readmission within one year. The proportion of readmissions did not change over the study period but those living in deprived areas had an increased risk.

Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods.

BACKGROUND: In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high. METHODS AND FINDINGS: Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their "protection by marriage," cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men. CONCLUSIONS: Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy.

Trends in procurement costs for HIV commodities: a 7-year retrospective analysis of global fund data across 125 countries.

BACKGROUND: Nearly 40% of Global Fund money goes toward procurement. However, no analyses have been published to show how costs vary across regions and time, despite the availability of procurement data collected through the Global Fund's price and quality reporting system. METHODOLOGY: We analyzed data for the 3 most widely procured commodities for the prevention, diagnosis, and treatment of HIV. These were male condoms, HIV rapid tests, and the antiretroviral (ARV) combination of lamivudine/nevirapine/zidovudine. The compared costs, first across time (2005-2012), then across regions, and finally, between individual procurement reported through the price and quality reporting and pooled procurement reported through the Global Fund's voluntary pooled procurement system. All costs were adjusted for inflation and reported in US dollars. KEY FINDINGS: There were 2337 entries from 578 grants in 125 countries. The procurement cost for the ARV dropped substantially over the period, whereas those for condoms and HIV tests remained relatively stable. None of the commodity prices increased. Regional variations were pronounced for HIV tests, but minimal for condoms and the ARV. The unit cost for the 3-table ARV combination, for instance, varied between US$0.15 and US$0.23 in South Asia and the Eastern Europe/Central Asia regions, respectively, compared with a range of $0.23 (South Asia)-$1.50 (Eastern Europe/Central Asia) for a single diagnostic test. Pooled procurement lowered costs for condoms but not the other commodities. CONCLUSIONS: We showed how global procurement costs vary by region and time. Such analyses should be done more often to identify and correct market insufficiencies.

Regional and temporal trends in malaria commodity costs: an analysis of Global Fund data for 79 countries.

BACKGROUND: Although procurement consumes nearly 40% of Global Fund's money, no analyses have been published to show how costs vary across regions and time. This paper presents an analysis of malaria-related commodity procurement data from 79 countries, as reported through the Global Fund's price and quality reporting (PQR) system for the 2005-2012 period. METHODS: Data were analysed for the three most widely procured commodities for prevention, diagnosis and treatment of malaria. These were long-lasting insecticide-treated nets (LLINs), malaria rapid diagnostic tests (RDTs) and the artemether/lumefantrine (AL) combination treatment. Costs were compared across time (2005-2012), regions, and between individual procurement reported through the PQR and pooled procurement reported through the Global Fund's voluntary pooled procurement (VPP) system. All costs were adjusted for inflation and reported in US dollars. RESULTS: The data included 1,514 entries reported from 79 countries over seven years. Of these, 492 entries were for LLINs, 330 for RDTs and 692 for AL. Considerable variations were seen by commodity, although none showed an increase in cost. The costs for LLINs, RDTs and AL all dropped significantly over the period of analysis. Regional variations were also seen, with the cost for all three commodities showing significant variations. The median cost for a single LLIN ranged from USD 4.3 in East Asia to USD 5.0 in West and Central Africa. The cost of a single RDT was lowest in West and Central Africa at US$ 0.57, and highest in the Latin American region at US$ 1.1. AL had the narrowest margin of between US$ 0.06 per tablet in sub-Saharan Africa and South Asia, and US$ 0.08 in the Latin American and Eastern Europe regions. CONCLUSION: This paper concludes that global procurement costs do vary by region and have reduced overall over time. This suggests a mature market is operating when viewed from the global level, but regional variation needs further attention. Such analyses should be done more often to identify and correct market insufficiencies.

Angina and intermittent claudication in 7403 participants of the 2003 Scottish Health Survey: impact on general and mental health, quality of life and five-year mortality.

BACKGROUND: Angina and intermittent claudication impair function and mobility and reduce health-related quality of life. Both symptoms have similar etiology, yet the physical and psychological impacts of these symptoms are rarely studied in community-based cohorts or in individuals with isolated symptoms. METHODS: The 2003 Scottish Health Survey was a cross-sectional survey which enrolled a random sample of individuals aged 16-95 years living in Scotland. The Rose Angina Questionnaire, the Edinburgh Claudication Questionnaire, the Short Form-12 (SF-12) and the General Health Questionnaire were completed. Self-assessed general health was reported. Survey results were linked to national death records and mortality at five years was calculated. Subjects with isolated angina or intermittent claudication and neither symptom were compared (22 participants with both symptoms were excluded); 7403 participants (aged ≥ 16 years) were included. RESULTS: Participants with angina (n=205; 60 ± 15 years; 45% male) rated their general health worse and were more likely to have a potential mental-health problem than those with intermittent claudication (n=173; 61 ± 15 years; 41% male). Mean (standard deviation) physical and mental component scores on the SF-12 were higher for participants with intermittent claudication relative to those with angina (physical component score: 42.3 (10.6) vs. 35.0 (11.7), p<0.001; mental component score: 52.3 (8.5) vs. 46.5 (11.7), p=0.001). There was an observed absolute difference in five-year mortality of 4.8% (angina 12.3%, 95% CI 8.5-17.6; intermittent claudication 7.5%, 95% CI 4.4-12.6) although not statistically significant (p=0.16). CONCLUSIONS: Both intermittent claudication and angina adversely impact general and mental health and survival, even in a relatively young, community-based cohort.

Gogo care and protection of vulnerable children in rural Malawi: changing responsibilities, capacity to provide, and implications for well-being in the era of HIV and AIDS.

The role of older women in the care and protection of vulnerable children in sub-Saharan Africa may be changing given increasing rates of orphanhood due to AIDS. Concern regarding their capacity to provide for children and implications for their health and well-being dominate the literature. However, studies have not yet examined the situation of older caregivers in comparison to their younger counterparts over time. In this study, panel data on 1,219 caregivers in rural Malawi between 2007 and 2009 is complemented by in-depth interview (N=62) and group discussion (N=4) data. Caregiver responsibilities, capacity to care for children, and implications for well-being are examined. Chi-square tests examine differences in these measures between older foster caregivers and younger foster caregivers, parents of orphans, and parents of non-orphans. Older women, in comparison with younger counterparts, are more stable as primary caregivers for orphans. Care by older women is particularly valued when younger family stability is threatened by burdens of orphan care. Qualitative data reveal many challenges that older caregivers face, most notably provision of food. However, survey data suggest that the capacity to provide food, schooling and other basic needs is similar among older and younger caregivers. Self-reported health status is generally poorer among older caregivers, however levels of emotional distress and social capital are similar among older and younger caregivers. Providing care for children in old age appears to entail a number of benefits. Older women committed to providing care and protection for children are important assets, particularly in the context of threats to child well-being due to HIV and AIDS. Bolstering older caregivers with material and social support to help sustain their key roles in fostering is a promising avenue for maintaining extended family responses to HIV and AIDS.

Mobile phone use for contacting emergency services in life-threatening circumstances.

BACKGROUND: The potential health benefits of mobile phone use have not been widely studied, except for telemedicine-type applications. STUDY OBJECTIVES: This study seeks to determine whether initial contact with emergency services via a mobile phone in life-threatening situations is associated with potential health benefits when compared to contact via a landline. METHODS: A record-linkage study was carried out in which data from all emergency dispatches for immediately life-threatening events from a United Kingdom county ambulance service were linked to the Patient Admission System at two major local hospitals. Mortality (at the scene, at the emergency department [ED], and during hospitalization); transfer to the ED; admission (inpatient care, and intensive care unit); and length of stay were analyzed for calls classified as Code Red (immediately life-threatening) by initial exposure (mobile phone vs. landline), while controlling for potential confounding variables. RESULTS: Of 354,199 ambulances dispatched to attend emergency incidents, 66% transported patients to the hospital while 2% stood down due to death at the scene. Mobile phone compared to landline reporting of emergencies resulted in significant reductions in the risk of death at the scene (odds ratio [OR] 0.77), but not for death in the ED or during inpatient admission. The risk of being transferred to the ED and subsequent inpatient admission were significantly lower with reporting from mobile phones compared to landline (OR 0.93 and OR 0.82, respectively). CONCLUSIONS: In this study, evidence of statistical association was demonstrated between the use of mobile phones to alert ambulance services in life-threatening situations and improved outcomes for patients.

Prior psychiatric hospitalization is associated with excess mortality in patients hospitalized with non-cardiac chest pain: a data linkage study based on the full Scottish population (1991-2006).

AIMS: Non-cardiac chest pain (NCCP) is considered a benign condition. We investigate case-fatality following an incident hospitalization for NCCP and determine whether previous psychiatric hospitalization is associated with short-term mortality. METHODS AND RESULTS: This was a population-based retrospective cohort study of 159 888 patients discharged from hospital in Scotland (1991-2006) following a first NCCP hospitalization, using routinely collected morbidity and mortality data. All-cause and cardiovascular disease (CVD) mortality at 1 year following hospitalization was examined. A total of 3514 (4.4%) men and 3136 (3.9%) women with a first NCCP hospitalization had a psychiatric hospitalization in the 10 years preceding incident NCCP hospitalization. Those with a previous psychiatric hospitalization were younger and more socioeconomically deprived (SED). Overall, crude case fatality at 1 year was 4.4% in men and 3.7% in women. This was higher in patients with a previous psychiatric hospitalization compared with those without (overall: men 6.3 vs. 4.3%; women: 5.3 vs. 3.6%), in all age groups and all SED quintiles. Following adjustment (year of NCCP hospitalization, SED, co-morbid diabetes, and hypertension), the hazard of all-cause and CVD-specific death at 1 year was higher in men and women with a previous psychiatric hospitalization than without, with effect modification according to age group. CONCLUSION: Non-cardiac chest pain is not an entirely benign condition. Individuals with a hospital discharge diagnosis of NCCP who have a previous psychiatric hospitalization have a greater risk of death, all-cause, and CVD-specific, at 1 year, than those without. A NCCP hospitalization is an opportunity to engage, and where appropriate, intervene to modify cardiovascular risk in this difficult-to-reach and high-risk group.

Determinants of hanging and use of ITNs in the context of near universal coverage in Zambia.

Roll Back Malaria recently recommended a policy of universal coverage with insecticide-treated nets (ITNs) so that all age groups can benefit from protection against malaria. Countries adopting the 'universal access' policy include Zambia. Policy implementation in many settings involves mass distribution of free ITNs to achieve a measure of universal coverage. This study examines ITN deployment and use in the context of mass distribution efforts towards achieving universal coverage in a malaria-endemic district in Zambia. We use multiple logistic regression to identify predictors of ITN deployment and use by anyone in the household and by children under five. Among ITN-owning households with a child under five, 69% used at least one ITN the night before the survey. About half of those children (54%) in ITN-owning households were covered the previous night. A strong and consistent predictor of use is household deployment of at least one ITN. Just over half of all ITNs were observed hanging, and reported use of nets for purposes other than malaria prevention was only 3%. Net characteristics, including shape, colour and whether or not the ITN was purchased, were not associated with net deployment. However, ITNs in poor condition are more likely to be observed hanging than ITNs in new or good condition. In the context of free mass distribution of ITNs, behaviour change communication and activities are necessary to improve use. Results suggest campaigns and messages that persuade recipients to hang up their ITNs would contribute towards closing the gap between ownership and use.

The influence of orphan care and other household shocks on health status over time: a longitudinal study of children's caregivers in rural Malawi.

In the context of rising rates of orphanhood in AIDS-affected settings, very little is understood about implications for caregiver well-being given increasing and intensifying responsibilities for the care of orphaned children. Emotional distress and self-reported health status as well as shifts in household orphan care, wealth, food security and recent illness and death among household members were measured among a panel of 1219 caregivers in rural Malawi between 2007 and 2009. Logistic regression was used to identify predictors of improved and diminished caregiver health and emotional distress. Results suggest that becoming an orphan caregiver is associated with a shift from good to poor health status (adjusted odds ratio [AOR]=2.29, 95% confidence interval [CI]=1.16-4.54), and that elevated levels of distress and poor health both persist over time in comparison with care for non-orphans only. Once engaged in orphan care, taking on additional orphans is associated with increased emotional distress in relation to not caring for orphans (AOR=3.16, 95% CI=1.30-7.73) as well as in relation to maintaining the same number of orphans in care over time (AOR=2.84, 95% CI=1.04-7.70). In addition, findings illustrate the strong influence of household wealth and food security on caregiver well-being. Food insecurity and poverty that persist or develop over time are associated with increasing distress. Conversely, maintenance or improvement in food security and household wealth are associated with decreases in distress. Providing all aspects of household maintenance and care for children, primary caregivers are key to the extended family solution for orphaned and vulnerable children. Bolstering the foundation of rural African families to ensure care and protection of these children involves targeting support to orphan caregivers but must also include addressing the issues of poverty and food insecurity that pose a wider threat to caregiving capacity.

Trends in incidence and in short term survival following a subarachnoid haemorrhage in Scotland, 1986-2005: a retrospective cohort study.

BACKGROUND: To examine age and sex specific incidence and 30 day case fatality for subarachnoid haemorrhage (SAH) in Scotland over a 20 year period. METHODS: A retrospective cohort study using routine hospital discharge data linked to death records. RESULTS: Between 1986 and 2005, 12,056 individuals experienced an incident SAH. Of these 10,113 (84%) survived to reach hospital. Overall age-standardised incidence rates were greater in women than men and remained relatively stable over the study period. In 2005, incidence in women was 12.8 (95% CI 11.5 to 14.2) and in men 7.9 (95% CI 6.9 to 9.1). 30 day case fatality in individuals hospitalised with SAH declined substantially, falling from 30.0% in men and 33.9% in women in 1986-1990 to 24.5% in men and 29.1% in women in 2001-2005. For both men and women, the largest reductions were observed in those aged between 40 to 59 years. After adjustment for age, socio-economic status and co-morbidity, the odds of death at 30 days in 2005 compared to odds of death in 1986 was 0.64 (0.54 to 0.76), p < 0.001 for those below 70 years, and 1.14 (0.83 to 1.56), p = 0.4 in those 70 years and above. CONCLUSIONS: Incidence rates for SAH remained stable between 1986 and 2005 suggesting that a better understanding of SAH risk factors and their reduction is needed. 30 day case fatality rates have declined substantially, particularly in middle-age. However, they remain high and it is important to ensure that this is not due to under-diagnosis or under-treatment.

Alcohol brewing and the African tuberculosis epidemic.

Countries in much of Africa are struggling with large tuberculosis (TB) epidemics. Although the treatment programs are being implemented as well as the many constraints allow, more prevention of TB is needed. Based on literature on alcohol and TB, and observations and case studies, we consider one potential area for intervention might be the popular and ubiquitous small bars and beer huts in many towns and cities. In these usually poverty-ridden sites, with their densely packed clientele, large amounts of alcohol are consumed often by those with compromised immune systems who are at risk of acquiring the disease. The alcohol brewers-called Mama Pimas (from kupima, to measure, in Kiswahili) in Kenya-are the subject of this editorial. We look at the risks and potential benefits of reaching these women. Medical anthropologists are needed to help provide better evidence for TB prevention programs.

Overcoming barriers to engaging socio-economically disadvantaged populations in CHD primary prevention: a qualitative study.

BACKGROUND: Preventative medicine has become increasingly important in efforts to reduce the burden of chronic disease in industrialised countries. However, interventions that fail to recruit socio-economically representative samples may widen existing health inequalities. This paper explores the barriers and facilitators to engaging a socio-economically disadvantaged (SED) population in primary prevention for coronary heart disease (CHD). METHODS: The primary prevention element of Have a Heart Paisley (HaHP) offered risk screening to all eligible individuals. The programme employed two approaches to engaging with the community: a) a social marketing campaign and b) a community development project adopting primarily face-to-face canvassing. Individuals living in areas of SED were under-recruited via the social marketing approach, but successfully recruited via face-to-face canvassing. This paper reports on focus group discussions with participants, exploring their perceptions about and experiences of both approaches. RESULTS: Various reasons were identified for low uptake of risk screening amongst individuals living in areas of high SED in response to the social marketing campaign and a number of ways in which the face-to-face canvassing approach overcame these barriers were identified. These have been categorised into four main themes: (1) processes of engagement; (2) issues of understanding; (3) design of the screening service and (4) the priority accorded to screening. The most immediate barriers to recruitment were the invitation letter, which often failed to reach its target, and the general distrust of postal correspondence. In contrast, participants were positive about the face-to-face canvassing approach. Participants expressed a lack of knowledge and understanding about CHD and their risk of developing it and felt there was a lack of clarity in the information provided in the mailing in terms of the process and value of screening. In contrast, direct face-to-face contact meant that outreach workers could explain what to expect. Participants felt that the procedure for uptake of screening was demanding and inflexible, but that the drop-in sessions employed by the community development project had a major impact on recruitment and retention. CONCLUSION: Socio-economically disadvantaged individuals can be hard-to-reach; engagement requires strategies tailored to the needs of the target population rather than a population-wide approach.

Estimating the impact of stroke unit care in a whole population: an epidemiological study using routine data.

BACKGROUND AND PURPOSE: Randomised trials indicate that organised inpatient (stroke unit) care has an important impact on patient outcomes with an absolute risk difference (ARD) of 3% for survival and 5% for returning home. However, it is unclear what impact this complex intervention actually has in routine practice. A comprehensive national dataset was used to study the impact of stroke unit implementation. METHODS: The Scottish linked discharge database was used to identify all patients admitted to hospital with an incident stroke. Analyses compared case fatality and discharge home (adjusted for age, sex, deprivation and comorbidity) for hospitals with or without a stroke unit during four consecutive study periods: 1986-1990, 1991-1995, 1996-2000 and 2001-2005. RESULTS: During the study period, the percentage of admissions to hospitals that had a stroke unit increased from 0% to 87%, the 6 month case fatality decreased from 45% to 29% and discharges home increased from 46% to 59%. Adjusted ORs (95% CI) for case fatality (stroke unit versus no unit) in each study period were as follows: not calculable (no units before 1991), 0.83 (0.78-0.89), 0.90 (0.86-0.94) and 0.87 (0.82-0.91). These equate to an ARD of 3.0% over the whole study period. Equivalent data for discharge home indicated an increased odds of discharge home: not calculable, 1.23 (1.15-1.31), 1.15 (1.10-1.21) and 1.17 (1.11-1.23) with an overall ARD of 5%. CONCLUSIONS: These results indicate a positive impact of a policy of stroke unit care on case fatality and discharge home. The estimated impact, after adjusting for case mix, appears very similar to that calculated using clinical trial data.