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Harwood H, Rhead R, Chui Z, Bakolis I, Connor L, Gazard B, Hall J, MacCrimmon S, Rimes KA, Woodhead C, Hatch SL. Variations by ethnicity in referral and treatment pathways for IAPT service users in South London. Psychol Med 2023; 53:1084-1095. [PMID: 34334151 PMCID: PMC9976018 DOI: 10.1017/s0033291721002518] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 05/27/2021] [Accepted: 06/04/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Improving Access to Psychological Therapies (IAPT) programme aims to provide equitable access to therapy for common mental disorders. In the UK, inequalities by ethnicity exist in accessing and receiving mental health treatment. However, limited research examines IAPT pathways to understand whether and at which points such inequalities may arise. METHODS This study examined variation by ethnicity in (i) source of referral to IAPT services, (ii) receipt of assessment session, (iii) receipt of at least one treatment session. Routine data were collected on service user characteristics, referral source, assessment and treatment receipt from 85 800 individuals referred to South London and Maudsley NHS Foundation Trust IAPT services between 1st January 2013 and 31st December 2016. Multinomial and logistic regression analysis was used to assess associations between ethnicity and referral source, assessment and treatment receipt. Missing ethnicity data (18.5%) were imputed using census data and reported alongside a complete case analysis. RESULTS Compared to the White British group, Black African, Asian and Mixed ethnic groups were less likely to self-refer to IAPT services. Black Caribbean, Black Other and White Other groups are more likely to be referred through community services. Almost all racial and minority ethnic groups were less likely to receive an assessment compared to the White British group, and of those who were assessed, all racial and ethnic minority groups were less likely to be treated. CONCLUSIONS Racial and ethnic minority service users appear to experience barriers to IAPT care at different pathway stages. Services should address potential cultural, practical and structural barriers.
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Affiliation(s)
- Hannah Harwood
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Rebecca Rhead
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Zoe Chui
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Ioannis Bakolis
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Health Service & Population Research Department, Centre for Implementation Science, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Luke Connor
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Billy Gazard
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Jheanell Hall
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Shirlee MacCrimmon
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Katharine A. Rimes
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Charlotte Woodhead
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Economic and Social Research Council (ESRC) Centre for Society and Mental Health, King's College London, London, UK
| | - Stephani L. Hatch
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Economic and Social Research Council (ESRC) Centre for Society and Mental Health, King's College London, London, UK
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Dorrington S, Carr E, Stevelink SAM, Dregan A, Woodhead C, Das-Munshi J, Ashworth M, Broadbent M, Madan I, Hatch SL, Hotopf M. Multimorbidity and fit note receipt in working-age adults with long-term health conditions. Psychol Med 2022; 52:1156-1165. [PMID: 32895068 DOI: 10.1017/s0033291720002937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Research on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population. METHODS Lambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017. RESULTS We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73-12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60-4.87), chronic pain and depression (HR 4.14; 95% CI 3.69-4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36-4.95). CONCLUSIONS Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults.
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Affiliation(s)
- Sarah Dorrington
- Institute of Psychiatry, Psychology & Neuroscience King's College London, 16 De Crespigny Park, London SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Ewan Carr
- Institute of Psychiatry, Psychology & Neuroscience King's College London, 16 De Crespigny Park, London SE5 8AF, UK
| | - Sharon A M Stevelink
- Institute of Psychiatry, Psychology & Neuroscience King's College London, 16 De Crespigny Park, London SE5 8AF, UK
- King's Centre for Military Health Research, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alex Dregan
- Institute of Psychiatry, Psychology & Neuroscience King's College London, 16 De Crespigny Park, London SE5 8AF, UK
| | - Charlotte Woodhead
- Institute of Psychiatry, Psychology & Neuroscience King's College London, 16 De Crespigny Park, London SE5 8AF, UK
| | - Jayati Das-Munshi
- Institute of Psychiatry, Psychology & Neuroscience King's College London, 16 De Crespigny Park, London SE5 8AF, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, Addison House, London SE1 1UL, UK
| | | | - Ira Madan
- Department of Occupational Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stephani L Hatch
- Institute of Psychiatry, Psychology & Neuroscience King's College London, 16 De Crespigny Park, London SE5 8AF, UK
| | - Matthew Hotopf
- Institute of Psychiatry, Psychology & Neuroscience King's College London, 16 De Crespigny Park, London SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Dorrington S, Carr E, Stevelink SAM, Dregan A, Whitney D, Durbaba S, Ashworth M, Mykletun A, Broadbent M, Madan I, Hatch S, Hotopf M. Demographic variation in fit note receipt and long-term conditions in south London. Occup Environ Med 2020; 77:418-426. [DOI: 10.1136/oemed-2019-106035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 12/02/2019] [Accepted: 02/14/2020] [Indexed: 11/04/2022]
Abstract
ObjectivesIntroduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.MethodsData were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.ResultsIn a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.ConclusionsFor the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.
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Pham TM, Carpenter JR, Morris TP, Wood AM, Petersen I. Population-calibrated multiple imputation for a binary/categorical covariate in categorical regression models. Stat Med 2019; 38:792-808. [PMID: 30328123 PMCID: PMC6492126 DOI: 10.1002/sim.8004] [Citation(s) in RCA: 248] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 01/06/2023]
Abstract
Multiple imputation (MI) has become popular for analyses with missing data in medical research. The standard implementation of MI is based on the assumption of data being missing at random (MAR). However, for missing data generated by missing not at random mechanisms, MI performed assuming MAR might not be satisfactory. For an incomplete variable in a given data set, its corresponding population marginal distribution might also be available in an external data source. We show how this information can be readily utilised in the imputation model to calibrate inference to the population by incorporating an appropriately calculated offset termed the "calibrated-δ adjustment." We describe the derivation of this offset from the population distribution of the incomplete variable and show how, in applications, it can be used to closely (and often exactly) match the post-imputation distribution to the population level. Through analytic and simulation studies, we show that our proposed calibrated-δ adjustment MI method can give the same inference as standard MI when data are MAR, and can produce more accurate inference under two general missing not at random missingness mechanisms. The method is used to impute missing ethnicity data in a type 2 diabetes prevalence case study using UK primary care electronic health records, where it results in scientifically relevant changes in inference for non-White ethnic groups compared with standard MI. Calibrated-δ adjustment MI represents a pragmatic approach for utilising available population-level information in a sensitivity analysis to explore potential departures from the MAR assumption.
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Affiliation(s)
- Tra My Pham
- Department of Primary Care and Population HealthUniversity College LondonLondonUK
| | - James R Carpenter
- London Hub for Trials Methodology ResearchMRC Clinical Trials Unit at UCLLondonUK
- Department of Medical StatisticsLondon School of Hygiene and Tropical MedicineLondonUK
| | - Tim P Morris
- London Hub for Trials Methodology ResearchMRC Clinical Trials Unit at UCLLondonUK
| | - Angela M Wood
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Irene Petersen
- Department of Primary Care and Population HealthUniversity College LondonLondonUK
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de Lusignan S, Konstantara E, Joy M, Sherlock J, Hoang U, Coyle R, Ferreira F, Jones S, O’Brien SJ. Incidence of household transmission of acute gastroenteritis (AGE) in a primary care sentinel network (1992-2017): cross-sectional and retrospective cohort study protocol. BMJ Open 2018; 8:e022524. [PMID: 30139907 PMCID: PMC6112382 DOI: 10.1136/bmjopen-2018-022524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Acute gastroenteritis (AGE) is a highly transmissible condition. Determining characteristics of household transmission will facilitate development of prevention strategies and reduce the burden of this disease.We are carrying out this study to describe household transmission of medically attended AGE, and explore whether there is an increased incidence in households with young children. METHODS AND ANALYSIS This study used the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care sentinel network, comprising data from 1 750 167 registered patients (August 2017 database). We conducted a novel analysis using a 'household key', to identify patients within the same household (n=811 027, mean 2.16 people). A 25-year repeated cross-sectional study will explore the incidence of medically attended AGE overall and then a 5-year retrospective cohort study will describe household transmission of AGE. The cross-sectional study will include clinical data for a 25-year period-1 January 1992 until the 31 December 2017. We will describe the incidence of AGE by age-band and gender, and trends in incidence. The 5-year study will use Poisson and quasi-Poisson regression to identify characteristics of individuals and households to predict medically attended AGE transmitted in the household. This will include whether the household contained a child under 5 years and the age category of the first index case (whether adult or child under 5 years). If there is overdispersion and zero-inflation we will compare results with negative binomial to handle these issues. ETHICS AND DISSEMINATION All RCGP RSC data are pseudonymised at the point of data extraction. No personally identifiable data are required for this investigation. The protocol follows STrengthening the Reporting of OBservational studies in Epidemiology guidelines (STROBE). The study results will be published in a peer-review journal, the dataset will be available to other researchers.
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Affiliation(s)
- Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK
| | | | - Mark Joy
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Julian Sherlock
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Uy Hoang
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Rachel Coyle
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Filipa Ferreira
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Simon Jones
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Center for Healthcare Innovation and Delivery Science, Department of Population Health, NYU School of Medicine, New York City, New York, USA
| | - Sarah J O’Brien
- NIHR Health Protection Research Unit in Gastrointestinal Infections, Liverpool, UK
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Campbell J, Vaghela K, Rogers S, Pyer M, Simon A, Waller J. Promoting prompt help-seeking for symptoms - assessing the impact of a gynaecological cancer leaflet on presentations to primary care: a record-based randomised control trial. BMC Public Health 2018; 18:997. [PMID: 30092768 PMCID: PMC6085674 DOI: 10.1186/s12889-018-5920-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/31/2018] [Indexed: 11/10/2022] Open
Abstract
Background Information leaflets have been shown to significantly improve awareness of the symptoms of gynaecological cancers and to reduce perceived barriers to seeking medical help. This record-based, parallel, randomised control trial study aimed to assess whether receipt of a leaflet would change the behaviour of women experiencing symptoms indicative of gynaecological cancers by prompting them to visit their general practitioner (GP). Methods 15,538 women aged 40 years or over registered with five general practices in Northamptonshire, UK were randomised to two groups using the SystmOne randomise facility. Those in the intervention group received an educational leaflet from their general practice explaining the symptoms of gynaecological cancers and advising symptomatic women to visit their GP. The control group were not contacted. Electronic records were interrogated to extract sociodemographic data and details of GP consultations for symptoms, tests, referrals and diagnoses relating to gynaecological cancers in the 4-month period following the mail-out of the leaflets. Results 7739 records were extracted from the intervention group and 7799 from the control group. 231 (3.0%) of the women in the intervention group, and 207 (2.7%) of the controls, presented to their GP with a relevant symptom during the 4-month period following leaflet distribution. The slightly higher rate in the intervention group did not reach statistical significance at the 5% level (RR = 1.11; 95% CI 0.92–1.33; z = 1.08; p = 0.28). There was a significantly lower mean time to first presentation in the symptomatic intervention group (57.2 days, sd = 36.5) compared to the control group (65.2 days, sd = 35.0) (t = − 2.415; p = 0.016). Survival analysis did not reveal a difference between the patterns of presentation in the two cohorts (Log Rank (Mantel-Cox) χ2 = 1.42; p = 0.23). Conclusion There was no difference between intervention and control groups in the proportion of women presenting with symptoms identified in the leaflet in the four months following leaflet distribution, although the women who had been sent a leaflet presented earlier than those in the control group. A larger study is needed to test for a modest effect of leaflet distribution. Trial registration Listed on the ISRCTN registry with study ID ISRCTN61738692 on 23–8-2017 (retrospectively registered).
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Affiliation(s)
- Jackie Campbell
- Faculty of Health and Society, University of Northampton, Northampton, NN2 7AL, UK.
| | | | - Stephen Rogers
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK
| | - Michelle Pyer
- Faculty of Health and Society, University of Northampton, Northampton, NN2 7AL, UK
| | - Alice Simon
- Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, Camberwell, London, SE5 8AF, UK
| | - Jo Waller
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, UK
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Jackson C, Dyson L, Bedford H, Cheater FM, Condon L, Crocker A, Emslie C, Ireland L, Kemsley P, Kerr S, Lewis HJ, Mytton J, Overend K, Redsell S, Richardson Z, Shepherd C, Smith L. UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study. Health Technol Assess 2018; 20:1-176. [PMID: 27686875 DOI: 10.3310/hta20720] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services, including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. AIMS (1) Investigate the barriers to and facilitators of acceptability and uptake of immunisations among six Traveller communities across four UK cities; and (2) identify possible interventions to increase uptake of immunisations in these Traveller communities that could be tested in a subsequent feasibility study. METHODS Three-phase qualitative study underpinned by the social ecological model. Phase 1: interviews with 174 Travellers from six communities: Romanian Roma (Bristol); English Gypsy/Irish Traveller (Bristol); English Gypsy (York); Romanian/Slovakian Roma (Glasgow); Scottish Showpeople (Glasgow); and Irish Traveller (London). Focus on childhood and adult vaccines. Phase 2: interviews with 39 service providers. Data were analysed using the framework approach. Interventions were identified using a modified intervention mapping approach. Phase 3: 51 Travellers and 25 service providers attended workshops and produced a prioritised list of potentially acceptable and feasible interventions. RESULTS There were many common accounts of barriers and facilitators across communities, particularly across the English-speaking communities. Scottish Showpeople were the most similar to the general population. Roma communities experienced additional barriers of language and being in a new country. Men, women and service providers described similar barriers and facilitators. There was widespread acceptance of childhood and adult immunisation, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough. Cultural concerns about vaccines offered during pregnancy and about human papillomavirus were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified by Travellers and service providers as barriers for some. Trustful relationships with health professionals were important and continuity of care was valued. A few English-speaking Travellers described problems of booking and attending for immunisation. Service providers tailored their approach to Travellers, particularly the Roma. Funding cuts, NHS reforms and poor monitoring challenged their work. Five 'top-priority' interventions were agreed across communities and service providers to improve the immunisation among Travellers who are housed or settled on an authorised site: (1) cultural competence training for health professionals and frontline staff; (2) identification of Travellers in health records to tailor support and monitor uptake; (3) provision of a named frontline person in general practitioner practices to provide respectful and supportive service; (4) flexible and diverse systems for booking appointments, recall and reminders; and (5) protected funding for health visitors specialising in Traveller health, including immunisation. LIMITATIONS No Travellers living on the roadside or on unofficial encampments were interviewed. We should exert caution in generalising to these groups. FUTURE WORK To include development, implementation and evaluation of a national policy plan (and practice guidance plan) to promote the uptake of immunisation among Traveller communities. STUDY REGISTRATION Current Controlled Trials ISRCTN20019630 and UK Clinical Research Network Portfolio number 15182. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 72. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Cath Jackson
- Visiting Senior Research Fellow, Department of Health Sciences, University of York, York, UK
| | - Lisa Dyson
- Department of Health Sciences, University of York, York, UK
| | - Helen Bedford
- Institute of Child Health, University College London, London, UK
| | | | - Louise Condon
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | | | - Carol Emslie
- Institute for Applied Health Research, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Lana Ireland
- Institute for Applied Health Research, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Philippa Kemsley
- Institute of Child Health, University College London, London, UK
| | - Susan Kerr
- Institute for Applied Health Research, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Helen J Lewis
- Department of Health Sciences, University of York, York, UK
| | - Julie Mytton
- Centre for Child and Adolescent Health, University of the West of England, Bristol, UK
| | - Karen Overend
- Department of Health Sciences, University of York, York, UK
| | - Sarah Redsell
- Faculty of Health, Social Care & Education, Anglia Ruskin University, Cambridge, UK
| | - Zoe Richardson
- Department of Health Sciences, University of York, York, UK
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Correa A, Hinton W, McGovern A, van Vlymen J, Yonova I, Jones S, de Lusignan S. Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) sentinel network: a cohort profile. BMJ Open 2016; 6:e011092. [PMID: 27098827 PMCID: PMC4838708 DOI: 10.1136/bmjopen-2016-011092] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) is one of the longest established primary care sentinel networks. In 2015, it established a new data and analysis hub at the University of Surrey. This paper evaluates the representativeness of the RCGP RSC network against the English population. PARTICIPANTS AND METHOD The cohort includes 1 042 063 patients registered in 107 participating general practitioner (GP) practices. We compared the RCGP RSC data with English national data in the following areas: demographics; geographical distribution; chronic disease prevalence, management and completeness of data recording; and prescribing and vaccine uptake. We also assessed practices within the network participating in a national swabbing programme. FINDINGS TO DATE We found a small over-representation of people in the 25-44 age band, under-representation of white ethnicity, and of less deprived people. Geographical focus is in London, with less practices in the southwest and east of England. We found differences in the prevalence of diabetes (national: 6.4%, RCPG RSC: 5.8%), learning disabilities (national: 0.44%, RCPG RSC: 0.40%), obesity (national: 9.2%, RCPG RSC: 8.0%), pulmonary disease (national: 1.8%, RCPG RSC: 1.6%), and cardiovascular diseases (national: 1.1%, RCPG RSC: 1.2%). Data completeness in risk factors for diabetic population is high (77-99%). We found differences in prescribing rates and costs for infections (national: 5.58%, RCPG RSC: 7.12%), and for nutrition and blood conditions (national: 6.26%, RCPG RSC: 4.50%). Differences in vaccine uptake were seen in patients aged 2 years (national: 38.5%, RCPG RSC: 32.8%). Owing to large numbers, most differences were significant (p<0.00015). FUTURE PLANS The RCGP RSC is a representative network, having only small differences with the national population, which have now been quantified and can be assessed for clinical relevance for specific studies. This network is a rich source for research into routine practice.
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Affiliation(s)
- Ana Correa
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Royal College of General Practitioners, London, UK
| | - William Hinton
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Andrew McGovern
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Jeremy van Vlymen
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Ivelina Yonova
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Royal College of General Practitioners, London, UK
| | - Simon Jones
- Division of Healthcare Delivery Science, New York University, New York, NY, USA
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Royal College of General Practitioners, London, UK
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Rao R, Schofield P, Ashworth M. Alcohol use, socioeconomic deprivation and ethnicity in older people. BMJ Open 2015; 5:e007525. [PMID: 26303334 PMCID: PMC4550718 DOI: 10.1136/bmjopen-2014-007525] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 07/15/2015] [Accepted: 07/17/2015] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES This study explores the relationship between alcohol consumption, health, ethnicity and socioeconomic deprivation. PARTICIPANTS 27,991 people aged 65 and over from an inner-city population, using a primary care database. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome measures were alcohol use and misuse (>21 units per week for men and >14 for units per week women). RESULTS Older people of black and minority ethnic (BME) origin from four distinct ethnic groups comprised 29% of the sample. A total of 9248 older drinkers were identified, of whom 1980 (21.4%) drank above safe limits. Compared with older drinkers, older unsafe drinkers contained a higher proportion of males, white and Irish ethnic groups and a lower proportion of Caribbean, African and Asian groups. For older drinkers, the strongest independent predictors of higher alcohol consumption were younger age, male gender and Irish ethnicity. Independent predictors of lower alcohol consumption were Asian, black Caribbean and black African ethnicity. Socioeconomic deprivation and comorbidity were not significant predictors of alcohol consumption in older drinkers. For older unsafe drinkers, the strongest predictor variables were younger age, male gender and Irish ethnicity; comorbidity was not a significant predictor. Lower socioeconomic deprivation was a significant predictor of unsafe consumption whereas African, Caribbean and Asian ethnicity were not. CONCLUSIONS Although under-reporting in high-alcohol consumption groups and poor health in older people who have stopped or controlled their drinking may have limited the interpretation of our results, we suggest that closer attention is paid to 'young older' male drinkers, as well as to older drinkers born outside the UK and those with lower levels of socioeconomic deprivation who are drinking above safe limits.
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Affiliation(s)
- Rahul Rao
- Department of Old Age Psychiatry, Institute of Psychiatry, London, UK
| | - Peter Schofield
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
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Jackson C, Bedford H, Condon L, Crocker A, Emslie C, Dyson L, Gallagher B, Kerr S, Lewis HJ, Mytton J, Redsell SA, Schicker F, Shepherd C, Smith L, Vousden L, Cheater FM. UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): protocol for an exploratory, qualitative study. BMJ Open 2015; 5:e008564. [PMID: 26056124 PMCID: PMC4466610 DOI: 10.1136/bmjopen-2015-008564] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/22/2015] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Gypsies, Travellers and Roma (referred to here as Travellers) experience significantly poorer health and have shorter life expectancy than the general population. They are also less likely to access health services including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. This study has two aims: (1) Investigate the barriers and facilitators to acceptability and uptake of immunisations among six Traveller communities in the UK; (2) Identify potential interventions to increase uptake in these Traveller communities. METHODS AND ANALYSIS A three-phase qualitative study with six Traveller communities. PHASE 1: In each community, we will explore up to 45 Travellers' views about the influences on their immunisation behaviours and ideas for improving uptake in their community. PHASE 2: In each community, we will investigate 6-8 service providers' perspectives on barriers and facilitators to childhood and adult immunisations for Traveller communities with whom they work, and ideas to improve uptake. Interview data will be analysed using the Framework approach. PHASE 3: The findings will be discussed and interventions prioritised in six workshops, each with 10-12 phase 1 and 3-4 phase 2 participants. ETHICS AND DISSEMINATION This research received approval from NRES Committee Yorkshire and The Humber-Leeds East (Ref. 13/YH/02). It will produce (1) findings on the barriers and facilitators to uptake of immunisations in six Traveller communities; (2) a prioritised list of potentially feasible and acceptable interventions for increasing uptake in these communities; and (3) methodological development in undertaking research with diverse Traveller communities. The study has the potential to inform new ways of delivering services to ensure high immunisation uptake. Findings will be disseminated to participants, relevant UK organisations with responsibility for the implementation of immunisation policy and Traveller health/welfare; and submitted for publication in academic journals. TRIAL REGISTRATION NUMBER ISRCTN20019630.
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Affiliation(s)
- Cath Jackson
- Department of Health Sciences, University of York, York, UK
| | | | - Louise Condon
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Annie Crocker
- Formerly in the Gypsy and Traveller Team, Bristol City Council, Bristol, UK
| | - Carol Emslie
- Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK
| | - Lisa Dyson
- Department of Health Sciences, University of York, York, UK
| | - Bridget Gallagher
- Formerly at South Glasgow Community Health Partnership, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Susan Kerr
- Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK
| | - Helen J Lewis
- Department of Health Sciences, University of York, York, UK
| | - Julie Mytton
- Centre for Child and Adolescent Health, University of the West of England, Bristol, UK
| | - Sarah A Redsell
- Faculty of Health, Social Care and Education, Anglia Ruskin University, Cambridge, UK
| | | | | | | | - Linda Vousden
- Women and Children's Directorate, North Bristol NHS Trust, Bristol, UK
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Nikolaidis C, Nena E, Agorastakis M, Constantinidis TC. Differences in survival and cause-specific mortality in a culturally diverse Greek population, 1999-2008. J Public Health (Oxf) 2015; 38:71-5. [PMID: 25740904 DOI: 10.1093/pubmed/fdv018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Modern urban populations exhibit considerable internal heterogeneity. Several social groups, such as ethnic minorities or immigrants, constitute individual clusters with different demographic and epidemiological characteristics. METHODS Death records were collected from the Municipality Registry between 1999 and 2008. Kaplan-Meier survival analysis was conducted for (i) natively born Greeks, (ii) former USSR-repatriated Greeks and (iii) Roma. Further evaluation was conducted by log-rank (Mantel-Cox) test. Relative mortality rates were assessed by means of cross-tabulation (Pearson's χ(2)). RESULTS Statistically significant differences in median survival were observed among the three social groups (P < 0.001). The relative mortality from infectious diseases was higher in the Roma population compared with natively born Greeks, odds ratio (OR) = 8.31 [confidence interval (CI) 95% 3.19-21.61]. More than 70% of these deaths were attributed to respiratory tract infections and were associated with children under the age of 5. Excess mortality due to external causes, injuries and substance abuse was observed in repatriated males compared with their natively born counterparts, OR = 2.27 (CI 95% 1.35-3.81). CONCLUSIONS Specific public health interventions are required, to improve the survival of different cultural groups. For example, improvement of immunization status and increase in overall hygiene awareness can ameliorate high infant/childhood mortality in Roma population, while social integration can help reduce acculturation-related mortality among repatriated Greeks.
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Affiliation(s)
- Christos Nikolaidis
- Laboratory of Hygiene and Environmental Protection, Medical Department, Democritus University of Thrace, Alexandroupolis 68100, Greece
| | - Evangelia Nena
- Laboratory of Hygiene and Environmental Protection, Medical Department, Democritus University of Thrace, Alexandroupolis 68100, Greece
| | - Michalis Agorastakis
- Laboratory of Demographic Analysis, Department of Planning and Regional Development, University of Thessaly, Volos 38334, Greece
| | - Theodore C Constantinidis
- Laboratory of Hygiene and Environmental Protection, Medical Department, Democritus University of Thrace, Alexandroupolis 68100, Greece
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Tarrant C, Angell E, Baker R, Boulton M, Freeman G, Wilkie P, Jackson P, Wobi F, Ketley D. Responsiveness of primary care services: development of a patient-report measure – qualitative study and initial quantitative pilot testing. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundPrimary care service providers do not always respond to the needs of diverse groups of patients, and so certain patients groups are disadvantaged. General practitioner (GP) practices are increasingly encouraged to be more responsive to patients’ needs in order to address inequalities.Objectives(1) Explore the meaning of responsiveness in primary care. (2) Develop a patient-report questionnaire for use as a measure of patient experience of responsiveness by a range of primary care organisations (PCOs). (3) Investigate methods of population mapping available to GP practices.Design settingPCOs, including GP practices, walk-in centres and community pharmacies.ParticipantsPatients and staff from 12 PCOs in the East Midlands in the development stage, and 15 PCOs across three different regions of England in stage 3.InterventionsTo investigate what responsiveness means, we conducted a literature review and interviews with patients and staff in 12 PCOs. We developed, tested and piloted the use of a questionnaire. We explored approaches for GP practices to understand the diversity of their populations.Main outcome measures(1) Definition of primary care responsiveness. (2) Three patient-report questionnaires to provide an assessment of patient experience of GP, pharmacy and walk-in centre responsiveness. (3) Insight into challenges in collecting diversity data in primary care.ResultsThe literature covers three overlapping themes of service quality, inequalities and patient involvement. We suggest that responsiveness is achieved through alignment between service delivery and patient needs, involving strategies to improve responsive service delivery, and efforts to manage patient expectations. We identified three components of responsive service delivery: proactive population orientation, reactive population orientation and individual patient orientation. PCOs tend to utilise reactive strategies rather than proactive approaches. Questionnaire development involved efforts to include patients who are ‘seldom heard’. The questionnaire was checked for validity and consistency and is available in three versions (GP, pharmacy, and walk-in centre), and in Easy Read format. We found the questionnaires to be acceptable to patients, and to have content validity. We produced some preliminary evidence of reliability and construct validity. Measuring and improving responsiveness requires PCOs to understand the characteristics of their patient population, but we identified significant barriers and challenges to this.ConclusionsResponsiveness is a complex concept. It involves alignment between service delivery and the needs of diverse patient groups. Reactive and proactive strategies at individual and population level are required, but PCOs mainly rely on reactive approaches. Being responsive means giving good care equally to all, and some groups may require extra support. What this extra support is will differ in different patient populations, and so knowledge of the practice population is essential. Practices need to be motivated to collect and use diversity data. Future work needed includes further evaluation of the patient-report questionnaires, including Easy Read versions, to provide further evidence of their quality and acceptability; research into how to facilitative the use of patient experience data in primary care; and implementation of strategies to improve responsiveness, and evaluation of effectiveness.FundingThe National Institute for Health Research Service Delivery and Organisation programme.
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Affiliation(s)
- Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Angell
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mary Boulton
- Department of Clinical Health Care, Oxford Brookes University, Oxford, UK
| | - George Freeman
- School of Public Health, Imperial College London, London, UK
| | - Patricia Wilkie
- National Association for Patient Participation, Walton-on-Thames, UK
| | - Peter Jackson
- School of Management, University of Leicester, Leicester, UK
| | - Fatimah Wobi
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Diane Ketley
- Department of Health Sciences, University of Leicester, Leicester, UK
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Mathur R, Bhaskaran K, Chaturvedi N, Leon DA, vanStaa T, Grundy E, Smeeth L. Completeness and usability of ethnicity data in UK-based primary care and hospital databases. J Public Health (Oxf) 2013; 36:684-92. [PMID: 24323951 PMCID: PMC4245896 DOI: 10.1093/pubmed/fdt116] [Citation(s) in RCA: 489] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ethnicity recording across the National Health Service (NHS) has improved dramatically over the past decade. This study profiles the completeness, consistency and representativeness of routinely collected ethnicity data in both primary care and hospital settings. METHODS Completeness and consistency of ethnicity recording was examined in the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES), and the ethnic breakdown of the CPRD was compared with that of the 2011 UK censuses. RESULTS 27.1% of all patients in the CPRD (1990-2012) have ethnicity recorded. This proportion rises to 78.3% for patients registered since April 2006. The ethnic breakdown of the CPRD is comparable to the UK censuses. 79.4% of HES inpatients, 46.8% of outpatients and 26.8% of A&E patients had their ethnicity recorded. Amongst those with ethnicity recorded on >1 occasion, consistency was over 90% in all data sets except for HES inpatients. Combining CPRD and HES increased completeness to 97%, with 85% of patients having the same ethnicity recorded in both databases. CONCLUSIONS Using CPRD ethnicity from 2006 onwards maximizes completeness and comparability with the UK population. High concordance within and across NHS sources suggests these data are of high value when examining the continuum of care. Poor completeness and consistency of A&E and outpatient data render these sources unreliable.
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Affiliation(s)
- Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Nish Chaturvedi
- NHLI Division, Faculty of Medicine, International Centre for Circulatory Health, London W2 1LA, UK
| | - David A Leon
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Tjeerd vanStaa
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht TB 3508, The Netherlands Medicines and Healthcare Products Regulatory Agency, LondonSW1W 9SZ, UK
| | - Emily Grundy
- Department of Social Policy, London School of Economics and Political Science, London WC2A 2AE, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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de Lusignan S. Informatics as tool for quality improvement: rapid implementation of guidance for the management of chronic kidney disease in England as an exemplar. Healthc Inform Res 2013; 19:9-15. [PMID: 23626913 PMCID: PMC3633175 DOI: 10.4258/hir.2013.19.1.9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 03/25/2013] [Accepted: 03/25/2013] [Indexed: 11/24/2022] Open
Abstract
Objectives Chronic kidney disease (CKD) is an important cause of excess cardiovascular mortality and morbidity; as well as being associated with progression to end stage renal disease. This condition was largely unheard of in English primary care prior to the introduction of pay-for-performance targets for management in 2006. A realist review of how informatics has been a mechanism for national implementation of guidance for the improved management of CKD. Methods Realist review of context, the English National Health Service with a drive to implement explicit national quality standards; mechanism, the informatics infrastructure and its alignment with policy objectives; and outcomes are describe at the micro-data and messaging, meso-patient care and quality improvement initiatives, and marco-national policy levels. Results At the micro-level computerised medical records can be used to reliably identify people with CKD; though differences in creatinine assays, fluctuation in renal function, and errors in diabetes coding were less well understood. At the meso-level more aggressive management of blood pressure (BP) in individual patients appears to slow or reverse decline in renal function; technology can support case finding and quality improvement at the general practice level. At the macro-level informaticians can help ensure that leverage from informatics is incorporated in policy, and ecological investigations inform if there is any association with improved health outcomes. Conclusions In the right policy context informatics appears to be an enabler of rapid quality improvement. However, a causal relationship or generalisability of these findings has not been demonstrated.
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Affiliation(s)
- Simon de Lusignan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
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15
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Lusignan SD, de Lusignana S, Gallagher H, Jones S, Chan T, van Vlymen J, Tahir A, Thomas N, Jain N, Dmitrieva O, Rafi I, McGovern A, Harris K. Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results. Kidney Int 2013; 84:609-20. [PMID: 23536132 PMCID: PMC3778715 DOI: 10.1038/ki.2013.96] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Revised: 01/16/2013] [Accepted: 01/17/2013] [Indexed: 12/20/2022]
Abstract
Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59-4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05-1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.
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Affiliation(s)
| | - Simon de Lusignana
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK.
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Pinto R, Rijsdijk F, Frazier-Wood AC, Asherson P, Kuntsi J. Bigger families fare better: a novel method to estimate rater contrast effects in parental ratings on ADHD symptoms. Behav Genet 2012; 42:875-85. [PMID: 23053732 DOI: 10.1007/s10519-012-9561-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
Abstract
Many twin studies on parental ratings of attention deficit hyperactivity disorder (ADHD) symptoms report low or negative DZ correlations. The observed differences in MZ and DZ variances indicate sibling contrast effects, which appear to reflect a bias in parent ratings. Knowledge of the factors that contribute to this rater contrast effect is, however, limited. Using parent-rated ADHD symptoms from the Twins' Early Development Study and a novel application of a twin model, we explored a range of socio-demographic variables (ethnicity, socio-economic status, and family size), as potential contributors to contrast effects and their interactive effect with gender composition of twin pairs. Gender did moderate contrast effects but only in DZ opposite-sex twin pairs. Family size also showed a moderating effect on rater contrast effects, which was further modified by gender. We further observed an effect of rating scale, with the DSM-IV ADHD subscale of the Revised Conners' Parent Rating Scale more resistant to contrast effects than shorter scales of ADHD symptoms. The improved identification of situations where the accuracy of the most common informant of childhood ADHD symptoms-parents-is compromised as a result of rater bias, might have implications for future research on ADHD.
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Affiliation(s)
- R Pinto
- King's College London, MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, London, UK.
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Alsanjari ON, de Lusignan S, van Vlymen J, Gallagher H, Millett C, Harris K, Majeed A. Trends and transient change in end-digit preference in blood pressure recording: studies of sequential and longitudinal collected primary care data. Int J Clin Pract 2012; 66:37-43. [PMID: 22171903 DOI: 10.1111/j.1742-1241.2011.02781.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND End-digit preference (EDP) is a known cause of inaccurate BP recording. Distortion has been reported around pay-for-performance (P4P) indicators. METHODS We studied sequential datasets (n = 148,000 to n = 900,000) and performed a longitudinal analysis of CONDUIT data (n = 250,000) over a 10-year period. We examined general trends in EDP and investigated the impact of diabetes and chronic kidney disease (CKD) P4P targets. RESULTS EDP reduces over time in both datasets; the percentage of patients with a zero EDP declined from 70% to 27% and 68% to 26% for SBP and DBP respectively. There is more zero EDP at the extremes of BP, but in people with chronic disease, the use of zero EDP was mainly seen at higher BP levels. P4P targets are associated with increased preference for the even end-digit just below target: in diabetes odds ratio (OR) is 1.47 (p = 0.003) for SBP, 1.19 (p = 0.09) for DBP and in CKD OR 1.65 (p < 0.001) for SBP and 1.48 (p = 0.0001) for DBP. Trends observed in pilot data were validated with a longitudinal set. CONCLUSIONS The decline in EDP is levelling off and P4P targets are associated with sub-target-EDP. Primary care should automate BP measurement and recording.
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de Lusignan S, Nitsch D, Belsey J, Kumarapeli P, Vamos EP, Majeed A, Millett C. Disparities in testing for renal function in UK primary care: cross-sectional study. Fam Pract 2011; 28:638-46. [PMID: 21719474 DOI: 10.1093/fampra/cmr036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In the UK, explicit quality standards for chronic disease management, including for diabetes and chronic kidney disease (CKD), are set out National Service Frameworks and pay-for-performance indicators. These conditions are common with a prevalence of 4% and 5.4%, respectively. CKD is largely asymptomatic, detected following renal function testing and important because associated with increased mortality and morbidity, especially in people with diabetes and proteinuria. OBJECTIVES To investigate who has their renal function tested and any association with age, sex, ethnicity and diabetes. METHOD A cross-sectional survey in a primary care research network in south-west London (n = 220 721). The following data were extracted from routine data: age, gender, ethnicity, latest serum creatinine, diagnosis of diabetes and recording of proteinuria. We used logistic regression to explore any association in testing for CKD. RESULTS People (82.1%) with diabetes had renal function and proteinuria tested; the proportion was much smaller (<0.5%) in those without. Women were more likely to have a creatinine test than men (28% versus 24%, P < 0.05), but this association was modified by age, ethnicity and presence of diabetes. People >75 years and with diabetes were most likely to have been tested. Black [adjusted odds ratio (AOR) 2.1, 95% confidence interval (CI) 2.0-2.2] and south Asian (AOR 1.65, 95% CI 1.56-1.75) patients were more likely to be tested than whites. Those where ethnicity was not stated were the only group not tested more than whites. CONCLUSIONS Quality improvement initiatives and equity audits, which include CKD should take account of disparities in renal function testing.
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Affiliation(s)
- Simon de Lusignan
- Department of Health Care Policy and Management, School of Management, University of Surrey, Guildford GU2 7XH, UK.
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de Lusignan S, Navarro R, Chan T, Parry G, Dent-Brown K, Kendrick T. Detecting referral and selection bias by the anonymous linkage of practice, hospital and clinic data using Secure and Private Record Linkage (SAPREL): case study from the evaluation of the Improved Access to Psychological Therapy (IAPT) service. BMC Med Inform Decis Mak 2011; 11:61. [PMID: 21995837 PMCID: PMC3204226 DOI: 10.1186/1472-6947-11-61] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 10/13/2011] [Indexed: 11/10/2022] Open
Abstract
Background The evaluation of demonstration sites set up to provide improved access to psychological therapies (IAPT) comprised the study of all people identified as having common mental health problems (CMHP), those referred to the IAPT service, and a sample of attenders studied in-depth. Information technology makes it feasible to link practice, hospital and IAPT clinic data to evaluate the representativeness of these samples. However, researchers do not have permission to browse and link these data without the patients' consent. Objective To demonstrate the use of a mixed deterministic-probabilistic method of secure and private record linkage (SAPREL) - to describe selection bias in subjects chosen for in-depth evaluation. Method We extracted, pseudonymised and used fuzzy logic to link multiple health records without the researcher knowing the patient's identity. The method can be characterised as a three party protocol mainly using deterministic algorithms with dynamic linking strategies; though incorporating some elements of probabilistic linkage. Within the data providers' safe haven we extracted: Demographic data, hospital utilisation and IAPT clinic data; converted post code to index of multiple deprivation (IMD); and identified people with CMHP. We contrasted the age, gender, ethnicity and IMD for the in-depth evaluation sample with people referred to IAPT, use hospital services, and the population as a whole. Results The in IAPT-in-depth group had a mean age of 43.1 years; CI: 41.0 - 45.2 (n = 166); the IAPT-referred 40.2 years; CI: 39.4 - 40.9 (n = 1118); and those with CMHP 43.6 years SEM 0.15. (n = 12210). Whilst around 67% of those with a CMHP were women, compared to 70% of those referred to IAPT, and 75% of those subject to in-depth evaluation (Chi square p
< 0.001). The mean IMD score for the in-depth evaluation group was 36.6; CI: 34.2 - 38.9; (n = 166); of those referred to IAPT 38.7; CI: 37.9 - 39.6; (n = 1117); and of people with CMHP 37.6; CI 37.3-37.9; (n = 12143). Conclusions The sample studied in-depth were older, more likely female, and less deprived than people with CMHP, and fewer had recorded ethnic minority status. Anonymous linkage using SAPREL provides insight into the representativeness of a study population and possible adjustment for selection bias.
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Affiliation(s)
- Simon de Lusignan
- Department of Health Care Management and Policy, University of Surrey, Guildford, GU2 7XH, UK.
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Lakha F, Gorman DR, Mateos P. Name analysis to classify populations by ethnicity in public health: validation of Onomap in Scotland. Public Health 2011; 125:688-96. [PMID: 21907365 DOI: 10.1016/j.puhe.2011.05.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 03/29/2011] [Accepted: 05/10/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Health inequalities between ethnic minorities and the general population are persistent. Addressing them is hampered by the inability to classify individuals' ethnicity accurately. This is addressed by a new name-based ethnicity classification methodology called 'Onomap'. This paper evaluates the diagnostic accuracy of Onomap in identifying population groups by ethnicity, and discusses applications to public health practice. STUDY DESIGN Onomap was applied to three independent reference datasets (birth registration, pupil census and register of Polish health professionals) collected in Britain and Poland at individual level (n = 260,748). METHODS Results were compared with the reference database ethnicity 'gold standard'. Outcome measures included sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Ninety-five percent confidence intervals and Chi-squared tests were used. RESULTS Onomap identified the majority of those in the British participant group with high sensitivity and PPV (>95%), and low misclassification (<5%), although specificity and NPV were lowest in this group (56-87%). Outcome measures for all other non-British groupings were high for specificity and NPV (>98%), but variable for sensitivity and PPV (17-89%). Differences in misclassification by gender were statistically significant. Using maiden name rather than married name in women improved classification outcomes for those born in the British Isles (0.53%, 95% confidence interval 0.26-0.8%; P < 0.001) but not for South Asian or Polish groups. CONCLUSIONS Onomap offers an effective methodology for identifying population groups in both health-related and educational datasets, categorizing populations into a variety of ethnic groups. This evaluation suggests that it can successfully assist health researchers, planners and policy makers in identifying and addressing health inequalities.
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Affiliation(s)
- F Lakha
- NHS Lothian, Waverley Gate, 2-4 Waterloo Place, Edinburgh EH1 3EG, UK
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Petersen J, Longley P, Gibin M, Mateos P, Atkinson P. Names-based classification of accident and emergency department users. Health Place 2011; 17:1162-9. [DOI: 10.1016/j.healthplace.2010.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 09/08/2010] [Accepted: 09/20/2010] [Indexed: 10/19/2022]
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Abstract
BACKGROUND Elevated incidence of psychotic illness has been consistently shown among migrant populations. Ethnic density, the proportion of an ethnic group in a defined area, is cited as one factor with a reduced risk of psychosis where ethnicity is shared. However, UK studies have shown mixed results. We set out to re-examine the ethnic density effect at a greater level of geographic detail than previous studies. METHOD Using a large sample of patient records from general practitioners in South East London, we were able to assess neighbourhood factors at the detailed lower super output area level. This comprises, on average, 1500 people compared with around 6000 per ward, the measure used in previous studies. We compared black (Afro-Caribbean) and white psychosis incidence by neighbourhood ethnic density over a 10-year period. RESULTS We found a clear negative association between ethnic density and psychosis incidence. In neighbourhoods where black people comprised more than 25% of the population, there was no longer a statistically significant ethnic difference in psychosis rates. However, where black people were less well represented, their relative risk increased nearly threefold [odds ratio (OR) 2.88, 95% confidence interval (CI) 1.89-4.39]. Furthermore, incidence rates for black people in the lowest density quintiles were over five times greater than in the most dense quintile (OR 5.24, 95% CI 1.95-14.07). However, at ward level this association was much weaker and no longer statistically significant. CONCLUSIONS Ethnic density is inversely related to psychosis incidence at a detailed local neighbourhood level.
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Affiliation(s)
- P Schofield
- Department of Primary Care and Public Health Sciences, Kings College, London UK.
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Ethnic differences in blood pressure monitoring and control in south east London. Br J Gen Pract 2011; 61:190-6. [PMID: 21439177 DOI: 10.3399/bjgp11x567126] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND High blood pressure is the single most important risk factor worldwide for the development of cardiovascular disease, and has been shown to affect some ethnic minority groups disproportionately. AIM To explore ethnic inequalities in blood pressure monitoring and control. METHOD Data from Lambeth DataNet was used, based on case records from GP practices in one inner-city London borough. Blood pressure monitoring and control was compared using Quality and Outcomes Framework (QOF) targets for patients with: diabetes, coronary heart disease, stroke, hypertension, and chronic kidney disease. The study controlled for age, sex, social deprivation, and clustering within GP practices. RESULTS A total of 16 613 patients met the study criteria, with 5962 categorised as black/black British. Blood pressure monitoring was similar across ethnic groups and as good, if not better, for black patients compared to white. However, marked ethnic inequalities in blood pressure control were found, with black patients significantly less likely to achieve QOF targets than their white counterparts (odds ratio [OR] 0.73; 95% confidence interval [CI] = 0.64 to 0.82). Further inequalities were revealed in blood pressure control within disease groups and ethnic subgroups. In particular, blood pressure control was poor in African patients with diabetes (OR 0.63; 95% CI = 0.50 to 0.79) and Caribbean patients with coronary heart disease (OR 0.53; 95% CI = 0.37 to 0.77) when compared with white patients. DISCUSSION While black patients with chronic conditions are equally likely to have their blood pressure monitored, their blood pressure control is consistently poorer than that of their white counterparts. This may have important implications for cardiovascular risk management in black patients.
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Murray J, Saxena S, Millett C, Curcin V, de Lusignan S, Majeed A. Reductions in risk factors for secondary prevention of coronary heart disease by ethnic group in south-west London: 10-year longitudinal study (1998-2007). Fam Pract 2010; 27:430-8. [PMID: 20538744 DOI: 10.1093/fampra/cmq030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To explore trends by ethnicity in clinical risk factor recording and control among patients with coronary heart disease (CHD), during a period of major investment in quality improvement initiatives in general practice in England. DESIGN Longitudinal study from 1998 to 2007, using general practice data extracted from electronic patient records of all adult patients (n=177,412) registered in 2007. SETTING Twenty-nine general practices in Wandsworth south-west London. SUBJECTS Three thousand two hundred registered patients with a recorded diagnosis of CHD, in 2007. MAIN OUTCOME MEASURES Mean systolic and diastolic blood pressure and mean cholesterol of patients with CHD, for each calendar year. RESULTS From 1998 to 2007, the proportion of patients with CHD who had their blood pressure recorded rose from 33.2% to 93.9% and cholesterol from 21.7% to 83.5%. Over this period, mean blood pressure decreased from 140/80 to 133/74 mmHg (P<0.001). There was a reduction in mean cholesterol from 5.2 to 4.3 mmol/l (P<0.001). Reductions in mean blood pressure and cholesterol occurred across all ethnic groups. CONCLUSIONS From 1998 to 2007, risk factor control among patients with CHD improved, with reductions in their mean blood pressure and cholesterol across all ethnic groups. Widespread policy change has helped to improve the quality and equity of primary care for heart disease patients. Health improvements predated implementation of the Quality and Outcomes Framework and have since continued. Our findings illustrate how a national health care system with universal coverage can significantly reduce inequalities and improve chronic disease care for all ethnic groups.
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Affiliation(s)
- Joanna Murray
- Department of Primary Care & Public Health, Imperial College London, London W6 8RP, UK.
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Pinto R, Ashworth M, Seed P, Rowlands G, Schofield P, Jones R. Differences in the primary care management of patients with psychosis from two ethnic groups: a population-based cross-sectional study. Fam Pract 2010; 27:439-46. [PMID: 20308245 DOI: 10.1093/fampra/cmq014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ethnicity is an important dimension in many aspects of psychosis. OBJECTIVE To investigate ethnic differences in the primary care management of patients with psychosis. METHODS Data were obtained from Lambeth DataNet, a database of computerized general practice case records derived from practices in an inner city London borough. We undertook a cross-sectional survey of patients with psychosis. OUTCOME MEASURES health screening, chronic disease management and prescribing data and differences between ethnic groups were expressed as odds ratios (ORs). RESULTS One thousand six hundred and ninety-four of 165,911 (1.02%) registered patients had a diagnosis of psychosis; 1090 (64%) had ethnicity recorded; 501 were White and 403 were Black or Black British. There were no significant ethnic differences for blood pressure, cholesterol or HbA1c monitoring or control; cervical or mammography screening; treatment with hypotensives, statins, antidepressants, lithium, antipsychotics or atypical antipsychotics. Depot injectable antipsychotics were more likely to be prescribed to Black patients than other delivery modes: OR 2.10 (95% CI: 1.20-3.67). CONCLUSIONS Measurable aspects of physical health care of patients with psychosis were similar, regardless of ethnicity. Increased use of the depot antipsychotic medication in black patients needs further exploration.
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Affiliation(s)
- Rebecca Pinto
- Department of Primary Care and Public Health Sciences, King's College London School of Medicine at Guy's, King's College and St Thomas' Hospitals, Guy's Campus, Capital House, Weston Street, London SE1 3QD, UK
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Price CL, Szczepura AK, Gumber AK, Patnick J. Comparison of breast and bowel cancer screening uptake patterns in a common cohort of South Asian women in England. BMC Health Serv Res 2010; 10:103. [PMID: 20423467 PMCID: PMC2867962 DOI: 10.1186/1472-6963-10-103] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Accepted: 04/27/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inequalities in uptake of cancer screening by ethnic minority populations are well documented in a number of international studies. However, most studies to date have explored screening uptake for a single cancer only. This paper compares breast and bowel cancer screening uptake for a cohort of South Asian women invited to undertake both, and similarly investigates these women's breast cancer screening behaviour over a period of fifteen years. METHODS Screening data for rounds 1, 2 and 5 (1989-2004) of the NHS breast cancer screening programme and for round 1 of the NHS bowel screening pilot (2000-2002) were obtained for women aged 50-69 resident in the English bowel screening pilot site, Coventry and Warwickshire, who had been invited to undertake breast and bowel cancer screening in the period 2000-2002. Breast and bowel cancer screening uptake levels were calculated and compared using the chi-squared test. RESULTS 72,566 women were invited to breast and bowel cancer screening after exclusions. Of these, 3,539 were South Asian and 69,027 non-Asian; 18,730 had been invited to mammography over the previous fifteen years (rounds 1 to 5). South Asian women were significantly less likely to undertake both breast and bowel cancer screening; 29.9% (n = 1,057) compared to 59.4% (n = 40,969) for non-Asians (p < 0.001). Women in both groups who consistently chose to undertake breast cancer screening in rounds 1, 2 and 5 were more likely to complete round 1 bowel cancer screening. However, the likelihood of completion of bowel cancer screening was still significantly lower for South Asians; 49.5% vs. 82.3% for non-Asians, p < 0.001. South Asian women who undertook breast cancer screening in only one round were no more likely to complete bowel cancer screening than those who decided against breast cancer screening in all three rounds. In contrast, similar women in the non-Asian population had an increased likelihood of completing the new bowel cancer screening test. The likelihood of continued uptake of mammography after undertaking screening in round 1 differed between South Asian religio-linguistic groups. Noticeably, women in the Muslim population were less likely to continue to participate in mammography than those in other South Asian groups. CONCLUSIONS Culturally appropriate targeted interventions are required to reduce observed disparities in cancer screening uptakes.
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Szczepura A, Price C, Gumber A. Breast and bowel cancer screening uptake patterns over 15 years for UK south Asian ethnic minority populations, corrected for differences in socio-demographic characteristics. BMC Public Health 2008; 8:346. [PMID: 18831751 PMCID: PMC2575216 DOI: 10.1186/1471-2458-8-346] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 10/02/2008] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND A number of studies have reported low uptake of cancer screening programmes by South Asian populations in the UK. However, studies to date have not adjusted findings for differences in demographics and socio-economic status of these populations. METHODS SUBJECTS All residents in Coventry and Warwickshire, UK, eligible for screening. Uptakes compared for round 1 (2000-02) and round 2 (2003-05) of a national bowel cancer screening pilot, and for rounds 1, 2 and 5 of the established NHS breast cancer screening programme (commenced 1989). DATA Bowel screening data were analysed for 123,367 invitees in round 1 and 116,773 in round 2 (total 240,140 cases). Breast screening data were analysed for 61,934, 62,829 and 86,749 invitees in rounds 1, 2 and 5 respectively (total 211,512 cases). ANALYSIS Screening uptake was compared for two broad meta-categories (South Asian and non-Asian) and for five Asian subgroups (Hindu-Gujarati; Hindu-Other; Muslim; Sikh; South Asian Other). Univariate and multivariate analyses examined screening uptake and various demographic attributes of invitees, including age, gender, deprivation and ethnic group. RESULTS South Asians demonstrated significantly lower (p < 0.001) unadjusted bowel screening uptake; 32.8% vs. 61.3% for non-Asians (round 1). Rates were particularly low for the Muslim subgroup: 26.1% (round 1), 21.5% (round 2). For breast screening, a smaller difference was observed between South Asians and non-Asians; initially 60.8% vs. 75.4% (round 1) and later 66.8% vs. 77.7% (round 5). Thus, the disparity reduced gradually over time, alongside an overall trend of increased uptake. However, figures remained consistently low for Muslims (51% in rounds 1 and 5). After adjusting for age, deprivation (and gender), bowel screening uptake remained significantly lower for all South Asian subgroups. After similar adjustments, breast screening uptake remained lower for all subgroups except Hindu-Gujaratis. For Muslims registered with an Asian (vs. non-Asian) GP, bowel screening uptake was significantly lower (p < 0.001). However, breast screening uptake for Muslims with an Asian (vs. non-Asian) GP showed no difference (p = 0.12) in the same period. Colonoscopy and breast assessment uptakes were similar for both meta-categories, but Asian response time appeared slower for colonoscopy. The percentage of abnormal FOBT results was significantly higher for South Asian invitees. A slight increase in abnormal mammograms was observed for Muslims over time (2.7% to 4.2% in rounds 1 and 5 respectively). CONCLUSION The lower cancer screening uptakes observed for the South Asian population cannot be attributed to socio-economic, age or gender population differences. Although breast screening disparities have reduced over time, significant differences remain. We conclude that both programmes need to implement and assess interventions to reduce such differences.
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Affiliation(s)
- Ala Szczepura
- Clinical Sciences Institute, Warwick Medical School, University of Warwick, Coventry, UK
| | - Charlotte Price
- Clinical Sciences Institute, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anil Gumber
- Clinical Sciences Institute, Warwick Medical School, University of Warwick, Coventry, UK
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