South Africa like many countries is moving towards a system of community care for people with mental health problems. This is set against a backdrop of under-resourced and overburdened services. These problems are particularly apparent in the township communities. The aim of this study was to devise an education programme for South African volunteer health workers using principles adapted from the UK evidence base for psychosocial intervention (PSI) and to evaluate the impact of the education programme on community volunteer health workers' knowledge about mental health issues. A stakeholder consultation exercise was held to explore: the context of South African services; the transferability of the UK evidence base and educational strategies to South Africa; and to inform the design of an educational programme. Evaluation of the community volunteer educational programme was undertaken using pre- and post-education focus groups. Twenty-one volunteers working with mentally ill people in the community from one township attended a three-day, six module course. After the course, volunteers: were able to articulate a greater range of aetiological and contributing factors to the development of mental health problems, including stress vulnerability and traditional belief frameworks; could describe a more humanistic model of mental health identification; identified a wider range of both formal and informal helping strategies; were more aware of the negative impact of interpersonal behaviours for people with mental health problems. Volunteer involvement has been confined to communicable diseases in South Africa. Volunteers educated about mental health care could assist in the South African policy of ‘horizontal’ integration of services into primary care from their current ‘vertical’, specialist-orientated structures.

Historically, few randomized controlled trials (RCTs) have been conducted in primary care and problems have been experienced applying this methodology in these settings. In 2001, The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) was developed. This RCT aimed to compare two detoxification drugs to inform best practice for the treatment of opiate users presenting to primary care requesting detoxification. This paper presents descriptive data from a postal survey of 12 general practitioners (GPs) from 10 primary care practices who were involved in the LEEDS trial. The questionnaire was sent out in November 2004, used open and closed questions and was self-administered. It uncovered factors that affected patient recruitment, GPs' views on the trial and their experience of randomizing opiate using patients. Flexible solutions to overcoming recruitment difficulties are presented alongside idealistic solutions to the problems experienced. The implications of our experiences of conducting this RCT in primary care practices are discussed in the light of conducting RCTs in primary care settings. This will benefit other research teams and clinicians who may be planning to use a similar research methodology.

Participant recruitment is often the rate-limiting step in clinical trials, but the methods used and the processes involved in recruitment are rarely reported. Although various methods will often be adopted, there is a dearth of information about the factors which facilitate or impede recruitment to trials. Such information is potentially very valuable to researchers. The present pilot study aimed to recruit a minimum of 30 participants through primary care to a randomized controlled trial (RCT) of three interventions for older adults with depression. The aim was to determine how recruitment to RCTs in primary care may be optimized. A wide range of recruitment methods was used, including both direct general practitioner (GP) referrals and self-referrals. Potential participants were informed about the study in a variety of ways, including GP recruitment when attending surgeries, contacting suitable patients identified from the GP database, posters and leaflets in the GP surgery, and the specific targeting of older people by the distribution of leaflets at 'flu clinics. Both GP referrals and direct referrals were successful. Interestingly and rather unexpectedly, the greatest numbers of individuals were recruited by self-referral. No differences were found between these two groups as to the severity of their depression. Recruiting from primary care can be successful, if primary health care teams are willing to work in partnership with researchers, and if researchers are willing to be flexible and try many approaches. In particular, the study found that cultivating self-referrals was a profitable strategy, which was not what had been initially expected with this particular target group of older people with depression. These self-referrals were a cost-effective method of recruitment, each costing around one-third less than those recruited by other methods, and without them the recruitment targets would not have been met.

Although there are often clear benefits from health screening strategies there is also evidence that some individuals experience emotional difficulties when participating, these reactions are often as a result of inconclusive or equivocal results from the screening tests. Most of the research literature explores this from a female perspective – there is less evidence of how men experience the uncertainties of screening. This article presents findings from a qualitative research study exploring the experiences of men who received equivocal results when participating in prostate specific antigen (PSA) testing. The men were drawn from a larger clinical trial to identify men with early signs of prostate cancer. In-depth interviews were conducted with seven men from one general practice in the North of England who had received an equivocal result from PSA testing and subsequent prostate biopsy. Phenomenological analysis revealed five inter-related themes in the men's experiences. The theme pre-conceptions centred around men's beliefs about the links between early diagnosis and was linked to their perceptions about responsibility towards their own health. However, men also reported feelings of uncertainty when receiving results that did not definitely indicate they did or did not have prostate cancer. This uncertainty generated reactions of stoicism towards the equivocal result and subsequent participation in further investigations. However, men also reported that participation in PSA screening did make them feel ‘looked after’. These findings are closely comparable with the literature on women's reactions to screening test uncertainty. This is possibly heightened by the lack of clear evidence about the accuracy of PSA testing to detect prostate cancer. These men participated in order to find out if they had prostate cancer or not and seemed unprepared for the possibility of an equivocal result.

Links between homelessness and ill health are well established. However, homeless people are less likely to access traditional health care due to administrative barriers and hostility of professionals. For this reason more flexible modes of health care delivery, including nurse led care, have been explored. There has been a rapid increase in innovative nursing roles over the last two decades and the literature suggests that a clear role definition, good interprofessional working and supportive cultures are some of the features which ensure role effectiveness. A large study exploring new roles in nursing and midwifery in Northern Ireland identified an innovative nurse led approach in meeting the needs of single homeless people. The aim of this paper is to explore the effectiveness of this role using a public health framework. A case study design was used incorporating semi-structured interviews with analysis of secondary sources and a period of observation. Results demonstrated that the role fitted within a public health framework in that it involved assessment of need, skills to meet need, facilitation of access to care, partnership working, health promotion, health protection and influencing policy, and strategy development. The conclusion is that the role met the set criteria for innovative nursing roles. Furthermore, this practitioner meets the criteria for advanced nursing practice, providing evidence of effective nurse led care that meets the health agenda of targeting inequalities in health.

Partnership working, engagement and participation of service recipients and providers are issues at the core of UK and international health and social care policies. Although always considered desirable, recent legislation makes this practice a legal imperative in England. However, the operationalization of the concepts pose a number of challenges. This paper draws on evaluative data to examine how these concepts were addressed within one of the largest health action zones (HAZ) in England. The research took a generative perspective and was intended to promote learning, deepen understanding, model actions and consequences, and to provide a guide to decision making. Three approaches of theories of change, pluralistic evaluation and soft systems methodology were combined in the research design. Data was collected through 39 individual tape-recorded interviews with people involved with HAZ at both strategic and operational levels. The findings allowed partnership and engagement activity to be categorized into two domains, those that led to entrenchment in old practices and those that facilitated engaging with a partnership and community involvement ethos. By making the facilitating and inhibiting variables more explicit, the potential for working to a partnership philosophy is enhanced.

It is anecdotally reported that general practitioners (GPs) consider that some of their time is wasted by patients consulting with minor ailments. This study aimed to investigate patients’ definitions of minor ailments and explore the reasons behind their decision to seek a GP consultation about ailments that they perceive to be minor. Qualitative interviews were conducted with a purposive sample of 19 adult patients from two demographically and socially diverse general practices in England. Interviewees’ views on (i) the types of symptoms and illnesses they thought of as minor ailments and (ii) the precipitating factors that had influenced their decision to consult a GP about a minor ailment were explored. What interviewees considered as minor ailments depended not only upon factors relating to the current condition (such as severity), but also other issues (such as previous experience and knowledge).

Although a condition that could be self-managed was considered a minor ailment; a minor ailment was not necessarily synonymous with a condition that could be handled alone. It is therefore unhelpful to think of specific conditions as being minor or major or to dismiss all minor ailment consultations as a waste of GP time. From a patient perspective the decision to consult their GP about a minor ailment may be a rational and evaluated one. The importance of understanding why some patients consult with minor ailments, and allowing them to retain choice in the way they seek advice, should not be underestimated when considering ways of increasing access to health professionals.

The aim of this article is to report the results of a study examining salaried payment for general practitioners (GPs) in Scotland. The study examines ‘paragraph 52’ salaried payment, where GPs can employ a GP as a member of practice staff and claim reimbursement from the health board. The paper reports results of 18 semi-structured interviews with managers at two health boards, and at seven general practices who have a salaried GP. The paper also presents quantitative data about the nature of the salaried contracts and presents a comparison of practices with a salaried GP with other practices in Scotland. Seventeen practices employed a salaried GP 18 months after the scheme began. Ex-fundholders and training practices were more likely to have been selected by health boards to employ a salaried GP. The two health boards took different approaches to the scheme. The first selected those practices that were more likely to have identified specific service developments as part of their bid for a salaried GP. This approach might reward those practices that were already innovative, thus potentially increasing inequality in service provision between practices. The second health board used the scheme to maintain and support practices in rural areas, and was less concerned with service development, thus potentially reducing inequalities in access. Salaried GPs were ex-GP registrars and ex-locums who wanted more stability and less responsibility, and administration. Some were happy in their post, while others saw it as a stepping stone to a partnership. Most practices used the salaried GP to release the time of partners to engage in practice development. Some practices mentioned the financial benefits of the scheme and benefits in terms of enabling service development. Compared to using locums, it was suggested that referral rates of salaried GPs may be lower, and continuity of care higher. Participants felt strongly that the scheme should continue. The paragraph 52 scheme was used little, but was potentially valuable in introducing stability and experience for younger GPs who do not want a partnership. Health boards had different interpretations of the objectives and use of the scheme reflecting different local circumstances. The potential of the scheme to address inequalities in the distribution of GPs is uncertain.

Jurisdictions around the world have articulated a need for development of an integrated health care system with increased emphasis on primary health care and incorporation of the principles and practices of health promotion. To date, the medical model has been the default model of care. Yet, treatment alone is unlikely to have marked effects on health inequities or health status. This article presents and discusses two foundational dimensions (values, structures) of a health promotion philosophy and approach in primary health care settings. We propose a strategy and framework to support practical and attainable action. Our article (the first of a series of two) is based on a literature review, validation by key experts and a national survey of Canadian primary health care settings. We argue that fundamental philosophical values provide a foundation for health promotion in primary health care. These values should be reflected in the structures that create a supportive environment for health promotion. Our remaining three domains (strategies, processes, outcomes) are presented in a second following article. Based on values and structures, we conclude that subsequent strategies (interventions), processes (client- and community-centred care), and desired health promotion outcomes (intended or unintended) may be achieved.