Is screening for tuberculosis acceptable to immigrants? A qualitative study.

BACKGROUND: Screening of immigrants has been a widespread response to the global resurgence of tuberculosis but has been criticized as discriminatory and stigmatising. Acceptability is an essential but neglected ethical prerequisite of screening programmes, particularly those targeting vulnerable groups such as refugees. No data exist concerning acceptability of tuberculosis screening. We therefore examined the responses of immigrants to screening for tuberculosis in a range of settings. METHODS: We carried out a qualitative interview study of a maximum diversity sample of 53 immigrants offered screening for tuberculosis in east London. We recruited people screened in three settings: a social service centre for asylum seekers, a hospital clinic for new entrants and primary care. We confirmed validity of our findings at a focus group of asylum seekers. RESULTS: The opportunity to be screened for tuberculosis was valued highly by recipients. Moreover, many saw being screened as a socially responsible activity. Of the minority raising concerns, few mentioned the possibility of discrimination. Acceptability was high irrespective of setting, with respondents expressing preference for their chosen place of screening. CONCLUSION: Screening for tuberculosis was highly acceptable to recipients in these settings. Screening should be offered in a range of settings.

Deaths certified as asthma and use of medical services: a national case-control study.

BACKGROUND: Studies have linked asthma death to either increased or decreased use of medical services. METHODS: A population based case-control study of asthma deaths in 1994-8 was performed in 22 English, six Scottish, and five Welsh health authorities/boards. All 681 subjects who died were under the age of 65 years with asthma in Part I on the death certificates. After exclusions, 532 hospital controls were matched to 532 cases for age, district, and date of asthma admission/death. Data were extracted blind from primary care records. RESULTS: The median age of the subjects who died was 53 years; 60% of cases and 64% of controls were female. There was little difference in outpatient attendance (55% and 55%), hospital admission for asthma (51% and 54%), and median inpatient days (20 days and 15 days) in the previous 5 years. After mutual adjustment and adjustment for sex, using conditional logistic regression, three variables were independently associated with asthma death: fewer general practice contacts (odds ratio 0.82 (95% confidence interval (CI) 0.74 to 0.91) per 5 contacts) in the previous year, more home visits (1.14 (95% CI 1.08 to 1.21) per visit) in the previous year, and fewer peak expiratory flow recordings (0.83 (95% CI 0.74 to 0.92) per occasion) in the previous 3 months. These associations were similar after adjustment for markers of severity, psychosocial factors, systemic steroids, short acting bronchodilators and antibiotics, although the association with peak flow was weakened and just lost significance. CONCLUSION: Asthma death is associated with less use of primary care services. Both practice and patient factors may be involved and a better understanding of these may offer possibilities for reducing asthma death.

Psychological, social and health behaviour risk factors for deaths certified as asthma: a national case-control study.

BACKGROUND: Uncontrolled studies suggest that psychosocial factors and health behaviour may be important in asthma death. METHODS: A community based case-control study of 533 cases, comprising 78% of all asthma deaths under age 65 years and 533 hospital controls individually matched for age, district and asthma admission date corresponding to date of death was undertaken in seven regions of Britain (1994-98). Data were extracted blind from anonymised copies of primary care records for the previous 5 years and non-blind for the earlier period. RESULTS: 60% of cases and 63% of controls were female. The median age in both groups was 53. Cases had an earlier age of asthma onset, more chronic obstructive lung disease, and were more obese. 48% of cases and 42% of controls had a health behaviour problem; repeated non-attendance/poor inhaler technique was related to increased risk of death. Overall, 85% and 86%, respectively, had a psychosocial problem. Four psychosocial factors were associated with increased risk of death (psychosis, alcohol/drug abuse, financial/employment problems, learning difficulties) and two with reduced risk (anxiety/prescription of antidepressant drugs and sexual problems). While alcohol/drug abuse lost significance after adjustment for psychosis, other associations appeared independent of each other and of indicators of severity and co-morbidity. None of the remaining 13 factors including family problems, domestic abuse, bereavement, and social isolation were significantly related to risk of asthma death. CONCLUSION: There was an apparently high burden of psychosocial problems in both cases and controls. The associations between health behaviour, psychosocial factors, and asthma death are varied and complex with a limited number of factors showing positive relationships.

Did the London Initiative Zone investment programme affect general practice structure and performance in East London? A time series analysis of cervical screening coverage and asthma prescribing.

A programme of incentives was set up in the London Initiative Zones to improve primary care in inner London based on the findings of the Tomlinson Enquiry in 1992. This descriptive study is a 4-y time series analysis of changes in general practice structure in East London as the result of London Initiative Zone investment, and an exploration of the possible effect of investment on practice performance. We used routinely available administrative data for the whole analysis. General practice characteristics and two selected performance indicators: the asthma prophylaxis to bronchodilator ratio and cervical cytology screening rate, for all practices in the East London and the City Health Authority for 4 y, 1993-1996, were used. Both reflect practice efficiency, but relate to different aspects of practice performance. The prescribing indicator is more indicative of the quality of clinical practise, whereas cervical screening coverage relates more to the characteristics of the practice population and to practice organisation. Repeated measures analyses were used to identify trends and to explore the relationship between changes in practice characteristics and performance. Graphical methods were used to compare East London trends with the rest of England. There were significant improvements in practice structure as the consequence of London Initiative Zone investment. There was a positive association with improvements in practice performance, but East London still lagged some way behind national patterns. The findings suggest that while improvements in asthma prescribing follow the national trend, practices have difficulty in achieving and sustaining the 80% target for cervical cytology screening, and that an overall population coverage of 80% may be in doubt.Increased investment in practice staffing may be influential in improving some aspects of performance. However, in common with other inner cities, a greater effort and more innovative strategies may be needed to achieve a standard of performance equal to the best.

Do practice-based preventive child health services affect the use of hospitals? A cross-sectional study of hospital use by children in east London.

BACKGROUND: Acute paediatric admissions have risen steadily over the past 20 years. During the same period, practice-based child health clinics have increased, although provision is less common in areas of deprivation where hospital use is greatest. AIM: To investigate the contribution of practice-based, preventive child health services to rates of hospital utilisation in children under five years of age. METHOD: A cross-sectional retrospective study examining practice variations in paediatric acute admissions, outpatient referrals, and accident and emergency (A&E) department attendances in the East London and the City Health authority, including all 164 practices in the inner-city boroughs of Hackney, Newham, Tower Hamlets, and the City of London. The main outcome measures were practice-based paediatric hospital attendance rates, for discrete age and sex bands, for the year to 31 March 1996. RESULTS: Hospital use varied with age and sex, with the rates being highest for the youngest children and for boys. The median A&E attendance rate (including reattendances) for boys up to one year of age was 897 per thousand children per practice. In east London, 62% of practices are registered for child health surveillance and 71% provide a child health clinic. Practice approval for child health surveillance, and the provision of child health clinics, did not account for differences between practices in hospital use, but proportionally greater health visiting hours were significantly related to lower rates of emergency hospital admission by young children. Multivariate analyses revealed that up to 23% of the variation between practice admission rates could be explained by health visiting hours. CONCLUSIONS: We found significant associations between the amount of health visiting time available to the practice population and rates of acute admission and outpatient referral among children up to five years of age. These findings suggest that increasing health visitor provision could contribute to lower paediatric emergency admission and outpatient referral rates. A small change would have a significant effect, particularly among the youngest children, given that during the study year 10,000 children under two years of age in east London were either admitted or referred to hospital.

Prescribing for persistent cough in children.

To identify the medications general practitioners consider for the treatment of persistent isolated cough, we undertook a postal questionnaire survey of a sample of general practitioners in east London. Fewer than 10% indicated that they never prescribed for such cough. About 70% sometimes considered antibiotics and/or bronchodilators in all age groups. Inhaled steroids and cromoglycate were considered by about 30% of prescribers for infants compared with over 60% for older age groups. As yet there is no evidence that medication is beneficial for persistent isolated cough. The role of asthma drugs for children with this symptom needs to be evaluated so that we can better identify those who are likely to benefit.

Hospital admissions for asthma in east London: associations with characteristics of local general practices, prescribing, and population.

OBJECTIVE: To determine the relative importance of appropriate prescribing for asthma in explaining high rates of hospital admission for asthma among east London general practices. DESIGN: Poisson regression analysis describing relation of each general practice's admission rates for asthma with prescribing for asthma and characteristics of general practitioners, practices, and practice populations. SETTING: East London, a deprived inner city area with high admission rates for asthma. SUBJECTS: All 163 general practices in East London and the City Health Authority (complete data available for 124 practices). MAIN OUTCOME MEASURES: Admission rates for asthma, excluding readmissions, for ages 5-64 years; ratio of asthma prophylaxis to bronchodilator prescribing; selected characteristics of general practitioners, practices, and practice populations. RESULTS: Median admission rate for asthma was 0.9 (range 0-3.6) per 1000 patients per year. Higher admission rates were most strongly associated with small size of practice partnership: admission rates of singlehanded and two partner practices were higher than those of practices with three or more principals by 1.7 times (95% confidence interval 1.4 to 2.0, P < 0.001) and 1.3 times (1.1 to 1.6, P = 0.001) respectively. Practices with higher rates of night visits also had significantly higher admission rates: an increase in night visiting rate by 10 visits per 1000 patients over two years was associated with an increase in admission rates for asthma by 4% (1% to 7%). These associations were independent of asthma prescribing ratios, measures of practice resources, and characteristics of practice populations. CONCLUSIONS: Higher asthma admission rates in east London practices were most strongly associated with smaller partnership size and higher rates of night visiting. Evaluating ways of helping smaller partnerships develop structured proactive care for asthma patients at high risk of admission is a priority.

Appropriate prescribing in asthma and its related cost in east London.

OBJECTIVES: To determine the patterns of preventive to reactive prescribing for asthma among general practices in the City and East London Family Health Services Authority area and their relation to prescribing cost. DESIGN: Descriptive study of asthma prescribing during April 1992 to March 1993. Prescribing data were linked with general practice and population data on one database. SETTING: City and East London Family Health Services Authority area, including all general practices in contract with the authority, which covers the inner city London Boroughs of Hackney, Tower Hamlets, and Newham and the Corporation of the City of London. SUBJECTS: All 163 general practices as at 1 June 1993. MAIN OUTCOME MEASURES: Ratios of prescribed inhaled corticosteroids plus cromoglycates (prophylactic treatment) to bronchodilators; distribution of the cost of asthma prescribing; distribution of overall generic prescribing; proportion of asthma generic prescribing; distribution of cost of overall drugs prescribed per prescribing unit. RESULTS: Practices approved for band 3 health promotion or asthma surveillance and those with a general practitioner trainer had on average higher ratios of prophylactic to bronchodilator treatment and significantly higher asthma drug costs than other practices. Those practices with high levels of overall generic prescribing had significantly higher prophylactic to bronchodilator ratios than those with lower levels of generic prescribing. Practices with higher levels of asthma drug generic prescribing also had significantly higher prophylactic prescribing. However, the proportion of generically prescribed asthma drugs was lower than overall generic prescribing. There was no correlation between the ratio of prophylactic to bronchodilator asthma prescribing and the proportion of overall drugs expenditure, but high spending practices spent significantly more on asthma drugs. CONCLUSIONS: Pressure to reduce the cost of asthma prescribing may lead to a lowering of the ratio of prophylactic to bronchodilator treatments. However, reducing prophylactic prescribing would run contrary to the British Thoracic Society guidelines and might worsen the quality of asthma care.

Analysing morbidity determination with flawed data: the case of dysentery in regional India.

A method is suggested for removing measurement error from morbidity data collected in Third World countries. The method assumes the existence of diseases which are independent of socio-economic factors and exploits observed correlations between these disease and these factors to construct an index of measurement error. This index may be used as an explanatory variable in the analysis of other diseases which are hypothesised to have socio-economic causes which are the object of research. The method is applied to statewide data for India where the index of measurement error is based on influenza data which is then used to isolate the socio-economic factors that influenced dysentery.