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Background: Depression is an important cause of certified sickness absence in the UK. It is not known what factors are associated with variation in length of sickness certificates issued by the GP ...

AimsWhen using an assessment tool, brevity and validity are essential. Although brief depression inventories exist, they rely heavily on the inclusion of somatic symptoms. This can be problematic in advanced cancer populations; weight loss and sleep disturbance are for the most part ubiquitous in these patients and may not necessarily be indicative of depression.The Brief Edinburgh Depression Scale (BEDS) is a 6-item shortened version of the Edinburgh Depression Scale which has been validated for use in patients with advanced cancer and is used internationally. The BEDS cut off threshold of 6/18 indicates that depression may be present. However, the BEDS currently provides no information regarding severity. The aim of this study is to establish severity thresholds for the BEDS by comparing it to another depression scale: the commonly used, rigorously validated, Patient Health Questionnaire (PHQ-9).Method284 advanced cancer patients attending hospice day services in the North West of England completed both the PHQ-9 and the BEDS. Mean participant age was 66.7 (Standard Deviation = 13.2) and the sample contained both males (n = 102, 36%) and females (n = 182, 64%). BEDS severity thresholds with the highest Sensitivity (Sn) and Specificity (Sp) were selected based on their ability to predict PHQ-9 categories.ResultA BEDS score of 4 to 6 was selected to indicate ‘mild depression’ (Sn = 81.7, Sp = 65); 7 to 8 ‘moderate depression’ (Sn = 74.8, Sp = 78.7); 9 to 11 ‘moderately severe depression’ (Sn = 82, Sp = 82.9) and 12 or more ‘severe depression’ (Sn = 63.2, Sp = 92.8). A linearly weighted kappa (with s weighting) showed a moderate level of agreement (0.47, 95% Confidence Interval: 0.40-0.54).ConclusionThe BEDS is a simple and brief tool used to screen for depression in advanced cancer patients. It is administered throughout the UK and multiple translation studies have enabled its global a (including in resource poor countries). The severity thresholds calculated here are derived from a large sample of patients with advanced cancer attending hospice services and demonstrate acceptable sensitivity and specificity in relation to the PHQ-9, a thoroughly validated reference standard. We conclude that the generated BEDS thresholds support use of the BEDS in determining the presence and severity of depression in advanced cancer populations.

Simple Summary We know that socio-economic factors influence delay in presentation and diagnosis of cancer and that patients living in areas of greater socio-economic deprivation are less likely to be referred to palliative care services including hospice. However, very little is known regarding the impact of socio-economic deprivation on symptom burden in advanced cancer patients. Our study found that patients experiencing greater socio-economic deprivation were more likely to report depression and pain and greater global symptom burden than patients from less socio-economically deprived areas. We also found that reporting a lack of information at time of diagnosis was significantly associated with socio-economic deprivation. Although more than one-third of patients recruited into this study were diagnosed with cancer within the preceding 12 months, this was not associated with socio-economic factors and socio-economic factors did not appear to influence survival in our study. The impact of socio-economic factors on symptom burden and information needs should be acknowledged within palliative care settings. Abstract Socio-economic deprivation is known to impact on cancer diagnosis, treatment and access to services, but little is known of the impact of socio-economic deprivation on symptom burden in patients with advanced cancer. Patients with advanced cancer attending hospice day services were recruited into a 24 week longitudinal study. An area-based index of social deprivation was collected along with depression and symptom burden at baseline, 8, 16 and 24 weeks. Of the 595 patients included, with an age range of 33–89 years and a mean age of 68 years, 67% were female, and 37% were diagnosed with cancer in the last 12 months. Twenty nine percent lived in one of the most deprived 20% of neighbourhoods. Patients living in the most socio-economically deprived areas were significantly likely to report receiving insufficient information regarding their cancer at diagnosis (p = 0.007), greater pain (p = 0.02), moderate to severe depression (p = 0.04) and higher global symptom burden (p = 0.04). This study is the first to report that patients with advanced cancer attending hospice services, living in the most deprived neighbourhoods experience significantly greater symptom burden, notably depression and pain. We recommend using patient outcome measures in order to provide targeted support and thereby reduce the increased symptom burden that socio-economically disadvantaged patients experience at the end of life.

Background Little consideration has previously been given to the implications of a change in diagnosis during a sickness certification episode. Objective To report the extent and patterns of change in diagnosis and to identify factors associated with likelihood of change. Methods Sixty-eight general practices in the UK recorded details of sickness certificates (fit notes) issued to patients in a 12-month data collection period. Diagnoses on fit notes were assigned to modified READ categories. Results Over 23% (3841/16400) of episodes consisting of more than one sickness certificate had a change in diagnosis during the course of the episode. Over 4% (438/10398) of initial physical health episodes had a later mental health diagnosis. Lowest rate of change was found within episodes with an initial mental health diagnosis, the highest when an unspecified physical symptom was entered on the first fit note in the episode. A change in diagnosis was more likely when the total duration of the episode was longer, the episode included more fit notes and the patient was living in a socially deprived neighbourhood. Episodes where the patient had been issued fit notes by more than one GP were more likely to have a change in diagnosis. Conclusion Change in diagnosis on fit notes is much less common when the patient has a psychological health problem.

Compared to other areas of sickness certification, recurrence of certified sickness absence has been relatively under-researched.This study aims to report the extent and patterns of recurrence and to identify factors associated with higher rates of recurrence.Sickness certification ('fit note') data were collected from 68 general practices in eight regions of the UK for 12 months.Twenty percent of 31,453 patients in the study had a recurrent certified sickness episode, with over half of these having the second episode in the same diagnostic category as their first. Mental health problems accounted for over a half of all days certified in same-diagnosis recurrent episodes. Male gender, residing in an area of social deprivation, a longer episode of initial certified sickness absence, not having return to work ('may be fit') advice in the first episode, having a mental disorder or musculoskeletal (particularly back) problem were all independently associated with a higher incidence of recurrence.Differential risk of recurrence needs to be considered when designing return-to-work interventions. Evaluation of effectiveness of interventions (particularly for sickness absentees with mental health problems) has to consider the sustainability of employment after a return to work.

Background The ‘fit note’, with the opportunity for the GP to advise that a patient ‘may be fit’ to do some work, was introduced in April 2010. Aim To estimate numbers of fit notes with ‘may be fit’ advice, the types of advice, and factors associated with any inclusion of such advice in the fit note. Design and setting Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland. Method Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months. Results The ‘may be fit’ box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to ‘amend duties’ of patient as a prerequisite for return to work (included in 42% of all notes containing any ‘may be fit’ advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any ‘may be fit’ advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note. Conclusion Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers).

Introduction A pilot trial was carried out to determine if a focussed narrative interview could alleviate the components of suffering and anxiety and depression in advanced cancer patients. Intervention Patients recruited were invited to participate in a focussed narrative interview and reflect on their perspectives on their sense of “meaning”, regarding suffering and their psychological, physical, social and spiritual well being – the emphasis was on allowing the patient to tell their story. Patients were encouraged to share what resources they themselves had utilised in addition to what professional care they may have received, to maintain a sense of well being. Method Patients with advanced metastatic disease were recruited from hospices in the North West of England – the only exclusion criteria were not being able to understand written and spoken English and a non cancer diagnosis. At recruitment patients were asked to complete a numerical scale for suffering; the Brief Edinburgh Depression Scale, Edmonton Symptom Assessment Scale (ESAS), FACIT Spiritual well being questionnaire, Demographic information was collected and patients were randomised to either the intervention arm of the trial or the usual care arm of the study. Patients in both groups were invited to complete each measure at 2, 4 and 8 weeks. Results One hundred people were recruited into the study – 49 were randomised to intervention group and 51 to control group. The median age of patients was 66 years age range (31–89 years) and 68% of patients were female. At baseline the ECOG performance of 75% of patients recruited was 1 or 2. The median survival of all patients in the study was 169.5 days (range 10 days to still alive at end of study). There was no significant difference at any timepoint in scores on suffering measure between intervention group and control group. At each time point the intervention demonstrated mean improvement in scores for depression and anxiety on ESAS – the greatest changes for both depression and anxiety were seen at 4 weeks. Conclusion This pilot randomised controlled trial of a focussed narrative intervention demonstrated an improvement in mean changes in scores for depression and anxiety at 2, 4, and 8 weeks. We suggest this intervention may have beneficial effects on depression and anxiety, but a larger powered trial is required to determine the full effects.

PurposeThe purpose of this paper is to investigate to what extent urban regeneration programmes were targeted at the most deprived geographical areas and populations within the boundaries of nine local authorities (LAs) in the North West of England.Design/methodology/approachFor each of the nine LAs, area‐level and individual survey data were used in estimating the proportions of the more deprived neighbourhoods and individuals included in (or excluded from) regeneration target populations after 1995.FindingsThe area‐level approach found that, in general, the more deprived neighbourhoods within local authority districts had been included in a main regeneration programme target area. However there was evidence of inconsistent coverage between LA areas, as well as some cases of very deprived local areas having no involvement at all in major regeneration programmes since 1995. Additional analysis of available survey data found that substantial numbers of residents with one or more individual indicators of deprivation (not in full‐time employment, not owning home, in difficult financial situation) had not been included in a regeneration target population.Research limitations/implicationsThe basic nature of the measures of regeneration and deprivation used in the study reflect its status as the first stage of a wider project investigating the association between regeneration activity, social exclusion and health.Practical implicationsThe findings of the study highlight the requirement for evaluators of a regeneration programme to consider how successful the intervention has been in targeting those residents for whom it was initially designed. This should precede any measurement of the programme outputs and their impact upon the “well‐being” of the targeted community.Originality/valueThe study is original in its use of both aggregated and individual level data in its consideration of how regeneration targets “need”.

AimTo report the types and duration of sickness certification for different common mental disorders (CMDs) and the prevalence of GP advice aimed at returning the patient to work.BackgroundIn the United Kingdom, common mental health problems, such and depression and stress, have become the main reasons for patients requesting a sickness certificate to abstain from usual employment. Increasing attention is being paid to mental health and its impact on employability and work capacity in all parts of the welfare system. However, relatively little is known about the extent to which different mental health diagnoses impact upon sickness certification outcomes, and how the GP has used the new fit note (introduced in 2010) to support a return to work for patients with mental health diagnoses.MethodsSickness certification data was collected from 68 UK-based general practices for a period of 12 months.FindingsThe study found a large part of all sickness absence certified by GPs was due to CMDs (29% of all sickness absence episodes). Females, younger patients and those living in deprived areas were more likely to receive a fit note for a CMD (compared with one for a physical health problem). The highest proportion of CMD fit notes were issued for ‘stress’. However, sickness certification for depression contributed nearly half of all weeks certified for mental health problems. Only 7% of CMD fit notes included any ‘may be fit’ advice from the GP, with type of advice varying by mental health diagnostic category. Patients living in the most socially deprived neighbourhoods were less likely to receive ‘may be fit’ advice on their CMD fit notes.

To test the impact of socio-economic and psychological adversity and healthcare on long-term recovery from depression. A community sample of 347 people with depressive disorders was followed up after 9 years. Baseline socio-economic adversity, social support, healthcare use, and psychiatric history were identified. Respondents completed self-report instruments on current depressive status (Beck depression inventory) and longstanding psychosocial adversity (sexual, physical or emotional abuse). Univariate analyses tested for association between recovery and respondent characteristics. Follow-up was achieved for 182 (52%) of the sample, of whom 75 (41%) indicated recovery from depression. Psychological adversity definitely and socio-economic adversity probably were associated with lack of recovery. Baseline healthcare had no apparent impact on outcome. Rurality and support after life events were associated with recovery. History of depression was associated with non-recovery. Psychological adversity is, and socio-economic adversity may be, associated with long-term non-recovery from depression in community settings.

Aims: To investigate the association of patient, clinician, and general practice factors with long-term certified sickness absence. Methods: Analysis of a sickness certification database constructed via the use of carbonized sick notes by clinicians at nine general practices in the north-west of England. A total of 3,385 patient sickness episodes certified by 44 general practitioners (GPs) were included in the analysis. Three logistic regression models were constructed in order to estimate independent effects of the patient, GP, and the general practice on risk of long-term (>28 weeks) incapacity. Results: The logistic regression models explained a maximum of 27% of the variation in long-term certified sickness. The diagnostic reason for the sickness episode explained over 18% of variance, while clinician and general practice effects explained only 3.4% and 2.3% respectively. In all models, older patient age and an episode within the mild mental disorder (MMD) diagnostic category significantly increased the risk of long-term work incapacity. Conclusions: The study results imply that, rather than basing `return to work' interventions on identification of individual patient/claimant characteristics or on GP training initiatives, it may be more productive to focus upon a more diagnosis-based approach within primary care itself. Interventions aiming to reduce mild mental disorder-related work incapacity should be given priority.

Background The development of a brief valid tool to screen for depression in patients with advanced cancer is important. This paper reports data on the psychometric properties of the Brief Edinburgh Depression Scale. Method Two hundred and forty six patients who fulfilled the inclusion criteria completed the 10-item EDS and Present State Examination. Results Factor extraction revealed 6 items from the ten item EDS. The most valid cut off for defining a case, using the PSE diagnosis as the “gold-standard”, was a score of 6 out of 18 on the Brief Edinburgh Depression Scale which gave a sensitivity of 72% and specificity of 83% with a PPV of 65.1% and NPV of 87.1%. Conclusions The six item EDS is a brief and sensitive method of screening for depression in advanced cancer patients — this novel use of the Edinburgh depression scale may have a significant impact on the assessment and thus management of this distressing symptom.

BACKGROUND Little research has focused upon how GP and patient gender interact to influence the outcome of consultation. In particular, no UK studies have investigated the effect of gender interaction on the duration of patients' certified sickness. OBJECTIVE To investigate associations between the four GP-patient gender interaction categories and patient risk of intermediate or long-term work incapacity. METHODS DESIGN Use of carbonized sickness certificates to collect routine sick note data over a 12-month collection period. SETTING Nine general practices in the Mersey Primary Care R&D Consortium. SUBJECTS A total of 3906 patients, certified sick by 67 GPs (including 45 GP principals). MAIN OUTCOME MEASURES The effect of gender interaction was measured against two outcomes: intermediate (6-28 week) and long-term (28 weeks or over) periods of certified sickness. RESULTS After univariate and multivariate analyses, it was discovered that certification of male patients by male GPs was significantly associated with increased prevalence of intermediate (6-28 week) certified sickness outcomes, compared with females certified by females (OR=1.38 P=0.009). This result was replicated in the subgroup of patients with mild mental disorder-related sickness absence. However, no association was demonstrated between gender interaction and long-term (>or=28 week) outcome, in the total patient group or within diagnostic subcategories. CONCLUSION GP and patient gender appear to have most impact upon sickness certification in the intermediate period. This period is already recognized as the optimum time for interventions to prevent onset of long-term incapacity, particularly in cases where the cause of sickness absence is reversible (as in psychological-related certified sickness absence). Further research is needed (particularly focusing upon attitudes and content of consultations) in order to shed more light on the gender differences found in this study.

Spiritual care is an integral part of palliative care and if asked, most members of a palliative care team would state they address spiritual issues. The majority of hospices have support from a chaplain. This study was to determine the roles of chaplains within hospices and to look at their levels of stress. A questionnaire containing both open and closed questions was sent to chaplains working within hospices in the UK. The questionnaire enquired about number of sessions, specific roles of chaplain, whether they were members of the multidisciplinary team and their sources of internal support. Stress was measured on a 10-point Likert scale and the GHQ12. One hundred and fifteen questionnaires were returned, with a 72% response rate. The majority (62%) defined their denomination as Church of England and Free Church (24%); 71% of respondents had parish commitments in addition to their hospice role. Roles were predominantly defined as spiritual care of patients and staff (95%) and bereavement support of relatives (76%) and 75% regularly attended the multidisciplinary meetings. Senior medical and nursing staff and other chaplains were perceived as providing most support. Median Likert score for stressfulness was 5, and 23% scored at or above the threshold on the GHQ12 for identifiable psychological morbidity. Clear role definition was associated with less perceived stress whereas the provision of bereavement support was associated with statistically significant increased perceived stress. The role of a chaplain within a hospice is varied and this study suggests that the provision of training and formal support is to be recommended.

BACKGROUND/OBJECTIVES: Evidence-based research has been criticized for not being relevant to the real world of patient care in the community, mainly because participants in research studies are dissimilar to those typically seen in every day practice. This article examines recruitment difficulties, and identifies the main reasons why patients with heart failure declined to participate in a research trial. METHODS: Postal survey of potential trial participants (n=667), at time of recruitment. Analysis of (1) clinical and sociodemographic characteristics of respondents and nonrespondents to survey, and decliners and consenters to participation in a randomized controlled trial. RESULTS: No significant differences were found between respondents and nonrespondents in respect to sociodemographic or clinical variables. Males (OR=1.58, CI=1.04-2.41), younger patients (OR=1.05, CI=1.03-1.08), and those prescribed an angiotensin converting enzyme (ACE) inhibitor (OR=1.68, CI=1.10-2.57) were significantly more likely to consent to participate. Main reasons for nonparticipation were perceptions of being too old, too unwell, or too busy. CONCLUSIONS: Explanations of the purpose of research need to counter against perceptions among participants and clarify the benefits and disadvantages of participating in an intervention study when unwell. Study design should recognize that many elderly patients have busy lives and caring responsibilities. Financial support for participation should be considered.

Background. Good communication is a crucial clinical skill. Previous research demonstrated better clinical outcomes when practitioners and patients agree about the nature of patients' core presenting complaints. We investigated the nature of this agreement and its impact on outcome among depressed primary care patients.Method. We compared presenting problem formulations completed by patients, GPs and therapists in a primary care randomized controlled trial of cognitive-behavioural therapy and non-directive counselling for depression. Participants compiled formulations from a list of 13 potential problems of self-completed questionnaires. Subjects scored at least 14 on the Beck Depression Inventory (BDI) at baseline. Outcome measure for this study included BDI at 4 and 12 months, failure to attend for therapy when referred, dropout from therapy and patient satisfaction.Results. Among 464 trial patients, 395 received therapy. Patient baseline problem formulations included significantly more items than GPs, who identified significantly more items than therapists. Agreement levels varied according to a range of patient and professional variables. While patients in complete agreement with their therapists about their main problem after assessment had lower average BDI scores at 12 months (9·7 v. 12·8, P=0·03); we found no other significant associations between the extent of agreement and clinical outcome. There were significant (but relatively weak) associations between agreement and aspects of patient satisfaction.Conclusion. Our results suggest that detailed mutual understanding of the presenting complaints may be less important than agreement that the core problem is psychological, and that referral for psychological therapy is appropriate.

Background The beliefs of people receiving treatment about the causes of their own mental health problems are researched less often than the causal beliefs of the public, but have important implications for relationships with prescribers, treatment choices and recovery. Method An online survey on a range of beliefs about depression, and experiences with antidepressants, was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants. Results Six of 17 beliefs about the causes of their own depression were endorsed by more than half the sample: chemical imbalance, family stress, work stress, heredity, relationship problems and distressing events in childhood. There were some marked differences in content, structure and level of conviction of beliefs about one׳s own depression and the sample׳s previously published beliefs about depression in general . There were also significant differences between the beliefs of demographic groupings. Regression analyses revealed that self-reported effectiveness of the antidepressants was positively associated with bio-genetic causal beliefs. The quality of the relationship with the prescribing doctor was positively related to a belief in chemical imbalance as a cause and negatively related to a belief in unemployment as a cause. Limitations The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression. Conclusions People experiencing depression hold complex, multifactorial and idiosyncratic sets of beliefs about the causes of their own depression, apparently based at least in part on their own life experiences and circumstances. Exploring those beliefs may enhance the doctor–patient relationship and selection of appropriate treatment modality.

Background Public beliefs about the causes of mental health problems are related to desire for distance and pessimism about recovery, and are therefore frequently studied. The beliefs of people receiving treatment are researched less often. Method An online survey on causal beliefs about depression and experiences with antidepressants was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants. Results The most frequently endorsed of 17 causal beliefs were family stress, relationship problems, loss of loved one, financial problems, isolation, and abuse or neglect in childhood. Factor analysis produced three factors: ‘bio-genetic’, ‘adulthood stress’ and ‘childhood adversity’. The most strongly endorsed explanations for increases in antidepressant prescribing invoked improved identification, reduced stigma and drug company marketing. The least strongly endorsed was ‘Anti-depressants are the best treatment’. Regression analyses revealed that self-reported efficacy of the antidepressants was positively associated with bio-genetic causal beliefs, negatively associated with childhood adversity beliefs and unrelated to adulthood stress beliefs. The belief that ‘People cannot׳ get better by themselves even if they try’ was positively associated with bio-genetic beliefs. Limitations The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression. Conclusions Clinicians׳ should consider exploring patients׳ causal beliefs. The public, even when taking antidepressants, continues to hold a multi-factorial causal model of depression with a primary emphasis on psycho-social causes. A three factor model of those beliefs may lead to more sophisticated understandings of relationships with stigma variables.

Christopher Shiels and Brenda Roe report on a survey into the prevalence and care of pressure sores among older people living in residential care and nursing homes in Liverpool. Setting up appropriate information systems and auditing available pressure-relieving equipment are just two of a number of important recommendations arising from the survey.

This paper reports the conduct, results and implications of a survey of residential and nursing homes for elderly people in Liverpool, with particular reference to the prevalence and care of pressure sores. The objectives of the survey were to establish prevalence rates, to collect data on the process of preventing and managing pressure sores, and to look at differences between the two types of home sector in terms of care policy and practice.

To date, most condom research has focused on young or high-risk groups, with little evidence about influences on condom use amongst lower-risk community samples. These groups are not risk free and may still wish to negotiate safer sex; yet the considerations involved could be different from those in higher-risk groups. Our research addresses this gap: We report a cross-sectional questionnaire study enquiring about recent condom use and future use intentions in community settings. Our sample (n = 311) purposively included couples in established relationships, known to be condom users. Items included demographics, sexual history and social-cognitive variables taken from the theory of planned behaviour. The strongest association with condom use/use intentions amongst our respondents was sexual partner's perceived willingness to use them. This applied across both univariate and multivariate analyses. Whilst most social-cognitive variables (attitudes; self-efficacy and peer social norms) were significant in univariate analyses, this was not supported in multivariate regression. Of the social-cognitive variables, only "condom-related attitudes" were retained in the model explaining recent condom use, whilst none of them entered the model explaining future use intentions. Further analysis showed that attitudes concerning pleasure, identity stigma and condom effectiveness were most salient for this cohort. Our results suggest that, in community samples, the decision to use a condom involves different considerations from those highlighted in previous research. Explanatory models for established couples should embrace interpersonal perspectives, emphasising couple-factors rather than individual beliefs. Messages to this cohort could usefully focus on negotiation skills, condom advantages (other than disease prevention) and reducing the stigma associated with use.

The measurement of health outcomes is central to the development of health services. Many acute and chronic illnesses and health interventions have implications for mental health. This study tests the validity of a 22 item measure of psychological well-being, the adapted general well-being index (AGWBI). A postal health survey, including the AGWBI, was sent to a 10% random sample of patients aged 16 or over drawn from the computerized list of one general practice. Two hundred and sixty-six respondents returned questionnaires (a response rate of 76%). The AGWBI was fully completed by 94% (249) of the respondents who returned their questionnaires. Only respondents who fully completed the AGWBI are included in the analysis. The AGWBI significantly discriminated people with a limiting long term illness, those reporting suffering from anxiety, depression or bad nerves, users of general practitioner services over the previous two weeks and respondents reporting taking anti-depressants, tranquillizers or sleeping tablets. It was also able to discriminate respondents with psychosocial difficulties in a small sub-sample who reported that they were in excellent health and did not have a limiting long term health problem or psychological illness. The results are broadly supportive of the validity of the AGWBI and suggest it may be appropriate for use in the evaluation of several developing areas of primary care. Further research is needed to test concurrent validity, responsiveness and to establish population norms.

International audience; ABSTRACT Objectives. To examine inequalities in immunisation and breastfeeding by ethnic group and their relation to relative deprivation. Design. Cross –sectional study. Setting. Manchester, UK Participants. 20,203 children born in Manchester (2002-7), who had been coded as of White, Mixed, Indian, Pakistani, Bangladeshi and Black or Black British ethnicity in the Child Health System database. Main Outcome Measures. Breastfeeding at 2 weeks postpartum; uptake of Triple Vaccine (Diptheria, Pertussis and Tetanus) at 16 weeks postpartum; uptake of the Measles, Mumps and Rubella Vaccine (MMR) by the age of 2. Results. Black or Black British infants had the highest rates of breastfeeding at 2 weeks postpartum (89%), and South Asian infants had highest Triple and MMR vaccination rates ( Indian, 95%, 96%; Pakistani 95%, 95%; Bangladeshi 96.%, 95%) after controlling for area level of deprivation, parity, parenthood status and age. White infants were least likely to be breastfed at 2 weeks postpartum (36%), and to be vaccinated with Triple (92%) and MMR vaccines (88%). Within the White ethnic group lower percentages of immunisation and breastfeeding were significantly associated with living in a deprived area and with increasing parity. This was not found within Black or Black British and Pakistani ethnic groups. Discussion Practices that are protective of child health were consistently less likely to be adopted by White mothers living in deprived areas. Methods of health education and service delivery that are designed for the general population are unlikely to be successful in this context and evidence of effective interventions needs to be established.

Objective Depression is common in patients with late stage cancer. This study was carried out to investigate whether depression is associated with survival, measuring physical symptoms as a potential confounding variable. Patients and methods One hundred and thirty two patients formed the study sample and eighty-seven patients participated in the study. The Edinburgh Depression Scale (EDS) and self-rated symptoms list were completed three times over an eight-week period and analyzed, together with relevant demographic and clinical factors. Results Depression was self-rated in 29% (25/87) of patients at the initial screen and 54.5% of surviving patients remained depressed at eight-week follow-up. No significant associations were found between baseline EDS ‘caseness’ and demographic factors or tumour type. However EDS scores were significantly correlated with four symptoms measures. Sixty two percent (54/87) of patients died during the 12 month period of the study. The EDS score had a significant independent effect upon risk of death in study period — a one-point increase in EDS score raises risk of outcome (death) by 7%. Conclusions Depression is an independent predictor of poor survival in patients with advanced cancer. It is important that patients with advanced cancer are screened for depression and appropriate interventions offered.

We analysed the difficulties encountered in recruiting predominantly older patients, suffering from an acute exacerbation of a chronic illness, to a randomized controlled trial of home telecare. Of 653 patients approached for study participation, after full assessment, 80% (519) met the trial eligibility criteria. Of these, 104 (20%) consented to study participation and 415 (80%) refused. A logistic regression model was constructed to examine independent effects of patient factors on probability of trial participation. Only two independent variables were associated with decreased likelihood of consent: increasing age (1 year older: odds ratio [OR] = 0.96); and being on inhaled steroid medication (OR = 0.60). The most common reason for refusal to participate, accounting for almost one-third of respondents, was a stated preference for a face-to-face nurse visiting service rather than a telecare service. Perhaps home telecare services should continue to be targeted at the more stable chronically ill population and not at those suffering from acute illness.

Although comparatively few people have regular contact with a church or spiritual leader, during times of terminal illness or bereavement, clergy are expected to be available and able to provide support. This study was carried out to determine the perceptions of clergy on the training they had received in supporting the dying patient and the bereaved. A sample of clergy working in the diocese of Sheffield was sent a questionnaire to assess what skills and knowledge clergy believed they had in this area, together with areas where they would wish for further training. The questionnaire was developed with input from hospital, hospice, and academic chaplains, and palliative care consultants. A subsidiary questionnaire was sent to clergy training colleges to evaluate the teaching offered. There was a trend across all denominations that those who had trained more recently were more likely to have received relevant training. Most clergy believed that they possessed adequate liturgical skills, but 13% felt they possessed none or little skill in pastoral care of the dying. Seventy-one percent indicated that they would like further training in pastoral care of the dying and 66.3% desired training in care of the bereaved. Of the 50% of training colleges that responded, the number of hours of training on pastoral care of the dying ranged from 6 to 36 hours (median 23 hours and mean 25 hours) and only 26% believed that their training in pastoral support skills was comprehensive. This study suggests that care of the dying and the bereaved is identified by clergy as an area in need of further training by the majority of clergy and should be part of the core curriculum within clergy training colleges and late training programs.

A randomized controlled trial of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease has been undertaken in the north-west of England. A videophone was used that communicates via the ordinary telephone network. The intervention period for each participant was two weeks. Participants in the telecare arm of the trial were asked to complete logbooks to record their experiences of each telecare encounter. A simple, self-completed, 10–item questionnaire was used that consisted of a Likert scale, ranging from 1 (totally disagree) to 5 (totally agree). Fourteen nurses completed 150 logbooks and 22 patients completed 145 logbooks. These results demonstrate significant differences in perception between patients and their health-care providers with regard to telecare encounters across all the domains addressed. Participating patients consistently demonstrated more positive views of the telecare encounters than their health-care providers.

BackgroundDoctors are less likely to diagnose depression in men than in women. Little research has been conducted to explore the underlying reasons for this in rural settings, or to compare primary care doctors' and male patients' ratings of perceived depression.AimsTo identify symptomatic and socio-demographic correlates of depression in men attending a rural practice, and to compare and contrast general practitioners' and patients' assessments of depression.MethodAll male patients of working age attending a rural general practice over a 12-month period were invited to participate.ResultsMen reporting recent’ chest pain’ or ‘feeling tired/little energy’, expressing low job enjoyment or with a previous diagnosis of depression were more likely to be scored above threshold on the Hospital Anxiety and Depression Scale – Depression sub-scale. There was little agreement between the doctors and their male patients about the degree of perceived depression.ConclusionsEducational interventions aimed at addressing the diagnosis of depression in men should take greater account of factors within a particular social setting.

summary We conducted a qualitative evaluation of the introduction of a telenursing service. The service used an analogue videophone linked with a physiological monitoring device, which allowed the transmission of data between the patient's home and the hospital. A researcher kept a detailed diary of day-to-day activity for the first year of the project. Computer software for qualitative data analysis was used to code the text and the analysis followed the principles of constant comparison. The diary entries documented how the commercially available equipment was adapted to suit the organization and content of the nurses’ work. The nurses made a number of suggestions to improve the user-friendliness of the equipment. The technology, the existing home care service (the comparison arm of the study) and the randomized controlled trial itself all underwent continuous change. The traditionalrandomized control design of trial has limitations in this situation, and there is a need for more realistic trial designs.