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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Communicating with people who have limited English
Around 340 different languages are spoken in London alone, and a high (but not formally quantified) proportion of healthcare consultations take place across a language barrier (Baker and Eversley, 2000). Other cities in the UK have comparable challenges, as evidenced by a large 'grey literature' on interpreting need by acute and primary care trusts. People from ethnic minorities have a higher prevalence of diabetes than the indigenous white British population, and diabetes also disproportionately affects the poor, so people with diabetes who are from ethnic minorities are less likely to be educated and fluent in English (Greenhalgh et al, 2001).
Food beliefs and practices among British Bangladeshis with diabetes: Implications for health education
In order successfully to promote 'healthier' food choices, health professionals must first understand how people classify and select the foods they eat. We explored the food beliefs and classification system of British Bangladeshis by means of qualitative interviews with 40 first-generation adult immigrants with diabetes. Methods included audiotaped, unstructured narrative interview in which participants were invited to 'tell the story' of how diabetes affects them, pile sorting of food items, and participant observation of meals. We found considerable heterogeneity of individual food choices against a background of structural and economic factors (i.e. food choices were partly determined by affordability and availability), as well as cultural influences. Important themes included strong religious restrictions on particular food items (chiefly the Islamic prohibition of pork), and widely held ethnic customs based on the availability of foods in rural Bangladesh. Modification of the diet on immigration did not generally incorporate many 'Western' foods but included increased quantities of 'special menu' Bangladeshi foods such as meat and traditional sweets. Foods were not classified or selected according to Western notions of food values (protein, carbohydrate, etc.). Rather, within religious and ethnic patterns, further food choices were determined by two interrelated and intersecting binary classification systems: 'strong'/'weak' and 'digestible'/'indigestible', which appear to replace the 'hot'/'cold' classification prevalent elsewhere in South Asia. Different methods of cooking (especially baking and grilling) were perceived to alter the nature of the food. A desire for dietary balance, and a strong perceived link with health, was apparent. These findings have important implications for the design of health education messages. Dietary advice should reflect religious restrictions, ethnic customs and the different cultural meaning of particular foods, while also acknowledging the ability of the individual to exercise choice within those broad limits.
Determinants of knowledge gain in evidence-based medicine short courses: An international assessment
Background: Health care professionals worldwide attend courses and workshops to learn evidence-based medicine (EBM), but evidence regarding the impact of these educational interventions is conflicting and of low methodologic quality and lacks generalizability. Furthermore, little is known about determinants of success. We sought to measure the effect of EBM short courses and workshops on knowledge and to identify course and learner characteristics associated with knowledge acquisition. Methods: Health care professionals with varying expertise in EBM participated in an international, multicentre before-after study. The intervention consisted of short courses and workshops on EBM offered in diverse settings, formats and intensities. The primary outcome measure was the score on the Berlin Questionnaire, a validated instrument measuring EBM knowledge that the participants completed before and after the course. Results: A total of 15 centres participated in the study and 420 learners from North America and Europe completed the study. The baseline score across courses was 7.49 points (range 3.97-10.42 points) out of a possible 15 points. The average increase in score was 1.40 points (95% confidence interval 0.48-2.31 points), which corresponded with an effect size of 0.44 standard deviation units. Greater improvement in scores was associated (in order of greatest to least magnitude) with active participation required of the learners, a separate statistics session, fewer topics, less teaching time, fewer learners per tutor, larger overall course size and smaller group size. Clinicians and learners involved in medical publishing improved their score more than other types of learners; administrators and public health professionals improved their score less. Learners who perceived themselves to have an advanced knowledge of EBM and had prior experience as an EBM tutor also showed greater improvement than those who did not. Interpretation: EBM course organizers who wish to optimize knowledge gain should require learners to actively participate in the course and should consider focusing on a small number of topics, giving particular attention to statistical concepts.
Training in general practice: Three contemporary controversies
In this essay we present Trisha Greenhalgh's intervention at the 2006 Wonca Europe Conference. The Author speaks about training, in particular about contemporary controversies emerging in our professional training. In teaching family medicine when we consider three aspects of learning we face up with an impact area: What should we know? We need to acquire knowledge necessary to our practice from research. What should we do? In order to answer this question, which includes the great part of medical activities, we should know ethical principles and human virtues. What should we dare to hope? To learn to use creativity and imagination both in scientific reasoning and in the human dimension of our practice. These reminders are then resumed by Giorgio Bert in a comment full of stimulus very useful for professional training in medicine.
Towards a broader agenda for training in critical appraisal
Much progress has been made in recent years towards an evidence-based approach to health care, ie the routine framing of an explicit decision sequence in the clinical encounter, the systematic search for published evidence, and the appraisal of relevant research articles. We argue that this is a commendable but limited milestone, and that training in evidence-based health care, particularly the use of critical appraisal techniques, is in need of a broader agenda. We outline a proposal through which the skills and attitudes needed for the critical appraisal of published articles may be applied to all other aspects of clinical practice, from planning research projects to presenting results and guidelines and peer review of articles submitted for publication.