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Background: In the United Kingdom ethnic minority groups from the Indian sub-continent (India, Pakistan and Bangladesh) are at increased risk of diabetes and coronary heart disease. Variation in outcome these diseases in minority ethnic populations are related to inequity due, in part, to inadequate identification and treatment of underlying risk factors such as obesity but also in access to appropriate health care. Aims objectives: This thesis explores three possible contributing factors to these variations in health experience. Firstly, data from the Health Survey for England (HSE) is used to assess whether using waist circumference (WC) rather than body mass index (BMI) among patients of Indian subcontinent (South Asian) origin would improve risk prediction (related to obesity) for diabetes and hence increase the opportunity to detect those at risk. Secondly, a quantitative study using data from an electronic centralised cardiac rehabilitation register in the north west of England explores the variation in recording of cardiovascular disease risk factors and other clinical data in relation to ethnicity. Thirdly, a qualitative study explores the experiences and needs of South Asian patients following an acute cardiac event. Methods: Study 1: Subjects from the HSE 1999 were selected for analysis based on ethnicity. Logistic regression analysis was carried out to see how effective WC to an established risk score would be at identifying the South Asians with undiagnosed diabetes or impaired glucose regulation. Study 2: A shared central electronic database was developed for recording patient demographics and clinical information for all patients assessed for CR in East Lancashire. Analysis of the recording of clinical data was undertaken by ethnicity, gender and age. Study 3: Twenty participants (12 Pakistani, 6 and 2 Bangladeshi) eligible for CR were interviewed using a semi-structured format. Results: Inclusion of WC resulted a greater sensitivity (72%) and specificity (69%) increasing from 69% and 64% respectively with improved overall level of prediction for the identification of patients at risk of diabetes at the optimal cut point. WC was less likely to be recorded than BM! ( 2.5% versus 57.1 %). WC and BMl were both significantly less likely to have been recorded for women than for men (We: 20.7% vs. 28.7%; BMI: 57.0% vs. 68.2%) and for South Asian populations than for White populations (We: 18.7% vs. 26.7%; BMI: 55.0% vs. 65.3%). Patients in the study had a poor understanding of their disease and underlying risk factors with significant misconceptions. The importance of interventions by professional friends and family members (a doctor or nurse for example) was a recurrent theme in determining appropriate access to care. Reasons for non-attendance included those related to service provision (flexibility, setting, timing of classes and paternalistic attitude in relation to communication) and patient factors (language barrier, transport, health and religious beliefs). Conclusion: It was possible to include 'ethnic' specific WC cut-off points for use with the Cambridge risk score identifying individuals with diabetes among South Asian populations. CR database revealed inequity in recording of risk factors such as We. The qualitative study confirmed the inequity in both access and experience of CR services for South Asian patients. The barriers which restrict or diminish access to chronic disease health care such as CR services for the South Asian population are complex and related to not only to patient factors but also to system/provider levels and institutional factors, and the interactions between them.

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Background and Aims: One method for understanding the quality of care provided by community pharmacies is to assess it using objective measures such as indicators. These, however, should be based on a common frame of reference for describing quality. As no such definition exists specifically for community pharmacy, this research aimed to gain an understanding of community pharmacy quality and its assessment. Methodology: In order to conceptualise community pharmacy quality, ten focus groups were conducted across the northwest of England with 47 purposively sampled participants who had experiences with community pharmacy healthcare services. Constant comparative analysis was used to analyse the verbatim transcripts. To develop the quality indicators, a scoping review was conducted to identify descriptive statements which mirrored the quality attributes and quality dimensions analysed from the focus groups. Then, once customised into clearly defined statements with a measurable element, 458 potential quality indicators were arranged into four questionnaires to be rated on their face-validity. Finally, consensus was gathered on each indicator's face-validity by using a two-round modified Delphi technique. Panellists were recruited from across England and were community pharmacists or PCT employees who were involved with community pharmacies (second round: n₁=20, n₂=19, n₃=19, n₄=19). Findings: It emerged that community pharmacy quality can be conceptualised as dynamic and complex with interdependent dimensions of 'opportunity', 'effectiveness' and 'positive perceptions of the experience'. Each dimension contains structures, processes and associated outcomes. These were illustrated by a dynamic model of quality dimensions and by its related static framework of structures processes and outcomes. In the Delphi questionnaires, a total of 51 potential indicators were added by panellists, and after the second rounds, 452 indicators achieved consensus for having face-validity as community pharmacy quality indicators. These assessed one or more of the three quality dimensions and related to: the pharmacy environment, equipment and facilities; patient access to medicines, advice and services; effectiveness; and management and leadership in the pharmacy. Ten indicators achieved consensus for lacking face-validity, and 47 indicators did not achieve consensus. Discussion: This research provides a foundation for future work in community pharmacy quality, and could enable those who design, develop and provide pharmacy services to better target their efforts in delivering high quality care. The quality indicators may help with assessing pharmacies and with making changes based on objective data. Before the 452 quality indicators are implemented, future study should include testing them in pharmacies to determine their reliability, feasibility and acceptability. Other recommendations for research, policy and practice are outlined in the text.

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