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Introduction: Symptom prevalence and management have important implications for the use of healthcare services, as well as the health of individuals. Aim: To describe symptom prevalence and management in the UK and to investigate decision-making and preferences for care. Methods: Two questionnaire surveys were undertaken: 1) a symptom survey of 8,000 working-age adults in the UK, 2) a discrete choice experiment (DCE) with 1,370 respondents to the symptom survey. Results: Symptom survey - Over 75% of respondents experienced at least one symptom in the last two weeks (mean 3.7). The two-week prevalence of symptoms varied from 0.2% for coughing-up blood to 41.3% for feeling tired/run down. Prevalence of specific symptoms was associated with a number of participant characteristics. The most common response to symptoms was doing nothing at all (49%) followed by over-the-counter medicine use (25%). Approximately 8% consulted a GP, while use of other members of the primary-care team (pharmacist, nurse, complementary practitioner and NHS24/NHSDirect) was very small (<2%). Symptom characteristics were more commonly associated with actions taken than participant characteristics. DCE - Significant differences were found for three symptom scenarios of increasing seriousness (diarrhoea, dizziness and chest pain). Self-care was the preferred option for diarrhoea. Consulting a GP was the preferred option for dizziness and chest pain. For all symptom scenarios there was a preference for less waiting time, less cost, greater convenience/availability and a very good chance of a satisfactory outcome. These preferences were valued more highly as the seriousness of the symptom scenario increased. Respondents were willing to trade between different attributes, with waiting time and chance of a satisfactory outcome being the attributes most likely to influence preferences for different actions. Conclusion: Further research is required to examine the public’s knowledge and perceptions of the services offered by different members of the primary care team for managing symptoms.

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C. ABSTRACT Introduction: Medical pluralism is a worldwide phenomenon. The reality in South Africa is that healthcare is provided by both orthodox and traditional healthcare providers. There is a great reliance on traditional medicine (TM) especially in rural communities. The complex interplay between patient centeredness and empowerment, health economics, failure of the biomedical approach and many other factors has resulted in an increasing prevalence of medical pluralism. Aim: The aim of the study was to explore the existence and extent of medical pluralism in my practice population, to quantify the prevalence of use and to qualify the determinants of choice. Methods: A cross sectional community household survey was conducted in the Makwarela Township of the Thulamela municipality (which forms part of the Vhembe district in the Limpopo Province in South Africa) using systematic sampling based on interval numbers. Interviewer administered questionnaires were used to obtain information from 65 households. Information was collected regarding the dependent variables (illness episodes, consultation behaviour, choice of primary health care provider) and the independent variables (socio-demographics, characteristics of illness, characteristics of health services). These were then analysed to assess prevalence of use and to elucidate significant associations. Results: Only 48 households representing 73,8% of the sample agreed to be interviewed. The total household members numbered 242. There were 364 illness episodes experienced by the household members in the 6 months prior to the survey. The ever use of TM in the sample was 70,8% (57,9% - 83,7%, 95% CI), whereas the ever use of orthodox medicine was 100%. The percentage of respondents who feel that they would probably use TM in future was 50%. The only significant correlates of TM use were highest education, household size, health belief model, waiting times at OM practitioner and past utilisation of TM. Conclusion: The study confirms the hypothesis of the existence of a pluralistic primary healthcare system and high prevalence of use of TM in the sample. The pattern of use of TM is that of an adjunct rather than as exclusive therapy. The study also confirms the complex interplay of a myriad of factors in healthcare choice. Despite the limitations of the study it can serve as a preliminary investigation prompting further studies to elucidate healthcare utilisation in the province and nationally. There are many ensuing implications for healthcare providers, funders and health system planners.

Resumo: Ao longo da história da humanidade, a família tem-se mantido como instituição social permanente devendo ser fortalecida. Mas, para definir família, é necessário compreender uma série de fatores, contextos e realidades e para conhecer famílias, é necessário ter uma visão das relações entre familiares, vizinhos, parentes e da rede de suporte. A família tornou-se foco de pesquisa e objeto de investigações após a implantação do Programa de Saúde da Família pelo Ministério de Saúde em 1994. A enfermagem assume um importante papel em criar vínculos com a família na construção de um novo paradigma de saúde. Nesta oportunidade, priorizou-se desenvolver o estudo sobre o enfoque de risco familiar a agravos ou danos a saúde, com o objetivo de avaliar o instrumento "Critério UFES" para identificação e classificação de risco familiar no âmbito da Estratégia Saúde da Família, adaptado pela Universidade Federal do Espírito Santo, da Escala de Coelho. Os dados foram coletados após atualização dos cadastros das famílias, por meio da Ficha A1 do Sistema de Informação da Atenção Básica, complementadas pelos agentes comunitários de saúde. Os dados foram lançados em planilha Excel para processamento dos escores. E, para analisar a consistência e coerência do instrumento, foi calculado o Coeficiente α de Cronbach. As famílias foram classificadas: 20% em Risco Zero; 63% como Risco 1; 8% como Risco 2 e 7% como Risco 3. As sentinelas de risco mais frequentes foram baixas condições de saneamento e higiene, uso de drogas lícitas e ilícitas e doenças crônicas. O instrumento em foco permite classificação de risco familiar, porém apresenta alguns limites, principalmente relacionados às definições das sentinelas, sendo que na área rural o Coeficiente α de Cronbach apresentou resultados considerados de regulares a discretos; sendo necessário a sua ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Over human history, the family has been a permanent social institution that must be strengthened. But, in order to define family, it is necessary to understand a number of factors, contexts and realities. And, in order to know families, it is necessary to have a view of the relationships among relatives, neighbors and members of the support network. The family became an object of investigation after the implantation of the Family Health Program by the Health Ministry in 1994. Nursing then assumes an important role in creating bonds with the family for the construction of a new health care paradigm. In this scenario, this study aimed at investigating family risk for health aggravations and damage, with the purpose to evaluate the instrument "UFES Criterion" for family risk identification and classification in the realm of the Family Health Strategy, adapted from the Coelho Scale by Espiríto Santo Federal University. The data were collected after updating families' records by means of SIAB Form A1, complemented by community health agents. Hence, the data were entered on an Excel sheet for score processing. In order to analyze the consistency and coherence of the instrument, Cronbach's α Coefficient was calculated. The families were classified as: 20% under Zero Risk; 63% under Risk 1; 8% under Risk 2 and 7% under Risk 3. The most frequent risk sentinels were poor sanitation and hygiene conditions, use of licit and illicit drugs and chronic diseases. The focused instrument classifies family risk; however, it has some limits particularly in relation to the definitions of sentinels, and, in the rural area, Cronbach's α Coefficient showed results that are considered to be regular and discreet. Well-defined criteria are necessary for its application or for inclusion of specific sentinels in the rural area / Orientador: José Eduardo Corrente / Coorientador: Vera Lúcia Pamplona Tonete / Banca: Ethel Leonor Nóia Maciel / Banca: Antonio Luiz Caldas Júnior / Banca: Carmem Maria Casquel Monti Juliani / Banca: Maria José Bistafa / Mestre

INTRODUCTION Lack of follow-up to recommended appointments can decrease vision outcomes. Research is needed to determine the best approach to scheduling follow-up appointments in the primary eye care setting to help overcome barriers and decrease disparities in vision health. The specific aim of this work is to evaluate the effectiveness of automated and personal telephone interventions to improve follow-up adherence in the primary eye care setting. METHODS In a prospective, single-blind, randomized, controlled trial, 1,095 patients seen in the Cataract and Primary Care service (CPEC) at Wills Eye Hospital who were due for follow-up appointments were randomly assigned to usual care, automated telephone intervention or personal telephone intervention group. Patients in the usual care group (n=364) received a form letter reminding them to make an appointment and an automated reminder phone call one day prior to their scheduled visit. Automated intervention participants (n=365) received the usual care form letter and an automated call 1-month prior to their recommended follow-up date, a mailed appointment reminder if an appointment was scheduled, and an automated telephone reminder the day before the scheduled appointment. If a patient in the automated intervention group did not attend the scheduled appointment, a reminder postcard was sent. Personal intervention participants (n=365) received the traditional form letter and a personal telephone call 1-month prior to the recommended follow-up date, a mailed appointment reminder if an appointment was scheduled, and a personal telephone reminder prior to the scheduled appointment. If a patient in the personal intervention group did not attend the scheduled appointment, they received a personal call. Scheduling and attendance data were extracted from the electronic medical record system. RESULTS Patients in the personal intervention group had greater adherence to follow-up recommendations than patients in the usual care group (37.70% vs. 27.47%; RR: 1.37; CI 1.24-1.52; p<0.001) and automated intervention group (29.59%; RR: 1.27; CI 1.15-1.41; p=0.02). Patients in the usual care group were not significantly different than patients in the automated intervention group in regards to adherence to follow-up recommendations (27.47% vs. 29.59%; RR: 1.08; CI 0.98-1.18; p=0.53). Personal intervention improved adherence for patients who have been previously recognized as at risk including men (37.04% vs. 22.39%; RR: 1.65; CI: 1.41-1.94; p=0.01), African Americans (39.58% vs. 29.52%; RR: 1.34; CI 1.16-1.55; p=0.03), patients under 65 (28.93%-18.67%; RR: 1.55; CI 1.40-1.71; p=0.01), and patients who live greater than 20 miles from Wills Eye Hospital (44.74% vs. 12.50%; RR: 3.58; CI 2.59-4.95; p=0.01). Additionally, personal intervention improved adherence in patients with Medicare (58.42% vs. 43.56%; RR: 1.34; CI 1.01-1.79; p=0.03) and urban patients who live within 2 miles of Wills Eye Hospital (41.18% vs. 17.54%; RR: 2.35; CI 1.81-3.04; p=0.01). As a secondary endpoint, personal intervention significantly improved appointment scheduling over usual care (51.09% vs. 32.14%; RR 1.59; 95% CI 1.33-1.90; p<0.001) and automated intervention (51% vs. 36%; RR: 1.40; CI 1.18-1.66; p<0.001). Automated intervention did not significantly improve appointment scheduling over usual care (36% vs. 32%; RR: 1.13; CI 0.93-1.39; p=0.22). CONCLUSION Personal intervention improved adherence to recommended follow-up for primary eye care appointments overall and in at-risk populations. Automated intervention had no significant improvement over usual care. The cost effectiveness of personal intervention to improve outcomes in a primary ophthalmology setting should be evaluated to determine whether the intervention should be implemented as a process change at Wills Eye Hospital and at other primary ophthalmology care centers.

Objective: I sought to determine the systolic intensification threshold, time-to-intensification and time-to-follow-up associated with the lowest risk of cardiovascular events or death in primary care patients with hypertension. Methods: A retrospective cohort study of 88,756 patients was performed. Systolic intensification threshold, time-to-intensification and time-to-follow-up were analyzed with respect to risk of acute cardiovascular event or death. The Cox model was adjusted for age, sex, smoking status, socioeconomic deprivation, history of diabetes, cardiovascular disease or CKD, Charlson Comorbidity Index, BMI, medication possession ratio, and baseline blood pressure. Results: During median follow-up of 37.4 months, 9,985 participants experienced acute cardiovascular event or death (11.3%). Systolic intensification thresholds of 130-150 mmHg were associated with no difference in risk, while higher thresholds were associated with progressively greater risk. Risk increased progressively from the lowest (0-1.4 months) to the highest quintile of time to medication intensification. The highest quintile of time to-follow-up (>2.7 months) was also associated with increased risk. Conclusions: Systolic intensification threshold higher than 150 mmHg, delays of greater than 1.4 months before medication intensification following systolic blood pressure elevation, and delays of greater than 2.7 months before blood pressure follow-up following medication intensification were associated with increased risk for acute cardiovascular events or death.

Includes bibliographical references. / Most patients with type 2 diabetes in Cape Town are attending at primary care community health centers (CHCS) and have unsatisfactory glycaemic control. Insulin therapy is indicated in patients with type 2 diabetes, with inadequate metabolic control on maximum oral therapy. Insulin can be initiated in these CHCs.