Background to the Research

• This report builds on data contained in an earlier report entitled 'An Assessment of Health Inequalities in Two Northern Ireland Communities: An Ethnographic Approach' (1997). The original data is further analysed in order to examine the perspectives of health professionals on issues of service delivery in two rural communities in Northern Ireland - the pseudonyms of Ballymacross and Hunterstown were used to preserve confidentiality.
  

Research Approach

• Data sources included key informants, interviews, group discussions, participant observation and use of secondary data. Snowball and chain sampling techniques were used and interviews were carried out with 15 health workers.
  

Profile of Ballymacross

• This is a small predominantly Catholic town with a population of 982 in 1991. There was no doctor in the town and the nearest health centre was located in a small Protestant town nearly 2 miles away. The nearest hospital was in a largely Catholic town 7 miles away.
• There are few childcare facilities, and recreational opportunities during the day for women and poor transport made it difficult for women to access services in the larger towns. Local people and health professionals noted a rise in the incidence of post natal depression.
• Heavy drinking was not uncommon in the town and there was evidence of binge drinking by teenagers as young as 13 and 14 years old. Health concerns relating to children included the increased incidence of asthma, accidents on busy roads and on farms and underage sex and illicit drug use. Low rates of breastfeeding were a concern for health professionals, but not for mothers and young people. Teenagers consumed a high fat diet.

Profile of Hunterstown

• This is a predominately Protestant town with a population of 1,337 in 1992. It has a health centre with 3 male doctors and a variety of nursing and administration staff. A wide range of health promotion and treatment clinics were offered. The nearest hospital was in a large Catholic town nearly 10 miles away.
• Unemployment was considered to be a significant problem in the whole district council area, which experienced higher than average rates. The town lacked social cohesion with divisions between the wealthy and the relatively poor and 'drinkers' and 'non-drinkers', who disapproved of alcohol.
• Social isolation was common amongst women, especially those with children. Heavy drinking amongst men and binge drinking were problematic, there appeared to be a marked rise in drinking and drunkenness among young people. Smoking was on the rise among young girls, and parents expressed concerns about the availability and use of illicit drugs by young people. A high fat diet and lack of exercise were commonplace.

Main Findings

• Amongst health professionals, there was no coherent approach to achieving health gain, little collaboration and minimal interaction between different health, social and community workers.
• Those community workers who worked in a collaborative way with local people did not rate health concerns as a matter of priority and health professionals tended not to work in a collaborative way with local people.
• The two important health sectors in each community of the churches and local traditional healers were ignored by the professional health care sector.
• Neither location had a co-ordinated approach to health needs assessment at local level.
• Amongst NHS-employed primary care health professionals, there was a common experience of stress, pressure and low morale.
• The major problems for community development in both locations were funding and sustainability.
• There was little evidence of effective teamwork amongst health workers; instead there appeared to be rivalries between sets of health workers.

Recommendations

Community Level

• Formal mechanisms for interagency working should be established at local level to complement the work of the Ministerial Group on Public Health.
• Local community forums should be set up to open up lines of communication between health care professionals and local community representatives.
• Health priorities should be integrated into ongoing community development work through discussion and negotiation between primary care health professionals and local community development leaders.
• In accordance with guidance from the Regional Strategy for Health and Social Well-being, the Department, Boards and Trusts should encourage, support and expand community development approaches throughout the health and personal social services.

Primary Care Level

• The morale of front line primary care health professionals should be assessed, and if necessary improved.
• Research should be carried out to assess the effectiveness of primary health care teams.
• Front line primary health care professionals should make long term plans to ensure the sustainability and continuity of local health initiatives.

Health Needs Assessment

• Mechanisms should be established from 'ground to Board level' in order that primary health care professionals can communicate local health needs and identify gaps in service.
• Data from the community health profiles, completed by community nurses, should be systematically collated and used by GPs, managers, locality planning groups and Boards to assess health needs and shape service delivery.
• Concerted action should be taken at local level to find and treat the causes of ill health, to complement health promotion to individuals.
• Primary health care professionals and local communities should explore together what they understand by 'health', in order to reach mutual understanding and goals and agreed health activities.