Prostate Cancer Screening of Heterosexual Caribbean American and African American Men and their Partners

The incidence and prevalence of prostate cancer are very alarming among men in general, among African American men more narrowly, and among Caribbean American men more specifically. While the disease has variable impact on men of different racial and ethnic backgrounds the impact of the disease on diagnosed Caribbean American men and their families is of particular importance. Prostate cancer screening decisions and behaviors can be very helpful in prevention, early intervention, treatment and recovery from prostate cancer. This research uses a symbolic interactionist framework within a family systems approach towards evaluating and understanding the experience of prostate cancer screening decision making among heterosexual Caribbean American men and their partners. A family systems approach is a comprehensive approach that considers important concepts relevant to the experience of illness and decision making surrounding health maintenance decisions. Symbolic interactions theory (SIT) focuses on the associations between symbols or shared meanings and verbal and non-verbal interactions actions and communications. It is a framework for understanding how human beings engage in relationships with each other and illustrates how they experience a variety of decision making processes. People are seen as employing their reasoning and symbolizing capacities and flexibly interpreting circumstances while simultaneously adapting to the same circumstances based on how they interpret the situations they confront. A qualitative research using Focus Groups of with 26 men and 24 women who identified as heterosexual Caribbean American and African American men and their partners was done. Their prostate cancer screening decision making experiences were evaluated in order to aid in the development of hypotheses and generate understanding about preventive and intervention strategies for serving the African American and Caribbean American community

A PHENOMENOLOGICAL INVESTIGATION OF TIME TO PRESENTATION, DIAGNOSIS, AND TREATMENT FOR INDIANA FARMERS WITH PROSTATE CANCER AND MEASUREMENTS OF TRADITIONAL MASCULINITY IDEOLOGY

Thesis (Ph.D.) - Indiana University, School of Public Health, 2020Introduction: The most common and second-deadliest cancer in the U.S. for men is prostate cancer (PCa). Extensive research shows that farmers have higher PCa incidence and mortality than nonfarmers. This study aims to better understand U.S. farmers’ increased risk of PCa by exploring care-seeking behaviors and masculinities in Indiana farmers with a history of PCa. Methods: Eleven farmers with a PCa history completed a questionnaire about their traditional masculinity beliefs and an interview focused on their PCa experiences, from signs and symptoms to after treatment. Interview questions were based on three theories, and the questionnaire was the 21-item Male Role Norms Inventory-Short Form (MRNI-SF). Results: MRNI-SF results showed farmers endorsed traditional masculine norms. Specifically, they agreed with avoiding femininity, having negative attitudes towards sexual minorities, being self-reliant through mechanical skills, toughness, and sex being important. Farmers did not endorse men being dominant nor with men restricting emotions. Seven themes described farmers’ PCa experiences: the body was an occasional guide for detection, routine checkups were the primary method of suspicion, PSA-testing was a powerful predictor, biopsy was somewhat of a bugaboo, diagnosis put psychological health on display, healthcare professional characteristics and others’ experiences reigned paramount in treatment decisions, and treatments invoked physical concerns and side effects. Discussion: Farmers did not agree with men always dominating and restricting emotions, which does not reflect previous studies. More research is suggested utilizing the MRNI-SF with larger populations of farmers. Based on the themes, increased somatic awareness is suggested for farmers, as well as continued routine checkups and PSA-testing. Farmers also require improved health education and resources to prepare for a PCa biopsy, to cope with a diagnosis, to make treatment decisions, and to manage treatment symptoms

Decolonising Health Inequalities: Uncovering the hidden factors behind biological models of Caribbean and African health outcomes in Greater Manchester

This thesis presents qualitative research conducted into an exploration of the hidden factors contributing to the disproportionate burden of disease for people of Caribbean and African descent in Greater Manchester. The study uncovers the hidden factors behind biological models of Caribbean and African health outcomes. It recognises the differences in morbidity and mortality between majority and minority Black groups and how the current evidence base constitutes consistent epidemiological findings of poor health across a range of health measures. The voices of Caribbean and African people were centralised through two phases of ethnographic data collection. Participants shared snapshots of their daily lives which captured their health and social interactions within the health system. This interdisciplinary piece of work is underpinned by several theories and frameworks and begins by presenting the social construction and post/decolonial legacy of race and its impact on Black people in the health market. It uses the sociological frameworks of Critical Race Theory (CRT) and Kimberlé Crenshaw and Patricia Hill Collins' iterations of intersectionality to explain how through health economic theory, gatekeepers' habitus and the unequal power relationships underpin institutional and systemic decision-making. Thematic analysis identified themes from the data that exposed external structural biases in the health market with concomitant internal pressures that have post-colonial origins. Findings revealed wide-ranging overarching themes, which were identified throughout the analytical process in phase 2 that had captured and developed themes from phase 1 of the study. Phase 2 themes included Significant Influences on Individuals’, ‘Discrimination’ and ‘the Mirror of Black Health’. I conclude that racial disparities in health endure primarily because the foundations upon which racial hierarchies were built are still present and used today. There has been a fundamental systemic and structural failure across government including public health practices to address the root causes that sustain the poor health of Black people. This study highlights how the deconstruction of race based and discriminatory practices can open possibilities for reconstruction to bring about more equitable solutions in practice-based outcomes. This will require a combination of post and decolonial scholarship, relationship building, health advocacy and political action to mount a sustained communities’ campaign for structural change within the health sector

Racialized Health, COVID-19, and Religious Responses

This volume draws attention to multiple ways black health prospects and outcomes are configured by the actions, inactions, and cultural capital of social institutions and leaders, including within the governmental sector, the healthcare sector, and the religious sector. Facilitating and ensuring conditions conducive to public health, and capacities for provision of public healthcare, are macro tasks, requiring substantial institutional, financial, and technological resources. Government sectors and healthcare sectors around the globe are where this scale of resources are concentrated, though in varying degrees reflective of global wealth disparities. As these disparities and inequities have become increasingly evident, including as a result of the COVID-19 crisis, it has become more urgent to hold sectors charged with public health accountable in fulfilling their public charge. Racialized Health, COVID-19, and Religious Responses: Black Atlantic Contexts and Perspectives explores black religious responses to black health concerns amidst persistent race-based health disparities and healthcare inequities. This cutting-edge edited volume provides theoretically and descriptively rich analysis of cases and contexts where race factors strongly in black health outcomes and dynamics, viewing these matters from various disciplinary and national vantage points. The volume is divided into the following four parts: Systemic and Socio-Cultural Dimensions of Black Health Ecclesial Responses to Black Health Vulnerabilities Public Education and Policy Considerations Spirituality and the Wellness of Black Minds, Bodies and Souls Part I explores ways social and cultural factors such as racial bias, religious conviction, and resource capacity have influenced and delimited black health prospects. Part II looks historically and contemporarily at denominational and ecumenical responses to collective black health emergencies in places such as Nigeria, the UK, the US, and the Caribbean. Part III focuses on public advocacy, particularly collective black health, both in terms of policy and education. The final section deals with spiritual, psychological, and theological dimensions, understandings, and pursuits of black health and wholeness. Collectively, the essays in the volume delineate analysis and action that wrestle with the multidimensional nature of black wellness and with ways broad public resources and black religious resources should be mobilized and leveraged to ensure collective black wellness

Racialized Health, COVID-19, and Religious Responses

This volume draws attention to multiple ways black health prospects and outcomes are configured by the actions, inactions, and cultural capital of social institutions and leaders, including within the governmental sector, the healthcare sector, and the religious sector. Facilitating and ensuring conditions conducive to public health, and capacities for provision of public healthcare, are macro tasks, requiring substantial institutional, financial, and technological resources. Government sectors and healthcare sectors around the globe are where this scale of resources are concentrated, though in varying degrees reflective of global wealth disparities. As these disparities and inequities have become increasingly evident, including as a result of the COVID-19 crisis, it has become more urgent to hold sectors charged with public health accountable in fulfilling their public charge. Racialized Health, COVID-19, and Religious Responses: Black Atlantic Contexts and Perspectives explores black religious responses to black health concerns amidst persistent race-based health disparities and healthcare inequities. This cutting-edge edited volume provides theoretically and descriptively rich analysis of cases and contexts where race factors strongly in black health outcomes and dynamics, viewing these matters from various disciplinary and national vantage points. The volume is divided into the following four parts: Systemic and Socio-Cultural Dimensions of Black Health Ecclesial Responses to Black Health Vulnerabilities Public Education and Policy Considerations Spirituality and the Wellness of Black Minds, Bodies and Souls Part I explores ways social and cultural factors such as racial bias, religious conviction, and resource capacity have influenced and delimited black health prospects. Part II looks historically and contemporarily at denominational and ecumenical responses to collective black health emergencies in places such as Nigeria, the UK, the US, and the Caribbean. Part III focuses on public advocacy, particularly collective black health, both in terms of policy and education. The final section deals with spiritual, psychological, and theological dimensions, understandings, and pursuits of black health and wholeness. Collectively, the essays in the volume delineate analysis and action that wrestle with the multidimensional nature of black wellness and with ways broad public resources and black religious resources should be mobilized and leveraged to ensure collective black wellness

Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds

Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers – the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people’s lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers – effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to ‘know’ the person is key. Stakeholder responses highlighted the need for development of Health-care professionals’ confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people’s lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is ‘ready’ for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information

Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds

BackgroundThis study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning.ObjectiveThe aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning?DesignThis was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings.SettingThe study was set in Nottinghamshire and Leicestershire in the UK.ResultsKey barriers – the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people’s lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers – effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to ‘know’ the person is key. Stakeholder responses highlighted the need for development of Health-care professionals’ confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified.LimitationsIt was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included.ConclusionsWhat constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people’s lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this.Future workPriorities for future research: How can health professionals identify if/when a patient is ‘ready’ for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding?FundingThis project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information

Using participatory, practice development, Delphi and realist research approaches to understand how frontline teams can use the workplace to make sustainable improvements in the quality of their practice

The symposium will share the approaches and findings from three funded national and international research studies which all contribute to the body of knowledge about how to support person centred, safe and effective care in the workplace. The final presentation will integrate the theoretical insights emerging from the three studies to present a model for sustainable transformation in frontline teams. Paper 1 Safety culture, quality improvement, realist evaluation Authors and affiliations Professor Kim Manley CBE, (Presenter), Carolyn Jackson, Christine McKenzie, Anne Martin, Dr Toni Wright. Abstract Safety in health care is an international concern with impact on quality of care (Hollnagel, et al, 2015). A Regional Patient Safety Collaborative (PSC), one of 15 nationally set up to place patients, carers and staff at the heart of quality improvements in patient safety, supported four large acute NHS hospital trusts with a PSC model to help facilitators use safety and quality improvement tools with frontline teams and to be mutually supported through action learning. The evaluation used realistic evaluation (Pawson & Tilley, 2004) (and the study and its findings are reported using the RAMESES 11 international standards (Wong et al, 2017). The study took place between June 2016-October 2017. Its aim was to understand what works for whom 3S.40-5.10pm1 Symposia- – Tuesday 17 April 2018 and why, when: working with frontline teams in large acute hospitals to embed a safety culture, and grow leadership and quality improvement capability. Specifically, to identify which strategies are effective in supporting front line teams to sustain bottom up change and quality improvement driven by the needs of patients and practitioners. The study drew on ethnographic principlesacross study sites usingdescriptive case study design. Mixed methods of critical observation of frontline practice, stakeholder evaluation,emotional touch points, self-assessment;qualitative 360 degree feedback; and the Texas safety culture survey tool were used to facilitate the development of a rich picture for each teamand each context so as to answer the evaluation questions. In tandem, interrogation of the literature to distilled relationships between context, mechanisms and outcomes generating hypotheses at individual, team and organisational level factors for safety culture. Key findings identified an interdependence between clinical leadership within frontline teams, safety culture, safety behaviours and teamwork echoed in microcosm through safety huddles; the skills and attributes of facilitators;and the impact of organisations on microsystems. Theories of culture change at the microsystems level are further embellished. References Hollnagel E., Wears R.L. and Braithwaite J. From Safety-I to Safety II: A White Paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia. http://citeseerx.ist.psu.edu/viewdoc/download doi=10.1.1.911.6550&rep=rep1&type=pdf (accessed 1st November 2017) Pawson, R. & Tilley, N. (2004) Realist Evaluation. [Online]. Available at: . Accessed: 14th November 2014. Wong, G.; Westhorp, G.; Greenhalgh, J.; Manzano, A.; Jagosh, J.; Greenhalgh, T, (2017) Quality and reporting standards, resources, training materials and information for realist evaluation: the RAMESES II project. Health Services and Delivery Research, 5(28) National Institute for Health Research October ISSN 2050-4349 DOI 10.3310/ Paper 2 Developing integrated facilitation standards to embrace the facilitation of learning in the workplace using e-Delphi Authors and affiliations Professor Kim Manley CBE, (Presenter), Carolyn Jackson, Anne Martin, Dr Toni Wright. Abstract This paper shares insights into the impact of system wide leadership initiatives that develop the facilitation capacity of the workforce to be effective clinical leaders in a time of increasingly complex system wide change (Manley et al, 2016, Crisp & Wilson 2011). The aim of this Delphi study (2015-16), was to develop a set of standards that could be used to guide an integrated approach to facilitation in and about the workplace. This includes the key qualities and skills required of facilitators who aim to integrate learning, development, improvement, inquiry, knowledge translation and innovation in and about the workplace. The study influenced by the knowledge base underpinning practice development methodology engaged international facilitation expertise. Three e-Delphi rounds involved participants from ten countries with expertise in facilitating either one or more of the purposes in work and/or about the workplace. The result, a set of standards builds on the current knowledge base about facilitation. The standards clarify the key components that facilitators need to attend to when supporting individuals, teams, organisations and services to achieve higher order learning in and about the workplace and positively impact on person centred cultures and health outcomes. The contribution of practice development as a discipline that integrates all the agendas was highlighted and needs to be promoted more explicitly at the policy level. The key messages from this work are that: Facilitators work within different contexts and help staff appreciate the broader contexts in which they work. These contexts impact on both facilitator and staff purposes within and across each context. An integrated approach to facilitation aims to support a number of purposes. Enablers, skills and strategies for achieving these purposes are identified in the set of standards developed Facilitators need to attend to the evaluation of outcome and impact in the given context whilst keeping focus on constantly refining the processes that are effective. References Crisp, J., & Wilson, V. (2011). How do facilitators of practice development gain the expertise required to support vital transformation of practice and workplace cultures? Nurse Education in Practice, 11(3), 173-178. Manley, K., Martin, A., Jackson, C., & Wright, T. (2016). Using systems thinking to identify workforce enablers for a whole systems approach to urgent and emergency care delivery: a multiple case study. BMC Health Services Research, 16(1), 1 Paper 3 Developing theoretical insights into sustainable transformation in front line teams – the Venus model Authors and affiliation Carolyn Jackson, Director, England Centre for Practice Development, Canterbury Christchurch University, UK (Presenter), Professor Kim Manley CBE, Anne Martin, DrToni Wright. Abstract Definitions for continuous Professional Development (CPD) tend to focus on individual objectives, yet the goals of CPD activity are mutually interdependent on individual and system aspects (Billet, 2002) This paper presents the theoretical and practical insights gathered from a realist synthesis and evaluation (2014-2015) that led to a tool designed to measure the impact of learning on individual, team and organisational effectiveness in relation to improvements in quality of care and patient outcomes in the workplace. The aim of the project was to develop and test a CPD Impact Tool that identifies mechanisms for measuring the impact of learning on individual, team and organisational effectiveness and the indicators useful for providing information on individual and team effectiveness in relation to outcomes in the workplace? The study used mixed methods across two phases with different stakeholder groups to first develop theories about the relationship between contexts, mechanisms and outcomes for CPD to help understand which strategies work best for whom in what circumstance and why? Phase 1 methods included: a literature review, underpinned by 12 critical questions, to identify what is known about CPD across three broad themes 1) What is CPD is and why it is important? 2) Purpose and impact of CPD, and 3) Facilitating and Judging the Effectiveness of CPD. This together with a stakeholder surveyanalysis and documentary analysis of CPDlearning outputs informed the development of the CPD framework and indicators which was then further tested in phase 2 with CPD providers, learner and an expert international reference group. Key findings centre on four transformation theories that underpin an overarching framework for understanding effective CPD and a set of Impact indicators for guiding evaluation In order for CPD to be effective it has to address all of the interdependent outcomes for individual, team, service and organisational transformation. Reference Billett S. Critiquing Workplace Learning Discourses: Participation and Continuity at Work. Stud Educ Adults. 2002; 34(1):56-67. Paper 4 Developing theoretical insights into sustainable transformation in front line teams – the Venus model Authors and affiliation Carolyn Jackson, Director, England Centre for Practice Development, CanterburyChristchurch University, UK (Presenter), Professor Kim Manley CBE. Abstract This paper presents a synthesis of the theoretical insights emerging from the three research studies together with outputs from a workshop for an international network of fellows. This synthesis is presented as a theoretical framework – the Venus Model for sustainable person centered transformation. This framework describes the key elements and linked concepts (and relationships) required to support front line teams (micro-systems) transform practice through interprofessional learning, development, improvement and innovation, and the essential organisational and systems factors required to enable this. The five key elements of the model are 1) supporting development of facilitation skills across a continuum of complex purposes, 2) leadership development at clinical to systems levels, 3) practice development - a complex methodology that focuses on collaborative, inclusive and participative approaches with stakeholders,to develop person-centred, safe and effective cultures, 4) using quality improvement skills and tools, and 5) the culture change skills at the front line of practice. Bottom up, as opposed to top down models for supporting complex change in organisations are crucial to understand how to transform systems, services and cultures of care within and across organisations to deliver new models for 21st century health and well-being. The symposium will conclude by sharing implications for practice based research and inquiry, workforce development and new emergent roles by considering how best to support and evidence the contribution of nurses to the future workforce on a global platform. This will include consideration of how nurses can take a leadership roles in both the delivery and evaluation of sustainable transformation across the health economy to impact on future new models of care

Migrants’ health beliefs and their impact on general practice encounters: an in-depth interview study of French- and Swahili-speaking Africans and general practitioners working with migrant patients

Background. The growing population of migrants (including sub-Saharan Africans) in the United Kingdom poses challenges to British general practice. First, migrants tend to seek health care at times of crisis rather than for preventive measures. This is despite being at increased risk of certain chronic conditions compared with the indigenous population. For sub-Saharan Africans this includes hypertension-related diseases and some cancers. Little has been published about Africans’ awareness of this risk or their knowledge of associated causative factors. Second, discordant health beliefs and healthcare expectations between migrants and doctors in the UK have been found to undermine trust during consultations with general practitioners and to lead to poor patient satisfaction. Little is known about the health behaviours of African migrants whose expectations are not met by primary care in the UK. A related area where health beliefs and practices differ between African migrants and their GPs is in the use of traditional medicines. A final challenge lies in considering the wider issues that GPs must address when consulting with migrant patients, including time pressures, organisational factors and the complex nature of problems presented by migrant patients. These issues are the focus of this study. Aims. To examine African migrants’ perceptions of chronic disease and their experience of seeking primary health care in the UK. To explore the impact upon GPs of caring for migrants. Objectives. To explore: 1) perceptions of chronic disease risk facing African migrants and their underlying explanatory models; 2) experiences of consultations about antibiotic prescriptions; 3) traditional African medicine use in the UK; and (4) to consider the effect of workload and work patterns on GP consultations with migrants. Design. In-depth interviews were conducted with 19 Africans from French- or Swahili- speaking countries, one African key informant and 13 GPs working with migrants. African participant recruitment was from community organisations and GPs were approached via an informal network of doctors. Interviews were transcribed and ten were translated by the principal investigator (three Swahili and seven French). Data analysis was undertaken following the approach of applied thematic analysis using the Nvivo software package. Data collection and analyses were underpinned by the following theoretical frameworks: Kleinman’s explanatory models of illness and of cultural health care systems and Lipsky’s street-level bureaucracy. Results. Narratives suggested low awareness of chronic disease risk amongst Africans. Infectious diseases were considered the dominant health threat for African migrants, mainly HIV but also tuberculosis and ‘flu’. Chronic diseases were sometimes described by Africans as contagious. Explanatory models of chronic disease included bodily/dietary imbalance, stress/exertion, heredity/predisposition and food contamination. Cancer was feared but not considered a major threat. Cancer was considered more common in Europe than in Africa and was attributed by Africans to chemical contamination from fertilizers, food preservatives and industrial pollution. Evidence cited for these chemicals was rapid livestock/vegetable production, large size of farmed products (e.g. fish), softness of meat and flavourless food. Chemicals were reported to circulate silently inside the body and cancer to develop in the part where they deposit, sometimes years later. Africans’ belief in infective explanations of disease extended to minor illnesses and was manifested in an expectation of antibiotics from GPs for problems such as a sore throat. This arose from participants’ experience in Africa, witnessing life-threatening infectious diseases and experience of unregulated access to antibiotics. Africans described various alternative measures to fulfil their unmet expectations, including approaching other National Health Service doctors, importing medication, and using private healthcare services in London, francophone Europe and east Africa. A further option was the use of traditional African medicine, reported by one quarter of African participants. Traditional African herbal medicine use was based upon a perception of its purity and natural origin in African soil and a deep belief in its efficacy. Consulting traditional African healers in the UK was reported to be undertaken in secret. Some GPs and Africans described consultations in terms of pressure, processing and conflict. Migrants were reported to present with complex health problems that were frequently compounded by language barriers. GPs described a need to remain in control of consultations and this included some use of personal discretion to render their tasks easier to complete. The most common example was accepting patients’ family and friends as informal interpreters – a choice that ran contrary to formal policy of only using professional interpreters. Burnout was reported to be one consequence of excessive workload for patient-centred GPs working with vulnerable groups like asylum seekers. Conclusions. There is a need to improve health literacy amongst African migrants in order to promote preventive behaviours for chronic disease and alternatives to antibiotics for minor illnesses. As part of this, further research is required into the use and properties of traditional African medicine. Interventions should be built upon participants’ existing knowledge of disease causation, their self-reliance in the pursuit of a healthy lifestyle and desire to retain cultural practices. One challenge to improving migrant health lies in the service dilemmas facing GPs, including excessive workload, the complex nature of migrants’ presenting problems and professional dilemmas. GPs who act as advocates for vulnerable migrant patients may be at increased risk of burnout and greater consideration should be given to providing them with appropriate support