Community-Links Practitioners in Scotland

The primary purpose of this study was to investigate whether or not the implementation of Community-Links Practitioners (CLP) into primary care improves quality of life for underserved communities. The authors suggest that social interventions should prove a holistic solution to the needs of patients that is not being addressed by primary care. They used participants in a program utilized by the Scottish government called the Glasgow Deep End Links Worker Programme to provide a quantitative analysis of how well CLPs help improve the quality of life for underserved populations. Because previous analyses that investigated effectiveness of CLP programs were unable to randomize or use large sample sizes, the authors utilized this Scottish program because they could randomize a large enough sample size to provide a stronger contribution to the literature. This study was a quasi-experimental, cluster-randomized controlled trial. Data was clustered by clinic where participants were recruited and quasi- experimental because they did not match clinics while randomizing the control versus study populations. One improvement to the methods could have been to create specific recruitment criteria for the participants, though this would increase the cost and amount of resources required for the study. Having recruitment criteria will assist in knowing exactly who is being recruited into the study at the individual level and what comorbid conditions they may or may not have. There was no definition or qualification for participants. If definitions or qualifications for participants were implemented, then the focus of the analysis could be narrower and provide more definitive results and conclusions. The groups also felt the removal of patients considered inappropriate for health or social reasons by senior general practitioner was a potential issue with the recruitment. Thought the EQ-5D-5L is a standardized measure of health quality, we discussed that it might have been too broad and too general of a measure, leading to the finding that there was no difference between groups before and after their first CLP appointment. It would also be helpful if there was an explanation of why the EQ-5D-5L and specific outcomes were chosen. Since the groups that were targeted were underserved patients, it would be interesting to know what social determinants of health are playing a role into their health outcomes and how they may be confounders in the analysis. Justification and explanations for why CLPs would specifically improve the unhealthy behaviors and quality of life would be useful. Qualitative analysis would have provided useful results and insight into potential reasons for why or why not CLPs are effective. We suspect that having patients engage and follow up in programs such as CLPs is difficult, and it would be helpful to have qualitative insight into what motivates patients to come versus what inhibits them from coming. Is it lack access to transportation, not having time to come, or are they just not interested? Are there certain aspects of CLPs that patients enjoy more than others? Do they even want to improve the certain aspects of health that were analyzed in this study? Qualitative answers to these questions would be helpful for futures studies and implementation of programs that are similar to CLPs. This group also discussed that looking at a change in quality of life may have shown a benefit for poor populations since any improvement in the positive direction is beneficial. Because this study used a quantitative analysis, they were not able to show an improvement in the lives of the more underserved populations. However, if they had measured any improvement in quality of life for the poorer populations then perhaps they would find that CLPs provide at least some benefit to the patients in these populations. A qualitative analysis would help provide insight into this limitation and could show that there are improvements that do actually help these patient populations, even if it is not a quantitatively significant difference. Another question we would like to consider is what kind of resources do these populations have access to? Especially in underserved communities, this kind of information could advise program implementation and could also be useful in providing social support.

If investigators want to determine the feasibility of CLP programs or similar types of community programs, they need to include a more targeted (well-defined) population and use a more focused intervention. The broad focus in this study prevents us from being able to make strong conclusions. A narrowed focus would allow for the determination that the outcome being measured is directly impacted by the intervention. Future analyses would also benefit from a discussion about the difficulty in retaining and engaging the patients in these types of programs and systems. It is important to note that this critique is coming from the view-point of healthcare professionals in the United States. One noticeable difference is the education system. Scotland residents can begin trade school or college earlier than US residents and also get up to five years of free post-high school education. This difference might result in a different quality of life between poor residents in Scotland versus the US. Another stark difference is that the legal drinking age in Scotland is 18, which may or may not affect the onset of substance dependence. Finally, the weather could potentially confound results when measuring quality of life in Scottish communities versus US communities. If a study looks at US communities that have warmer weather or more sunny weather on average, then the quality of life may not be an equal comparison with Scottish communities. There was no discussion about political issues or struggles with implementing beneficial social support in these types of deprived communities. It would be helpful to have a discussion about how politics impacts the use of social resources to help underserved communities. This group also wants to know whether we are trying to help by raising awareness of what resources are available to deprived communities, or are we trying to encourage implementation of newer and better resources such as parks, walking trails and community centers. Analyses would benefit from looking at a model which investigates CLPs that go out into the community versus models where patients have to travel to the CLP. Underserved communities frequently may not have access to public transportation or reliable transportation, thus it is valuable to bring help directly to them. We understand the caveat is this requires more money and resources but we also believe that the rewards would outweigh the increased burden of additional resources. This paper assumes there are resources in the area in which the patients who are deprived live. For example, rural towns in Illinois severely lack these types of resources and it would be helpful to discuss how we address this issue. Perhaps telemedicine and technology can provide solutions.

This group thinks the most improvement of this analysis can be made by focusing on patient populations that have defined eligibility criteria. This would provide a more focused outcome and more reliable analyses. Providing more objective outcomes, which would require a targeted patient population, would improve the results immensely.

Competing interests: None declared