In this article I provide a reflexive account of my research experiences with families of African descent. I examine the ways in which, as a researcher of African descent, I became part of the research process. Using data from an ethnographic study that explored the healthy lifestyle experiences and attitudes of families and adolescents of African descent in the northwest of England, I present a detailed discussion of the identity alteration, researcher-researched relationships, and insider-outsider tensions and dilemmas that arose while I collected data. I argue that researchers working with participants with whom they share similar ethnicity and historical experiences are likely to find that their professional self and personal life experiences overlap, and there can be difficulties in keeping them separate.

Background The by-pass of the primary level of care to the referral facilities has continued to raise concerns for the healthcare delivery system. About 60–90% of patients in Nigeria are reported to self-refer to a referral level of care. Thus, this study sought to identify the factors that influence service-users’ decision to self-refer to the secondary healthcare facilities in Nigeria by exploring the perceptions and experiences of the service-users. Methods Twenty-four self-referred service-users were interviewed from three selected secondary healthcare facilities (general hospitals) in Niger state, Nigeria. The interviews were tape-recorded, each lasting 20 min on average. This was subsequently transcribed and framework analysis was employed for the analysis. Results Various reasons were identified to have resulted in the bypass of the primary healthcare facilities in favour of the secondary level of care. The identified themes were organised based on the predisposing, enabling and need component of Andersen’s model. These themes included: patients understanding of the healthcare delivery system; perceptions about the healthcare providers; perceptions about healthcare equipment/ facilities; advice from relatives and friends; service-users’ expectations; access to healthcare facilities; regulations/ policies; medical symptoms; perceptions of severity of medical symptoms. Conclusions The findings from this study call for an evaluation of the current healthcare referral system, particularly in developing settings like Nigeria and consequently the need for developing a contextual model as applicable to individual settings. Therefore, a multifaceted approach is needed to address the current concerns to ensure patients utilise the appropriate level of care. This will ensure the primary healthcare facilities are not undermined and allow the referral levels of care to live up to their mandate.

In this discussion paper we consider the influence of ethnicity, religiosity, spirituality and health literacy on Advance Care Planning for older people. Older people from cultural and ethnic minorities have low access to palliative or end-of-life care and there is poor uptake of advance care planning by this group across a number of countries where advance care planning is promoted. For many, religiosity, spirituality and health literacy are significant factors that influence how they make end-of-life decisions. Health literacy issues have been identified as one of the main reasons for a communication gaps between physicians and their patients in discussing end-of-life care, where poor health literacy, particularly specific difficulty with written and oral communication often limits their understanding of clinical terms such as diagnoses and prognoses. This then contributes to health inequalities given it impacts on their ability to use their moral agency to make appropriate decisions about end-of-life care and complete their Advance Care Plans. Currently, strategies to promote advance care planning seem to overlook engagement with religious communities. Consequently, policy makers, nurses, medical professions, social workers and even educators continue to shape advance care planning programmes within the context of a medical model. The ethical principle of justice is a useful approach to responding to inequities and to promote older peoples’ ability to enact moral agency in making such decisions.

The findings have a number of implications for health promotion practitioners; in particular, the need to work collaboratively with migrant groups in order to identify and develop appropriate cultural sensitive communication strategies. The study concludes by suggesting the need to explore further the communication needs of migrant families and the implications for the take-up of health promotion services.

Objective To explore the process of adolescent peer leaders and the benefits of being a peer leader in a sexual health HIV/AIDS peer education programme. Design A qualitative study using the principles of grounded theory method. Setting Individual interviews were carried out by the researcher in a room within the building where training of peer leaders took place. Method Fifteen semi-structured in-depth interviews, followed by grounded theory investigation. Results Findings indicated that the process of peer leadership although complex was largely beneficial. The peer leaders were able to identify areas where the experience had benefited them as individuals. Conclusion The peer leaders that participated in the study highlighted positive changes in attitudes and also discussed the effects on their personal lifestyles. From the findings a correlation framework emerged that could be used for studying the interrelationship of factors that determine the effects of being a peer leader.