Compassion in healthcare – lessons from a qualitative study of the end of life care of people with dementia

Objectives

A lack of compassion in UK healthcare settings has received much recent attention. This study explores the experiences of people with dementia in the last year of life and time surrounding death and how the presence and lack of compassion, kindness and humanity influenced the experience of care.

Design

Qualitative in-depth interviews with bereaved informal carers of people with dementia.

Setting

United Kingdom.

Participants

Forty bereaved carers – 31 women and nine men – with an age range of 18–86 years and from wide socioeconomic backgrounds participated.

Main outcome measures

Experiences of carers of care for person with dementia during last year of life.

Results

The interviews highlighted differences and challenges in care settings in providing compassionate, humanistic care and the impact of the care experienced by the person with dementia during the last year of life on informal carers during the bereavement period and beyond. Excellent examples of compassionate care were experienced alongside very poor and inhumane practices.

Conclusion

The concepts of compassion, kindness and humanity in dementia care are discussed within the paper. The ability to deliver care that is compassionate, kind and humanistic exists along a continuum across care settings – examples of excellent care sit alongside examples of very poor care and the reasons for this are explored together with discussion as to how health and social care staff can be trained and supported to deliver compassionate care.     

Individual and Contextual Determinants of Social Homecare Usage in Slovenia

Theory

Social homecare is important for older people, as it enables them to remain in their own homes during worsening health, thus relieving the burden on institutional facilities such as homes for the elderly or nursing homes and hospitals.

Method

A representative survey of social homecare users was employed to assess determinants of the scope of social homecare in Slovenia. Multiple regression analysis was used to evaluate determinants defined by Andersen’s behavioral model that affect the scope of social homecare.

Results

As expected, need (Functional impairment B = .378, P = 0.000) was the most important explanatory component, followed by availability of informal care network (Lives alone B = −.136, P = 0.000; Has children B = − .142; P = 0.000) and other contextual factors such as total costs of the services (B = −.075; P = 0.003) and temporal availability of services (B=−.075, P=0.012). The model explained 18% of variability in the scope of social homecare.

Conclusion

This study showed that data on the individual level, as opposed to data on an aggregated level, show different determinants of social homecare utilization. Moreover, the results showed that social homecare is especially important in two circumstances: when older people have a high level of need and when they do not have access to informal care networks. Contextual factors had a moderate effect on the scope of social homecare, which shows universal access to the latter at the individual level.     

Kangaroo mother care: a systematic review of barriers and enablers

Objective

To investigate factors influencing the adoption of kangaroo mother care in different contexts.

Methods

We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization’s regional databases, for studies on “kangaroo mother care” or “kangaroo care” or “skin-to-skin care” from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems.

Findings

We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption.

Conclusion

Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake.     

The relationship between formal and informal care among adult Medicaid Personal Care Services recipients

Objectives

To test hypotheses concerning the relationship between formal and informal care and to estimate the impact of hours of formal care authorized for Medicaid Personal Care Services (PCS) on the utilization of informal care.

Data Sources/Study Setting

Data included home care use and adult Medicaid beneficiary characteristics from assessments of PCS need in four Medicaid administrative areas in Texas.

Study Design

Cross-sectional design using ordinary least-squares (OLS) and instrumental variable (IV) methods.

Data Collection/Extraction Methods

The study database consisted of assessment data on 471 adults receiving Medicaid PCS from 2004 to 2006.

Principal Findings

Both OLS and IV estimates of the impact of formal care on informal care indicated no statistically significant relationship. The impact of formal care authorized on informal care utilization was less important than the influence of beneficiary need and caregiver availability. Living with a potential informal caregiver dramatically increased the hours of informal care utilized by Medicaid PCS beneficiaries.

Conclusions

More formal home care hours were not associated with fewer informal home care hours. These results imply that policies that decrease the availability of formal home care for Medicaid PCS beneficiaries will not be offset by an increase in the provision of informal care and may result in unmet care needs.     

Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey

Objective

To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts.

Data Sources/Study Setting

Nationally representative data from the 2009 Health Center Patient Survey.

Study Design

Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients'' health care experiences.

Data Collection

Computer-assisted personal interviews were conducted with health center patients.

Principal Findings

Homeless patients had worse health status—lifetime burden of chronic conditions, mental health problems, and substance use problems—compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24–3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37–2.92).

Conclusions

There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.     

Disability and Care Needs Among Older Americans

Context

The cost of late-life dependency is projected to grow rapidly as the number of older adults in the United States increases in the coming decades. To provide a context for framing relevant policy discussions, we investigated activity limitations and assistance, care resources, and unmet need for a national sample of older adults.

Methods

We analyzed the 2011 National Health and Aging Trends Study, a new national panel study of more than 8,000 Medicare enrollees.

Findings

Nearly one-half of older adults, or 18 million people, had difficulty or received help in the last month with daily activities. Altogether, 1 in 4 older adults receiving help lived in either a supportive care (15%) or a nursing home (10%) setting. Nearly 3 million received assistance with 3 or more self-care or mobility activities in settings other than nursing homes, and a disproportionate share of persons at this level had low incomes. Nearly all older adults in settings other than nursing homes had at least 1 potential informal care network member (family or household member or close friend), and the average number of network members was 4. Levels of informal assistance, primarily from family caregivers, were substantial for older adults receiving help in the community (164 hours/month) and living in supportive care settings (50 hours/month). Nearly all of those getting help received informal care, and about 3 in 10 received paid care. Of those who had difficulty or received help in settings other than nursing homes, 32% had an adverse consequence in the last month related to an unmet need; for community residents with a paid caregiver, the figure was nearly 60%.

Conclusions

The older population—especially those with few economic resources—has substantial late-life care needs. Policies to improve long-term services and supports and reduce unmet need could benefit both older adults and those who care for them.     

Walking the Line: Navigating Market and Gift Economies of Care in a Consumer‐Directed Home‐Based Care Program for Older Adults

Context

Paid caregivers of low-income older adults navigate their role at what Hochschild calls the “market frontier”: the fuzzy line between the “world of the market,” in which services are exchanged for monetary compensation, and the “world of the gift,” in which caregiving is uncompensated and motivated by emotional attachment. We examine how political and economic forces, including the reduction of long-term services and supports, shape the practice of “walking the line” among caregivers of older adults.

Methods

We used data from a longitudinal qualitative study with related and nonrelated caregivers (n = 33) paid through California’s In-Home Supportive Services (IHSS) program and consumers of IHSS care (n = 49). We analyzed the semistructured interviews (n = 330), completed between 2010 and 2014, using a constructivist grounded theory approach.

Findings

Related and nonrelated caregivers are often expected to “gift” hours of care above and beyond what is compensated by formal services. Cuts in formal services and lapses in pay push caregivers to further “walk the line” between market and gift economies of care. Both related and nonrelated caregivers who choose to stay on and provide more care without pay often face adverse economic and health consequences. Some, including related caregivers, opt out of caregiving altogether. While some consumers expect that caregivers would be willing to “walk the line” in order to meet their needs, most expressed sympathy for them and tried to alter their schedules or go without care in order to limit the caregivers’ burden.

Conclusions

Given economic and health constraints, caregivers cannot always compensate for cuts in formal supports by providing uncompensated time and resources. Similarly, low-income older adults are not competitive in the caregiving marketplace and, given the inadequacy of compensated hours, often depend on unpaid care. Policies that restrict formal long-term services and supports thus leave the needs of both caregivers and consumers unmet.     

Management of Gastrointestinal Disorders in Central and Eastern Europe: Self-Reported Practice of Primary Care Physicians

Background

Gastrointestinal disorders account for 7–10% of all consultations in primary care. General practitioners’ management of digestive disorders in Central and Eastern European countries is largely unknown.

Aims

To identify and compare variations in the self-perceived responsibilities of general practitioners in the management of digestive disorders in Central and Eastern Europe.

Methods

A cross-sectional survey of a randomized sample of primary care physicians from 9 countries was conducted. An anonymous questionnaire was sent via post to primary care doctors.

Results

We received 867 responses; the response rate was 28.9%. Over 70% of respondents reported familiarity with available guidelines for gastrointestinal diseases. For uninvestigated dyspepsia in patients under 45 years, the “test and treat” strategy was twice as popular as “test and scope”. The majority (59.8%) of family physicians would refer patients with rectal bleeding without alarm symptoms to a specialist (from 7.6% of doctors in Slovenia to 85.1% of doctors in Bulgaria; p<0.001). 93.4% of respondents declared their involvement in colorectal cancer screening. In the majority of countries, responding doctors most often reported that they order fecal occult blood tests. The exceptions were Estonia and Hungary, where the majority of family physicians referred patients to a specialist (p<0.001).

Conclusions

Physicians from Central and Eastern European countries understood the need for the use of guidelines for the care of patients with gastrointestinal problems, but there is broad variation between countries in their management. Numerous efforts should be undertaken to establish and implement international standards for digestive disorders’ management in general practice.     

Influence of Shared Medical Appointments on Patient Satisfaction: A Retrospective 3-Year Study

PURPOSE

Shared medical appointments (SMAs) are becoming popular, but little is known about their association with patient experience in primary care. We performed an exploratory analysis examining overall satisfaction and patient-centered care experiences across key domains of the patient-centered medical home among patients attending SMAs vs usual care appointments.

METHODS

We undertook a cross-sectional study using a mailed questionnaire measuring levels of patient satisfaction and other indicators of patient-centered care among 921 SMA and 921 usual care patients between 2008 and 2010. Propensity scores adjusted for potential case mix differences between the groups. Multivariate logistic regression assessed propensity-matched patients’ ratings of care. Generalized estimating equations accounted for physician-level clustering.

RESULTS

A total of 40% of SMA patients and 31% of usual care patients responded. In adjusted analyses, SMA patients were more likely to rate their overall satisfaction with care as “very good” when compared with usual care counterparts (odds ratio = 1.26; 95% CI, 1.05–1.52). In the analysis of patient-centered medical home elements, SMA patients rated their care as more accessible and more sensitive to their needs, whereas usual care patients reported greater satisfaction with physician communication and time spent during their appointment.

CONCLUSIONS

Overall, SMA patients appear more satisfied with their care relative to patients receiving usual care. SMAs may also improve access to care and deliver care that patients find to be sensitive to their needs. Further research should focus on enhancing patient-clinician communication within an SMA as this model of care becomes more widely adopted.     

Effectiveness of Evidence-based Pneumonia CPOE Order Sets Measured by Health Outcomes

Objective

Evidence-based sets of medical orders for the treatment of patients with common conditions have the potential to induce greater efficiency and convenience across the system, along with more consistent health outcomes. Despite ongoing utilization of order sets, quantitative evidence of their effectiveness is lacking. In this study, conducted at Advocate Health Care in Illinois, we quantitatively analyzed the benefits of community acquired pneumonia order sets as measured by mortality, readmission, and length of stay (LOS) outcomes.

Methods

In this study, we examined five years (2007–2011) of computerized physician order entry (CPOE) data from two city and two suburban community care hospitals. Mortality and readmissions benefits were analyzed by comparing “order set” and “no order set” groups of adult patients using logistic regression, Pearson’s chi-squared, and Fisher’s exact methods. LOS was calculated by applying one-way ANOVA and the Mann-Whitney U test, supplemented by analysis of comorbidity via the Charlson Comorbidity Index.

Results

The results indicate that patient treatment orders placed via electronic sets were effective in reducing mortality [OR=1.787; 95% CF 1.170-2.730; P=.061], readmissions [OR=1.362; 95% CF 1.015-1.827; P=.039], and LOS [F (1,5087)=6.885, P=.009, 4.79 days (no order set group) vs. 4.32 days (order set group)].

Conclusion

Evidence-based ordering practices have the potential to improve pneumonia outcomes through reduction of mortality, hospital readmissions, and cost of care. However, the practice must be part of a larger strategic effort to reduce variability in patient care processes. Further experimental and/or observational studies are required to reduce the barriers to retrospective patient care analyses.     

Improving Access to HIV and AIDS Information Resources for Patients,Caregivers, and Clinicians: Results from the SHINE Project

Background

Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) remains a significant international public health challenge. The Statewide HIV/AIDS Information Network (SHINE) Project was created to improve HIV/AIDS health information use and access for health care professionals, patients, and affected communities in Indiana.

Objective:

Our objective was to assess the information-seeking behaviors of health care professionals and consumers who seek information on the testing, treatment, and management of HIV/AIDS and the usability of the SHINE Project’s resources in meeting end user needs. The feedback was designed to help SHINE Project members improve and expand the SHINE Project’s online resources.

Methods:

A convenience sample of health care professionals and consumers participated in a usability study. Participants were asked to complete typical HIV/AIDS information-seeking tasks using the SHINE Project website. Feedback was provided in the form of standardized questionnaire and usability “think-aloud” responses.

Results:

Thirteen participants took part in the usability study. Clinicians generally reported the site to be “very good,” while consumers generally found it to be “good.” Health care professionals commented that they lack access to comprehensive resources for treating patients with HIV/AIDS. They requested new electronic resources that could be integrated in clinical practice and existing information technology infrastructures. Consumers found the SHINE website and its collected information resources overwhelming and difficult to navigate. They requested simpler, multimedia-content rich resources to deliver information on HIV/AIDS testing, treatment, and disease management.

Conclusions:

Accessibility, usability, and user education remain important challenges that public health and information specialists must address when developing and deploying interventions intended to empower consumers and support coordinated, patient-centric care.     

Environmental Exposure,Obesity, and Parkinson’s Disease: Lessons from Fat and Old Worms

Background

A common link has been exposed, namely, that metal exposure plays a role in obesity and in Parkinson’s disease (PD). This link may help to elucidate mechanisms of neurotoxicity.

Objective

We reviewed the utility of the nematode, Caenorhabditis elegans, as a model organism to study neurodegeneration in obesity and Parkinson’s disease (PD), with an emphasis on the neurotransmitter, dopamine (DA).

Data sources

A PubMed literature search was performed using the terms “obesity” and any of the following: “C. elegans,” “central nervous system,” “neurodegeneration,” “heavy metals,” “dopamine” or “Parkinson’s disease.” We reviewed the identified studies, including others cited therein, to summarize the current evidence of neurodegeneration in obesity and PD, with an emphasis on studies carried out in C. elegans and environmental toxins in the etiology of both diseases.

Data extraction and data synthesis

Heavy metals and DA have both been linked to diet-induced obesity, which has led to the notion that the mechanism of environmentally induced neurodegeneration in PD may also apply to obesity. C. elegans has been instrumental in expanding our mechanism-based knowledge of PD, and this species is emerging as a good model of obesity. With well-established toxicity and neurogenetic assays, it is now feasible to explore the putative link between metal-and chemical-induced neurodegeneration.

Conclusions

One side effect of an aging population is an increase in the prevalence of obesity, metabolic disorders, and neurodegenerative orders, diseases that are likely to co-occur. Environmental toxins, especially heavy metals, may prove to be a previously neglected part of the puzzle.     

Barriers to access and the purchasing function of health equity funds: lessons from Cambodia

Problem

High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very low incomes. Their impact on access to health services must be carefully examined.

Approach

Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers.

Local setting

Two-thirds of total health expenditure consists of patients’ out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes.

Relevant changes

HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care.

Lessons learned

HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully.     

Surveillance of an Online Social Network to Assess Population-level Diabetes Health Status and Healthcare Quality

Objective:

Test a novel health monitoring approach by engaging an international online diabetes social network (SN) in consented health surveillance.

Methods:

Collection of structured self-reports about preventive and self-care practices and health status using a software application (“app”) that supports SN-mediated health research. Comparison of SN measures by diabetes type; and, SN with Behavioral Risk Factor Surveillance System (BRFSS) data, for US-residing insulin dependent respondents, using logistic regression.

Results:

Of 2,414 SN app users, 82% (n=1979) provided an A1c and 41% (n=996) completed a care survey of which 931 have diabetes. Of these: 65% and 41% were immunized against influenza and pneumonia respectively, 90% had their cholesterol checked, 82% and 66%, had their eyes and feet checked, respectively. Type 1/LADA respondents were more likely than Type 2/pre-diabetic respondents to report all five recommended practices (Adjusted OR (95% CI) 2.2 (1.5, 3.2)). Past year self-care measures were: 58% self-monitored their blood glucose (SMBG) ≥ 5 times daily, 37% saw their diabetes nutritionist, 56% saw a diabetes nurse educator, 53% saw a doctor for their diabetes ≥ 4 times. Reports of health status did not differ by diabetes type in the SN sample. The SN group was more likely than the BRFSS comparator group to use all five preventive care practices (Adjusted OR (95% CI) 1.8 (1.4, 2.1) and SMBG ≥ 5 times daily (Adjusted OR (95% CI) 10.1 (6.8, 14.9).

Conclusions:

Rapid assessment of diabetes care practices using a novel, SN-mediated approach can extend the capability of standard health surveillance systems.     

Factors Influencing Family Physicians’ Contribution to the Child Health Care Workforce

PURPOSE

We wanted to explore demographic and geographic factors associated with family physicians’ provision of care to children.

METHODS

We analyzed the proportion of family physicians providing care to children using survey data collected by the American Board of Family Medicine from 2006 to 2009. Using a cross-sectional study design and logistic regression analysis, we examined the association of various physician demographic and geographic factors and providing care of children.

RESULTS

Younger age, female sex, and rural location are positive predictors of family physicians providing care to children: odds ratio (OR) = 0.97 (95% CI, 0.97–0.98), 1.19 (1.12–1.25), and 1.50 (1.39–1.62), respectively. Family physicians practicing in a partnership are more likely to provide care to children than those in group practice: OR = 1.53 (95% CI, 1.40–1.68). Family physicians practicing in areas with higher density of children are more likely to provide care to children: OR = 1.04 (95% CI, 1.03–1.05), while those in high-poverty areas are less likely 0.10 (95% CI, 0.10–0.10). Family physicians located in areas with no pediatricians are more likely to provide care to children than those in areas with higher pediatrician density: OR = 1.80 (95% CI, 1.59–2.01).

CONCLUSIONS

Various demographic and geographic factors influence the likelihood of family physicians providing care to children, findings that have important implications to policy efforts aimed at ensuring access to care for children.     

Dietary Intakes,Obesity and Health Behaviors in Native Hawaiians Residing in Southern California

Objectives

Accessing dietary intakes, body mass index (BMI) and health behaviors in Native Hawaiians residing in Southern California.

Design

Cross-sectional, community based participatory research.

Participants

Native Hawaiian (N = 55); Mean age 59 (± 15).

Main Outcome Measures

Diet, body mass index (BMI), and diet/exercise health behaviors. Collected diet via 24-hr dietary recalls, health behaviors through questionnaires and BMI via measurement/self-report.

Analysis

Frequencies/means and multiple linear regression were used to assess diet, BMI, and health behaviors.

Results

Nearly 90% of the participants were either overweight or obese. Less than 20% met the vegetable, fruit, fiber, and whole grain recommendations. Most were a little or somewhat sure (relative to almost always sure) about their ability “to stick with an exercise program when attending a cultural gathering”, and “when visiting Hawai‘i”.

Conclusions and Implications

These results suggest that developing a culturally-based education program to reduce obesity and improve diet is critical for Native Hawaiians residing in Southern California.     

Perception of Childhood Obesity in Mothers of Preschool Children

Objectives

The purpose of this study was to identify the perception of childhood obesity in mothers of preschool children using Q methodology.

Methods

A total of 38 Q statements about childhood obesity were obtained from 41 participants. The QUANL PC program was used to analyze the results.

Results

There were three types of perception toward obesity in mothers of preschool children: the “authoritative discipline type,” the “generous home meal focused type,” and the “home meal based on household financial situation type.”

Conclusion

The perception of mothers toward childhood obesity can affect the extent of maternal interaction with children or meal preparation for the family. Based on these results, it is necessary to plan specific programs according to the types of maternal perception toward childhood obesity.     

Permanent education in health: a review

OBJECTIVE

To undertake a meta-synthesis of the literature on the main concepts and practices related to permanent education in health.

METHODS

A bibliographical search was conducted for original articles in the PubMed, Web of Science, LILACS, IBECS and SciELO databases, using the following search terms: “public health professional education”, “permanent education”, “continuing education”, “permanent education health”. Of the 590 articles identified, after applying inclusion and exclusion criteria, 48 were selected for further analysis, grouped according to the criteria of key elements, and then underwent meta-synthesis.

RESULTS

The 48 original publications were classified according to four thematic units of key elements: 1) concepts, 2) strategies and difficulties, 3) public policies and 4) educational institutions. Three main conceptions of permanent education in health were found: problem-focused and team work, directly related to continuing education and education that takes place throughout life. The main strategies for executing permanent education in health are discussion, maintaining an open space for permanent education, and permanent education clusters. The most limiting factor is mainly related to directly or indirect management. Another highlight is the requirement for implementation and maintenance of public policies, and the availability of financial and human resources. The educational institutions need to combine education and service aiming to form critical-reflexive graduates.

CONCLUSIONS

The coordination between health and education is based as much on the actions of health services as on management and educational institutions. Thus, it becomes a challenge to implement the teaching-learning processes that are supported by critical-reflexive actions. It is necessary to carry out proposals for permanent education in health involving the participation of health professionals, teachers and educational institutions.     

Physician Styles of Patient Management as a Potential Source of Disparities: Cluster Analysis from a Factorial Experiment

Objective

To identify styles of physician decision making (as opposed to singular clinical actions) and to analyze their association with variations in the management of a vignette presentation of coronary heart disease (CHD).

Data Source

Primary data were collected from primary care physicians in North and South Carolina.

Study Design

In a balanced factorial experimental design, primary care physicians viewed one of 16 (2⁴) video vignette presentations of CHD and provided detailed information about how they would manage the case.

Data Collection Method

256 MD primary care physicians were interviewed face-to-face in North and South Carolina.

Principal Findings

We identify three clusters depicting unique styles of CHD management that are robust to controls for physician (gender and level of experience) and patient characteristics (age, gender, socioeconomic status, and race) as well as key organizational features of physicians'' work settings. Physicians in Cluster 1 “Cardiac” (N = 92) were more likely to focus on cardiac issues compared with their counterparts; physicians in Cluster 2 “Talkers” (N = 93) were more likely to give advice and take additional medical history; whereas physicians in Cluster 3 “Minimalists” (N = 71) were less likely than their counterparts to take action on any of the types of management behavior.

Conclusions

Variations in styles of decision making, which encompass multiple outcome variables and extend beyond individual-level demographic predictors, may add to our understanding of disparities in health quality and outcomes.     

Cultural adaptation of birthing services in rural Ayacucho, Peru

Problem

Maternal mortality is particularly high among poor, indigenous women in rural Peru, and the use of facility care is low, partly due to cultural insensitivities of the health care system.

Approach

A culturally appropriate delivery care model was developed in poor and isolated rural communities, and implemented between 1999 and 2001 in cooperation with the Quechua indigenous communities and health professionals. Data on birth location and attendance in one health centre have been collected up to 2007.

Local setting

The international nongovernmental organization, Health Unlimited, and its Peruvian partner organization, Salud Sín Límites Perú, conducted the project in Santillana district in Ayacucho.

Relevant changes

The model involves features such as a rope and bench for vertical delivery position, inclusion of family and traditional birth attendants in the delivery process and use of the Quechua language. The proportion of births delivered in the health facility increased from 6% in 1999 to 83% in 2007 with high satisfaction levels.

Lessons learned

Implementing a model of skilled delivery attendance that integrates modern medical and traditional Andean elements is feasible and sustainable. Indigenous women with little formal education do use delivery services if their needs are met. This contradicts common victim-blaming attitudes that ascribe high levels of home births to “cultural preferences” or “ignorance”.