The lay resource in health and health care.

In our preoccupation with developing professional health care services, we have lost sight of the contribution of lay people to their own health care. Indeed, health care has become synonymous with professional care. Recently, however, studies in Europe and North American suggest that the lay resource in health care constitutes at least 85% of all health care provided. As our knowledge of the world of lay health care expands, there is an emerging appreciation of multiple levels of lay self care, including behaviours relating to promotion, prevention, minor illnesses and injury treatment, chronic disease care, and rehabilitation. These activities appear to derive from an eclectic conceptual base that incorporates both allopathic and non-allopathic values, beliefs, and care-giving approaches. Furthermore, there is evidence of patterns of lay health care where care functions tend to be selectively distributed among discrete elements of the lay health care "system", comprised of individuals, the immediate family, the extended family, friends, mutual aid groups, lay voluntary organizations, and religious organizations. There remain, however, serious conceptual and methodological limitations in defining, observing, evaluating and interpreting the extent, quality and impact of the lay health resource. It is not, by and large, a regulated or officially sanctioned resource, so baseline data are not routinely available. Research methods useful in accounting for the lay system need further development and must be sensitive to often very subtle social and cultural aspects of lay health care. Many questions remain regarding demographic and social variations on the self-care theme.(ABSTRACT TRUNCATED AT 250 WORDS)     

The lay resource in health and health care

In our preoccupation with developing professional health careservices, we have lost sight of the contribution of lay peopleto their own health care. Indeed, health care has become synonymouswith professional care. Recently, however, studies in Europeand North America suggest that the lay resource in health careconstitutes at least 85% of all health care provided. As ourknowledge of the world of lay health care expands, there isan emerging appreciation of multiple levels of lay self care,including behaviours relating to promotion, prevention, minorillnesses and injury treatment, chronic disease care, and rehabilitation.These activities appear to derive from an eclectic conceptualbase that incorporates both allopathic and non-allopathic values,beliefs, and care-giving approaches. Furthermore, there is evidenceof patterns of lay health care where care functions tend tobe selectively distributed among discrete elements of the layhealth care "system", comprised of individuals, the immediatefamily, the extended family, friends, mutual aid groups, layvoluntary organizations, and religious organizations. There remain, however, serious conceptual and methodologicallimitations in defining, observing, evaluating and interpretingthe extent, quality and impact of the lay health resource. Itis not, by and large, a regulated or officially sanctioned resource,so baseline data are not routinely available. Research methodsuseful in accounting for the lay system need further developmentand must be sensitive to often very subtle social and culturalaspects of lay health care. Many questions remain regardingdemographic and social variations on the self-care theme. Several factors are proposed as important in enhancing self-care.Chief among these are: The shift in disease patterns from acuteto chronic; increased access to an effective self-care technology;widening public demand for more personal control in health;and the general health information explosion that has contributedto demystify the hitherto sacrosanct domain of medical care.Research on self-care remains on a frontier of knowledge.     

Towards a conceptual framework of lay evaluation of health care

It is argued in this paper that much of the empirical research into the public's and patients' perceptions of the adequacy of health care has suffered from conceptual weaknesses. In addition, and maybe as a result of these weaknesses, a contradictory pattern of findings has emerged from this research. To overcome some of these problems it is suggested that an investigation of lay evaluation of health care should be carried out within a conceptual framework which incorporates the following elements. (i) The goals of those seeking health care in each specific instance. (ii) The level of experience of use of health care. (iii) The socio-political values upon which the particular health care system is based. (iv) The images of health held by the lay population. Each of these elements interrelates with the others and their influence will be mediated through socio-demographic characteristics of the service users.     

Data sources for health care quality evaluation

The central purpose of this article is to review the major approaches to evaluation of health care quality in terms of its use of different data sources. The areas of application, advantages, and disadvantages of seven data sources are presented, including direct observation, clinical records, record abstracts, clinical and administrative staff survey, patient survey, significant others survey, and population survey. Then the selection of data sources is discussed as this process is influenced by the answers to seven critical questions concerning the context of the quality assurance effort.     

Measuring the physician perspective on quality of care in health plans

Physicians provide one source of information about the quality of care in health plans, but concerns exist that physicians cannot distinguish quality from financial considerations or other underlying attitudes. We examined whether physicians can (a) distinguish different domains of health plan quality and (b) distinguish health plan quality from their underlying attitudes. We analyzed data on 419 generalist physicians from four health plans. Three scales assessed physicians' perceptions of facilitators and barriers to high-quality care in the plans and the clinical capabilities of plan physicians. Structural equation modeling indicated that physicians could distinguish domains of health plan quality. Physicians could also distinguish plan quality from their attitudes toward the plan, but plan quality was more highly correlated with general managed care attitudes than expected. These data suggest that physicians can provide information about health plan quality, but it will be important to validate these measures against patient outcomes.     

The quality of medical care delivered by lay practitioners in a feminist clinic.

The completion of essential components of patient encounters by lay paramedics in a feminist clinic was compared to that of nurse practitioners in a student health gynecology clinic using explicit criteria for the gynecological annual examination and the examination for vulvo-vaginitis. According to evidence charted in medical records, the lay paramedics conducted patient encounters as well as the nurse practitioners, with the exception that the lay paramedics consulted more frequently.     

A note on the depreciation of the societal perspective in economic evaluation of health care

It is common in cost-effectiveness analyses of health care to only include health care costs, with the argument that some fictive 'health care budget' should be used to maximize the health effects. This paper provides a criticism of the 'health care budget' approach to cost-effectiveness analysis of health care. It is argued that the approach is ad hoc and lacks theoretical foundation. The approach is also inconsistent with using a fixed budget as the decision rule for cost-effectiveness analysis. That is the case unless only costs that fall into a single annual actual budget are included in the analysis, which would mean that any cost paid by the patients should be excluded as well as any future cost changes and all costs that fall on other budgets. Furthermore the prices facing the budget holder should be used, rather than opportunity costs. It is concluded that the 'health care budget' perspective should be abandoned and the societal perspective reinstated in economic evaluation of health care.     

Evaluating prevention and quality of care in managed care plans: a public health perspective.

Public health practitioners are challenged to ensure the continued provision of necessary services in a rapidly changing delivery system. To accomplish this, new approaches to evaluating access and quality on a population basis are needed. This article presents a number of possible methods for evaluation, with particular emphasis on strategies related to managed care in Medicaid. The importance of considering cost containment in evaluating access and quality and in changing systems is discussed.     

The evaluation of health care

This paper is about the practical problems of evaluating health care. It argues that too little attention has been paid to the how and why, the what and the wherefore of evaluation. First, the paper reviews the well known problems of the classic evaluation model: in particular the difficulty of generalising the findings of a randomised control trial (RCT) to real clinical situations and the concentration of cost-effectiveness analyses (CEA) on the margins of the health sector where criteria and objectives can be debated or where there is a question of relative exposure and power. The second section examines the problem of measuring output in three typical situations: the comparison of different techniques for screening diagnosis, maintenance or therapy; the measurement of the cost-effectiveness of instructions in providing health care; and the operative evaluation of the health care system as a whole. The third section examines the sociological approach to evaluation in the same three typical situations: a comparison of different treatments; the effectiveness of antenatal care; and the implementation of health policy. Whilst these evaluations are considerably more sensitive, they still ignore some of the crucial questions. The final section considers the fundamental problem of participation and power. It argues that all evaluations are ideologically based even a thorough going anthropological approach being open to bias and distortion. It concludes in favour of the alternative of popular participation and control whilst recognising the considerable organisational and political problems involved.     

The Danish health care system from a British perspective.

The organisation and financing of the Danish health care system was evaluated within a framework of a SWOT analysis (analysis of strengths, weakness, opportunities and threats) by a panel of five members with a background in health economics. The evaluation was based on reading an extensive amount of selected documents and literature on the Danish health care system, and a one-week visit to health care authorities, providers and key persons. The present paper includes the main findings by one of the panel members. The dominance of tax financing helps to achieve control over the level of health care expenditure, as well as securing equity in financing the services. The reliance on local government for financing and running health care has both advantages and disadvantages, and the split between county and municipal responsibility leads to problems of co-ordination. The remuneration of general practitioners by a mix of capitation payment and fee for services has the advantage of capping expenditure whilst leaving the GPs with an incentive to compete for patients by providing them with good services. The GP service is remarkably economical. The hospital sector displays much strength, but there seem to be problems with respect to: (i) perceived lack of resources and waiting lists; (ii) impersonal care, lack of continuity of care and failures in communication between patients and staff; (iii) management problems and sometimes demotivated staff. The relationship between patients and providers is facilitated by free access to GPs and absence of any charges for hospital treatment. The biggest threat is continuation of avoidable illness caused by poor health habits in the population. The biggest opportunity is to strengthen public health measures to tackle these poor health habits.