A model for the integration of primary health-care services in the province of KwaZulu-Natal,South Africa

Aims To analyse integrated primary health care and ultimately develop a model for integrated care. Background In South Africa, Integration of Services Policy was enacted in 1996 with the aim of increasing health service utilization. However, the problem with the policy arises in the implementation of integrated primary health care as there is no agreed understanding of what this phenomenon means in the South African context. Method A cross-sectional study, using Strauss and Corbin’s grounded theory approach was utilised. Policy makers as well as primary health care nurses at functional level participated in the study. The data was collected by means of observations and interviews. The sample size for interviews comprised 38 participants. Results Integrated primary health care was understood either as comprehensive health care, supermarket approach or one-stop shop. Conclusion It was concluded that integrated primary health care meant different things in different contexts. Implications for nursing management Integrated primary health care, if implemented, would advance health equity in all countries rich and poor and, as a result, promote human and national development. This model could be used to guide policy formulation and implementation of integrated primary health care at provincial and national levels.     

Why patients attend emergency departments for conditions potentially appropriate for primary care: reasons given by patients and clinicians differ

Objectives: To compare reasons identified by clinical staff for potential primary care attendances to the ED with those previously identified by patients. Methods: Survey of staff and primary care patients in five ED in New South Wales, Australia using questionnaire based on reasons identified in published studies. Results: Clinicians in the survey identify a broader spectrum of reasons for potential primary care cases presenting to the ED than the patients themselves report. Doctors reported on average 4.1 very important reasons and nurses 4.8 compared with patients 2.4 very important reasons. The main reasons identified by both doctors and nurses were similar and quite different to those identified by patients. Clinicians were more likely to emphasize cost and access issues rather than acuity and complexity issues. There was no difference within the clinician group between doctors and nurses nor by varying levels of experience. Furthermore doctors with significant experience in both primary care and emergency medicine did not differ from the overall clinicians' pattern. Conclusions: These data confirm that clinician perspectives on reasons for potential primary care patients' use of ED differ quite markedly from the perspectives of patients themselves. Those differences do not necessarily represent a punitive or blaming philosophy but will stem from the very different paradigms from which the two protagonists approach the interactions, reflecting the standard tension in a provider – consumer relationship. If policy is to be developed to improve system use and access, it must take both perspectives into account with respect to redesign, expectations and education.     

Effects of a Doctors’ Strike on Primary Care Utilization in Varkaus,Finland

Changes in out-patient medical care utilization at the health centre of Varkaus were studied during the Finnish doctors’ strike in spring, 1984. In this urban and semi-urban area, about 80% of the out-patient medical services to the population are provided by the municipal health centre. Visits to the physicians decreased by 70% during the strike, and for urgent visits the decrease was 55%. The private sector compensated only a very small share of this “deficit”. Of the common urgent illnesses the relative decrease was greatest for “cold” and ill-defined “abdominal pains”. Open wounds were treated normally although there was some indication that the wounds treated were more serious than normally. The post-strike increase in visits suggests an increase in unmet needs. For all face-to-face encounters the increase was eight per cent, but for low back pain, urinary infection and hypertension the observed post-strike rates were more than 40% higher than expected by pre-strike rates. A marked reduction in various other activities of the health centre, such as telephone calls and home visits, was observed. The present study gave no evidence of harmful effects of the strike. This was the impression of the health care personnel, too. There were no public claims of reduced access to care or its delay. The distress among patients or other experiences of the population were, however, not measured. The strike was fairly short and any conclusions concerning the effects of a more prolonged or extensive strike on health or health care are unwarranted.     

Determinants of physicians' attitude towards prescribing

OBJECTIVE: To identify the primary care physicians' (PCP) characteristics that are associated with their prescribing attitude. METHODS: A validated questionnaire was sent to randomly selected PCPs stratified in three groups according to any higher qualification in family medicine. RESULT: The best predictor for orientation of quality of care in prescribing was the country of qualification. Duration after qualification was negatively associated with PCP's belief in the use of drugs. Physicians who were female, with higher qualification, sooner after qualification, and working in group practice were less likely to perceive pressure from patients to prescribe, with group practice being the most significant determinant. CONCLUSION: Different physician factors affect different aspects of PCPs' prescribing attitude. As duration after qualification was an important but negative attribute, quality use of medication should be emphasized in continuing medical education.     

Primary health care practitioners' tools for mental health care

The purpose of this study was to describe and analyse the content of mental health care from the practitioner's point of view. The specific aim of this paper was to outline the types of mental health care tools and the ways in which they are used by primary health care practitioners. The data were derived from interviews with doctors and nurses (n = 29) working in primary health care in six different health care centres of the Pirkanmaa region in Finland. The data were analysed by using qualitative content analysis. The tools of mental health care used in primary health care were categorized as communicative, ideological, technical and collaborative tools. The interactive tools are either informative, supportive or contextual. The ideological tools consist of patient initiative, acceptance and permissiveness, honesty and genuineness, sense of security and client orientation. The technical tools are actions related to the monitoring of the patient's physical health and medical treatment. The collaborative tools are consultation and family orientation. The primary health care practitioner him/herself is an important tool in mental health care. On the one hand, the practitioner can be categorized as a meta-tool who has control over the other tools. On the other hand, the practitioner him/herself is a tool in the sense that s/he uses his/her personality in the professional context. The professional skills and attitudes of the practitioner have a significant influence on the type of caring the client receives. Compared with previous studies, the present informants from primary health care seemed to use notably versatile tools in mental health work. This observation is important for the implementation and development of mental health practices and education.     

Part 1 – unravelling primary health care conceptual predicaments through the lenses of complexity and political economy: a position paper for progressive transformation

Objective  To disentangle the concepts of primary health care and primary care as well as their conceptual and empirical ramifications for progressive transformation.
Methods  over 400 international and interdisciplinary abstracts and papers with 96 annotated bibliography abstracts of literature across multiple dimensions relating to the knowledge base around mechanisms in PHC development were reviewed. The text is confronted with the reality, as it exists in the field and makes the case for complexity perspectives to assess this phenomenon in its context.
Conclusion  PHC complexity is an important analytical tool to interrogate the ways in which this phenomenon is socially constructed as well as in the matrices in which it is embedded. It is also a potent analytical tool to assist in the deconstruction of prevalent linear thinking built around PHC as a whole.     

Factors determining the motivation of primary health care professionals to implement and continue the 'Beweegkuur' lifestyle intervention programme

Aim To examine factors explaining motivation among health care professionals to implement and continue a multidisciplinary primary care‐based lifestyle intervention, called BeweegKuur, to support prevention and treatment of type 2 diabetes mellitus. Methods Questionnaire research with two measurements among Dutch general practitioners, practice nurses and physiotherapists participating in a pilot study. At baseline, professionals were generally preparing to start the implementation. At second measurement, all practices were implementing BeweegKuur. Results The results reveal a positive motivation among professionals to implement and continue the intervention. The motivation of practice nurses to continue implementation was lower compared with other professionals. Social support by colleagues, compatibility and perceived relative advantage of the intervention for the professionals were associates of the baseline motivation to implement it. High‐baseline self‐efficacy and profession (i.e. not being practice nurse) positively predicted the motivation to continue the intervention at second measurement. Conclusions Professionals in our study can be characterized as innovators or early adopters, and inclusion of BeweegKuur in the basic health insurance package may persuade other adoption categories to implement the intervention. An intensified focus on skills building (e.g. motivational interviewing skills, general lifestyle counselling skills) is expected to contribute to sustained high‐quality implementation of the intervention.     

Health,health promotion and the elderly

• ? Health promotion is a mode of practice which is being increasingly examined by policymakers (DHSS, 1987; DoH, 1992).
• ? Although practitioners are being required to screen people over 75 years of age and are exhorted to reduce accidents in the elderly by 33% between 1990 and 2005 (DoH, 1992), there is evidence that they do not value this sort of work (Pursey & Luker, 1993).
• ? This paper looks at the findings from 178 interviews with people aged over 75 years, examining the importance of health and health promotion to the elderly.
• ? Further to the work of Cox et al. (1987), it is clear that people aged over 75 years continue to engage in a wide variety of activities which are designed to keep or improve their health.
• ? Elderly people's accounts of their health suggest that the real influence of social circumstances and environment must be assessed and planned for if health promotion activity is to have relevance and meaning to this group of people.
• ? Evidence is presented which indicates that the elderly are a group of people who would welcome health-promotion activity provided it is given in easily accessible forms.
• ? The notion of client participation is highlighted as a difficult area, which is likely to require particular skill in working with elderly clients. In the light of these findings, practitioners may need to examine their own attitudes to their work with the elderly.

     

Marital status, feeling depressed and self-rated health in rural female primary care patients

Objective To determine whether marital status and self‐assessed mental health are independent risk factors for poor self‐rated overall health among female primary care patients. Design We conducted a cross‐sectional survey of family medicine patients treated in a clinic in rural Minnesota. Complete responses were obtained from 723 women. Self‐ratings of mental health, demographics and symptoms were used to predict self‐rated overall health. Results Women who were single, divorced or otherwise not married, or widowed had lower odds of good self‐rated overall health (OR = 0.39, P = 0.004) compared with married women. Women who were 65 years of age and over (OR = 0.31, P = 0.017), women who rated themselves as depressed (OR = 0.54, P = 0.029), and women who reported more physical symptoms (OR = 0.78, P = 0.000) also were less likely to have good health, compared with younger women, women who did not feel depressed, and women with fewer physical symptoms, respectively. Education was not independently related to health in this sample. Worry was related to health in the univariate analysis but not after controlling for self‐assessed depression. Conclusions In order to improve overall health among rural women seen in primary care settings, special attention may need to be directed at women who are single, are older, report more physical symptoms, and feel depressed. Programmes should include self‐help materials, support groups and counselling services addressing social isolation, employment and financial hardship.     

Barriers to preventive health care for young children

PURPOSE: To review the literature on barriers to availability, access, and utilization of preventive health care for young children three to five years of age and their families and to discuss the role of nurse practitioners (NPs) in future research, education, and practice in this area. DATA SOURCES: A comprehensive literature search was conducted of online material and CINAHL and Medline (CD-ROM 1990 to present). In addition, experts in this area were asked to recommend extra reading materials. Additional references in textbooks and articles were examined. CONCLUSIONS: The literature review supports that there are major barriers to be addressed in the areas of availability, access, and utilization of preventive health care services for young children and their families. Major concerns include mandatory system for preventative health care, lack of health insurance coverage, cultural issues, and parental effects. IMPLICATIONS FOR PRACTICE: Health professionals in the community will need to work together to reevaluate current preventive health care practices for young children. Alternative methods for approaching and providing preventive health care services may become increasingly important if these services for young children are to be provided at current or increased levels.     

Seeking the attitudes and perceptions of the Greek primary-care professionals on voluntary work in caring for people with HIV/AIDS

BACKGROUND: During the last two decades Greece has moved towards a national health system. However, in a country with limited economic resources the necessity for reducing the increasing costs of the health care services by an effective use of available human resources, such as community volunteers, becomes inevitable. This paper reports the findings of a pilot study on attitudes and perceptions of primary-care staff towards voluntary work for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients. METHODS: Of the 300 primary-care professionals who are serving the health centres of the largest area of Athens, a sample of 153 was selected. The population surveyed was predominately female (n = 104, 69.3%) and most of them (n = 77, 50.7%) were between 31 and 40 years of age. A 28-item questionnaire was used, especially designed to investigate attitudes and perceptions of primary health care (PHC) professionals regarding the contribution of volunteers to HIV/AIDS-related programmes. RESULTS: Most of the respondents (n = 131, 85.6%) reported little or no experience of caring for HIV/AIDS patients and only 14 (9%) reported participation in any voluntary programmes. Eighty-eight per cent of patients (n = 135) consider the participation of volunteers in AIDS programmes as very useful and the vast majority of the participants pointed out the usefulness of the participation of health professionals and other influencing persons in voluntary programmes. Participants also suggested that sharing time with HIV patients and families, offering emotional support and practical help and distributing information leaflets for the general population should be the volunteers' contribution in AIDS-related programmes. The PHC professionals' role in voluntary programmes is considered by the 91 respondents (59.5%) as 'planning and organizing', for 66 (43.1%), 'coordinating' and for 37 (24.2%), 'supporting'. Although the majority of the participants (n = 90, 58.8%) said they would participate as a volunteer in an AIDS-related programme, only one-third of the total sample (n = 48, 31.4%) agree with the statement that they have a professional duty to support such a type of programme. CONCLUSIONS: Primary-care workers present little experience in caring for HIV/AIDS patients or participating in volunteer programmes and mainly positive attitudes and perceptions to voluntary work. Continuing educational programmes together with awareness activities may increase the involvement of primary-care professionals in the effective management of AIDS in Greece.     

Evidence-based practice in primary care: past, present and future

As in other health care specialities, evidence-based practice is beginning to have an impact on the philosophy and workings of primary care. Some practising clinicians, however, may wish to question its relevance to their everyday work, and whether general practitioners and other members of the primary health care team can realistically adopt a new approach to clinical decision making, at a time of such high workload and competing priorities.
Major changes have taken place during the last 20 years as a result of the National Health Service (NHS) reforms, the development of general practice and primary care research, and other health service innovations such as the introduction of new technologies, which have had an important impact on primary care. Issues such as the availability and use of different research methods, the role of experts, and the development of guidelines, audit and evaluation of care, are becoming subject to renewed scrutiny.
Within this context, this article explores the potential of an evidence-based approach in the primary care setting, and discusses possible strategies for change to assist the dissemination of research into practice and the implementation of evidence-based health care.     

Oral Health–Related Knowledge,Attitudes, and Practice Patterns of Nurse Practitioners: A Mixed Methods Study

This mixed methods study explored the oral health–related knowledge, attitudes, and practice patterns of nurse practitioners (NPs) in Canada. The survey was sent to all NPs across Canada (N = 4,540); 153 respondents (3.4% response rate) completed the online survey, and 4 respondents were subsequently selected to participate in qualitative, semistructured interviews. NPs believe that they have a role in oral health care and are motivated to include oral health into their practice. However, a lack of knowledge and skills, likely caused by gaps in education and training, is limiting their ability to do so with confidence.     

Population Health and Tailored Medical Care in the Home: the Roles of Home-Based Primary Care and Home-Based Palliative Care

With the growth of value-based care, payers and health systems have begun to appreciate the need to provide enhanced services to homebound adults. Recent studies have shown that home-based medical services for this high-cost, high-need population reduce costs and improve outcomes. Home-based medical care services have two flavors that are related to historical context and specialty background—home-based primary care (HBPC) and home-based palliative care (HBPalC). Although the type of services provided by HBPC and HBPalC (together termed “home-based medical care”) overlap, HBPC tends to encompass longitudinal and preventive care, while HBPalC often provides services for shorter durations focused more on distress management and goals of care clarification. Given workforce constraints and growing demand, both HBPC and HBPalC will benefit from working together within a population health framework—where HBPC provides care to all patients who have trouble accessing traditional office practices and where HBPalC offers adjunctive care to patients with high symptom burden and those who need assistance with goals clarification. Policy changes that support provision of medical care in the home, population health strategies that tailor home-based medical care to the specific needs of the patients and their caregivers, and educational initiatives to assure basic palliative care competence for all home-based medical providers will improve access and reduce illness burden to this important and underrecognized population.     

Weak smoking cessation awareness in primary health care before surgery: a real-world,retrospective cohort study

Abstract

Objective: Tobacco smoking is a well-established risk factor for postoperative complications. Research on preoperative smoking cessation in primary health care is scarce.

Design: This was a retrospective cohort study.

Setting: The Stop Smoking before Surgery Project (SSSP) started in Porvoo, Finland, in May of 2016, involving both primary health care and specialized health care. The goals of the project were smoking awareness and preoperative smoking cessation.

Subjects: Our study involved 1482 surgical patients operated at Porvoo Hospital between May and December of 2016.

Main outcome measures: We studied the recording of smoking status in all patients, and ICD-10 diagnosis of nicotine dependency and the initiation of preoperative smoking cessation in current smokers. Variables were studied from electronic patient records, comparing primary health care referrals and surgical outpatient clinic records.

Results: Smoking status was visible in 14.2% of primary health care referrals, and in 18.4% of outpatient clinic records. Corresponding rates for current smokers (n?=?275) were 0.0 and 8.7% for ICD-10 diagnosis of nicotine dependence, and 2.2 and 15.3% for initiation of preoperative smoking cessation. The differences between primary health care referrals and outpatient clinic records were statistically significant for all three variables (p?≤?.001).

Conclusion: In primary health care, very little attention was paid to preoperative smoking cessation. Rates were significantly better at the surgical outpatient clinic, but still low. We could not demonstrate any certain effect of the intervention. Our results call for future research on ways to improve smoking cessation rates.

• Key points

• Tobacco smoking is a well-established risk factor for postoperative complications. Research on preoperative smoking cessation in primary health care is scarce.

• We found weak smoking awareness and weak smoking cessation intervention numbers among both primary and specialized health care doctors. Our results indicate an urgent need for an efficient preoperative smoking cessation model involving both primary and specialized health care.