Front‐line perspectives on ‘joined‐up’ working relationships: a qualitative study of social prescribing in the west of Scotland

Cross‐sector collaboration has been promoted by government policies in the United Kingdom and many western welfare states for decades. Literature on joint working has focused predominantly on the strategic level, neglecting the role of individual practitioners in putting ‘joined‐up working’ into practice. This paper takes the case of ‘social prescribing’ in the west of Scotland as an instance of joined‐up working, in which primary healthcare professionals are encouraged to refer patients to non‐medical sources of support in the third sector. This study draws on social capital theory to analyse the quality of the relationships between primary healthcare professionals and third sector practitioners. Eighteen health professionals and 15 representatives of third sector organisations participated in a qualitative interview study. Significant barriers to collaborative working were evident. The two stakeholder groups expressed different understandings of health, with few primary healthcare professionals considering non‐medical sources of support to be useful or relevant. Health professionals were mistrustful of unknown third sector organisations, and concerned about their accountability for referrals that were not successful or positive for the patient. Third sector practitioners sought to build trust through face‐to‐face interactions with health professionals. However, primary healthcare professionals and third sector practitioners were not connected in effective networks. We highlight the ongoing imbalance of power between primary healthcare professionals and third sector organisations. Strategic collaborations should be complemented by efforts to build shared understandings, trust and connections between the diverse front‐line workers whose mutual co‐operation is necessary to achieve effective joined‐up working.     

Access and utilisation of social and health services as a social determinant of health: the case of undocumented Latin American immigrant women working in Lleida (Catalonia,Spain)

Although Spain has social and healthcare systems based on universal coverage, little is known about how undocumented immigrant women access and utilise them. This is particularly true in the case of Latin Americans who are overrepresented in the informal labour market, taking on traditionally female roles of caregivers and cleaners in private homes. This study describes access and utilisation of social and healthcare services by undocumented Latin American women working and living in rural and urban areas, and the barriers these women may face. An exploratory qualitative study was designed with 12 in‐depth interviews with Latin American women living and working in three different settings: an urban city, a rural city and rural villages in the Pyrenees. Interviews were recorded, transcribed and analysed, yielding four key themes: health is a tool for work which worsens due to precarious working conditions; lack of legal status traps Latin American women in precarious jobs; lack of access to and use of social services; and limited access to and use of healthcare services. While residing and working in different areas of the province impacted the utilisation of services, working conditions was the main barrier experienced by the participants. In conclusion, decent working conditions are the key to ensuring undocumented immigrant women's right to social and healthcare. To create a pathway to immigrant women's health promotion, the ‘trap of illegality’ should be challenged and the impact of being considered ‘illegal’ should be considered as a social determinant of health, even where the right to access services is legal.     

‘After the stroke’: patients’ and carers’ experiences of healthcare after stroke in Scotland

We report findings on patients with stroke and carers experiences of the healthcare system in Scotland after stroke. These findings emerged from data collected in a primary qualitative study exploring patients with stroke and carers perception of a Functional Electrical Stimulation (FES) Clinic. Rich data emerged in relation to healthcare after stroke as experienced by both patients and carers, highlighting important clinically relevant messages and constituting an important area for dissemination. Thirteen patients with stroke and nine carers consented to participate. Data were collected using face‐to‐face semi‐structured interviews, undertaken in April and May 2007, and analysed using the framework of Interpretative Phenomenological Analysis (IPA). IPA aims to explore in depth the participants lived experiences of a specific phenomenon. An overarching theme of ‘After the stroke’ was identified. Within this, six sub‐themes emerged entitled, (1) ‘What is wrong?’; (2) ‘Help came quickly’; (3) ‘Something is still wrong’; (4) ‘In the hospital’; (5) ‘I’m taking them home’ and (6) ‘Back at home’. Interestingly, patients with stroke and carers recalled similar parts of the pathway through the healthcare system after stroke, resulting in the six chronological sub‐themes. The data highlighted issues surrounding recognition of stroke symptoms by both participants and professionals; expeditious admission to hospital and stroke unit; consultation during the discharge planning process and access to support and community follow up. Despite the availability of clinical guidelines to direct the management of stroke, this study suggests that the experiences of patients with stroke and carers do not always concur with guideline recommendations. These results highlight that such recommendations do not always transfer into clinical practice. Both clinicians and service managers should consider these issues when delivering care to patients after stroke.     

“Automatic assumption of your gender,sexuality and sexual practices is also discrimination”: Exploring sexual healthcare experiences and recommendations among sexually and gender diverse persons in Arctic Canada

Sexual and mental health disparities are reported in Arctic Canada as in other Arctic regions that experience shared challenges of insufficient healthcare resources, limited transportation, and a scarcity of healthcare research. Lesbian, gay, bisexual, transgender, and queer persons (LGBTQ+) report sexual and mental health disparities in comparison with their heterosexual and cisgender counterparts, and these disparities may be exacerbated in rural versus urban settings. Yet limited research has explored sexual healthcare experiences among LGBTQ+ persons in the Arctic who are at the juncture of Arctic and LGBTQ+ health disparities. We conducted a qualitative study from May 2015 to October 2015 with LGBTQ+ persons in the Northwest Territories, Canada that involved in‐depth individual interviews with LGBTQ+ youth (n = 16), LGBTQ+ adults (n = 21), and key informants (e.g. coaches, teachers, nurses, social workers, and healthcare providers) (n = 14). We conducted thematic analysis, a theoretically flexible approach that integrates deductive and inductive approaches, to identify and map themes in the data. Findings reveal geographical, social, and healthcare factors converge to shape healthcare access. Specifically, the interplay between heterosexism and cisnormativity, intersectional forms of stigma, and place limited LGBTQ+ persons’ sexual healthcare access and produced negative experiences in sexual healthcare. Limited healthcare facilities in small communities resulted in confidentiality concerns. Heteronormativity and cisnormativity constrained the ability to access appropriate sexual healthcare. LGBTQ+ persons experienced LGBTQ+, HIV, and sexually transmitted infections stigma in healthcare. Participants also discussed healthcare provider recommendations to better serve LGBTQ+ persons: non‐judgment, knowledge of LGBTQ+ health issues, and gender inclusivity. Findings can inform multi‐level strategies to reduce intersecting stigma in communities and healthcare, transform healthcare education, and build LGBTQ+ persons’ healthcare navigation skills.     

Closing the gap between rhetoric and practice in strengths‐based approaches to Indigenous public health: a qualitative study

Objective : To understand strengths‐based practice as articulated by urban Indigenous community workers and to consider its application for public health approaches to Australian Indigenous health advancement. Methods : Semi‐structured interviews with community workers from an urban Indigenous community. Interviews were video and audio recorded and transcribed verbatim. Data were analysed using thematic analysis, using an Indigenist research framework. Results : For our participants (11 Indigenous and one non‐Indigenous), a strengths‐based approach was fundamental to their practice. This approach reconfigured the usual relationship of client and service provider to fellow community member. They understood the strength of Indigeneity that empowers individuals and communities. They were not blinkered to the challenges in the community but resisted defining themselves, their community or their community practice by these deficits. Conclusions : Our participants had a sophisticated experiential understanding that a strengths‐based practice is not simply a ‘culturally acceptable’ way for non‐Indigenous peoples to work for Indigenous peoples, but rather it is the only way of working with Indigenous people. Implications for public health : Strengths‐based practice requires a reconfiguring of relationships of power, of attending to structure over stereotypes, and privileging Indigenous ways of knowing, being and doing. This reconfiguration is an ethical prerequisite for an approach that is genuinely strengths‐based.     

The significance of relational continuity of care for Māori patient engagement with predominantly non‐Māori doctors: findings from a qualitative study

Objective : This qualitative study explored self‐reported experiences of primary healthcare among a sample of urban Māori adults. This paper specifically focuses on the theme of relational continuity of care identified in participant discussions of access and engagement with their predominantly non‐Māori general practitioners (GPs). Methods : The study involved a purposively selected subsample (n=42) of the Christchurch Māori cohort of the Hauora Manawa Community Heart Study (n=244). Participants took part in in‐depth interviews, which were transcribed and analysed thematically. Results : Analysis identified compromised access to a preferred GP as a principal barrier to receiving quality and non‐discriminatory care from predominantly non‐Māori clinicians. In contrast to discussions of healthcare provided by usual GPs, episodic encounters with non‐regular clinicians were commonly framed as experiences discouraging utilisation and the perceived value of primary healthcare. Conclusions : Facilitating relational continuity of care for Māori patients and their clinicians may contribute towards mediating determinants of inequality at the clinical interface. Implications : Reducing significant health disparities between Māori and non‐Māori was a key goal of the reconfiguration of primary healthcare in the early 2000s. The role of relational continuity of care in achieving equitable inter‐ethnic health outcomes in primary healthcare settings is an important consideration.     

At the margins of biomedicine: the ambiguous position of ‘Registered Medical Practitioners’ in rural Indian healthcare

This analysis challenges a tendency in public health and the social sciences to associate India's medical pluralism with a distinction between biomedicine, as a homogeneous entity, and its non‐biomedical ‘others’. We argue that this overdrawn dichotomy obscures the important part played by ‘informal’ biomedical practice, an issue with salience well beyond India. Based on a qualitative study in rural Andhra Pradesh, South India, we focus on a figure little discussed in the academic literature – the Registered Medical Practitioner (RMP) – who occupies a niche in the medical market‐place as an informal exponent of biomedical treatment. We explore the significance of these practitioners by tracking diagnosis and treatment of one increasingly prominent medical ‘condition’, namely diabetes. The RMP, who despite the title is rarely registered, sheds light on the supposed formal‐informal sector divide in India's healthcare system, and its permeability in practice. We develop our analysis by contrasting two distinctive conceptualisations of ‘informality’ in relation to the state in India – one Sarah Pinto's, the other Ananya Roy's.     

‘Genuine doctor care’: Perspectives on general practice and community‐based care of Australian men experiencing homelessness

People with complex health and social needs, including tri‐morbidity and homelessness, are challenging for modern healthcare systems. These clients have poor health and social outcomes. They tend to use available health resources inefficiently, with fragmented, uncoordinated use of multiple health and social care services. Increasing access for these clients to well‐supported general practice care may be an effective response to these challenges. The aim of this study was to explore client experiences of, and attitudes to, community‐based healthcare, and general practice in particular, to identify opportunities to improve healthcare provision. Five focus groups with a total of 20 men currently experiencing homelessness were facilitated by the corresponding author in an inner‐city homeless hostel. Discussions were transcribed, coded and analysed thematically. The analysis was informed by earlier focus group discussions with community‐based homeless healthcare providers. Participants reported reluctance to engage with healthcare providers outside times of perceived crisis, and experiences of stigma and dismissive care. Some participants were sceptical of the motivations of health and social care providers, including general practitioners. Presentations with physical and psychological pain featured prominently in participant accounts. Three key themes identified important aspects of client experiences of community‐based healthcare which indicate potential areas for improvement. These themes were as follows: the relative invisibility and low salience of general practice compared to hospital‐based emergency and inpatient services; discontinuity within community‐based healthcare and across transitions between community‐based and other healthcare; and inconsistent and unsatisfactory general practitioner responses to physical and psychological pain. These responses included apparent over‐prescribing, under‐prescribing and short‐term ‘band‐aid’ responses. Generalist medical expertise was valued in general practitioners, but not consistently experienced. A number of challenges and opportunities exist, at both individual and system levels, for general practice to realise its potential to deliver effective, compassionate and efficient care to clients experiencing homelessness.     

The everyday risk work of Dutch child‐healthcare professionals: inferring ‘safe’ and ‘good’ parenting through trust,as mediated by a lens of gender and class

Amidst intensifying policy concerns with children's wellbeing and development, healthcare professionals are required not only to assess risk of abuse and neglect, but to manage risk of ‘poor parenting’ more broadly. Drawing on 15 in‐depth interviews and non‐participant observations of 61 professional‐family interactions, across four preventative public health services for children in the Netherlands, we explored how professionals accomplished such risk work amid intractable uncertainties. Building inferences from brief encounters with families, professionals gauged the extent to which they trusted parents to care ‘appropriately’. This trust developed most readily with parents experienced as ‘familiar’ by the largely middle‐class female professionals. Harnessing Schutzian phenomenology, we analyse the related manifestations of social structure within the interactional‐dynamics and lifeworlds of risk assessment. We argue that social structures of gender, class and ethnicity can be seen as influential both through the differing potential for ‘we‐relationships’ to be formed and via the generalising and stereotyped knowledge applied in their absence.     

Patients’ autonomy as a negotiated order: an ethnographic perspective on the clinical management of childhood obesity

The principle of patients’ autonomy has assumed a central place in healthcare. Patients are encouraged to play an active role in the management of their health, especially when they are affected by chronic illnesses that require long‐term follow‐up. In this article, we analyse patients’ and professionals’ conceptions of patients’ autonomy in the context of childhood obesity management. Based on the results of an ethnographic study that we conducted within a paediatric hospital in French‐speaking Switzerland, we put into perspective the discourses that professionals, parents and children construct around their experiences of the therapy. Our study reveals that the conceptions that these three different actors have of patients’ autonomy converge on several points, but they also diverge on many others. While the rise of autonomy in healthcare has mostly been analysed as a form of empowerment of patients, our results show that this principle also introduces new forms of social control over patients’ lives, and it creates new tensions for patients who are unable to match with the normative expectations of professionals in terms of self‐management and self‐care.     

What attracts and sustain urban poor to informal healthcare practitioners? A study on practitioners' perspectives and patients' experiences in an Indian city

The practice of allopathic medicine by informal healthcare practitioners (IHPs) is ubiquitous in India. However, a little is known about the patients' experiences and IHPs' perspectives. The core questions guided the present study were (1) why do urban poor approach IHPs for healthcare? (2) what are their experiences of availing services from IHPs? and (3) what are the perspectives of IHPs about their practice with the population they serve? A qualitative research design guided the study. The study was conducted in the Gurugram city of Haryana, India. Nine IHPs and twenty‐seven patients who fit into the pre‐established inclusion criteria were interviewed. The findings of the study underline the structural constrains of healthcare access to the poor in India and the mutual dependencies between IHPs and the urban poor. Three themes were emerged corresponding to the perspectives of IHPs, and five themes were generated, which describes patients' experiences and perspectives of availing treatment. The factors that attract and sustain patients to IHPs are a mixture of socio‐economic aspects, which include poverty, inaccessibility, unaffordability, inefficient public healthcare facilities, and the positive behavioural and treatment attributes of the practitioners. The study implies urgent policy interventions to ensure quality healthcare to urban poor.     

Using Geographic Information Systems to investigate variations in accessibility to ‘extended hours’ primary healthcare provision

There are ongoing policy concerns surrounding the difficulty in obtaining timely appointments to primary healthcare services and the potential impact on, for example, attendance at accident and emergency services and potential health outcomes. Using the case study of potential access to primary healthcare services in Wales, Geographic Information System (GIS)‐based tools that permit a consideration of population‐to‐provider ratios over space are used to examine variations in geographical accessibility to general practitioner (GP) surgeries offering appointment times outside of ‘core’ operating hours. Correlation analysis is used to explore the association of accessibility scores with potential demand for such services using UK Population Census data. Unlike the situation in England, there is a tendency for accessibility to those surgeries offering ‘extended’ hours of appointment times to be better for more deprived census areas in Wales. However, accessibility to surgeries offering appointments in the evening was associated with lower levels of working age population classed as ‘economically active’; that is, those who could be targeted beneficiaries of policies geared towards ‘extended’ appointment hours provision. Such models have the potential to identify spatial mismatches of different facets of primary healthcare, such as ‘extended’ hours provision available at GP surgeries, and are worthy of further investigation, especially in relation to policies targeted at particular demographic groups.     

Engaging Indigenous families in a community‐based Indigenous early childhood programme in British Columbia,Canada: A cultural safety perspective

This article is part of a larger study that explored how an Indigenous early intervention programme in British Columbia (BC), Canada, known as the ‘Aboriginal Infant Development Program’ (AIDP), influenced family and children's health and well‐being and was responsive to child health inequities. Postcolonial feminist and Indigenous feminist perspectives provided a critical analytical lens to this qualitative inquiry. The study was undertaken with AIDPs based in diverse community organisations located in off‐reserve urban municipalities throughout the province of BC. From September 2013 to March 2014, in‐depth, semi‐structured interviews were undertaken with: Indigenous primary caregivers (n = 10), Indigenous Elders (n = 4), AIDP workers (n = 18) and administrative leaders (n = 3). The purpose of this article is to examine and analyse the findings that focus on how AIDP workers supported family and children's health and well‐being by transforming their routine policies and practices in ways that fostered caregivers' active engagement in their programmes. Findings centre on three main themes: (i) overcoming mistrust; (ii) ‘being willing to move a step forward’ and (iii) resisting what's taken‐for‐granted. These inter‐related themes are examined and discussed in relation to the concept of cultural safety. The findings have international relevancy for social and healthcare community‐based programmes that are questioning how to engage with parents who may be hard to reach as a result of multi‐faceted social and structural factors.     

Organising through compassion: The introduction of meta‐virtue management in the NHS

This paper investigates the comprehensive compassionate care reform programme within the National Health Service (NHS) in England. Through a synoptic reading of policy documents, we show how ‘compassion’ is introduced as an overarching meta‐virtue designed to govern relationships and formal positions in health care. Invoking an ‘ethics of office’ perspective, mainly drawing on the thinking of Max Weber, we evaluate the promotion of compassion as a managerial technology and argue how seemingly humanistic and value‐based approaches to healthcare management might have unintended consequences for the quality of care and the conduct of health professionals that in some ways resemble and in some ways exceed those of the more traditional New Public Management measures, which the new compassion paradigm is expected to outdo. In the paper's final sections, we turn to the original work of the nursing icon Florence Nightingale to argue that compassion and other virtues should continuously be formulated and re‐formulated in relation to the role‐specific skills and duties of particular offices in the healthcare sector.     

Permanent emergency: Inequality in access to hospitalisation among urban elderly Chinese

The phenomenon of elderly patients staying in hospital emergency department observation units for extended time in urban China poses a challenge to China’s healthcare system and presents a social problem of inequality. In this paper, we analyse statistics collected from 16 major public hospitals in Beijing to assess the extent and intensity of the problem and examine interviews of medical professionals to understand the mechanisms linking the issue to the Chinese healthcare system. We study the issue with the literature on market transition theory and on China’s recent healthcare reforms and view this age-based inequality as an outcome of the economic and social transformations in China. We make a few policy recommendations including using age-specific bed turnover and mortality rates for evaluating performance, employing three different release-status dependent mortality rates of emergency department patients for the evaluation of hospitals, and improving the capacity of post-acute, ambulatory care and geriatric care services in urban China.     

The dispositions of things: the non‐human dimension of power and ethics in patient‐centred medicine

This article explores power relations between clinicians, patients and families as clinicians engage in patient‐centred ethical work. Specifically, we draw on actor‐network theory to interrogate the role of non‐human elements in distributing power relations in clinical settings, as clinicians attempt to manage the expectations of patients and families. Using the activities of a multidisciplinary team providing deep brain stimulation to children with severe movement disorders as an example, we illustrate how a patient‐centred tool is implicated in establishing relations that constitute four modes of power: ‘power over’, ‘power to’, “power storage” and “power/discretion”. We argue that understanding the role of non‐human elements in structuring power relations can guide and inform bioethical discussions on the suitability of patient‐centred approaches in clinical settings.     

Overestimation of health urgency as a cause for emergency services inappropriate use: Insights from an exploratory economics experiment in Portugal

Increasing visits to emergency departments add strain to public healthcare systems. The misperception of symptoms’ severity can partly explain inappropriate use of hospitals’ emergency departments by non‐urgent patients. This paper focuses on the misperception of symptoms’ severity as a cause for the inappropriate use of emergency departments. It explores the role that informing potential patients of the correct severity level can play in correcting this inefficiency. We implement in an incentivised manner an exploratory economic experiment to elicit the degree of severity of five sets of symptoms, corresponding to frequent causes of emergency department visits. The study was setup in Braga, Northern Portugal, recruiting voluntary participants through civic local organisations. We ask participants to indicate the more suitable health service, before and after revealing the true degree of severity. Results show that there is an overestimation of the degree of severity of some clinical profiles, and when confronted with the real severity, in only half of the cases are choices changed to other health services. Although exploratory, this study provides insights into the potential role of health education policies concerning symptoms’ severity but it also highlights the limits of such policies. Furthermore, the use of economic experiments can provide meaningful insights for the design of policies addressing demand‐side healthcare inefficiencies.     

Impact of COVID‐19 on access to healthcare in low‐ and middle‐income countries: Current evidence and future recommendations

The COVID‐19 pandemic continues to be a major public health threat globally and low‐ and middle‐income countries (LMICs) are not an exception. The impact of the COVID‐19 pandemic is far‐reaching on many areas including but not limited to global health security, economic and healthcare delivery with a potential impact on access to healthcare in LMICs. We evaluate the impact of the COVID‐19 pandemic on access to healthcare in LMICs, as well as plausible strategies that can be put in place to ensure that the delivery of healthcare is not halted. In order to mitigate the devastating effect of the COVID‐19 pandemic on the already weak health systems in LMICs, it is much necessary to reinforce and scale up interventions and proactive measures that will ensure that access to healthcare is not disrupted even in course of the pandemic.     

Social determinants in the sexual health of adolescent Aboriginal Australians: a systematic review

While research indicates that Aboriginal and Torres Strait Islander adolescents may be at increased risk of some sexually transmitted infections, there is limited information about factors that may place these young people at more risk of adverse sexual health than their non‐Indigenous counterparts. Current research has tended to focus on surveillance‐type data, but there is an increasing need to understand social determinants of sexual health risk. This systematic review assessed the evidence of social determinants impacting on Aboriginal and Torres Strait Islander adolescents’ sexual health in Australia. Published, English‐language literature was searched across key databases from 2003 to 2015. Fourteen studies were included in the qualitative synthesis. Findings suggest that social determinants such as access to healthcare, poverty, substance use, educational disadvantage, sociocultural context, gender inequalities, status and identity, and social disadvantage impacted on Indigenous adolescents’ sexual behaviours and sexual health risk. Evidence from the literature included in the review suggests that peer education may be an acceptable and appropriate approach for addressing such issues. There remains a need for programmes and services to be community‐developed and community‐led, thus ensuring cultural appropriateness and relevance. However, there is also a significant need for such programmes to be effectively and rigorously evaluated with data that goes beyond surveillance, and seeks to unpack how sexual norms are experienced by Indigenous adolescents, particularly outside of remote Australia – and how these experiences act as either risk or protective factors to good sexual health and positive social and emotional well‐being.     

An exploration of chronic pain patients’ perceptions of home telerehabilitation services

Objectives To explore patients’ perceptions regarding prospective telerehabilitation services and the factors that facilitate or impede patients’ intentions to use these services. Design Using semi‐structured interviews, patients reflected on the pros and cons of various scenarios of prospective telerehabilitation services. Patients’ arguments were first arranged according to the Unified Theory of Acceptance and Use of Technology (UTAUT). Next, using inductive analysis, the data for each UTAUT component were analysed and arranged into subthemes. Setting and participants Twenty‐five chronic pain patients were selected from a rehabilitation centre in the Netherlands. Results Overall, participants considered telerehabilitation helpful as a complementary or follow‐up treatment, rather than an autonomous treatment. Arguments mainly related to the UTAUT constructs of ‘performance expectancy’ and ‘facilitating conditions’. Patients valued the benefits such as reduced transportation barriers, flexible exercise hours and the possibility to better integrate skills into daily life. However, many patients feared a loss of treatment motivation and expressed concerns about both reduced fellow sufferer contact and reduced face‐to‐face therapist contact. Few arguments related to ‘social norms’ and ‘effort expectancy’. Conclusions The effect of telerehabilitation on healthcare strongly depends on patients’ willingness to use. Our study showed that chronic pain patients valued the benefits of telerehabilitation but hesitate to use it as an autonomous treatment. Therefore, future initiatives should maintain traditional care to some degree and focus on patients’ attitudes as well. Either by giving information to increase patients’ confidence in telerehabilitation or by addressing reported drawbacks into the future design of these services. Further quantitative studies are needed to explore patients’ intentions to use telerehabilitation.