Screening for alcoholism in the primary care setting: are we talking to the right people?

BACKGROUND: This study assessed which demographic groups were most likely to consume alcohol excessively, and which groups had received inquiries and discussion about alcohol use from their physicians compared with discussions about other health risks. STUDY DESIGN: This was a cross-sectional study using data from the Centers for Disease Control Behavioral Risk Factors Surveillance System 1997 data set that represents a stratified random sample in the United States. POPULATION: We selected 23,349 adults who reported a routine physical examination within the last 3 years. OUTCOMES MEASURED: The main variables involved responses to questions about alcohol intake and whether the respondent's physician had initiated discussions about drinking. RESULTS: Physicians spoke to patients about alcohol use much less frequently than about other health-related behaviors. Discussions were roughly targeted to groups with the largest intake. However, physicians were least likely to speak with white patients, women, and widows who drank significantly. CONCLUSIONS: Regularly asking patients about alcohol use could substantially reduce the under-recognition of alcoholism. Since brief counseling is effective, negative consequences of excessive alcohol intake may be avoided.     

Assessing the potential for improvement of primary care in 34?countries: a cross-sectional survey

Objective

To investigate patients’ perceptions of improvement potential in primary care in 34 countries.

Methods

We did a cross-sectional survey of 69 201 patients who had just visited general practitioners at primary-care facilities. Patients rated five features of person-focused primary care – accessibility/availability, continuity, comprehensiveness, patient involvement and doctor–patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. We calculated the potential for improvement by multiplying the proportion of negative patient experiences with the mean importance score in each country. Scores were divided into low, medium and high improvement potential. Pair-wise correlations were made between improvement scores and three dimensions of the structure of primary care – governance, economic conditions and workforce development.

Findings

In 26 countries, one or more features of primary care had medium or high improvement potentials. Comprehensiveness of care had medium to high improvement potential in 23 of 34 countries. In all countries, doctor–patient communication had low improvement potential. An overall stronger structure of primary care was correlated with a lower potential for improvement of continuity and comprehensiveness of care. In countries with stronger primary care governance patients perceived less potential to improve the continuity of care. Countries with better economic conditions for primary care had less potential for improvement of all features of person-focused care.

Conclusion

In countries with a stronger primary care structure, patients perceived that primary care had less potential for improvement.     

Accessible medical equipment for patients with disabilities in primary care clinics: Why is it lacking?

BackgroundPrevious research has identified inaccessible medical equipment as a barrier to health care services encountered by people with disabilities. However, no research has been conducted to understand why medical practices lack accessible equipment.Objectives/hypothesisThe purpose of this study was to examine practice administrators' knowledge of accessible medical equipment and cost of accessible medical equipment to understand why medical practices lack such equipment. Hypotheses were: 1) Practice administrators lacked knowledge about accessible medical equipment and 2) The cost of accessible medical equipment was too great compared to standard equipment for the clinic.MethodsThis study was a mixed methods survey of primary care practice administrators. The sixty-three participates were members of a medical management organization. Data were collected between December 20, 2011 and January 17, 2012. Proportions, Guttman scalogram, and Spearman's Rho correlation analyses were utilized.ResultsFor this sample, less than half of the administrators knew that accessible equipment existed and a fourth knew what accessible equipment existed. There was a significant (p < 0.01), positive correlation between knowledge of accessible equipment and pieces of accessible equipment in the clinics. Because less than half of the administrators had ever considered purchasing accessible equipment, it was inconclusive if cost of accessible equipment was too great.ConclusionPractice administrators' lack of knowledge of accessible medical equipment emphasizes the need not only for more education about the availability of accessible equipment but also about the importance of accessible equipment for their patients with disabilities and for physicians who provide them care.     

What makes primary care effective for people in poverty living with multiple chronic conditions?: study protocol

Background  

The inverse care law persists: people living in poverty have the greatest needs and face considerable challenges in getting the care they need. Evidence reveals that GPs encounter difficulties in delivering care to poor patients, while many of those patients feel stigmatized by healthcare professionals. Patients living in poverty report negative healthcare experiences and unmet healthcare needs. Indeed, there is a growing recognition in primary care research of the importance of addressing the capabilities and social conditions of the poor when delivering care. Few studies have looked at the factors contributing to effective and "socially responsive" care for people living in poverty.     

Developmental services in primary care for low-income children: Clinicians’ perceptions of the healthy steps for young children program

Difficulties with providing quality primary health care for low-income Americans have been well documented. Few studies have addressed the challenges faced by pediatric clinicians serving low-income families or whether practice-based interventions improve clinicians’ ability to provide quality preventive health services. We investigated if, over time, the Healthy Steps for Young Children program affected the practices and perceptions of clinicians in pediatric primary care practices serving low-income families compared to practices serving more affluent families. Self-administered questionnaires were completed at baseline (N=104) and at 30 months (N=91) by clinicians at 20 pediatric practices participating in the Healthy Steps program. Practices were divided into three groups: those serving families with low, middle, and high incomes. Barriers to providing care, provision of preventive developmental services, and perceptions of care were assessed at baseline and at 30 months after introducing the program. Across all income groups and over time, clinicians were more likely to report the provision of preventive developmental health services. Clinicians in low-income practices reported increased problems with both reimbursement and time barriers; clinicians in high-income practices reported increased problems with reim-bursement. At 30 months, clinicians serving low-income families reported the greatest positive changes in their perceptions about the quality of care provided by their practices. They also were more likely to strongly agree that they gave support to families and to be very satisfied with the ability of their clinical staff to meet the developmental needs of children. We found that Healthy Steps was successful in universally increasing developmental services despite the reported practice barriers for both low- and high-income practices. The Healthy Steps program enabled low-income practices to achieve similar levels of clinician satisfaction as middle- and high-income practices despite having reported lower levels at the beginning months of the program. The Healthy Steps for Young Children Program is a program of the Commonwealth Fund, local funders, and health care providers across the nation. It is cosponsored by the American Academy of Pediatrics. Funding for the Healthy Steps National Evaluation is being provided by the Commonwealth Fund, the Robert Wood Johnson Foundation, the Atlantic Philanthropic Foundation, and local funders. The views presented here are those of the authors and not necessarily those of the funders, their directors, officers, or staff.     

Translating and validating an instrument for measuring patients’ satisfaction with primary care physicians in Palestine: The case of EUROPEP

Abstract

Introduction: The aim of this study was to determine how routinely recorded data could predict early the likelihood of patient non-adherence to a primary care-delivered secondary prevention programme for established coronary heart disease (CHD), with patients with CHD (10 851) invited to attend four times per year. Method: Non-adherence was defined as attending no more than three GP visits ever. The study sample was selected to allow a possible two-year recorded follow-up period in which patients could take up invitations. Administrative recordings of visit dates and intervals between visits, baseline results of key parameters and early changes were examined using logistic regression to determine independent predictors of non-adherence. Result: Longer interval between early visits, no family history of CHD, smoking and being outside target for exercise at baseline were independently associated with non-adherence.

Conclusion: Early identification by GPs of those who fail to attend on time or who defer appointments, in addition to persistence of lifestyle factors unchanged by a prior serious cardiac event should serve as a warning sign that targeted interventions to maintain adherence in primary care-delivered secondary prevention programmes are necessary.     

“Eyes Wide Shut”: Narratives of Women Living with Hepatitis C in Australia

ABSTRACT

Hepatitis C is the leading notifiable infectious disease in Australia and in the last few years, the number of new diagnoses among young women is beginning to outnumber men. For many, infection with hepatitis C virus (HCV) results in a chronic condition, which, in addition to a range of symptoms, carries with it the stigma attached to injecting drug use. Despite the growing prevalence of HCV, women's health has barely begun to address the gender specific impact of this illness on women. We report the results of a qualitative study of young women's experiences of living with HCV with a specific focus on the meaning of this condition and its impact on their lives. In 1999–2000, twenty-five in-depth interviews were conducted with women between the ages of 18 and 43 years, who were current or past injecting drug users and who had been diagnosed with HCV. One focus group discussion was held with health workers who provide treatment and care to this population. A number of key issues were identified that women believed impacted negatively on their lived experiences of HCV. Of most concern was the meaning of HCV and the social stigma attached. Stigma coupled with the lack of knowledge and awareness among health professionals and the high cost of treatment contributed to women's reluctance to seek support and care. HCV has yet to be taken up by the women's health movement as a key issue, especially for young women and we argue that this trend needs to be reversed.     

Reconciling a “pleasant exchange” with evidence of information bias: A three-country study on pharmaceutical sales visits in primary care

ObjectivesTo examine and compare the experiences and attitudes of primary care physicians in three different regulatory environments (United States, Canada, and France) towards interactions with pharmaceutical sales representatives, particularly their perspectives on safety information provision and self-reported influences on prescribing.MethodsWe recruited primary care physicians for 12 focus groups in Montreal, Sacramento, Toulouse and Vancouver. A thematic analysis of the interview data followed a five-stage framework analysis approach.ResultsFifty-seven family physicians (19 women, 38 men) participated. Physicians expected a commercial bias and generally considered themselves to be immune from influence. They also appreciated the exchange and the information on new drugs. Across all sites, physicians expressed concern about missing harm information; however, attitudes to increased regulation of sales visits in France and the US were generally negative. A common solution to inadequate harm information was to seek further commercially sourced information. Physicians at all sites also expressed sensitivity to critiques from medical students and residents about promotional interactions.ConclusionsPhysicians have contradictory views on the inadequate harm information received from sales representatives, linked to their lack of awareness of the drugs’ safety profiles. Commonly used strategies to mitigate information bias are unlikely to be effective. Alternate information sources to inform prescribing decisions, and changes in the way that physicians and sales representatives interact are needed.     

Antenatal psychosocial risk status and Australian women’s use of primary care and specialist mental health services in the year after birth: a prospective study

Background

Poor mental health in the perinatal period can impact negatively on women, their infants and families. Australian State and Territory governments are investing in routine psychosocial assessment and depression screening with referral to services and support, however, little is known about how well these services are used.The aim of this paper is to report on the health services used by women for their physical and mental health needs from pregnancy to 12 months after birth and to compare service use for women who have been identified in pregnancy as having moderate-high psychosocial risk with those with low psychosocial risk.

Methods

One hundred and six women were recruited to a prospective longitudinal study with five points of data collection (2–4 weeks after prenatal booking, 36 weeks gestation, 6 weeks postpartum, 6 months postpartum and 12 months postpartum) was undertaken. Data were collected via face-to-face and telephone interviews, relating to psychosocial risk factors, mental health and service use. The prenatal psychosocial risk status of women (data available for 83 of 106 women) was determined using the Antenatal Risk Questionnaire (ANRQ) and was used to compare socio-demographic characteristics and service use of women with ‘low’ and ‘moderate to high’ risk of perinatal mental health problems.

Results

The findings indicate high use of postnatal universal health services (child and family health nurses, general practitioners) by both groups of women, with limited use of specialist mental health services by women identified with moderate to high risk of mental health problems. While almost all respondents indicated that they would seek help for mental health concerns most had a preference to seek help from partners and family before accessing health professionals.

Conclusion

These preliminary data support local and international studies that highlight the poor uptake of specialist services for mental health problems in postnatal women, where this may be required. Further research comparing larger samples of women (with low and psychosocial high risk) are needed to explore the extent of any differences and the reasons why women do not access these specialist services.

     

Telephone triage by nurses in primary care: what is it for and what are the consequences likely to be?

OBJECTIVES: To examine the perceptions that those working in primary care have about the purpose and impact that telephone triage by nurses may have on their clinical roles and identities. METHODS: Twenty-six semi-structured interviews were carried out with general practitioners (GPs), practice nurses and practice managers from a purposive sample of nine practices in one health district in the North West of England. Analysis drew on the techniques of constant comparison and discourse analysis. RESULTS: Four themes emerged from the data: justifying triage - the respondents justify the introduction of telephone triage by emphasising the managerial benefits of controlling access and by suggesting the benefits this may bring to the patient-clinician relationship; categorising patients - patients are categorised and allocated on the basis of their biomedical diagnoses to the nurses or GPs in the practice; changing roles and identities - the hierarchy of patients and conditions created by allocating patients in this way strengthens and extends the professional hierarchy within a practice; and achieving a balance between conflicting aims - there is tension between the managerial need to triage patients according to their biomedical diagnosis and the aspirations that health care professionals have to personal and patient-centred care. CONCLUSION: Telephone triage by nurses may be effective at managing patient access to GPs but the need to categorise patients according to biomedical and managerial criteria needs to be balanced against the professional roles and identities that those working in general practice aspire to.     

A call for better care: the impact of postnatal contact services on women’s parenting confidence and experiences of postpartum care in Queensland,Australia

Background

Universal postnatal contact services are provided in several Australian states, but their impact on women’s postnatal care experience has not been evaluated. Furthermore, there is lack of evidence or consensus about the optimal type and amount of postpartum care after hospital discharge for maternal outcomes. This study aimed to assess the impact of providing Universal Postnatal Contact Service (UPNCS) funding to public birthing facilities in Queensland, Australia on women’s postnatal care experiences, and associations between amount and type (telephone or home visits) of contact on parenting confidence, and perceived sufficiency and quality of postnatal care.

Methods

Data collected via retrospective survey of postnatal women (N?=?3,724) were used to compare women who birthed in UPNCS-funded and non-UPNCS-funded facilities on parenting confidence, sufficiency of postnatal care, and perceived quality of postnatal care. Associations between receiving telephone and home visits and the same outcomes, regardless of UPNCS funding, were also assessed.

Results

Women who birthed in an UPNCS-funded facility were more likely to receive postnatal contact, but UPNCS funding was not associated with parenting confidence, or perceived sufficiency or perceived quality of care. Telephone contact was not associated with parenting confidence but had a positive dose–response association with perceived sufficiency and quality. Home visits were negatively associated with parenting confidence when 3 or more were received, had a positive dose–response association with perceived sufficiency and were positively associated with perceived quality when at least 6 were received.

Conclusions

Funding for UPNCS is unlikely to improve population levels of maternal parenting confidence, perceived sufficiency or quality of postpartum care. Where only minimal contact can be provided, telephone may be more effective than home visits for improving women’s perceived sufficiency and quality of care. Additional service initiatives may be needed to improve women’s parenting confidence.

     

‘It helps me make sense of the world’: the role of an art intervention for promoting health and wellbeing in primary care—perspectives of patients, health professionals and artists

Background

Art interventions are increasingly used in public health for the enhancement of patients’ health and wellbeing. The present study investigated perceived outcomes and role of an art intervention from the collective perspectives of participants (patients who took part), deliverers (artists) and referrers (general practitioners and practice nurses).

Methods

A qualitative methodology, using interviews and focus groups, allowed investigation of participants (n?=?18) perceived outcomes and role of the intervention. Participants included patients (n?=?10), artists (n?=?5), and referring health professionals (n?=?3).

Results

Themes that emerged from the analysis included perceived benefits, role and value of the intervention, and setting and referral process. Central to these themes were psychological and mental health benefits, an appreciated holistic treatment option and the merits of the intervention being situated in the surgery setting.

Conclusions

The study showed that art interventions within primary care are valuable in the promotion of public health, and in particular, patients’ mental health. Interactions between other participants and the artist were central to achieving patients’ perceived health improvement. Locating the intervention in primary care facilitated patient participation and provided health professionals with a holistic treatment alternative. There is also some evidence that participation in the intervention encourages less dependence on the health professional.     

“In the Bible Belt:” The role of religion in HIV care and prevention for transgender people in the United States South

Within the United States South, the socio-religious norms that shape life for many residents may have public health implications. Drawing from 12 key informant interviews, this study explores the role of religious institutions in HIV care and prevention access among transgender people of color in Southern cities. Findings suggest that while religious anti-transgender stigma is pervasive, the regional importance of faith-based beliefs and institutions necessitates targeted faith-based initiatives for the population. Broadly, findings suggest regional environments may demand interventions that negotiate historically marginalizing relationships between at-risk groups and dominant cultural institutions.