Providing health care to low-income women: a matter of trust

BACKGROUND: Trust is an important indicator of quality in patient-provider relationships and predicts adherence to certain protective health behaviours. It has been relatively unexplored among low-income or minority women. OBJECTIVES: We explored health care experiences that influence patient trust among low-income women in the USA with respect to professionals and lay health workers (LHWs). METHODS: Focus groups were conducted with 33 prenatal and postpartum women, aged 18-45 years, recruited from community-based public prenatal care programmes. Focus groups were audio-recorded, transcribed, and independently coded by readers. A model of factors associated with trust was developed based on the major thematic categories. RESULTS: Most women were Black (67%) and had completed high school (85%). Factors related to greater trust specific to patient-provider relationships were: continuity of the patient-provider relationship, effective communication, demonstration of caring and perceived competence. Women with less trust in their physicians reported an unwillingness to follow his/her advice. Most women reported having more trusting relationships with LHWs and nurses than with physicians, probably due to greater contact with these staff. Several women with a low level of trust reported experiences of discrimination due to lack of insurance. CONCLUSIONS: Prenatal care presents a unique opportunity for providers to contribute to the elimination of health disparities among low-income women. Improving continuity with public health prenatal care providers and building strong relationships with LHWs may enhance quality of care and contribute to achieving this goal. Better patient-provider communication is also a practical area of focus towards improving patient trust.     

Social capital, trust in the health-care system and self-rated health: the role of access to health care in a population-based study

This paper investigates the relationship between institutional trust in the health-care system, i.e. an institutional aspect of social capital, and self-rated health, and whether the strength of this association is affected by access to health-care services. The 2004 public health survey in the Scania region of Sweden is a cross-sectional study; a total of 27,963 respondents aged 18-80 years answered a postal questionnaire, which represents 59% of the random sample. Logistic regression model was used to investigate the association between institutional trust and self-rated health. Multivariate analyses of self-rated health were performed in order to investigate the importance of possible confounders (age, country of origin, education, economic stress, generalized trust in other people, and care-seeking behaviour) on this association. A 28.7% proportion of the men and 33.2% of the women reported poor self-rated health. A total of 15.0% and 58.3% of the respondents reported "very high" and "rather high" trust in the health-care system, respectively. Almost one-third of all respondents reported low institutional trust. Respondents born outside Sweden, with low/medium education, low generalized trust and low institutional trust had significantly higher odds ratios of poor self-rated health. Multiple adjustments for age, country of origin, education, economic stress, and horizontal trust had some effect on the significant relationship between institutional trust and poor self-rated health, for both men and women, but the additional introduction of care-seeking behaviour in the model substantially reduced the odds ratios. In conclusion, low trust in the health-care system is associated with poor self-rated health. This association may be partly mediated by "not seeking health care when needed". However, this is a cross-sectional exploratory study and the causality may go in both directions.     

围产保健与儿童保健监测的方法与应用

目的：研究最佳围产保健与儿童保健的监测方法与应用,为母婴与儿童提供及时,系统的保健服务。方法：新婚妇女在婚前检查时建立围产保健册、随后开始月经监测,确定早孕后,定期作产前复查等监测。直到产后42d为止;新生儿应在出生42d内建立儿童保健册,然后根据监测对象的年龄 常规体检的原则,完成相应年龄段的询问,体检、实验室检查与评价。监测全程均有质量控制措施,所有的监测结果均录入计算机。实现计算机化管理。结果：该监测系统已经在我国的32个县（市）中实施,覆盖地区的总人口超过2千万,从1993年至,围产保健监测系统已成地连续运转了8年,儿童保健监测系统已成功地连续运转了4年。结论：该围产保健与儿童保健监监适合我国,国情,运转顺利,对促进和提高当地的围产保健与儿童保健工作水平,提高我国人口素质将发挥重要作用。     

Contribution of primary care to health systems and health

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.     

Improving health equity through health care systems research

Objective

To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes.

Data Sources and Study Setting

This project was conducted as a component of the Agency for Healthcare Research and Quality's (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government.

Study Design

Expert group consensus, informed by stakeholder engagement and targeted evidence review.

Data Collection/Extraction Methods

Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQ's 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors' consensus.

Principal Findings

Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines.

Conclusions

As the nation's primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.     

A treatment decision aid may increase patient trust in the diabetes specialist. The Statin Choice randomized trial

Aims Decision aids in practice may affect patient trust in the clinician, a requirement for optimal diabetes care. We sought to determine the impact of a decision aid to help patients with diabetes decide about statins (Statin Choice) on patients’ trust in the clinician. Methods We randomized 16 diabetologists and 98 patients with type 2 diabetes referred to a subspecialty diabetes clinic to use the Statin Choice decision aid or a patient pamphlet about dyslipidaemia, and then to receive these materials from either the clinician during the visit or a researcher prior to the visit. Providers and patients were blinded to the study hypothesis. Immediately after the clinical encounter, patients completed a survey including questions on trust (range 0 to total trust = 100), knowledge, and decisional conflict. Researchers reviewed videotaped encounters and assessed patient participation (using the OPTION scale) and visit length. Results Overall mean trust score was 91 (median 97.2, IQR 86, 100). After adjustment for patient characteristics, results suggested greater total trust (trust = 100) with the decision aid [odds ratio (OR) 1.77, 95% CI 0.94, 3.35]. Total trust was associated with knowledge (for each additional knowledge point, OR 1.3, 95% CI 1.1, 1.6), patient participation (for each additional point in the OPTION scale, OR 1.1, 95% CI 1.1, 1.2), and decisional conflict (for every 5‐point decrease in conflict, OR 1.5, 95% CI 1.2, 1.9). Total trust was not associated with visit length, which the decision aid did not significantly affect. There was no significant effect interaction across the trial factors. Conclusions Preliminary evidence suggests that decision aids do not have a large negative impact on trust in the physician and may increase trust through improvements in the decision‐making process.     

Unmet health care and health care utilization

The objective of this study is to examine the causal effect of health care utilization on unmet health care needs. An IV approach deals with the endogeneity between the use of health care services and unmet health care, using the presence of drug insurance and the number of physicians by health region as instruments. We employ three cycles of the Canadian Community Health Survey confidential master files (2003, 2005, and 2014). We find a robustly negative relationship between health care use and unmet health care needs. One more visit to a medical doctor on average decreases the probability of reporting unmet health care needs by 0.014 points. The effect is negative for the women‐only group whereas it is statistically insignificant for men; similarly, the effect is negative for urban dwellers but insignificant for rural ones. Health care use reduces the likelihood of reporting unmet health care. Policies that encourage the use of health care services, like increasing the coverage of public drug insurance and increasing after hours accessibility of physicians, can help reduce the likelihood of unmet health care.     

Changes in patient experiences of primary care during health service reforms in England between 2003 and 2007

PURPOSE Major primary care reforms have been introduced in recent years in the United Kingdom, including financial incentives to improve clinical quality and provide more rapid access to care. Little is known about the impact of these changes on patient experience. We examine patient reports of quality of care between 2003 and 2007, including random samples of patients on practice lists and patients with long-term conditions.METHODS We conducted a cross-sectional design study of family practices in which questionnaires were sent to serial samples of patients in 42 representative general practices in England. Questionnaires sent to samples of patients with chronic disease (asthma, angina, and diabetes) and random samples of adult patients (excluding patients who reported any long-term condition) in 2003, 2005, and 2007 addressed issues of access, communication, continuity of care, coordination, nursing care, and overall satisfaction.RESULTS There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication, nursing care, coordination, and overall satisfaction. Some aspects of access improved significantly for patients with chronic disease, but not for the random samples of patients. Patients in both samples reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care. Most scores were significantly higher for the chronic illness samples than for the random samples of patients in 2003, even after adjusting for age.CONCLUSIONS There was a modest improvement in access to care for patients with chronic illness, but all patients now find it somewhat harder to obtain continuity of care. This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care. The possibility of unintended effects needs to be considered when introducing pay for performance schemes.     

Development of a scale to measure patients' trust in health insurers

OBJECTIVE: To develop a scale to measure patients' trust in health insurers, including public and private insurers and both indemnity and managed care. A scale was developed based on our conceptual model of insurer trust. The scale was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties. DATA SOURCES/STUDY SETTING: The scale was developed and validated on a random national sample (n = 410) of subjects with any type of insurance and further validated and used in a regional random sample of members of an HMO in North Carolina (n = 1152). STUDY DESIGN: Factor analysis was used to uncover the underlying dimensions of the scale. Internal consistency was assessed by Cronbach's alpha. Construct validity was established by Pearson or Spearman correlations and t tests. DATA COLLECTION: Data were collected via telephone interviews. PRINCIPAL FINDINGS: The 11-item scale has good internal consistency (alpha = 0.92/ 0.89) and response variability (range = 11-55, M = 36.5/37.0, SD = 7.8/7.0). Insurer trust is a unidimensional construct and is related to trust in physicians, satisfaction with care and with insurer, having enough choice in selecting health insurer, no prior disputes with health insurer, type of insurer, and desire to remain with insurer. CONCLUSIONS: Trust in health insurers can be validly and reliably measured. Additional studies are required to learn more about what factors affect insurer trust and whether differences and changes in insurer trust affect actual behaviors and other outcomes of interest.     

A measure of trust in insurers

BACKGROUND: Patient-centered assessments are increasingly important. Patients repeatedly emphasize the importance of trust in health care institutions and personnel. OBJECTIVES: (1) Develop a conceptual framework for trust in health care organizations and a comprehensive, reliable measure of trust in health insurers. (2) Examine predictors and correlates of trust in insurers. STUDY DESIGN: A conceptual framework for trust in health organizations based on theory and empirical studies was used to develop items for a structured telephone survey, which also included measures of health and utilization, doctor-patient trust, and satisfaction with care. Principal components factor analyses identified hypothesized domains of trust in health insurers and identified items for scales. Internal consistency assessment used Cronbach's alpha. Univariate analyses used Pearson's r or Student's t-tests. SAMPLE: Insured residents of Southeastern Michigan (n=400). RESULTS: Respondents were diverse in age, gender, ethnicity, health, and socioeconomic status. One dominant factor (eigenvalue>10) included hypothesized domains: administrative competence, clinical competence, advocacy and beneficence, fairness, honesty and openness, and one global item. Multidimensional scales were reliable (long version 13 items, alpha=0.95, short: 9 items, alpha=0.91). Insurer trust correlated strongly with trust in doctors (r=0.49 and 0.46) and satisfaction with care (r=0.70 and 0.66), and with an item assessing overall worry about health insurance (r=-0.37 and -0.35). Those with less trust in their insurer were more likely to say that they would change insurance plans (p<.001). CONCLUSIONS: This well-grounded, reliable measure of enrollee trust in insurers can be a useful patient-centered assessment tool.     

Development and initial validation of a measure of coordination of health care.

OBJECTIVE: To describe the development and initial validation of the self-administered Client Perceptions of Coordination Questionnaire. DESIGN: The instrument was developed between 1996 and 1997 through iterative item generation; within a framework of six domains of coordination, addressed across four sectors of health care provision. SETTING: 1193 individuals with complex and chronic health care needs as judged by their general practitioners (GPs), who were participants in a 2-year randomized controlled trial of a coordinated care intervention in Australia. Other samples were collected in one general practice (98) and from attendees of a chronic pain management course (29). MAIN MEASURES: Face and content validity, completion rates, transferability, internal consistency, and construct validity of the 32-item instrument. RESULTS: Most items achieved excellent completion and comprehension rates. The instrument was transferable to another chronically unwell population. Cronbach's alpha of the entire instrument was 0.92, and for six individual scales scores ranged from 0.31 to 0.86. The six scales based on principal components analysis were acceptability, received care, GP, nominated provider, client comprehension, and client capacity. The first four scales were satisfactory, but the client scales were inadequate with poor internal consistency, and convergent and discriminant validity. People with chronic pain syndromes had significantly worse experiences for almost all items, supporting construct validity. CONCLUSION: This instrument is one of the first to attempt to measure coordination of health care. Its strengths include ease of completion, transferability, and promising psychometric properties and construct validity. Problems capturing data about the patient's contribution to coordination highlight a lack of theoretical development in this area. A valid measure of coordination should be useful in needs assessment, program evaluation, and individual provider/practice audit, and would contribute to research into the experience and measurement of patient-focused care.     

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study

BackgroundWidespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team‐based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care.ObjectiveThe main study objective was to understand patients’ perspectives on the quality of care that they received for anxiety and depression in primary care teams.MethodsThis was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data.ResultsForty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs.ConclusionGreater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.     

Low institutional trust in health insurers in Dutch health care

A central element of the 2006 health insurance reform in the Netherlands is strategic purchasing by health insurers. After a brief elaboration of the concept of trust this article discusses the trust of insured in the new purchasing role of health insurers. There are various indications of a trust problem or credible commitment problem in Dutch health care. Insured say to trust their own health insurer (specific trust) but also say to have little trust in the behaviour of health insurers in general(institutional trust). The article briefly explores four models to explain the trust problem: the lack-of information model, the anticompetition model, the pro-profession model and the political communication model. A critical analysis demonstrates that the 'objective ground' for low institutional trust is rather questionable. Low trust seems to be based more on perceptions than on the insurers' objective purchasing behaviour. The article ends with a discussion on some potential strategies to address the trust problem. Low institutional trust may be something insurers have to live with.     

患者参与促进医务人员提高手卫生依从性

目的通过在门诊输液室开展患者参与促进医务人员提高手卫生依从性活动,获取手卫生的真实数据,为进一步在全院范围内开展该活动提供决策依据。方法采用感控工作间手机APP,对门诊输液室护士进行四个阶段的手卫生依从性观察。第一阶段无任何干预,第二阶段进行手卫生知识宣教,第三阶段模拟患者参与,第四阶段患者真实参与。并自制《患者参与促进医务人员提高手卫生依从性意愿调查表》对患者和门诊护士进行调查。结果门诊输液室护士四阶段的手卫生依从率分别为21.43%、44.27%、61.48%、82.88%,四阶段手卫生依从率比较差异有统计学意义(χ~2=110.35,P0.01);四阶段的手卫生正确率分别为44.44%、74.14%、81.33%、81.82%,四阶段的手卫生正确率比较差异有统计学意义(χ~2=18.50,P0.01)。结论患者参与手卫生模式可以提高医务人员手卫生依从性,此方法简单有效,值得推广。