Encounters with unemployment in occupational health care: Nurses' constructions of clients without work

This study explores occupational health nurses' encounters with unemployed clients in Finland. It involved setting up and evaluating a new service, Career Health Care, that resembled occupational health care, except that clients were recruited from among job seekers who were participating in one of three active labour market policy measures: vocational training, subsidised employment in the public sector, or participatory training for entering the labour market. Our main interest focused on nurses' perceptions of the unemployed and their professional practices in the context of Career Health Care. The analysis revealed four overlapping discourses with regard to clients: the client as a casualty of unemployment, the client as unemployed but active, the client as a deviant in the labour market, and the client as a skilled user of the system. Each discourse had implications for professional practice. The risk of negative stereotyping and consequent exclusion from services is discussed here. In conclusion, we stress the complexity of providing health services that can match the increasing diversity of contemporary labour market trajectories.     

Australian health and medical workers’ concerns around providing care to people living with hepatitis B

There is established literature on health workers’ attitudes towards working with people living with stigmatised health conditions and behaviours, such as HIV, hepatitis C and injecting drug use. Less is known about health workers’ attitudes and concerns around providing care to people living with hepatitis B virus (HBV), which is concerning as research indicates that negative attitudes may impact on the quality of care provided to these populations, with adverse health outcomes for clients. The aim of this paper is to examine health and medical workers’ concerns about providing care to people living with HBV, and the factors that may influence these concerns. Australian health and medical workers (n = 551) completed an online survey measuring their concerns about providing care to people living with HBV, stigmatising attitudes towards this group, perceived comfort of themselves and colleagues in providing care towards clients with HBV, and witnessing their colleagues behaviour in a discriminatory way towards clients with HBV. Multiple regression was used to ascertain factors predictive of health workers’ concerns about working with clients with HBV. Results showed that older participants and those who had spent less time working in the health and medical field had greater concerns about caring for people living with HBV. Workers who did not know someone living with HBV, who were less comfortable around clients with HBV, who perceived their colleagues to be less comfortable working with clients with HBV, and who had more negative attitudes towards this group also had greater concerns around providing care to people living with HBV. Efforts should be made to improve health and medical workers’ attitudes towards working with people with HBV. This may also improve workers’ level of comfort with people with HBV and reduce the reported reticence they have towards working with this client group.     

Using information to guide managed behavioral health care

This evaluation of substance abuse and mental health treatment services in Arizona discusses and illustrates the use of data already collected by the State to manage and monitor the public behavioral health sector. The authors utilize a framework that focuses on rate-setting and financial incentives; provider profiling and education; and monitoring of data quality and system-wide performance. Information and analysis can contribute to key management activities and forces that guide behavior in the system toward optimal system performance. Using data from 33,208 Medicaid-covered and uninsured adults, service mix varied substantially by region; for example, spending on residential care ranged from 0% to 40% for substance abuse treatment clients. By focusing on a smaller group of client with functional assessments, it also appears that regional spending levels varied considerably, for reasons not explained by client demographics or clinical measures. Finally, longitudinal data show that the regional managed care organizations are moving in different directions with regard to client mix and spending priorities. All of this variation suggests that there may be considerable latitude to guide and improve system-wide performance.     

Maternal health services for refugee populations: Exploration of best practices

ABSTRACT

The full scope of women’s health needs is not necessarily addressed in refugee camps and after resettlement, particularly pregnancy and postnatal services. The aims of this research are to examine the maternal care services provided to refugee women in camps and after resettlement to the United States, and to analyse organisational successes and challenges in service provision. With this understanding, policies can improve service delivery for refugee women. We interviewed respondents from five organisations, ranging from local non-profits to international non-governmental organisations. Most of the organisations do not provide direct medical care, but rather education and social service support to clients, and in some cases midwife training. Their success stemmed from a focus on client capacity building, individualised support, effective partnerships, and cultural competency. Respondents described the need for physical resources, effective leadership, and additional personnel, especially with linguistic capabilities. The dialogue in the interviews supports themes of education as empowerment and client self-sufficiency. Respondents emphasised the importance of funding and policies that support their work. This knowledge can lead to improved models of service delivery and inform the development of best practices and policies in maternal and reproductive health for refugee women.     

The potential of ecological theory for building an integrated framework to develop the public health contribution of health visiting

In line with recent UK and Scottish policy imperatives, there is increasing pressure for the health visiting service to assume an enhanced role in improving public health. Although health visiting has so far maintained its unique position as a primarily preventive service within the UK health service, its distinctive contribution now appears under threat. The continuing absence of a comprehensive and integrated conceptual basis for practice has a negative impact on the profession’s ability to respond to current challenges. Establishing an integrative framework to conceptualise health visiting practice would enable more sensitive, focused and appropriate research, education and evaluation in relation to practice. Work in this area could thus usefully contribute to the future development of the service at a difficult time. Our paper aims to make such a contribution. In support of our conceptual aims, we draw on a study of health visiting practice undertaken within a large conurbation in central Scotland. The study used a mixed method, collaborative approach involving 12 audio‐recorded and observed health visitor–client interactions, semi‐structured interviews with the 12 HVs and 12 clients, examination of related documentation and workshops with the HV participants. We critically consider prevalent models of health visiting practice and describe the more integrative conceptual approach provided by Bronfenbrenner’s ecological, ‘person‐in‐context’ framework. The paper subsequently explores relationships between this framework and understandings of need demonstrated by health visitors who participated in our study. Current policy emphasises the need to focus on public health and social inclusion in order to improve health. However, if this policy is to be translated into practice, we must develop a more adequate understanding of how practitioners work effectively with families and individuals in a sensitive and context‐specific manner. Bronfenbrenner’s framework appears to offer a promising means of building on the current strengths of the health visiting service to further develop a ‘person‐in‐context’ approach to health improvement that is mindful of and responsive to multiple, inter‐related influences on health. We therefore recommend further research to directly test the utility of this framework.     

Acceptability as a key determinant of client satisfaction: lessons from an evaluation of adolescent friendly health services in Mongolia

PurposeThe primary focus of this study is to investigate which characteristics of health service quality are most likely to determine client satisfaction with health services among adolescents in Mongolia.MethodsData were gathered from 1301 male and female clients. Exit interviews were used to measure client satisfaction; 82 clinics were visited. All clients between the ages of 10 and 19 years were asked to participate in the client exit interview; those who agreed to participate completed the questionnaire. Bivariate and multivariate analyses were conducted to determine significant associations between service satisfaction and the independent variables. All variables showing a significant bivariate association with service satisfaction (p ≤ .05) were retained for logistic regression analyses.ResultsThe strongest determinant to client satisfaction related to acceptability: adequate facility physical environment, receiving adequate information about the facility, and if the facility was private (i.e., other people didn’t know the services the client received). Additionally, clients who said they received some interruptions, either by other health workers or clients, were significantly less likely to be satisfied with the services.ConclusionsThis study demonstrates the importance of understanding and measuring different aspects of health service quality in defining client satisfaction. Although both accessibility and acceptability of services have been shown to be important in other studies, characteristics relating to acceptability emerged as critical in determining client satisfaction among adolescents in Mongolia. Efforts to improve health service delivery to adolescents need to understand and address the “adolescent friendly” characteristics that are most salient, and least fulfilled, in each particular context.     

Introducing coordinated care (2): evaluation of design features and implementation processes implications for a preferred health system reform model

The study investigated why the goals of the Australian Coordinated Care trials for clients with complex care needs were not achieved. Significantly higher health service use and costs were incurred in the absence of clear evidence of improved client health outcomes. The validity of assumptions underpinning trial design and the success of implementation at each step in application of the model were examined. There were failures in both design and implementation. Many clients did not require care coordination. The funds pooling arrangements contributed to limited possibilities for service substitution and training of GP care coordinators was inadequate. Trial design did not focus on either clinical guidelines or consumer empowerment. Furthermore, the expectations of the overall national trial were unrealistic both in trial design and expected outcomes given the rigidities and realities of the Australian health care system. Broader system reform in the form of funds pooling and health services planning at the regional level, based on large populations, may be a more effective means to address problems of care coordination and an inflexible supply system.     

Mutual powerlessness in client participation practices in mental health care

Background Client participation has become a dominant policy goal in many countries including the Netherlands and is a topic much discussed in the literature. The success of client participation is usually measured in terms of the extent to which clients have a say in the participation process. Many articles have concluded that client participation is limited; professionals often still control the participation process and outcomes. Objective The objective of this study is to gain insight into (i) the practice of client participation within a quality improvement collaborative in mental health care and (ii) the consequences of a Foucauldian conceptualization of power in analysing practices of client participation. Design We used an ethnographic design consisting of observations of national events and improvement team meetings and interviews with the collaborative’s team members and programme managers. Results Contrary to many studies on client participation, we found both clients and service providers frequently felt powerless in its practice. Professionals and clients alike struggled with the contributions clients could make to the improvement processes and what functions they should fulfil. Moreover, professionals did not want to exert power upon clients, but ironically just for that reason sometimes struggled with shaping practices of client participation. This mutual powerlessness (partly) disappeared when clients helped to determine and execute specific improvement actions instead of participating in improvement teams. Conclusion Recognizing that power is inescapable might allow for a more substantive discussion concerning the consequences that power arrangements produce, rather than looking at who is exerting how much power.     

Assessing and managing risk with people with physical disabilities: the development of a safety checklist

Assessing risk with adults with physical disabilities who receive social care services is a task at the confluence of three perspectives on risk: the rights and choices of clients, the role and task of the social worker and the responsibilities of the service provider organisation in managing risk. The purpose of this article is to articulate and contextualise some of these issues of risk and risk-taking when people receive social care services. The tensions between client concerns and organisational risk management perspectives are illustrated by drawing on a project to engage clients in jointly assessing their risks with social workers, undertaken with teams in the Physical Health and Disability Programme of Care in a Health and Social Care Trust in Northern Ireland in 2010. In this article, we show how a risk discourse can be a useful aspect of the dealings between social workers and clients, whilst locating this within the risk regulation framework for managing risk within which health and social care services operate. We argue that incorporating both client perceptions of risk-taking and organisational risk management provides a balanced approach more likely to be effective than championing one at the expense of the other.     

An evaluation of the attitudes and productivity of public health nurses in mental health service programs for the elderly]

The relationship between productivity of public health nurses (PHN) employed in mental health programs including home visit service for elderly people with dementia, and their attitudes toward mental health services was studied by surveying PHN at 31 health centers (HC) in Osaka Prefecture. A review of the services provided for 382 clients with dementia visited during a one-year period showed that PHN had provided the following services: home health care education: family education to promote understanding of the disease; management of interpersonal relations in the family; intervention to reduce the burden placed on the family members; medical facility referral; social service resource referral. For each of these PHN-provided services, the service had been provided to more than 60% of the clients. The percentage of clients who had been visited by a PHN accompanying a psychiatrist or a social worker was significantly higher at the 13 HC where PHN attach importance to counseling programs for the elderly, the 8 HC which provide group work services, and the 13 HC which hold case conferences more than six times a year than at other HC. In addition, the service provision rates for many PHN-provided services were significantly higher for these HC than for other HC. Analysis on the basis of whether PHN did or did not attach importance to the counseling program, showed that in either group, clients who had been visited by a PHN accompanying a psychiatrist or a social worker were more likely to have received PHN-provided services than other clients. Furthermore, at HC where PHN actively participated in mental health programs, PHN attitudes toward mental health care were more enthusiastic than at other HC. These results indicate that increased productivity of PHN employed in mental health programs and promotion of a multidisciplinary approach in client services are correlated with each other, and that both factors contribute to improving the quality of home visit services provided by PHN.     

Balancing Accessibility and Selectivity in 21st Century Public Mental Health Services: Implications for Hard to Engage Clients

This research highlights the importance of expanding examinations of service accessibility for hard to engage client populations to include assessments of individuals’ ability to gain entrance to services and the system’s ability to meet the service needs of particular client populations. The results of this research provide a framework to support these examinations. The increasing levels of selectivity and targeting of mental health services to particular client populations found in this study raise fundamental questions about the goals of service accessibility in 21st century public mental health services generally, and for hard-to-engage clients particularly. These findings also point to the need for examinations of the eligibility criteria and gatekeeping mechanism that are used to target services to particular client populations to determine if they are working as intended and to assess what impact these mechanisms have on hard to engage clients’ ability to gain entrance to needed services.     

What Indigenous Australian clients value about primary health care: a systematic review of qualitative evidence

Objective: To synthesise client perceptions of the unique characteristics and value of care provided in Aboriginal Community Controlled Health Organisations (ACCHOs) compared to mainstream/general practitioner services, and implications for improving access to quality, appropriate primary health care for Indigenous Australians. Method: Standardised systematic review methods with modification informed by ethical and methodological considerations in research involving Indigenous Australians. Results: Perceived unique valued characteristics of ACCHOs were: 1) accessibility, facilitated by ACCHOs welcoming social spaces and additional services; 2) culturally safe care; and 3) appropriate care, responsive to holistic needs. Conclusion: Provider‐client relationships characterised by shared understanding of clients' needs, Indigenous staff, and relationships between clients who share the same culture, are central to ACCHO clients' perceptions of ACCHOs' unique value. The client perceptions provide insights about how ACCHOs address socio‐economic factors that contribute to high levels of chronic disease in Indigenous communities, why mainstream PHC provider care cannot substitute for ACCHO care, and how to improve accessibility and quality of care in mainstream providers. Implications for public health: To increase utilisation of PHC services in Indigenous Australian communities, and help close the gaps between the health status of Indigenous and non‐Indigenous Australians, Indigenous community leaders and Australian governments should prioritise implementing effective initiatives to support quality health care provision by ACCHOs.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

武汉市社区老年人健康相关问题调查分析

目的了解武汉市社区老年人口的健康需求,寻求符合城市老年居民生活方式和老年社区卫生服务基本功能需求的健康教育策略.方法采取系统随机抽样的方法对武汉市2463名老年人进行了问卷调查.结果武汉市社区老年人健康状况不够理想,这与社区老年人文化素质较低、卫生知识缺乏、存在较多不良行为、健康教育与健康促进开展得不够、社区卫生服务机构对老年健康管理不力等因素有关.另外经济因素起着很重要作用.结论社区老年卫生服务应以建立适应当前需要的新型老年卫生服务体系、构建新的"医患关系"、开展多种卫生服务形式为突破口,加强健康教育,形成适合于武汉市社区老年人卫生服务特色.     

Client satisfaction and quality of health care in rural Bangladesh.

OBJECTIVE: To assess user expectations and degree of client satisfaction and quality of health care provided in rural Bangladesh. METHODS: A total of 1913 persons chosen by systematic random sampling were successfully interviewed immediately after having received care in government health facilities. FINDINGS: The most powerful predictor for client satisfaction with the government services was provider behaviour, especially respect and politeness. For patients this aspect was much more important than the technical competence of the provider. Furthermore, a reduction in waiting time (on average to 30 min) was more important to clients than a prolongation of the quite short (from a medical standpoint) consultation time (on average 2 min, 22 sec), with 75% of clients being satisfied. Waiting time, which was about double at outreach services than that at fixed services, was the only element with which users of outreach services were dissatisfied. CONCLUSIONS: This study underscores that client satisfaction is determined by the cultural background of the people. It shows the dilemma that, though optimally care should be capable of meeting both medical and psychosocial needs, in reality care that meets all medical needs may fail to meet the client's emotional or social needs. Conversely, care that meets psychosocial needs may leave the clients medically at risk. It seems important that developing countries promoting client-oriented health services should carry out more in-depth research on the determinants of client satisfaction in the respective culture.     

How state-funded home care programs respond to changes in Medicare home health care: resource allocation decisions on the front line

OBJECTIVE: To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment. DATA SOURCES/STUDY SETTING: Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders. STUDY DESIGN: Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N = 2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices. DATA COLLECTION/EXTRACTION METHODS: Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients. PRINCIPAL FINDINGS: Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels. CONCLUSIONS: Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics.     

Towards network and citizen: collaborative care for drug abusers

In Sweden like in many other countries, inter‐organizational collaboration has been introduced to co‐ordinate the care for clients. Even so, the knowledge of how inter‐organizational collaboration is developed over time is limited today. This study focuses on how the inter‐organizational collaboration was conducted in the care for drug abusers over a period of 5 years. The study sought to answer the following questions: Which effect does inter‐organizational collaboration have on ways‐of‐working among professionals and which effect does inter‐organizational collaboration have on the services provided by the clients? We argue that inter‐organizational collaboration is developed through three processes. First, the professionals redefine ‘areas of responsibilities’ in the different organizations. Second, the professionals ‘reconstruct their ways of working’ with clients. Third, the professionals ‘organize a networking model with the client as citizen in the centre’. This paper describes how the three processes appeared in the studied inter‐organizational collaboration project ‘SANNA’ (Collaborative Care for drug abusers). Copyright © 2009 John Wiley & Sons, Ltd.     

An investigation of the health beliefs and motivations of complementary medicine clients

The current study was concerned with factors associated with the use of complementary medicine (CM). The reasons for CM use were examined by dividing complementary medicine clients into two groups based on the frequency and length of their use of complementary therapies, and comparing them with conventional medicine clients as well as to each other. New/infrequent CM clients (n = 70), established CM clients (n = 71), and orthodox medicine clients (n = 58) were distinguished on the basis of health beliefs, socio-demographic, medical, and personality variables. Different patterns of predictors of CM use emerged depending on which client groups were compared. In general, health-aware behaviors and dissatisfaction with conventional medicine were the best predictors of overall and initial/ infrequent CM use, and more frequent health-aware behaviors were associated with continued CM use. Medical need also influenced the choice to use CM, and was the best predictor of committed CM use, with the established CM clients reporting more health problems than the new/infrequent CM group. Overall, income was a significant discriminator, but did not predict initial or continued CM use. Openness to new experience was associated with CM use in general, but was most notable in the decision to initially try or explore using CM. The findings support the utility of the three components (predisposing, enabling, and need factors) of the socio-behavioral model for explaining why some people choose CM. Overall, the results of the current study suggest that CM clients need to be looked at in more sophisticated ways, rather than being treated simply as a homogenous group with similar beliefs, motivations and needs.     

Community psychiatric care for homeless people in inner London.

Data about 'homeless' and 'home-based' clients referred to and recorded by community psychiatric nurses (CPNs) in Bloomsbury, an inner London health district, in 1985 and 1986 were reviewed. Of the 974 people seen, 642 were home-based and 322, homeless at time of referral. The homeless were more commonly under 65-years-of-age, living alone and unemployed. Two thirds of both groups had a psychiatric history, with half also having been admitted to a mental hospital. CPNs identified mental health problems in both groups with equal frequency, but homeless people were more likely to express their main problem as related to housing, finance or unemployment. Four out of five home-based clients were referred by statutory services compared with only two out of five homeless clients. The latter were less likely to receive supportive care from the CPN service and were more often referred to other agencies; these differences remained after controlling for the presenting problems. One in three people referred to this service were homeless. The social aspects of their problems, and their lack of contact with statutory services, suggest that homeless people need a multi-disciplinary approach for mental health care.