Changing discourses and changing institutional child substitute care: new terms and processes toward family-like and family-based care

This article is an attempt to analyse and describe the process of change in child substitute care that has taken place since the re-independence of Estonia in 1991. These changes started with adopting new terms and ideas. However, while international terminology and concepts have been accepted, local conditions affect this acceptance of concepts as well as their practical development. In the present article, the aim is to look at the process of changing discourse in Estonian institutional substitute care. Overall, it was found that, in the reform of substitute care, the way in which and the extent to which new concepts have been applied through current activities are not enough to achieve internal changes in the development of the substitute care itself. Although family-like care and family-based care have been promoted and applied, the nature of these terms and their place in child substitute care remain dormant. It seems that, contrary to the desired goal of decreasing the burden of institutional substitute care, this burden has in fact increased. In addition, an issue of concern needing attention is a remarkable tension between paid professional and relationship-based care.     

互补还是替代：家庭照料与社区居家养老服务

文章使用国家卫生健康委2014年开展的中国计划生育家庭发展追踪调查数据,采用Probit模型和工具变量方法,实证检验家庭老年照料与社区上门生活护理服务和社区上门医疗服务之间的关系。研究发现：（1）家庭照料会显著减少老年人使用社区上门生活护理服务的概率,二者呈替代关系,但是在高龄和中、重度失能老人中,两者呈互补关系;（2）对于上门医疗服务则存在互补关系,家庭照料会显著增加老年人使用社区上门医疗服务的概率,但是在低收入老年人中,二者存在替代关系。文章建议社区居家养老服务体系建设要注重与家庭照料之间的协调发展,特别要关注高龄、中、重度失能和低收入老年人群体的照料需求,实现家庭照料与社区居家养老服务的优势互补。     

上海市徐汇区流动人口孕产妇保健研究

目的：了解城市外来人口孕产妇保健状况。方法：调查上海两医院１９９５年１月～１９９７年２月的分娩病历,并以问卷形式调查来医院分娩的产妇。结果：外来孕产妇及新生儿健康状况明显差于本地人,主要原因是缺少合理的产前保健。文化程度、妇幼保健知识及经济收入是影响是否接受孕产期保健的因素。结论：在加强健康教育和文化教育,促进外来孕产妇主动积极地接受孕产期保健的同时,也要从保健制度方面作些改革,以减少外来孕产妇接受孕产期保健的困难和阻力。     

孕前保健服务的内涵及现状分析

通过文献归纳分析、供需双方访谈及现场调查,系统阐述了孕前保健服务的价值及内涵,分析了孕前保健服务在我国的开展现状,从政策、供方及需方等方面探讨了我国孕前保健服务未系统开展的原因,并就我国孕前保健服务开展的机构、时机和内容进行了专家意向访谈,提出了我国孕前保健服务亟需解决的问题。     

Informal care and health care use of older adults

Informal care by adult children is a common form of long-term care for older adults and can reduce medical expenditures if it substitutes for formal care. We address how informal care by all children affects formal care, which is critically important given demographic trends and the many policies proposed to promote informal care. We examine the 1998 Health and Retirement Survey (HRS) and 1995 Asset and Health Dynamics Among the Oldest-Old Panel Survey (AHEAD) using two-part utilization models. Instrumental variables (IV) estimation controls for the simultaneity of informal and formal care. Informal care reduces home health care use and delays nursing home entry.     

英国整合型保健发展经验及启示

通过现场观察与深度访谈的定性研究方法,总结了英格兰NHS整合型保健的做法和经验,并针对我国卫生服务体系存在的碎片化问题,提出了相关的政策建议:大力发展初级卫生保健和社区卫生服务,加强以全科医生为核心的多学科服务团队建设,建立全科医生"守门人"制度,建立相关政府部门间的沟通协作机制,在社区层面横向整合多方社会服务资源等。     

Family day care and day care centres: Carer, family and child differences and their implications

The present study investigated child, maternal and caregiver characteristics in two day care settings, the independent contributions of these characteristics to children's adjustment to day care, and the utility of a goodness-of-fit framework as a means of assessing the impact of parent-caregiver differences on children's adjustment. Eight measures were used to assess child behavioural problems, maternal satisfaction with care, child temperament, maternal and caregiver child rearing practices, developmental timetables, day care goals, and demographic background. The study found strong support for the existence of differences between mothers choosing different types of care, between caregivers in these two settings, and between mothers and caregivers; and for the linkage between child, maternal and caregiver characteristics and child adjustment. However, the impact of goodness-of-fit between mothers and caregivers on children's adjustment to day care was not supported.     

The quality and adequacy of care received at home in the last 3 months of life by people who died following a stroke: a retrospective survey of surviving family and friends using the Views of Informal Carers Evaluation of Services questionnaire

Stroke is the third leading cause of death in the UK. Despite this, little is known about the care needs of people who die from or following a stroke. In early 2003, a total of 183 questionnaires were returned from a survey of 493 people who had registered a stroke-related death in four Primary Care Trusts, giving a response rate of 37%. This paper reports on 53 deceased from the survey who had lived at home during their last 3 months and who had been ill for more than 1 month. The data were analysed to explore the role of informal carers and the provision of community-based care in the last 3 months of life. Family and friends helped 82% of deceased with household tasks, 68% with personal care, 66% with taking medication and 54% with night-time care. By contrast, health and social services helped 30% with household tasks, 54% with personal care, 20% with taking medication and 6% with night-time care. Two-fifths (43%) of informants had to give up work or make major life changes to care for the deceased, and 26% of informants found looking after them 'rewarding'. Half (51%) reported that help and support from health services were excellent or good compared to 38% for social services. Results from the Regional Study of Care for the Dying indicated that people who died from a stroke in 1990 and their informal carers would have benefited from increased levels of community-based care and enhanced communication with care professionals. Our data suggest that informal carers continue to provide the majority of care for those who die from stroke, despite government initiatives to improve care for stroke patients and frail elderly people. Further research is required to explore best practice and service provision in caring for this group.     

责任制护理的回顾与展望

责任制护理自80年代引进国内以来,对促进护理质量的提高和护理队伍的建设起到了良好的作用,但在实践中还没有摸索出适合我国国情的整体护理模式。原因是:护理观念没有彻底更新,未能严格按护理程序工作,护理模式没有彻底改变,护理教育、护理管理各个环节与护理业务不配套等。文章主张要使整体护理继续深化,必须实施护理临床业务与护理管理各个环节系统化的护理工作模式。     

The care receivers perspective: How care‐dependent people struggle with accepting help from family members,friends and neighbours

In many countries in north‐western Europe, the welfare state is changing, and governments expect a great deal of informal care. In the Netherlands, citizens are also increasingly expected to rely on informal instead of professional care. In this study, we aim to determine to what extent Dutch care‐dependent people want to rely on social network members and what reasons they raise for accepting or refusing informal care. To answer this question, we observed 65 so‐called ‘kitchen table talks’, in which social workers assess citizens’ care needs and examine to what extent relatives, friends and/or neighbours can provide help and care. We also interviewed 50 professionals and 30 people in need of care. Our findings show that a great deal of informal care is already given (in 46 out of 65 cases), especially between people who have a close emotional bond. For this reason, people in need of care often find it difficult to ask their family members, friends or neighbours for extra assistance. People are afraid to overburden their family members, friends or neighbours. Another reason people in need of care raise against informal care is that they feel ashamed of becoming dependent. Although the government wants to change the meaning of autonomy by emphasising that people are autonomous when they rely on social network members, people who grew up in the heyday of the welfare state feel embarrassed and ashamed when they are not able to reciprocate. Our findings imply that policymakers and social professionals need to reconsider the idea that resources of informal care are inexhaustible and that citizens can look after each other much more than they already do. It is important that social policymakers approach the codes and norms underlying social relations more cautiously because pressure on these relations can have negative effects.     

The characteristics of children and young people in residential care in Wales

Care for children in residential settings is popularly characterised as the last resort for children who have had multiple failed placements and often high levels of need, requiring therapeutic help. It is often assumed that children will leave residential care for independent living. Using administrative data for a six-year period (2008–2014) for children “looked after” in Wales, univariate and bivariate analyses were conducted to provide a characteristic profile of the residential child care population. Of those placed in a residential setting, the vast majority of children were voluntarily placed and the most common reason for leaving residential care was going home. A similar number of children left residential care to move back to a family setting as entered residential care from a family setting, which challenges the assumption of residential care as necessarily the final destination in a troubled care history. The fact that large numbers of children are placed voluntarily in residential care might suggest some potential for preventing some of these placements and keeping children at home with support. Appropriate measures are needed to support children returning from residential care to live with birth families, as well as support for independent living.     

Primary care attributes and mortality: a national person-level study

PURPOSE

Research demonstrates an association between the geographic concentration of primary care clinicians and mortality in the area, but there is limited evidence of a mortality benefit of primary care at the individual patient level. We examined whether patient-reported access to selected primary care attributes, including some emphasized in the medical home literature, is associated with lower individual mortality risk.

METHODS

We analyzed data from 2000–2005 Medical Expenditure Panel Survey respondents aged 18 to 90 years (N = 52,241), linked to the National Death Index through 2006. A score was constructed from 5 yes/no items assessing whether the respondent’s usual source of care had 3 attributes: comprehensiveness, patient-centeredness, and enhanced access. Scores ranged from 0 to 1 (higher scores = more attributes). We examined the association between the primary care attributes score and mortality during up to 6 years of follow-up using Cox survival analysis, adjusted for social, demographic, and health-related characteristics.

RESULTS

Racial/ethnic minorities, poorer and less educated persons, individuals without private insurance, healthier persons, and residents of regions other than the Northeast reported less access to primary care attributes than others. The primary care attributes score was inversely associated with mortality (adjusted hazard ratio = 0.79; 95% confidence interval, 0.64–0.98; P = .03); supplementary analyses showed mortality decreased linearly with increasing score.

CONCLUSIONS

Greater reported patient access to selected primary care attributes was associated with lower mortality. The findings support the current interest in ensuring that patients have access to a medical home encompassing these attributes.     

关于完善老年服务和长期护理制度的思考与建议

我国以家庭为基础,社区为依托、机构为补充、医养结合的多元福利体系已经建成。本文认为与医疗有关的长期护理应纳入基本医疗保险,与生活有关的长期照料属私人事务,当私人在经济上和服务上不能提供有效供给时,政府需要"兜底线",瞄准对象,建立长期照护津贴制度,为弱势家庭提供长期生活照料的帮助;财政支出政策应由"补供方"为主转向"补需方"为主。文章认为现阶段社会长期护理保险不适合中国国情,建议完善健康养老、积极养老政策降低失能概率;构建"支持和维护家庭"的养老和长期照护政策体系。     

Grandparenting: Roles and responsibilities and its implications for kinship care policies

The current literature with regard to grandparents providing care to their grandchildren, whether on an informal basis or when the children are under the auspices of children's protection services (state-mandated intervention), highlights a number of issues or concerns for the caregivers. In the province of Newfoundland and Labrador (Canada), there is a focus on giving priority to grandparents (and significant others) as caregivers, which is embedded in the current child welfare legislation. There appears to be an underlying assumption that grandparents are willing and able to provide such care. However, no research has been completed in order to gain an understanding of some of the dynamics of caregiving by grandparents in this province. The authors are interested in grandparents as potential caregivers, particularly with regard to children who may come under the auspices of children's protection services. In addition, the policies and practices appear to be incongruent with current research, concerns and issues. This province is unique in that it has the fastest-growing senior population, the highest median age for seniors in Canada and has a high number of young families that have moved to other provinces to work. This research will provide insight into the willingness and ability of grandparents to provide care to their grandchildren, whether through informal or formal care (state intervention), as well as implications for current policies and practices.     

Reforms in the Portuguese health care sector: Challenges and proposals

Portugal has one of the most complete public systems worldwide. Since 1979, the Portuguese National Health Service (NHS) was developed based on the integration and complementarity between different levels of care (primary, secondary, continued, and palliative care). However, in 2009, the absence of economic growth and the increased foreign debt led the country to a severe economic slowdown, reducing the public funding and weakening the decentralized model of health care administration. During the austerity period, political attention has focused primarily on reducing health care costs and consolidating the efficiency and sustainability with no structural reform. After the postcrisis period (since 2016), the recovery of the public health system begun. Since then, some proposals have required a reform of the health sector's governance structure based on the promotion of access, quality, and efficiency. This study presents several key issues involved in the current postcrisis reform of the Portuguese NHS response structure to citizens' needs. The article also discusses the implications of this Portuguese experience based on current reforms with impact on the future of citizens' health.     

美国整合卫生保健主要做法及启示

随着人口老龄的快速发展、慢性病负担逐步加重,居民对综合、协调、连续、安全、可及的卫生保健服务需求日益增加。整合卫生保健有助于提高卫生保健服务的可及性、公平性、效率和患者满意度。文章梳理美国在整合卫生保健领域的做法,总结特点和成效,提出中国开展整合卫生保健的建议。     

Avoiding Hospital Admissions and Delayed Transfers of Care by Improved Access to Intermediate Care: A Simulation Study

ObjectiveThe current waiting times for intermediate care in the Netherlands prohibit timely access, leading to unwanted and costly hospital admissions. We propose alternative policies for improvement of intermediate care and estimate the effects on the waiting times, hospitalization, and the number of patient replacements.DesignSimulation study.Setting and ParticipantsFor our case study, data were used of older adults who received intermediate care in Amsterdam, the Netherlands, in 2019. For this target group, in- and outflows and patient characteristics were identified.MethodsA process map of the main pathways into and out of the intermediate care was obtained and a discrete event simulation (DES) was built. We demonstrate the use of our DES for intermediate care by evaluating possible policy changes for a real-life case study in Amsterdam.ResultsBy means of a sensitivity analysis with the DES, we show that in Amsterdam the waiting times are not a result of a lack in bed capacity but are due to an inefficient triage and application process. Older adults have to wait a median of 1.8 days for admission, leading to hospitalization. If the application process becomes more efficient and evening and weekend admissions are allowed, we find that unwanted hospitalization can be decreased substantially.Conclusion and ImplicationsIn this study, a simulation model is developed for intermediate care that can serve as a basis for policy decisions. Our case study shows that the waiting times for health care facilities are not always solved by increasing bed capacity. This underlines the necessity for a data-driven approach to identify logistic bottlenecks and find the best ways to solve them.     

中国部分地区孕产妇早孕检查状况及其影响因素

孕早期是胚胎完成各器官、系统、人体外形和四肢发育的关键时期。在孕早期进行检查(早孕检查)可有效地预防孕期合并症和死亡等不良妊娠结局[1]。国外针对早孕检查开展了许多研究[2～5],我国也重视早孕检查并进行了一些研究工作[6～8]。研究发现,我国的早孕检查率从1971年到2003