Part 1 – unravelling primary health care conceptual predicaments through the lenses of complexity and political economy: a position paper for progressive transformation

Objective  To disentangle the concepts of primary health care and primary care as well as their conceptual and empirical ramifications for progressive transformation.
Methods  over 400 international and interdisciplinary abstracts and papers with 96 annotated bibliography abstracts of literature across multiple dimensions relating to the knowledge base around mechanisms in PHC development were reviewed. The text is confronted with the reality, as it exists in the field and makes the case for complexity perspectives to assess this phenomenon in its context.
Conclusion  PHC complexity is an important analytical tool to interrogate the ways in which this phenomenon is socially constructed as well as in the matrices in which it is embedded. It is also a potent analytical tool to assist in the deconstruction of prevalent linear thinking built around PHC as a whole.     

Sustained use of a tool for lifestyle intervention implemented in primary health care: a 2‐year follow‐up

Rational, aims and objectives Sustainability of new methods implemented in health care is one of the most central issues in addressing the gap between research and practice, but is seldom assessed in implementation studies. The aim of this study was to evaluate the implementation of a new tool for lifestyle intervention in primary health care (PHC) 2 years after the introduction, and assess if the implementation strategy used influenced sustainability. Method A computer‐based lifestyle intervention tool (CLT) was introduced at six PHC units in Sweden in 2008, using two implementation strategies: explicit and implicit. The main difference between the strategies was a 4‐week test period followed by a decision session, included in the explicit strategy. Evaluations were performed after 6, 9 and 24 months. After 24 months, the RE‐AIM framework was applied to assess and compare outcome according to strategy. Results A more positive outcome regarding reach, effectiveness, adoption and implementation in the explicit group could be almost completely attributed to one of the units. Maintenance was low and after 24 months, differences according to strategy were negligible. Conclusion After 24 months, the most positive outcomes regarding all RE‐AIM dimensions were found in one of the units where the explicit strategy was used. The explicit strategy per se had some effect on the dimension effectiveness, but was not associated with sustainability overall. Staff at the most successful unit earlier had positive expectations regarding the CLT and found it compatible with existing routines.     

Women’s experience with receiving advice on diet and Self-Monitoring of blood glucose for gestational diabetes mellitus: a qualitative study

ObjectiveWe aimed to explore how women with gestational diabetes mellitus (GDM) experience advice about diet and self-monitoring of blood glucose received in primary health care (PHC) and secondary health care (SHC) with a focus on how women perceived the care coordination and collaboration between healthcare professionals.Design, setting and subjectsIndividual interviews were conducted with 12 pregnant women diagnosed with GDM. Six women had immigrant backgrounds, and six were ethnic Norwegian. Women received GDM care in the area of Oslo, Norway. Interviews were analysed using thematic analysis.ResultsWomen described feeling shocked when they were diagnosed with GDM and feeling an immediate need for information about the consequences and management of GDM. Most of the women felt that their general practitioner (GP) had too little knowledge about GDM. Women with an immigrant background felt that the PHC midwives provided them with sufficient dietary advice related to GDM. Ethnic Norwegian women appreciated receiving more individually tailored dietary advice in SHC. Self-monitoring of blood glucose influenced women’s daily lives; however, they perceived the training in PHC and SHC as adequate. The women experienced poor collaboration between healthcare professionals in PHC and SHC, which implied that they sometimes had to initiate follow-up steps in their GDM care by themselves.ConclusionsIdeally, women diagnosed with GDM should meet healthcare professionals with sufficient knowledge about GDM as soon as possible after being diagnosed. The collaboration between healthcare professionals involved in the care of women with GDM should be improved to avoid having women feel that they need to coordinate their own care.

KEY POINTS

• Current awareness
• •The management of gestational diabetes mellitus requires appropriate follow-up by healthcare professionals
• Main statements
• •Pregnant women’s need for information about the consequences and management of gestational diabetes mellitus was highest immediately after diagnosis
• •Women perceived that they received more individually tailored information about diet and self-monitoring of blood glucose in secondary health care compared to primary health care
• •Women felt that general practitioners had insufficient knowledge about gestational diabetes mellitus
• •Based on our results, care coordination and collaboration between healthcare professionals involved in the care of women with gestational diabetes mellitus should be improved

     

‘One mission accomplished,more important ones remain’: commentary on Every‐Palmer,S., Howick,J. (2014) How evidence‐based medicine is failing due to biased trials and selective publication. Journal of Evaluation in Clinical Practice, 20 (6), 908–914

Every‐Palmer and Howick suggest that evidence‐based medicine (EBM) is failing in its mission because of contamination of research by manufacturer and researcher‐motivated bias and self‐interest. They fail to define that mission and to distinguish between the EBM movement and the research enterprise it was developed to critique. An educational movement, EBM accomplished its mission to simplify and package clinical epidemiological concepts in a form accessible to clinical learners. Its wide adoption within educational circles fostered critical literacy among several generations of practitioners. Illumination of bias, subterfuge and incomplete reporting of research has been a strength of EBM. Increased uptake and use of clinical research within the health care system properly defines the failing mission that eludes Every‐Palmer and Howick. Responsibility for failure to make progress towards its achievement is shared by virtually all relevant streams within the system, including policy, clinical guideline development, educational movements and the development of approaches to evidence synthesis. Discordance between the epistemological premises pervading today's research and health care community and the complex social processes that ultimately determine research use constitutes an important factor that must be addressed as part of a remedy. Enhanced emphasis on and demonstration of alternative approaches to research such as realism and realist synthesis and the momentum towards development of a learning health care system hold promise as guideposts for the rapidly evolving health care environment.     

Telephone survey of service‐user experiences of a telephone‐based mental health triage service

The participation of service users in all aspects of mental health service delivery including policy development, service planning and evaluation is increasingly an expectation of contemporary mental health care. Although there are a growing number of publications reporting service‐user perspectives in the evaluation of mental health services, little attention has been paid to the views of service users about mental health triage services. The purpose of the study reported here was to examine service‐users' (consumers and informal carers) experiences of a telephone‐based mental health triage service. Using a framework developed from the World Health Organisation's elements of responsiveness, we conducted structured telephone interviews with service users who had contacted a telephone‐based mental health triage service in regional Victoria, Australia. The main findings of the study were that consumers experienced more difficulty than carers in accessing the service and that, although most participants were satisfied, only a minority reported being involved in decision‐making. Further work is needed to improve accessibility of mental health triage services and to investigate barriers to consumer self‐referral. Professional development and practice support systems should be established to support mental health triage nurses in the development of collaborative, consumer‐focused care.     

Personal access to health care: a concept analysis

The objective of this concept analysis was to formulate an operational definition, so that those seeking, providing, and legislating health care policy would share a common interpretation of the concept. A concept analysis following the strategy suggested by Walker and Avant was used to identify antecedents, attributes, and empirical referents of access to health care. Furthermore, model, borderline, contrary, and invented cases were described. A theoretical definition was derived, which will lead to a better understanding of the concept and bring the concept closer to measurability and readiness for an operational definition. Access to health care has been addressed in political campaigns, studied by numerous legislative committees, and purported to be in an emergency state of despair. However, a measurable definition of access to health care continues to elude providers and legislators of health care; in as much, the meaning of the concept varies with the user.     

Governing citizens and health professionals at a distance: A critical discourse analysis of policies of intersectorial collaboration in Danish health‐care

It is widely recognised that the delivery of services across health‐care sectors faces multiple challenges related to incoherence in patient pathways. There are multiple reasons for this incoherence, which are often dealt with through national legislation and policy‐making. This paper discusses policies as powerful actors and explores how effects of a concrete policy are adapted for intersectorial collaboration in Danish health‐care. The paper is based on a critical discourse analysis of a central policy document in Danish health‐care known as the ‘Health Agreements’. Using Fairclough's three‐dimensional model for discourse analysis, we explored the document to clarify the construction of actors participating in intersectorial collaboration. The analysis revealed the Health Agreement as a ‘negotiated text’, appearing as an overriding document legitimising one possible discourse regarding the premises of intersectorial collaboration. The premises of intersectorial collaboration are maintained through a specific presentation of actors leaving little room for discussion, where professionals are constructed as actors who are expected to develop ways of collaborating according to the Triple Aim approach in order to promote productivity and efficiency. Furthermore, this presentation constructs citizens and patients as active, participating individuals who consciously prioritise and act with the purpose of controlling their life situation.