Enhancing measurement of primary health care indicators using an equity lens: An ethnographic study

Introduction  

One important goal of strengthening and renewal in primary healthcare (PHC) is achieving health equity, particularly for vulnerable populations. There has been a flurry of international activity toward the establishment of indicators relevant to measuring and monitoring PHC. Yet, little attention has been paid to whether current indicators: 1) are sensitive enough to detect inequities in processes or outcomes of care, particularly in relation to the health needs of vulnerable groups or 2) adequately capture the complexity of delivering PHC services across diverse groups. The purpose of this paper is to contribute to the discourse regarding what ought to be considered a PHC indicator and to provide some concrete examples illustrating the need for modification and development of new indicators given the goal of PHC achieving health equity.     

Making medicine for the poor: primary health care interpretations in Pelotas,Brazil

This paper explores the local political setting in which primary health care and community participation have been implemented in Pelotas, Brazil over the past two decades. We argue that in a medically plural setting with a mixture of private and public health care schemes, capitalist-based principles and ideals (such as the predominant role given to technology) shape generalized concepts of good clinical skills and quality of care, thereby regulating the medical system as a whole. The analysis shows that some women living in shantytowns reject the negative class-based associations made with their communities in a variety of ways, including the non-use of their local primary health care (PHC) centre which they considered to be a poor substitute for what the wealthy take for granted. Recent studies show that primary level antenatal care is of low quality when compared with other sectors. Nevertheless, local politicians and physicians often blamed various aspects of local 'culture' (folk health beliefs, low valuing of biomedicine, lack of modern concepts of community-building and altruism) for failed PHC programmes, contributing a prejudicial feedback cycle between frustrated professionals often engaging in prejudicial clinical practices and offended users. Rather than discuss community participation through vague concepts such as empowerment and citizenship, those involved in PHC reform would do well to take explicit (publicly stated) responsibility for the socio-political, financial and bureaucratic constraints to PHC.     

Physical health care of patients with schizophrenia in primary care: a comparative study

BACKGROUND: Excess morbidity and mortality associated with schizophrenia is well established. Despite this, no previous multi-centre study has investigated whether patients with schizophrenia receive equitable physical healthcare within primary care. OBJECTIVE: To determine whether patients with a diagnosis of schizophrenia receive the same levels of physical health care from primary care practitioners as patients without schizophrenia. METHODS: Design: Case-matched retrospective case note review. Setting: Twenty-two general practices in the Birmingham area (UK). Subjects: 195 patients with a diagnosis of schizophrenia, 390 matched controls with a diagnosis of asthma and 390 general control patients. Main outcome measures: Proportions of patients within each group having received six pre-defined routine health checks in a 3 year period. Conditional logistic regression models were used to identify differences between groups. RESULTS: Patients with schizophrenia were half as likely as asthma controls to have blood pressure and cholesterol levels recorded (odds ratio 0.51; 95% confidence interval (CI) 1.35-0.73 and 0.50; 0.31-0.82, respectively) and were also less likely to have smoking status noted (0.60; 0.41-0.85). Similarly, patients with schizophrenia were significantly less likely than general population controls to have either blood pressure or cholesterol recorded (0.68; 0.47-0.97 and 0.58; 0.35-0.95). The significant differences observed were maintained after adjusting for potential confounders with the exception of cholesterol recording between the asthma and schizophrenia groups (0.57; 0.30-1.05). CONCLUSIONS: Patients with a diagnosis of schizophrenia are less likely to receive some important general health checks than patients without schizophrenia.     

社区高血压糖尿病自我管理对患者相关行为影响的研究

目的 在社区慢性病管理研究中引入患者自我管理模式并观察自我管理对患者相关行为的影响。方法对274名高血压患者和94名糖尿病患者发放自我管理手册，通过讲座等形式培训自我管理技能，并指导患者填写自我管理手册，对照目标行为进行自我管理，由责任医生根据目标行为达标天数和记录情况判定自我管理水平。结果自我管理的患者中定期测量血压（血糖），家庭测量血压（血糖），规律运动，控制饮食、控制脂肪和钠盐摄入和规范服药的比例有不同程度地提高，其中家庭测量血压和血糖的患者比例分别提高了37．6％和52．5％；定期监测血压血糖的比例也分别提高了10．0％和28．9％。结论在社区卫生人员指导下设立健康行为目标，进行自我管理并进行监测和评估，对控制高血压和糖尿病的相关正确行为的形成是有效的。     

Perspective of patients on type-2 diabetes and their relationship with primary care health professionals: a qualitative study

Aim. The objective of this study is to investigate the perception that people with type 2 diabetes have about the disease and about their relationship with the primary healthcare professionals.Design. Qualitative research, carried out between September-November 2000.Setting. Primary healthcare center Barrio del Pilar from Madrid. Participants. 15 persons with type 2 diabetes. Variables considered to design the profiles of the interviewed were: age, gender, educational level, and time since diagnosis.Method. Structural sampling and open interviews.Results. Patients express having scarce information regarding the consequences of diabetes. As diabetes is symptom free represents a difficulty for being perceived as a severe disease. The most valued aspects of the relationship with health professionals are that they provide with clear and tailored information, build a trust context, support changes and take account their perspectives and living circumstances.Conclusions. It is essential to recognize how patients understand and shape the disease. Information provided by professionals have to be tailored to patients necessities, and take place in a trusting environment. Decisions related with diabetes management have to be aligned with patients perspectives. Effective communication could be considered as a useful tool to encourage adherence and improve healthcare quality.     

Truth telling and truthfulness in the care for patients with advanced dementia: an ethnographic study in Dutch nursing homes

The purpose of this study was to investigate and analyze the moral tension that exists in the care for demented nursing home patients, between the principle of respect for autonomy and the value that is attached to respect for the subjective world of the patient. To this end an ethnographical field study was carried out by two researchers in two Dutch nursing homes. Among the central topics that evolved were the different moral problems that nurses experience concerning truth telling and acting truthfully in relation to demented patients. In situations unrelated to the dementia and its diagnosis, the right to be informed is in principle respected, even if the information is sometimes painful. More specific questions of demented patients about their situation are a regular cause of embarrassment for their carers, who rely on various treatment strategies to deal with such questions. These strategies are often successful. However, when they fail, the nurses are faced with a problem they cannot solve, namely the loss of a common shared world and the resulting unmentionable truth about the diagnosis of dementia, as objective basis and legitimization for their approach to the demented patient. We conclude that in the training and professional support given to nurses, more attention should be paid to (awareness of) the moral problems that arise from this loss of a common shared world, so that they can react to the subjective world of demented patients without feeling that they are deceiving them.     

Access to primary care for patients with diabetes at an urban public hospital walk-in clinic

The purpose of this study was to determine the regular source of primary care, the content of care, and barriers to accessing primary care for 218 medically indigent adults with diabetes mellitus. Patients were surveyed at a public hospital walk-in clinic and were queried regarding demographics, regular source of care, and the content of care they received during the preceding year. Seventy percent of the patients were medically uninsured, and 60 percent had household incomes under $10,001. Forty-three percent reported no regular source of care, and 18 percent named an episodic care site as their regular source. Patients with a regular source of primary care had twice as many annual ambulatory visits as those without primary care. Patients with a regular source of primary care reported more diabetic-related services than those without. This patient population is largely poor and uninsured and has difficulty accessing primary care.     

Achieving blood pressure control in patients with diabetes: a case study in primary care

This article presents a case study from a primary care practice that achieves blood pressure control (ie, less than 130/85 mm Hg) in a majority of patients with diabetes. Fifty-three percent of the last blood pressures measured in 2001 were controlled and 38% of patients achieved blood pressure control without medications or with a single agent. Blood pressure control is achieved in a majority of patients in this practice secondary to their focus on guidelines, involvement of nursing staff in case management, and medication use consistent with recommendations.     

Empowering patients with diabetes: a qualitative primary care study focusing on South Asians in Leicester, UK

OBJECTIVES: We aimed to explore the experience and attitudes of primary care patients with diabetes living in a UK community with a high proportion of South Asian patients of Indian origin, with particular reference to patient empowerment. METHODS: Semi-structured interviews were conducted with patients with diabetes attending two general practices in Leicester, UK. Patients were interviewed in English, Gujarati or Punjabi and interviews were transcribed with translation into English where necessary. Broad themes were identified and Framework charting was used to organise data for analysis. RESULTS: Interviews were conducted with 15 South Asian and 5 white patients. We identified both similar and culturally specific elements within the experience, attitudes and barriers in the two ethnic groups. High regard for education, particularly in South Asians, was associated with a positive attitude to empowerment through knowledge, but also sometimes led to low motivation to become partners in diabetes management. High prevalence of diabetes and strong family networks meant that families were an important source of knowledge for South Asians and that these patients generally had good emotional support. Practical considerations such as the need for a convenient venue for educational initiatives were common to both ethnic groups, but some cultural preferences were also identified, for example for appropriate language provision and separate gender sessions. CONCLUSIONS: Educational initiatives aimed at promoting self-management in chronic diseases such as diabetes need to be designed with an awareness of the complexity of social and cultural experiences and attitudes in target communities.     

Organization of primary health care in cities belonging to project for expansion and consolidation of the family health strategy in Mato Grosso State, Brazil

This article presents part of the results from the Baseline Study on the PROESF. The objective was to evaluate primary health care in the cities of Cuiabá, Várzea Grande, and Rondonópolis, Mato Grosso State, Brazil, based on the inter-subjectivity in human relations (among health workers, users of health services, and the public at large and within institutionalized levels of social control). A qualitative and quantitative methodology was used, including interviews with key informants; short meetings with managers; focal groups with managers; and interviews with users and health professionals from pre-selected health units. Scores were assigned to all the questions that indicated participatory processes in primary care practices in the various municipalities. Despite the geopolitical identity among the municipalities and their similar access to the same public policies, there was a significant difference in their performance of the functions pertaining to the organization of primary care and the Family Health Program, in terms of portal of entry into the system, longitudinality, comprehensiveness, and coordination. Differences were observed in the type of relations that were established (participatory versus non-participatory), corresponding to the previous difference.     

Breastfeeding promotion, protection, and support in primary health care in the State of Rio de Janeiro, Brazil: a case of evidence-based public health policy

This article evaluates a policy for breastfeeding promotion, protection, and support in primary health care units in Rio de Janeiro State, Brazil, analyzing the assumptions, interventions, and results based on a log-frame model. A systematic review sought to identify effective procedures and strategies for extending breastfeeding duration, constituting the basis for creating "Ten Steps" in the "Breastfeeding-Friendly Primary Care Initiative" launched in Rio de Janeiro State in 1999. A corresponding evaluation method was developed and applied to verify the performance of 24 primary health care units from different parts of the State. A direct association was found between the practical implementation of these steps and prevalence of exclusive breastfeeding, as well as with mothers' satisfaction. An analysis of meanings ascribed by pregnant women and mothers to the support provided for breastfeeding identified five categories: "no support", "doubtful support", "encouragement", "guidance", and "partnership". The evaluation model allowed staff at the health care units to recognize opportunities for improving the program, in order to reverse the current low prevalence of exclusive breastfeeding.     

"Those of you who have never had an abortion, raise your hand!": rethinking ethnographic data on the dissemination of abortion practices among low-income populations in Brazil

Based on recently published research findings on abortion rates, this paper re-examines original ethnographic data on abortion in order to open a discussion on the dissemination of abortion, its possible cultural configurations and its social legitimacy among low-income populations in Brazil. It refers retrospectively to two works of empirical research studies and presents an estimate of the prevalence of abortion of around of 34%; it describes abortion practices and the social representation of what abortion means in a given context. The studies presented here seek to contribute to the understanding of women's decision-making regarding this reproductive choice in a context where abortion is illegal. The data allow us to construct an abortion typology, classifying it as tolerated, unacceptable and recommended and point to a fluidity of meanings regarding pregnancy interruption practices. It is possible to infer that the magnitude of the problem of abortion, both with regard to number of cases and the existing diversity of abortion practices and methods, has not changed over a period of 20 years in Brazil.     

Risk factors for weaning among users of a primary health care unit in Belo Horizonte, Minas Gerais State, Brazil, from 1980 to 2004

This study was a comparative analysis of factors affecting duration of breastfeeding among users of the S?o Marcos primary care clinic in Belo Horizonte, Minas Gerais State, Brazil, in 1980, 1986, 1992, 1998, and 2004. Five retrospective longitudinal studies (historical cohorts) were performed with the same questionnaire, and 790 mothers of children less than 24 months of age were interviewed. The statistical analysis was conducted year-by-year using the Kaplan-Meier method and Cox model. From 1980 to 2004, conditions significantly associated with risk of weaning were: primiparity; difficulty in postpartum breastfeeding; belief in ideal breastfeeding duration of less than six months; start of breastfeeding after discharge from the maternity hospital, non-recognition of the advantages of breastfeeding for the child; and unfavorable, unknown, or indifferent paternal opinion concerning breastfeeding. In four of the five studies, difficulty in breastfeeding (RR: 1.70-3.97) and belief in ideal breastfeeding duration of less than six months (RR: 1.67-3.27) were risk factors for weaning. Median duration of breastfeeding was five months in 1980 and 11 months in 2004.