Tailoring intervention procedures to routine primary health care practice; an ethnographic process evaluation

Background  

Tailor-made approaches enable the uptake of interventions as they are seen as a way to overcome the incompatibility of general interventions with local knowledge about the organisation of routine medical practice and the relationship between the patients and the professionals in practice. Our case is the Quattro project which is a prevention programme for cardiovascular diseases in high-risk patients in primary health care centres in deprived neighbourhoods. This programme was implemented as a pragmatic trial and foresaw the importance of local knowledge in primary health care and internal, or locally made, guidelines. The aim of this paper is to show how this prevention programme, which could be tailored to routine care, was implemented in primary care.     

Promotion of children's early psychosocial development through primary health care services

Summary. The paper presents the study design of the development and organisation of an EU/WHO multicentre study on the promotion of children's early psychosocial development through primary health care services. The aim of the programme is to develop training for primary health care workers (PHCWs) that improves their ability to assess factors relevant to children's psychosocial development and gives them preventive approaches to foster that development, building on the families' strengths. The focus is on the period from conception to the end of the second year of the child's life. Two main components are the training of die PHCWs and the semi-structured interviews that guide the workers in practice. The training has content and structure that is feasible within primary health care resources working in collaboration with mental health services. The programme is evaluated in terms of (a) the impact of training on both the PHCWs' knowledge and attitudes with regard to infant behaviour and development, and on practice as assessed by the delivery of the semi-structured interview; and (b) the effect of the intervention on maternal well-being, infant language development and behaviour, home environment and mother-infant interaction. The programme is taking place in Cyprus, Greece, the Federal Republic of Yugoslavia, Portugal, Slovenia and Turkey.     

Estimating the cost of primary care training in ambulatory settings

The Balanced Budget Act of 1997 legislated the idea of reimbursing ambulatory sites for training medical professionals. However, very little is known about the costs of training in such settings. This paper assesses the cost of primary care training in ambulatory settings. Selection models were used to separate the cost of teaching from the cost of infrastructural differences between teaching and non-teaching sites. A probit equation modelled the likelihood of an ambulatory site having a teaching programme and a cost function related total medical practice costs to clinical output, the presence of a health professions educational programme, the price of resources used, characteristics of the medical practice and location. Data on 184 community health centres (CHCs), group practices, health maintenance organizations (HMOs) and outpatient clinics were used. Teaching sites were found to have 36% higher operating costs than their non-teaching counterparts: 38% of these higher costs were due to infrastructural differences and 62% were the 'pure' costs of teaching, i.e. the costs of teaching the net of infrastructural effects.     

Practice preferences of primary medical care and traditional internal medicine house officers

In an academic medical centre between 1980 and 1985, the attitudes, preferences and career goals of house officers in a primary medical care residency training programme were assessed at entry and at the end of each house officer year. Primary care trainees who went on to practise in a general medicine setting were compared to primary care trainees who subsequently received subspecialty training and also to traditional internal medicine trainees. House officers in the primary care programme generally maintained attitudes and preferences central to the practice of primary care, and scored significantly higher than traditional track house officers on attitudes and preferences compatible with the practice of medicine in a primary care setting. However, primary care house officers who later went into subspecialty training received scores similar to those of traditional track house officers on practice preferences relating to specialty care. There were no significant differences between primary care and traditional track house officers on standard measures of knowledge and clinical skill.     

Tracing patients exposed to health care workers with tuberculosis.

OBJECTIVES: Following an outbreak of tuberculosis (TB) among health care workers at a public hospital, the study was undertaken to (a) locate all exposed patients and administer tuberculin skin tests (TSTs) to them, (b) provide clinical treatment or prophylaxis to infected patients, and (c) ascertain the risk of M. tuberculosis transmission from health care workers to patients. METHODS: The authors identified all patients who had been hospitalized on floors where health care workers with symptomatic TB worked. The staff of the hospital''s outpatient HIV/AIDS clinic notified and evaluated clinic patients who had been hospitalized on those floors. County health department personnel attempted to contact the remaining patients by letter and phone. RESULTS: The authors identified 586 patients hospitalized during the health care worker outbreak, of whom 503 were potentially susceptible. Of these, 172 (34.2%) could be contacted, and 138 (80.2%) completed tuberculin skin testing or other follow-up evaluation. Of 134 who completed testing, 28 (20.9%) had reactive TSTs. In all, 362 patients (72%) were lost to follow-up, including many HIV-positive and homeless patients, who are at high risk of developing active TB once infected with M. tuberculosis. CONCLUSIONS: The reemergence of TB as a public health threat and the emergence of other infectious diseases make it imperative to elicit accurate addresses and contact information from hospitalized patients and to develop better methods of contacting patients after hospital discharge.     

Training for primary eye care in leprosy

Reported are the results of a primary eye care training programme for community-based leprosy control workers in the Republic of Korea. The 20-hour programme emphasized the detection and management of lagophthalmos (and its complications) and chronic iridocyclitis. Leprosy patients in four resettlement villages were examined independently by the health workers and an ophthalmologist. Agreement between the health workers and the ophthalmologist was good for the detection of most signs (lagophthalmos, acute iridocyclitis, and chronic iridocyclitis). Based on these preliminary results it is recommended that primary eye care be included as a part of the training for leprosy paramedical workers.     

Skin diseases in family medicine: prevalence and health care use

PURPOSE Ongoing care for patients with skin diseases can be optimized by understanding the incidence and population prevalence of various skin diseases and the patient-related factors related to the use of primary, specialty, and alternative health care for these conditions. We examined the recent prevalence of skin diseases in a defined population of family medicine patients, self-reported disease-related quality of life, extent and duration of skin disease, and the use of health care by patients with skin diseases.METHODS We undertook a morbidity registry-based epidemiological study to determine the prevalence of various skin diseases, using a patient questionnaire to inquire about health care use, within a network of family practices in the Netherlands with a practice population of approximately 12,000 citizens.RESULTS Skin diseases accounted for 12.4% of all diseases seen by the participating family physicians. Of the 857 questionnaires sent to patients registered with a skin disease, 583 (68.0%) were returned, and 501 were suitable for analysis. In the previous year, 83.4% of the patients had contacted their family physician for their skin disease, 17.0% had contacted a medical specialist, and 5.2% had consulted an alternative health care practitioner. Overall, 65.1% contacted only their family physician. Patients who reported more severe disease and lower quality of life made more use of all forms of health care.CONCLUSION This practice population-based study found that skin diseases account for 12.4% of diseases seen by family physicians, and that some skin problems may be seen more frequently. Although patients with more extensive skin diseases also obtain care from dermatologists, most patients have their skin diseases treated mainly by their family physician. Overall, patients with more severe disease and a lower quality of life seek more treatment.     

Epidemiological approach to planning and development of occupational health services at a national level

In developing the national occupational health programme in Thailand it was necessary to obtain information on workers' health to enable proper planning and implementation of the programme. A stratified sample of different types of small (up to 50 workers) and medium-sized factories (51-150 workers) located in one geographical area was selected. In all, 98 plants were surveyed and a total of 1449 workers were examined. The prevalence of diseases, many of which were work-related, was higher in the small than in the medium-sized plants. Additional information confirmed the need for controlling the multitude of health problems of these under-served workers. The Ministry of Health used this data in training primary health care workers in the small workplaces, controlling the health problems discovered, developing laboratories and drafting legislation.     

An eating disorder curriculum for primary care providers.

OBJECTIVE: Primary care providers frequently lack adequate training in treating eating disorders. This study examined the effectiveness of an eating disorder curriculum designed to address the lack of knowledge among primary care providers. METHOD: Medical social workers completed four intensive training sessions, each lasting 75 min. Participants completed questionnaires assessing eating disorder knowledge, perceived ability to treat eating disorders, and practice behaviors, before and after training as well as at 6-month follow-up. RESULTS: The eating disorder curriculum resulted in a significant increase in eating disorder knowledge and a moderate improvement in practice behaviors such as screening new patients for an eating disorder. Training did not significantly change providers' perceived ability to intervene. DISCUSSION: The results of this pilot study suggest that brief intensive training can increase providers' knowledge and change their routine clinical practices, resulting in increased rates of detection and intervention in the primary care setting.     

江苏省扬州市部分医务人员吸烟行为及控烟知识现状调查

目的对江苏省扬州市医务人员的吸烟行为和控烟知识现状进行调查,为今后在医务人员群体中实施控烟干预提供依据。方法采用问卷调查的方法,对扬州市4家医疗机构605名直接从事医务工作的人员进行问卷调查。结果医务人员人群总吸烟率为16.03%,现在吸烟率为11.57%;烟草危害的知晓率为73.61%,7种吸烟相关疾病的知晓率为71.00%,6种被动吸烟相关疾病的知晓率为77.60%;对医疗机构控烟认同率为83.63%;43.46%的医务人员获得过控烟方面的知识培训,能为病人制定戒烟计划的有1.69%;能对病人在门诊和病房提供健康教育的有31.40%。结论医务人员人群烟草相关知识掌握相对不足,应当进一步加强医务人员控烟知识和技能的健康教育和培训,改变其吸烟行为,同时也更好地推动社会控烟工作。     

A regionalized perinatal continuing education programme: successful adaptation to a foreign health care system and language

Much of the decline in perinatal mortality over the past two decades in the United States has been attributed to regionalization of perinatal care. Outreach education from regional medical centres to community hospitals is an essential component of regionalization. The Perinatal Continuing Education Program (PCEP) has been successfully used for outreach education in more than 30 states since 1979. This project tested the efficacy of implementing the PCEP strategy in Poland. PCEP was adapted to Polish conditions, translated, and implemented in four phases. The scheme allowed gradual transfer of ownership to Polish leaders and use of the existing regional structure to disseminate information from regional centres to community hospitals. Evaluation included measures of programme use (participation and completion rates) and acceptance (participant evaluation forms), cognitive knowledge (pre- vs. post-tests), and patient care (chart reviews). Of 2093 doctors, nurses and midwives who began, 1615 (77%) completed the programme, with higher completion by regional centre than community hospital staff. All participant groups responded favourably to the materials and expressed moderate confidence in their mastery of the information and skills. Test scores improved significantly for all phases and for all disciplines, with baseline and final scores consistent with degrees of previous professional education. Large baseline and inter-hospital variations in chart review data restricted analysis of care practices. A comprehensive perinatal education programme can be successfully transferred to a foreign health care system. We believe the following to be particularly important: multidisciplinary instructors and students; a self-instructional format; content aimed at practice rather than theory; and an organized implementation strategy co-ordinated by local personnel.     

Health workers' community practices in primary health care models in South and Northeast Brazil

In order to verify the prevalence of health workers' participation in health practices in the community, a cross-sectional study was conducted with 3,743 primary care health workers in 41 municipalities with more than 100 thousand inhabitants each in South and Northeast Brazil. Overall prevalence of participation in the community was 62.7%, and was significantly higher in the Northeast and in the Family Health Program (FHP). The most common practice was health education on special holidays, in talks, and in groups. There was a positive association between participation and: female gender, training in the management of chronic diseases, use of protocols, satisfaction with community meetings, and academic health services. Differences in the prevalence of participation by region and health care model reaffirmed the inherent expectations in the historical context of reorganization of primary care. The results indicate that it is necessary to expand participation by health workers in the community, considering that primary care is the level of care that provides the best possibilities for promoting health practices with equity.     

Qualité de la communication soignant-patient : quels apports de l'intégration de la santé mentale dans des services de première ligne en Guinée ?

BackgroundPatient-centred care presupposes communication based on empathy, active listening and dialogue. Our study examines the effects of integrating mental health in multi-purpose health centres on health workers’ communication with patients who consult for problems unrelated to mental health. The objective is to compare the quality of communication in health centres where staff have received specific training in the management of mental disorders (SM+) compared to those without such training (SM−).MethodsThe study was conducted among 18 health workers in charge of primary curative consultations in 12 non-governmental health centers in Guinea: 7 health workers in 4 SM+ health centers and 11 health workers in 8 SM− health centres. The study is based on mixed methods: observation, semi-structured and group interviews. The Global Consultation Rating Scale (GCRS) was applied to assess patient-centered communication.ResultsThe SM+ GCRS scores obtained by SM+s during observations are generally higher than the SM− scores. The odds of having a "good quality" consultation are almost 3 times higher in SM+ than in SM− for some steps in the consultation process. The SM+ discourse is more patient-centered, and differs from the more biomedical discourse of SM−. SM− health workers do not consider all of the stages of a patient-centred consultation to be applicable and recommend "leapfrogging". On the contrary, SM+ health workers consider all stages to be important and are convinced that the integration of mental health has improved their communication through the training they have received and the practice of caring for persons with mental disorders.ConclusionThe integration of mental health into primary care provision represents an opportunity to improve the quality of care in its "patient-centred care" dimension. That said, optimal development of patient-centred care presupposes favorable structural conditions.     

HIV/aids related home based care practices among primary health care workers in Ogun state, Nigeria

ABSTRACT: BACKGROUND: HIV/AIDS is fast becoming a chronic disease with the advent of antiretroviral drugs, therefore making home based care key in the management of chronically ill HIV/AIDS patient. The objective of this study was to determine the perception and practice of health care workers on HIV/AIDS related home based care in the health facilities in Ogun state, Nigeria. METHODS: This study is an analytical cross-sectional study. A multistage cluster sampling technique was used to obtain a representative sample of the primary health care workers in Ogun state. An interviewer administered structured questionnaire was administered by trained health workers to elicit the required information. Result A total of 350 health care workers were interviewed, 70% of the respondents could adequately describe the components of home based care. Only 38.7% were aware of the National guideline on home based care practices and 17.1% believe that home based care will not significantly improve the prognosis of PLWAs. Few 19.1% had ever been trained or ever involved 16.6% in home based care practices. Only 20 [5.7%] are involved on a weekly basis, 16 [4.6%] monthly and 22 [6.3%] quarterly. Reasons given for non implementation of home based care are inadequate number of healthcare workers 45%, lack of political will 24.4%, lack of implementation by facility managers 14% and inadequate funds 16.6%. Factors that were significantly associated with the practice of home based care were perception of its relevance in improving prognosis [OR = 54.21, C.I = 23.22-129.52] and presence of a support group in the facility [OR = 4.80, C.I = 2.40-9.57]. There was however no statistically significant relationship between adequate knowledge of home based care [OR = 0.78, C.I = 0.39-1.54] and previous training on home based care (OR = 1.43, C.I = 0.66- 3.06]. CONCLUSION: The practice of home based care for HIV/AIDS among the study population is low and it is greatly influenced by perception of its effectiveness and relevance. The study recommends that the health care workers should be adequately educated on the importance of home based care in the management of chronic illnesses in order to enhance its practice.     

Young people's satisfaction of transitional care in adolescent rheumatology in the UK

BACKGROUND: To examine the quality of transitional health care from the perspectives of young people with juvenile idiopathic arthritis (JIA) and their parents. METHODS: Adolescents with JIA and their parents were recruited from 10 major UK rheumatology centres. Satisfaction with health-care delivery was measured prior to, and 12 months after, the implementation of a structured and co-ordinated programme of transitional care using self-completed questionnaires designed for this study. RESULTS: Of 359 families invited to participate, 308 (86%) adolescents with JIA and 303 (84%) parents/guardians accepted. A fifth of adolescents had persistent oligoarthritis. Median age was 14.2 (11-18) years with median disease duration of 5.7 (0-16) years. Young people and their parents rated provider characteristics more important than aspects of the physical environment or process issues. Staff honesty and knowledge were rated as the most essential aspects of best practice. Prior to implementing the programme of transitional care, parents rated service delivery for all items significantly worse than best practice. Overall satisfaction improved 12 months after entering the programme. However, while parent satisfaction improved for 70.4% of items, significant improvements were only observed for three (13.6%) items rated by adolescents. CONCLUSION: The perceived quality of health care for young people with JIA and their parents was significantly lower than what they would like. Satisfaction with many aspects of care during transition from paediatric to adult services can be improved through the implementation of a structured, co-ordinated programme of transitional care.     

舟山海岛医生健康演讲能力培训应用效果评价

目的评价《健康科普演讲能力三循环培训模式》在海岛社区医生健康演讲培训中的转化应用效果。方法采用准实验研究方法,实验组医生参加健康科普演讲能力培训,培训前后请专家评分。培训转化应用前后由听众各自对实验组和对照组医生演讲能力进行评分,并对听众进行健康知识基线和终末调查。结果实验组医生经过培训后演讲能力明显提升,由培训前的（57.78±21.56）分提高到培训后的（85.28±11.32）分,听众健康知识知晓率明显提升,实验组知识知晓率为81.67%,对照组为70.65%,差异有统计学意义（P〈0.05）。结论健康科普演讲能力三循环培训模式在海岛社区医生健康演讲能力提升中的应用效果明显,适合在基层卫生单位推广。     

Knowledge and attitudes of primary health care personnel concerning mental health problems in developing countries.

A semi-structured interview for assessing the knowledge and attitude of health workers concerning mental health problems was applied in seven developing country areas within the context of a World Health Organization coordinated collaborative study. The results indicate a lack of basic mental health training associated with a failure to recognize mental health problems, restricted knowledge concerning psychotropic drug therapy, and an inability to visualize practical forms of mental health care which could be introduced at primary care level. The results were used to design appropriate training programs, and the observations will be repeated to assess the effectiveness of training.     

Shaping the future: a primary care research and development strategy for Scotland

Primary care is at the centre of the National Health Service (NHS) in Scotland; however, its R & D capacity is insufficiently developed. R&D is a potentially powerful way of improving the health and well-being of the population, and of securing high quality care for those who need it. In order to achieve this, any Scottish strategy for primary care R&D should aim to develop both a knowledge-based service and a research culture in primary care. In this way, decisions will be made based upon best available evidence, whatever the context. Building on existing practice and resources within primary care research, this strategy for achieving a thriving research culture in Scottish primary care has three key components: A Scottish School of Primary Care which will stimulate and co-ordinate a cohesive programme of research and training. A comprehensive system of funding for training and career development which will ensure access to a range of research training which will ensure that Scotland secures effective leadership for its primary care R&D. Designated research and development practices (DRDPs) which will build on the work of existing research practices, in the context of Local Health Care Co-operatives (LHCCs) and Primary Care Trusts (PCTs), to create a co-operative environment in which a range of primary care professionals can work together to improve their personal and teams' research skills, and to support research development in their areas. A modest investment will create substantial increases in both the quality and quantity of research being undertaken in primary care. This investment should be targeted at both existing primary care professionals working in service settings in primary care, LHCCs and PCTs, and at centres of excellence (including University departments). A dual approach will foster collaboration and will allow existing centres of excellence both to undertake more primary care research and to support the development of service based primary care professionals in their research. Resources should be distributed equitably, taking into account demography, geography and the health needs of patients in Scotland. The strategy and its components must be seen as a whole. The Scottish School of Primary Care will stimulate and co-ordinate both research and training programmes. DRDPs will become research active and will participate in School-led training and research, and will contribute to research programmes. Comprehensive funding for training and career development will ensure that staff have the skills to participate in both DRDPs and in the School's activities. Thus, inadequate commitment to any one component of the strategy will mean that other components will be less successful. Commitment to all three components will maximise the chances of success.