Family physicians' personal experiences of their fathers' health care.

OBJECTIVES: The American health care system is complicated and can be difficult to navigate. The physician who observes the care of a family member has a uniquely informed perspective on this system. We hoped to gain insight into some of the shortcomings of the health care system from the personal experiences of physician family members. STUDY DESIGN: Using a key informant technique, we invited by E-mail any of the chairpersons of US academic departments of family medicine to describe their recent personal experiences with the health care system when their parent was seriously ill. In-depth semi-structured telephone interviews were conducted with each of the study participants. The interviews were transcribed, coded, and labeled for themes. POPULATION: Eight family physicians responded to the E-mail, and each was interviewed. These physicians had been in practice for an average of 19 years, were nationally distributed, and included both men and women. Each discussed their father's experience. RESULTS: All participants spoke of the importance of an advocate for their fathers who would coordinate medical care. These physicians witnessed various obstacles in their fathers's care, such as poor communication and fragmented care. As a result, many of them felt compelled to intervene in their fathers' care. The physicians expressed concern about the care their fathers received, believing that the system does not operate the way it should. CONCLUSIONS: Even patients with a knowledgeable physician family member face challenges in receiving optimal medical care. Patients might receive better care if health care systems reinforced the role of an accountable attending physician, encouraged continuity of care, and emphasized the value of knowing the patient as a person.     

Using physician-led automated communications to improve patient health

One common thread to health care reform in the United States is an emphasis on effectively managing the care of patients with chronic conditions. A landmark study by McGlynn et al demonstrated that patients receive about 55% of the treatment they need. While technological advances allow automated means for identifying and reaching out to patients in need of treatment, few studies have evaluated their impact. The purpose of this study is to measure how an automated outreach program can be used to improve the quality of care for patients with diabetes and hypertension. Billing and electronic medical records data from a large health system in Wisconsin were studied, identifying patients with a history of diabetes and hypertension but no visits recorded in billing data related to their condition in the past 6 months. The outcomes of interest were the occurrence of a chronic care-related visit and a necessary test within 6 months of the nonadherence date. Diabetes patients who were successfully contacted were significantly more likely to have both a chronic care-related visit and an HbA1c test (odds ratio [OR]?=?4.61, 95% confidence interval [CI] 3.87-5.49) than their counterparts who were not contacted. As well, hypertension patients were significantly more likely to have both a chronic care-related visit and a systolic blood pressure reading recorded in an electronic medical record (OR?=?3.18, 95% CI 2.90-3.48). An automated patient identification and outreach program can be an effective means to supplement existing practice patterns to ensure that patients with chronic conditions in need of care receive the necessary treatment.     

Computerised dietary assessment interviews: Health professionals and patients' opinions about web communications

Aim: To describe the acceptance of DietAdvice, an automated dietary assessment website, by its stakeholders. Methods: One‐month evaluation study using audio‐recorded telephone interviews with 10 patients who had used DietAdvice, 10 dietitians, 10 general practitioners who recruited many patients and 10 general practitioners who recruited few or no patients to the website to obtain their beliefs and opinions about DietAdvice, health, nutrition and technology. Interviews were transcribed verbatim and analysed for categorical themes using NVivo software. Results: Patients were concerned about Internet difficulties and had a preference for face‐to‐face interviews and dietitians felt that DietAdvice could save time prior to dietary education and counselling. Recruiting general practitioners believed that patient computer literacy was a limitation, although increased availability of dietary services created by DietAdvice. Non‐recruiting general practitioners felt that they had a lack of time available to recruit patients, patient computer literacy was limited and there was a need for face‐to‐face contact. Conclusion: The perspectives of patients and health‐care providers show variation based on their experience with DietAdvice, their focus on nutrition and their role in the health‐care system. Automated technologies are likely to play a significant part in the future of dietetics.     

Warnings about vulnerability in clients with diabetes and hypertension

The purpose of the grounded theory study discussed in this article was to discover and explicate the basic social problem in clients with diabetes and hypertension that affects their adherence to health care directives. In-depth interviews with 21 clients with both diabetes and hypertension and 3 health care providers who care for such clients were concurrently conducted, coded, and analyzed according to the grounded theory method. Clients with diabetes and hypertension described being bombarded repeatedly with warnings about their vulnerability. The warnings were both external (coming from health care providers, family, and friends) and internal (coming from within themselves). Internal warnings were discovered to be far more influential in affecting adherence. This discovery can be used to shape health care providers' social interactions and treatment plan strategies with clients with diabetes and hypertension.     

Client acceptability and quality of life--telepsychiatry compared to in-person consultation

We evaluated client satisfaction and one-month mental health outcomes for telepsychiatry clients compared with those undergoing a face-to-face psychiatric consultation. Clients were asked to complete an SF-12 health survey before the consultation, a satisfaction survey after the consultation, and were contacted for a one-month follow-up SF-12 survey by telephone. Forty-eight of the 62 initial responders (77%) were available for contact by telephone after one month. Telepsychiatry clients demonstrated significant improvements on pre- and post-SF-12 mental health measures (t = 3.7; P = 0.001), while there was no change for the in-person group (t = 1.0; P = 0.35). Telepsychiatry clients felt that they could present the same information as in person (93%), were satisfied with their session (96%), and were comfortable in their ability to talk (85%); this was similar to the in-person clients. They reflected slightly lower levels of satisfaction regarding feeling supported and encouraged than did the in-person clients. Both telepsychiatry clients and traditional face-to-face psychiatry clients were satisfied with their experience of mental health care service provision, and mental health improvements were evident in the telepsychiatry patients.     

Computers in the examination room and the electronic health record: physicians' perceived impact on clinical encounters before and after full installation and implementation

Purpose We compared physicians' self-reported attitudes and behaviours regarding electronic health record (EHR) use before and after installation of computers in patient examination rooms and transition to full implementation of an EHR in a family medicine training practice to identify anticipated and observed effects these changes would have on physicians' practices and clinical encounters. Methods We conducted two individual qualitative interviews with family physicians. The first interview was before and second interview was 8 months later after full implementation of an EHR and computer installation in the examination rooms. Data were analysed through project team discussions and subsequent coding with qualitative analysis software. Results At the first interviews, physicians frequently expressed concerns about the potential negative effect of the EHR on quality of care and physician-patient interaction, adequacy of their skills in EHR use and privacy and confidentiality concerns. Nevertheless, most physicians also anticipated multiple benefits, including improved accessibility of patient data and online health information. In the second interviews, physicians reported that their concerns did not persist. Many anticipated benefits were realized, appearing to facilitate collaborative physician-patient relationships. Physicians reported a greater teaching role with patients and sharing online medical information and treatment plan decisions. Conclusions Before computer installation and full EHR implementation, physicians expressed concerns about the impact of computer use on patient care. After installation and implementation, however, many concerns were mitigated. Using computers in the examination rooms to document and access patients' records along with online medical information and decision-making tools appears to contribute to improved physician-patient communication and collaboration.     

Characterizing the acceptability of a vaccine for West Nile virus by public health practitioners

This study examines health care personnel's knowledge of West Nile virus (WNv) and attitudes towards a proposed chimeric yellow fever/WNv vaccine within the province of Saskatchewan. Telephone and in-person interviews with medical health officers and public health nurses provided information with which to assess the acceptability of implementing vaccination as a component for prevention of WNv within the province with the highest number of WNv cases to date in western Canada. The majority of health care professionals felt confident in the potential efficacy of vaccination for prevention of WNv but suggested that targeted vaccination programs could be most effective.     

Living with diabetes on Baffin Island: Inuit storytellers share their experiences

BACKGROUND: The prevention and management of Type 2 diabetes mellitus has become a concern in Inuit communities across Canada. Although Inuit living with diabetes in remote Canadian Arctic communities could help guide the development of health services, their voices have not been heard. The experiences and perceptions of Inuit themselves are often overlooked in research. In this study, Inuit living in a small rural Arctic community on Baffin Island were invited to share their experiences of living with diabetes. METHODS: A qualitative multi-case study approach was taken. In-depth interviews (n=4), field observations, and informal interviews over one month in the community were used to build and contextualize the cases. In-depth interviews were transcribed, and analyzed using holistic thematic analysis and open coding. RESULTS: Accessibility was a concern with respect to foods, health knowledge, language interpretation and health services. In all methods of analysis, the importance of language and effective cross-cultural communication figured prominently. It was also evident that trust and rapport is crucial when discussing diabetes. There was strong interest in promoting diabetes education and prevention within the community. INTERPRETATION: These findings suggest that current health education and services may not be adequate for this setting. The voices of Inuit should be integral in steering the direction of their future diabetes education and health service delivery. Focusing on language barriers may help to improve the accessibility of knowledge about diabetes and nutrition, and enhance relationships between non-Inuit health service providers and Inuit.     

Male callers to NHS Direct: the assertive carer, the new dad and the reluctant patient

It has been suggested in the light of mortality and morbidity rates, and men's reluctance to seek medical help and advice, that there is a crisis in men's health. Little is known about men's experiences of using health care services, despite an emergent UK men's health movement. NHS Direct, the new telephone advice line, was designed to be more accessible, convenient and responsive to the public's needs for health care. In-depth interviews with male callers to the service, aged between 29 and 59, reveal that they sought help in their roles as fathers, partners and on their own behalf. Having used it once, they anticipated doing so again. Their learning about health matters, from both the formal structure and the informal agenda of the telephone consultation, suggests the potential of men's use of this service for 'normalizing' help seeking by men, and thereby for longer-term improvements in men's health.     

Lay perceptions of type 2 diabetes in Scotland: bringing health services back in

The growing prevalence of type 2 diabetes is placing Scottish health services under considerable strain. Consequently, diabetes services are undergoing a major process of reorganisation, including the devolvement of routine diabetes care/diabetic review from secondary to primary healthcare settings. This qualitative study was devised to explore newly diagnosed type 2 diabetes patients' perceptions of their disease and the health services they receive at a time when this restructuring of services is taking place. The sample comprised 40 patients resident in Lothian, Scotland, who had diverse experiences of services, some receiving GP-based care only, others having varying contact with hospital diabetes clinics. In-depth interviews were undertaken with patients, three times at six monthly intervals over 1 year, enabling their experiences to be tracked at critical junctures during the post-diagnostic period. Disease perceptions and health service delivery were found to be mutually informing and effecting. Not only did (different types of) health service delivery influence the ways in which patients thought about and self-managed their disease, over time patients' disease perceptions also informed their expectations of, and preferences for, diabetes services. We thus argue that there is a need for a reconceptualisation within the medical social sciences to take into account the context of healthcare and the economic/policy factors that inform health service delivery when looking at patients' disease perceptions. We also discuss the logistical and ethical challenges of drawing upon patients' perspectives, preferences and views in the design and delivery of future health services.     

Trends in national and state-level obesity in the USA after correction for self-report bias: analysis of health surveys

OBJECTIVES: To quantify population-level bias in self-reported weight and height as a function of age, sex, and the mode of self-report, and to estimate unbiased trends in national and state level obesity in the USA. DESIGN: Statistical analysis of repeated cross-sectional health examination surveys (the National Health and Nutrition Examination Survey [NHANES]) and health surveys (the Behavioral Risk Factor Surveillance System [BRFSS]) in the USA. SETTING: The 50 states of the USA and the District of Columbia. RESULTS: In the USA, on average, women underreported their weight, but men did not. Young and middle-aged (<65 years) adult men over-reported their height more than women of the same age. In older age groups, over-reporting of height was similar in men and women. Population-level bias in self-reported weight was larger in telephone interviews (BRFSS) than in-person interviews (NHANES). Except in older adults, height was over-reported more often in telephone interviews than in-person interviews. Using corrected weight and height in the year 2000, Mississippi (30%) and Texas (31%) [corrected] had the highest prevalence of obesity for men; Texas (37%), Louisiana (37%), Mississippi (37%), District of Columbia (37%), Alabama (37%), and South Carolina (36%) for women. CONCLUSIONS: Population-level bias in self-reported weight and height is larger in telephone interviews than in-person interviews. Telephone interviews are a low-cost method for regular, nationally- and sub-nationally representative monitoring of obesity. It is possible to obtain corrected estimates of trends and geographical distributions of obesity from telephone interviews by using systematic analysis which measure weight and height from an independent sample of the same population.     

Primary care attributes and care for depression among low-income African American women

OBJECTIVES: We examined the association between attributes of primary care providers and care for depression, from a patients' perspective, among a sample of predominantly low-income African American women. METHODS: Computer-assisted telephone interviews were conducted among a population-based sample of 1202 women residing in Washington, DC. RESULTS: Respondents whose primary care physicians provided more comprehensive medical services were more likely to be asked about and treated for depressive symptoms than women whose providers were less medically comprehensive. Women who rated their providers as having more respect for them also were more likely to be asked about and treated for depression. CONCLUSIONS: More comprehensive primary care delivery and a physician-patient relationship focused on mutual respect are associated with greater rates of physician inquiry about and treatment for depression among vulnerable women.     

Drug information for consumers: should it be disease or medication specific? Results of a community survey

OBJECTIVE: To investigate the information-seeking behaviour of medicine users. METHODS: A telephone survey and follow-up in-depth interviews of a random sample of the adult population in the Hunter Region, NSW, Australia. The survey sought information on medicine use, information seeking, and satisfaction and understanding of the information received. In-depth interviews examined the barriers and facilitators of information seeking. RESULTS: Seven hundred and eighty-six people completed the telephone survey and 58 completed the follow-up interviews. Over half (51%) of the medicine users sought information, primarily to 'manage' their medicines, such as how to use the medicine. Over 30% of the questions asked by users related to 'therapeutic choices', such as how well the medicine worked for a particular condition. Doctors and pharmacists were the most frequent sources of information. A small proportion (10%) reported a potential unmet need for medicines information by indicating they would have liked to ask a question, but did not, or were dissatisfied with the information they received. Barriers to information seeking included perceptions that health care professionals were 'too busy', and that they were unwilling to provide information. CONCLUSIONS: Physicians and pharmacists continue to play an important role in providing consumers with medicines information. Although the reported level of unmet need was low, a significant proportion identified needs relating to information on therapeutic choice, rather than 'classical' drug information. IMPLICATIONS: Medicines-related information for the public should include advice on comparative performance of drugs, and be provided within the wider framework of general health information.     

Coping With Client Death: How Prepared Are Home Health Aides and What Characterizes Preparedness?

This study explored the experiences of 80 home health aides (HHAs) whose client died within the last 2 months. Data collection involved comprehensive semi-structured in-person interviews to try to better understand characteristics of HHAs and their clients associated with preparedness for death. Among those, personal end-of-life (EOL) care preferences of HHAs and having knowledge of preferences and decisions regarding client’s EOL care showed significant links to preparedness. Findings suggest that HHAs’ preparedness for client death could be enhanced both by addressing their personal views on EOL care and by providing more information about the client’s EOL care plans.     

Indigenous women's perceptions of breast cancer diagnosis and treatment in Queensland

OBJECTIVE: To identify social, structural and personal factors among indigenous women in Queensland associated with the detection of breast cancer, and the treatment and post-treatment care and support of cancer. METHODS: Qualitative research including interviews, case studies and focus group discussions were conducted, among Aboriginal women and service providers in urban, rural and remote areas of Queensland over nine months in 1998/99. RESULTS: A range of factors were identified as influencing women's willingness to perform BSE, receive screening mammograms, and receive and complete treatment compared to the non-indigenous population. Personal history of health services, provision of information about mammography, the cost of treatment and care, and availability of personal support, all influenced women's willingness to access services and maintain treatment. Indigenous women in Queensland experience various barriers to effective and appropriate detection, treatment and care of breast cancer. CONCLUSION: Barriers to diagnosis, treatment and care can be addressed by increasing women's awareness of breast cancer and the benefits of preventative health behaviour, and improving the quality and appropriateness of health care and counselling services for Indigenous women and their families. IMPLICATIONS: Indigenous women's knowledge and practice relating to the early diagnosis and prevention of breast cancer may improve through outreach work with women, to encourage their confidence in preventative health. Women's commitment to preventive health will also be enhanced by improved quality and access to health care, and improved relationships between practitioners and patients.     

Factors Associated with Continued Participation in Mammography Screening

BACKGROUND: Relatively little is known about factors that predict ongoing participation in mammography screening at regular intervals. Members of managed care plans have access to this preventive service; yet, many still do not receive it routinely. METHODS: Using administrative data from HIP Health Plan of New York, a group model HMO, 24,215 women ages 50-80 years identified as having a screening mammogram during the baseline period were followed for 2 years to determine demographic and utilization factors that might be related to having a subsequent mammogram within the recommended time interval. RESULTS: Of the 24,215 women with an index mammogram, 71.8;pc had a subsequent screening mammogram within 2 years. Women ages 65-74 years and those with Medicare coverage had the highest mammogram rates among the age and coverage categories. Number of primary care and gynecology physician visits was strongly related to having a subsequent mammogram. The average (mean) time between index and subsequent mammogram was 14.4 months. CONCLUSION: The significance of health plan visits in subsequent mammography underscores the importance of physician-patient communication in a managed care plan and the integration of health plan members into the HMO delivery system. Even in this environment with equal access for all types of coverage, Medicaid members were less likely to receive this preventive service.     

The reliability of telephone interviews compared with in-person interviews using memory aids

PURPOSE: Information obtained by telephone interviews and in-person interviews is generally considered comparable, but it is unclear if extensive memory aids can be used effectively with telephone interviews. We compared a telephone interview to an in-person interview using the same questionnaire and memory aids in both. METHODS: A convenience sample of 103 women, aged 25 to 69 years, completed a telephone interview and at least four weeks later, completed an in-person interview. Memory aids included a life events calendar, cue lists, and worksheets. RESULTS: Agreement values, measured by kappa/weighted kappa, were as follows: parity (1.00), age at menarche (0.76), menopausal status (0.95), a history of reproductive organ surgery (0.98) or tubal ligation (0.91), self-reported infertility (0.76), and a first degree family history of breast/ovarian cancer (0.90). Agreement values for duration variables, measured by the intraclass correlation, were as follows: lactation (0.96), oral contraceptive use (0.98), any hormone replacement therapy (0.98), exclusive estrogen and progesterone therapy (0.83), and exclusive estrogen therapy (0.99). CONCLUSIONS: The good to excellent level of agreement found in this study indicates that telephone administration of our questionnaire with extensive memory aids is a reliable method of obtaining detailed exposure information relative to in-person interviews.     

Barriers to implementing South Africa's Termination of Pregnancy Act in rural KwaZulu/Natal

INTRODUCTION: South Africa's Termination of Pregnancy Act, the most liberal abortion law in Africa, took effect early in 1997. In spite of the anticipated benefits to women's health, however, public reaction has been mixed. In the country's most populous province, KwaZulu/Natal, opposition is strong and most health care providers have refused to provide the service. This study explored attitudes and beliefs about abortion and the Termination of Pregnancy Act among primary care nurses and community members in a rural district in order to better understand barriers to implementation of the new law. METHODS: As part of a community survey on women's reproductive health (n = 138), questions on knowledge, attitudes and beliefs about abortion were asked, as well as awareness of the provisions of the Termination of Pregnancy Act. To better understand the perspectives of health care workers, a survey among primary care nurses on duty (n = 25) was also conducted. In-depth interviews were conducted with both nurses and women in the community to further pursue issues raised in the two surveys. RESULTS: Support for the Act was low (11%) among both community members and nurses, and few supported abortion on request (18 and 6%, respectively). Within each group, however, a clear hierarchy of support was observed: a majority of nurses (56%) and community members (58%) supported abortion in the case of rape or incest, or if the continued pregnancy would endanger a woman's health (61 and 56%, respectively), but few supported abortion for social or economic reasons. In-depth interviews revealed that abortion is seen as contrary to prevailing community norms; nurses were poorly informed about the Termination of Pregnancy Act and felt confused in their professional responsibilities. CONCLUSIONS AND RECOMMENDATIONS: Legalization alone cannot ensure implementation of abortion services. In South Africa, extensive media coverage prior to passage of the law ensured almost universal awareness of the Act, but little public education took place at the same time. In spite of general opposition to the law, however, there is an encouraging level of support for abortion in some circumstances. These findings suggest that abortion services can be implemented, even in conservative rural areas, but that a process of information dissemination and community consent prior to implementation is essential. Locating abortion within broader reproductive health services could be an effective way to improve access and acceptability.     

Falling into the medical poverty trap in Sri Lanka: what can be done?

Sri Lanka's public health care system is free at the point of use and maintains a focus on equity. However, noncommunicable diseases, such as diabetes, are rapidly increasing in prevalence and posing new challenges to the system and to patients and households. In-depth interviews and focus group discussions were conducted in four districts of Sri Lanka to investigate the care-seeking experiences of diabetes patients from households at different income levels. Although health care is free, other direct and indirect costs served as deterrents to care seeking before and after diagnosis, and placed a high burden on households. The need for frequent visits to clinics with appropriate facilities for diagnosis and management of diabetes, often far from rural communities, posed high costs, in particular due to income foregone. Households employed coping strategies, but the need for frequent clinic visits posed repeated costs, which made it difficult for households to recover their economic status. Many patients, especially those from low-income, rural households, could not maintain the management regimen, and their condition deteriorated. There is a need for specialist facilities for the diagnosis and management of diabetes at locations closer to rural areas.