Patients as Partners: A Qualitative Study of Patients’ Engagement in Their Health Care

To advocate for patients to be more actively involved with the healthcare services they receive, particularly patients living with chronic illness, the Faculty of Medicine of the University of Montreal and its affiliated hospitals developed the Patients as Partners concept where the patient is considered a full-fledged partner of the health care delivery team and the patient’s experiential knowledge is recognized. This study aims to show how patients view their engagement with healthcare professionals regarding their direct care. Using theoretical sampling, 16 semi-structured interviews were conducted with patients with chronic illness who were familiar with the concept of Patients as Partners. Data analysis followed a constructivist grounded theory approach. Patients describe themselves as proactively engaging in three types of practice, regardless of health professionals’ openness to their role as partners. The first is a process of continuous learning that allows them to acquire experiential knowledge about their health, as well as scientific information and technical know-how. The second involves their assessment of the healthcare they receive, in terms of its quality and how it aligns with their personal preferences. It includes their assessment of the quality of their relationship with the health professional and of the latter’s scientific knowledge and technical know-how. The third type, adaptation practices, builds on patients’ learning and assessments to compensate for and adapt to what has been perceived as optimal or non-optimal health or healthcare circumstances. Patients appear to play a more active and less docile role in their own direct care than suggested so far in the literature, regardless of the degree of reciprocity of the partnership or the degree to which the health professional seeks to encourage patient engagement.     

Fragmentation of Care Threatens Patient Safety in Peripheral Vascular Catheter Management in Acute Care– A Qualitative Study

Background

The use of peripheral vascular catheters (PVCs) is an extremely common and necessary clinical intervention, but inappropriate PVC care poses a major patient safety risk in terms of infection. Quality improvement initiatives have been proposed to reduce the likelihood of adverse events, but a lack of understanding about factors that influence behaviours of healthcare professionals limits the efficacy of such interventions. We undertook qualitative interviews with clinical staff from a large group of hospitals in order to understand influences on PVC care behaviors and subsequent patient safety.

Methods

Ten doctors, ten clinical pharmacists, 18 nurses and one midwife at a National Health Service hospital group in London (United Kingdom) were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework.

Results

Four key themes emerged: 1) Fragmentation of management and care, demonstrated with a lack of general overview and insufficient knowledge about expected standards of care or responsibility of different professionals; 2) feelings of resentment and frustration as a result of tensions in the workplace, due to the ambiguity about professional responsibilities; 3) disregard for existing hospital policy due to perceptions of flaws in the evidence used to support it; and 4) low-risk perception for the impact of PVC use on patient safety.

Conclusion

Fragmentation of practice resulted in ill-defined responsibilities and interdisciplinary resentment, which coupled with a generally low perception of risk of catheter use, appeared to result in lack of maintaining policy PVC standards which could reduced patient safety. Resolution of these issues through clearly defining handover practice, teaching interdisciplinary duties and increasing awareness of PVC risks could result in preventing thousands of BSIs and other PVC-related infections annually.     

Dimensions and Determinants of Trust in Health Care in Resource Poor Settings – A Qualitative Exploration

Background

Trust in health care has been intensely researched in resource rich settings. Some studies in resource poor settings suggest that the dimensions and determinants of trust are likely to be different.

Objectives

This study was done as a qualitative exploration of the dimensions and determinants of trust in health care in Tamil Nadu, a state in south India to assess the differences from dimensions and determinants in resource rich settings.

Methodology

The participants included people belonging to marginalized communities with poor access to health care services and living in conditions of resource deprivation. A total of thirty five in depth interviews were conducted. The interviews were summarized and transcribed and data were analyzed following thematic analysis and grounded theory approach.

Results

The key dimensions of trust in health care identified during the interviews were perceived competence, assurance of treatment irrespective of ability to pay or at any time of the day, patients’ willingness to accept drawbacks in health care, loyalty to the physician and respect for the physician. Comfort with the physician and health facility, personal involvement of the doctor with the patient, behavior and approach of doctor, economic factors, and health awareness were identified as factors determining the levels of trust in health care.

Conclusions

The dimensions and determinants of trust in health care in resource poor settings are different from that in resource rich settings. There is a need to develop scales to measure trust in health care in resource poor settings using these specific dimensions and determinants.     

Healthcare Professionals’ and Policy Makers’ Views on Implementing a Clinical Practice Guideline of Hypertension Management: A Qualitative Study

IntroductionMost studies have reported barriers to guideline usage mainly from doctors’ perspective; few have reported the perspective of other stakeholders. This study aimed to determine the views and barriers to adherence of a national clinical practice guideline (CPG) on management of hypertension from the perspectives of policymakers, doctors and allied healthcare professionals.MethodsThis study used a qualitative approach with purposive sampling. Seven in depth interviews and six focus group discussions were conducted with 35 healthcare professionals (policy makers, doctors, pharmacists and nurses) at a teaching hospital in Kuala Lumpur, Malaysia, between February and June 2013. All interviews were audio-recorded, transcribed verbatim and checked. Thematic approach was used to analyse the data.ResultsTwo main themes and three sub-themes emerged from this study. The main themes were (1) variation in the use of CPG and (2) barriers to adherence to CPG. The three sub-themes for barriers were issues inherent to the CPG, systems and policy that is not supportive of CPG use, and attitudes and behaviour of stakeholders. The main users of the CPG were the primary care doctors. Pharmacists only partially use the guidelines, while nurses and policy makers were not using the CPG at all. Participants had suggested few strategies to improve usage and adherence to CPG. First, update the CPG regularly and keep its content simple with specific sections for allied health workers. Second, use technology to facilitate CPG accessibility and provide protected time for implementation of CPG recommendations. Third, incorporate local CPG in professional training, link CPG adherence to key performance indicators and provide incentives for its use.ConclusionsBarriers to the use of CPG hypertension management span across all stakeholders. The development and implementation of CPG focused mainly on doctors with lack of involvement of other healthcare stakeholders. Guidelines should be made simple, current, reliable, accessible, inclusive of all stakeholders and with good policy support.     

Effect of Ethiopia’s Health Extension Program on Maternal and Newborn Health Care Practices in 101 Rural Districts: A Dose-Response Study

Background

Improving newborn survival is essential if Ethiopia is to achieve Millennium Development Goal 4. The national Health Extension Program (HEP) includes community-based newborn survival interventions. We report the effect of these interventions on changes in maternal and newborn health care practices between 2008 and 2010 in 101 districts, comprising 11.6 million people, or 16% of Ethiopia’s population.

Methods and Findings

Using data from cross-sectional surveys in December 2008 and December 2010 from a representative sample of 117 communities (kebeles), we estimated the prevalence of maternal and newborn care practices, and a program intensity score in each community. Women with children aged 0 to 11 months reported care practices for their most recent pregnancy and childbirth. The program intensity score ranged between zero and ten and was derived from four outreach activities of the HEP front-line health workers. Dose-response relationships between changes in program intensity and the changes in maternal and newborn health were investigated using regression methods, controlling for secular trend, respondents’ background characteristics, and community-level factors.Between 2008 and 2010, median program intensity score increased 2.4-fold. For every unit increase in the score, the odds of receiving antenatal care increased by 1.13 times (95% CI 1.03–1.23); the odds of birth preparedness increased by 1.31 times (1.19–1.44); the odds of receiving postnatal care increased by 1.60 times (1.34–1.91); and the odds of initiating breastfeeding immediately after birth increased by 1.10 times (1.02–1.20). Program intensity score was not associated with skilled deliveries, nor with some of the other newborn health care indicators.

Conclusions

The results of our analysis suggest that Ethiopia’s HEP platform has improved maternal and newborn health care practices at scale. However, implementation research will be required to address the maternal and newborn care practices that were not influenced by the HEP outreach activities.     

Patients’ Knowledge,Attitudes, Behaviour and Health Care Experiences on the Prevention,Detection, Management and Control of Hypertension in Colombia: A Qualitative Study

Hypertension is a leading cause of premature death worldwide and the most important modifiable risk factor for cardiovascular disease. Effective screening programs, communication with patients, regular monitoring, and adherence to treatment are essential to successful management but may be challenging in health systems facing resource constraints. This qualitative study explored patients’ knowledge, attitudes, behaviour and health care seeking experiences in relation to detection, treatment and control of hypertension in Colombia. We conducted in-depth interviews and focus group discussions with 26 individuals with hypertension and 4 family members in two regions. Few participants were aware of ways to prevent high blood pressure. Once diagnosed, most reported taking medication but had little information about their condition and had a poor understanding of their treatment regime. The desire for good communication and a trusting relationship with the doctor emerged as key themes in promoting adherence to medication and regular attendance at medical appointments. Barriers to accessing treatment included co-payments for medication; costs of transport to health care facilities; unavailability of drugs; and poor access to specialist care. Some patients overcame these barriers with support from social networks, family members and neighbours. However, those who lacked such support, experienced loneliness and struggled to access health care services. The health insurance scheme was frequently described as administratively confusing and those accessing the state subsidized system believed that the treatment was inferior to that provided under the compulsory contributory system. Measures that should be addressed to improve hypertension management in Colombia include better communication between health care professionals and patients, measures to improve understanding of the importance of adherence to treatment, reduction of co-payments and transport costs, and easier access to care, especially in rural areas.     

Results of Observational Studies: Analysis of Findings from the Nurses’ Health Study

Background

The role of observational studies in informing clinical practice is debated, and high profile examples of discrepancies between the results of observational studies and randomised controlled trials (RCTs) have intensified that debate. We systematically reviewed findings from the Nurses’ Health Study (NHS), one of the longest and largest observational studies, to assess the number and strength of the associations reported and to determine if they have been confirmed in RCTs.

Methods

We reviewed NHS publication abstracts from 1978–2012, extracted information on associations tested, and graded the strength of the reported effect sizes. We searched PubMed for RCTs or systematic reviews for 3 health outcomes commonly reported in NHS publications: breast cancer, ischaemic heart disease (IHD) and osteoporosis. NHS results were compared with RCT results and deemed concordant when the difference in effect sizes between studies was ≤0.15.

Findings

2007 associations between health outcomes and independent variables were reported in 1053 abstracts. 58.0% (1165/2007) were statistically significant, and 22.2% (445/2007) were neutral (no association). Among the statistically significant results that reported a numeric odds ratio (OR) or relative risk (RR), 70.5% (706/1002) reported a weak association (OR/RR 0.5–2.0), 24.5% (246/1002) a moderate association (OR/RR 0.25–0.5 or 2.0–4.0) and 5.0% (50/1002) a strong association (OR/RR ≤0.25 or ≥4.0). 19 associations reported in NHS publications for breast cancer, IHD and osteoporosis have been tested in RCTs, and the concordance between NHS and RCT results was low (≤25%).

Conclusions

NHS publications contain a large number of analyses, the majority of which reported statistically significant but weak associations. Few of these associations have been tested in RCTs, and where they have, the agreement between NHS results and RCTs is poor.     

Rural Doctors’ Views on and Experiences with Evidence-Based Medicine: The FrEEDoM Qualitative Study

Background

Evidence-based medicine is the integration of individual clinical expertise, best external evidence and patient values which was introduced more than two decades ago. Yet, primary care physicians in Malaysia face unique barriers in accessing scientific literature and applying it to their clinical practice.

Aim

This study aimed to explore the views and experiences of rural doctors’ about evidence-based medicine in their daily clinical practice in a rural primary care setting.

Methods

Qualitative methodology was used. The interviews were conducted in June 2013 in two rural health clinics in Malaysia. The participants were recruited using purposive sampling. Four focus group discussions with 15 medical officers and three individual in-depth interviews with family medicine specialists were carried out. All interviews were conducted using a topic guide and were audio-recorded, transcribed verbatim, checked and analyzed using a thematic approach.

Results

Key themes identified were: (1) doctors viewed evidence-based medicine mainly as statistics, research and guidelines, (2) reactions to evidence-based medicine were largely negative, (3) doctors relied on specialists, peers, guidelines and non-evidence based internet sources for information, (4) information sources were accessed using novel methods such as mobile applications and (5) there are several barriers to evidence-based practice, including doctor-, evidence-based medicine-, patient- and system-related factors. These included inadequacies in knowledge, attitude, management support, time and access to evidence-based information sources. Participants recommended the use of online services to support evidence-based practice in the rural settings.

Conclusion

The level of evidence-based practice is low in the rural setting due to poor awareness, knowledge, attitude and resources. Doctors use non-evidence based sources and access them through new methods such as messaging applications. Further research is recommended to develop and evaluate interventions to overcome the identified barriers.     

A Quantitative Approach to the Prioritization of Zoonotic Diseases in North America: A Health Professionals’ Perspective

Background

Currently, zoonoses account for 58% to 61% of all communicable diseases causing illness in humans globally and up to 75% of emerging human pathogens. Although the impact of zoonoses on animal health and public health in North America is significant, there has been no published research involving health professionals on the prioritization of zoonoses in this region.

Methodology/Principal Findings

We used conjoint analysis (CA), a well-established quantitative method in market research, to identify the relative importance of 21 key characteristics of zoonotic diseases for their prioritization in Canada and the US. Relative importance weights from the CA were used to develop a point-scoring system to derive a recommended list of zoonoses for prioritization in Canada and the US. Study participants with a background in epidemiology, public health, medical sciences, veterinary sciences and infectious disease research were recruited to complete the online survey (707 from Canada and 764 from the US). Hierarchical Bayes models were fitted to the survey data to derive CA-weighted scores for disease criteria. Scores were applied to 62 zoonotic diseases to rank diseases in order of priority.

Conclusions/Significance

We present the first zoonoses prioritization exercise involving health professionals in North America. Our previous study indicated individuals with no prior knowledge in infectious diseases were capable of producing meaningful results with acceptable model fits (79.4%). This study suggests health professionals with some knowledge in infectious diseases were capable of producing meaningful results with better-fitted models than the general public (83.7% and 84.2%). Despite more similarities in demographics and model fit between the combined public and combined professional groups, there was more uniformity across priority lists between the Canadian public and Canadian professionals and between the US public and US professionals. Our study suggests that CA can be used as a potential tool for the prioritization of zoonoses.     

Disclosure of Past Crimes: An Analysis of Mental Health Professionals’ Attitudes Towards Breaching Confidentiality

Ensuring confidentiality is the cornerstone of trust within the doctor–patient relationship. However, health care providers have an obligation to serve not only their patient’s interests but also those of potential victims and society, resulting in circumstances where confidentiality must be breached. This article describes the attitudes of mental health professionals (MHPs) when patients disclose past crimes unknown to the justice system. Twenty-four MHPs working in Swiss prisons were interviewed. They shared their experiences concerning confidentiality practices and attitudes towards breaching confidentiality in prison. Qualitative analysis revealed that MHPs study different factors before deciding whether a past crime should be disclosed, including: (1) the type of therapy the prisoner-patient was seeking (i.e., whether it was court-ordered or voluntary), (2) the type of crime that is revealed (e.g., a serious crime, a crime of a similar nature to the original crime, or a minor crime), and (3) the danger posed by the prisoner-patient. Based on this study’s findings, risk assessment of dangerousness was one of the most important factors determining disclosures of past crimes, taking into consideration both the type of therapy and the crime involved. Attitudes of MHPs varied with regard to confidentiality rules and when to breach confidentiality, and there was thus a lack of consensus as to when and whether past crimes should be reported. Hence, legal and ethical requirements concerning confidentiality breaches must be made clear and known to physicians in order to guide them with difficult cases.     

Coverage and Quality of Antenatal Care Provided at Primary Health Care Facilities in the ‘Punjab’ Province of ‘Pakistan’

Background

Antenatal care is a very important component of maternal health services. It provides the opportunity to learn about risks associated with pregnancy and guides to plan the place of deliveries thereby preventing maternal and infant morbidity and mortality. In ‘Pakistan’ antenatal services to rural population are being provided through a network of primary health care facilities designated as ''Basic Health Units and Rural Health Centers. Pakistan is a developing country, consisting of four provinces and federally administered areas. Each province is administratively subdivided in to ‘Divisions’ and ‘Districts’. By population ‘Punjab’ is the largest province of Pakistan having 36 districts. This study was conducted to assess the coverage and quality antenatal care in the primary health care facilities in ‘Punjab’ province of ‘Pakistan’.

Methods

Quantitative and Qualitative methods were used to collect data. Using multistage sampling technique nine out of thirty six districts were selected and 19 primary health care facilities of public sector (seventeen Basic Health Units and two Rural Health Centers were randomly selected from each district. Focus group discussions and in-depth interviews were conducted with clients, providers and health managers.

Results

The overall enrollment for antenatal checkup was 55.9% and drop out was 32.9% in subsequent visits. The quality of services regarding assessment, treatment and counseling was extremely poor. The reasons for low coverage and quality were the distant location of facilities, deficiency of facility resources, indifferent attitude and non availability of the staff. Moreover, lack of client awareness about importance of antenatal care and self empowerment for decision making to seek care were also responsible for low coverage.

Conclusion

The coverage and quality of the antenatal care services in ‘Punjab’ are extremely compromised. Only half of the expected pregnancies are enrolled and out of those 1/3 drop out in follow-up visits.     

Malign Neglect: Assessing Older Women’s Health Care Experiences in Prison

The problem of providing mandated medical care has become commonplace as correctional systems in the United States struggle to manage unprecedented increases in its aging prison population. This study explores older incarcerated women’s perceptions of prison health care policies and their day-to-day survival experiences. Aggregate data obtained from a sample of 327 older women (mean age?=?56) residing in prison facilities in five Southern states were used to identify a baseline of health conditions and needs for this vulnerable group. With an average of 4.2 chronic health conditions, frequently histories of victimization, and high rates of mental health issues, the women’s experiences of negotiating health care was particularly challenging. By incorporating the voices of older women, we expose the contradictions, dilemmas, and obstacles they experience in their attempts to obtain health care. It is clear from the personal accounts shared that, despite court mandates, penal harm practices such as delaying or denying medical treatment as well as occasional staff indifferences are common in women’s prisons. With older women having the greatest need for health care, an age- and gender-sensitive approach is recommended.     

Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania’s Health System

IntroductionPeople in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system.MethodsUsing mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child’s respiratory symptoms.ConclusionADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective.     

Health of the Land,Health of the People: A Case Study on Gwich’in Berry Harvesting in Northern Canada

Many Aboriginal groups, in northern Canada and elsewhere, recognize the strong relationship between the health and well-being of people and environment. Western science, including theory and literature related to forest ecosystem management, has been slow to recognize the complex and diverse values that Aboriginal people associate with their lands and resources. Through case study research on the berry-harvesting practices of Gwich’in women from the community of Fort McPherson, Northwest Territories, Canada, we investigated the values that Teetl’it Gwich’in women associate with the land or nan kak. Nine different values, as well as a set of detailed measures, were identified during the research, including individual preference and well-being, family well-being, social connectivity, cultural continuity, land and resource use, stewardship, self-government, and spirituality. The commercial value of berries was not identified as important to women. This interdisciplinary research has the potential to contribute to several bodies of literature including that on social-ecological systems.     

Health Professionals “Make Their Choice”: Pharmaceutical Industry Leaders’ Understandings of Conflict of Interest

Conflicts of interest, stemming from relationships between health professionals and the pharmaceutical industry, remain a highly divisive and inflammatory issue in healthcare. Given that most jurisdictions rely on industry to self-regulate with respect to its interactions with health professionals, it is surprising that little research has explored industry leaders’ understandings of conflicts of interest. Drawing from in-depth interviews with ten pharmaceutical industry leaders based in Australia, we explore the normalized and structural management of conflicts of interest within pharmaceutical companies. We contrast this with participants’ unanimous belief that the antidote to conflicts of interest with health professionals were “informed consumers.” It is, thus, unlikely that a self-regulatory approach will be successful in ensuring ethical interactions with health professionals. However, the pharmaceutical industry’s routine and accepted practices for disclosing and managing employees’ conflicts of interest could, paradoxically, serve as an excellent model for healthcare.     

Impact of Free Delivery Care on Health Facility Delivery and Insurance Coverage in Ghana’s Brong Ahafo Region

Background

Many sub-Saharan countries, including Ghana, have introduced policies to provide free medical care to pregnant women. The impact of these policies, particularly on access to health services among the poor, has not been evaluated using rigorous methods, and so the empirical basis for defending these policies is weak. In Ghana, a recent report also cast doubt on the current mechanism of delivering free care – the National Health Insurance Scheme. Longitudinal surveillance data from two randomized controlled trials conducted in the Brong Ahafo Region provided a unique opportunity to assess the impact of Ghana’s policies.

Methods

We used time-series methods to assess the impact of Ghana’s 2005 policy on free delivery care and its 2008 policy on free national health insurance for pregnant women. We estimated their impacts on facility delivery and insurance coverage, and on socioeconomic differentials in these outcomes after controlling for temporal trends and seasonality.

Results

Facility delivery has been increasing significantly over time. The 2005 and 2008 policies were associated with significant jumps in coverage of 2.3% (p = 0.015) and 7.5% (p<0.001), respectively after the policies were introduced. Health insurance coverage also jumped significantly (17.5%, p<0.001) after the 2008 policy. The increases in facility delivery and insurance were greatest among the poorest, leading to a decline in socioeconomic inequality in both outcomes.

Conclusion

Providing free care, particularly through free health insurance, has been effective in increasing facility delivery overall in the Brong Ahafo Region, and especially among the poor. This finding should be considered when evaluating the impact of the National Health Insurance Scheme and in supporting the continuation and expansion of free delivery care.     

Exploring Managers’ Perspectives on MNCH Program in Pakistan: A Qualitative Study

Background

Pakistan’s Maternal, Newborn and Child Health (MNCH) Program is faced with multiple challenges in service delivery, financial and logistic management, training and deployment of human resources, and integration within the existing health system. There is a lack of evidence on managerial aspects of the MNCH program management and implementation.

Methods and Findings

This study used qualitative methods to explore the challenges national, provincial and district program managers have faced in implementing a community midwifery program in province of Punjab while also exploring future directions for the program under a devolved health system. While the program had been designed in earnest, the planning lacked critical elements of involving relevant stakeholders in design and implementation, socio-demographic context and capacity of the existing health system. Financial limitations, weak leadership and lack of a political commitment to the problem of maternal health have also had an impact on program implementation.

Conclusions

Our study results suggest that there is a need to re-structure the program while ensuring sustainability and collaboration within the health sector to increase uptake of skilled birth attendance and improve maternal health care in Pakistan.