Pharmaceuticals as folk medicine: transformations in the social relations of health care in Uganda

The deterioration of government health services in Uganda since 1971 has been accompanied by a process of privatization which has made pharmaceuticals readily available outside of biomedical institutions. On the basis of material from eastern Uganda, the article analyses this development in terms of the sector model of health care systems, with special attention to the relations between the professional and folk sectors. Folk practitioners of pharmaceutical medicine include a broad range of specialists, from government trained paramedicals in private practice to vendors bringing medicine to local markets. Like other folk specialists, they respect the customer's opinion, provide treatment by proxy and adjust their services to the customer's ability to pay. Although there are negative aspects of this development, from the local point of view there are also positive ones, which deserve the consideration of health planners.     

Telemedicine: lessons remain unheeded.

Telemedicine, the delivery of health care with the patient and health professional at different locations, has been around for over 30 years. Its driving force has been developments in communications technology, and as new communications systems are developed health applications are proposed such as supporting the delivery of primary health care to geographically remote areas or regions underserved through the maldistribution of professional expertise. Despite rapid technological advances, evaluations of such systems have been largely superficial, and more thorough evaluations have failed to show significant advantages for more advanced and expensive technology over older technology such as the telephone. Methods for evaluating the impact of particular technologies on the health care system need to be developed and clearer benefits shown in terms of improved standards of care.     

Health care and health care seeking strategies among Puyallup Indians

This study replicated Kleinman's research on family-based popular health care in Taiwan among the Puyallup Indians of Washington. Standardized interviews were conducted among 80 Puyallup families to determine family health practices and beliefs, and the patterns of referral to professional practitioners. Comparisons are made between the Puyallup and Taiwanese family health care practices and health care seeking processes. The author concludes that the relative absence of folk medicine and the availability of free medical care among the Puyallup are the most important factors causing the variance between the rates of family treatment and the patterns of health care seeking behaviors between the Puyallup and the Taiwanese.     

Blame the Patient,Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

Objective

Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.

Method

Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.

Results

Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.

Conclusion

Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.     

Is Private Health Care the Answer to the Health Problems of the World's Poor?

Background to the debate: The global burden of disease falls disproportionately upon the world''s low-income countries, which are often struggling with weak health systems. Both the public and private sector deliver health care in these countries, but the appropriate role for each of these sectors in health system strengthening remains controversial. This debate examines whether the private sector should step up its involvement in the health systems of low-income countries.     

Poverty in the Midst of Plenty: Unmet Needs and Distribution of Health Care Resources in South Korea

Background

The unmet needs for health care have been used as an alternative measurement to monitor equity in health services. We sought to examine contextual influences on unmet needs for health care whereas precedent studies have been focused on individual characteristics on them.

Methods and Findings

The current study conducted multilevel logistic regression analysis to assess the effects of individual- and contextual-level predictors in meeting individual health care needs in South Korea. We sampled 7,200 individuals over the age of 19 in the Fourth Korea National Health and Nutrition Examination Survey in 2009. Included in the regression model were individual predictors such as demographic variables, socio-economic status, and self-rated health; the density of beds and physicians in public and private sectors within different regions were used as contextual-level predictors. This study showed the inverse association between unmet needs and regional resources in private sectors after controlling for the effects of individual-level predictors.

Conclusion

Our findings suggest that increasing regional resources in private sectors might produce inefficiency in the health care system and inequity in access to health services, particularly where the competition in private health care sectors was highly stimulated under the fee-for-service reimbursement scheme. Policies for the reallocation of health care resources and for reduction of individual health care costs are needed in Korea.     

How primary health care professionals and residents assess issues related to the oral health of older persons?

doi: 10.1111/j.1741‐2358.2009.00355.x
How primary health care professionals and residents assess issues related to the oral health of older persons? Background and objectives: It is known that older persons need integrated primary health care. However, oral health may not be a frequent concern of multi‐professional teams taking care of older persons. The aim of the present study was to evaluate knowledge and practices related to oral health care, as reported by professionals and residents in a primary health care service. Material and methods: One hundred and seventy‐three health professionals and residents were assessed in this cross‐sectional study by means of a structured questionnaire containing questions pertaining to oral health practices and beliefs. Participants were grouped based on their professions into “primary health care dentists” or “other primary health care professionals” and based on their working status into “permanent team” or “residents”. Results: Permanent team members (other professionals) assessed and recommended dental care more frequently than residents. Permanent team members (other professionals) also reported that they felt they were able to inform older patients in respect to oral health‐related issues more frequently than did residents (68.7% vs. 31.3%, respectively). Conclusion: Oral health‐related knowledge and beliefs were frequent among non‐dentists primary health care workers, suggesting that primary health care which integrates oral health represents an attainable goal.     

A model of oncologic care in general medicine

The problems related to cancer and its control initially manifest in local community, and general practitioners are those who most commonly have to face them there. The aim of the study was to develop a program of comprehensive oncologic care for primary care physicians, which would be highly professional, efficient, economically justified and feasible, with the ultimate goal of upgrading the target population health and quality of life. Opinions on the priorities and intensity of work in particular activities of general practitioners in the field of oncologic care were obtained from 54 Croatian experts in oncologic care. An Expert Opinion was designed to collect oncologists' opinions by use of Delphi method. The study was performed in two runs, yielding a high rate of accordance among the oncologists. 38 of 54 participants responded in the first run, and 40 of 54 (74%) responded in the second run. The results indicated pain therapy and terminal care to be given highest priority, whereas measures of primary prevention ranked first as a group. There was a unanimous agreement that current activities of primary care physicians in the field of oncologic care were not satisfactory, and that they should take the role of a coordinator of the oncologic care of both individual patients and the population at large. The study showed that a model of oncologic care applicable throughout the country could be developed by combining data from a small health care office with the knowledge of renowned experts in the field.     

Focus: Rare Disease: mEDUrare: Supporting Integrated Care for Rare Diseases by Better Connecting Health and Education Through Policy

Rare diseases affect an estimated 6-10% of the Australian population, a prevalence similar to that seen in other regions worldwide. These multi-system conditions are often severely debilitating and affect multiple domains of a person’s life. A salient necessity for effective care provision thus, is holistic care, achieved by appropriate and continual multi-disciplinary and cross-sectoral collaboration. Synonymous with this priority for collaborative care, is the need for increased partnerships between the health and education sectors. This partnership has the potential to benefit people with rare disease of all educational ages, but in particular, school-aged children and young adults. More than 70% of rare diseases affect children, and this population often experiences difficulties with overall well-being and functioning, including impaired school performance and confounding mental and social comorbidities. Ensuring adequate schooling needs and experiences along with provision of adequate medical care, is crucial in ensuring overall well-being for this population. For this, effective partnerships between the health and education sectors are paramount. This article highlights fundamental elements of health and education priorities, ingrained in current strategic documents, to build a policy foundation that informs and supports increased inter-sectoral partnerships between health and education services. Shared priorities identified in both sectors’ guidelines, co-developed with those with lived experience of rare diseases, build a strong policy base for future advocative initiatives to mold better integration between the sectors, a partnership which is vital to improving the overall quality of life, experiences and journeys of people living with rare disease.     

Primary and managed care. Ingredients for health care reform.

The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.     

Community mental health care worldwide: current status and further developments

This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low‐ and middle‐income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long‐term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness.     

Challenges in the Care of Clients with Established Cardiovascular Disease: Lessons Learned from Australian Community Pharmacists

Background

As primary healthcare professionals, community pharmacists have both opportunity and potential to contribute to the prevention and progression of chronic diseases. Using cardiovascular disease (CVD) as a case study, we explored factors that influence community pharmacists’ everyday practice in this area. We also propose a model to best illustrate relationships between influencing factors and the scope of community pharmacy practice in the care of clients with established CVD.

Methods

In-depth, semi-structured interviews were conducted with 21 community pharmacists in New South Wales, Australia. All interviews were audio-recorded, transcribed ad verbatim, and analysed using a “grounded-theory” approach.

Results

Our model shows that community pharmacists work within a complex system and their practice is influenced by interactions between three main domains: the “people” factors, including their own attitudes and beliefs as well as those of clients and doctors; the “environment” within and beyond the control of community pharmacy; and outcomes of their professional care. Despite the complexity of factors and interactions, our findings shed some light on the interrelationships between these various influences. The overarching obstacle to maximizing the community pharmacists’ contribution is the lack of integration within health systems. However, achieving better integration of community pharmacists in primary care is a challenge since the systems of remuneration for healthcare professional services do not currently support this integration.

Conclusion

Tackling chronic diseases such as CVD requires mobilization of all sources of support in the community through innovative policies which facilitate inter-professional collaboration and team care to achieve the best possible healthcare outcomes for society.     

Over the counter drugs. The interface between the community pharmacist and patients.

Pharmacists play an important part in primary health care, and their accessibility is a key factor. Their NHS payments relate predominantly to the dispensing of prescribed medicines; to recognise the service element of their advisory role, an NHS funded professional fee could be built into the cost structure for pharmacy medicines. The increased number of medicines available over the counter has highlighted the need for training for counter assistants; it will become compulsory in July 1996, and some family health services authorities are providing this. The shift to care in the community could mean that pharmacists will have an even greater role in the primary health care team. Encouraging the public to seek advice from the community pharmacist may lead to a greater proportion of visits to doctors resulting from referrals from the pharmacist. Joint development by pharmacists and doctors of guidelines for advice on, and recommendation of, over the counter medicines is needed.     

Weaknesses in primary health care favor the growth of acquired syphilis

Acquired syphilis is a sexually transmitted infection that affects the general population and has been growing in recent years in many countries. A study was developed aiming to analyze the trends of acquired syphilis associated with sociodemographic aspects and primary health care in Brazil, in the period from 2011 to 2019. This study used secondary data from the national notification systems of the 5570 Brazilian cities and a database of 37,350 primary health care teams, as well as socioeconomic and municipal demographic indicators. The trends of acquired syphilis at the municipal level were calculated from the log-linear regression, crossing them with variables of primary health care and sociodemographic indicators. Finally, a multiple model was built from logistic regression. 724,310 cases of acquired syphilis have been reported. In primary care units, 47.8% had partial coverage and 74.1% had health teams with poor or regular scores. 52.6% had rapid test for syphilis partially available. Male and female condoms are available in 85.9% and 62.9% respectively and 54.4% had penicillin available in the health facility. The increase in trends of acquired syphilis was associated with better availability of the rapid test; lower availability of male condoms; lower availability of female condoms; lower availability of benzathine penicillin; partial coverage of the teams in primary health care; limited application of penicillin in primary health care; higher proportion of teams classified as Poor/Regular in primary health care; higher proportion of women aged 10 to 17 years who had children; higher HDI; higher proportion of people aged 15 to 24 years who do not study, do not work and are vulnerable; and population size with more than 100,000 inhabitants. The following variables remained in the multiple model: not all primary health care teams apply penicillin; higher proportion of primary health care teams with poor/regular scores; population size >100000 inhabitants; partially available female condom. Thus, the weakness of primary health care linked to population size may have favored the growth of the acquired syphilis epidemic in Brazilian cities.     

The Role of Ecology in the Design of a Health Care System

The weight of evidence does not support the hypothesis that the health status of the population is largely dependent on the quality and quantity of its medical services. Evidence to test this hypothesis is presented in a conceptual model of the relationship between health and disease and their care systems, suggesting that medical care is largely unrelated to the health status of the population.Examples of disease trends and distribution are presented to support the thesis that ecology is the primary determinant of the health status of the populationData from selected epidemiological studies point to poverty and air pollution as key factors in determining the pattern of mortality in the urban eco-system.     

Explanatory Models and Mental Health Treatment: Is Vodou an Obstacle to Psychiatric Treatment in Rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.     

Measuring the health of nations: analysis of mortality amenable to health care

Objective To assess whether and how the rankings of the world''s health systems based on disability adjusted life expectancy as done in the 2000 World Health Report change when using the narrower concept of mortality amenable to health care, an outcome more closely linked to health system performance.Design Analysis of mortality amenable to health care (including and excluding ischaemic heart disease).Main outcome measure Age standardised mortality from causes amenable to health careSetting 19 countries belonging to the Organisation for Economic Cooperation and Development.Results Rankings based on mortality amenable to health care (excluding ischaemic heart disease) differed substantially from rankings of health attainment given in the 2000 World Health Report. No country retained the same position. Rankings for southern European countries and Japan, which had performed well in the report, fell sharply, whereas those of the Nordic countries improved. Some middle ranking countries (United Kingdom, Netherlands) also fell considerably; New Zealand improved its position. Rankings changed when ischaemic heart disease was included as amenable to health care.Conclusion The 2000 World Health Report has been cited widely to support claims for the merits of otherwise different health systems. High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good.     

Evidence use in decision-making on introducing innovations: a systematic scoping review with stakeholder feedback

Background

A range of evidence informs decision-making on innovation in health care, including formal research findings, local data and professional opinion. However, cultural and organisational factors often prevent the translation of evidence for innovations into practice. In addition to the characteristics of evidence, it is known that processes at the individual level influence its impact on decision-making. Less is known about the ways in which processes at the professional, organisational and local system level shape evidence use and its role in decisions to adopt innovations.

Methods

A systematic scoping review was used to review the health literature on innovations within acute and primary care and map processes at the professional, organisational and local system levels which influence how evidence informs decision-making on innovation. Stakeholder feedback on the themes identified was collected via focus groups to test and develop the findings.

Results

Following database and manual searches, 31 studies reporting primary qualitative data met the inclusion criteria: 24 were of sufficient methodological quality to be included in the thematic analysis. Evidence use in decision-making on innovation is influenced by multi-level processes (professional, organisational, local system) and interactions across these levels. Preferences for evidence vary by professional group and health service setting. Organisations can shape professional behaviour by requiring particular forms of evidence to inform decision-making. Pan-regional organisations shape innovation decision-making at lower levels. Political processes at all levels shape the selection and use of evidence in decision-making.

Conclusions

The synthesis of results from primary qualitative studies found that evidence use in decision-making on innovation is influenced by processes at multiple levels. Interactions between different levels shape evidence use in decision-making (e.g. professional groups and organisations can use local systems to validate evidence and legitimise innovations, while local systems can tailor or frame evidence to influence activity at lower levels). Organisational leaders need to consider whether the environment in which decisions are made values diverse evidence and stakeholder perspectives. Further qualitative research on decision-making practices that highlights how and why different types of evidence come to count during decisions, and tracks the political aspects of decisions about innovation, is needed.