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.     

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.     

Need for and Access to Health Care and Medicines: Are There Gender Inequities?

Objective

Differences between women and men in political and economic empowerment, education, and health risks are well-documented. Similar gender inequities in access to care and medicines have been hypothesized but evidence is lacking.

Methods

We analyzed 2002 World Health Survey data for 257,922 adult respondents and 80,932 children less than 5 years old from 53 mostly low and middle-income countries. We constructed indicators of need for, access to, and perceptions of care, and we described the number of countries with equal and statistically different proportions of women and men for each indicator. Using multivariate logistic regression models, we estimated effects of gender on our study outcomes, overall and by household poverty.

Findings

Women reported significantly more need for care for three of six chronic conditions surveyed, and they were more likely to have at least one of the conditions (OR 1.41 [95% CI 1.38, 1.44]). Among those with reported need for care, there were no consistent differences in access to care between women and men overall (e.g., treatment for all reported chronic conditions, OR 1.00 [0.96, 1.04]) or by household poverty. Of concern, access to care for chronic conditions was distressingly low among both men and women in many countries, as was access to preventive services among boys and girls less than 5 years old.

Conclusions

These cross-country results do not suggest a systematic disadvantage of women in access to curative care and medicines for treating selected chronic conditions or acute symptoms, or to preventive services among boys and girls.     

Staff attitudes to oral health care. A comparative study of registered nurses,nursing assistants and home care aides

This study compares differences in attitude, of oral health care of nursing personnel working with dependent elderly and severely disabled patients. A questionnaire was administered to 398 personnel covering (1) personal oral health care habits. (2) experiences and attitudes in assisting oral care and (3) willingness to assist patients/residents with their daily oral hygiene. Three hundred and sixty - four persons answered the questionnaire, including 70 registered nurses, 148 nursing assistants and 146 home care aides. The study revealed that oral care assistance is viewed as more disagreeable than other nursing activities. Although registered nurses were found to have more positive attitudes toward oral care assistance than the other nursing groups, they were seldom invoked in the daily practice of oral hygiene care. The results indicate a gap between knowledge and practice in nursing personnel's attitudes toward oral health care of dependent elderly and severely disabled patients.     

White doctors and nurses on racial inequality in health care in the USA: whiteness and colour-blind racial ideology

In this paper we report on an interdisciplinary project interviewing doctors and nurses about racial inequality in health care in the USA. We analysed data from interviews with twenty-two white doctors and nurses in which they were asked to offer explanations for racial inequality in health care. Results provide insight into how whiteness operates to provide white patients more often with appropriate health care and how colour-blind ideology can be adapted to accommodate naming white advantage and potential racial discrimination. However, even when naming mechanisms of white advantage in accessing resources, the white respondents avoided acknowledging how they are implicated in racial inequality in health care. We discuss the implications for understanding whiteness and colour-blind ideology.     

Nurse practitioners in primary care iv. Impact of an interdisciplinary team on attitudes of a rural population.

Attitudes toward the expanded role of nurse practitioners in primary care (family practice nurses) have been determined for persons from a semirural area who chose as their principal souce of care an interdisciplinary family medical centre (FMC) incorporating two nurse practitioners, and those for whom the FMC was not the usual source of care. Data were obtaine using"before-and-after" structured interviews of a random sample of persons living in a southern Ontario township. Slowly evolving, nonsignificant trends of greater acceptance were observed among patiens who had dealth with family practice nurses. The greatest change observed was an increased acceptance of the nnurse by FMC users as the person who would be contacted as a second choice if theirfirst choice, usually a physician, could not be reached in specific worrry-inducing situations. FMC users depended more on nurses to provide information. A conclusion of increased general acceptance of the family practive nurse by FMC users is supported by a 34 per cent higher use of nurses by FMC patients compared to other persons of comparable characteristics living in the same community.     

Experience on healthcare utilization in seven administrative regions of Tanzania

Health care utilization in many developing countries, Tanzania included, is mainly through the use of traditional medicine (TRM) and its practitioners despite the presence of the conventional medicine. This article presents findings on the study that aimed to get an experience of health care utilization from both urban and rural areas of seven administrative regions in Tanzania. A total of 33 health facility managers were interviewed on health care provision and availability of supplies including drugs, in their respective areas. The findings revealed that the health facilities were overburden with higher population to serve than it was planned. Consequently essential drugs and other health supplies were available only in the first two weeks of the month. Conventional health practitioners considered traditional health practitioners to be more competent in mental health management, and overall, they were considered to handle more HIV/AIDS cases knowingly or unknowingly due to shear need of healthcare by this group. In general conventional health practitioners were positive towards traditional medicine utilization; and some of them admitted using traditional medicines. Traditional medicines like other medical health systems worldwide have side effects and some contentious ethical issues that need serious consideration and policy direction. Since many people will continue using traditional/alternative medicine, there is an urgent need to collaborate with traditional/alternative health practitioners through the institutionalization of basic training including hygiene in order to improved healthcare in the community and attain the Millennium Development Goals by 2015.     

Who Uses Glucosamine and Why? A Study of 266,848 Australians Aged 45 Years and Older

Objectives

There has been a dramatic increase in the use of complementary medicines over recent decades. Glucosamine is one of the most commonly used complementary medicines in Western societies. An understanding of glucosamine consumption is of significance for public health and future health promotion. This paper, drawing upon the largest dataset to date with regards to glucosamine use (n = 266,844), examines the use and users of glucosamine amongst a sample of older Australians.

Design

Analysis of the self-reported data on use of glucosamine, demographics and health status as extracted from the dataset of the 45 and Up Study, which is the largest study of healthy ageing ever undertaken in the Southern Hemisphere involving over 265,000 participants aged 45 and over.

Results

Analysis reveals that 58,630 (22.0%) participants reported using glucosamine in the 4 weeks prior to the survey. Use was higher for those who were female, non-smokers, residing in inner/outer regional areas, with higher income and private health insurance. Of all the health conditions examined only osteoarthritis was positively associated with use of glucosamine, while cancer, heart attack or angina and other heart disease were all negatively associated with glucosamine use.

Conclusions

This study suggests that a considerable proportion of the Australia population aged 45 and over consume glucosamine. There is a need for health care practitioners to enquire with their patients about their use of glucosamine and for further attention to be directed to providing good quality information for patients and providers with regards to glucosamine products.     

Where medical science and human behaviour meet.

Although we may be wrong about the details, we should try to imagine what the future holds for hospital consultants. The days of the independent consultant in the same post for 30 years are over, and there will be a change from "the" consultant to a few tiers of senior staff. Patients will increasingly demand to see specialists, so more specialists will be needed. As patients and their advocates become better informed the traditional rationing of clinical care to patients in Britain, such as restricting access to specialists, cannot continue. There is a current trend for evidence based health care, but the idea that each element of medical practice can be dictated by systematic evidence based research will prove to be naïve--such research informs practice rather than dictates it. Science will continue to act as the guide to medical practice but specialists will not be turned into a set of logical operators running programs designed by health planners.     

Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients'' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices'' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.     

Barriers to psychological care of the dying.

Direct observation of doctors and nurses talking with real, stimulated, or role played patients suffering from a terminal illness has shown that they consistently use distancing tactics. These prevent them getting close to their patients'' psychological suffering and are used to try to ensure their own emotional survival. Since these tactics discourage patients from disclosing their psychological concerns they are a serious barrier to effective psychological care. If those concerned in terminal care are to risk relinquishing these distancing tactics they will need better selection, more appropriate training, regular psychological support, and real opportunities for taking time out.     

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.     

Development of Health Equity Indicators in Primary Health Care Organizations Using a Modified Delphi

Objective

The purpose of this study was to develop a core set of indicators that could be used for measuring and monitoring the performance of primary health care organizations'' capacity and strategies for enhancing equity-oriented care.

Methods

Indicators were constructed based on a review of the literature and a thematic analysis of interview data with patients and staff (n = 114) using procedures for qualitatively derived data. We used a modified Delphi process where the indicators were circulated to staff at the Health Centers who served as participants (n = 63) over two rounds. Indicators were considered part of a priority set of health equity indicators if they received an overall importance rating of>8.0, on a scale of 1–9, where a higher score meant more importance.

Results

Seventeen indicators make up the priority set. Items were eliminated because they were rated as low importance (<8.0) in both rounds and were either redundant or more than one participant commented that taking action on the indicator was highly unlikely. In order to achieve health care equity, performance at the organizational level is as important as assessing the performance of staff. Two of the highest rated “treatment” or processes of care indicators reflects the need for culturally safe and trauma and violence-informed care. There are four indicators that can be used to measure outcomes which can be directly attributable to equity responsive primary health care.

Discussion

These indicators and subsequent development of items can be used to measure equity in the domains of treatment and outcomes. These areas represent targets for higher performance in relation to equity for organizations (e.g., funding allocations to ongoing training in equity-oriented care provision) and providers (e.g., reflexive practice, skill in working with the health effects of trauma).     

Night workload in one health district.

The night work (11 pm-7 am) in primary care in one health district (population 195 212 with 93 general practitioners) was studied over a three month period, starting 1 January 1983. The workload proved to be small (15% of all "out of hours" work for general practitioners). An average of three night visits was done a night in the whole health district, and 26 general practitioners were available for these. On average, over seven doctors were available each night for each patient who required a visit in primary care in the health district. It is concluded that there is only sufficient work for (at maximum) two doctors, and a system is proposed to make more efficient use of the general practitioner''s time.