Looking beyond the next patient: sociology and modern health care

Primary care doctors' understandings of and strategies to tackle health inequalities: a qualitative study

Aim

To examine general practitioners’ knowledge of and their role in tackling health inequalities, in relation to their professional responsibilities.

Background

Primary care is often seen as being in the frontline of addressing health inequalities and the social determinants of health (SDH).

Methods

A qualitative study with a maximum variety sample of English General Practitioners (GPs). In-depth, semi-structured interviews were held with 13 GPs in various geographical settings; they lasted between 30 and 70 min. Interviews were audio-recorded and transcribed. The analysis involved a constant comparison process undertaken by both authors to reveal key themes.

Findings

GPs’ understanding of health inequalities reflected numerous perspectives on the SDH and they employ various different strategies in tackling them. This study revealed that GPs’ strategies were changing the nature of (medical) professionalism in primary care. We locate these findings in relation to Gruen’s model of professional responsibility (comprising a distinction between obligation and aspiration, and between patient advocacy, community participation and political involvement). We conclude that these GPs do not exploit the full potential of their contribution to tackling health inequalities. These findings have implication for policy and practice in other practitioners and in other health systems, as they seek to tackle health inequalities.

Training lay-people to use automatic external defibrillators: are all of their needs being met?

AIMS

We explored the experiences of lay people who have been trained to use automatic external defibrillators. The research questions were: (1) How can training courses help prepare people for dealing with real life situations? (2) Who is ultimately responsible for providing critical incident debriefing and how should this be organised? (3) What is the best process for providing feedback to those who have used an AED?

METHODOLOGY

Fifty-three semi-structured, qualitative interviews were conducted, some with those who had been trained and others with trainers. Locations included airports, railway stations, private companies and first responder schemes. Geographically, we covered Nottinghamshire, Lincolnshire, Yorkshire, Staffordshire, Essex and the West Midlands in the UK.

RESULTS

Our analysis of the data indicates that most people believe scenarios based within their place of work were most useful in preparing for 'real life'. Many people had not received critical incident debriefing after using an AED. There were a variety of systems in place to provide support after an incident, many of which were informal.

CONCLUSION

Training scenarios should be conducted outside the classroom. There should be more focus on critical incident debriefing during training and a clear identification of who should provide support after an incident. Other issues which were of interest included: (1) people's views on do not attempt resuscitation (DNAR); (2) perceived boundaries of responsibility when using an AED; (3) when is someone no longer 'qualified' to use an AED?

Consumers' perceptions of community pharmacy in Portugal: a qualitative exploratory study

OBJECTIVE

Pharmacists are health professionals who are ideally positioned to perform a primary health care role. However, the definition of professional value needs to be considered not just as professional education and skills, but also in terms of how consumers perceive it. The main aim of this work was to explore the public's perceptions and attitudes towards community pharmacy in Portugal.

METHODS

A pure qualitative approach was undertaken. The data were collected through a semi-structured interview, conducted with a 'snowball' like sample. First, individuals (n = 15) were interviewed, allowing for adjustment and validation of the interview schedule, followed latter by group interviews with adults in rural and urban areas. Group participants (n = 25) were asked about their behaviour and beliefs, resulting from their perceptions of community pharmacies, pharmacists and medicines. Future expectations regarding the community pharmacy service were also explored. The interviews were tape recorded and transcribed verbatim. An iterative, reflexive coding process was applied, assisted by the qualitative software package QSR NUD*IST v4. The inductive analysis of the extracted codes assembled those codes into themes.

RESULTS AND DISCUSSION

This article will mainly focus on community pharmacy service representations and cognitions (theme A) and community pharmacy evaluative perceptions and behaviours (theme B). Participants displayed general and contradictory ideas about the actual functions of the pharmacist, including weak conceptualizations and a positive demand for services in relation to product supply. This superficial understanding is in line with previous results from satisfaction studies, confirming a low expectation level. The public's poor knowledge and low expectations can justify a reduced desire for an extended role of the pharmacist in the community. This uncertain service conceptualization does not define the professional responsibility from a consumer's perspective.

CONCLUSIONS

Although these results allow for the development of a framework to describe the perceptions of community pharmacy users, further research is needed to determine the prevalence of these and other possible results.

The impact of chronic illness: partnerships with other healthcare professionals

Healthcare workforce shortfalls require a rethinking of models for delivering care to people with chronic disease. Chronic disease needs to be managed by a multiskilled team of healthcare professionals with specialist input. Education at undergraduate, graduate and postgraduate levels needs to prepare healthcare professionals for this new paradigm. Some tasks currently seen only as part of a doctor's purview could be performed by other trained professionals to allow doctors to concentrate on more appropriate activities. We need to explore new collaborations to deliver multidisciplinary healthcare for chronic disease and evaluate these for patient outcomes and cost effectiveness.

Mentoring nursing career pathways: the Maryvale High School Student Nurse Academy

The health care system faces a critical challenge in recruiting younger and more ethnically diverse students into the nursing profession. The innovative Maryvale High School Student Nurse Academy was developed as a collaborative partnership among the public school system, the community college system, public and private universities, and the hospital industry, with guidance from Arizona Nursing Associations and Sigma Theta Tau. The program provides at-risk, minority teens exposure to the health system, professional nurses in a variety of roles, and employment opportunities that can expand in a number of directions within the health industry. Results of the first year pilot are encouraging, resulting in a 100% completion of the program with high student satisfaction ratings. Students demonstrated an increase in overall grade point average and a decrease in school absence rates.

Sexually transmitted infections and associated socio-demographic and behavioural factors in women seeking primary care suggest Madagascar's vulnerability to rapid HIV spread

OBJECTIVES

To examine sexually transmitted infections (STIs) and associated socio-demographic and behavioural factors in women seeking care for genital discharge syndrome in Antananarivo, Madagascar.

METHODS

One thousand and sixty-six consecutive symptomatic women were interviewed and examined; bacterial vaginosis (BV), vulvovaginal candidiasis, trichomoniasis (TV), cervical infection (CI) due to chlamydial or gonococcal infections, and syphilis seroreactivity were determined by laboratory diagnosis. Associations between STIs and individual characteristics were evaluated using bivariate and logistic regression analyses.

RESULTS

The prevalence of BV, TV, CI, and syphilis seroreactivity was, respectively, 85%, 16%, 49%, 16% in 94 prostitutes; 70%, 18%, 30%, 13% in 96 occasional sex traders; and 53%, 24%, 17%, and 4% in 876 general women. CI was independently and positively associated with a symptomatic partner, new sex partner in last 3 months, unfaithful partner, prostitution, joblessness and being < 25 years old. Syphilis was associated with low schooling, young age at coital debut, sex trading, and > 1 sex partner in the previous 3 months.

CONCLUSIONS

These high STI rates and associated characteristics suggest the local vulnerability to rapid HIV spread and show the need for prevention efforts that involve youth, prostitutes, occasional sex traders, sex clients, and men who have concurrent sexual partnerships.

Health, medicine, and ophthalmology: facing the facts and paying the piper LVI Edward Jackson Memorial Lecture

PURPOSE

To describe the sources of tension within the health care system and methods for pursuing their solution.

METHODS

Presentation of observations pertinent to patient, provider, and payer perspectives relevant to the cost, delivery, and quality of care and their impact on health.

RESULTS

Societal forces, not just wealth, are major determinants of both health and the costs of health care.

CONCLUSIONS

Tensions created by rising health care costs in the face of finite societal resources will increase in the years ahead. These can be resolved only by realizing new efficiencies in care, and prioritizing, through an explicit process, the care that is to be provided.

Tensions between policy makers and general practitioners in implementing new genetics: grounded theory interview study

OBJECTIVE

To explore general practitioners' perceptions of their role in implementing genetic technology.

DESIGN

Grounded theory interview study.

SETTING

Primary care.

SUBJECTS

Purposive sample of 30 general practitioners with a further theoretical sample of 14.

RESULTS

Inconsistencies were identified between policy makers' and general practitioners' definitions of general practitioners' role in implementing the new genetics. General practitioners emphasised the need to build on current practice, whereas policy makers focused on transforming practice to include the new specialised roles and skills. Two core themes were identified: genetics in a generalist context, which included appropriate generalist intervention, the ethical dilemmas implicit in the "therapeutic gap," the familial-hereditary distinction in primary care, and the implications for generalist identity, including the potential marginalisation of generalism.

CONCLUSION

New technologies such as genetics that require implementation in general practice should be integrated within existing generalist frameworks.