Principles and practice of women's health care

Emancipatory actions displayed by multi-ethnic women: "Regaining control of my health care"

PURPOSE

Despite the recognized importance of patient involvement in primary care interactions, little information describing women's needs and expectations for these interactions is available. This participatory action study was based in Critical Action Theory and designed to describe any emancipatory interests that surfaced when eight ethnically diverse women examined their interactions with primary care nurse practitioners (PCNPs) over the course of five successive focus group meetings.

DATA SOURCES

Focus group meeting transcripts, field notes, interaction notations, seating maps, and first impression summaries.

CONCLUSIONS

Participants wanted to learn how to "stand up" for themselves in primary care interactions. They believed this could be accomplished by developing a positive sense of self-esteem. Ultimately, they identified the right way to "talk back" to clinicians and created a method for regaining control of their own health care and maintaining equality in interactions with primary care clinicians.

IMPLICATIONS FOR PRACTICE

Nurse practitioners working in the primary setting are especially well situated to support self-management and foster patient participation by women as they live with chronic disease, engage in health promotion activities, and deal with common symptomatic problems for themselves and their families.

Integrating gender into a basic medical curriculum

INTRODUCTION

In 1998, gaps were found to exist in the basic medical curriculum of the Radboud University Nijmegen Medical Centre regarding health-related gender differences in terms of biological, psychological and social factors. After screening the curriculum for language, content and context, adjustments aimed at incorporating gender issues were proposed. The aim of this study was to evaluate those adjustments, as well as to investigate whether gender had been successfully incorporated into the basic medical curriculum, and to identify the factors that played a role in this.

METHODS

The education material of 9 curricular blocks was re-evaluated and interviews were held with block co-ordinators.

RESULTS

Since the beginning of the project, gender has increasingly been brought to the attention of the students. Various factors have played a role: concrete and directly executable content-oriented proposals for adjustment; adequate translation of gender differences into actual patient care; motivated block co-ordinators; the presence of a 'trigger person' in the faculty; incorporation into the existing education programme; the involvement of block co-ordinators in decision making, and the provision of practical support.

DISCUSSION

Integrating gender into the basic medical curriculum has been largely successful. Block co-ordinators' personal recognition of the importance of gender in patient care greatly facilitated implementation. The evaluation stimulated the forming of new ideas. It is recommended that these factors and those mentioned above should be taken into consideration when integrating gender into other faculties.

Is the communicative behavior of GPs during the consultation related to the diagnosis? A cross-sectional study in six European countries

This study explores the relation between the diagnosis made by the general practitioner (GP) and his or her communicative behavior within a consultation, by means of the analysis of 2095 videotaped consultations of 168 GPs from six countries participating in the Eurocommunication study. The doctors' diagnoses were coded into ICPC chapters and merged into seven clinically relevant diagnostic clusters. The communicative behavior was gauged by means of the Roter interaction analysis system (RIAS). We found the most important differences for consultations about psychosocial problems as compared to all other diagnostic categories. In these consultations, doctors show more affective behavior, are more concerned about having a good relationship with their patients, ask more questions and give less information than in other consultations. The percentages of utterances in the other diagnostic categories were pretty similar. The communicative behavior of doctors reflects a global pattern in every consultation. This pattern is the most stable for affective behavior (social talk, agreement, rapport building and facilitation). Within instrumental behavior (the other categories), the directions and the information the doctor gives are adapted to the problems presented.

Characteristics of and problems with primary care interactions experienced by an ethnically diverse group of women

PURPOSE

To reflect women's voices as they discussed characteristics of health care interactions and spontaneously identified problems in primary care interactions.

DATA SOURCES

Five successive meetings with an ethnically diverse group of eight women were held to discuss primary care interactions with nurse practitioners. Field notes, seating charts, participant interaction notations, session transcripts, and audiotapes were repeatedly reviewed to identify significant statements. These were grouped into common categories to identify essential themes. Results were validated with participants.

CONCLUSIONS

Components of primary care interactions included the process of making an appointment, access to the clinic, comfort of the waiting area and clinic rooms, and interactions with staff and clinicians. Problems were identified with interactions. The overarching issue was a lack of caring--a pervasive attitude demonstrated when clinicians failed to show concern, did not listen, were not trustworthy, or treated the women with disrespect or prejudice.

IMPLICATIONS FOR PRACTICE

The women strongly valued caring clinicians. Caring, according to these women, is demonstrated when clinicians treat women as equals and show respect for their individual knowledge and life experiences.

Consultation in general practice: a standard operating procedure?

The objectives of this study were to describe the features of consultation within general practice with special attention to the differences between short, moderate and long consultations. An analysis of 2801 videotaped consultations of 183 General Practitioners from six countries participating in the Eurocommunication Study was made. The communicative behaviour was gauged by means of the Roter Interaction Analysis System. The consultation can be seen as a "standard operating procedure" consisting of 8% social behaviour, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counselling. A short consultation can be described as an encounter with a little bit of social behaviour to set the contact, medical questioning, giving directions for the further consultation and advises in order to solve the problem(s) mentioned. In a long consultation doctors take more time for a social talk, they give more attention to the relation or contact with the patient, they listen more extensively, especially to psychosocial problems, and they give more information.

Consultation length in general practice: cross sectional study in six European countries

OBJECTIVES

To compare determinants of consultation length discussed in the literature with those found in consultations with general practitioners from different European countries; to explore the determinants of consultation length, particularly the effect of doctors' and patients' perceptions of psychosocial aspects.

DESIGN

Analysis of videotaped consultations of general practitioners from the Eurocommunication study and of questionnaires completed by doctors and by patients.

SETTING

General practices in six European countries.

PARTICIPANTS

190 general practitioners and 3674 patients.

RESULTS

In a multilevel analysis with three levels (country, general practitioner, and patient), country and doctor variables contributed a similar amount to the total variance in consultation length (23% and 22%, respectively) and patient variables accounted for 55% of the variance. The variables used in the multilevel analysis explained 25% of the total variation. The country in which the doctor practised, combined with the doctors' variables, was as important for the variance in consultation length as the variation between patients. Consultations in which psychosocial problems were considered important by the doctor and the patient lasted longer than consultations about biomedical problems only. The doctor's perception had more influence in this situation than the patient's. Consultation length is influenced by the patients' sex (women got longer consultations), whether the practice was urban or rural, the number of new problems discussed in the consultation (the more problems the longer the consultation), and the patient's age (the older the patient the longer the consultation). As a doctor's workload increased, the length of consultations decreased. The general practitioner's sex or age and patient's level of education were not related to the length of consultation.

CONCLUSION

Consultation length is determined by variables related to the doctor and the doctor's country as well as by those related to patients. Women consulting in an urban practice with problems perceived as psychosocial have longer consultations than other patients.

Multidisciplinary women's health care and quality of care

Multidisciplinary women's health centers have appeared in academic and community settings throughout the United States as a response to the historical fragmentation of women's health care. This paper addresses the influence of this model for comprehensive primary care on quality of care for women. Attributes of care that may differ between multidisciplinary centers and traditional sites for women's health care and quality measurements sensitive to these differences are considered. The paper reviews the literature on characteristics of patients who attend women's health centers and studies evaluating quality of care in these centers as compared to traditional settings.