Doctor-Patient Relationship Between Individuals With Fibromyalgia and Rheumatologists in Public and Private Health Care in Mexico

Stigmatisation in medical encounters for persistent physical symptoms/functional disorders: Scoping review and thematic synthesis

OBJECTIVE

To conduct a scoping review of stigma in medical encounters for persistent physical symptoms and functional disorders (PPS/FD). Stigma is a social attribute that links a person to an undesirable characteristic. It has been extensively studied in relation to mental illness but less so in relation to PPS/FD.

METHODS

We followed PRISMA-ScR reporting guidelines for scoping reviews. Searches for were designed using the SPIDER tool. We used descriptive and thematic analysis.

RESULTS

The searches identified 68 articles, of which 32 were eligible for inclusion. 31 out of the 32 studies used a qualitative methodology. 8 studies used an explicit definition of stigma, of which 6 used the Goffman (1963) definition. Only 2 studies directly examined clinical consultations, the remainder relied on recalled accounts by patients or professionals. Descriptive analysis identified the focus of the studies included: patient-physician interaction (n = 13); health care professionals' perceptions (n = 7); experiences of illness/stigma (n = 6); broader meaning of illness (n = 3); and patients' experiences of stigma in health care consultations (n = 3).

CONCLUSION

Patients experience stigmatisation in consultations for a wide range of PPS/FD. This suggests the presence of structural stigmatisation.

PRACTICE IMPLICATIONS

There is a need for effective stigma reduction strategies in consultations about persistent physical symptoms.

Patient-journey of fibromyalgia patients: A scoping review

BACKGROUND

Fibromyalgia (FM) is a chronic disease characterized by widespread pain. Although much is known about this disease, research has focused on diagnosis and treatment, leaving aside factors related to patient's experience and the relationship with healthcare system.

OBJECTIVES

The aim was to analyze the available evidence on the experience of FM patients from the first symptoms to diagnosis, treatment, and follow-up.

METHODS

A scoping review was carried out. Medline and the Cochrane Library were searched for original studies or reviews dealing with FM and focusing on "patient journey". Results were organized using a deductive classification of themes.

RESULTS

Fifty-four articles were included in the qualitative synthesis. Five themes were identified: the patient journey, the challenge for the health systems, a complex doctor-patient relationship, the importance of the diagnosis, and the difficulty of standardizing the treatment.

CONCLUSIONS

This scoping review confirms the negative impact of FM on the patient, their social environment, and health systems. It is necessary to minimize the difficulties encountered throughout the diagnosis and follow-up of patients with FM.

“You have to believe the patient”: What do people with fibromyalgia find helpful (and hindering) when accessing healthcare?

Background

Fibromyalgia (FM) is a complex, still poorly understood, and difficult-to-treat chronic pain condition for which many people struggle to find adequate care.

Aims

This study investigated the research question, "What do people accessing health care services for fibromyalgia perceive as helpful, hindering, and absent but desired?" with the aim of identifying clear, implementable changes for clinical practice.

Materials and methods

This study used the enhanced critical incident technique (ECIT), a qualitative research method that focuses on helping, hindering, and desired factors, to explore the health care experiences of 14 individuals (12 women and 2 men) diagnosed with FM.

Results

Using qualitative data analysis, results identified three categories of health care experiences: (1) systemic navigation, including financial and economic security; accessibility, flexibility, and continuity of care; and diversity of treatment options; (2) clinician-patient alliance, including invalidation and prejudice; therapeutic bond; and clinician-patient alignment on treatment plan; and (3) patient self-management strategies, including information-seeking and education, self-advocacy, social supports, symptom management strategies, and other coping strategies. Participants tended to conceptualize their health care concerns as a multilayered systemic problem.

Conclusions

Participants described a medical system they perceived as poorly equipped to support their needs and tended to invalidate their health concerns. Helping experiences tended to be the result of unique efforts on the part of individual clinicians. Findings emphasize the importance of recognizing the complexities and psychological impact of pain, trusting clinician-patient relationships, multidisciplinary/interdisciplinary care within a biopsychosocial framework, and improved education and awareness around psychosocial aspects of FM and effective management of chronic pain.

Cultural Differences in Patients' Preferences for Paternalism: Comparing Mexican and American Patients' Preferences for and Experiences with Physician Paternalism and Patient Autonomy

Following up on previous research demonstrating the high level of care realized by a paternalistic Mexican physician, the present research further explored the hypothesis that there are cultural differences in preferences for and experiences with physician paternalism vs. patient autonomy in White American culture as compared with Mexican culture. In this research, we interviewed sixty (60) people including twenty (20) Mexican, twenty (20) Mexican American, and twenty (20) White American respondents. We asked these patients about their experiences with and attitudes towards paternalism and patient autonomy in healthcare interactions. With some caveats, our data showed strong support for both hypotheses while also suggesting a high level of care can be realized by paternalistic physicians when "paternalism" is understood in a cultural context. We close with a brief consideration of the implications of these findings.

Factors Associated With the Quality of the Patient-Doctor Relationship: A Cross-Sectional Study of Ambulatory Mexican Patients With Rheumatic Diseases

BACKGROUND

The patient-doctor relationship (PDR) is a complex phenomenon with strong cultural determinants, which impacts health-related outcomes and, accordingly, does have ethical implications. The study objective was to describe the PDR from medical encounters between 600 Mexican outpatients with rheumatic diseases and their attending rheumatologists, and to identify factors associated with a good PDR.

METHODS

A cross-sectional study was performed. Patients completed the PDRQ-9 (Patient-Doctor Relationship Questionnaire, 9 items), the HAQ-DI (Health Assessment Questionnaire Disability Index), the Short-Form 36 items (SF-36), a pain-visual analog scale, and the Ideal Patient Autonomy Scale. Relevant sociodemographic, disease-related, and treatment-related variables were obtained. Patients assigned a PDRQ-9 score to each patient-doctor encounter. Regression analysis was used to identify factors associated with a good PDR, which was defined based on a cutoff point established using the borderline performance method.

RESULTS

Patients were primarily middle-aged female subjects (86%), with substantial disease duration (median, 11.1 years), without disability (HAQ-DI within reference range, 55.3%), and with deteriorated quality of life (SF-36 out of reference range, 73.7%-78.6%). Among them, 36.5% had systemic lupus erythematosus and 31.8% had rheumatoid arthritis. There were 422 patients (70.3%) with a good PDR and 523 medical encounters (87.2%) involved certified rheumatologists.Patient paternalistic ideal of autonomy (odds ratio [OR], 3.029; 95% confidence interval [CI], 1.793-5.113), SF-36 score (OR, 1.014; 95% CI, 1.003-1.025), female sex (OR, 0.460; 95% CI, 0.233-0.010), and being certified rheumatologist (OR, 1.526; 95% CI, 1.059-2.200) were associated with a good PDR.

CONCLUSIONS

Patient-related factors and the degree of experience of the attending physician impact the quality of the PDR, in Mexican outpatients with rheumatic diseases.

Interpersonal challenges in surgical care provision in rural Mexico: A qualitative study

Background

Chiapas is among the states with the lowest access to health care in Mexico. A better understanding of the role of interpersonal relationships in referral systems could improve access to care in the region. The purpose of this study was to analyze the underlying barriers and facilitators to accessing surgical care at public hospitals run by the Ministry of Health in Chiapas.

Methods

In this qualitative interview study, we performed semi-structured interviews with 19 surgical patients and 18 healthcare workers at three public hospitals in the Fraylesca Region of Chiapas to explore barriers and facilitators to successfully accessing surgical treatment. Transcripts were coded and analyzed using an inductive, thematic approach to data analysis.

Findings

The five major themes identified as barriers to surgical care were dehumanization of patients, the toll of rehumanizing patients, animosity in the system, the refraction of violence onto patients, and poor resource coordination. Three themes identified as facilitators to receiving care were teamwork, social capital, and accompaniment.

Interpretation

Health care workers described a culture of demoralization and mistrust within the health system worsened by a scarcity of resources. As a result, patient care is hampered by conflict, miscommunication, and feelings of dehumanization. Efforts to improve access to surgical care in the region should consider strategies to improve teamwork and expand patient accompaniment.

Funding

Harvard University and the Abundance Fund provided funding for this project. Funding sources had no role in the writing of the manuscript or decision to submit it for publication.Resumen.

Antecedentes

Chiapas es uno de los estados en Mexico con el menor acceso a la atención médica, y a los servicios quirúrgicos. Una mejor comprensión del papel de las relaciones interpersonales en los sistemas de referencias podría mejorar el acceso a la atención medica en la región. El objetivo del estudio es analizar las barreras y facilitadores para acceder a la atención quirúrgica en los hospitales públicos pertenecientes a la Secretaria de Salud del estado de Chiapas.

Método

En este estudio cualitativo, realizamos entrevistas semiestructuradas con 19 pacientes quirúrgicos y 18 trabajadores de la salud en tres hospitales públicos en la región de la Frailesca de Chiapas para explorar barreras y facilitadores para acceder al tratamiento quirúrgico. Las transcripciones se codificaron y analizaron utilizando un enfoque temático.

Resultados

Las cinco barreras principales identificadas fueron la deshumanización de los pacientes, el costo a re humanizar pacientes, la animosidad en el sistema, la refracción de la violencia sobre los pacientes y la mala coordinación de recursos. Tres facilitadores para recibir cirugía fueron el trabajo en equipo, el capital social, y el acompañamiento.

Interpretaciones

Los trabajadores de la salud describieron una cultura de desmoralización y desconfianza en el sistema de salud que se agrava con la escasez de recursos. Como resultado se obtiene, conflicto, falta de comunicación, y sentimientos de deshumanización que empeoran la atención al paciente. Recomendaciones para mejorar el acceso a los servicios quirúrgicos en la región incluyen estrategias para mejorar el trabajo en equipo y ampliar el acompañamiento de los pacientes.

Financiamiento

La Universidad de Harvard y the Abundance Fund proporcionaron fondos para este proyecto. Las fuentes de financiamiento no influyen en la redacción ni en la publicación del manuscrito.

Concordance between clinician- and 2016 criteria-based diagnoses of fibromyalgia

OBJECTIVES

The Fibromyalgia Survey Diagnostic Criteria-2016 (FSD-2016 criteria) were recently recommended for both clinical and research purposes. The present study aims to examine whether there is concordance between clinician-based and FSD-2016 criteria-based diagnoses of FM, and secondly, to examine how the illness severity and physical function relate to the criteria-based diagnosis among patients referred to a rheumatism hospital.

METHODS

Participants with a clinician-based diagnosis of FM were included consecutively when referred to a patient education programme for patients with FM. Illness severity was assessed with the Fibromyalgia Survey Questionnaire (FSQ). Based on the FSQ, the fulfilment of the FSD-2016 criteria was evaluated. Physical function was assessed using the Fibromyalgia Impact Questionnaire (FIQ) function scale and self-reported employment status.

RESULTS

The sample included 130 patients (84% women) from 20 to 66 years of age. Eighty-nine per cent met the FSD-2016 criteria, and 44% of the patients were fully or partially employed. Great variability in illness severity was seen irrespective of employment status. There was an association between illness severity and physical function (r=0.4, p<0.001). For 95% of the patients, the FSQ illness severity scores classify as severe or very severe, and even for those not fulfilling the diagnostic criteria the scores were moderate and severe.

CONCLUSIONS

There was relatively high agreement between clinician- and criteria-based diagnoses. The illness severity overlapped irrespective of different employment status and fulfilment of FSD-2016 criteria.

Relational dynamics involved in therapeutic discordance among prescribers and patients: A Grounded Theory study

OBJECTIVE

No studies have explored the negative process of concordance: discordance in prescribing-medication-taking. This study provides a deeper understanding of discordance as a co-constructed process among patients and prescribers.

METHODS

To explore the question "what psychological and relational processes are involved when therapeutic discordance among prescribers and receivers occurs?" a constructivist Grounded Theory study was carried out through semi-structured interviews with patients and their medical doctors.

RESULTS

The final sample of our study was composed of 29 participants: 16 receivers and 13 prescribers. "Neglecting the relationship", the core category, shapes the therapeutic discordance and connects three main conceptual phases: signing a non-negotiating contract, acting alone, and establishing a superficial relationship.

CONCLUSION

Our grounded theory conceptualization contributes to the concordance-related debate by evidencing the processes among prescribers and receivers in interwoven actions. It offers another dimension to how notions of compliance, adherence and concordance have been theorized to date.

PRACTICE IMPLICATIONS

More than one interaction with receivers is recommended. If there are hints that conflict potentially is compromising the relationship, prescribers should involve intermediaries. Setting aside for a moment, evidence-based justification for treatments and trying to understand prescribers' motivations may boost a positive change.

Shared decision making in musculoskeletal pain consultations in low- and middle-income countries: a systematic review

BACKGROUND

Global populations, especially those in low- and middle-income countries (LMICs), are at an increased risk of musculoskeletal (MSK) pain, a leading cause of years lived with disability. Shared decision making (SDM) in the management of these conditions may drive improvements in healthcare outcomes and quality. This study aimed to synthesize and appraise available evidence regarding SDM in MSK pain consultations in LMICs.

METHODS

Comprehensive literature searches were conducted in 12 databases for primary studies investigating SDM in MSK pain consultations across all healthcare and community settings in LMICs. Study eligibility screening, data extraction and quality appraisal (using the Critical Appraisals Skills Programme tool) were completed by pairs of reviewers. Findings were brought together using thematic synthesis of data from all the primary studies.

RESULTS

Seven studies (mostly moderate quality) were included. There was low awareness of SDM among healthcare professionals (HCPs); however, this is not explicitly practised due to cultural and operational barriers. HCP training and patient empowerment through health literacy were proposed facilitators. The traditional paternalistic approach to treatment poses a key barrier to SDM, decreases adherence to prescribed treatments and raises the risk of poor clinical outcomes.

CONCLUSIONS

SDM is still a relatively 'foreign concept' within consultations and management of MSK pain patients in LMICs. There is a dearth of research in SDM and patient-centred care. Given the socio-economic impact of MSK pain, further research into the value of SDM in LMIC healthcare settings requires further consideration.

Views of Mexican outpatients with rheumatoid arthritis on sexual and reproductive health: A cross-sectional study

BACKGROUND

Rheumatoid arthritis (RA) impacts sexual and reproductive health (SRH), which is a prominent component of a patient´s quality of life and highly influenced by the cultural background. The aim of the study was to explore the interest of Mexican outpatients with RA in SRH and to examine patient view on SRH.

METHODS

This cross-sectional study surveyed 303 consecutive outpatients with RA on their perceptions of SRH importance, SRH satisfaction, access to SRH information, preferences regarding SRH communication with healthcare professionals, and understanding of SRH (qualitative open-ended descriptions). Descriptive statistics and inferential analysis were used. Patient knowledge of each dimension of SRH was rated based on pre-specified criteria. Two assessors assigned ten major themes to each patient´s description of both dimensions of SRH.

RESULTS

Patients perceived their SRH as an important component of their general health and wished to address the topic, although few had access to such communication. Female patients assigned lesser importance to SRH, showed lesser degree of satisfaction with SRH, and expressed preference for a truthful physician. Age showed a linear association with individual survey responses, except for satisfaction with reproductive health dimension. There was a linear association between increased age and decreased years of formal education with a lower level of SRH knowledge. Ten major themes emerged for each of the two dimensions of the SRH construct, although most individual descriptions were assigned to one or two major themes.

CONCLUSIONS

Further education and assessment of SRH in Mexican patients with RA is warranted.

Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services

The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients' experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers' subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers' perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.

Concordance among patients and physicians about their ideal of autonomy impacts the patient-doctor relationship: A cross-sectional study of Mexican patients with rheumatic diseases

INTRODUCTION

In patient-doctor interaction both parties play a role. Primary objective was to determine if the concordance among rheumatologists and their patients of their ideal of autonomy was associated with a better patient-doctor relationship. Secondary objective was to describe factors associated to a patient paternalistic ideal of autonomy (PPIA).

MATERIALS AND METHODS

This cross-sectional study had 3 steps. Step-1 consisted in translation/cultural local adaption of Ideal Patient Autonomy Scale (IPAS), a 14-items Dutch questionnaire. Step-2 consisted of IPAS validity and reliability in 201 outpatients. Step-3 consisted of the application of IPAS and the patient-doctor relationship questionnaire (PDRQ) to 601 outpatients with a medical encounter, and of IPAS to the 21 attending rheumatologists. Each patient-physician encounter was classified into with/without concordance in the ideal of autonomy and PRDQ scores were compared (Man Whitney U test). Regression analysis was used for associations.

RESULTS

Step-1 followed ISPOR task force recommendations. Patients from Step-2 and Step-3 were representative outpatients with rheumatic diseases. IPAS structure underwent a modification; the 14 items were redistributed into four subscales, further combined into PPIA vs. patient-centered autonomy ideal. IPAS was valid and reliable. There were 497 patients with a preferred ideal of autonomy, primarily (84.9%) PPIA. There were 363 patient-doctor encounters with concordance in the autonomy ideal and their PDRQ-9 scores were higher. Religious beliefs and higher PDRQ-9 item 8 score ("I feel pleased with my doctor´s treatment") were associated to a PPIA.

CONCLUSIONS

Concordance of autonomy ideal among patients and their rheumatologists positively impacts on the patient-doctor relationship.

Educational needs of patients with rheumatic and musculoskeletal diseases attending a large health facility in Austria

INTRODUCTION

Patient education is an important part of the management of rheumatic and musculoskeletal diseases. Given that patients with diverse diseases do not have the same needs, it is crucial to assess the educational requirements of targeted groups to provide tailored educational interventions. The aim of our study was to assess educational needs of a large cohort of patients with different rheumatic and musculoskeletal diseases attending a health facility in Austria.

METHODS

We assessed educational needs, via an online survey of patients with fibromyalgia (FMS), rheumatoid arthritis (RA), and ankylosing spondylitis (AS) recruited from an Austrian health-care facility, using the Austrian version of the Educational Needs Assessment Tool (OENAT).

RESULTS

For our sample of 603 patients, AS (62%), RA (15%), and FMS (24%), there were no educational need differences for the domains of movements, disease process, and self-help measures. Patients with FMS had less need for pain management education and greater need for education about feelings, than other disease groups. Patients with RA had a greater need for education related to treatments than other groups, and patients with AS had a greater need for treatment education than patients with FMS. Patients with AS reported greater need for support system education than other patient groups.

CONCLUSION

Educational needs vary by disease groups, suggesting that health-care professionals should assess disease-specific needs for education to provide optimal assistance in disease management for patients.

"No one wants to look after the fibro patient". Understanding models, and patient perspectives, of care for fibromyalgia: reviews of current evidence

Fibromyalgia is a common and complex long-term pain condition. Despite advancements in our understanding and treatment of fibromyalgia, patients report patchy health care provision and frustrating journeys through the health care system. To inform how best to deliver care, we undertook 2 narrative reviews examining existing evidence on (1) models of care for fibromyalgia and (2) patients' experiences, preferences, and unmet needs regarding their health care. Seven databases were systematically searched. Quantitative data was narratively synthesised and qualitative data thematically analysed. No evidence-based model of care covering the patient journey through the entire health care system was identified. Limited evidence suggests no clear benefit for ongoing care in secondary care settings. Patients with fibromyalgia report difficult interactions with the health care system that might equally be expressed by those with other long-term conditions, such as inconsistent and poorly coordinated care. However, they also face unique problems; fibromyalgia was often not viewed as a real condition, resulting in difficult encounters with health care staff, in particular not feeling believed or listened to. Significant delays in diagnosis were commonplace. Positive care experiences such as being listened to and shared decision-making made patients feeling better informed, well supported, and more satisfied. There is little evidence to inform how best to organise health care for patients with fibromyalgia and ensure care is delivered in a coordinated and consistent way. These findings provide a strong rationale for developing a new model of care for fibromyalgia.

Participatory decision-making for cancer care in a high-risk sample of low income Mexican-American breast cancer survivors: The role of acculturation

Background

Despite declining cancer incidence and mortality rates, Latina patients continue to have lower 5-year survival rates compared to their non-Hispanic white counterparts. Much of this difference has been attributed to lack of healthcare access and poorer quality of care. Research, however, has not considered the unique healthcare experiences of Latina patients.

Methods

Latina women with prior diagnoses of stage 0-III breast cancer were asked to complete a cross-sectional survey assessing several socio-demographic factors along with their experiences as cancer patients. Using a series of linear regression models in a sample of 68 Mexican-American breast cancer survivors, we examined the extent to which patients' ratings of provider interpersonal quality of care were associated with patients' overall healthcare quality, and how these associations varied by acculturation status.

Results

Findings for Latina women indicated that both participatory decision-making (PDM) (β = 0.62, p < .0001) and trust (β = 0.53, p = .02) were significantly associated with patients' ratings of healthcare quality. The interaction between acculturation and PDM further suggested that participating in the decision-making process mattered more for less acculturated than for more acculturated patients (β = -0.51, p ≤ .01).

Conclusions

The variation across low and high acculturated Latinas in their decision-making process introduces a unique challenge to health care providers. Further understanding the relationship between provider-patient experiences and ratings of overall healthcare quality is critical for ultimately improving health outcomes.

"I can't have it; I am a man. A young man!" - men, fibromyalgia and masculinity in a Nordic context

Purpose: Research shows that gender has a substantial impact on the health behaviour such as expression of physical symptoms like persistent pains and aches. However, there is yet little knowledge about the gendered aspect of pain by men who suffer from typical female diseases like fibromyalgia. The purpose of the study was to elucidate the interplay between illness and gender by exploring life-stories of men who suffer from fibromyalgia. Methods: The data were collected through life-story interviews of eight men suffering from fibromyalgia. A narrative methodology for analysis was applied to explore the storytelling and the linguistic and performative aspects of the life-stories. Results: The masculine identity of the participants was re-negotiated by comparisons to other men and life before symptom onset, and by discussing expectations and beliefs of how men should act in contemporary societies. The transition from experiencing a strong, active and reliable body to experiencing a painful, vulnerable and helpless body was perceived as fundamental. Conclusions: Self-management and rehabilitation of fibromyalgia it is not only about learning to manage the symptoms but also about the struggle to find coherence in life through re-constructing gender identity that is acceptable both for the individual and for the community.

Nothing and Everything: Fibromyalgia as a Diagnosis of Exclusion and Inclusion

The diagnostic process promises a label that validates patients' embodied experiences and a road map for living with and treating illness. Drawing on 31 qualitative interviews with women and men in Canada and the United Kingdom who have been diagnosed with fibromyalgia (FM), in this article, I examine the participants' experiences of the diagnostic process and how they feel about receiving this label. The interviews reflect that the FM label is plagued by uncertainty because the diagnosis is based on the absence of verifiable pathology. The respondents' narratives also reveal that FM is a vague diagnosis that includes a multitude of symptoms, overlaps with several other diagnoses, and results in feelings of doubt regarding whether it is the correct label. Thus, the participants' narratives reflect that the FM diagnosis is largely an empty promise because it fails to provide definitive answers or confer meaning and legitimacy to their illness experiences.

Health beliefs, attitudes, and health-related quality of life in persons with fibromyalgia: mediating role of treatment adherence

Fibromyalgia is a chronic illness characterized by pain and fatigue. Persons with fibromyalgia experience increased the risk for poor mental and physical health-related quality of life, which may be dependent on multiple factors, including health beliefs, such as confidence in physicians and the health-care system, and health behaviors, such as treatment adherence. Respondents with fibromyalgia (n = 409) were recruited nationally, via support organizations, and completed self-report measures: Multidimensional Health Profile - Health Functioning Index (MHP-H), Short-Form-36 Health Survey (SF-36v2), and Medical Outcomes Study (MOS) Measure of Patient Adherence - General Adherence Items. In mediation models, belief in the healthcare system and health-care personnel, and health efficacy exerted an indirect effect through treatment adherence on mental and physical quality of life. Adaptive health beliefs and attitudes were related to greater treatment adherence and, in turn, to a better quality of life. Maladaptive health beliefs and mistrusting attitudes about physician-level and systemic-level healthcare provision are negatively related to both treatment adherence and consequent physical and mental health-related quality of life in persons with fibromyalgia. Future randomized controlled trials are needed to determine if therapeutic strategies to alter health values might improve adherence and self-rated health.

Diagnostic experience of patients with fibromyalgia - A meta-ethnography

Objective To examine how individuals experience the process and consequences of receiving a diagnosis of fibromyalgia syndrome. Methods A systematic literature search of qualitative studies up to May 2016 was performed. Twenty-eight reports including information on patients' diagnostic experiences were subjected to an interpretive analysis in accordance with the principles of meta-ethnography. Results Years were normally spent consulting specialists in an attempt to confirm the reality of symptoms and make sense of the illness. Great relief was felt at finally achieving the fibromyalgia syndrome diagnosis. However, relief waned when therapies proved ineffective. Health professionals and others questioned whether individuals were genuinely ill, that the illness had a psychological nature, and whether they were doing their best to recover. The diagnosis did not provide a meaningful explanation of individuals' suffering and had limited power to legitimate illness. Patients felt blamed for their failure to recover, threatening their personal credibility and moral identity. Conclusion The fibromyalgia syndrome diagnosis has limitations in validating and making sense of patients' illness experiences and in providing social legitimation of their illness. Social relationships are strained during the diagnostic process and in the course of ineffective therapies.

Perceptions and Uses of Public and Private Health Care in a Brazilian Favela

Since 1988, Brazil has reorganized and expanded its public health care system, defining access to health care as a right of every citizen. In parallel, the private health care sector grew rapidly to become one of the largest in the world. We explore the use of public and private health care by a low-income population living in a favela, Rio das Pedras, in Rio de Janeiro. At the time of data collection, only part of the community was covered by the primary health care program. We conducted semistructured interviews with 14 adults, both with and without access to the public primary care program. Regardless of program coverage, participants noted barriers and negative experiences while accessing public health care. The perceived inability of health professionals to deal compassionately with a low-income population was prominent in their narratives, and in the expressed motivation for pursuing private sector health care alternatives. We explore the tension arising from the more recent rights-based health care provision and historic social control and assistentialist framing of state intervention in Brazilian favelas.

Chronicity and use of health services: peer education of the School of Patients

OBJECTIVE

To evaluate the impact of the training strategy of the Escuela de Pacientes (School of Patients) on the use of health services among people with chronic diseases.

METHOD

Quantitative design study of pretest and posttest evaluation with a population of 3,350 chronic patients of the Escuela de Pacientes (Andalusia, 2013-2015). A questionnaire adapted from the Stanford University was used. It measured the self-perceived health, number of health visits, and level of trust and communication with health personnel. A descriptive and bivariate study, a correlation study and a pretest/posttest net gain analysis were performed.

RESULTS

Participation of 964 patients (28.8% of the population), of which 18.8% were men, mean age 56 years. Training increased trust in Primary Care (PC) and Hospital Care (HC) professionals (0.44 and 0.65 points), medical visits decreased by 25%, and hospital admissions fell by 51% with statistically significant differences by sex and disease. The correlation index between trust in professionals and use of health services was -0.215.

CONCLUSION

The training strategy had a positive impact on the use of health services and trust in health professionals, and were identified areas of improvement from which recommendations are established.