Finnish Health Centres Research Articles

Does the doctors' professional experience reduce referral rates? Evidence from the Finnish referral study.

To examine hospital referral rates in Finnish health centres according to doctors' and health centres characteristics. Survey of all general practice hospital referrals over one week. Central and northern part of Finland, in a region comprising 72% of the area of the country and one-third of the population. 851 health centre doctors. Referral rates in terms of characteristics of doctors and health centres. During the study period, the 851 health centre doctors had 58 760 consultations (mean 69 patients/week), and 2 921 (5%) patients were referred to secondary care. The variation between the highest and lowest referral quintile of the doctors was almost 17-fold, and of the health centres 2.4-fold. Relatively more referrals were made by locums, young, not yet graduated and female doctors than by specialized, more experienced and male doctors. A low referral rate is closely connetected with the extent of the general practitioners' professional experience and specialist training. Investing in specialist training and continuing medical education seems to be the best way to reduce high referral rates.

Strengths and weaknesses in health counseling in Finnish primary health care

Representative samples of Finnish health centres and of their physicians, nurses and physiotherapists were selected for a comprehensive survey on the professionals' work characteristics, health education attitudes and counseling practices. The main objectives of the study were to study the degree of implementation of patient counseling, with special reference to the national goals in health policy and to analyze the determinants of counseling practices in terms of predisposing, enabling and reinforcing factors. Broadly defined patient counseling was frequent in the contacts with all 3 professional groups and no differences in counseling frequency were found between different sizes of health centres. However, the objective of implementing counseling in every patient contact, with the incorporation of guidance regarding healthy living habits in it, recommended in the national health policy goals, was only partially realized. There were distinct differences between the 3 professional groups in counseling attitudes, topics, methods and purposes. These differences reflect, to a great extent, the differences in the professional tasks and the basic training between the 3 groups and also differences in the characteristics of patient contacts. These findings indicate a need for further in-service training in the methods of patients counseling, as well as restructuring the health care delivery system to allow more time for counseling, better continuity between contacts and more co-work between the members of primary care teams.

How is oral health education conducted in Finnish health centers'

The oral health education (OHE) given in Finnish health centers is mostly implemented by dental assistants and hygienists. However, there is no exact information concerning the distribution of OHE work and the working methods among individual health educators. The aims of this study were to assess 1) the time used for OHE by the dental professionals who bear most of the responsibility for OHE in health centers, and to evaluate 2) the collaboration between OH-educators and the parents of schoolchildren, school personnel and the other health care personnel and 3) the sources of the OHE knowledge and skills of these OH-educators and their methods according to their work load. The data for this study were collected from 323 OH-educators. About one fourth (28%) of the OH-educators used 40% or more of their working time for group OHE and one third (33%) used 40% or more of their time for individual OHE. These workers were considered to be full-time OH-educators. The mean age of the OH-educators was 36 yr. The mean length of the OHE career was 8 yr. The most common OHE methods were a usual type of school lesson or a lesson in which the audience was questioned. Slides, models, transparencies and leaflets were the most general visual aids used.

Beliefs and experiences of oral health educators in Finnish health centres

In Finland the personnel with the greatest oral health education (OHE) work-load are dental assistants and dental hygienists. Some of the OH educators spend the main part of their working time in OHE and can be considered to be full-time health educators. Others are part-time or occasional health educators. The aims of this study were to determine the beliefs, motivation, experiences, feedback, goal determination and methods of health education adopted by the OH educators in Finnish health centres. The 2 OH educators with the most OHE duties from every Finnish health centre (221) were asked to answer a questionnaire. Altogether 323 OH educators returned an acceptable questionnaire. Almost all (96%) of the respondents believed that OHE certainly or at least to some extent had affected the oral health habits of their patients. Their own enthusiasm was reported as a reason for choosing an OHE career by 50% of the respondents. OH educators described their work more frequently as difficult than easy, effective than ineffective, inspiring than boring, many-sided than simple and rewarding than frustrating. The most frequently mentioned inconveniences were the lack of OHE materials and the lack of systematic plans for OHE. Their professional training for OHE was felt to be adequate by 44% of the hygienists, 25% of the OHE dental assistants, 24% of the dental assistants and 16% of the dentists. It was rare that the goals of OHE were written in the patients' records; only 15% of the educators did so frequently. The most important means of promoting oral health were the model of the parents, encouraging and strengthening self-confidence and removing dental anxiety. It is concluded that the OHE personnel in Finland are well motivated and enthusiastic, but they lack more systematic plans, demonstration materials and professional training for OHE and their awareness of goals should be improved.

Use of primary health services in sparsely populated country districts by patients with musculoskeletal symptoms: consultations with a physician.

To examine the extent to which people consult health centre doctors about various musculoskeletal symptoms and to identify those groups of patients who are responsible for the main workload in primary health care caused by musculoskeletal complaints. A cross sectional investigation based on case records of people who visited health centre physicians. The population of six Finnish health centre districts (93,000 inhabitants, 64 physicians' posts in primary care centres). 6526 patients (7634 visits) who consulted a physician at any of six health centres during a two week period, of which 1380 consulted for musculoskeletal symptoms. The reasons for the visits were abstracted from the case records and were analysed by cross tabulation. The rate of people visiting for musculoskeletal symptoms during a two week period was on average 15 per 1000 inhabitants. It was highest in men aged 45-54 years (25/1000) and in women aged 55-64 years (26/1000); the rate fell to the average in men over 54 and women over 64 years. Patients with musculoskeletal symptoms accounted for 21% of all patients and 27% of those over 15 years of age. Low back pain was the most common reason for consultation in men aged 25-54 years, while for women aged 35-74 years, the most common reason was neck and shoulder pain. Over one quarter of adults visiting a health centre doctor do so because of musculoskeletal disorders. This fact must be considered when developing health care services and organising basic education and further in-service training for doctors.

Free-standing Papers: Abstracts

Possible and preferable outcome measures in primary care are increasingly discussed in Finland. An ad hoc committee of the Finnish Medical Association used a new classification of outcome measures for health care. The measures are divided into operational measures (input, process, and output); measures of medical quality; intermediate outcome measures; and true health outcome measures. In order to chart the availability of measuring instruments, their appropriateness and utilisation, a questionnaire was sent to all Finnish health centres in 1991. The response rate was 76%. Operational measures were overwhelmingly used for resource allocation (85% of criteria). Need for usable measures of medical quality was evident, while quality indicators are not used at all for resource allocation at present. The main metholodogical problems of this research concern the study design and concepts. 1) Method of eliciting knowledge. We could have used statistics of the health centre activity; an interview instead of a questionnaire; or a multiple choice instead of open questions. The nature of our primary questions led to the choice of method and much work ensued in classification. We still prefer having personal, fresh opinions to work from. Interviews would have given more answers, but the possibility of altering the opinions or giving ctrightn answers had to be avoided. Open questions have given us rich material especially in view of future needs and present problems. '2) Choice of respondent. The complexity of the process of planning and resource allocation in health' centres is obvious, and we had to narrow the point of view to only one person. We chose to send the questionnaire to the chief administrative physician. Many of them have consulted others in the health centre, and some questionnaires were answered by other personnel. Asking for a group opinion would probably have balanced the views. At the cost of generalisability, our method perhaps allows more delicate problems to be identified than a udemocratic>) process would have produced. 3) Classifying the measures used. The classification criteria were laid down in advance, but these was difficulty in sorting specific measures to one class only. Most problems were caused by the measures that could belong to either intermediate or true health outcomes, and indicators of either quality or true health outcomes. Defining criteria and concepts is a lengthy process, and the results change with time. This reflects not only a methodological problem but is a result of the study as well.

Client-public health nurse relationships in child health care: a grounded theory study.

Client-public health nurse relationships are considered to be important in nursing literature. However, little research in nursing has touched this area. The purpose of this paper is to describe a study of the patterns of interaction in terms of relationships between clients (mother and child under 1 year of age) and public health nurses in child health care at Finnish health centres. The qualitative data were collected by observing client-public health nurse interactions during visits. In total, 1554 interactions were observed over 2 years from 20 visits to child health centres. The grounded theory method was used in this study. Various relationships were identified between child and mother, child and public health nurse and mother and public health nurse. The relationship between child and mother during the visit was called a tender, protective and persuasive relationship. The relationship between child and public health nurse was called a persuasive and entertainment relationship. The main relationship between mother and public health nurse was called relationship supporting self-confidence. Suggestions for nursing practice and further research are made.

A 1-year follow-up of prescribing patterns of analgesics in primary health care.

The prescription of analgesics and anti-inflammatory drugs (analgesics) was studied using computerized patient records from a Finnish health centre with a population base of some 27,000 inhabitants. A random sample of every fifth patient visiting the health centre in 1986 was chosen. This study sample consisted of 4,577 patients with 17,021 physician contacts and altogether 14,035 prescriptions during the 1-year follow-up: of these analgesics comprised 14.8%. The proportion of the study population who received at least one analgesic prescription was 23 +/- 1.2% (95% CI). The use of physician contacts as a base revealed 10.7 +/- 0.5% (95% CI) of the contacts with an analgesic prescription. The exposure to analgesics among males increased with age from 17% for those aged 15-34 years to 34% for those aged 75 years or more. Among women, exposure to analgesics increased from 17% (15-34 years) to 41% (75 years or more). Most of patients who received analgesic prescriptions were incidental users (one or two analgesic prescriptions per year). Only 4% of women and 3% of men were categorized as heavy users of analgesics (seven or more analgesic prescriptions per year). The proportion of heavy users increased with age and was highest in the oldest age-group (75 years or more). In order to make informed policy judgements about drug use in society, we need routine sales statistics and patient-specific drug-use data such as those presented in this paper.

Organization and Problems in Emergency Dental Care at Finnish Health Centres

The Public Dental Service in Finland is, in principle, responsible for emergency dental services for the population. The organization of the prevailing emergency care system in the 215 health centres was studied. 90% of the health centres had some kind of emergency services, usually during regular working hours. Few health centres offered treatment outside normal hours or had a telephone-based back-up system. The main problems reported were the unpredictability of the need for emergency services, great variations in the number of patients, the heavy work load created by continuing treatment of emergencies, and shortage of personnel.

Economic aspects of dental care in Finnish health centers

In recent years economic evaluations of publicly funded governmental and community based activities have become more common. Although the Public Dental Service in Finland has been in operation for 17 yr, little is known of the effectiveness of the system. The aim of this study was to assess the effectiveness, output and costs of dental care using available data from 34 randomly selected health centers during 1982-85. Great differences were found in running expenses and productivity between the health centers studied. The study indicated that dental care arrangements tended to be more expensive in communities with high governmental subsidies than in those with low ones. The ratio of chairside assistants to dentists was also shown to have a statistically significant positive correlation with the cost of a dental visit.

Farmers' occupational health program in Finland, 1979‐1988: From research to practice

The Kuopio Regional Institute of Occupational Health, in collaboration with the Social Insurance Institution and the National Board of Health, conducted and evaluated a national model for the farmers' occupational health services. In January 1985 the National Board of Health instructed the Finnish municipal health centers to start the provision of farmers' occupational health services based on the recommendation given by the research group. The service was evaluated by experiments carried out during 1982, 1985, and 1986. The main problem in function of the services was that the health hazards (exposures) were difficult to observe and evaluate. The system of how the occupational health nurse evaluates the working conditions should be further developed. The efficiency of the services was studied by postal inquiries in 1982 and 1986. Farmers' knowledge about the appropriate means of reducing hazardous exposures had increased significantly due to the occupational health services. At the local level, the main problem in providing services for occupational farmers is that health centers do not have the resources to offer services for all farmers at the same time. Altogether by the end of 1986, about 30% of all active farmers in Finland (45,000 farmers) were willing to have occupational health services, which is voluntary for self-employed farmers.

Health centre efficiency. First results of an organizational analysis of four Finnish health centres.

First results are given on the opinions and perceptions of the health centre personnel (including administrative staff, doctors, nursing and office personnel) concerning their work at four health centres, which represent different types of organization with respect to urbanrural axis, geographical location, and size of base population. Data were collected using a pretested questionnaire. The number of completed forms was 710, of which 702 were included in the final analysis. The response rate was 95%. The results indicated that doctors and administrative staff considered their work mentally more stressful than the other groups. According to the doctors, important adverse factors in their work were 1) the forced pace of work and 2) the perceived haste and tight schedule. The findings also suggest that, at least in those health centres studied, communication between various professional groups was insufficient. Likewise, the transfer of information between the various functional units was problematic. These findings may indicate difficulties in the planning, organization, and coordination of the work. Therefore the attention should be focused especially on the management of health centre organizations.

Quality of care in general practice.

In this article the author discusses some of the principles of evaluation of quality of care in general practice and connects this with some empiric results of a study which attempted to evaluate the quality of work of the general practitioners in a Finnish health centre. Data were obtained by 1) recording all the 8701 persons visiting during one year; 2) drawing a systematic sample of 2540 persons from all those who visited; and 3) abstracting the required information from patient documents to specially planned precoded and pretested forms. The objectives of the study included the investigation of the quality aspects of the health centre doctor services, among other things also the continuity and coordination of care. The results raise questions concerning the quality of work. No general conclusions on the quality of care are drawn, since the data may not be adequate for that. According to the author, the findings emphasise the importance of at least three things: The consideration of what is done in the context of the patients' prognosis, the communication skills of the general practitioners and the communication between the general practitioners who work in the same place. In the light of the described and other findings of the study it is strongly recommended that the study of the contents of the work should be an integral part of today's general practice.

Rapid Throat-culture as Diagnostic Aid: Ineffective in Decreasing Antibiotic Prescriptions

An overnight slide-culture for the detection of group A streptococci was introduced in a Finnish health centre. The number of patients from whom a throat culture was obtained increased from 55% to 70% with the new method. Despite this increase, the prescribing habits of primary care physicians did not change. Treatment was in most cases (84-90% of those treated) still initiated before culture results were available, and antibacterial medication was discontinued only occasionally (1-3%). Physicians usually decided the treatment during the first consultation. These findings contradict earlier studies where prescriptions decreased during rapid culture. Use of throat cultures as diagnostic aid should be reconsidered, especially when more rapid methods now are available.

Strategies for improving compliance in hypertensive patients.

The results of the present trial, aimed at elucidating and improving the treatment situation of hypertensives, show that--within the domain of the Finnish community health centres--it continues to be unsatisfactory. The prevalence of the male hypertensives (those without treatment and with a permanent diastolic pressure level of at least 100 mmHg and those under treatment) aged 35 to 49 years, was 12.8%. Only half of them were receiving treatment and of these the treatment was adequate (diastolic pressure less than 90 mmHg) in only one case out of five. Overweight turned out to be common among hypertensives, 63.2% of them had at least 10% overweight (BMI greater than or equal to 27.0 kg/m2) while 15.7% had at least 30% overweight (BMI greater than or equal to 32.0 kg/m2). There were no differences worth noting in overweight between treated and untreated cases. With respect to tobacco smoking there was a clear difference in favour of the hypertensives receiving treatment, among whom only 26.1% were regular smokers, while the corresponding figure for untreated hypertensives were 41.7%. Within short time an improved, supervising physician-based treatment system could be seen to have led to favourable results in the treatment of hypertensive community health centre patients. The proportion of those receiving adequate treatment among subjects already under treatment prior to the screening, for instance, had become threefold within a few months.

Etiological, social and therapeutical aspects of osteoarthrosis and soft-tissue rheumatism in a Finnish health centre material.

A study of 690 osteoarthrosis (OA) patients with corresponding controls, and 475 soft-tissue rheumatism (STR) patients with the same number of controls was made in Finnish health centres. The aim of the study was to clarify certain etiological, social and therapeutical aspects. No clear differences were found in the working conditions of patients with OA, STR, or their controls, or in their occupational classes. OA patients were less satisfied with their working conditions than were the other. OA and STR patients had been more actively engaged in sports earlier in life, but during the study there were no differences; nor did the localisation of OA differ. The weight index qas slightly higher in OA, particularly when knee and ankle were affected, but not with arthrosis of the hip. There were no clear associations with other diseases. The maximum duration of a treatment period in this study was 1 month. The average sick leave in OA was 17.8 days, in STR 13.4 and in controls 15.4 days. After treatment, 31% of OA patients, and 56% of STR were recommended to resume work; 4% were recommended to change their occupation; 21% of OA and 7% of STR patients were recommended to retire on pension. Sulindac, indomethacin and many other drug combinations were used for medication. Certain side effects were found in about 5% of sulindac- and in 8-10% of indomethacin-treated patients. In 17% of OA and in 12% of STR patients, it was found necessary to consult a specialist for diagnosis or treatment.