Provision Of Primary Health Care Services Research Articles

Chronic non-communicable diseases and the challenge of universal health coverage: insights from community-based cardiovascular disease research in urban poor communities in Accra, Ghana.

BackgroundThe rising burden of chronic non-communicable diseases in low and middle income countries has major implications on the ability of these countries to achieve universal health coverage. In this paper we discuss the impact of cardiovascular diseases (CVD) on primary healthcare services in urban poor communities in Accra, Ghana.MethodsWe review the evidence on the evolution of universal health coverage in Ghana and the central role of the community-based health planning services (CHPS) programme and the National Health Insurance Scheme in primary health care. We present preliminary findings from a study on community CVD knowledge, experiences, responses and access to services.ResultsThe rising burden of NCDs in Ghana will affect the achievement of universal health coverage, particularly in urban areas. There is a significant unmet need for CVD care in the study communities. The provision of primary healthcare services for CVD is not accessible, equitable or responsive to the needs of target communities.ConclusionsWe consider these findings in the context of the primary healthcare system and discuss the challenges and opportunities for strengthening health systems in low and middle-income countries.

Toleranse, kultursensitivitet og akkulturasjon: <br>Interkulturelle utfordringer for primærhelsetjenesten og nyankomne innvandrere i Norge

Background: Since the 1970s, Norway has experienced a significant increase in population diversity. In 2001, a patient-list system, also referred to as the General Practitioner (GP) Scheme (Norwegian: Fastlegeordning), was introduced to ensure access to primary health care for the entire population. At the time of its introduction, the scheme, which was designed for a homogenous population, was intended to improve the quality of GP services. By facilitating stability and continuity in the doctor-patient relationship, the scheme aimed to ensure equitable access to, and use of, secondary health care. Despite the intention to facilitate stable doctor-patient relationships, employees in health care facilities report that many immigrants use the emergency room rather than GP services. Equity in health care is the absence of systematic disparities in health care. Since the provision of equitable health services is a priority in Norway, this study aimed to investigate the possible motives for immigrants’ choice of service provider and to propose measures to increase the uptake of GP services by this group.Purpose and approach: The aim of the article is to examine newly arrived immigrants' experiences with primary health care. The article attempts to shed light on why immigrants seek medical help at the emergency room and not from their assigned GPs in non-life-threatening situations.Methods and materials: We adopted an exploratory approach in order to investigate both the motives and experiences of diverse groups of immigrants. Semi-structured interviews were conducted with 12 Oslo GPs and 13 immigrant representatives, all living in Oslo. To illustrate patterns on a large scale, we adopted a quantitative approach based on data from health authorities’ registers of consultations. 1,935,000 primary health care consultations conducted in the Greater Oslo area over a two-year period were included in the regression analyses.Results and interpretation: The study shows a varied pattern of use of GP services among the diverse groups of foreign-born residents. Results suggest that immigrants are more likely to use emergency-room services during the first few years after arrival. Results also indicate that information about the patient-list system does not always reach newly arrived immigrants. Contrary to general understanding, non-visible immigrants (when considering factors such as skin color and clothing) diverge the most from the pattern of the majority. Immigrants originating from European countries, such as Sweden and Poland, use the emergency room most frequently. From the qualitative aspects of the study, we have also found that primary health care services are not perceived as equitable.Conclusion: Recently arrived immigrants’ utilization of primary health care services shows an unfavorable pattern. The choice of primary health care service providers is dependent on the individual’s preferences, expectations, experiences and/or actual obstacles. The observed utilization of services provided at emergency rooms is one more reason for monitoring and increasing tolerance and cultural sensitivity in primary health care.

An ANT Analysis of Healthcare Services for the Nomadic Patients of Namibia

Patients seek attention and treatments to various types of diseases and symptoms. Diseases infection and symptoms are often not predictive. Normally, there is a spread and movement of people across the geographical locations, of both the rural and urban communities, in countries including Namibia. As such, healthcare could be needed at any location, and at any time. There is significant mobility of individuals and groups within a country. Unfortunately, the healthcare services are not always as mobile at the level and speed that individuals and groups does in Namibia. Hence, there is need for the mobility of healthcare services at both primary and secondary healthcare levels, particularly in the developing countries, such as Namibia. The population of Namibia is scantly spread among its towns and cities. The major towns and cities are situated, in the average of 175km far apart from each other, in the country's 825, 418km square landscape. The spread necessitates movements of individuals and groups, particularly the old, poor, and nomadic people. Unfortunately, healthcare records in the country are not centralised and virtualised, making accessibility into patients' records difficult or impossible, from any location. As a result, healthcare service delivering is challenged. This study therefore explored and examined the possibility of mobility of healthcare services to those who live in the country. The study employed the qualitative research method, within which data was gathered from primary healthcare service providers, using open-ended questionnaires. The Moments of Translation from the perspective of actor-network theory (ANT) was used as a lens in the analysis of the data, to examine and understand the power and factors, which influences mobility of healthcare service in Namibia. Categorisation of Patients, Response Time, Understanding the Actors, Actors' participatory to service delivery, and Actors' Alliance were found to be the influencing factors in the provision of mobility of healthcare services.

Experiences with primary healthcare in Fuzhou, urban China, in the context of health sector reform: a mixed methods study

China has recently placed increased emphasis on the provision of primary healthcare services through health sector reform, in response to inequitably distributed health services. With increasing funding for community level facilities, now is an opportune time to assess the quality of primary care delivery and identify areas in need of further improvement. A mixed methodology approach was adopted for this study. Quantitative data were collected using the Primary Care Assessment Tool-Chinese version (C-PCAT), a questionnaire previously adapted for use in China to assess the quality of care at each health facility, based on clients' experiences. In addition, qualitative data were gathered through eight semi-structured interviews exploring perceptions of primary care with health directors and a policy maker to place this issue in the context of health sector reform. The study found that patients attending community health and sub-community health centres are more likely to report better experiences with primary care attributes than patients attending hospital facilities. Generally low scores for community orientation, family centredness and coordination in all types of health facility indicate an urgent need for improvement in these areas. Healthcare directors and policy makers perceived the need for greater coordination between levels of health providers, better financial reimbursement, more formal government contracts and recognition/higher status for staff at the community level and more appropriate undergraduate and postgraduate training.

Community pharmacists in Khartoum State, Sudan: their current roles and perspectives on pharmaceutical care implementation

The contribution of community pharmacists to the provision of primary healthcare is widely believed to be important. The health authority in Sudan is interested in developing pharmaceutical care (PC) practice as a means of improving the provision of primary healthcare services. However, there is a need for research to inform this development. To describe the current roles of community pharmacists; to describe their views about their current role and potential future role with regard to PC practice. Community pharmacies in Khartoum State, Sudan. This study applied a two-phase mixed methods approach. The first phase used a pre-tested, piloted, self-administered questionnaire with a stratified random sample of 246 pharmacies (26 % of total number) in Khartoum State. The sample size was based on 95 % confidence level, 5 % confidence interval and the response rate from the pilot study. The second phase applied semi-structured interviews with a purposive sample of 24 of the responded pharmacists. Current activities of community pharmacists; pharmacists' opinions on PC practice and the barriers they might face in its implementation. Results For the questionnaire study the response rate was 83 % (205/246). Most dispensing activities were reported to be performed by a vast majority of respondents (94 % or more). A few PC activities were reported to be already performed by the majority of participants e.g. checking indications, interactions and contraindication (83 %, n = 171) and checking each repeat prescription for compliance (78 %, n = 159). However, the majority of PC activities were not performed. Nearly all pharmacist (99 %, n = 203) were willing to further implement PC practice, but reported a number of barriers to its implementation. Efficient dispensing of prescriptions is the primary focus of community pharmacists in Khartoum State with some PC activities. The pharmacists have expressed a willingness to implement PC practice but indicated a number of barriers to successful implementation.

Identifying challenges and barriers in the delivery of primary healthcare at the district level: a study in one Thai province

In 2001, the universal health coverage policy was adopted by Thailand with primary healthcare (PHC) as the major focus of the policy. In order to understand the structural and institutional factors affecting the implementation of PHC in rural Thailand, a qualitative study, utilising individual interviews with national and provincial policy decision makers, community health directors, heads of hospital primary care units, chiefs of district health offices, heads of health centres and community representatives, from one rural province was undertaken. Findings showed that the sustainability of PHC service provision under the administration of community hospitals is problematic as barriers exist at the policy and operational levels and access to PHC for all citizens may not be achieved until these barriers are addressed. Furthermore, although PHC needs to be acknowledged and implemented by all stakeholders within the health industry and government, the roles and responsibilities of the stakeholders in health services management at the district level need to be clarified.

Reply to Drs. Endersby et al

The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research—a core element of high-quality PHC—in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the <i>micro</i> (practice), <i>meso</i> (institutional) and <i>macro</i> (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and ‘brain drain’ may reduce available research support; however, we provide recommendations on how to deal with these tensions.

Determinants of the intention of elementary school nurses to adopt a redefined role in health promotion at school

BackgroundThe quest for greater efficiency in the provision of primary healthcare services and the implementation of a "health-promoting school" approach encourage the optimal redefinition of the role of school nurses. School nurses are viewed as professionals who might be significant actors in the promotion of youth health. The aim of this study was to identify the determinants of the intention of elementary school nurses to adopt a new health-promotion role as a strategic option for the health-promoting school.MethodsThis study was based on an extended version of the theory of planned behaviour (TPB). A total of 251 respondents (response rate of 70%) from 42 school health programs across the Province of Québec completed a mail survey regarding their intention to adopt the proposed health-promotion role. Multiple hierarchical linear regression analyses were performed to assess the relationship between key independent variables and intention. A discriminant analysis of the beliefs was performed to identify the main targets of action.ResultsA total of 73% of respondents expressed a positive intention to accept to play the proposed role. The main predictors were perceived behavioural control (β = 0.36), moral norm (β = 0.27), attitude (β = 0.24), and subjective norm (β = 0.21) (ps < .0001), explaining 83% of the variance. The underlying beliefs distinguishing nurses who had a high intention from those who had a low intention referred to their feelings of being valued, their capacity to overcome the nursing shortage, the approval of the school nurses' community and parents of the students, their leadership skills, and their gaining of a better understanding of school needs.ConclusionsResults suggest that leadership is a skill that should be addressed to increase the ability of school nurses to assume the proposed role. Findings also indicate that public health administrators need to ensure adequate nurse staffing in the schools in order to increase the proportion of nurses willing to play such a role and avoid burnout among these human resources.

General practitioner networks matter in primary health care team service provision

Australia is undergoing significant primary health care policy reforms in response to concerns about quality of care, increasing burden of complex and chronic diseases, and workforce shortages. Governments are encouraging multidisciplinary teamwork between general practitioners (GP) and other primary health care service providers. Essential elements of teamwork have been addressed in policy initiatives, yet important dimensions of the way GP develop and use their work-related relationships in their practice remain unrecognised. This paper draws upon a doctoral thesis that explored the types and the qualities of GP work-related relationships. A qualitative research methodology combined with a relational perspective was used. Data were collected from a pilot, main and a validation study. Fifty interviews were conducted, including: GP, clinic staff, service providers, support organisation personnel and policymakers. A complex web of interdependent work-related relationships exist between GP and other health care providers. Four main types of GP work-related relationships emerged: clinical problem solving, obtaining metaknowledge, obtaining legitimisation, and validation. Key qualities of GP work-related relationships included the nominated providers’ competence, accessibility, goodwill, honesty, consistency and communication styles. A validation study verified research findings. The research provides evidence that the nature of GP work-related relationships have implications for other practitioners who need to work with GP. The findings challenge the current primary health care policy emphasis on using structural reforms such as prescribed service delivery processes and financial incentives to encourage teamwork.

Reasons for attending dental-care services in Ouagadougou, Burkina Faso.

To determine why patients attend dental-care facilities in Ouagadougou, Burkina Faso and to improve understanding of the capacity of oral health-care services in urban west Africa. We studied a randomly selected sample of patients attending 15 dental-care facilities in Ouagadougou over a 1-year period in 2004. Data were collected using a simple daily record form. From a total of 44,975 patients, the final sample was established at 14,591 patients, of whom 55.4% were new patients and 44.6% were "booking patients". Most patients seeking care (71.9%) were aged 15-44 years. Nongovernmental not-for-profit dental services were used by 41.5% of all patients, 36% attended private dental-care services, and 22.5% of patients visited public services. The most common complaint causing the patient to seek dental-care services was caries with pulpal involvement (52.4%), and 60% of all complaints were associated with pain. The patients' dental-care requirements were found to differ significantly according to sex, health insurance coverage and occupation. Urban district health authorities should ensure provision of primary health-care services, at the patients' first point of contact, which are directed towards the relief of pain. In addition to the strengthening of outreach emergency care, health centres should also contribute to the implementation of community-based programmes for the prevention of oral disease and the promotion of oral health. Exchange of experiences from alternative oral health-care systems relevant to developing countries is urgently needed for tackling the growing burden of oral disease.

A baseline survey of the Primary Healthcare System in South Eastern Nigeria

A baseline survey to audit the PHC operations and determine community perception and expectations of PHC service delivery was conducted in 72 communities in Enugu state, southeastern Nigeria. The study was intended to facilitate the development of intermediate performance indicators for monitoring the progress of an ongoing health sector reform and to gather baseline data for planning and policy formulation. The tools used for the operations audit assessed indicators for evaluating: (a) Stewardship, (b) Service Provision and (c) Administrative and financial management; while the community survey was assessed by, (a) utilization of health services, (b) perception of service delivery and (c) health care financing. One hundred and sixteen respondents from each of the facilities in the sample frame were interviewed using a structured self-assessment questionnaire and a qualitative assessment was undertaken in 53 of the facilities using an audit guide. Focus group discussions (FGD) were conducted with the policy makers and planners in each of the 17 LGAs in the state. A total of 832 respondents were interviewed in the communities (using a structured questionnaire) and 42 community FGDs were conducted. The results indicate a lack of operational efficiency in the majority of the facilities audited. It was also observed that majority of the facilities do not provide all services required of it, are poorly maintained, do not have enough skilled health workers and operate without a budget. There appears to be no formal financial management system in place and no policy on financial resource generation. The community survey identified two major problems; low utilization of PHCs and poor service provision. The key indicator identified by the community for evaluating performance of the PHCs remains “access to essential drugs”. The major prospect was the willingness of an appreciable number of respondents to invest in health financing through insurance schemes and payment of health tax among others. It was evident that poor funding, bad management practices and infrastructural decay is the bane of efficient PHC delivery. Consequently, we propose that cost determination studies, to establish the financial implication of the minimum package for provision of primary healthcare services, should be an essential prerequisite to the reform process. Some critical cross-cutting issues identified from the data obtained which could form the basis for major policy thrust include, development of strategies for sustainable promotion of public–private–partnership for enhanced community involvement in healthcare management, ensuring that interventional investment is proportional to the felt health needs of the populace and funding of healthcare through equitable integration of user fees/charges.

Socio-economic and geographic differentials in costs and payment strategies for primary healthcare services in Southeast Nigeria

The study explored socio-economic and geographic inequalities that exist in healthcare seeking, expenditures and methods of paying for healthcare. The study was conducted in two communities (one rural and urban) in Southeast Nigeria. A pre-tested questionnaire was administered to household heads or their representatives by trained interviewers. A socio-economic status (SES) index, together with urban–rural comparisons was used to examine the inequalities. The expenditures on healthcare and the proportions of respondents that used the different payment strategies were compared across SES quartiles and between the urban and rural areas. There were varying degrees of socio-economic and geographic inequalities in treatment expenditures, providers seen and payment modalities that were used. User fee without reimbursement was the commonest type of payment strategy, followed distantly by instalment payment. The two poorest quartiles were less likely to have used user fee and they mostly used instalment payment in the rural area. Logistic regression analysis showed that location was significantly and positively related to user fee but not to instalment payment. In conclusion, the poorest SES group and rural dwellers are the major sufferers of inequality and this could be mitigated through improved provision of primary healthcare services in rural areas and initiation of exemptions, vouchers and other pro-poor payment strategies for the poorest SES groups.

A study of health services for the Chinese minority in Manchester.

This article describes a small-scale study which examined the views of both users and providers of primary healthcare services for the Chinese minority in Manchester. Thirty Chinese mothers of pre-school children were selected from immunization records and interviewed face-to-face at their homes using structured questionnaires and unstructured discussions. Thirty-eight GPs who had the largest number of Chinese patients (n = 10) registered with them, and 26 health visitors who worked with these GPs were also interviewed, using semi-structured questionnaires. The findings indicate that a discrepancy exists between the views of GPs, health visitors and Chinese mothers on the use of primary healthcare services. The health professionals' awareness of the effects of socio-economic characteristics, demographic profile and indigenous health beliefs and attitudes on the quality of primary healthcare services for Chinese families in Manchester is discussed.

Nurse practitioners in a crowded marketplace: 1965-1985.

Since the late 1960s, nurse practitioners have played a major role in the provision of primary health-care services to previously underserved communities. However, with the accelerated supply of primary care providers, particularly physicians, and with the declining utilization of services, opportunities for practice are becoming increasingly constrained for nurse practitioners. This article examines some of the factors that influence workplace encroachment experienced by a growing number of nurse practitioners. It also suggests strategies for mitigating the limiting effects of these factors and for achieving stable practice opportunities for nurse practitioners.