Improving the quality of private sector delivery of public health services: challenges and strategies.
(9/1327)
Despite significant successes in controlling a number of communicable diseases in low and middle income countries, important challenges remain, one being that a large proportion of patients with conditions of public health significance, such as tuberculosis, malaria, or sexually transmitted diseases, seek care in the largely unregulated 'for profit' private sector. Private providers (PPs) often offer services which are perceived by users to be more attractive. However, the available evidence suggests that serious deficiencies in technical quality are often present. Evaluations of interventions to promote evidence-based care in high income countries have shown that multi-faceted strategies which increase provider knowledge have had some success in improving service quality. A wider range of factors needs to be considered in low and middle income countries (LMICs), especially factors which contribute to discrepancies between provider knowledge and practice. Studies have shown that PPs, especially, perceive or experience patient and community pressures to provide inappropriate treatments. LMIC governments also lack the capacity to enforce regulatory controls. Context-specific multi-faceted strategies are needed, including the local adaptation and dissemination to providers of relevant evidence, the education of patients and communities to adopt effective treatment-seeking and treatment-taking behaviour, and feasible mechanisms for ensuring and monitoring service quality, which may include a role for self-regulation by provider organizations or provider accreditation. Developing, implementing and evaluating strategies to improve the quality of service provision will depend on the involvement of the key stakeholders, including policy makers and PPs. Focusing on studies from Asia, Africa and Latin America, this paper develops a model for identifying the influences on PPs, mainly private medical practitioners, in their management of conditions of public health significance. Based on this, multi-faceted strategies for improving the quality of treatment provision are suggested. Interventions need to be inexpensive, practical, efficient, effective and sustainable over the medium to long term. Achieving this is a significant challenge. (+info)
Development and evaluation of a pharmacist-directed pharmacotherapy center.
(10/1327)
This article is designed for ambulatory pharmacy specialists, pharmacy administrators, and managed care pharmacy and/or medical directors interested in developing systems for improved drug therapy outcomes. GOAL: To describe an alternative method for the effective delivery of pharmaceutical care. OBJECTIVES: 1. Identify the barriers to delivery of pharmaceutical care in current systems. 2. Describe the steps to take to implement a referral-based pharmaceutical care service. 3. Describe the financial and patient satisfaction outcomes of a referral-based pharmacy. 4. Describe the services that can be offered by a referral-based pharmacy. (+info)
Communication and interpretation of risk.
(11/1327)
The 'new genetics' enables people's risk status for many diseases and disorders to be assessed much more accurately than before, yet considerable uncertainty remains over how risk information will be evaluated and acted upon. This paper summarises some of the main themes of psychological research on risk. Risk is traditionally defined in terms of probability. However, people often have difficulty in processing statistical information and may rely instead on simplified decision rules. Decision making under risk is also critically affected by people's subjective assessments of benefits and costs. In the field of genetic risk, such assessments may vary greatly between individuals, reflecting personal and cultural preferences and ethical concerns. The goals of risk communication should, therefore, not be merely the imparting of statistical 'facts' or the reduction of anxiety, but also enabling individuals and their families to make important decisions under conditions of uncertainty. (+info)
Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions.
(12/1327)
The first part of this paper examines the practice of informed treatment decisions in the protective medical system in China today. The second part examines how health care professionals in China perceive and carry out their responsibilities when relaying information to vulnerable patients, based on the findings of an empirical study that I had undertaken to examine the moral experience of nurses in practice situations. In the Chinese medical ethics tradition, refinement [jing] in skills and sincerity [cheng] in relating to patients are two cardinal virtues that health care professionals are required to possess. This notion of absolute sincerity carries a strong sense of parental protectiveness. The empirical findings reveal that most nurses are ambivalent about telling the truth to patients. Truth-telling would become an insincere act if a patient were to lose hope and confidence in life after learning of his or her disease. In this system of protective medical care, it is arguable as to whose interests are being protected: the patient, the family or the hospital. I would suggest that the interests of the hospital and the family members who legitimately represent the patient's interests are being honoured, but at the expense of the patient's right to know. (+info)
Projective identification, self-disclosure, and the patient's view of the object: the need for flexibility.
(13/1327)
Certain patients, through projective identification and splitting mechanisms, test the boundaries of the analytic situation. These patients are usually experiencing overwhelming paranoid-schizoid anxieties and view the object as ruthless and persecutory. Using a Kleinian perspective, the author advocates greater analytic flexibility with these difficult patients who seem unable to use the standard analytic environment. The concept of self-disclosure is examined, and the author discusses certain technical situations where self-disclosure may be helpful. (The Journal of Psychotherapy Practice and Research 1999; 8:225-233) (+info)
Are Latinos less satisfied with communication by health care providers?
(14/1327)
OBJECTIVE: To examine associations of patient ratings of communication by health care providers with patient language (English vs Spanish) and ethnicity (Latino vs white). METHODS: A random sample of patients receiving medical care from a physician group association concentrated on the West Coast was studied. A total of 7,093 English and Spanish language questionnaires were returned for an overall response rate of 59%. Five questions asking patients to rate communication by their health care providers were examined in this study. All five questions were administered with a 7-point response scale. MAIN RESULTS: We estimated the associations of satisfaction ratings with language (English vs Spanish) and ethnicity (white vs Latino) using ordinal logistic models, controlling for age and gender. Latinos responding in Spanish (Latino/Spanish) were significantly more dissatisfied compared with Latinos responding in English (Latino/English) and non-Latino whites responding in English (white) when asked about: (1) the medical staff listened to what they say (29% vs 17% vs 13% rated this "very poor," "poor," or "fair"; p <.01); (2) answers to their questions (27% vs 16% vs 12%; p <.01); (3) explanations about prescribed medications (22% vs 19% vs 14%; p <.01); (4) explanations about medical procedures and test results (36% vs 21% vs 17%; p <.01); and (5) reassurance and support from their doctors and the office staff (37% vs 23% vs 18%; p <.01). CONCLUSION: This study documents that Latino/Spanish respondents are significantly more dissatisfied with provider communication than Latino/English and white respondents. These results suggest Spanish-speaking Latinos may be at increased risk of lower quality of care and poor health outcomes. Efforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed. (+info)
Computer-based approaches to patient education: a review of the literature.
(15/1327)
All articles indexed in MEDLINE or CINAHL, related to the use of computer technology in patient education, and published in peer-reviewed journals between 1971 and 1998 were selected for review. Sixty-six articles, including 21 research-based reports, were identified. Forty-five percent of the studies were related to the management of chronic disease. Thirteen studies described an improvement in knowledge scores or clinical outcomes when computer-based patient education was compared with traditional instruction. Additional articles examined patients' computer experience, socioeconomic status, race, and gender and found no significant differences when compared with program outcomes. Sixteen of the 21 research-based studies had effect sizes greater than 0.5, indicating a significant change in the described outcome when the study subjects participated in computer-based patient education. The findings from this review support computer-based education as an effective strategy for transfer of knowledge and skill development for patients. The limited number of research studies (N = 21) points to the need for additional research. Recommendations for new studies include cost-benefit analysis and the impact of these new technologies on health outcomes over time. (+info)
Stroke patients' informal caregivers. Patient, caregiver, and service factors that affect caregiver strain.
(16/1327)
BACKGROUND AND PURPOSE: Research has revealed that caring for a stroke patient can result in caregiver strain and a myriad of other difficulties for caregivers. This study aims to identify the level of strain experienced by caregivers in the early months after stroke and to assess the relationship between caregiver strain and caregiver characteristics, patient characteristics, and service inputs. METHODS: Stroke patients were identified through a random stratified sample of general practices. Patients were asked to identify their principal informal caregiver. Strain was measured with the Caregiver Strain Index, and all data were collected from caregivers at 1, 3, and 6 months after the patient's stroke. Multiple regression analysis was used to examine the factors associated with caregiver strain. RESULTS: Six months after stroke, 37% of caregivers were experiencing considerable strain. The amount of time a caregiver spent helping a stroke patient, the amount of time the caregiver spent with the patient, and the caregiver's health were all significantly associated with the level of strain experienced. Although none of the services or patient factors tested in this study were consistently associated with strain, an indicator of stroke severity was significant at each time point. CONCLUSIONS: Caregivers are experiencing strain, which has implications for research and service provision. Service providers need to identify caregivers at risk of greater strain and to help caregivers work through situations that services cannot alter. Research is needed to identify services that are effective in strain alleviation. Future research should also aim to identify the interface between patient characteristics and strain, burden, and depression and particularly to assess the caregiver's perception of these relationships. (+info)