[Opinions of family doctors on the involvement of patients in the taking of decisions: a study with focus groups]

OBJECTIVE

To determine what family doctors think about various aspects of patient involvement in clinical decision making in Primary Care.

DESIGN

Qualitative study using focus groups.

LOCATION

Primary Care.

PARTICIPANTS

Family physicians with and without expertise in clinical communication.

METHODS

Three focus groups were developed, involving 6-8 professionals per group, and took part in two meetings. The conversations were recorded and transcribed verbatim. The discussion was analysed using literature-based categories and other emerging from the text, encoding the information and making an inductive interpretation.

RESULTS

Family physicians refer mainly to involving the patient in decisions by proposing a plan tailored to the knowledge of patient problems and then verifying their approval or rejection. However, some professionals ponder whether this could be classified as patient involvement, questioning the real role that both players would take at the time of deciding.

CONCLUSIONS

The explanation of how family physicians would involve the patient in decisions clashes with the most widespread theories on the subject and, also opposes the view of patients who would like to be involved more actively. Taking into account discordant reflections on the relevance of considering this process as real patient involvement, it is necessary to describe a realistic theoretical model that allows further development of strategies to improve the attitude and training of professionals to patient involvement in clinical decisions.

[Etnography as an Integrative Method]

INTRODUCTION

Ethnography is understood from three perspectives: approach, methodology and text. In the health field, ethnography can be used not only from the standpoint of the research process, but also from the very instances of medical consultation, diagnose and treatment. The pacient appreciates the fact of being heard and understood as a subject who has her/his own story and is involved in a particular culture related to her/his own status and to the effectsa caused by life experiences.

METHODS

Analysis of the literature related to ethnography, participanting observation and an relationship between health and qualitative research.

RESULTS

There is a diversity of opinions and attitudes about ethnography, its validity and usefulness as well as in considerations related to its method and the techniques that nourish it. Ethnography is an integrative approach that may resorty to multiple tools for collecting, analyzing and interpreting the data. Therefore, ethnography constitutes an option for the physician when performing individual assessment.

CONCLUSIONS

Ethnography provides an opportunity to approach the reality of an individual or group of individuals in order to obtain information about the matter under investigation, its understanding and interpretation.

[The access to health services and their use by immigrant patients: the voice of the professionals]

OBJECTIVE

To find out, from the health professionals' point of view, how different immigrant groups access and use the health services.

DESIGN

Qualitative, descriptive and phenomenological study carried out in Barcelona between September and December of 2007.

SETTING

The study was carried out in the 6 Basic Health Areas of Barcelona, where there is a higher percentage of immigrant population, and in 3 public hospitals.

PARTICIPANTS

A total of 73 hospital and primary health care professionals. Theoretical sampling was carried out on respondents who defined 4 professional profiles: directors or coordinators, physicians, nurses, and cultural mediators.

METHODS

There were 7 debate groups and 12 partly-structured interviews. Both the interviews and groups were analysed by a narrative analysis of the content.

RESULTS

The outcomes indicate that, according to the professionals, the immigrant patients do not find barriers that can make their access to health services more difficult. The perception that the emergency service is their main access gate for them is unanimous, as well as that most of the immigrant patients have less continuity of care. Finally, professionals detect differences in the access and use of health services depending on their origin and the level of social integration of the immigrant group.

CONCLUSIONS

Professionals attribute a higher use of emergencies, late access to the health services, and less continuity of care, to a series of factors related to economic precariousness and to aspects related to the social inclusion. There is the room for social inclusion policies to reduce these inequalities.

[Stated theory of family doctors on their relationships with patients]

OBJECTIVE

To identify and analyse the "theory" expressed by family doctors on the essential features of an effective and functional doctor-patient relationship and on how to achieve one ("stated theory" of Argyris and Schon).

DESIGN

Qualitative, based on discourse analysis.

SETTING

Primary care.

METHOD

Interviews recorded with 10 family doctors selected by intentional sampling that were then transcribed. The propositions in the discourses were identified and conceptual maps were constructed. An inductive analysis classified the questions and positions that emerged and identified similarities and differences between subjects.

RESULTS

Confidence and absence of conflict were the main desirable features of the doctor-patient relationship. Patients with a "demanding" attitude and their dishonesty were the most quoted obstacles. Doctors accepted negotiation, but held a very limited view of patient participation. Differences were appreciated on distance, the biomedical versus psychosocial focus and health education. Doctors' communication skills and qualities were little cited. Technical terminology in this area appeared little in the discourses.

CONCLUSIONS

Discourses highlighted "health consumerism" and revealed disagreements on distance in the relationship and the psycho-social approach. These points, which should be prioritised in training, along with education, can serve to define family doctors distinct professional orientations. Training methodology must bear in mind that experience dominates "stated theory" in this area.

[Qualitative research: a valid alternative]

OBJECTIVE

To describe the main qualitative research techniques through systematic review of Spanish studies published during the previous 5 years.

DESIGN

Systematic review.

DATA SOURCES

The Indice Médico Español (bibliographic database of items published in Spanish health sciences journals) was searched, and systematic searches of the journals Atención Primaria, Gaceta Sanitaria, and Revista de Calidad Asistencial were done. Study selection. We included studies carried out with any type of qualitative research technique. Also included were studies that reviewed qualitative research techniques. We excluded studies that used a qualitative technique but were based mainly on quantitative research techniques. The review was done during the period from April 1997 to April 2002.

RESULTS

Most of the studies we reviewed used only one technique (80.5%). When more than one technique was used in combination (19.5% of the articles we reviewed), focus groups and interviews were usually used. The techniques identified were focus group (used in 34% of the articles reviewed), interview (24%), the Delphi technique (10%), content analysis (8%), nominal group (8%), metaplan (2%), and Philips 6/6 (2%).

CONCLUSIONS

Qualitative research is a valid alternative, and if used with appropriate methodological rigor it can be of considerable use to health care professionals.

[MIR family medicine program: cross-professional interaction in a complex reality]

OBJECTIVE

To find the view of trainers (tutors and teaching assistants) of third-year family and community medicine (FCM) residents concerning their own teaching activity in areas such as training, the skills and qualities required to be a teacher and the inter-professional relationships that are current and that are needed in a primary care teaching team.

DESIGN

Qualitative study developed between June 2000 and May 2002. Sample design with a volunteer population.

SETTING

FCM teaching unit under the Primary Care Administration of Murcia. PARTICIPANTS AND/OR CONTEXTS: Tutors and teaching assistants in the FCM residents' programme.

METHOD

Semi-structured interview for information gathering. Contents analysis to construct results on the basis of the semiological analysis of the textual discourse. Systematic return of the results.

RESULTS

Belonging to the teaching team is the highest motivation for taking part in teaching. It gives the tutors more benefits (affective, care load) than difficulties (organisational adaptation). The tutor profile is sustained by his/her scientific-technical and personal qualities; that of the nurse, by his/her community qualities. Collaboration between nurse and tutor is informal and the teaching strategies most employed by tutors are guidance, guide-lines and encouragement of residents' autonomy. Nurses collaborate with teaching by transmitting a model of professional development and facilitating teamwork.

CONCLUSIONS

The complexity of the training process stands out. Postgraduate FCM training is cross-professional, not exclusively circumscribed by the tutor-resident teaching relationship. The qualitative paradigm is shown to be useful for obtaining a vision of the teaching process from the perspective of different actors.

[Expectations of patients: what aspects of a health centre do they value? A qualitative-quantitative study]

OBJECTIVES

To identify the factors valued by users of health centres; to weigh the relative importance of each factor.

DESIGN

Qualitative stage (4 focus groups) to identify the factors valued. Quantitative stage (questionnaire to 225 people) to weigh their relative importance.

SETTING

Primary care.

PARTICIPANTS

Citizens from middle-high and middle-low social classes, urban, rural and over 65, were chosen through key informants for their interest in the health services. They were recruited with the assistance of various residents' associations and town councils.

METHOD

The factors valued were identified through focus groups and classified in categories. Their relative importance was weighed through a questionnaire and a factorial analysis to identify the main components was run.

RESULTS

60 factors that could be valued by patients were identified. Eight of these referred to the centre and concrete assets, nine to organisation and acessibility, 18 to relationship with the health professionals, and 25 to the services available. The most highly valued factor was: "The centre has sufficient material available for cures, minor surgery, bandages, etc." The factorial analysis confirmed the categories established. Organisation and accessibility, and relationship with professionals were the most highly valued dimensions.

CONCLUSIONS

The combination of qualitative and quantitative methods seems very fitting for this kind of study. Although many of the factors were to be expected, other little-expected ones emerged. In addition, users seem to value certain factors in a different way from how the professionals do.

[Perspective of patients on type-2 diabetes and their relationship with primary care health professionals: a qualitative study]

AIM

The objective of this study is to investigate the perception that people with type 2 diabetes have about the disease and about their relationship with the primary healthcare professionals.

DESIGN

Qualitative research, carried out between September-November 2000.

SETTING

Primary healthcare center Barrio del Pilar from Madrid.

PARTICIPANTS

15 persons with type 2 diabetes. Variables considered to design the profiles of the interviewed were: age, gender, educational level, and time since diagnosis.

METHOD

Structural sampling and open interviews.

RESULTS

Patients express having scarce information regarding the consequences of diabetes. As diabetes is symptom free represents a difficulty for being perceived as a severe disease. The most valued aspects of the relationship with health professionals are that they provide with clear and tailored information, build a trust context, support changes and take account their perspectives and living circumstances.

CONCLUSIONS

It is essential to recognize how patients understand and shape the disease. Information provided by professionals have to be tailored to patients necessities, and take place in a trusting environment. Decisions related with diabetes management have to be aligned with patients perspectives. Effective communication could be considered as a useful tool to encourage adherence and improve healthcare quality.

[Patients and quality of primary health care services. Survey of practitioners at the Bahía de Cádiz and La Janda health centers]

AIM

To report the opinions of practitioners at health centers on dimensions of quality that affect user satisfaction.

DESIGN

Cross-sectional study of focus groups (FG).

SETTING

Bahía de Cádiz and La Janda health centers in southwestern Spain.

PARTICIPANTS

We studied 4 FG whose participants were staff members of the two health centers: FG1, physicians; FG2, user satisfaction service staff; FG3, social workers; FG4, nurses. The groups were based on the different functions of staff at the two centers.

METHOD

The analysis was based on variables in the SERCAL model (an adaptation of the SERVQUAL model for the Spanish health care system) of opinions regarding service quality: access, comfort (tangibles), personalized service (courtesy), competence, and loyalty. The data were analyzed with version N-Vivo of the NUDIST program.

RESULTS

All dimensions of the theoretical model were identified by practitioners as constructs of users' perceptions of service quality. Users' and practitioners' views contrasted with and complemented each other to generate a model that could be validated. Access, personalized service and problem-solving (responsiveness) were key variables.

CONCLUSIONS

Practitioners' opinions provided information of use in improving the quality model. Differences in opinion between users and practitioners merit further study based on an understanding of these groups' values and interests, and on the care provision context. Practitioners identified access, personalized service and problem-solving as features that influenced users' opinions of the quality of the health center.

[Qualitative approach to the attitudes and expectations of doctors during the process of computerising primary care]

OBJECTIVE

To find the attitudes and expectations of doctors during the process of computerising primary care (PC).

DESIGN

Qualitative investigation through discussion groups.

PARTICIPANTS

Thirty-one doctors from the two PC regions of Gipuzkoa.

METHOD

Intentional stratified sampling by regions and by experience in using a computer in the consulting-room. Five discussion groups with recording and transcription of the contents with prior authorisation and guarantee of confidentiality. Qualitative analysis of the notes and transcriptions with the help of computer back-up. Validation through sending of results to participants and discussion between the authors.

RESULTS

Introducing computers into PC consulting-rooms had repercussions both on the ordering and contents of the information recorded. The effort <> was not accompanied by subsequent evaluation. Notable deficiencies in management of the computerising process were perceived. Computer use created additional symbolic effects for both patients and doctors.

CONCLUSIONS

Computerising PC is a process whose repercussions on medical care are far from neutral and so require rigorous discussion and evaluation. Defining step-by-step and measurable objectives, transparency in management and the promotion of evaluative research would all favour the effective development of projects to computerise PC.

[What lines of action should the Valencia Society of Family and Community Medicine adopt over the next 4 years?]

OBJECTIVE

To identify the areas of activity in which the Valencia Society of Family and Community Medicine (SVMFyC) should become involved over the next four years.

DESIGN

Qualitative research.Setting. SVMFyC members.

PATIENTS AND OTHER PARTICIPANTS

27 experts belonging to the SVMFyC took part.

INTERVENTIONS

Qualitative consensus-seeking techniques. Reliability and validity of the technique were ensured through triangulation and the selection of experts from among the different professional groups within the SVMFyC.

MEASUREMENTS AND MAIN RESULTS

To determine the recommended lines of action, productivity, spontaneous representativity, intensity of recommendation and degree of agreement were analysed. The priority lines recommended were: defending the MIR path, proposing reforms in undergraduate study plans, watching over the transparency of job selection procedures and the annual OPE selection, promoting the professional degree course, creation of posts for teachers in family and community medicine, defining the size of the population registered with a doctor, proposing an incentives list and studying alternatives to uniform salaries in the form of target-linked remuneration.

CONCLUSIONS

The lines of action recommended by the experts were established.

[What do family medicine residents expect of their tutors? A qualitative approach]

OBJECTIVE

To find the view of family and community medicine (FCM) residents on the kinds of relationship between tutors and residents and their training.

DESIGN

The methodology employed was qualitative; and the technique chosen, that of focus groups.

SETTING AND PARTICIPANTS

FCM residents belonging to the teaching units in Murcia and Cartagena.

INTERVENTION

Five groups were organised, two second-year resident groups, two third-year ones, and one first-year one. At the start of each group the objectives and norms of the meeting were explained. Residents were then asked four questions about their relationship with their tutor and the training received during their residency. The information arising was classified as a function of the time of debate, the number of residents expressing the same view and the intensity of their emotional involvement on expressing their views.

RESULTS

The tutor's confidence in the resident's work was what residents valued most highly, along with the exchange of views as equals. The participants stated that they wanted to take part in planning their training and that they needed to participate in the clinical and organisational decisions taken in the tutor's clinic.

CONCLUSIONS

Trust between tutor and resident is essential. Communication between the two must be on an equal basis. Training procedures are valued higher than training content. Residents want to intervene in planning their training. Tutors are models for training.

[Opinions and expectations of primary care professionals concerning team work]

OBJECTIVE

To find the views and expectations of professionals working at primary care centres on team-work.

DESIGN

Qualitative study. Focus group.

SETTING

The study was conducted during May 1997 at the following primary care centres: Terrassa North, Sant Llatzer (Terrassa) and Antón de Borja (Rubí). These PCCs depend on the Department of Health and Social Security and are managed by the Terrassa Health Consortium.

PARTICIPANTS

38 primary care professionals, distributed in 5 independent groups of 8 doctors, 9 nurses, 3 social workers, 9 clerical staff and 9 auxiliaries.

MEASUREMENTS AND RESULTS

Qualitative methodology and focal group technique were used. Contents of session transcriptions were analysed and the information classified according to themes. Views on the definition of team-work, basic aspects of its proper functioning, restrictions met by professionals at present and suggestions to overcome these restrictions were all identified.

CONCLUSIONS

The setting of objectives, the clear and structured definition of the functions of each professional group, the participation of all the team components in decision-taking, communication, and positive enabling approaches to team-work were all specified as basic features of the team's proper functioning. Ill-defined functions, few meetings, heterogeneity within the teams, scant team-work training, and passive and ill-adapted approaches were seen as restrictions. Training, the coordinator's activities, more meetings and changes in attitude were posed as alternatives.

[Use of the rapid appraisal method for the identification of perceived needs in a low-class barrio in the city of Buenos Aires]

OBJECTIVE

To present rapid appraisal as a qualitative technique for researching the perceived needs of a population, which is valid, rapid and cheap.

DESIGN

Qualitative method: semi-structured interviews with key informants, focus group.

SETTING

A poor quarter with 2921 inhabitants in the city of Buenos Aires.

PARTICIPANTS

Key informants: people resident in the area for over 10 years.

MEASUREMENTS AND MAIN RESULTS

The main problems perceived by the community were: environmental pollution because of the accumulation of rubbish, alcohol and drug abuse among the young, and the need to extend the opening hours of the area's health centre.

CONCLUSIONS

The needs perceived surpassed specific medical problems. They covered social questions, environmental problems and how to organise the health care system.