Lay referral patterns involved in cardiac treatment decision making among middle-aged and older adults

Use, characteristics and influence of lay consultation networks on treatment-seeking decisions in slums of Nigeria: a cross-sectional survey

OBJECTIVES

To describe the use, characteristics and influence of lay consultants on treatment-seeking decisions of adults in slums of Nigeria.

DESIGN

Cross-sectional survey using a pre-piloted questionnaire.

SETTINGS

Two slum communities in Ibadan city, Nigeria.

PARTICIPANTS

480 adults within the working age group (18-64).

RESULTS

Most respondents (400/480, 83.7%) spoke to at least one lay consultant during their last illness/health concern. In total, 683 lay consultants were contacted; all from personal networks such as family and friends. No respondent listed online network members or platforms. About nine in 10 persons spoke to a lay consultant about an illness/health concern without intending to seek any particular support. However, almost all (680/683, 97%) lay consultants who were contacted provided some form of support. Marital status (OR=1.92, 95% CI: 1.10 to 3.33) and perceiving that an illness or health concern had some effects on their daily activities (OR=3.25, 95% CI: 1.94 to 5.46) had a significant independent association with speaking to at least one lay consultant. Age had a significant independent association with having lay consultation networks comprising non-family members only (OR=0.95, 95% CI: 0.92 to 0.99) or mixed networks (family and non-family members) (OR=0.97, 95% CI: 0.95 to 0.99), rather than family-only networks. Network characteristics influenced individual treatment decisions as participants who contacted networks comprising non-family members only (OR=0.23, 95% CI: 0.08 to 0.67) and dispersed networks (combination of household, neighbourhood and distant network members) (OR=2.04, 95% CI: 1.02 to 4.09) were significantly more likely to use informal than formal healthcare, while controlling for individual characteristics.

CONCLUSIONS

Health programmes in urban slums should consider engaging community members so, when consulted within their networks, they are able to deliver reliable information about health and treatment-seeking.

Health Help-Seeking Behavior: The Scavengers' Perspective

Scavengers are prone to various health problems, hence seeking healthcare is inevitable. Despite the importance of the help-seeking behavior of scavengers, it has not been addressed explicitly in the existing literature. Addressing this gap, this study intends to explore the help-seeking behavior of scavengers and to identify the factors that influence healthcare utilization among them. This qualitative study conducted thirty-one in-depth interviews through a semi-structured interview guide and analyzed them using thematic analysis. Andersen’s Behavioral Model of Health Service Use was employed to explore the findings. The findings showed that the scavengers utilized multiple healthcare options depending on the severity and reoccurrence of the illness. The process of help-seeking and health services utilization was largely influenced by the cost of the health service, long distance to the health facility, traveling cost and waiting time. The study highlights the need for scavengers’ enrolment in micro health insurance schemes. The initiative would facilitate scavengers’ access to medical care. Health awareness campaigns and the provision of free mobile medical services, especially at the landfill sites, would also improve curative treatment among scavengers.

Self-Care Practices of Primary Health Care Patients Diagnosed with Chronic Heart Failure: A Cross-Sectional Survey

Chronic heart failure patients require self-care behaviors and active monitoring of signs and symptoms to prevent worsening. Most patients with this condition are attended in primary healthcare centers. This study aimed to evaluate the endorsement of and adherence to self-care behaviors in primary health care patients with chronic heart failure. We conducted a multicenter cross-sectional study. We randomly included chronic heart failure patients from 10 primary healthcare centers in the Barcelona metropolitan area (Spain). Patients completed the European Heart Failure Self-Care Behaviour Scale, a health literacy questionnaire. Differences between groups were studied using ANOVA tests. We included 318 patients with a mean age of 77.9 years, mild limitations in functional activity New York Heart Association scale (NYHA) II = 51.25%), and a low health literacy index of 79.6%. The endorsement of self-care behaviors was low in daily weighing (10.66%), contacting clinicians if the body weight increased (22.57%), and doing physical exercise regularly (35.58%). Patients with lower educational levels and a worse health literacy had a lower endorsement. The screening of individual self-care practices in heart failure patients might improve the clinician follow-up. We suggest that primary healthcare clinicians should routinely screen self-care behaviors to identify patients requiring a closer follow-up and to design and adapt rehabilitation programs to improve self-care.

Manageability, vulnerability and interaction: A qualitative analysis of acute myocardial infarction patients’ conceptions of the event

Background

Delay in seeking care remains a problem for many patients with myocardial infarction. There is a great deal of knowledge available about clinical factors contributing to this delay, while studies focusing on the patients’ own experiences are few.

Aim

Describe variations in how individuals perceived suffering symptoms of an acute myocardial infarction.

Design

A qualitative method using phenomenographic design was applied. Interviews were conducted with 15 strategically selected patients with myocardial infarction.

Findings

Eight sub-categories in the pre-hospital phase were summarised into three categories: manageability, vulnerability, and interaction. To manage their situation, patients expressed a need to understand it and to have a similar situation to compare with. They also described coping with the arising threat to their lives by self-medication or denying their symptoms. Patients expressed vulnerability, with feelings of anxiety, both as triggers and barriers to seeking medical care. In interaction with others, psychosocial support and guidance from the environment, was fundamental in helping the patients to manage the situation.

Conclusions

There were large variations in myocardial infarction patients’ conceptions of the event. To improve disease management in the pre-hospital phase, the awareness of this large variation in conceptions about suffering symptoms of an myocardial infarction could be used in the dialogue between patients and health care professionals, in cardiac prevention programmes, as well as in health care education.

Six 'biases' against patients and carers in evidence-based medicine

BACKGROUND

Evidence-based medicine (EBM) is maturing from its early focus on epidemiology to embrace a wider range of disciplines and methodologies. At the heart of EBM is the patient, whose informed choices have long been recognised as paramount. However, good evidence-based care is more than choices.

DISCUSSION

We discuss six potential 'biases' in EBM that may inadvertently devalue the patient and carer agenda: limited patient input to research design, low status given to experience in the hierarchy of evidence, a tendency to conflate patient-centred consulting with use of decision tools; insufficient attention to power imbalances that suppress the patient's voice, over-emphasis on the clinical consultation, and focus on people who seek and obtain care (rather than the hidden denominator of those that do not seek or cannot access care). To reduce these 'biases', EBM should embrace patient involvement in research, make more systematic use of individual ('personally significant') evidence, take a more interdisciplinary and humanistic view of consultations, address unequal power dynamics in healthcare encounters, support patient communities, and address the inverse care law.

Which patients and where: a qualitative study of patient transfers from community hospitals

BACKGROUND

Interhospital transfer of patients is a routine part of the care at community hospitals, but the current process may lead to suboptimal patient outcomes. A microlevel analysis of the processes of patient transfer has not earlier been carried out.

RESEARCH DESIGN

We conducted semistructured qualitative interviews with care providers at 3 purposively sampled community hospitals to describe patient transfer mechanisms, focusing on perceptions of transfers and transfer candidates, choice of transfer destination, and perceived process. We interviewed physicians, nurses, and care technicians from emergency departments and intensive care units at the hospitals, and analyzed the resultant transcripts by content analysis.

RESULTS

Appropriate triage and the transfer of patients was a highly valued skill at the community hospitals. On the basis of participant accounts, the transfer process had 4 components: (1) Identifying transfer-eligible patients; (2) Identifying a destination hospital; (3) Negotiating the transfer; and (4) Accomplishing the transfer. There were common challenges at each component across hospitals. Protocolization of care was perceived to substantially facilitate transfers. Informal arrangements played a key role in the identification of the receiving hospital, but patient preferences and hospital quality were not discussed as important in decision making. The process of arranging a patient transfer placed a significant burden on the staff of community hospitals.

CONCLUSIONS

The patient transfer process is often cumbersome, varies by condition, and may not be focused on optimizing patient outcomes. Development of a more fluid transfer infrastructure may aid in implementing policies such as selective referral and regionalization.

Interhospital transfers among Medicare beneficiaries admitted for acute myocardial infarction at nonrevascularization hospitals

BACKGROUND

Patients with acute myocardial infarction (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability, yet we know little about the basis for how such revascularization hospitals are selected.

METHODS AND RESULTS

We examined interhospital transfer patterns in 71 336 AMI patients admitted to hospitals without revascularization capabilities in the 2006 Medicare claims using network analysis and regression models. A total of 31 607 (44.3%) AMI patients were transferred from 1684 nonrevascularization hospitals to 1104 revascularization hospitals. Median time to transfer was 2 days. Median transfer distance was 26.7 miles, with 96.1% within 100 miles. In 45.8% of cases, patients bypassed a closer hospital to go to a farther hospital that had a better 30-day risk standardized mortality rates. However, in 36.8% of cases, another revascularization hospital with lower 30-day risk-standardized mortality was actually closer to the original admitting nonrevascularization hospital than the observed transfer destination. Adjusted regression models demonstrated that shorter transfer distances were more common than transfers to the hospitals with lowest 30-day mortality rates. Simulations suggest that an optimized system that prioritized the transfer of AMI patients to a nearby hospital with the lowest 30-day mortality rate might produce clinically meaningful reductions in mortality.

CONCLUSIONS

More than 40% of AMI patients admitted to nonrevascularization hospitals are transferred to revascularization hospitals. Many patients are not directed to nearby hospitals with the lowest 30-day risk-standardized mortality, and this may represent an opportunity for improvement.

"Is it half full or half empty?" Affective responses to chronic illness

Using a combined qualitative/quantitative approach, we interviewed 132 older African-Americans and whites with either osteoarthritis of the hip or knee (OAK/OAH) or ischemic heart disease (IHD) to address two questions: 1) What types of reactions to illness are expressed by this group of older adults who have OA or IHD? 2)? Are there differences in the characteristics of the respondents who respond more positively than those who respond more negatively? The responses were coded to illustrate those that reflected positive, negative, or combined (positive/negative) statements. The majority of the respondents, who were categorized as positive or combined, approached the illness experience with statements illustrating their ability to cope with their illness and adapt their lifestyles to the limitations imposed by the disease such as acceptance, feeling that others were worse off, or changing their lifestyles to adapt to their limitations. Those expressing negative reactions to their illness were fewer in number and responded with terms reflecting loss of identity, physical limitations, and other disease symptoms. The differences were more pronounced between the positive and negative groups where the latter were somewhat more likely to be African-American and female and significantly more likely to have less income, greater perceived disease severity, and more disability. We should look to the larger group in both the positive only and combined responses to explore how culture may play a role in perceptions of subjective well-being and the importance of "the local worlds of experience" experienced by both men and women, and African-Americans and whites. This study illustrates that using a simple, open-ended question that stimulates older people to narrate their reactions to having a chronic illness may allow clinicians to identify the persons most at-risk and intervene appropriately.

Stroke Symptoms and the Decision to Call for an Ambulance

BACKGROUND AND PURPOSE

Few acute stroke patients are treated with alteplase, partly because of significant prehospital delays after symptom onset. The aim of this study was to determine among ambulance-transported stroke patients factors associated with stroke recognition and factors associated with a call for ambulance assistance within 1 hour from symptom onset.

METHODS

For 6 months in 2004, all ambulance-transported stroke or transient ischemic attack patients arriving from a geographically defined region in Melbourne (Australia) to 1 of 3 hospital emergency departments were assessed. Tapes of the call for ambulance assistance were analyzed and the patient and the caller were interviewed.

RESULTS

One hundred ninety-eight patients were included in the study. Stroke was reported as the problem in 44% of ambulance calls. Unprompted stroke recognition was independently associated with facial droop (P=0.015) and a history of stroke or transient ischemic attack (P<0.001). More than half of the calls for ambulance assistance were made within 1 hour from symptom onset and only 43% of these callers spontaneously identified the problem as "stroke." Factors independently associated with a call within 1 hour were: speech problems (P=0.009), caller family history of stroke (P=0.017), and the patient was not alone at symptom onset (P=0.018).

CONCLUSIONS

Stroke was reported as the problem (unprompted) by <50% of callers. Fewer than half the calls were made within 1 hour from symptom onset. Interventions are needed to more strongly link stroke recognition to immediate action and increase the number of stroke patients eligible for acute treatment.

"I really should've gone to the doctor": older adults and family caregivers describe their experiences with community-acquired pneumonia

BACKGROUND

Responding to acute illness symptoms can often be challenging for older adults. The primary objective of this study was to describe how community-dwelling older adults and their family members responded to symptoms of community-acquired pneumonia (CAP).

METHODS

A qualitative study that used face-to-face semi-structured interviews to collect data from a purposeful sample of seniors aged 60+ and their family members living in a mid-sized Canadian city. Data analysis began with descriptive and interpretive coding, then advanced as the research team repeatedly compared emerging thematic categories to the raw data. Searches for disconfirming evidence and member checking through focus groups provided additional data and helped ensure rigour.

RESULTS

Community-acquired pneumonia symptoms varied greatly among older adults, making decisions to seek care difficult for them and their family members. Both groups took varying amounts of time as they attempted to sort out what was wrong and then determine how best to respond. Even after they concluded something was wrong, older adults with confirmed pneumonia continued to wait for days, to over a week, before seeking medical care. Participants provided diverse reasons for this delay, including fear, social obligations (work, family, leisure), and accessibility barriers (time, place, systemic). Several older adults and family members regretted their delays in seeking help.

CONCLUSION

Treatment-seeking delay is a variable, multi-phased decision-making process that incorporates symptom assessment plus psychosocial and situational factors. Public health and health care professionals need to educate older adults about the potential causes and consequences of unnecessary waits. Such efforts may reduce the severity of community-acquired pneumonia upon presentation at clinics and hospitals, and that, in turn, could potentially improve health outcomes.

Family involvement in residential long-term care: a synthesis and critical review

The objective of this review is to critically synthesize the existing literature on family involvement in residential long-term care. Studies that examined family involvement in various long-term care venues were identified through extensive searches of the literature. Future research and practice must consider the complexity of family structure, adopt longitudinal designs, provide direct empirical links between family involvement and resident outcomes, and offer rigorous evaluation of interventions in order to refine the literature.

Gender differences in reasons patients delay in seeking treatment for acute myocardial infarction symptoms

Patients (n = 194) with confirmed acute myocardial infarction (AMI) were interviewed to determine sociodemographic, clinical, social, behavioral, cognitive and emotional factors that contribute to delay in seeking treatment for their symptoms. Initial symptom experience was similar for men and women: both were most commonly at home when symptoms began; both were most commonly in the presence of their spouse or other family member; few patients (<10%) called the emergency medical system as their first reaction. Several factors contributed similarly to delay in men and women. Factors that exerted a differential effect on delay between men and women were age, history of AMI, type of AMI (Q-wave and non-Q-wave), concerns about not wanting to trouble others, and prior knowledge of thrombolytics. There was no difference in delay between men and women (median 3.08 versus 3.10 h), but there are important gender differences in the reasons patients delay and in their patterns of decision-making that may assist clinicians trying to tailor interventions.

Cancer caregiving and subjective stress: a multi-site, multi-dimensional analysis

Although research has emerged documenting the psychosocial impact of family care for cancer patients, few efforts capture the multi-dimensional nature of cancer caregiving stress, particularly among socioeconomically diverse samples. Utilizing data collected from cancer caregivers at a non-urban, Southern US site and an inner-city, Northeastern US site (N=233), the present study identified predictors of multiple dimensions of caregivers' subjective stress (i.e. emotional appraisals of care demands). Various indicators representing the sociodemographic context of care, cancer care demands, and psychosocial resources were found to exacerbate or buffer caregivers from feelings of exhaustion, role entrapment, and loss of intimacy with the cancer patient. The multivariate regression model also emphasized the diffuse yet potent role care recipient mood problems and caregiver mastery/optimism have on multiple dimensions of subjective stress. The findings offer a number of recommendations for future research and practice focused on informal cancer care.

Living Arrangement Decisions at Discharge and Later: Differences in Criteria and Outcomes

This study examined the pattern of post rehabilitation living arrangements over 18 months of 172 adults discharged from a geriatric rehabilitation unit at a large urban medical center, all of whom were living alone prior to admission. Results showed the diminishing importance of physical function and cognition as factors in decisions to return home as the length of time after hospital discharge increased. Patients who returned home to live alone after a period of time living in more supported environments had significantly lower assessment scores on physical function (p < 0.001) and cognition (p < 0.001) compared to patients who went home to live alone immediately upon discharge. As well, patients who returned home to live alone later than three months post discharge were significantly more likely to move to more supported environments by 18 months after discharge (p = 0.043) and to experience re-hospitalizations (p = 0.008), which raises questions about the appropriateness of these later decisions.