Primary health care and family medicine at the core of health care: challenges and priorities in how to further strengthen their potential

Disparities in cancer-related healthcare among people with intellectual disabilities: A population-based cohort study with health insurance claims data

Background

Concerns have been raised about the accessibility and quality of cancer‐related care for people with intellectual disabilities (ID). However, there is limited insight into cancer incidence and the utilization of cancer care at the ID population level to inform targeted cancer control strategies. Therefore, we aimed to examine differences in the utilization of cancer‐related care between people with and without ID, identified through diagnostic codes on health insurance claims.

Methods

In a population‐based cohort study, Dutch individuals of all ages who received residential care through the Chronic Care Act due to an ID (n = 65 183) and an age and sex‐matched sample of persons without ID (1:2 ratio), who were cancer‐free at enrollment in 2013 were followed through 2015. Incidence rates (IRs) of newly started cancer care and IR ratios (IRRs) with 95% CIs were used to compare groups. Separate analyses were performed per cancer type.

Results

Individuals with ID received less cancer‐related care than individuals without (IRR = 0.64, 95% CI 0.62‐0.66). Differences increased with age and were larger for females than for males. Utilization of care for cancers within the national screening program (female breast, cervical, and colon cancer) was lower for people with ID compared to people without ID.

Conclusion

Cancer may be underdiagnosed and/or undertreated in people with ID, or cancer is truly less prevalent in this population. In particular, the differences detected between males and females with ID, and the potential underutilization of national screening programs, require urgent follow‐up investigations.

Insight in the development of the mutual trust relationship between trainers and trainees in a workplace-based postgraduate medical training programme: a focus group study among trainers and trainees of the Dutch general practice training programme

OBJECTIVES

Trust plays an important role in workplace-based postgraduate medical education programmes. Trainers must trust their trainees for granting them greater independence. Trainees must trust their trainer for a safe learning environment. As trainers' and trainees' trust in each other plays an important role in trainee learning and development, the authors aimed to explore the development of the mutual trust relationship between trainers and trainees.

SETTING

This study was performed in a general practice training department in the Netherlands.

PARTICIPANTS

All trainers and trainees of the general practice training department were invited to participate. Fifteen trainers and 34 trainees, voluntarily participated in focus group discussions.

OUTCOME MEASURES

The authors aimed to gain insight in the factors involved in the development of the mutual trust relationship between trainers and trainees, in order to be able to create a model for the development of a mutual trust relationship between trainers and trainees. The risk-based view of trust was adopted as leading conceptual framework.

RESULTS

In the first stage of trust development, trainers and trainees develop basic trust in each other. Basic trust forms the foundation of the trust relationship. In the second stage, trainers develop trust in trainees taking into account trainees' working and learning performance, and the context in which the work is performed. Trainees trust their trainer based on the trainer'savailability and accessibility and the personal relationship between the trainee and their trainer. Trainee self-confidence modifies the development of a trust relationship.

CONCLUSION

The development of a mutual trust relationship between trainers and trainees is a complex process that involves various stages, goals, factors and interactive aspects. As the mutual trust relationship influences the learning environment for trainees, greater emphasis on the mutual trust relationship may improve learning outcomes. Further research may explore the effect of long-term and short-term educational relationships on the trust relationship between trainers and trainees.

Use of Animal and Animal Products for Rheumatoid Arthritis Treatment: An Explorative Study in Odisha, India

Severe fatigue, pain, deformity, and disability, are the major concerns for rheumatoid arthritis (RA). The extreme pain experienced by the patients often force them to experiment with various indigenous substances including animals and animal products. However, there is little evidence on the use of animals or animal products as traditional medicine in RA. Hence, this study was aimed to explore the experience and perception of patients toward the use of animals and animal products for the treatment of RA. A qualitative, explorative study was conducted at the out-patient-department of Rheumatology of a tertiary care medical college and hospital at Cuttack, Odisha, India. Out of 113 patients with RA, 18 patients gave history of use of animal and/or animal products and were selected for in-depth interviews. The content analysis methods were used for data analysis. Four major categories emerged: (1) prevailing patterns of traditional treatment of RA using animals, (2) beliefs and values behind the traditional treatment of RA, (3) sources and traditional learning pathway of indigenous practices on RA, and (4) ethical aspects of the indigenous practice of using animals and/or animal products in the treatment of RA. This study revealed the practice of eating dead animals to get relief from RA. However, there was hardly any perceived positive outcome of the practice; which indicates the lack of awareness of rational, scientific, treatment, and prevalence of irrational and unethical practices for the treatment of RA. Hence, community awareness, social mobilization, and newer screening tools are necessary to improve the timely detection and prevention of irrational treatment practices among RA patients.

Using Participatory Learning & Action (PLA) research techniques for inter-stakeholder dialogue in primary healthcare: an analysis of stakeholders' experiences

PLAIN ENGLISH SUMMARY

It is important for health care workers to know the needs and expectations of their patients. Therefore, service users have to be involved in research. To achieve a meaningful dialogue between service users, healthcare workers and researchers, participatory methods are needed. This paper describes how the application of a specific participatory methodology, Participatory Learning and Action (PLA) can lead to such a meaningful dialogue. In PLA all stakeholders are regarded as equal partners and collaborators in research.During 2011-2015, a European project called RESTORE used PLA in Austria, Greece, Ireland, The Netherlands and the UK to investigate how communication between primary health care workers and their migrant patients could be improved.Seventy eight migrants, interpreters, doctors, nurses and other key stakeholders (see Table 2) participated in 62 PLA sessions. These dialogues (involving discussions, activities, PLA techniques and evaluations) were generally 2-3 h long and were recorded and analysed by the researchers.Participants reported many positive experiences about their dialogues with other stakeholders. There was a positive, trusting atmosphere in which all stakeholders could express their views despite differences in social power. This made for better understanding within and across stakeholder groups. For instance a doctor changed her view on the use of interpreters after a migrant explained why this was important. Negative experiences were rare: some doctors and healthcare workers thought the PLA sessions took a lot of time; and despite the good dialogue, there was disappointment that very few migrants used the new interpreting service.

ABSTRACT

Background In order to be effective, primary healthcare must understand the health needs, values and expectations of the population it serves. Recent research has shown that the involvement of service users and other stakeholders and gathering information on their perspectives can contribute positively to many aspects of primary healthcare. Participatory methodologies have the potential to support engagement and dialogue between stakeholders from academic, migrant community and health service settings. This paper focuses on a specific participatory research methodology, Participatory Learning and Action (PLA) in which all stakeholders are regarded as equal partners and collaborators in research.Our research question for this paper was: "Does the application of PLA lead to meaningful engagement of all stakeholders, and if so, what elements contribute to a positive and productive inter-stakeholder dialogue?". Methods We explored the use of PLA in RESTORE, a European FP7-funded project, during 2011-2015 in 5 countries: Austria, Greece, Ireland, the Netherlands and the UK. The objective of RESTORE was to investigate and support the implementation of guidelines and training initiatives (G/TIs) to enhance communication in cross-cultural primary care consultations with migrants.Seventy eight stakeholders (migrants, interpreters, doctors, nurses and others - see Table 2) participated in a total of 62 PLA sessions (discussions, activities, evaluations) of approximately 2-3 h' duration across the five sites. During the fieldwork, qualitative data were generated about stakeholders' experiences of engagement in this dialogue, by means of various methods including participatory evaluations, researchers' fieldwork reports and researcher interviews. These were analysed following the principles of thematic analysis. Results Stakeholders involved in PLA inter-stakeholder dialogues reported a wide range of positive experiences of engagement, and very few negative experiences. A positive atmosphere during early research sessions helped to create a sense of safety and trust. This enabled stakeholders from very different backgrounds, with different social status and power, to offer their perspectives in a way that led to enhanced learning in the group - they learned with and from each other. This fostered shifts in understanding - for example, a doctor changed her view on interpreted consultations because of the input of the migrant service-users. Conclusion PLA successfully promoted stakeholder involvement in meaningful and productive inter-stakeholder dialogues. This makes it an attractive approach to enhance the further development of health research partnerships to advance primary healthcare.

The role of the family doctor in the management of adults who are obese: a scoping review protocol

Background

The role of family doctors in the management of obesity in primary care will become increasingly important as more of the adult population become overweight or obese. Having a solid understanding of the family doctor’s role as a sole practitioner is important for supporting practitioners in providing patient care and for informing future research.

Objective

The purpose of this paper is to describe a protocol for a scoping review that aims to examine and map the current research base for the role of the family doctor in managing adults who are overweight or obese.

Methods

This scoping review is based on the methodology as described by the Joanna Briggs Institute which involves final consultation with stakeholders. Two reviewers (ES, NE) will be responsible for the iterative development of a search strategy based on the basic initial search terms obesity, doctor and primary care. Black and grey literature will be searched to elucidate any manuscripts involving the family doctor in the management of adults who are overweight or obese. A customised data extraction tool will be used to collect relevant items from each manuscript.

Results

Data extraction will expose the role family doctors are playing in obesity management in all stages of research including recruitment, intervention or as a control group. By looking at a broad scope of manuscripts we will discover the family doctor’s role as portrayed in research, in international guidelines and by peak bodies. We will also determine if there are any gaps in the research base.

Conclusion

This protocol describes a scoping review that will illustrate the supporting international research for the role family doctors are playing in the management of adults who are overweight or obese. Scoping of the international literature will then be translated for Australian primary care.

Understanding medical symptoms: a conceptual review and analysis

The aim of this article is to present a conceptual review and analysis of symptom understanding. Subjective bodily sensations occur abundantly in the normal population and dialogues about symptoms take place in a broad range of contexts, not only in the doctor's office. Our review of symptom understanding proceeds from an initial subliminal awareness by way of attribution of meaning and subsequent management, with and without professional involvement. We introduce theoretical perspectives from phenomenology, semiotics, social interactionism, and discourse analysis. Drew Leder's phenomenological perspectives deal with how symptom perception occurs when any kind of altered balance brings forward a bodily attention. Corporeality is brought to explicit awareness and perceived as sensations. Jesper Hoffmeyer's biosemiotic perspectives provide access to how signs are interpreted to attribute meaning to the bodily messages. Symptom management is then determined by the meaning of a symptom. Dorte E. Gannik's concept "situational disease" explains how situations can be reviewed not just in terms of their potential to produce signs or symptoms, but also in terms of their capacity to contain symptoms. Disease is a social and relational phenomenon of containment, and regulating the situation where the symptoms originate implies adjusting containment. Discourse analysis, as presented by Jonathan Potter and Margaret Wetherell, provides a tool to notice the subtle ways in which language orders perceptions and how language constructs social interaction. Symptoms are situated in culture and context, and trends in modern everyday life modify symptom understanding continuously. Our analysis suggests that a symptom can only be understood by attention to the social context in which the symptom emerges and the dialogue through which it is negotiated.

Research and clinical practice: How to better answer the needs of patient care

This article analyzes the translation of research to clinical practice. Clinical practice is focused on a concrete context in which patients are encountered. This follows from the population under care in terms of their health status, socioeconomic circumstances, cultural and religious features, and social determinants of health but also from the actual function in which the encounter between patient and professional takes place. An understanding of this contextual complexity is as important in the translation of research into practice, as is an understanding of research. This asks for a partnership between practice and research, and the closer to the practice setting research data are collected, the more straightforward the translation is.

The importance of evaluating primary midwifery care for improving the health of women and infants

In most countries, maternal and newborn care is fragmented and focused on identification and treatment of pathology that affects only the minority of women and babies. Recently, a framework for quality maternal and newborn care was developed, which encourages a system-level shift to provide skilled care for all. This care includes preventive and supportive care that works to strengthen women's capabilities and focuses on promotion of normal reproductive processes while ensuring access to emergency treatment when needed. Midwifery care is pivotal in this framework, which contains several elements that resonate with the main dimensions of primary care. Primary health care is the first level of contact with the health system where most of the population's curative and preventive health needs can be fulfilled as close as possible to where people live and work. In this paper, we argue that midwifery as described in the framework requires the application of a primary care philosophy for all childbearing women and infants. Evaluation of the implementation of the framework should therefore include tools to monitor the performance of primary midwifery care.

Optimizing care and outcomes for people with type 2 diabetes - lessons from a translational research program on insulin initiation in general practice

BACKGROUND

Clinical inertia, failure to intensify treatment according to evidence-based guidelines, leads to prolonged, avoidable hyperglycemia in people with type 2 diabetes (T2D). This is a challenge for General Practice and Primary Care, where most people with T2D receive most of their care. Sustained, integrated translational research programs are needed to embed effective treatments in routine practice, yet many challenges exist for developing such programs.

OBJECTIVES

To explore challenges and facilitators to implementing a translational research program focused on insulin initiation and titration among people with T2D in general practice and to identify key factors important to support and sustain such translation research in primary care. Operationalizing a program of translational work in primary care: We describe a series of studies on insulin initiation and titration in general practice including theory and qualitative work (Phase 1), a small feasibility and acceptability pilot (Phase 2), a large scale pilot (Phase 3), and a pragmatic cluster randomized trial currently under way (Phase 4). We used mixed methods to explore practice level implementation issues, and reflective investigator discussions to explore broader research program sustainability. Challenges for translational research in primary care: Key facilitators and barriers at practice and research program levels, include: Appropriate funding structures to secure long-term capacity building and people support; Building and maintaining linkages between communities of practice, primary and secondary/tertiary care researchers, institutions, and industry partners; Strategies for engagement and support for practitioners and participants.

CONCLUSION

Building effective and sustainable translational research programs are critical for developing evidence-based policy that drives improved outcomes at a population level. Diverse sources of funding that support extensive and sustained trans-mural collaboration as well as engagement with practitioners, patients, and policymakers in the field are crucial.