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Information seeking for making evidence-informed
decisions: a social network analysis on the staff of a
public health department in Canada
Background:
Social network analysis is an approach to study the interactions and exchange of resourcesamong people. It can help understanding the underlying structural and behavioralcomplexities that influence the process of capacity building towards evidence-informeddecision making. A social network analysis was conducted to understand if and how the staffof a public health department in Ontario turn to peers to get help incorporating researchevidence into practice.
Methods:
The staff were invited to respond to an online questionnaire inquiring about informationseeking behavior, identification of colleague expertise, and friendship status. Three networkswere developed based on the 170 participants. Overall shape, key indices, the most centralpeople and brokers, and their characteristics were identified.
Results:
The network analysis showed a low density and localized information-seeking network. Interpersonalconnections were mainly clustered by organizational divisions; and people tended tolimit information-seeking connections to a handful of peers in their division. However,recognition of expertise and friendship networks showed more cross-divisional connections.Members of the office of the Medical Officer of Health were located at the heart of thedepartment, bridging across divisions. A small group of professional consultants and middlemanagers were the most-central staff in the network, also connecting their divisions to thecenter of the information-seeking network. In each division, there were some locally centralstaff, mainly practitioners, who connected their neighboring peers; but they were notnecessarily connected to other experts or managers.
Conclusions:
The methods of social network analysis were useful in providing a systems approach tounderstand how knowledge might flow in an organization. The findings of this study can beused to identify early adopters of knowledge translation interventions, forming Communitiesof Practice, and potential internal knowledge brokers.
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Accessing maternal and child health services in
Melbourne, Australia: Reflections from refugee
families and service providers
Background:
Often new arrivals from refugee backgrounds have experienced poor health and limitedaccess to healthcare services. The maternal and child health (MCH) service in Victoria,Australia, is a joint local and state government operated, cost-free service available to allmothers of children aged 0-6 years. Although well-child healthcare visits are useful inidentifying health issues early, there has been limited investigation in the use of theseservices for families from refugee backgrounds. This study aims to explore experiences ofusing MCH services, from the perspective of families from refugee backgrounds and serviceproviders.
Methods:
We used a qualitative study design informed by the socioecological model of health and acultural competence approach. Two geographical areas of Melbourne were selected to inviteparticipants. Seven focus groups were conducted with 87 mothers from Karen, Iraqi,Assyrian Chaldean, Lebanese, South Sudanese and Bhutanese backgrounds, who had lived anaverage of 4.7 years in Australia (range one month-18 years). Participants had a total of 249children, of these 150 were born in Australia. Four focus groups and five interviews wereconducted with MCH nurses other healthcare providers and bicultural workers.
Results:
Four themes were identified: facilitating access to MCH services; promoting continuedengagement with the MCH service; language challenges; and what is working well and couldbe done better. Several processes were identified that facilitated initial access to the MCHservice but there were implications for continued use of the service. The MCH service wasnot formally notified of new parents arriving with young children. Pre-arranged groupappointments by MCH nurses for parents who attended playgroups worked well to increaseongoing service engagement. Barriers for parents in using MCH services included access totransportation, lack of confidence in speaking English and making phone bookings. Serviceusers and providers reported that continuity of nurse and interpreter is preferred forincreasing client-provider trust and ongoing engagement.
Conclusions:
Although participants who had children born in Melbourne had good initial access to, andexperience of, using MCH services, significant barriers remain. A systems-oriented,culturally competent approach to service provision would improve the service utilisationexperience for parents and providers, including formalising links and notifications betweensettlement services and MCH services.
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Measuring data reliability for preventive services in
electronic medical records
Background:
Improvements in the quality of health care services are often measured using data present inmedical records. Electronic Medical Records (EMRs) contain potentially valuable newsources of health data. However, data quality in EMRs may not be optimal and should beassessed. Data reliability (are the same data elements being measured over time?) is aprerequisite for data validity (are the data accurate?). Our objective was to measure thereliability of data for preventive services in primary care EMRs during the transition to EMR.
Methods:
Our data sources were randomly selected eligible patients' medical records and data obtainedfrom provincial administrative datasets. Eighteen community-based family physicians inToronto, Ontario that implemented EMRs starting in 2006 participated in this study. Wemeasured the proportion of patients eligible for a service (Pap smear, screening mammogramor influenza vaccination) that received the service. We compared the change in rates ofselected preventive services calculated from the medical record audits with the change inadministrative datasets.
Results:
In the first year of EMR use (2006) services decreased by 8.7% more (95% CI 11.0%-6.4%, p < 0.0001) when measured through medical record audits as compared withadministrative datasets. Services increased by 2.4% more (95% CI 0%-4.9%, p = 0.05) in themedical record audits during the second year of EMR use (2007).
Conclusion:
There were differences between the change measured through medical record audits andadministrative datasets. Problems could include difficulties with organizing new data entryprocesses as well as continued use of both paper and EMRs. Data extracted from EMRs hadlimited reliability during the initial phase of EMR implementation. Unreliable data interfereswith the ability to measure and improve health care quality.
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Impact of data source and time reference of
functional status on hospital mortality prediction
Background:
The study objective was to compare physical function documented in the medical recordswith interview data, and also to evaluate hospital mortality predictions using pre-admissionand on-admission functional status derived from these two data sources.
Methods:
A prospective cohort study of 1402 subjects aged 65 years and older to the general medicinedepartment of an acute care hospital was conducted. Patient-reported pre-admission and onadmissionfunctional status for impairment in any of the five activities of daily living (ADLs)items (feeding, dressing, grooming, toileting and bathing), transferring and walking, werecompared with those extracted from the medical records. For the purpose of mortalityprediction, pre-admission and on-admission impairment in transferring from the two datasources were included in separate multivariable logistic regression models. We used avariable selection method that combines bootstrap resampling with stepwise backwardelimination.
Results:
For all ADL categories, the agreement between the data sources was good for pre-admissionfunctional status (k: 0.53-0.75) but poor for on-admission status (k: 0.18-0.31). Onadmissionimpairment was higher in the medical records than at interview for all basic ADLs.Using interview data as the gold standard, although sensitivity for pre- and on-admissionADLs was high (59-93%), specificity for on-admission status was poor (30-37%). The preadmissionmodels using interview data predicted mortality better than the model usingmedical records (c-statistic: 0.83 versus 0.82). Similar results were found for modelsincorporating on-admission functional status (c-statistic: 0.84 versus 0.81). However, thedifferences between the four models were not statistically significant.
Conclusion:
Medical records can be a good source for pre-admission functional status but on-admissionfunctional impairment was over-reported in the medical records. The discriminatory power ofthe hospital mortality prediction model was significantly improved with the incorporation offunctional status information but it was not significantly affected by their time reference orsource of data.
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Disease management projects and the Chronic Care
Model in action: baseline qualitative research
Background:
Disease management programs, especially those based on the Chronic Care Model (CCM),are increasingly common in the Netherlands. While disease management programs have beenwell-researched quantitatively and economically, less qualitative research has been done. Theoverall aim of the study is to explore how disease management programs are implementedwithin primary care settings in the Netherlands; this paper focuses on the early developmentand implementation stages of five disease management programs in the primary care setting,based on interviews with project leadership teams.
Methods:
At the five sites, eleven semi-structured interviews were conducted at the five selected siteswith sixteen professionals interviewed; all project leaders were interviewed. The interviewsfocused on each project's chosen chronic illness (diabetes, eating disorders, COPD, multimorbidity,CVRM) and project plan, barriers to development and implementation, the projectleaders' action and reactions, as well as their roles and responsibilities, and diseasemanagement strategies. Analysis was inductive and interpretive, based on the content of theinterviews. After analysis, the results of this research on disease management programs andthe Chronic Care Model are viewed from a traveling technology framework.
Results:
This analysis uncovered four themes that can be mapped to disease management and theChronic Care Model: (1) changing the health care system, (2) patient-centered care, (3)technological systems and barriers, and (4) integrating projects into the larger system. Projectleaders discussed the paths, both direct and indirect, for transforming the health care systemto one that addresses chronic illness. Patient-centered care was highlighted as needed and aparadigm shift for many. Challenges with technological systems were pervasive. Projectleaders managed the expenses of a traveling technology, including the social, financial, andadministration involved.
Conclusions:
At the sites, project leaders served as travel guides, assisting and overseeing the programs asthey traveled from the global plans to local actions. Project leaders, while hypothetically incontrol of the programs, in fact shared control of the traveling of the programs with patients,clinicians, and outside consultants. From this work, we can learn what roadblocks andexpenses occur while a technology travels, from a project leader's point of view.
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Acceptability - a neglected dimension of access to
health care: findings from a study on childhood
convulsions in rural Tanzania
Background:
Acceptability is a poorly conceptualized dimension of access to health care. Using a study onchildhood convulsion in rural Tanzania, we examined social acceptability from a userperspective. The study design is based on the premise that a match between health providers'and clients' understanding of disease is an important dimension of social acceptability,especially in trans-cultural communication, for example if childhood convulsions are notlinked with malaria and local treatment practices are mostly preferred. The study was linkedto health interventions with the objective of bridging the gap between local and biomedicalunderstanding of convulsions.
Methods:
The study combined classical ethnography with the cultural epidemiology approach usingEMIC (Explanatory Model Interview Catalogue) tool. EMIC interviews were conducted in a2007/08 convulsion study (n = 88) and results were compared with those of an earlier 2004/06convulsion study (n = 135). Earlier studies on convulsion in the area were also examined toexplore longer-term changes in treatment practices.
Results:
The match between local and biomedical understanding of convulsions was already high inthe 2004/06 study. Specific improvements were noted in form of (1) 46% point increaseamong those who reported use of mosquito nets to prevent convulsion (2) 13% point decreaseamong caregivers who associated convulsion with 'evil eye and sorcery', 3) 14% pointincrease in prompt use of health facility and 4)16% point decrease among those who did notuse health facility at all. Such changes can be partly attributed to interventions whichexplicitly aimed at increasing the match between local and biomedical understanding ofmalaria. Caregivers, mostly mothers, did not seek advice on where to take an ill child. Thisindicates that treatment at health facility has become socially acceptable for severe febrilewith convulsion.
Conclusion:
As an important dimension of access to health care 'social acceptability' seems relevant instudying illnesses that are perceived not to belong to the biomedical field, specifically intrans-cultural societies. Understanding the match between local and biomedicalunderstanding of disease is fundamental to ensure acceptability of health care services,successful control and management of health problems. Our study noted some positivechanges in community knowledge and management of convulsion episodes, changes whichmight be accredited to extensive health education campaigns in the study area. On the otherhand it is difficult to make inference out of the findings as a result of small sample sizeinvolved. In return, it is clear that well ingrained traditional beliefs can be modified withcommunication campaigns, provided that this change resonates with the beneficiaries.
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HIV/aids related home based care practices among primary health care workers in Ogun state, Nigeria
Background:
HIV/AIDS is fast becoming a chronic disease with the advent of antiretroviral drugs,therefore making home based care key in the management of chronically ill HIV/AIDSpatient. The objective of this study was to determine the perception and practice of healthcare workers on HIV/AIDS related home based care in the health facilities in Ogun state,Nigeria.
Methods:
This study is an analytical cross-sectional study. A multistage cluster sampling technique wasused to obtain a representative sample of the primary health care workers in Ogun state. Aninterviewer administered structured questionnaire was administered by trained health workersto elicit the required information.ResultA total of 350 health care workers were interviewed, 70% of the respondents couldadequately describe the components of home based care. Only 38.7% were aware of theNational guideline on home based care practices and 17.1% believe that home based care willnot significantly improve the prognosis of PLWAs. Few 19.1% had ever been trained or everinvolved 16.6% in home based care practices. Only 20 [5.7%] are involved on a weeklybasis, 16 [4.6%] monthly and 22 [6.3%] quarterly. Reasons given for non implementation ofhome based care are inadequate number of healthcare workers 45%, lack of political will24.4%, lack of implementation by facility managers 14% and inadequate funds 16.6%.Factors that were significantly associated with the practice of home based care wereperception of its relevance in improving prognosis [OR = 54.21, C.I = 23.22-129.52] andpresence of a support group in the facility [OR = 4.80, C.I = 2.40-9.57]. There was howeverno statistically significant relationship between adequate knowledge of home based care [OR= 0.78, C.I = 0.39-1.54] and previous training on home based care (OR = 1.43, C.I = 0.66-3.06].
Conclusion:
The practice of home based care for HIV/AIDS among the study population is low and it isgreatly influenced by perception of its effectiveness and relevance. The study recommendsthat the health care workers should be adequately educated on the importance of home basedcare in the management of chronic illnesses in order to enhance its practice.
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Community-based post-stroke service provision and challenges: a national survey of managers and inter-disciplinary healthcare staff in Ireland.
Background:
The extent of stroke-related disability typically becomes most apparent after patient discharge to the community. Maximising rehabilitation input at this point can minimise the impact of disability. As part of the Irish National Audit of Stroke Care (INASC), a national survey of community-based allied health professionals and public health nurses was conducted. The aim was to document the challenges to service availability for patients with stroke in the community and to identify priorities for service improvement.
Methods:
The study was a cross-sectional tailored interview survey with key managerial and service delivery staff. As comprehensive listings of community-based health professionals involved in stroke care were not available, a cascade approach to information gathering was adopted. Representative regional managers for services incorporating stroke care (N=7) and disciplinary allied health professional and public health nurse managers (N=25) were interviewed (94% response rate).
Results:
Results indicated a lack of formal, structured community-based services for stroke, with no designated clinical posts for stroke care across disciplines nationally. There was significant regional variation in availability of allied health professionals. Considerable inequity was identified in patient access to stroke services, with greater access, where available, for older patients (>65 years). The absence of a stroke strategy and stroke prevalence statistics were identified as significant impediments to service planning, alongside organisational barriers limiting the recruitment of additional allied health professional staff, and lack of sharing of discipline-specific information on patients.
Conclusions:
This study highlighted major gaps in the provision of inter-disciplinary team community-based services for people with stroke in one country. Where services existed, they were generic in nature, rarely inter-disciplinary in function and deficient in input from salient disciplines. Challenges to optimal care included the need for strategic planning; increased funding of healthcare staff; increased team resources and teamwork; and removal of service provision barriers based on age. There were notably many challenges beyond funding. Similar evaluations in other healthcare systems would serve to provide comparative lessons to serve to tackle this underserved aspect of care for patients with stroke and their families.
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"Completely out-at-sea" with "two-gender medicine":
A qualitative analysis of physician-side barriers to providing healthcare for transgender patients
Background:
Members of the transgender community have identified healthcare access barriers, yet a corresponding inquiry into healthcare provider perspectives has lagged. Our aim was to examine physician perceptions of barriers to healthcare provision for transgender patients.
Methods:
This was a qualitative study with physician participants from Ontario, Canada. Semi-structured interviews were used to capture a progression of ideas related to barriers faced by physicians when caring for their trans patients. Qualitative data were then transcribed verbatim and analysed with an emergent grounded theory approach.
Results:
A total of thirteen (13) physician participants were interviewed. Analysis revealed healthcare barriers that grouped into five themes: Accessing resources, medical knowledge deficits, ethics of transition-related medical care, diagnosing vs. pathologising trans patients, and health system determinants. A centralising theme of "not knowing where to go or who to talk to" was also identified.
Conclusions:
The findings of this study show that physicians perceive barriers to the care of trans patients, and that these barriers are multifactorial. Access barriers impede physicians when referring patients to specialists or searching for reliable treatment information. Clinical management of trans patients is complicated by a lack of knowledge, and by ethical considerations regarding treatments--which can be unfamiliar or challenging to physicians. The disciplinary division of responsibilities within medicine further complicates care; few practitioners identify trans healthcare as an interest area, and there is a tendency to overemphasise trans status in mental health evaluations. Failure to recognise and accommodate trans patients within sex-segregated healthcare systems leads to deficient health policy. The findings of this study suggest potential solutions to trans healthcare barriers at the informational level--with increased awareness of clinical guidelines and by including trans health issues in medical education--and at the institutional level, with support for both trans-focused and trans-friendly primary care models.
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A teachable moment communication process for smoking cessation talk: description of a group randomized clinician-focused intervention
Background:
Effective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease. Existing guidelines for specific health behavior counseling have been created and promulgated, but not successfully adopted in primary care practice. Building on work focused on creating effective clinician strategies for prompting health behavior change in the primary care setting, we developed an intervention intended to enhance clinician communication skills to create and act on teachable moments for smoking cessation. In this manuscript, we describe the development and implementation of the Teachable Moment Communication Process (TMCP) intervention and the baseline characteristics of a group randomized trial designed to evaluate its effectiveness.
Methods:
This group randomized trial includes thirty-one community-based primary care clinicians practicing in Northeast Ohio and 840 of their adult patients. Clinicians were randomly assigned to receive either the Teachable Moments Communication Process (TMCP) intervention for smoking cessation, or the delayed intervention. The TMCP intervention consisted of two, 3-hour educational training sessions including didactic presentation, skill demonstration through video examples, skills practices with standardized patients, and feedback from peers and the trainers. For each clinician enrolled, 12 patients were recruited for two time points. Pre- and post-intervention data from the clinicians, patients and audio-recorded clinicianpatient interactions were collected. At baseline, the two groups of clinicians and their patients were similar with regard to all demographic and practice characteristics examined. Both physician and patient recruitment goals were met, and retention was 96% and 94% respectively.DiscussionFindings support the feasibility of training clinicians to use the Teachable Moments Communication Process. The next steps are to assess how well clinicians employ these skills within their practices and to assess the effect on patient outcomes.Trial RegistrationClinicalTrials.gov Identifier: NCT01575886
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