The patient-centeredness of the consultation among patients with chronic disease: a cross-sectional study of the St. Joseph cluster of health centres in Trinidad and Tobago

Background: Several studies demonstrate patient-centered care enhances patient satisfaction, quality of care and health outcomes while decreasing health care costs and discrepancies in health care. The aims were to measure consultation length, patient's perception of patient centeredness (PPPC) and patient enablement instrument score (PEI) and to determine the patient factors associated with them. Method: A cross-sectional study was conducted over 2 months at four clinics. collecting data from 180 patients (82% response rate) attending. The interviewers timed the consultation as the patients entered and exited the doctor's room. The post-consultation questionnaire comprised demographics, consultation parameters, the PPPC survey (14 questions scored 1-4) and the PEI survey (6 questions scored 0-2). Results: The response rate was 82.5% with a sample of 180 patients. The average, median and mode of quality measures: PPPC average (3.67, 3.86 and 4), PEI score (5.93, 6 and 6) and consultation length (8.5, 7.74 and 10). The PPPC Average was higher in patients without stroke (p=0.022), those with more than 2 consultation interruptions (p=0.015) and those who knew the doctor very well (p=0.015). The PEI score was higher in patients without heart disease (p=0.022). The consultation length was longer in those with tertiary education (p=0.044) and those with two consultation interruptions (p=0.032). PPPC Average and PEI Score correlated well (p=0.408, p<0.001). The consultation length correlated with the PPPC Average (p=0.168, p=0.025). Conclusion: The PPPC Average, PEI Score and consultation length were above average compared internationally. The implementation of a 15-minute appointment system and training programmes for staff in patient-centeredness may improve care for patients. Future study should determine cut-off values for the surveys to assess standard of care.

A study of health risk behaviour and social factors of women between ages 25-59 years in Trinidad

The three main objectives of this study were to (a)describe and compare health status of urban and rural women in Trinidad with respect to economic, demographic and educational factors, (b) evaluate women's knowledge of and attitude towards self-breast examination and cervical screening and (d) determine their utilization pattern of health care services. A total of 1,450 women were interviewed for the study. The overall sample size, n, was calculated to be approximately 1,450 households, given a 5 percent non-response rate. Probability sampling and a nationally representative sample of the population was used. The statistical techniques used to assemble, describe and infer were exploratory analysis, partial correlation analysis and multi-step wise regression. The study identified several factors that influenced a woman's decision to have a Pap Smear Test: education level, age, religion, ethnicity, marital status, employment and income status. Those with higher levels of education had a greater probability of having a Pap test. Of the women aged 40-44 years, 48.1 percent were more knowledgeable about the purpose of the Pap test. The influence of religion was apparent with the Christian community exhibiting a higher percentage of screening compared to the Hindu and Muslim women. The results of Ethnicity found that (10.6 percent) of women of African origin had abnormal test results compared to women of East Indian origin, (4.4 percent). Married women had lower levels or cervical cancer, compared to unmarried women. The percentage of women feeling confident to perform breast self-examinations was lowest among women with low education level (36.4 percent) compared to women with tertiary level education, (68.0 percent). Cervical cancer is more common in women of low socioeconomic status and educational levels. Our study shows these factors influence their inadequate utilization of Pap smear services. Knowledge of the purpose of a Pap smear also relates to their socioeconomic status. It indicates that dissemination of information pertaining to Pap test, cervical cancer and availability of healthcare must be tailored to women represented in these groups (AU)

Implementing a continuous quality improvement programme in healthcare

Although the healthcare industry supports the view that TQM is the way of managing for the future, the implementation of CQI programmes could be problematic. This is because of certain characteristics that are unique to healthcare organisations and professionals, as evidenced by the studies in the UK, the USA, and the Bahamas. Based on the study at Princess Margaret Hospital, similarities in experiences were discovered. Some of the recommendations made were that:- sessions on CQI principles should be conducted specifically for top management, with a view that they too will employ these principles in their daily work; every effort should be made to involve physicians and to communicate that 'quality' includes them as well; adequate funding should be provided to implement and sustain quality programmes; all staff should be trained and involved in quality methods; a 'phased-in approach' should be used, this has been found to be more successful in implementing CQI; the patient must be seen as a priority in the equation, and therefore plans should be made to include them in their own care; staff should be rewarded and given incentives for quality improvement success (AU)

Evaluation of neonatal sepsis screening in a tropical area. Part I: Major risk factors of bacterial carriage at birth in Guadeloupe

This prospective study reports on screening for neonatal sepsis among 3,372 live births out of 6,060 consecutive deliveries at the University Hospital of Pointe-a-Pitre, Guadeloupe, during a 30 month period. Group B Streptococcus (GBS) was the most common pathogen, representing 46 percent (89/194) of positive blood cultures and 52 percent (335/637) of positive gastric aspirates. Although only 3,372 (55 percent) of all live births were screened, 637 (10 percent) had gastric bacterial carriage at birth; of those, 335 (5.5 percent) involved GBS. Similarly, there were 194 (3.2 percent) positive blood cultures, of which 89 (1.5 percent) involved GBS. In this report, all newborns who presented with a positive GBS blood culture had at least one of the external tests positive for GBS (gastric, ear canal, rectum and placenta). Thirty-seven per cent (14/38) of positive neonatal blood cultures occurred in newborns with foetid liquor while in deliveries with intrapartum fever 16.5 percent (32/195) of blood cultures were positive. In our clinical practice, characteristics that were evident in the delivery room (without knowledge of prenatal follow-up) such as foetid liquor, intrapartum fever, prolonged rupture of membranes, foetal tachycardia and meconium staining were associated with the great majority of neonatal sepsis.(Au)

A 4-year evaluation of blood pressure management in Trinidad and Tobago

This paper reports a 4-year evaluation of government primary care services in Trinidad and Tobago. The sample included 16 primary care health centres in Trinidad and Tobago with cross-sectional surveys of adult attenders in 1994 and 1998. Data were obtained from clinic records including details of processes of care, drug utilisation and blood pressure (BP) control. Intervention following the initial survey was by means of reports to the Ministry of Health and annual training workshops for medical officers. Data were analyzed for 1759 adult attenders at study clinics (981 in 1994 and 778 in 1998). Most attenders had blood pressure recorded (96 percent in 1994 and 98 percent in 1998). Among 1176 subjects with hypertension (BP > or = 160/95 mm Hg or treated with drugs) the proportion with dietary advice ever recorded increased from .139/662 (21 percent) in 1994 to 185/514 (36 percent) in 1998, and recording of exercise advice increased from 36 (5 percent) in 1994 to 99 (19 percent) in 1998. Among subjects treated with drugs, use of Brinerdin decreased from 191/625 (31 percent) in 1994 to 29/486 (6 percent) in 1998, while use of diuretics, beta-blockers, calcium antagonists and ACE inhibitors increased. The proportion of patients with blood pressure adequately controlled (<160/95 mm Hg) was 338 (51 percent) in 1994 and 297 (58 percent) in 1998 (odds ratio 1.39, 95 percent confidence interval 0.96 to 2.00). An audit study used to inform health care policy, staff training and clinical practice may contribute to improving processes of hypertension management in a middle-income country like Trinidad and Tobago.(Au)

Informing maternal and child health (MCH) policy through research

Maternal and Child Health (MCH) policy over the past two decades has been strongly influenced by research. The paper presents examples of some of the research undertaken and its significant influence in shaping health service delivery. Research in child health has focussed on oral rehydration therapy, immunization and perinatal morbidity and mortality. On the maternal side, morbidity and mortality have been examined with particular focus on problems which contribute to maternal and perinatal morbidity and mortality. Policies arising out of the outcome of these studies have influenced organization of service delivery, information system development, manpower development and deployment, maternal education, surveillance/auditing, quality of care, design of physical facilites and selection of equipment. The results of these studies have also led to the identification of areas requiring further study and testing of intervention to correct the deficiencies identified. These studies demonstrate that research can and does influence health policy, and has impacted positively on the quality and cost of care provided through our health services.(AU)

Quality of care of patients with diabetic foot problems in Barbados

In Barbados diabetics with foot problems account for 80 percent of the patients in the female and 50 percent of those in the male general surgery wards, and many patients have major amputations for preventable problems. A six month prospective study was undertaken of all cases admitted with foot problems to the general surgical wards of the the Queen Elizabeth Hospital (QEH) in order to determine the quality of foot care, particularly among diabetics. 67.5 percent of the 195 patients (55 percent female) admitted to the study were diabetic, most of whom were diagnosed 10 to 19 years previously. Most of the patients were 70 to 80 years old, but significantly more diabetics than non-diabetics were 40 to 70 years old. Foot problems in diabetics were precipitated by events that are considered trivial in non-diabetic patients. 87 (58 percent) of 150 responding patients had their feet inspected by health personnel in the previous year. 47 (63.5 percent) of the 74 who responded about the care of their nails said that they took care of their nails themselves. Nearly 40 percent of diabetic and non-diabetic patients had no reported source of care before their admission. 14 patients (10 diabetic) sought care the same day and 11 (nine diabetics) the day after noticing foot problems. Most patients presented with infection as part of their problem; recognition of the early signs of infection should be an integral part of the education of the diabetic patient. Educational efforts for patients must be continually reinforced because many patients said they had no education about the care of their feet in the previous year.(AU)

The relationship between health care, teaching and research

The practice of medicine has changed radically over the last generation. The advances in medical technology and the application of new knowledge of human biology have led to a huge rise in the costs of delivering health care. There is probably no country in the world now that does not ration health care either in terms of what is provided, to whom it is provided or when it will be available. Longevity has increased, but many of the survivors living into old age carry with them disabilities that require care and treatment. The management of chronic disability, as well as the treatment of acute illness, is part of the responsibility of all health care systems. Moreover, the stress of modern life, not least in urban communities, has led to a rise in illness not necessarily related to organic disease. The fundamental responsibility of a doctor in the health care team is diagnosis; in other words to answer the questions, "What is wrong?" and "Why is it wrong?" The other questions that emerge out of the consultation, such as "What can be done?" What should be done? Who should do it? What can I expect?" are ones to which the whole health care team, not just doctors, can contribute. Indeed the question, "What should be done?", given the availability and uncertainity of modern technology, is now important in the provision of health care. The changed demands on health care systems and the changing role of doctors have led to a realisation of the need for a radical reform of medical training, at both undergraduate and postgraduate levels. In the United Kingdom this process has been led by the General Medical Council, which in 1993 published a discussion document on "Tomorrow's Doctor" setting out principles for curriculum change which are now being developed in all medical schools in the UK. The process of change does not just relate to the content of the curriculum but also to the manner in which it is taught. More opportunities for problem-sloving, self-learning and special study modules are being introduced. Cell biology and molecular genetics, along with an increase emphasis on ethics and law, communication skills, public health medicine and team work with other health professionals are being introduced alongside the old disciplines.(AU)

Management of diabetes mellitus in three settings in Jamaica

A sample of 437 diabetic patients was selected during a six week census to evaluate the quality of diabetic care in three clinics in the private and public sector in Jamaica. A comparison was also made between a dedicated hospital clinic (UHWI) and general medical clinics. The mean age ranged from 54 to 62 years. Median duration of follow up ranged from 6 to 9 years. Less than 10 percent were controlled with diet only and insulin was used more commonly at the UHWI (46 percent) than at the general clinixa (7 percent each). Sulphonylurea drugs alone or in combination with metformin were the commonest agents at the other clinics. There was no significant difference among the clinics in the proportion of patients with satisfactory blood glucose control (< 8 mmol/l post-prandial). Surveillance of hypertension was frequently done (90-98 percent). The proportion of patients treated for concurrent hypertension ranged from 25 percent at UHWI to 71 percent at Spanish Town. Less than 25 percent of hypertensive patients in all clinics had good blood pressure control (BP<140/90 mmHg).(AU)

Quality of care of hypertension in three clinical settings in Jamaica

To determine quality of monitoring and control of hypertension in Jamaica, records of patients aged >30 years attending (1) Spanish Town Health Centre (STHC), a public general clinic; (2) University Hospital Specialist Hypertension Clinic (UHWI); (3) private group general clinic (PRGP), for >1 year were reviewed. 756 records were retrieved, 500 from STHC, 119 UHWI and 137 PRGP. Age and sex distribution differed between clinics (STHC mean 60 yrs, 15 percent men; UHWI mean 54 yrs, 34 percent men; PRCP mean 51 yrs, 54 percent; p<0.001). Smoking and alcohol habits (p<0.01) and body weight (p<0.001) were recorded significantly more in UHWI patients.(AU)

Quality management of public hospitals

Public hospitals throughout the Caribbean are struggling to meet demands from the public for quality services. The problems that have fuelled public concern include long waiting times, rudeness by staff, and poor clinical care. Some senior administrators attribute public dissatisfaction to the 'Miami' or 'Cable TV effect'. The theory is that Caribbean people have unrealistic standards of expectations of their hospitals due to the influence of the images of USA healthcare that they have experienced on the mainland USA or seen on television. Quite a number of hospitals have attempted to launch quality improvement programmes.... Despite all this effort quality initiatives in public hospitals in most Caribbean countries have not been sustained. Nurses who have been trained in QA have been restricted to working on nursing QA programmes. Laboratory based quality initatives have been very much restricted to laboratory services. And quality manuals lie on shelves collecting dust. Public hospitals have very little to show for all these efforts. It is important to know why 'quality' has not taken off if we are to do better in the future(AU)

Users perceptions of the quality of MCH services in Grenada

This study was done to analyse the quality of Maternal and Child Health (MCH) Services delivered according to the perception of users. Data was collected using a pre-tested structured questionnaire, focus group discussions and natural group interviews. 237 users of MCH services were interviewed at randomly selected community health facilities. Ninety-six percent of users were of the opinion that their health workers showed interest and understanding and were friendly and courteous. Ninety-six percent of users were comfortable with the health workers who attended to them. Ninety-two percent of users were questioned by health workers. However, 26 percent received no explanations and instructions. Forty-nine percent of users perceived consultations with health workers to be short. The hours of service delivery were inconvenient for employed persons using the service. Statistically significant differences existed in user satisfaction by location of facility and type of facility at which care was received. Areas identified for improvement include health workers' interpersonal relations and infrastructure including the availability of sanitary facilities and supplies for users. 65 percent of users of MCH services were not gainfully employed (37 percent - unemployed, 28 percent - housewives). Occupational status and educational attainment levels of respondents reflected a disproportionately higher number from lower socioeconomic groups among users of the MCH services. Rescheduling of hours for service delivery is recommended to encouraged more employed persons to use the services. (AU)

Issues in Resource Management: A model hospital

This paper seeks to present the issues in resource management facing Health Administrators in the English Speaking Caribbean against a service delivery backdrop. Using a model 150 bed acute care general hospital, the authors would try to demonstrate the benefits and value of accountability management change and paradigm shifts in the management of hospitals. The model hospital is characterised by high quality, efficiency and effective delivery of service, continuous improvement and value added to the community. All aspects of the organization will be considered. * Financial Resources - Adequacy and Control; * Human Resources - Staffing, Development and Planning; * Technology - Appropriateness use and Relevance; * Information - Decision support Services, Decision Making; * Quality - Service standards, Continuous improvement; * Organizational Design and Development; * Management Systems Development; * Policies and Procedures; * Physical Plant and Equipment; * Aesthetics; * Public and Community Relations (AU)

Quality of care in public and private primary health care facilities

This article examines the quality of care provided by Jamacian primary health care clinics by comparing various structural qualilty indexes derived from a nationwide 1990 survey of 366 public clinics. This compaison points up important differences in the quality of care being provided by public versus private and urban versus rural facilities that might not have been anticipated. Among other things, the study found that the public clinics provided better prenatal diagnosis and counseling and more family planning services than the private clinics. However, the private clinics tended to be in better condition, better equipped and supplied, and better able to provide certain laboratory test results in a timely manner. Comparison of urban and rural public clinics indicated that the urban clinics were somewhat better provisioned with equiptment, supplies, and pharmaceuticals. However, the rural clinics appeared to be in better repair. Comparison of basic and higher-level public clinics showed the basic clinics to be in in better condition and more fully staffed than the higher-lelel clinics while having similar perinatal diagnostic capabilities. However, the higher-level public clinics tented to have an overall profile more resembling that of the private clinics, being better equipped and supplied than the basic clinics. While structural measures of quality such as those employed here tend to poorly estimate health outcomes, they do serve as good indicators of access to services where resources are severely constrained. For policy-makers, the results presented here could prove useful in guiding concrete interventions, summarizing the structural elements of health care quality at different types of facilities, and providing a method for less costly evaluation of programs designed to improve services at primary health care clinics (AU)

The quality of services offered at primary health care centres in Jamaica - abstract

It is imperative to assess the quality of services, especially prior to making any major organizational changes. Such assessments furnish a strong platform for planning. The objectives of this study were to identify the factors that would influence the degree of customer satisfaction. A survey was carried out over a ten-day period on a sample of 261 patients selected from seven primary health care centres within the parishes of Kingston and St. Andrew. The results revealed that three-quarters of the users of health centres lived within a radius of five miles. In addition, three-quarters of the respondents were knowledgeable about the type of health services available to them. Within this group, there were 79 percent of women respondents as compared to 65 percent of male respondents (p<0.05). Seventy percent of respondents had a positive attitude towards the fee-payment for services. The younger age group had a more positive attitude towards fee-payment than older respondents (p<0.001). Respondents with relatively high education levels also had more positive attitudes towards fee-payment than less educated respondents (p<0.01). Approximately 50 percent of the respondents reported being satisfied with the interpersonal relationship with doctors and nurses, while only 20 percent expressed satisfaction for the relationship with their pharmacists. Three-quarters of the respondents expressed their dissatisfaction with the physical facilities at the health centres. A high proportion (92 percent) of the clientele was dissatisfied with the health care delivery process. The health care receivers were moderately satisfied with the health services offered to them (AU)