[Validation of a questionnaire on health literacy among Francophones in situation of linguistic minority]. / Validation d'un questionnaire sur l'alphabétisme en santé des francophones en situation linguistique minoritaire.

OBJECTIVE: This study was designed to develop and test the qualitative validity of a French questionnaire. The questionnaire explored the mechanisms by which Francophone in situation of linguistic minority mobilize their social capital and cultural assets in terms of health literacy. METHODS: We used evidence derived from a previous qualitative study in which we elaborated the characteristics of social capital and cultural assets. Drawing on models of social capital and self-determination of language behaviour in Francophone in situation of linguistic minority, 21 items were developed and assessed to confirm content validity. For this purpose, cognitive interviews were conducted with 92 natural experts. These cognitive interviews tested the linguistic and content validity of the instrument. Consultations with research professionals were also conducted to increase content validity. RESULTS: Parsimony and simplicity were tested by application of the Flesch test. The results demonstrate that 19 questions (93%) corresponded to the general public, relatively simple, and everyday use categories. Natural experts confirmed the readability and simplicity of the questionnaire. CONCLUSION: This study addressed a lack of simple and readable questionnaire for collecting data among Francophone in situation of linguistic minority. The findings underscore the lack of evidence related to the familiar construction of health literacy among members of this population.

Academic family health teams: Part 2: patient perceptions of access.

OBJECTIVE: To explore patients' perceptions of primary care (PC) in the early development of academic family health teams (aFHTs)--interprofessional PC teams delivering care where family medicine and other health professional learners are trained--focusing on patients' perceptions of access and patients' satisfaction with services. DESIGN: Self-administered survey. SETTING: Six aFHTs in Ontario. PARTICIPANTS: Adult patients attending appointments and administrators at each of the aFHTs. MAIN OUTCOME MEASURES: Answers to questions about access from the Primary Care Assessment Tool Adult Expanded Version, the Primary Care Assessment Survey, and research team questions. RESULTS: The response rate was 47.3% (1026 of 2167). The mean (SD) Primary Care Assessment Tool first-contact accessibility score was 2.28 (0.36) out of 4, with 96.5% of patients rating access less than 3, which was the minimum expected level of care. Two-thirds (66.6%) indicated someone from their aFHTs would definitely or probably see them the same day if they were sick, 56.8% could definitely or probably get advice quickly by telephone, and 14.5% indicated it was definitely or probably difficult to be seen by their primary health care provider (HCP). Additionally, 46.9% indicated they would like to get medical advice by e-mail. For a routine or follow-up visit, 73.4% would be willing to see another aFHT physician if their regular provider were unavailable, while only 48.3% would see a nonphysician HCP. If sick, 88.2% would see another aFHT physician and 55.2% would see a nonphysician HCP. Most (75.3%) were satisfied with access to their regular HCP. CONCLUSION: Although patients are generally satisfied with care, there is room for improvement in access. Strategies are needed to enhance access to care, including addressing appropriate roles and scopes of practice for nonphysician HCPs. The accessibility challenges for aFHTs will likely affect new family physicians and other HCPs training in these practices and their approach to future practice.

Academic family health teams: Part 1: patient perceptions of core primary care domains.

OBJECTIVE: To explore patients' perceptions of primary care (PC) in the early development of academic family health teams (aFHTs)--interprofessional PC teams delivering care where family medicine and other health professional learners are trained--focusing on the 4 core domains of PC. DESIGN: Self-administered survey using the Primary Care Assessment Tool Adult Expanded Version (PCAT), which addresses 4 core domains of PC (first contact, continuity, comprehensiveness, and coordination). The PCAT uses a 4-point Likert scale (from definitely not to definitely) to capture patients' responses about the occurrence of components of care. SETTING: Six aFHTs in Ontario. PARTICIPANTS: Adult patients attending appointments and administrators at each of the aFHTs. MAIN OUTCOME MEASURES: Mean PCAT domain scores, with a score of 3 chosen as the minimum expected level of care. Multivariate log binomial regression models were used to estimate the adjusted relative risks of PCAT score levels as functions of patient- and clinic-level characteristics. RESULTS: The response rate was 47.3% (1026 of 2167). The mean age of respondents was 49.6 years, and most respondents were female (71.6%). The overall PC score (2.92) was just below the minimum expected care level. Scores for first contact (2.28 [accessibility]), coordination of information systems (2.67), and comprehensiveness of care (2.83 [service available] and 2.36 [service provided]) were below the minimum. Findings suggest some patient groups might not be optimally served by aFHTs, particularly recent immigrants. Characteristics of aFHTs, including a large number of physicians, were not associated with high performance on PC domains. Distributed practices across multiple sites were negatively associated with high performance for some domains. The presence of electronic medical records was not associated with improved performance on coordination of information systems. CONCLUSION: Patients of these aFHTs rated several core domains of PC highly, but results indicate room for improvement in several domains, particularly first-contact accessibility. A future study will determine what changes were implemented in these aFHTs and if patient ratings have improved. This reflective process is essential to ensuring that aFHTs provide effective models of PC to learners of all disciplines.

Learning globally to enhance local practice: an international programme in primary care & family health.

PURPOSE: In a global context of growing health inequities, international learning experiences have become a popular strategy for equipping health professionals with skills, knowledge, and competencies required to work with the populations they serve. This study sought to analyse the Chilean Interprofessional Programme in Primary Health Care (CIPPHC), a 5 week international learning experience funded by the Ministry of Health in Chile targeted at Chilean primary care providers and delivered in Toronto by the Department of Family and Community Medicine at the University of Toronto. METHOD: The study focused on three cohorts of students (2010-2012). Anonymous programme evaluations were analysed and semi-structured interviews conducted with programme alumni. Simple descriptive statistics were gathered from the evaluations and the interviews were analysed via thematic content analysis. RESULTS: The majority of participants reported high levels of satisfaction with the training programme, knowledge gain, particularly in the areas of the Canadian model of primary care, and found the materials delivered to be applicable to their local context. CONCLUSIONS: The CIPPHC has proven to be a successful educational initiative and provides valuable lessons for other academic centres in developing international interprofessional training programmes for primary care health care providers.

Capacity-building in family health: innovative in-service training program for teams in Latin America.

PROBLEM BEING ADDRESSED: Brazil, Chile, and Canada are among the countries where development and deployment of human resources have been central to health reform; however, it is unclear how the education and training of primary care workers is best accomplished. OBJECTIVE OF THE PROGRAM To implement a model of in-service training in primary health care for interdisciplinary teams of primary health care professionals from Brazil and Chile. PROGRAM DESCRIPTION: This 5-module program targeted primary care providers from various disciplines who had at least 3 months of front-line experience. The program was offered in 2 formats: intermittent "in-country" training or an intensive course taught in Canada. In Brazil, the in-country training took place over a period of 8 to 12 months, during which 5 modules of 2 to 3 days each were interspersed with 2-month "action periods." The intensive course taught in Canada was delivered to Chilean participants in Toronto, Ont, where 3 modules were offered to a group of 12 to 20 primary health care professionals over a 6-week period. The educational methodology combined short didactic presentations, whole group learning exercises, and small group problem-based learning sessions, including team projects that were completed in between each module and presented at the beginning of the next one. During the course, the participants learned how to perform computer database searches and assess the best evidence in the management of common problems. CONCLUSION: Pretests, posttests, and evaluations of student projects demonstrated that participants had increased knowledge, as well as increased capacity to use the best evidence to address common problems in their communities. This is a promising model, adapted to the context of primary care reform in Latin America, with strong potential to support health human resource development and multidisciplinary care by front-line providers in other countries.

Enhancing continuity of information: essential components of consultation reports.

OBJECTIVE: To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients. DESIGN: Systematic review of the literature followed by a 2-round modified Delphi consensus process. SETTING: Province of Ontario. PARTICIPANTS: Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist. METHODS: We completed a systematic literature review to identify important components of consultation reports. We then engaged an 8-member panel in a 2-round modified Delphi consensus process, which led to the identification of components deemed essential to good continuity of information. MAIN FINDINGS: After 2 rounds, expert panelists reached consensus on 15 components, referred to here as minimum essential elements, of consultation reports generated by medical specialists in response to referring primary care providers' consultation requests. CONCLUSION: The expert panelists considered inclusion of the minimum essential elements in consultation reports essential to achieving good continuity of information. We assembled these elements in a suggested format for a consultation report. The format can be easily modified by practitioners caring for patients with other chronic diseases.

Genetics education in medical school: a qualitative study exploring educational experiences and needs.

BACKGROUND: Genetic discoveries increasingly have an impact on clinical medicine. Primary care providers (PCPs) need to be prepared to address patients' concerns about their genetic risks. AIMS: To explore family medicine residents' experiences with genetics in medical school and residency training and to understand their educational needs in genetics. METHODS: Four focus groups were held with 33 family medicine residents at the University of Toronto, which represented graduates of 9 different Canadian medical schools. Groups were audio-taped, transcribed and analysed independently by 4 reviewers using content analysis. Recurrent themes were identified. RESULTS: Participants described their experiences with genetics in medical school as almost entirely related to rare disorders, so genetics was not perceived to be clinically relevant. There was little awareness of the complex ethical and psychosocial issues that accompany genetics. However, participants felt that genetics would become significant in medical care in the future and PCPs would play an important role. They expressed a need for more knowledge of genetics to fulfill this role and practical teaching in genetics by clinicians. CONCLUSIONS: Medical school educational experiences may not be preparing future PCPs to address genetic issues with patients. A change and a broadening of the teaching of genetics are required to fulfill this need.

Enhancing continuity of information: essential components of a referral document.

OBJECTIVE: To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients. DESIGN: Systematic review of the literature followed by a 2-round modified Delphi consensus process. SETTING: Province of Ontario. PARTICIPANTS: Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist. METHOD: We completed a systematic literature review to develop a list of items or data elements related to patient information transfer in chronic care. We engaged an 8-member expert panel in a 2-round modified Delphi process to assess the importance of the 74 data elements identified in the literature review and to identify any additional important elements. MAIN FINDINGS: The expert panelists reached consensus on 24 components of information, referred to here as minimum essential elements of a referral document, needed for consultations on adult asthma patients. CONCLUSION: The 24 minimum essential elements of information that should be transferred during referral of asthma patients from primary care providers to experts in asthma care were generated by primary care physicians and thought essential for achieving continuity in information transfer. We assembled these elements into a suggested format for a referral document. The format can be easily modified by practitioners caring for patients with other chronic diseases.

Brazilian community health agents and qualitative primary healthcare information.

AIM: The aim of this study was to explore female community health agents' views about the value of recording qualitative information on contextual health issues they observe during home visits, data that are not officially required to be documented for the Brazilian System of Primary Healthcare Information. BACKGROUND: The study was conducted in community primary healthcare centres located in the cities of Araçatuba and Coroados (state of São Paulo) and Rio de Janeiro (state of Rio de Janeiro), Brazil. METHODS: The design was a qualitative, exploratory study. The purposeful sampling criteria were being female, with a minimum of three years of continuous service in the same location. Data collection with 62 participants was conducted via 11 focus groups (in 2007 and 2008). Audio files were transcribed and submitted to the method of thematic analysis. Four themes guided the analysis: working with qualitative information and undocumented observation; reflecting on qualitative information; integrating/analysing quantitative and qualitative information; and information-sharing with agents and family health teams. In 2010, 25 community health agents verified the final interpretation of the findings. FINDINGS: Participants valued the recording of qualitative, contextual information to expand understanding of primary healthcare issues and as an indicator of clients' improved health behaviour and health literacy. While participants initiated the recording of additional health information, they generally did not inform the family health team about these findings. They perceived that team members devalued this type of information by considering it a reflection of the clientele's social conditions or problems beyond the scope of medical concerns. Documentation of qualitative evidence can account for the effectiveness of health education in two ways: by improving preventative care, and by amplifying the voices of underprivileged clients who live in poverty to ensure the most appropriate and best quality primary healthcare for them.

Enhancing prevention in primary care: are interventions targeted towards consumers' and providers' perceived needs?

OBJECTIVE: To explore perceived barriers to the implementation of prevention guidelines, with a particular interest to perceived information needs from the point of view of health professionals and consumers. STUDY DESIGN: Focus group. SETTING AND PARTICIPANTS: Eight focus groups were held in three Canadian cities: three with consumer, three with family physician, and two with primary care nurses. ANALYSIS: Inductive analysis based on transcribed interviews. The material was analysed by two of the investigators. Agreement on interpretation was checked independently by three other researchers on 10% of the material. RESULTS: Lack of motivation, discontinuity of care and lack of adequate remuneration were perceived as the strongest barriers to prevention implementation. Computerized information management systems were not perceived by physicians and nurses as strong facilitating factors. Consumers expressed strongly a need for information on non-traditional preventive interventions. Physicians and nurses expressed a need for patient education material more than for practice guidelines. Research evidence was not considered as the first criteria to judge the value of preventive information. CONCLUSIONS: Evidence-based medicine has triggered a massive effort to develop technologies to support the dissemination of evidence-based information on the assumption that poor access to such information is an important barrier to implementation of effective practices. Our results suggest that such an assumption may not be correct. Providing only evidence-based information from the realm of traditional medicine will appear restrictive to most users, particularly to consumers, and may not be as valued as anticipated considering the expressed scepticism toward research evidence.

[Knowledge, attitudes and practice regarding Dengue in two neighborhoods in Bucaramanga, Colombia]. / Conocimientos, Actitudes y Prácticas sobre Dengue en Dos Barrios de Bucaramanga, Colombia.

OBJECTIVE: Identifying knowledge, attitudes and practice regarding dengue control for guiding prevention and control measures. METHODS: A community survey was carried out using house inspection visits during May 2007 in two neighbourhoods in Bucaramanga having a high incidence of dengue. Mosquito breeding places were identified and education concerning dengue prevention and control measures was provided. EPI-INFO was used for analysing the information so collected. RESULTS: 643 of the 780 households (82.4%) responded to the survey. Most people responding (518) were female (80.6%), average age being 39.6 (16.8 standard deviation (SD)), average schooling lasted 6.2 years (3.5 SD) and average household size was 5 people per house. Regarding dengue, 433 people (67.3%) described it as being a very serious disease; 545 (84.8%) stated that it was transmitted by a mosquito vector and 242 (37.6%) said that it was produced by a virus 59 (9.2%). The symptoms recognised were: fever by 570 people (88.6%), vomiting by 352 (54.7%), diarrhoea by 275 (43.0%), headache by 243 (37.8%), bone pain by 196 (30.5%) and muscle pain by 109 (17.0%). For prevention, 288 (44.7%) avoided stagnant water, 174 (27.2%) washed out their water tanks, 91 (14.2%) fumigated and 101 (15.8%) cleaned their houses. When anybody had dengue, 410 of them (63.8%) would go to a doctor, 129 (20.1%) would go to a hospital and 78 (12.0%) would treat themselves. Larval rate was 26.6% and there had been cases of dengue in 8.4% of the households during the last month. DISCUSSION: Knowledge about dengue was sketchy. Attitudes were favourable regarding dengue control but preventative practice was inadequate. The community must be educated and empowered to ensure their active participation in prevention and control programmes.

Five years of family health care in São José.

In 1994, the Federal Government of Brazil enacted legislation to share the costs with municipalities of establishing or remodelling up to 20 000 health clinics, covering a population of 69 million people. São José clinic was established with family physicians in 1993 in a community of 3000 in the City of Curitiba. The clinic was functioning by 1995 when the Canadian four principles of Family Medicine were introduced to clinic staff. The impact of the clinic's work has measured improvements in perinatal mortality and child nutrition, reduced hepatitis A infection and produced dramatic improvements in delivery of preventive services. The presence of the clinic has empowered a poor community to demand improved municipal services that have helped to improve overall health. The introduction of Family Health Clinics in Brazil, and assistance provided by Canada, has achieved the objectives of the national Government in one sample site.

Conocimientos, actitudes y prácticas sobre dengue en dos barrios de Bucaramanga, Colombia / Knowledge, attitudes and practice regarding Dengue in two neighborhoods in Bucaramanga, Colombia

Objetivo Identificar conocimientos, actitudes y prácticas sobre dengue para orientar medidas de prevención y control. Metodología Encuesta realizada, en dos barrios de alta incidencia de dengue en Bucaramanga, mayo de 2007, mediante visita domiciliaria. Se identificaron criaderos y se brindó educación sobre prevención y control. La información fue analizada en EPI-INFO. Resultados En 643 de las 780 viviendas (82,4 por ciento) se logró respuesta. La mayoría de los entrevistadas eran mujeres, 518 (80,6 por ciento), con edad promedio 39,6 años, desviación estándar (DE) 16,8, escolaridad 6,2 años (DE 3.5) y 5 habitantes por vivienda. En cuanto al dengue, 433 (67,3 por ciento) lo describieron como una enfermedad: muy grave 545 (84,8 por ciento), transmitida por zancudo 242 (37,6 por ciento) y producida por virus 59 (9,2 por ciento). Síntomas reconocidos: fiebre 570 (88,6 por ciento), vómito 352 (54,7 por ciento), diarrea 275 (43,0 por ciento), cefalea 243 (37,8 por ciento), dolor óseo 196 (30,5 por ciento) y muscular 109 (17,0 por ciento). Para prevenirlo: evitan agua estancada 288 (44,7 por ciento), lavan la pila 174 (27,2 por ciento), limpian la casa 101 (15,8 por ciento) y fumigan 91 (14,2 por ciento). Cuando alguien tiene dengue: lo llevan al médico 410 (63,8 por ciento), al hospital 129 (20,1 por ciento) o automedica 78 (12,0 por ciento). El índice larvario fue de 26,1 por ciento y en 8,4 por ciento de las viviendas hubo casos de dengue el mes anterior a la encuesta. Discusión Los conocimientos sobre dengue son escasos, las actitudes favorables al control, pero las prácticas son insuficientes. Se requiere educar y empoderar la comunidad para que participe activamente en los programas de prevención y control.

Objective Identifying knowledge, attitudes and practice regarding dengue control for guiding prevention and control measures. Methods A community survey was carried out using house inspection visits during May 2007 in two neighbourhoods in Bucaramanga having a high incidence of dengue. Mosquito breeding places were identified and education concerning dengue prevention and control measures was provided. EPI-INFO was used for analysing the information so collected. Results 643 of the 780 households (82.4 percent) responded to the survey. Most people responding (518) were female (80.6 percent), average age being 39.6 (16.8 standard deviation (SD)), average schooling lasted 6.2 years (3.5 SD) and average household size was 5 people per house. Regarding dengue, 433 people (67.3 percent) described it as being a very serious disease; 545 (84.8 percent) stated that it was transmitted by a mosquito vector and 242 (37.6 percent) said that it was produced by a virus 59 (9.2 percent). The symptoms recognised were: fever by 570 people (88.6 percent), vomiting by 352 (54.7 percent), diarrhoea by 275 (43.0 percent), headache by 243 (37.8 percent), bone pain by 196 (30.5 percent) and muscle pain by 109 (17.0 percent). For prevention, 288 (44.7 percent) avoided stagnant water, 174 (27.2 percent) washed out their water tanks, 91 (14.2 percent) fumigated and 101 (15.8 percent) cleaned their houses. When anybody had dengue, 410 of them (63.8 percent) would go to a doctor, 129 (20.1 percent) would go to a hospital and 78 (12.0 percent) would treat themselves. Larval rate was 26.6 percent and there had been cases of dengue in 8.4 percent of the households during the last month. Discussion Knowledge about dengue was sketchy. Attitudes were favourable regarding dengue control but preventative practice was inadequate. The community must be educated and empowered to ensure their active participation in prevention and control programmes.

Bases conceituais de trabalho em saúde da família / Concept bases at work in health family

O trabalho em saúde da família, enfoque sistêmico de companhamento da comunidade em atençäo primária, enfrenta a dificuldade de um referencial teórico de fácil leitura e aplicaçäo prática para atuaçäo das equipes em atividade. Os autores realizaram uma revisäo da literatura sobre o tema, buscando referências aplicáveis à realidade de trabalho, onde o enfoque sistêmico e os princípios da atençäo primária se mostrassem compatíveis com o dia a dia da saúde em nosso meio. A experiência internacional em atençäo primária, associada à prática de vigiläncia a saúde desenvolvida em Curitiba, permite uma proposta contextualizada e corente de enfrentamento das situaçöes que expöem a populaçäo a risco para a saúde. E abre espaço para futuras pesquisas sobre o assunto

Ferramenta de avaliaçäo para situaçöes indefinidas e manobras preventivas em saúde da família: ciclo de vida das famílias / Evaluation tools in family health: family life cycle

O trabalho em saúde da família, como nova especialidade de atençäo a saúde que considera o pensamento sistêmico, exige o desenvolvimento de habilidades e estratégias que permitam a eficiência no diagnóstico e prevençäo na promoçäo da saúde. Os autores revisam na literatura o instrumento, Ciclo de Vida das Famílias, e apresentam casos em que a utilizaçäo do mesmo pode ser de valia no trabalho desenvolvido. Conclui-se que a utilizaçäo desta ferramenta facilita a identificaçäo do processo de adoecer e os momentos em que a família se torna vulnerável ao surgimento de problemas

Ferramenta de descriçäo da família e dos seus padröes de relacionamento: genograma, uso em saúde da família / Genograma it's usefulness as a tool in health family

A comunicaçäo fácil e a percepçäo dos padröes de repetiçäo que permeiam as relaçöes familiares säo instrumentos indispensáveis no trabalho em equipe. A busca de uma forma simples e visual, que considere o trabalho em saúde da família, nos levou ao genograma. Os autores revisaram a literatura sobre formas de registro de patologias e padröes de relacionamento familiar, onde descrevem o genograma e aplicam o instrumento em uma família, para que fique de compreensäo fácil ao leitor. Conclui-se que a aplicaçäo do genograma à clínica em saúde da família permite uma visualizaçäo do processo de adoecer, facilitando o plano terapêutico e permitindo à família uma melhor compreensäo sobre o desenvolvimento de suas patologias

Trabalhando com famílias em saúde da família / Primary care: working with families

Os autores através de revisäo na literatura procuram definir uma metodologia de interaçäo com a comunidade, analisando as necessidades de implantaçäo de um programa eficiente de atençäo primária em saúde. Säo analisadas as etapas necessárias para um adequado trabalho com as famílias ao longo do tempo, a construçäo do autocuidado e de práticas de vida comprometidas com a saúde. Citam-se instrumentos de trabalho que sugerem diretrizes para o estudo e a atuaçäo em atençäo primária. Os autores recomendam a implantaçäo de um protocolo piloto da proposta para análise e estudo quantitativo de impacto