What do we mean by multimorbidity? An analysis of the literature on multimorbidity measures, associated factors, and impact on health services organization.

BACKGROUND: Multimorbidity is a consequence of both epidemiological and demographic transition. Unlike comorbidity, it currently has no consensus definition, making it difficult to assess its epidemiological and socioeconomic burden, to organize healthcare services rationally, and to determine the skills needed for patient self-reliance. The aim of this study is to define the spectrum of multimorbidity and to discuss current implications for the organization of care. METHODS: Two independent readers analyzed the literature indexed in PubMed, Embase, CINAHL, and Scopus. RESULTS: The bibliographic search conducted on July 16, 2013, retrieved 2287 articles (670 in PubMed, 666 in Embase, 582 in Scopus, and 369 in CINAHL). Of these, 108 articles were retained. Multimorbidity is designated by a variety of terms, none of them being MeSH terms. There is no single measure of multimorbidity, as this entity is usually studied for its functional or economic impact, rather than its causes. The prevalence varies considerably, depending on the measure used and the population studied. Factors associated with multimorbidity are age, gender, and socioeconomic characteristics of the populations studied. Studies evaluating the organization-of-care are inconclusive or insufficient. CONCLUSIONS: Multimorbidity serves as an avatar for the fundamental, recurrent problems of modern medicine and the organization-of-care. It may be defined by its causes or its consequences and reflects our concept of both individual health and its collective management. Tools that would allow a more appropriate measurement of this entity are available; we should use them to match medical reality to the needs of patients.

Analysis of the 2004-2007 literature on therapeutic patient education in diabetes: results and trends.

The purpose of this study is to identify the recent characteristics and the developments of therapeutic education in diabetes through an analysis of the international articles published from 2004 to 2007. Studies were selected from several databases: Medline, Embase, Eric, Cochrane central database, using the following keywords: diabetes, patient education, self management, programs. Two authors independently reviewed each study and selected the data using the same categories of analysis. Articles consistently related to patient education in diabetes (80 among 118) were included. The selected articles have been published in 43 scientific journals. The majority of them concern TPE for adult patients with type 2 diabetes. TPE is delivered in several structures and education to groups of patients represents the most widespread educational strategy mostly provided by a multiprofessional team. A total of 70% of the studies show the effectiveness of TPE based on bioclinical, educational, psychosocial, economical criteria. The problem of barriers to TPE concerns 21% of the studies we have analysed and most of the authors propose the implementation of specifically-designed TPE programs as strategy to overcome them. A large number of studies still assess the positive effects of TPE. Nowadays the problems of accessibility to TPE and the barriers to this practice have become a major issue for research.

[A concept mapping study of nutritional knowledge in diabetic children and their parents]. / Etude par cartes conceptuelles des connaissances sur l'alimentation des enfants diabétiques et de leurs parents.

This study describes, using concept mapping, the nature, organization of knowledge on nutrition and its evolution following therapeutic patient education program in 5 diabetic children (8 to 9 years old) and their mothers. Before the education session, mothers and children are highly knowledgeable about food. The organization of knowledge in children is conceptual and differs from that found in mothers which is based on problems solving. After education, new knowledge and new links between old and recent knowledge testify of learning. A comparison between the maps of children and their mother reveals similarities but also differences in their preoccupations. This research shows that using the preexisting knowledge networks of parents and children could contribute to improve their education on nutrition.

[Knowledges and beliefs related to nutrition of obese and overweight patients subjects: a study in Southern Italy]. / Connaissances et croyances sur l'alimentation de patients en surpoids et obèses: enquête en Italie du Sud.

303 obese and overweight south Italian patients (240 women and 63 men), volunteers to participate in a patient education programme delivered by the university hospital of Foggia, have fullfiled a 50 items true/false test exploring the knowledges and the beliefs on obesity, nutrition, physical activities. The majority of the subjects has both low socio economical status and education level. Women have better performed than men (p<0.005) and obese patients, better than overweight subjects (p<0.005). The more frequent mistakes have concerned items on nutrition, meanwhile a better performance has been observed with the items on beliefs.

[Nursing practice in the context of geographic isolation: implications for training]. / L'exercice infirmier dans un contexte d'isolement géographique. Implications pour la formation.

A survey on the characteristics of the unique working context of nursing practice in remote areas of French Polynesia and semi-remote areas of northern Quebec demonstrates the importance of a specific training to best prepare the professionals who find themselves in this type of setting. Twenty professionals were interviewed: six nurses practicing in isolated stations in French Polynesia (Tuamotu Archipelago, Marquesas Islands and Austral Islands), six nurses practicing in semi-remote areas within northern Quebec (namely among the Algonquins, the Crees and the Attikameks), four officials of the French Polynesian Health Directorate and four training programme designers from Quebec who were encountered during an expedition to Montreal, Mistissini and Trois-Rivieres. The authors identified ten characteristics which were then regrouped into two categories for both of the practice contexts: first, those inherently linked to professional practice in an isolated context (including the characteristics of nursing practice, the working conditions, the community's health problems, their forms of socio-professional relations, their way of life, and their perception and responses to isolation); and second, those pertaining to the social and natural environment, the economic conditions and the community's cultural specificities. All of the results strongly demonstrate that the specificities of the skills utilised by these nurses are indeed very different than those which they received in their initial preparatory training. If a training programme specific to nursing practice in isolated settings seems essential for these nurses, their individual predisposition to practice in such a complex environment and the acknowledgement of their professional competencies are equally to be considered within the perspective of human resources management.

The use of concept mapping to enlighten the knowledge networks of diabetic children: a pilot study.

OBJECTIVE: The value of concept mapping in enlightening nature and organization of knowledge was shown with adult diabetic or obese patients. Our objectives were to ascertain the relevance and feasability of concept mapping in diabetic children during an educational program. METHOD: This qualitative research was performed in 5 children from 8 to 13 years. Concept maps were drawn at the beginning (Phase 1) and at the end (Phase 2) of an educational program. During the interview each child was invited to express himself starting from the central concept: "diabetes", and to express his/her knowledge, representations, and life experience. RESULTS: The ten maps analysis shows: an increase of knowledge between phase 1 and phase 2 (+34%), towards a deepening of initial knowledge and an addition of new knowledge (43% and 41% of the added knowledge); a decrease of inaccurate knowledge in phase 2; an enrichment of the knowledge networks (+16 cross links); an increase of knowledge related to the ways to behave knowledge (+42%). CONCLUSION: This preliminary report demonstrated that concept maps were feasible, useful and relevant in therapeutic education of children. This method allowed us to show how every child connected his knowledge and how it was modified by an educational intervention. Concept maps therefore contributed to individual educational diagnosis and assessment of new knowledge integration.

Application of "Concept Mapping" in obese subjects: a pilot study in normo and underreporters.

BACKGROUND: One important step in nutritional education consists in identifying the patient prior knowledge in order to better educate him. The objectives of this pilot study, on twelve obese patients (6 underreporting patients - UR - and 6 normoreporting patients - NR) were to point out advantages and limits of a method: "concept mapping", a graphic representation of the nature and organization of knowledge, and to show eventual cognitive differences between the two groups of patients. METHODS: Concept maps were drawed during interviews and analysed, considering the concepts, the links between them, their regrouping in knowledge fields. Conceps maps of UR and NR patients were compared. RESULTS: Our results confirm the advantages of concept mapping as the mean to explore the cognitive representation of patients. Some differences between UR and NR patients were readable on the maps: UR patients are more sensitive to the difficulties of the diet than the NR patients. UR patients tend to express more frequently their feelings or personal experiences, and to be more easily invaded by their feelings (more numerous links of personal expressions at UR patients). CONCLUSION: Concept mapping brings new information on knowledge of obese patients. They appear important to better know the cognitive representations of underreporting patients. With such information, it would be easier for healthcare providers to adapt educational programs to the patients' understanding, taking into account their misconceptions, errors and lacks of learning.

An analysis, using concept mapping, of diabetic patients' knowledge, before and after patient education.

This study was designed to assess whether concept maps used with diabetic patients could describe their cognitive structure, before and after having followed an educational programme. Ten diabetic patients, in Paris and Geneva, were interviewed and, during the interview, a concept map was drawn up by the researcher, using the patient's words. This was done on three different occasions: the first day of the educational programme (Pre-evaluation), the last day (Post 1) of a week of education, then 3 to 4 months after education (Post 2). Twenty-eight maps were analysed, using a grid that quantified and qualified the knowledge expressed (knowledge categories, concept links, exactitude) and the organization of that knowledge (hierarchization of concept, cross-links). The examples shown in the maps of the 10 patients gave an illustration of how knowledge was developed or maintained with education, and also showed some learning difficulties encountered by the patients, the changes or preservation of their beliefs and the patients' preoccupations. This study shows that concept maps can be a suitable technique to explore the type and organization of the patients' prior knowledge and to visualize what they have learned after an educational programme.

[The use of telephone for counseling diabetic patients: a descriptive and pedagogic approach]. / Conseiller des patients diabétiques au téléphone: approche descriptive et pédagogique.

This descriptive study of telephone interviews, conducted between the staff of a diabetes unit and patients, is intended to clarify a professional manner in which the telephone should be used as part of patient care. Having examined simulated calls from diabetic patients, analysis of the interviews conducted by the doctors, nurses and members of the office staff in a hospital unit demonstrates wide differences in the content, the quality of the content, and the interview strategy. An interpretation of the results signals the importance of the manner in which the staff member answers, a knowledge of patients' genuine needs, and an ability to adequately acknowledge the emotional state of the patient. Structuring telephone conversations, allowing sufficient time for patient responses, avoids over-long interviews. The decisions taken by the staff member answering the call, in terms of advice and suggestions of actions to take, must be systematically backed-up by ensuring that the patient has properly understood what has been said. The study poses a number of questions, notably concerning the specific requirements demanded by these new remote-care services in the organization of care within a hospital unit, and the professional approach to the use of the telephone as part of the relationship with patients. Recommendations are given concerning the general principles governing a telephone interview and the definition of training objectives for healthcare professionals.

[Role of patient associations in the development of therapeutic education in France]. / Le rôle des associations de patients dans le développement de l'éducation thérapeutique en France.

The aim of this survey conducted among patient associations is to define the role and the position that they have with regard to the development of therapeutic education in France. 124 associations were solicited (out of over 500 existing), and 68 replied. 17 indicated that the survey was not relevant for them. 51 answered the 43 questions related to the conception and implementation of educational programmes, their goals and objectives, the choice and selection of educational activities, the target audiences and pedagogical principles of reference. The results obtained demonstrate the predominance of informational activities and psychological support. The responding associations declared that sometimes they conduct educational activities which rather resemble informational activities. Only three associations declared having Implemented and managed formalised educational programmes based on pedagogical methods. The aims and objectives most frequently targeted were focused on increasing the patients' knowledge on their disease and its treatment. These educational programmes are usually delivered by members of the association's office staff. However, overall most of the responding associations indicated that it is relatively difficult to provide precise data on the pedagogical methods of the activities undertaken. In light of the results, it is therefore necessary to consider the totality of the activities conducted by the associations as a mechanism for building educational resources in which the place of formalised educational programmes remains marginal, even quasi-absent, for the moment. Associations believe that patient education is an important issue for their development. It is highly likely that the emergence of such programmes will only be possible if the associations show some degree of autonomy in relation to the health care sector and assert a point of view specific to patients, above and beyond that of health care users.

[Analysis methods for educational needs assessment for family caregivers of HIV positive or AIDS patients in Thailand]. / Méthode d'analyse des besoins de formation des aidants naturels de patients VIH positif ou sida en Thaïlande.

Identification of educational needs of natural helpers for the home-based care of persons living with HIV or AIDS. Surin, Thailand. The very significant increase in the number of persons living with aids in Thailand, (1995: 20,154 notified cases; 1996: 23,309 cases; 1997: 25,064 cases), and the insufficiency of medical care for patients within Thailand's health structures, have driven Médecins Sans Frontières (MSF) to put in place since 1996 a home-based care project in Surin province (North-Eastern Thailand). In Thai culture, the sick are commonly cared for by one family member, known as the natural helper. An evaluation of the health situation showed that natural helpers who took care of a family member living with HIV or aids were not prepared for this situation. In order to better define the tasks that they ought to perform, we carried out a needs assessment in three interdependent steps: a records analysis of the activities delegated to natural helpers by nurses; an enquiry on the acceptability of natural helpers to carry out these cares and on the perceived usefulness of being trained; an expert consensus on the cares to be carried out by the natural helpers, obtained by the Delphi method. Twenty seven cares were identified as being able to be provided by natural helpers. They constitute as a list of reference for the training for natural helpers. This work has shown a social coherence between the different actors of the project. At no stage was the role of the natural helpers questioned. On the contrary, natural helpers have a privileged place within the family and in the home-based care programme. Natural helpers will allow continuity of care between the health structures and the patient's home.

Towards promotion, structuring and acknowledgement of patient education activities in France.

As patient education becomes more and more widespread in use among French health professionals, it is also becoming increasingly structured, but remains very heterogeneous depending on practitioners and institutions. For several years, this activity has been integrated into various professions. Training is becoming more frequent, and care providers show a certain willingness for common though on improvement and evaluation of their practices. At the same time, health institutions show an increasing interest in these activities, which they wish to promote. Significant improvements recently observed by them may finally lead to the professional and financial recognition expected by care providers.

Difficulties of diabetic patients in learning about their illness.

The aim of this report is to shed light on the difficulties experienced by diabetic patients in learning about their illness. One hundred and thirty-eight diabetic people (97 IDD and 41 NIDD) were questioned at two survey locations, one national (63) and one regional (75), by means of a closed answer questionnaire. One hundred and four (75%) had attended a formal programme of diabetes education. They were asked which points in their diabetes education they had best understood and which they had least understood. The main results show that, globally, they easily acquire the manual skills. Conversely, numerous learning difficulties are associated with the skills required to solve problems and make decisions, such as adaptation of doses of insulin. These results are comparable to those obtained in a previous study in which professional carers were asked about their difficulties in educating their patients.

An analysis of the teaching techniques used in diabetic specialist consultations.

We attempted to explore the teaching practices of 11 senior diabetic specialists consulting in a out-patient hospital setting and known to have a strong commitment to patient education. The survey consisted of a questionnaire dealing with the duration and distribution of speaking time, the classification of questions, the type of oral questions asked of patients, written materials, teaching aids, demonstrations, if any, care techniques used, and whether or not information was summarized. Our study of 44 consultations showed an average consultation time of 26 +/- 10 min and a balanced sharing of speaking time. The percentage of consultations during which no questions were asked depended on the type and classification of test questions, i.e. oral questions to check knowledge (13.6%), open-ended problem-solving questions (27.3%) or problems involving written materials (54.5%). One to two problems involving open-ended questions were set during 36.4% of the consultations and one to two problems involving written materials were set in 20.5% of the cases; visual aids prepared in advance took a back seat to sketches made during the consultation itself. Information was summed up by the caregiver 75% of the time, and 50% with the patient's help. Our results indicate a patient education orientation during consultations and help to design a standard model formation combined teaching/treatment consultations.

An initial experiment in haematology instruction using the problem-based learning method in third-year medical training in France.

We present an initial experiment in the teaching of haematology using the problem-based learning technique in the third year of medicine at the Bobigny Faculty of Medicine (Université Paris-Nord). This new approach to the clinical and bioclinical teaching of medicine is used in several hundred medical faculties throughout the world. It is based on students' integrated learning of concepts (scientific, clinical, psycho-social) through patient problems. The method alternates group meetings with a tutor and individual learning. Sixty-eight students with no previous training in haematology and eight tutors (eight groups) took part in this experiment, which lasted five weeks (with no other teaching) and enabled them to study ten patient problems representing the bulk of the objectives pursued in this discipline. The preparation of students and teachers for this experiment is described, as well as its conduct and the results obtained. These show that the problem-based learning students performed better in their clinical problem-solving examinations than did students from a previous year who had been taught using traditional methods for the same period of time. The comparison does not indicate, however, that problem-based learning students had any advantage in the acquisition of factual information. The high degree of satisfaction of the students beginning their third year and of tutors in respect of this experiment constitutes a very favourable point. The limitations of the experiment and the teaching method itself are also discussed.

[How do physicians evaluate their medical school training. Retrospective survey of 4 groups of medical students 8-11 years after graduation]. / Comment les médecins évaluent leur faculté de médecine et la formation qu'ils ont reçue. Enquête rétrospective auprès de 4 promotions d'étudiants en médecine, 8 à 11 ans après la fin de leur formation initiale.

A survey was conducted among 250 graduates of the Bobigny School of Medicine (University Paris-Nord) who had completed medical school from 1986 to 1989 in order to ascertain their opinion concerning the training received. Ninety former students (36%) responded. The mean age of the sample was 34 years; 46 women and 44 men. Most (88.9%) were practicing medicine, principally as general practitioners (61.8%). 81.6% felt they had been well prepared to practice medicine. The rate of satisfaction was higher in the area of fundamental science than in clinical science. The responders generally felt that teaching and validation methods should emphasize real situations. The main criticism concerning the curriculum was an insufficient degree of professionalism, particularly in fields currently of particular importance: epide miology, health economics, education, prevention, office management. Training was also considered to be insufficient in medical techniques, communication, priority decision making, team work, emergency care, organization of time and handling stress. The responders suggested that the future curriculum should focus more on information search, research methodology and computer science. The results of this survey collaborate findings of recent retrospective long-term analyses conducted in other European countries.

[Validation of an evaluation guide for healthcare training programs in the field of humanitarian efforts]. / Validation d'un guide d'évaluation de programmes de formation en santé dans le cadre de l'action humanitaire.

The training of healthcare professionals working in the field of humanitarian action is of fundamental importance but there have been few procedures for assessing the training programs. A specific guide was produced for the evaluation of healthcare training programs. It uses a three-pronged approach to improve the training of healthcare personnel, encouraging educators to take a fresh look at the way in which they work. The guide seeks to improve the efficiency of training by evaluating programs. The guide was tested on four training programs conducted by three non-governmental organizations in three countries: Handicap International in Cambodia and Mozambique, Médecins Sans Frontières in Cambodia and Action Nord Sud in Brazil. Questionnaires, guides and appraisals were analyzed, and the results suggested that the guide was valid, reproducible and easy to use. However, it is vital to provide external educational assistance during evaluation, to promote the implementation of decisions, thereby improving training practices.

Learning difficulties of diabetic patients: a survey of educators.

This study was designed to shed light on the learning difficulties of diabetic patients. An open-ended questionnaire was sent to 85 health care professionals working in the field of diabetes and nutrition who had been trained in patient education techniques. They were asked to describe the skills that were the easiest to teach patients and those that patients mastered the best, as well as the skills they found hardest to teach patients, those that patients mastered the least and those that gave rise to errors persisting after the patients education was completed. On the whole, the results showed that the educators found it easy to teach techniques: patients mastered procedures well and made few mistakes. In contrast, diabetic patients seem to have problems learning skills, such as insulin dose adjustment, that require complex problem-solving (involving multiple variables). Based on these findings, the authors discuss the notions of learning complexity and the time needed for successful patient education.

A French dental school programme appraisal by alumni of 5-9 years standing.

The objective of this study was to analyse the perception of the practical value of their training experience for 4 groups of alumni graduated between 1986 and 1989 at the Faculty of Odontology, University Paris 5. The 240 participants (45% response rate) perceived their training to have been adequate with respect to procedural activities. On the other hand, the graduates expressed a desire for more emphasis in emergencies, interpersonal relationship, office management and such clinical topics as fixed prosthodontics, surgery and periodontics. Surveys aimed at alumni may be useful for the evaluation of programme results and to determine which items should be added or deleted according to either health criteria or the conditions of dental practice.