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1.  Obstacles to the prevention of overweight and obesity in the context of child health care in Sweden 
BMC Family Practice  2013;14:143.
Background
Overweight and obesity in younger children could better be brought in focus through a deeper understanding of how Child Health Care nurses (CHC-nurses) perceive their work with the problems of overweight at the CHC Centers. The aim of this study was to elucidate the CHC-nurses conceptions of their preventive work with childhood overweight and obesity in Child Health Care.
Method
A qualitative study, based on open-ended interviews, involving 18 CHC-nurses strategically selected from 17 CHC Centres in the southern part of Sweden using a phenomenographic approach.
Results
Two categories of description emerged from the data: (i) Internal obstacles to the CHC- nurses’ work with overweight in children and (ii) External obstacles to the management of overweight in children. The CHC-nurses conceived their work with overweight in Child Health Care to be complicated and constrained by several obstacles depending on the nurses’ personal priorities, knowledge, responsibility and the absence of resources and cooperation, as well as the lack of uniform guidelines for preventing and managing childhood overweight and further a deficient management organisation.
Conclusion
Nurses’ attention to monitoring overweight in children, and their initiative for prevention, is based on their conceptions of the obstacles that hinder them in their efforts. An increased awareness of the CHC-nurses conceptions of the priorities, their sense of responsibility and prevention practices is warranted. If measures in this direction are not taken there is a growing risk that overweight children will pass through the CHC without any formal recognition of their situation. There is an indication that the present level of the CHC-nurses’ preventive work with childhood overweight has room for improvement in several areas. It is suggested that the specialist education of these health care professionals should be supplemented and that organisation of the management of childhood overweight should be also revised at the primary health care level.
doi:10.1186/1471-2296-14-143
PMCID: PMC3852529  PMID: 24079391
Child; Nurses; Obesity; Overweight; Perceptions; Preventive work; Primary care; Qualitative research
2.  Joint action between child health care nurses and midwives leads to continuity of care for expectant and new mothers 
Reduction of the duration of postpartum hospital stay in western countries highlights the need for better support and continuity of care for expectant and new mothers. The aim of this study was to investigate strategies to improve continuity of care for expectant and new mothers. The study also aimed to elaborate on a preliminary substantive grounded theory model of “linkage in the chain of care” that had been developed earlier. Grounded theory methodology, which involved multiple data sources comprising structured interviews with midwives and child healthcare nurses (n=20), as well as mothers (n=21), participant observation, and written material, was used. Comparative analysis was used to analyse the data. To achieve continuity, three main strategies, transfer, establishing and maintaining a relation, and adjustment, were identified. These strategies for continuity formed the basis of the core category, joint action. In all the strategies for continuity, midwives and child healthcare nurses worked together. In addition, mothers benefited from the joint action and recognized continuity of care when strategies for continuity were implemented. The results are discussed in relation to the established concepts of continuity.
doi:10.3402/qhw.v7i0.18183
PMCID: PMC3391663  PMID: 22783367
Continuity; collaboration; midwives; child healthcare nurses; expectant and new mothers; grounded theory
3.  Swedish Child Health Care nurses conceptions of overweight in children: a qualitative study 
BMC Family Practice  2012;13:57.
Background
Registered Sick Children’s Nurses and District Nurses employed at Child Health Care centres are in a position to help prevent childhood overweight and obesity. Prevention of this challenging public health threat could be improved through having a better understanding of how this group of nurses perceives childhood obesity. The aim of this study was to elucidate the conceptions of childhood overweight, including obesity, among nurses working in Child Health Care.
Method
A qualitative study using a phenomenographic approach, based on open-ended interviews with 18 Child Health Care nurses (CHC-nurses) strategically selected from 17 Child Health Care Centres in the southern part of Sweden.
Results
Four categories of description emerged from the data: Perception of childhood overweight changes, Overweight in younger children a neglected concern, Overweight a delicate issue and Importance of family lifestyle. The participating CHC-nurses conceived overweight in children, primarily obesity in children to be an extensive and serious problem which affects children, families and the surrounding society. Overweight in children was further perceived as a consequence of their parent’s lifestyle and their awareness of the problem, which was considered by the CHC-nurses as a sensitive and a provoking issue. It was also perceived that overweight in children is not taken seriously during the pre-school period and that concerns regarding overweight in younger children were mainly about the appearance and not the health of the child. The CHC-nurses perceived that the proportion of overweight children has increased, which Swedish society and the CHC-nurses have adapted to. This adaptation makes it difficult for CHC-nurses to define those children who are overweight.
Conclusion
CHC-nurses provide a comprehensive and complex picture of childhood overweight, which includes several difficulties dealing with this issue. Attention to CHC-nurse’s conceptions of overweight in children is important since it can affect the parent-nurse relationship and thereby the nurse’s, as well as the parent’s efforts to influence the children’s weight. It is suggested that CHC- nurses should work with person centered counseling and empowerment concerning parent to child relations in cases involving overweight.
doi:10.1186/1471-2296-13-57
PMCID: PMC3426496  PMID: 22697580
Child; Conceptions; Nurses; Overweight; Perceptions; Primary health care; Qualitative research
4.  Non-physician providers of obstetric care in Mexico: Perspectives of physicians, obstetric nurses and professional midwives 
Background
In Mexico 87% of births are attended by physicians. However, the decline in the national maternal mortality rate has been slower than expected. The Mexican Ministry of Health’s 2009 strategy to reduce maternal mortality gives a role to two non-physician models that meet criteria for skilled attendants: obstetric nurses and professional midwives. This study compares and contrasts these two provider types with the medical model, analyzing perspectives on their respective training, scope of practice, and also their perception and/or experiences with integration into the public system as skilled birth attendants.
Methodology
This paper synthesizes qualitative research that was obtained as a component of the quantitative and qualitative study that evaluated three models of obstetric care: professional midwives (PM), obstetric nurses (ON) and general physicians (GP). A total of 27 individual interviews using a semi-structured guide were carried out with PMs, ONs, GPs and specialists. Interviews were transcribed following the principles of grounded theory, codes and categories were created as they emerged from the data. We analyzed data in ATLAS.ti.
Results
All provider types interviewed expressed confidence in their professional training and acknowledge that both professional midwives and obstetric nurses have the necessary skills and knowledge to care for women during normal pregnancy and childbirth. The three types of providers recognize limits to their practice, namely in the area of managing complications.
We found differences in how each type of practitioner perceived the concept and process of birth and their role in this process. The barriers to incorporation as a model to attend birth faced by PMs and ONs are at the individual, hospital and system level. GPs question their ability and training to handle deliveries, in particular those that become complicated, and the professional midwifery model particularly as it relates to a clinical setting, is also questioned.
Conclusions
Hospitals in the Mexican public health sector have a heavy obstetric workload; physicians carry the additional burden of non-obstetric cases. The incorporation of a non- physician model at the primary health center level to attend low-risk, normal deliveries would contribute to the reduction of non-necessary referrals. There is also a role for these providers at the hospital level.
doi:10.1186/1478-4491-10-6
PMCID: PMC3444919  PMID: 22533705
Midwifery; Obstetric care; Mexico; Obstetric nurses; Skilled birth attendants
5.  Midwives’ views on factors that contribute to health care inequalities among immigrants in Sweden: a qualitative study 
Introduction
Ethnic and socioeconomic inequalities in the Swedish health care system have increased. Most indicators suggest that immigrants have significantly poorer health than native Swedes. The purpose of this study was to explore the views of midwives on the factors that contribute to health care inequality among immigrants.
Methods
Data were collected via semi-structured interviews with ten midwives. These were transcribed and related categories identified through content analysis.
Results
The interview data were divided into three main categories and seven subcategories. The category “Communication” was divided into subcategories “The meeting”, “Cultural diversity and language barriers” and “Trust and confidence”. The category “Potential barriers to the use of health care services” contained two subcategories, “Seeking health care” and “Receiving equal treatment”. Finally, the category “Transcultural health care” had subcategories “Education on transcultural health care” and “The concept”.
Conclusions
This study suggests that midwives believe that health care inequality among immigrants can be the result of miscommunication which may arise due to a shortage of meeting time, language barriers, different systems of cultural beliefs and practices and limited patient-caregiver trust. Midwives emphasized that education level, country of origin and length of stay in Sweden play a role when an immigrant seeks health care. Immigrants face more difficulties when seeking health care and in receiving adequate levels of care. However, different views among the midwives were also observed. Some midwives were sensitive to individual and intra-group differences, while some others viewed immigrants as a group of “others”. Midwives’ beliefs about subgroup-specific health services vs. integrating immigrants’ health care into mainstream health care services should be investigated further. Patients’ perspective should also be considered.
doi:10.1186/1475-9276-11-47
PMCID: PMC3462105  PMID: 22900923
Immigrants; Midwives; Communication; Inequality; Transcultural health care
6.  Being a bridge: Swedish antenatal care midwives’ encounters with Somali-born women and questions of violence; a qualitative study 
Background
Violence against women is associated with serious health problems, including adverse maternal and child health. Antenatal care (ANC) midwives are increasingly expected to implement the routine of identifying exposure to violence. An increase of Somali born refugee women in Sweden, their reported adverse childbearing health and possible links to violence pose a challenge to the Swedish maternity health care system. Thus, the aim was to explore ways ANC midwives in Sweden work with Somali born women and the questions of exposure to violence.
Methods
Qualitative individual interviews with 17 midwives working with Somali-born women in nine ANC clinics in Sweden were analyzed using thematic analysis.
Results
The midwives strived to focus on the individual woman beyond ethnicity and cultural differences. In relation to the Somali born women, they navigated between different definitions of violence, ways of handling adversities in life and social contexts, guided by experience based knowledge and collegial support. Seldom was ongoing violence encountered. The Somali-born women’s’ strengths and contentment were highlighted, however, language skills were considered central for a Somali-born woman’s access to rights and support in the Swedish society. Shared language, trustful relationships, patience, and networking were important aspects in the work with violence among Somali-born women.
Conclusion
Focus on the individual woman and skills in inter-cultural communication increases possibilities of overcoming social distances. This enhances midwives’ ability to identify Somali born woman’s resources and needs regarding violence disclosure and support. Although routine use of professional interpretation is implemented, it might not fully provide nuances and social safety needed for violence disclosure. Thus, patience and trusting relationships are fundamental in work with violence among Somali born women. In collaboration with social networks and other health care and social work professions, the midwife can be a bridge and contribute to increased awareness of rights and support for Somali-born women in a new society.
doi:10.1186/s12884-015-0429-z
PMCID: PMC4299129  PMID: 25591791
Violence; Somali born women; Antenatal care midwife; Communication; Trustful relationships; Networking; Person-centered; Qualitative method
7.  Primary prevention of childhood obesity through counselling sessions at Swedish child health centres: design, methods and baseline sample characteristics of the PRIMROSE cluster-randomised trial 
BMC Public Health  2014;14:335.
Background
Childhood obesity is a growing concern in Sweden. Children with overweight and obesity run a high risk of becoming obese as adults, and are likely to develop comorbidities. Despite the immense demand, there is still a lack of evidence-based comprehensive prevention programmes targeting pre-school children and their families in primary health care settings. The aims are to describe the design and methodology of the PRIMROSE cluster-randomised controlled trial, assess the relative validity of a food frequency questionnaire, and describe the baseline characteristics of the eligible young children and their mothers.
Methods/Design
The PRIMROSE trial targets first-time parents and their children at Swedish child health centres (CHC) in eight counties in Sweden. Randomisation is conducted at the CHC unit level. CHC nurses employed at the participating CHC received training in carrying out the intervention alongside their provision of regular services. The intervention programme, starting when the child is 8-9 months of age and ending at age 4, is based on social cognitive theory and employs motivational interviewing. Primary outcomes are children’s body mass index and waist circumference at four years. Secondary outcomes are children’s and mothers’ eating habits (assessed by a food frequency questionnaire), and children’s and mothers’ physical activity (measured by accelerometer and a validated questionnaire), and mothers’ body mass index and waist circumference.
Discussion
The on-going population-based PRIMROSE trial, which targets childhood obesity, is embedded in the regular national (routine) preventive child health services that are available free-of-charge to all young families in Sweden. Of the participants (n = 1369), 489 intervention and 550 control mothers (75.9%) responded to the validated physical activity and food frequency questionnaire at baseline (i.e., before the first intervention session, or, for children in the control group, before they reached 10 months of age). The food frequency questionnaire showed acceptable relative validity when compared with an 8-day food diary. We are not aware of any previous RCT, concerned with the primary prevention of childhood obesity through sessions at CHC that addresses healthy eating habits and physical activity in the context of a routine child health services programme.
Trial registration
ISRCTN16991919
doi:10.1186/1471-2458-14-335
PMCID: PMC3995501  PMID: 24717011
Childhood obesity; Primary prevention; Motivational interviewing; Primary care setting; Intervention study
8.  The process of community health nursing clinical clerkship: A grounded theory 
Background:
The performance of the community health nurse depends on a combination of scientific and practical competencies acquired by educational experiences during the nursing course. Curriculum planners of nursing education need to understand nursing education to train professional and community-oriented nurses. The aim of this article is to explore the experiences of nursing students during their community health nursing clinical clerkship courses.
Materials and Methods:
A grounded theory approach was used to conduct this study. Twelve nursing students, 13 health-care staff members, and 10 nursing instructors were interviewed individually in 2011-2012. The interviews were tape-recorded and later transcribed verbatim. The transcriptions were analyzed using the method of Strauss and Corbin.
Results:
Ambivalence of motivation was the main category and included five subcategories: Professional identity, educational atmosphere, educational management, motivation-based approaches, and inadequate productivity. This paper presents the aspects of the community health nursing clerkship course from the viewpoint of students in areas such as the role of the community health nurse, attitude toward the course, medical orientation, prerequisite skills/knowledge, poor administrative planning, rotation of students, insufficient activity for students, passiveness, providing service to clients, responsibility, and inproductivity. These categories could explain the nature of the community health nursing clerkship of the Mashhad Faculty of Nursing and probably others in Iran.
Conclusions:
The findings revealed inadequate productivity of the community health nursing education; so, it is suggested to define a position for nurses in this setting and remove barriers and provide conditions for them to play more important roles in the promotion of community health.
PMCID: PMC3917128  PMID: 24554943
Clinical clerkship; community health; grounded theory; Iran; nursing students
9.  The perceived meaning of a (w)holistic view among general practitioners and district nurses in Swedish primary care: a qualitative study 
Background
The definition of primary care varies between countries. Swedish primary care has developed from a philosophic viewpoint based on quality, accessibility, continuity, co-operation and a holistic view. The meaning of holism in international literature differs between medicine and nursing. The question is, if the difference is due to different educational traditions. Due to the uncertainties in defining holism and a holistic view we wished to study, in depth, how holism is perceived by doctors and nurses in their clinical work. Thus, the aim was to explore the perceived meaning of a holistic view among general practitioners (GPs) and district nurses (DNs).
Methods
Seven focus group interviews with a purposive sample of 22 GPs and 20 nurses working in primary care in two Swedish county councils were conducted. The interviews were transcribed verbatim and analysed using qualitative content analysis.
Results
The analysis resulted in three categories, attitude, knowledge, and circumstances, with two, two and four subcategories respectively. A professional attitude involves recognising the whole person; not only fragments of a person with a disease. Factual knowledge is acquired through special training and long professional experience. Tacit knowledge is about feelings and social competence. Circumstances can either be barriers or facilitators. A holistic view is a strong motivator and as such it is a facilitator. The way primary care is organised can be either a barrier or a facilitator and could influence the use of a holistic approach. Defined geographical districts and care teams facilitate a holistic view with house calls being essential, particularly for nurses. In preventive work and palliative care, a holistic view was stated to be specifically important. Consultations and communication with the patient were seen as important tools.
Conclusion
'Holistic view' is multidimensional, well implemented and very much alive among both GPs and DNs. The word holistic should really be spelt 'wholistic' to avoid confusion with complementary and alternative medicine. It was obvious that our participants were able to verbalise the meaning of a 'wholistic' view through narratives about their clinical, every day work. The possibility to implement a 'wholistic' perspective in their work with patients offers a strong motivation for GPs and DNs.
doi:10.1186/1471-2296-8-8
PMCID: PMC1828160  PMID: 17346340
10.  Does the organizational model of the maternity health clinic have an influence on women’s and their partners’ experiences? A service evaluation survey in Southwest Finland 
Background
In high-income countries, great disparities exist in the organizational characteristics of maternity health services. In Finland, primary maternity care is provided at communal maternity health clinics (MHC). At these MHCs there are public health nurses and general practitioners providing care. The structure of services in MHCs varies largely. MHCs are maintained independently or merged with other primary health care sectors. A widely used organizational model of services is a combined maternity and child health clinic (MHC & CHC) where the same public health nurse takes care of the family from pregnancy until the child is at school age. The aim of this study was to determine how organizational model, MHC independent or combined MHC & CHC, influence on women’s and their partners’ service experiences.
Methods
A comparative, cross-sectional service evaluation survey was used. Women (N = 995) and their partners (N = 789) were recruited from the MHCs in the area of Turku University Hospital. Four months postpartum, the participants were asked to evaluate the content and amount of the MHC services via a postal questionnaire. Comparisons were made between the clients of the separate MHCs and the MHCs combined to the child health clinics.
Results
Women who had used the combined MHC & CHCs generally evaluated services more positively than women who had used the separate MHCs. MHC’s model was related to several aspects of the service which were evaluated “good” (the content of the service) or “much” (the amount of the service). Significant differences accumulated favoring the combined MHC & CHCs’ model. Twelve aspects of the service were ranked more often as “good” or “much” by the parents who had used the combined MHC & CHC, only group activities regarding delivery were evaluated better by women who had used the separate MHCs.
Conclusions
Based on the women’s and partners’ experiences an organizational model of the combined MHC & CHC where the same nurse will take care of family during pregnancy and after birth of the child was preferred. This model also provides greater amount of home visits and peer support than the separate MHC.
doi:10.1186/1471-2393-12-96
PMCID: PMC3520862  PMID: 22974077
Health services research; Primary health care; Comparative study; Pregnancy; Maternal health services; Prenatal care; Continuity of patient care; Parents
11.  A randomised controlled trial of caseload midwifery care: M@NGO (Midwives @ New Group practice Options) 
Background
Australia has an enviable record of safety for women in childbirth. There is nevertheless growing concern at the increasing level of intervention and consequent morbidity amongst childbearing women. Not only do interventions impact on the cost of services, they carry with them the potential for serious morbidities for mother and infant.
Models of midwifery have proliferated in an attempt to offer women less fragmented hospital care. One of these models that is gaining widespread consumer, disciplinary and political support is caseload midwifery care. Caseload midwives manage the care of approximately 35-40 a year within a small Midwifery Group Practice (usually 4-6 midwives who plan their on call and leave within the Group Practice.) We propose to compare the outcomes and costs of caseload midwifery care compared to standard or routine hospital care through a randomised controlled trial.
Methods/design
A two-arm RCT design will be used. Women will be recruited from tertiary women's hospitals in Sydney and Brisbane, Australia. Women allocated to the caseload intervention will receive care from a named caseload midwife within a Midwifery Group Practice. Control women will be allocated to standard or routine hospital care. Women allocated to standard care will receive their care from hospital rostered midwives, public hospital obstetric care and community based general medical practitioner care. All midwives will collaborate with obstetricians and other health professionals as necessary according to the woman's needs.
Discussion
Data will be collected at recruitment, 36 weeks antenatally, six weeks and six months postpartum by web based or postal survey. With 750 women or more in each of the intervention and control arms the study is powered (based on 80% power; alpha 0.05) to detect a difference in caesarean section rates of 29.4 to 22.9%; instrumental birth rates from 11.0% to 6.8%; and rates of admission to neonatal intensive care of all neonates from 9.9% to 5.8% (requires 721 in each arm). The study is not powered to detect infant or maternal mortality, however all deaths will be reported. Other significant findings will be reported, including a comprehensive process and economic evaluation.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12609000349246
doi:10.1186/1471-2393-11-82
PMCID: PMC3235961  PMID: 22029746
12.  Well-Child Care Clinical Practice Redesign at a Community Health Center: Provider and Staff Perspectives 
Background
Community health centers (CHCs) are a key element of the health care safety net for underserved children. They may be an ideal setting to create well-child care (WCC) clinical practice redesign to drastically improve WCC delivery.
Objective
To examine the perspectives of clinical and administrative staff at a large, multisite urban CHC on alternative ways to deliver WCC services for low-income children aged 0 to 3 years.
Methods
Eight semistructured interviews were conducted with 4 pediatric teams (each consisting of 1 pediatrician and 2 medical assistants) and 4 CHC executive/administrative staff (Medical Director, COO, CEO, and Nurse Supervisor). Discussions were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis. Salient themes included WCC delivery challenges and endorsed WCC clinical practice redesign solutions.
Results
The 3 main WCC delivery challenges included long wait times due to insurance verification and intake paperwork, lack of time for parent education and sick visits due to WCC visit volume, and absence of a system to encourage physicians to use non–face-to-face communication with parents. To address WCC delivery challenges, CHC providers and administrators endorsed several options for clinical practice redesign in their setting. These included use of a health educator in a team-based model of care, a previsit tool for screening and surveillance, Web site health education, a structured system for non–face-to-face (eg, phone) parent communication, and group visits.
Conclusion
CHC-specific strategies for WCC clinical practice redesign endorsed by a large, multisite safety net clinic may lead to more efficient, effective, and family-centered WCC for low-income populations.
doi:10.1177/2150131913511641
PMCID: PMC4083095  PMID: 24327599
preventive care; community health centers; children; primary care; qualitative methods
13.  High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention 
Background
In Tanzania, more than 90% of all pregnant women attend antenatal care at least once and approximately 62% four times or more, yet less than five in ten receive skilled delivery care at available health units. We conducted a qualitative study in Ngorongoro district, Northern Tanzania, in order to gain an understanding of the health systems and socio-cultural factors underlying this divergent pattern of high use of antenatal services and low use of skilled delivery care. Specifically, the study examined beliefs and behaviors related to antenatal, labor, delivery and postnatal care among the Maasai and Watemi ethnic groups. The perspectives of health care providers and traditional birth attendants on childbirth and the factors determining where women deliver were also investigated.
Methods
Twelve key informant interviews and fifteen focus group discussions were held with Maasai and Watemi women, traditional birth attendants, health care providers, and community members. Principles of the grounded theory approach were used to elicit and assess the various perspectives of each group of participants interviewed.
Results
The Maasai and Watemi women's preferences for a home birth and lack of planning for delivery are reinforced by the failure of health care providers to consistently communicate the importance of skilled delivery and immediate post-partum care for all women during routine antenatal visits. Husbands typically serve as gatekeepers of women's reproductive health in the two groups - including decisions about where they will deliver- yet they are rarely encouraged to attend antenatal sessions. While husbands are encouraged to participate in programs to prevent maternal-to-child transmission of HIV, messages about the importance of skilled delivery care for all women are not given emphasis.
Conclusions
Increasing coverage of skilled delivery care and achieving the full implementation of Tanzania's Focused Antenatal Care Package in Ngorongoro depends upon improved training and monitoring of health care providers, and greater family participation in antenatal care visits.
doi:10.1186/1471-2393-10-13
PMCID: PMC2850322  PMID: 20302625
14.  A Survey of Factors Associated with the Utilization of Community Health Centers for Managing Hypertensive Patients in Chengdu, China 
PLoS ONE  2011;6(7):e21718.
Background
For decades the development of community health services has been emphasized in China to cope with the growing burden of chronic diseases by providing basic medical services. This survey aims at investigating factors associated with the use of Community Health Centers (CHCs) for the management of hypertensive patients in Chengdu, China.
Methods
We used a systematic sampling method to select 2,030 patients with hypertension or diabetes registered in 29 CHCs in Chengdu in 2007. Researchers interviewed patients who consented to participate at their home. This paper reports findings from the survey of 1,716 hypertensive patients with completed questionnaires. Univariate analyses and multiple logistic regression analyses were conducted to explore factors influencing the use of CHCs for the management of hypertensive patients.
Results
81.4% of hypertensive patients regularly used CHCs for hypertension monitoring and treatment in Chengdu. Univariate analyses indicated that use of CHCs was associated with the education level, occupation, types of medical insurance, Body Mass Index(BMI), patients' knowledge on hypertension, awareness of CHCs functions, satisfaction of the service of CHCs. Multiple regression analyses found that use of CHCs was positively associated with the following factors: the Urban Resident Basic Medical Insurance(URBMI), knowledge on blood pressure, awareness of the sites in CHCs to measure blood pressure, awareness of having to take life-long antihypertensive medicine once the treatment started, awareness of the health records registration in CHCs, regular follow up, improved convenience of seeing doctor. Patients with professional job were less likely to use the services of CHCs.
Conclusions
The use of CHCs for hypertension management could be increased by improving residents' knowledge on the monitoring and treatment of hypertension, and the awareness of CHCs functions. The CHCs could play an important role in providing medical care to low-income, unemployed and other disadvantaged patients with hypertension.
doi:10.1371/journal.pone.0021718
PMCID: PMC3131288  PMID: 21750725
15.  “An on-going individual adjustment”: a qualitative study of midwives’ experiences counselling pregnant women on physical activity in Sweden 
Background
In Sweden, midwives play prominent supportive role in antenatal care by counselling and promoting healthy lifestyles. This study aimed to explore how Swedish midwives experience the counselling of pregnant women on physical activity, specifically focusing on facilitators and barriers during pregnancy. Also, addressing whether the midwives perceive that their own lifestyle and body shape may influence the content of the counselling they provide.
Methods
Eight focus group discussions (FGD) were conducted with 41 midwives working in antenatal care clinics in different parts of Sweden between September 2013 and January 2014. Purposive sampling was applied to ensure a variation in age, work experience, and geographical location. The FGD were digitally recorded, transcribed verbatim, and analyzed using manifest and latent content analysis.
Results
The main theme– “An on-going individual adjustment” was built on three categories: “Counselling as a challenge”; “Counselling as walking the thin ice” and “Counselling as an opportunity” reflecting the midwives on-going need to adjust their counselling depending on each woman’s specific situation. Furthermore, counselling pregnant women on physical activity was experienced as complex and ambiguous, presenting challenges as well as opportunities. When midwives challenged barriers to physical activity, they risked being rejected by the pregnant women. Despite risking rejection, the midwives tried to promote increased physical activity based on their assessment of individual needs of the pregnant woman. Some participants felt that their own lifestyle and body shape might negatively influence the counselling; however, the majority of participants did not agree with this perspective.
Conclusions
Counselling on physical activity during pregnancy may be a challenging task for midwives, characterized by on-going adjustments based on a pregnant woman’s individual needs. Midwives strive to find individual solutions to encourage physical activity. However, to improve their counselling, midwives may benefit from further training, also organizational and financial barriers need to be addressed. Such efforts might result in improved opportunities to further support pregnant women’s motivation for performance of physical activity.
doi:10.1186/1471-2393-14-343
PMCID: PMC4190373  PMID: 25269457
16.  "Smoking in Children's Environment Test": a qualitative study of experiences of a new instrument applied in preventive work in child health care 
BMC Pediatrics  2011;11:113.
Background
Despite knowledge of the adverse health effects of passive smoking, children are still being exposed. Children's nurses play an important role in tobacco preventive work through dialogue with parents aimed at identifying how children can be protected from environmental tobacco smoke (ETS) exposure. The study describes the experiences of Child Health Care (CHC) nurses when using the validated instrument SiCET (Smoking in Children's Environment Test) in dialogue with parents.
Method
In an intervention in CHC centres in south-eastern Sweden nurses were invited to use the SiCET. Eighteen nurses participated in focus group interviews. Transcripts were reviewed and their contents were coded into categories by three investigators using the method described for focus groups interviews.
Results
The SiCET was used in dialogue with parents in tobacco preventive work and resulted in focused discussions on smoking and support for behavioural changes among parents. The instrument had both strengths and limitations. The nurses experienced that the SiCET facilitated dialogue with parents and gave a comprehensive view of the child's ETS exposure. This gave nurses the possibility of taking on a supportive role by offering parents long-term help in protecting their child from ETS exposure and in considering smoking cessation.
Conclusion
Our findings indicate that the SiCET supports nurses in their dialogue with parents on children's ETS exposure at CHC. There is a need for more clinical use and evaluation of the SiCET to determine its usefulness in clinical practice under varying circumstances.
doi:10.1186/1471-2431-11-113
PMCID: PMC3267672  PMID: 22172056
17.  Perspectives about and approaches to weight gain in pregnancy: a qualitative study of physicians and nurse midwives 
Background
Over one third of reproductive age women in the US are obese. Pregnancy is a strong risk factor for obesity, with excess weight gain as the greatest predictor of long term obesity. The majority of pregnant women gain more weight than recommended by the Institute of Medicine guidelines. The objective of this study was to understand prenatal care providers’ perspectives on weight gain during pregnancy.
Methods
Semi-structured qualitative interviews of 10 prenatal care providers (three family physicians, three obstetricians, and four nurse midwives) at a University Hospital in the Midwest, that included the ranking of important prenatal issues, and open-ended questions addressing: 1) general perceptions; 2) approach with patients; and 3) clinical care challenges.
Results
Providers felt that appropriate weight gain during pregnancy was not a high priority. Many providers waited until patients had gained excess weight before addressing the issue, were not familiar with established guidelines, and lacked resources for patients. Providers also believed that their counseling had low impact on patients, avoided counseling due to sensitivity of the topic, and believed that patients were more influenced by other factors, such as their family, habits, and culture.
Conclusions
Both providers and patients may benefit from increased awareness of the morbidity of excess weight gain during pregnancy. Practice-level policies that support the monitoring and management of weight gain during pregnancy could also improve care. Research that further investigates the barriers to appropriate weight gain is warranted.
doi:10.1186/1471-2393-13-47
PMCID: PMC3626918  PMID: 23433216
Prenatal care; Gestational weight gain; Obesity; Qualitative study; Obstetrics; Certified nurse midwives; Family physician
18.  A qualitative descriptive study of the group prenatal care experience: perceptions of women with low-risk pregnancies and their midwives 
Background
Group prenatal care (GPC) originated in 1994 as an innovative model of prenatal care delivery. In GPC, eight to twelve pregnant women of similar gestational age meet with a health care provider to receive their prenatal check-up and education in a group setting. GPC offers significant health benefits in comparison to traditional, one-on-one prenatal care. Women in GPC actively engage in their healthcare and experience a supportive network with one another. The purpose of this study was to better understand the GPC experience of women and care providers in a lower risk group of women than often has been previously studied.
Methods
This qualitative descriptive study collected data through three focus group interviews - two with women who had completed GPC at a midwifery clinic in Ontario, Canada and one with the midwives at the clinic. Data was analyzed through open coding to identify themes.
Results
Nine women and five midwives participated in the focus groups, from which eight categories as well as further subcategories were identified: The women and midwives noted reasons for participating (connections, education, efficiency). Participants suggested both benefits (learning from the group, normalizing the pregnancy experience, preparedness for labour and delivery, and improved relationships as all contributing to positive health outcomes) and concerns with GPC (e.g. sufficient time with the midwife) which generally diminished with experience. Suggestions for change focused on content, environment, partners, and access to the midwives. Challenges to providing GPC included scheduling and systems-level issues such as funding and regulation. Flexibility and commitment to the model facilitated it. Comparison with other models of care identified less of a relationship with the midwife, but more information received. In promoting GPC, women would emphasize the philosophy of care to other women and the midwives would promote the reduction in workload and women’s independence to colleagues.
Conclusions
Overall, women and midwives expressed a high level of satisfaction with their GPC experience. This study gained insight into previously unexplored areas of the GPC experience, perceptions of processes that contribute to positive health outcomes, strategies to promote GPC and elements that enhance the feasibility of GPC.
doi:10.1186/1471-2393-14-334
PMCID: PMC4262064  PMID: 25258167
Group prenatal care; Pregnant women; Midwives; Satisfaction; Experience; Qualitative research
19.  Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study 
PLoS Medicine  2014;11(5):e1001649.
Rashida Ferrand and colleagues combine quantitative and qualitative methods to investigate HIV prevalence among older children receiving primary care in Harare, Zimbabwe, and reasons why providers did not pursue testing.
Please see later in the article for the Editors' Summary
Background
There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.
Methods and Findings
Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.
Conclusions
The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Over 3 million children globally are estimated to be living with HIV (the virus that causes AIDS). While HIV infection is most commonly spread through unprotected sex with an infected person, most HIV infections among children are the result of mother-to-child HIV transmission during pregnancy, delivery, or breastfeeding. Mother-to-child transmission can be prevented by administering antiretroviral therapy to mothers with HIV during pregnancy, delivery, and breast feeding, and to their newborn babies. According to a report by the Joint United Nations Programme on HIV/AIDS published in 2012, 92% of pregnant women with HIV were living in sub-Saharan Africa and just under 60% were receiving antiretroviral therapy. Consequently, sub-Saharan Africa is the region where most children infected with HIV live.
Why Was This Study Done?
If an opportunity to prevent mother-to-child transmission around the time of birth is missed, diagnosis of HIV infection in a child or adolescent is likely to depend on HIV testing in health care facilities. Health care provider–initiated HIV testing and counselling (PITC) for children is important in areas where HIV infection is common because earlier diagnosis allows children to benefit from care that can prevent the development of advanced HIV disease. Even if a child or adolescent appears to be in good health, access to care and antiretroviral therapy provides a health benefit to the individual over the long term. The administration of HIV testing (and counselling) to children relies not only on health care workers (HCWs) offering HIV testing but also on parents or guardians consenting for a child to be tested. However, more than 30% of children in countries with severe HIV epidemics are AIDS orphans, and economic conditions in these countries cause many adults to migrate for work, leaving children under the care of extended families. This study aimed to investigate the reasons for acceptance and rejection of PITC in primary health care settings in Harare, Zimbabwe. By exploring HCW perspectives on providing HIV testing to children and adolescents, the study also sought to gain insight into factors that could be hindering implementation of testing procedures.
What Did the Researchers Do and Find?
The researchers identified all children aged 6 to 15 years old at six primary care clinics in Harare, who were offered HIV testing as part of routine care between 22 January and 31 May 2013. Study fieldworkers collected data on numbers of child attendances, numbers offered testing, numbers who underwent HIV testing, and reasons why HIV testing did not occur. During the study 2,831 children attending the health clinics were eligible for PITC, and just over half (1,534, 54.2%) underwent HIV testing. Eighty-two children tested HIV-positive, and nearly all of them received counselling, medication, and follow-up care. HCWs offered the test to around 75% of those eligible. The most frequent explanation given by HCWs for a diagnostic test not being offered was that the child was accompanied by a guardian not appropriate for providing consent (401 occasions, 59%); Other reasons given were a lack of available counsellors or test kits and counsellors refusing to conduct the test. The likelihood of being offered the test was lower for children not exhibiting symptoms (such as persistent skin problems), older children, or those attending with a male or a younger guardian. In addition, over 100 guardians or parents provided consent but left before the child could be tested.
The researchers also conducted semi-structured interviews with 12 clinic nurses and counsellors (two from each clinic) to explore challenges to implementation of PITC. The researchers recorded the factors associated with testing not taking place, either when offered to eligible children or when HCWs declined to offer the test. The interviewees identified the frequent absence or unavailability of parents or legal guardians as an obstacle, and showed uncertainty or misconceptions around whether testing of the guardian was mandatory (versus recommended) and whether specifically a parent (if one was living) must provide consent. The interviews also revealed HCW concerns about the availability of adequate counselling and child services, and fears that a child might experience maltreatment if he or she tested positive. HCWs also noted long waiting times and test kits being out of stock as practical hindrances to testing.
What Do These Findings Mean?
Prevalence of HIV was high among the children tested, validating the need for PITC in sub-Saharan health care settings. Although 76% of eligible attendees were offered testing, the authors note that this is likely higher than in routine settings because the researchers were actively recording reasons for not offering testing and counselling, which may have encouraged heath care staff to offer PITC more often than usual. The researchers outline strategies that may improve PITC rates and testing acceptance for Zimbabwe and other sub-Saharan settings. These strategies include developing clear laws and guidance concerning guardianship and proxy consent when testing older children for HIV, training HCWs around these policies, strengthening legislation to address discrimination, and increasing public awareness about HIV infection in older children.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001649.
This study is further discussed in a PLOS Medicine Perspective by Davies and Kalk
The Joint United Nations Programme on HIV/AIDS publishes an annual report on the global AIDS epidemic, which provides information on progress towards eliminating new HIV infections
The World Health Organization has more information on mother-to-child transmission of HIV
The World Health Organization's website also has information about treatment for children living with HIV
Personal stories about living with HIV/AIDS, including stories from young people infected with HIV, are available through Avert, through NAM/aidsmap, and through the charity website Healthtalkonline
doi:10.1371/journal.pmed.1001649
PMCID: PMC4035250  PMID: 24866209
20.  Smoothing out the transition of care between maternity and child and family health services: perspectives of child and family health nurses and midwives’ 
Background
In Australia, women who give birth are transitioned from maternity services to child and health services once their baby is born. This horizontal integration of services is known as Transition of Care (ToC). Little is known of the scope and processes of ToC for new mothers and the most effective way to provide continuity of services. The aim of this paper is to explore and describe the ToC between maternity services to CFH services from the perspective of Australian midwives and child and family health (CFH) nurses.
Method
This paper reports findings from phase two of a three phase mixed methods study investigating the feasibility of implementing a national approach to CFH services in Australia (the CHoRUS study). Data were collected through a national survey of midwives (n = 655) and CFH nurses (n = 1098). Issues specifically related to ToC between maternity services and CFH services were examined using descriptive statistics and content analysis of qualitative responses.
Results
Respondents described the ToC between maternity services and CFH services as problematic. Key problems identified included communication between professionals and services and transfer of client information. Issues related to staff shortages, early maternity discharge, limited interface between private and public health systems and tension around role boundaries were also reported. Midwives and CFH nurses emphasised that these issues were more difficult for families with identified social and emotional health concerns. Strategies identified by respondents to improve ToC included improving electronic transfer of information, regular meetings between maternity and CFH services, and establishment of liaison roles.
Conclusion
Significant problems exist around the ToC for all families but particularly for families with identified risks. Improved ToC will require substantial changes in information transfer processes and in the professional relationships which currently exist between maternity and CFH services.
doi:10.1186/1471-2393-14-151
PMCID: PMC4016663  PMID: 24766674
Transition of care; Maternity services; Child health services; Midwives; Child and family health nurses; Communication; Collaboration; Continuity
21.  System Factors Affect the Recognition and Management of Post-Traumatic Stress Disorder by Primary Care Clinicians 
Medical care  2009;47(6):686-694.
Background
Post-traumatic stress disorder (PTSD) is common with an estimated prevalence of 8% in the general population and up to 17% in primary care patients. Yet, little is known about what determines primary care clinician’s (PCC) provision of PTSD care.
Objective
To describe PCC’s reported recognition and management of PTSD and identify how system factors affect the likelihood of performing clinical actions with regard to patients with PTSD or “PTSD treatment proclivity.”
Design
Linked cross-sectional surveys of medical directors and PCCs.
Participants
Forty-six medical directors and 154 PCCs in community health centers (CHCs) within a practice-based research network in New York and New Jersey.
Measurements
Two system factors (degree of integration between primary care and mental health services, and existence of linkages with other community, social, and legal services) as reported by medical directors, and PCC reports of self-confidence, perceived barriers, and PTSD treatment proclivity.
Results
Surveys from 47 (of 58) medical directors (81% response rate) and 154 PCCs (86% response rate). PCCs from CHCs with better mental health integration reported greater confidence, fewer barriers, and higher PTSD treatment proclivity (all p<.05). PCCs in CHCs with better community linkages reported greater confidence, fewer barriers, higher PTSD treatment proclivity, and lower proclivity to refer patients to mental health specialists or to use a “watch and wait” approach (all p<.05).
Conclusion
System factors play an important role in PCC PTSD management. Interventions are needed that restructure primary care practices by making mental health services more integrated and community linkages stronger.
doi:10.1097/MLR.0b013e318190db5d
PMCID: PMC2762995  PMID: 19433999
. Primary care; post-traumatic stress disorder (PTSD); system factors; barriers
22.  Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states 
Background
Federally qualified community health centers (CHCs) and rural health clinics (RHCs) are intended to provide access to care for vulnerable populations. While some research has explored the effects of CHCs on population health, little information exists regarding RHC effects. We sought to clarify the contribution that CHCs and RHCs may make to the accessibility of primary health care, as measured by county-level rates of hospitalization for ambulatory care sensitive (ACS) conditions.
Methods
We conducted an ecologic analysis of the relationship between facility presence and county-level hospitalization rates, using 2002 discharge data from eight states within the US (579 counties). Counties were categorized by facility availability: CHC(s) only, RHC(s) only, both (CHC and RHC), and neither. US Agency for Healthcare Research and Quality definitions were used to identify ACS diagnoses. Discharge rates were based on the individual's county of residence and were obtained by dividing ACS hospitalizations by the relevant county population. We calculated ACS rates separately for children, working age adults, and older individuals, and for uninsured children and working age adults. To ensure stable rates, we excluded counties having fewer than 1,000 residents in the child or working age adult categories, or 500 residents among those 65 and older. Multivariate Poisson analysis was used to calculate adjusted rate ratios.
Results
Among working age adults, rate ratio (RR) comparing ACS hospitalization rates for CHC-only counties to those of counties with neither facility was 0.86 (95% Confidence Interval, CI, 0.78–0.95). Among older adults, the rate ratio for CHC-only counties compared to counties with neither facility was 0.84 (CI 0.81–0.87); for counties with both CHC and RHC present, the RR was 0.88 (CI 0.84–0.92). No CHC/RHC effects were found for children. No effects were found on estimated hospitalization rates among uninsured populations.
Conclusion
Our results suggest that CHCs and RHCs may play a useful role in providing access to primary health care. Their presence in a county may help to limit the county's rate of hospitalization for ACS diagnoses, particularly among older people.
doi:10.1186/1472-6963-9-134
PMCID: PMC2727502  PMID: 19646234
23.  Iran's Experience of Health Cooperatives as a Public-Private Partnership Model in Primary Health Care: A Comparative Study in East Azerbaijan 
Health Promotion Perspectives  2012;2(2):287-298.
Background: Iran started a new public-private partnership model in form of health coopera¬tives which is somehow different from other types of health cooperatives throughout the world. In this study we compared the performance and quality of health services in public health cen¬ters (PHCs) and cooperative health centers (CHCs).
Methods: In this comparative study performance quality of two cohorts of public and coopera¬tive health centers were compared in several health service delivery programs over the time pe¬riod of 2001- 2002.
Results: Screening program: the rate of visited population during screening program was higher in CHCs. Maternal health care program: In some of studied programs CHCs had better results. Child health care: Most indicators were better or similar in CHCs. School health program and Health education: All indices were better or similar in CHCs. Environmental health: population based positive function was not significantly different for the population covered by CHCs compared to population covered by PHCs. Management: Client and staff satisfaction as well as participation and attitudes of personnel towards management was better in CHCs. Mean annual cost per capita of the covered population by PHCs was higher.
Conclusion: CHCs as a public private partnership model in Iran may deliver preventive health care services as effective as PHCs in many fields and even better in some areas.
doi:10.5681/hpp.2012.034
PMCID: PMC3963636  PMID: 24688945
Health; Model; Public; Iran
24.  Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach 
PLoS Medicine  2006;3(10):e452.
Background
Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.
Methods and Findings
We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its “War on Drugs.” African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off “dopesickness” rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.
Conclusions
Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.
Bourgois and colleagues found that the African American and white men in their study had a different pattern of drug use and risk behaviors, adopted different strategies for survival, and had different personal histories.
Editors' Summary
Background.
There are stark differences in the health of different ethnic groups in America. For example, the life expectancy for white men is 75.4 years, but it is only 69.2 years for African-American men. The reasons behind these disparities are unclear, though there are several possible explanations. Perhaps, for example, different ethnic groups are treated differently by health professionals (with some groups receiving poorer quality health care). Or maybe the health disparities are due to differences across ethnic groups in income level (we know that richer people are healthier). These disparities are likely to persist unless we gain a better understanding of how they arise.
Why Was This Study Done?
The researchers wanted to study the health of a very vulnerable community of people: heroin users living on the streets in the San Francisco Bay Area. The health status of this community is extremely poor, and its members are highly stigmatized—including by health professionals themselves. The researchers wanted to know whether African American men and white men who live on the streets have a different pattern of drug use, whether they adopt varying strategies for survival, and whether they have different personal histories. Knowledge of such differences would help the health community to provide more tailored and culturally appropriate interventions. Physicians, nurses, and social workers often treat street-based drug users, especially in emergency rooms and free clinics. These health professionals regularly report that their interactions with street-based drug users are frustrating and confrontational. The researchers hoped that their study would help these professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients.
What Did the Researchers Do and Find?
Over the course of six years, the researchers directly observed about 70 men living on the streets who injected heroin as they went about their usual lives (this type of research is called “participant observation”). The researchers specifically looked to see whether there were differences between the white and African American men. All the men gave their consent to be studied in this way and to be photographed. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men. The researchers found that the white men were more likely to supplement their heroin use with inexpensive fortified wine, while African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime, and these men tended to consider themselves as destitute outcasts. African American men had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families, and these men tended to consider themselves as professional outlaws. The white men persevered less in attempting to find a vein in which to inject heroin, and so were more likely to inject the drug directly under the skin—this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most of their income through petty crime and/or through offering services such as washing car windows at gas stations.
What Do These Findings Mean?
Among street-based heroin users, there are important differences between white men and African American men in the type of drugs used, the method of drug use, their social backgrounds, the way in which they identify themselves, and the health risks that they take. By understanding these differences, health professionals should be better placed to provide tailored and appropriate care when these men present to clinics and emergency rooms. As the researchers say, “understanding of different ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care.” One limitation of this study is that the researchers studied one specific community in one particular area of the US—so we should not assume that their findings would apply to street-based heroin users elsewhere.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030452.
The US Centers for Disease Control (CDC) has a web page on HIV prevention among injection drug users
The World Health Organization has collected documents on reducing the risk of HIV in injection drug users and on harm reduction approaches
The International Harm Reduction Association has information relevant to a global audience on reducing drug-related harm among individuals and communities
US-focused information on harm reduction is available via the websites of the Harm Reduction Coalition and the Chicago Recovery Alliance
Canada-focused information can be found at the Street Works Web site
The Harm Reduction Journal publishes open-access articles
The CDC has a web page on eliminating racial and ethnic health disparities
The Drug Policy Alliance has a web page on drug policy in the United States
doi:10.1371/journal.pmed.0030452
PMCID: PMC1621100  PMID: 17076569
25.  A self-evaluation tool for integrated care services: the Development Model for Integrated Care applied in practice 
Purpose
The purpose of the workshop is to show the applications of the Development Model for Integrated Care (DMIC) in practice. This relatively new and validated model, can be used by integrated care practices to evaluate their integrated care, to assess their phase of development and reveal improvement areas. In the workshop the results of the use of the model in three types of integrated care settings in the Netherlands will be presented. Participants are offered practical instruments based on the validated DMIC to use in their own setting and will be introduced to the webbased tool.
Context
To integrate care from multiple providers into a coherent and streamlined client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and adequate transfers of clients. In the large range of possible activities it is often not clear what essential activities are and where to start or continue. Also, knowledge about how to further develop integrated care services is needed. The Development Model for Integrated Care (DMIC), based on PhD research of Mirella Minkman, describes nine clusters containing in total 89 elements that contribute to the integration of care. The clusters are named: ‘client-centeredness’, ‘delivery system’, ‘performance management’, ‘quality of care’, ‘result-focused learning’, ‘interprofessional teamwork’, ‘roles and tasks’, ‘commitment’, and ‘transparant entrepreneurship’ [1–3]. In 2011 a new digital webbased self-evolution tool which contains the 89 elements grouped in nine clusters was developed. The DMIC also describes four phases of development [4]. The model is empirically validated in practice by assessing the relevance and implementation of the elements and development phases in 84 integrated care services in The Netherlands: in stroke, acute myocardial infarct (AMI), and dementia services. The validation studies are recently published [5, 6]. In 2011 also other integrated care services started using the model [7]. Vilans developed a digital web-based self-evaluation tool for integrated care services based on the DMIC. A palliative care network, four diabetes services, a youth care service and a network for autism used the self-evaluation tool to evaluate the development of their integrated care service. Because of its generic character, the model and tool are believed to be also interesting internationally.
Data sources
In the workshop we will present the results of three studies in integrated diabetes, youth and palliative care. The three projects consist of multiple steps, see below. Workshop participants could also work with the DMIC following these steps.
One: Preparation of the digital self-evolution tool for integrated care services
Although they are very different, the three integrated care services all wanted to gain insight in their development and improvement opportunities. We tailored the digital self-evaluation tool for each specific integrated care services, but for all the basis was the DMIC. Personal accounts for the digital DMIC self-evalution survey were sent to multiple partners working in each integrated care service (4–16 partners).
Two: Use of the online self-evaluation tool each partner of the local integrated care setting evaluated the integrated care by filling in the web-based questionnaire. The tool consists of three parts (A-C) named: general information about the integrated care practice (A); the clusters and elements of the DMIC (B); and the four phases of development (C). The respondents rated the relevance and presence of each element in their integrated care practice. Respondents were asked to estimate in which phase of development their thought their service was.
Three: Analysing the results
Advisers from Vilans, the Centre of excellence for long-term care in the Netherlands, analysed the self-evolution results in cooperation with the integrated care coordinators. The results show the total amount of implemented integrated care elements per cluster in spider graphs and the development phase as calculated by the DMIC model. Suggestions for further development of the integrated care services were analysed and reported.
Four: Discussing the implications for further development
In a workshop with the local integrated care partners the results of the self-evaluation were presented and discussed. We noticed remarkable results and highlight elements for further development. In addition, we gave advice for further development appropriate to the development phase of the integrated care service. Furthermore, the professionals prioritized the elements and decided which elements to start working on. This resulted in a (quality improvement) plan for the further development of the integrated care service.
Five: Reporting results
In a report all the results of the survey (including consensus scores) and the workshops came together. The integrated care coordinators stated that the reports really helped them to assess their improvement strategy. Also, there was insight in the development phase of their service which gave tools for further development.
Case description
The three cases presented are a palliative network, an integrated diabetes services and an integrated care network for youth in the Netherlands. The palliative care network wanted to reflect on their current development, to build a guiding framework for further development of the network. About sixteen professionals within the network worked with the digital self-evaluation tool and the DMIC: home care organisations, welfare organizations, hospice centres, health care organisations, community organizations.
For diabetes care, a Dutch health care insurance company wished to gain insight in the development of the contracted integrated care services to stimulate further development of the services. Professionals of three diabetes integrated care services were invited to fill in the digital self-evaluation tool. Of each integrated care service professionals like a general practitioner, a diabetes nurse, a medical specialist, a dietician and a podiatrist were invited. In youth care, a local health organisation wondered whether the DMIC could be helpful to visualize the results of youth integrated care services at process- and organisational level. The goal of the project was to define indicators at a process- and organisational level for youth care services based on the DMIC. In the future, these indicators might be used to evaluate youth care integrated care services and improve the quality of youth care within the Netherlands.
Conclusions and discussion
It is important for the quality of integrated care services that the involved coordinators, managers and professionals are aware of the development process of the integrated care service and that they focus on elements which can further develop and improve their integrated care. However, we noticed that integrated care services in the Netherlands experience difficulties in developing their integrated care service. It is often not clear what essential activities are to work on and how to further develop the integrated care service. A guiding framework for the development of integrated care was missing. The DMIC model has been developed for that reason and offers a useful tool for assessment, self-evaluation or improvement of integrated care services in practice. The model has been validated for AMI, dementia and stroke services. The latest new studies in diabetes, palliative care and youth care gave further insight in the generic character of the DMIC. Based on these studies it can be assumed that the DMIC can be used for multiple types of integrated care services. The model is assumed to be interesting for an international audience. Improving integrated care is a complex topic in a large number of countries; the DMIC is also based on the international literature. Dutch integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding and improving their integrated care activities.
The web-based self-evaluation tool focuses on a process- and organisational level of integrated care. Also, the self assessed development phase can be compared to the development phase as calculated by the DMIC tool. The cases showed this is fruitful input for discussions. When using the tool, the results can also be used in quality policy reports and improvement plans. The web-based tool is being tested at this moment in practice, but in San Marino we can present the latest webversion and demonstrate with a short video how to use the tool and model. During practical exercises in the workshop the participants will experience how the application of the DMIC can work for them in practice or in research. For integrated care researchers and policy makers, the DMIC questionnaire and tool is a promising method for further research and policy plans in integrated care.
PMCID: PMC3617779
development model for integrated care; development of integrated care services; implementation and improvement of integrated care; self evaluation

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