Opportunities to catalyse improved healthcare access in pluralistic systems: a cross-sectional study in Haiti

ObjectiveTo identify determinants of intended versus actual care-seeking behaviours in a pluralistic healthcare system that is reliant on both conventional and non-conventional providers and discover opportunities to catalyse improved healthcare access.DesignCross-sectional study.Setting and participantsIn Haiti 568 households (incorporating 2900 members) with children less than 5 years of age were randomly sampled geographically with stratifications for population density. These households identified the healthcare providers they frequented. Among 140 providers, 65 were located and enrolled.Outcome measuresHousehold questionnaires with standardised cases (intentions) were compared with self-recall of health events (behaviours). The connectedness of households and their providers was determined by network analysis.ResultsHouseholds reported 636 health events in the prior month. Households sought care for 35% (n=220) and treated with home remedies for 44% (n=277). The odds of seeking care increased 217% for severe events (adjusted OR (aOR)=3.17; 95% CI 1.99 to 5.05; p<0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95% CI 1.06 to 1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favoured non-conventional providers (McNemar’s χ2 test p<0.001). Care was sought from primary providers for 68% (n=150) of cases within a three-tiered network; 25% (n=38/150) were non-conventional.ConclusionAddressing geographic barriers, possibly with technology solutions, should be prioritised to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome.

Advance care planning evaluation: a scoping review of best research practice

Various indicators have been used to evaluate advance care planning, including completion rates, type of care received, and satisfaction. Recent consensus suggests, though, that receiving care consistent with one’s goals is the primary outcome of advance care planning and assessment should capture this metric. Goal concordant care is challenging to measure, and there is little clarity about how best to do so. The aim of this scoping review is to explore what methods have been used to measure goal concordant care in the evaluation of advance care planning. PubMed, Embase, PsycINFO, CINAHL and Cochrane were searched in September 2020 to identify studies that aimed to track whether advance care planning affected the likelihood of patients receiving care that matched their preferred care. 135 original studies were included for review. Studies used retrospective chart review (36%, n=49), questionnaire (36%, n=48) and interview (31%, n=42), focusing on both patients and proxies. Studies considered both actual care received (55%, n=74) and hypothetical scenarios anticipating possible future care (49%, n=66); some studies did both. While the reviewed studies demonstrate the possibility of working towards a solid methodology, there were significant weaknesses. Notably, studies often lacked enough reporting clarity to be reproducible and, relatedly, key concepts, such as end-of-life or preferred care, were left undefined. The recommendations that follow from these findings inform future research approaches, supporting the development of a strong evidence base to guide advance care planning implementation in practice.

The SMOOTH-Robot: A Modular, Interactive Service Robot

The SMOOTH-robot is a mobile robot that—due to its modularity—combines a relatively low price with the possibility to be used for a large variety of tasks in a wide range of domains. In this article, we demonstrate the potential of the SMOOTH-robot through three use cases, two of which were performed in elderly care homes. The robot is designed so that it can either make itself ready or be quickly changed by staff to perform different tasks. We carefully considered important design parameters such as the appearance, intended and unintended interactions with users, and the technical complexity, in order to achieve high acceptability and a sufficient degree of utilization of the robot. Three demonstrated use cases indicate that such a robot could contribute to an improved work environment, having the potential to free resources of care staff which could be allocated to actual care-giving tasks. Moreover, the SMOOTH-robot can be used in many other domains, as we will also exemplify in this article.

Bridging Conversations

Both Judith Butler and Eva Kittay have formulated an ethics centered around concepts of dependency and vulnerability. However, they take these concepts into divergent normative directions. I trace these differences back to the contrasting empirical examples that inform their respective takes on dependency. Borrowing the words of Eva Kittay, I analyze their arguments in terms of “paradigm cases” of dependency. For Kittay, the paradigm case supporting her thought is a person with profound intellectual and multiple disabilities; for Butler, it is a refugee. Drawing out these paradigm cases brings the theoretical tensions between Butler and Kittay into sharp relief. Rather than resolving them, I suggest using the paradigm cases as heuristic devices to examine dependency in actual care practices.

The Contingency of the Lifeworld in a World of Standards. Repertoires of Resignification in (Evidence-Based) Healthcare Organization

In this article I discuss the irremediable tension between the universalistic dimension of contemporary medicine, represented by the paradigm of evidence-based medicine (EBM), and local daily practices in specific healthcare organizations. This tension constantly challenges the unitary, universalistic vision to which modern medicine and science aspire. The EBM paradigm, which is currently the most prevalent in every medical-nursing discipline, aims to standardize care procedures through the process of constant scientific literature review and the production of operational guidelines based on what epistemic communities define as the most reliable and effective results: the so-called gold standards. In everyday clinical, therapeutic, and care activities, these procedures are intertwined with the multiplicity of elements that make up the lifeworld. “Universalistic” premises are never merely “applied” to “local” interactive contexts but are always creatively “implicated” in them. Using data collected during a year of ethnographic research in an intensive care unit in Northern Italy, I discuss how the abstract indications of EBM and the formal dimension of health organizations are incorporated, through socially located interactive repertoires, in actual care trajectories. Following the Science and Technology Study perspective in a practice-based analysis of daily work, I show how interactions between human actors, technological artifacts and organizational apparatus in daily practices constitute repertoires of resignification through which local universality emerges, resolving the tension between medicine's universalistic aspirations and the unpredictable, situated nature of the lifeworld. I consider two repertoires: the interpretative (examining the production and dissemination of knowledge) and the relational (focusing on informal interactions between different professional groups and communities of practice). The article shows how care practices cannot disregard the specific organizational conditions in which they unfold and suggests that research should develop reflective analysis skills on what Annemarie Mol calls the logic of care, thus ceasing to treat the local dimension as a disturbing element in formal systems but, on the contrary, taking note of its impact and unavoidability in actual practice.

Legal Instruments Related to Refugees’ Mental Health Care: From Greek Legislation to Practice

Since the titled Global Refugee Crisis of 2013, the number of refugees has been constantly increasing. In 2018, the global number of persons of concern identified by UNHCR was 70.8 million, of which more than 25.9 million were refugees, and about half of them were below the age of 18. Refugees are subjected to multiple risk factors before, during, and after their displacement. Besides, the conditions why they had to flee their countries, the insecurity, and anxiety connected to their future, inter alia, are among the stressors that may affect refugees mental well-being. The relation between the existing international instruments related to refugees, mainly those concerning their right to health and the actual care they receive, compose complex scenery that asks for more attention to allow refugees to have positive outcomes, such as improving their mental well-being, which assists in social inclusion. This paper aimed at showing the gap between active mental health care rights and government practices, specifically those within the Greek context. This was made through exploratory research of qualitative nature, based on literature from the period of 2009-2019 and legal and international documents related to descriptors such as mental health care and refugees.

Transsexuality in the streets of Campinas: borderline resistance movements towards a humanistic care

According to WHO, transgender people are more likely to suffer from a broad range of health Issues high HIV prevalence, low access to health, discrimination, violence, rejection, unemployement, poverty, housing insecurity, and marginalisation. Structural macho-sexism is one of the main causes not only of violence, but also of lack of protective legislation and policy to this population. Developing research regarding transgender people's life experience in the streets and their pathways to healthcare is of major importance to achieve a more equitable society and public health system. This qualitative research is a chapter of the book “Experiências do Cuidado na Rua” (”Living Care in the Streets”). From the experience of offering care in downtown Campinas to people living in the streets, 2 case reports were selected. The narratives were collected in a field journal. Both participants were female transgenders living in the context of Brazil's Universal Health System. National policy and legislation were confronted with narrative analysis of the participants, to show the barriers to receiving proper and humanistic care. Some narratives show the clear violence suffered from law enforcement personnel: “We used to be beaten by the Police because we were prostituting ourselves”. Others show a transphobic moralistic context: “Last week a transexual had her heart torn here in Campinas, and a Saint image was put in her chest! I'm afraid to walk alone in the streets at night. “Yet others show a clear transphobic and problematic position from the now president Bolsonaro which reflects in transphobic sympathizers in hate speeches: “Nowadays [after presidential election] we hear in the streets 'let's send them to Bolsonaro!'”, as sending someone to the guillotine. The narratives show a clear need of global and local actions towards a more accepting society, and actions must be taken in a broad range of fields, such as human rights legislation, policy and surveillance. Key messages This research show the neglect for the transgender population and the lack of protective measures, which reflects in access to the health care system and actual care. A growth of discrimination and hate speeches directly related to the election of an extremist-right national administration has been observed.

Preferences and barriers to the utilization of primary health care by sick physicians: a nationwide survey

Background Physicians are often dissatisfied with their own medical care. Self-prescribing is common despite established guidelines that discourage this practice. From a pilot study, we know primary care physicians’ (PCP) preferences, but we lack information regarding other specialties and work places. Objectives The goal of this study was to examine whether physicians are satisfied with their personal primary care and how this could be improved. Methods We distributed an electronic survey to all physicians registered with the Israeli Medical Association. The questionnaire examined satisfaction with medical care, preferences for using formal care versus informal care, self-prescribing and barriers to using formal care. Results Two thousand three hundred and five out of 24 360 invited physicians responded. Fifty-six per cent of the respondents were satisfied with their personal primary care. Fifty-two per cent reported initiating self-treatment with a medication during the last year. Five and four per cent initiated treatment with a benzodiazepine and an antidepressant, respectively, during the last year. This was despite the fact that most physicians did not feel competent to treat themselves. Having a personal PCP was correlated with both a desire to use formal care and self-referral to formal care in practice. Regression analysis showed that the highest odds ratio (OR) for experiencing a large gap between desired and actual care were for physicians who had no personal PCP (OR = 1.92). Conclusions Physicians frequently engage in self-treatment and in informal medical care. Whether the root cause is the health care system structure that does not meet their needs or the convenience of self-treatment is not known.