The vulnerable healthcare consumer: an interpretive synthesis of the patient experience literature

The increased policy emphasis on the ‘patient experience’ places the health consumer in centre stage as the driver for healthcare delivery. This poses challenges for service providers to meet the needs of more vulnerable groups, notably those with disabilities, who are often more likely to be both in greater need of services and, at the same time, less able to access them. This paper reports an interpretive synthesis of qualitative research studies in the UK and US on the experience of vulnerable patient groups using a broad range of health services. An interpretive review method was adopted to capture the complexity of the data. Eighteen papers were identified as meeting the inclusion criteria for the review. Seven key themes were identified: life experience, service design, point of delivery, accessibility, availability, specialist education/training and consumer typology. Although policy makers and providers often refer to the need for greater consumerism in the development of health services, our review suggests that it may be appropriate to consider a model of ‘mediated consumerism’ for some groups of service users. While some concerns are common to both mainstream and vulnerable consumers, others such as accessibility of services, and the resulting experience of health care, are particular to specific vulnerable groups. Accessing the experiences of these more vulnerable groups therefore warrants close attention in the development of both policy and practice in health service delivery.     

Liminal mothers’ negotiation of conflicting service consumption

Pregnancy is a significant period of transition, transforming ‘women’ into ‘mothers’. The mid or liminal phase of transition is particularly ripe for consumer researchers. Transformative services research (TSR) considers that services may deliver objective well-being outcomes (e.g. consumer health). This article extends TSR into liminality and considers that services may also encompass hedonic (mood, satisfaction and happiness) and eudaimonic (mastery, autonomy, positive relations and self-acceptance) dimensions. The article unpacks women’s service experiences to enrich and expand understanding of positive and negative consumption meanings. It identifies that unanticipated outcomes emerge as a feature of transformative services. It demonstrates that services situates new mothers at the centre of a multiplicity of consumption. This may both overwhelm and act as transitional resource developing mothers as postmodern bricoleurs.     

Conceptual and mathematical model for quality improvement in health care

Numerous studies have shown that implemented models for quality assurance or improvement in healthcare facilities differ, even those models that are based on the same guidelines, i.e. standards, regulations or concepts. The cause of diversity in implemented quality models could be found in the process of translating guidelines into the implemented model for quality assurance or improvements in healthcare facilities, while neglecting processes of healthcare facilities that are not clinical processes, but still responsible for the quality of healthcare services. Therefore, this research recommends a conceptual model that should be a link between guidelines, implemented models and mathematical models derived from the conceptual model, which could provide a means of evaluating quality values of any part of the healthcare organization.     

上海市闵行区浦江镇“流动人口孕产妇平产分娩点”六年评估

通过对上海市闵行区浦江镇流动人口孕产妇平产分娩点的建立、运行和效果的评估,探讨政府在解决流动人口卫生保健问题中的作用。特约分娩点的建立是一项成功的政策措施,向农民工提供低收费和优质的基本产科服务深受农民工欢迎。目前每月在浦江镇特约分娩点分娩的产妇稳定在600-800例左右,服务质量优良。这是在我国城市化进程改善进城农民保健中一项成功的政策措施,卫生局起主导作用。     

Men as consumers of maternity services: a contradiction in terms

Research and policy on the consumers of maternity services have tended to focus on women, with service provision directed to meet their needs. It is, after all, women who get pregnant and give birth. However, since the 1970s, men have been encouraged to take up an active role in childbirth and, to a lesser extent, pregnancy. This has resulted in fathers becoming participatory in maternity services. In recent years, there has developed a greater focus on paternity and an awareness of the father’s experiences. This has led to an evaluation of maternity services and a desire to better address the ‘needs’ of men as consumers. This article examines some of the factors that have facilitated paternal participation during the antenatal period and birth, and some of the roles and responsibilities assigned to men. The recent debates regarding fathers within childbirth discourses, and what impact this will have on their experience of pregnancy, childbirth and status as maternity service users, are also discussed.     

Reconstructing consumer participation in evidence‐based health care: a polemic

Consumer participation in the evidence‐based health‐care movement is largely seen as important by those who promote evidence‐based health care but is surrounded by a range of competing discourses that variously critique medicine, nursing or health‐care systems; situate consumers as powerless players within systems characterized by controlling health professionals; or politicize the role of the consumer as activist and defender of patient rights. This paper explores these competing discourses and develops an argument that asserts that the social construction of the evidence‐based movement has rendered previously accepted terminology regarding the user or receiver of health services relatively meaningless. The result has been the ‘politicisation’ and ‘professionalisation’ of consumer participation and the time has come to reconstruct consumer participation in evidence‐based health care – from the generation of evidence to guideline development.     

An intersectionality framework for transformative services research

The authors introduce the theory of intersectionality which refers to the interactivity of social identities such as race, class, and gender in shaping individuals’ experiences. Intersectionality is explored using cases and examples from healthcare services, which involve high contact encounters with consumers who may possess multiple disadvantages (e.g. low income, illness, immigrant status) and therefore make for interesting contexts for intersectional analyses. Intersectionality is proposed as a framework that can shed light on the experiences of consumers who belong to multiple disadvantaged social groups, such as being black and low income, immigrant, and in poor health. Detailed guidelines for conducting intersectionality-driven services research are provided, which take into account the interconnected nature of multiple disadvantages. The authors emphasize that intersectionality offers a holistic look at the co-created nature of services and it can be instrumental in designing tailored and fair services to improve consumer and societal well-being.     

Working with risky consumers: multi‐professional care for substance‐using pregnant women

Substance use is increasingly common in many countries. Consumption and lifestyles associated with consumption often involve a number of specific health and legal risks for users. For pregnant women, the risks extend to the health and care of their unborn children. A multi‐professional approach to the management of substance use in pregnancy is recommended as best practice but, as with all strategies, effectiveness depends on the way that professional workers implement policy. This study evaluated evidence of multi‐professional working within local maternity services in and around a Scottish city by (a) collating and analysing data from the maternity records of 163 substance‐using women, who delivered between January 2001 and December 2003; and (b) conducting a questionnaire survey in 2004 with 120 midwives and neonatal nurses for their views on maternity care for substance‐using women and their babies. Despite the importance placed on multi‐professional working by midwives and neonatal nurses, maternity records indicated operational inconsistencies with implementation in some cases and not in others. Policy was not yet to be seen embedded in everyday practice.     

Rating healthcare services: consumer satisfaction vs. health system performance

The complex healthcare services and the consumer’s lack of technical knowledge to assess them engender a debate over using consumer satisfaction ratings as a quality-of-care marker. This paper aims firstly to investigate the effect of socio-demographic, socio-economic and spatial characteristics on the perception of quality of healthcare and secondly to evaluate the relationship between consumer satisfaction and health system performance. Reporting a Eurobarometer survey and the scores of the Euro Health Consumer Index, the finding is that some socio-demographic groups are more likely to get unsatisfied with healthcare services than others (e.g. women, those over 24 years old, those who self-define themselves as working class). Moreover, a strong relationship is revealed between consumer satisfaction and health system performance. The higher the performance of a health system, the higher the propensity to have consumers with positive perception of the healthcare services (satisfied consumers). The implications of the findings are then discussed.     

Some conjectures about access to US health care for disposed people

This paper hypothesizes the extent of access to health care by disposed people, particularly in the US. The disposed are people ‘thrown away’ as used‐up commodities. This paper briefly examines the theoretical idea of disposability. It then presents the basic results of new research showing that a sample of Americans sees that people in several different occupations are equally liable to be disposed. The section that follows proposes that the access these disposed people have to the US health‐care system is minimal overall and is not likely to improve. Because this total grouping has not previously been studied as a whole, these hypothetical findings are partly based on subsets of the disposed: the poor; those without health insurance; and the unemployed.     

Consumers’ views of breast care services in Ireland

One Irish woman in 14 develops breast cancer. There are 1700 new cases each year. These rates compare poorly with EU figures. The government indicated in 1995 that it favoured rapid, comprehensive diagnostic facilities, using the triple assessment model of clinical care, to improve survival rates and to diminish the anxiety women experience about breast cancer. Implementation of this policy was delayed until 1999, when a plan for centres of excellence in breast care was conceived. To compliment this plan, the Department of Health and Children wanted consumer views on existing breast care services. The Women’s Health Council was asked by the Department of Health and Children, through the National Cancer Forum, to conduct research on women’s views and reactions as consumers of existing services for symptomatic breast disease. The research team was asked to document women’s views on: diagnostic services; counselling; additional treatment services such as surgery and radiotherapy. The methodology consisted of four strands: questionnaires and focus groups with consumers of breast care services; postal questionnaires to clinic staff and a literature review. Striking aspects were the long delays women experienced before obtaining a completed diagnosis; often chaotic clinic settings which added greatly to women’s shock and anxiety; the lack of support if they received a diagnosis of cancer; and problems relating to limited resources for cancer treatment, including radiotherapy. We explored women’s coping mechanisms and their experiences, in the context of the model of quality of care. Finally, we argue that a centre of excellence must develop a multidimensional model of breast disease care that incorporates the full range of psycho‐social dimensions for women, if it is to earn its claim to excellence.     

Accounting and Medicine: An Exploratory Investigation into Physicians’ Attitudes Toward the Use of Standard Cost-Accounting Methods in Medicine

Research studies demonstrate wide variation in how physicians diagnose and treat patients with similar medical conditions and suggest that at least some of the variation reflects inefficiencies and unnecessary medical costs. Health care researchers are actively examining ways to reduce variations in practice through standardization of medicine to reduce the cost of treatment and ensure the quality of outcomes. The most widely accepted form of this standardization is Evidence Based Best Practices (EBBP). Furthermore, financial health care providers such as hospitals and managed care organizations are investigating methods to tie resource usage to medical protocols in their efforts to monitor and control health care costs. Such proposals are contentious because they report on physicians’ medical practice behaviors (such as the number of tests ordered, use of specific therapies, etc.) and such reports could potentially be used to influence their clinical behaviors. The intent of this exploratory study was to examine physicians’ perceptions about linking a standard costing system to EBBP guidelines. The authors interviewed nine practicing physicians asking each physician to respond to the question, ‘As a physician working in a hospital environment, what are your reactions to and concerns with combining standard costing techniques with EBBP?’ The interviews were in-depth and free form in nature. The physicians’ responses were recorded and analyzed using Grounded Theory Methodology. Using this methodology the field data was categorized into two major themes. The most important theme centered on ethics and the second theme was concerned with the implementation and use of a standard cost system in regard to EBBP. If physicians’ worries about ethical dilemmas and implementation issues are not resolved, then it is likely that doctors would be unwilling to participate in any efforts to develop or use a standard cost-reporting system in medicine. While this study was exploratory in nature, it should provide future guidance to accountants, health care researchers and health care providers about physicians’ issues with the use of standard costing methods in medicine.     

A critical review of primary health care reform in Bulgaria: impact on consumers

The Health Care System in Bulgaria is in a period of transition and is undergoing profound changes in financing, organization and ownership. A priority of this reform is to shift the focus of healthcare to the primary sector and to emphasize general practice. New legislation in support of this health care reform has been passed over the last few years. However, this legislation, although consistent with the global aims to be achieved, has proven to be contradictory in terms of its practical implementation. This has had a negative impact on health care consumers’ interests and rights. This paper evaluates the effects of primary health care reform in Bulgaria from the perspective of patient satisfaction. For this purpose, a major task to be fulfilled is to identify the contradictions emerging between the legislation outlining the reforms and the realities of practical implementation with respect to its impact on consumers. The methods applied include: a review of the legislation, a review of the practical progression of the reform process, and an assessment of the new developments in health care consumers’ interests and rights. Considerable contradictions have been found between the legal framework of health care reform in primary care and existing experiences, traditions and expectations. The legislation is inconsistent with the existing realities of healthcare provision. This is leading to turmoil in the health care system during its present transformation and is infringing upon consumers’ rights. Problems emerging in the process of reform need to be identified, and solutions need to be found and worked out as the reforms progress. An assessment system has to be developed to monitor the overall reform process and to evaluate the effectiveness and efficiency of the changes introduced. The impact on consumer and patient satisfaction should be an area of prime concern during these assessments.     

Internationalization journey of healthcare providers: The case of Turkish Acıbadem healthcare group

The advances in technology and global deregulation have led to the progressive internationalization of professional services, notably, the healthcare industry. The present case study examines the remarkable internationalization journey of Acibadem Healthcare Group (AHG) by scrutinizing the dynamics and outcomes of the agile and innovative strategies which propel their achievements. The case of AHG shows that successful internationalization in the service industry, in general, and healthcare, in particular, is not solely in the domain of large, established companies from advanced economies, but those ventures with liabilities of origin, newness, and size can also succeed with smart strategies and resourceful leveraging of their competitive advantages. The study provides unique insights on strategic management for successful internationalization of the healthcare services within an emerging market context and suggests future research avenues in this fast-growing field of inquiry.     

Facilitating transformative change in medication adherence practices

ABSTRACT

This article explores how healthcare consumer collectives integrate self-service technology as part of their everyday lives on a long-term basis. Combining previously published research with data collected from field observations, in-depth interviews and focus groups, the author uncovers distinct adoption styles and then links these to well-being in a chronic healthcare context. Importantly, findings from the research suggest that successful long-term adoption of new technology depends not only on improving a targeted practice (medicating patients in this case), but also other affected everyday practices in the lives of consumers. By drawing on insights from the literature of service-dominant logic and practice theory, the author identifies ‘value-in-context’ and ‘lifestyle fit’ that underlie resource integration in medication adherence. Four adoption styles were uncovered, in which two in particular, ‘door opener’ and ‘transformative change,’ should be emphasized by healthcare managers and developers as they tend to be associated with higher well-being.     

Measuring physician contribution to the healthcare safety net

There are an estimated 46 million Americans without health insurance and an even larger number for whom health insurance does not cover all needed medical services. These individuals and families have to rely more and more on government programs and physicians’ willingness to provide uncompensated services, most often described by providers as charity care. Previous studies have shown a downward trend in the percent of physicians willing or able to provide charity care. We extend this research by examining the results of the Medical Group Management Association's Cost Survey of Medical Group Practices for 2005, 2006, and 2007. It is important to examine the uncompensated care reported by medical groups because groups have policies that may govern how much, if any, charity care their physicians provide. This survey data shows that, overall, the number of medical practices providing charity care continues to decline. The results and analysis of the survey data indicate that uncompensated (charity) care is being offered by less than half of medical practices, and at less than 2% of total gross charges. We examined the results by potential explanatory variables: population density, practice size, physician practice specialty, practice ownership structure, payer mix, and practice financial performance. Results were consistent across all categories; charity care is declining. These results have major policy implications for both the federal government and all state governments, especially in light of the current recession and proposed healthcare reform legislation.     

Laypeople roles at road traffic crash scenes: a systematic review

This study aimed to identify the roles of laypeople at road traffic injuries (RTIs). A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words of ‘laypeople’, ‘layman’, ‘layperson’, ‘bystander’, ‘first responder’, ‘lay first responder’, ‘road traffic’, ‘road traffic injury’, ‘crash injury’, ‘crash scene’, ‘emergency’, ‘trauma care’, and ‘prehospital trauma care’ were used in combination with the Boolean operators OR and AND. We did electronic search on Google Scholar, PubMed, ISI Web of Science, CINAHL, Science Direct, Scopus, ProQuest. Based on the reviewed studies, some factors such as cultural conditions, knowledge, relief agencies, and demographic factors affect the interventions of laypeople at the crash scene in functional areas. Regarding the permanent presence of people at the crash scene, the present study can provide an opportunity to reduce different side effects of RTIs imposed on the society.     

Exchanging knowledge through healthcare manager placements in research teams

This study contributes to service industry theory by revealing how employers in the health service understand knowledge exchange as ‘transaction’. Although under pressure to deliver better services without additional resource, health service providers do not seek customers, making them unlike commercial service industries. This paper reports a UK knowledge exchange programme designed to bring together healthcare managers and researchers. Case study data were gathered from 36 semi-structured interviews with health services managers (Fellows) embedded in research teams, research team leads, and Fellows' workplace line-managers. Interviews were analysed thematically using a coding frame. The importance of personal contact in knowledge exchange mechanisms was confirmed but the knowledge model varied by interaction pairings (Fellow/research team; Fellow/health service). When with researchers, an exchange model was commonly in operation, marked by collaborative engagement. In contrast, line-managers tended to adopt a transactional approach, driven by instrumental motives. This transactional model merits further research.     

农民工跨城市二次流动与回流模式 ——基于最大似然估计方法的分析

本文采用上海财经大学"千村调查"抽样数据,基于最大似然估计方法,考察农民工跨城市二次流动和回流返乡的影响因素,以纠正样本的选择性偏误.研究结果发现,近六成的农民工发生二次流动,且表现"抱团流动"的典型特征,获取更高的收入和更好的工作待遇成为农民工跨城市二次流动的最主要原因;照顾老人孩子和结婚是农民工回流返乡的最主要原因.农村劳动力的城乡流动、 跨城市二次流动和回流返乡表现明显的差异,与城乡流动相反,女性、 年龄越大、 受教育程度较低的农民工更倾向于二次流动,而家庭负担较重、 外出务工期间无家人陪同的农民工更容易回流返乡.