Search results

The Models of Child Health Appraised (MOCHA) project identified the different models of primary care that exist for children, examined the particular attributes that might be different from those directed at adults and considered how these models might be appraised. The project took the multiple and interrelated dimensions of primary care and simplified them into a conceptual framework for appraisal. A general description of the models in existence in all 30 countries of the EU and EEA countries, focusing on lead practitioner, financial and regulatory and service provision classifications, was created. We then used the WHO ‘building blocks’ for high-performing health systems as a starting point for identifying a good system for children. The building blocks encompass safe and good quality services from an educated and empowered workforce, providing good data systems, access to all necessary medical products, prevention and treatments, and a service that is adequately financed and well led. An extensive search of the literature failed to identify a suitable appraisal framework for MOCHA, because none of the frameworks focused on child primary care in its own right. This led the research team to devise an alternative conceptualisation, at the heart of which is the core theme of child centricity and ecology, and the need to focus on delivery to the child through the life course. The MOCHA model also focuses on the primary care team and the societal and environmental context of the primary care system.

There is more to primary care than solely medical and nursing services. Models of Child Health Appraised (MOCHA) explored the role of the professions of pharmacy, dental health and social care as examples of affiliate contributors to primary care in providing health advice and treatment to children and young people. Pharmacies are much used, but their value as a resource for children seems to be insufficiently recognised in most European Union (EU) and European Economic Area (EEA) countries. Advice from a pharmacist is invaluable, particularly because many medicines for children are only available off-label, or not available in the correct dose, access to a pharmacist for simple queries around certain health issues is often easier and quicker than access to a primary care physician or nursing service. Preventive dentistry is available throughout the EU and EEA, but there are few targeted incentives to ensure all children receive the service, and accessibility to dental treatment is variable, particularly for disabled children or those with specific health needs. Social care services are an essential part of health care for many extremely vulnerable children, for example those with complex care needs. Mapping social care services and the interaction with health services is challenging due to their fragmented provision and the variability of access across the EU and EEA. A lack of coherent structure of the health and social care interface requires parents or other family members to navigate complex systems with little assistance. The needs of pharmacy, dentistry and social care are varied and interwoven with needs from each other and from the healthcare system. Yet, because this inter-connectivity is not sufficiently recognised in the EU and EEA countries, there is a need for improvement of coordination and with the need for these services to focus more fully on children and young people.

To examine a local primary health care infrastructure and the reality of primary health care from the perspective of residents of a small, urban community in the southern United States.

Data were derived from 13 semistructured focus groups, plus three semistructured interviews, and were analyzed inductively consistent with a grounded theory approach.

Structural barriers to the local primary health care infrastructure include transportation, clinic and appointment wait time, and co-payments and health insurance. Hidden barriers consist of knowledge about local health care services, nonphysician gatekeepers, and fear of medical care. Community residents have used home remedies and the emergency department at the local academic medical center to manage these structural and hidden barriers.

Findings might not generalize to primary health care infrastructures in other communities, respondent perspectives can be biased, and the data are subject to various interpretations and conceptual and thematic frameworks. Nevertheless, the structural and hidden barriers to the local primary health care infrastructure have considerably diminished the autonomy community residents have been able to exercise over their decisions about primary health care, ultimately suggesting that efforts concerned with increasing the access of medically underserved groups to primary health care in local communities should recognize the centrality and significance of power.

This study addresses a gap in the sociological literature regarding the impact of specific barriers to primary health care among medically underserved groups.

Adolescence is a time when a young person develops his or her identity, acquires greater autonomy and independence, experiments and takes risks and grows mentally and physically. To successfully navigate these changes, an accessible and health system when needed is essential.

We assessed the structure and content of national primary care services against these standards in the field of adolescent health services. The main criteria identified by adolescents as important for primary care are as follows: accessibility, staff attitude, communication in all its forms, staff competency and skills, confidential and continuous care, age appropriate environment, involvement in health care, equity and respect and a strong link with the community.

We found that although half of the Models of Child Health Appraised countries have adopted adolescent-specific policies or guidelines, many countries do not meet the current standards of quality health care for adolescents. For example, the ability to provide emergency mental health care or respond to life-threatening behaviour is limited. Many countries provide good access to contraception, but specialised care for a pregnant adolescent may be hard to find.

Access needs to be improved for vulnerable adolescents; greater advocacy should be given to adolescent health and the promotion of good health habits. Adolescent health services should be well publicised, and adolescents need to feel empowered to access them.

Improvements in neonatal and paediatric care mean that many children with complex care needs (CCNs) now survive into adulthood. This cohort of children places great challenges on health and social care delivery in the community: they require dynamic and responsive health and social care over a long period of time; they require organisational and delivery coordination functions; and health issues such as minor illnesses, normally presented to primary care, must be addressed in the context of the complex health issues. Their clinical presentation may challenge local care management. The project explored the interface between primary care and specialised health services and found that it is not easily navigated by children with CCNs and their families across the European Union and the European Economic Area countries. We described the referral-discharge interface, the management of a child with CCNs at the acute–community interface, social care, nursing preparedness for practice and the experiences of the child and family in all Models of Child Health Appraised countries. We investigated data integration and the presence of validated standards of care, including governance and co-creation of care. A separate enquiry was conducted into how care is accessed for children with enduring mental health disorders. This included the level of parental involvement and the presence of multidisciplinary teams in their care. For all children with CCNs, we found wide variation in access to, and governance of, care. Effective communication between the child, family and health services remains challenging, often with fragmentation of care delivery across the health and social care sector and limited service availability.

There is considerable heterogeneity between primary care systems that have evolved in individual national cultural environments. Models of Child Health Appraised (MOCHA) studied how the transfer of models or their individual components can be achieved across nations, using examples of combinations of settings, functions, target groups and tracer conditions. There are many factors that determine the feasibility of successful transfer of these from one setting to another, which must be recognised and taken into account. These include the environment of the care system, national policy-making and contextual means of directing population behaviour – in the form of penalties and incentives, which cannot be assessed or expected to work by means of rational actions alone. MOCHA developed a list of criteria to assess transferability, summarised in a population characteristics, intervention content, environment and transfer (PIET-T) process. To explore the process and means of transferability, we obtained consensus statements from the researchers on optimum model scenarios and conducted a survey of stakeholders, professionals and users of children’s primary care services that involved three specific health topics: vaccination coverage in infants, monitoring of a chronic or complex condition and early recognition of mental health problems. The results give insight into features of transferability – such as the availability and the use of guidelines and formal procedures; the barriers and facilitators of implementation and similarities and differences between model practices and the existing model of child primary care in the country. We found that successful transfer of an optimal model is impossible without tailoring the model to a specific country setting. It is vital to be aware of the sensitivity of the population and environmental characteristics of a country before starting to change the system of primary care.

Equity is an issue that pervades all aspects of primary care provision for children and as such is a recurring theme in the Models of Child Health Appraised project. All European Union member states agree to address inequalities in health outcomes and include policies to address the gradient of health across society and target particularly vulnerable population groups. The project sought to understand the contribution of primary care services to reducing inequity in health outcomes for children. We focused on some key features of inequity as they affect children, such as the importance of good health services in early childhood, and the effects of inequity on children, such as the higher health needs of underprivileged groups, but their generally lower access to health services. This indicates that health services have an important role in buffering the effects of social determinants of health by providing effective treatment that can improve the health and quality of life for children with chronic disorders. We identified common risk factors for inequity, such as gender, family situation, socio-economic status (SES), migrant or minority status and regional differences in healthcare provision, and attempted to measure inequity of service provision. We did this by analysing routine data of universal primary care procedures, such as vaccination, age at diagnosis of autism or emergency hospital admission for conditions that can be generally treated in primary care, against variables of inequity, such as indicators of SES, migrant/ethnicity or urban/rural residency. In addition, we focused on the experiences of child population groups particularly at risk of inequity of primary care provision: migrant children and children in the state care system.

Children’s voices are seldom heard directly. Most often, children, particularly young children, are represented by adults acting on their behalf who may or may not best represent the child’s views or best interests. This can be beneficial or problematic, if the child’s needs are not appreciated or recognised. This chapter looks at the changing attitudes to listening to young people, and the growing recognition of the value of children’s needs, as well as the growing voices of the children themselves, who make their needs increasingly clear. The results of our Models of Child Health Appraised (MOCHA) interviews with children and young people via the DIPEx International organisation give us clear direction as to the importance children using primary care services place on being taken seriously, being listened to and being able to make their own decisions. Other researchers asked input from primary care professionals on children’s autonomy and how the current and future primary care systems can best address the needs of young people, as well as the placing of these issues in a wider cultural context, and how this influences and is influenced by children’s choices. Finally, we look at how the MOCHA country agents have reported the assessment of the importance and function of listening to young people in our research.

The race concordance hypothesis suggests that matching patients and health providers on the basis of race improves communication and patients’ perceptions of health care, and by extension, encourages patients to seek and utilize health care, which may reduce health disparities. However, relatively few studies have examined the impact of race concordance on the utilization of health services. This chapter is grounded on Andersen’s Emerging Model of Health Services Utilization (Phase 4) and extends that model to include race concordance.

The data were collected from a stratified random sample of adult beneficiaries enrolled in North Carolina Medicaid’s primary care case management delivery system in 2006–2007. Propensity score matching techniques were used to sort respondents on their propensity for race concordance and indices were constructed to generate key control variables. Poisson regression was used to examine the impact of race concordance on the utilization of primary care and emergency room care, under the assumption that race concordance would increase the use of primary care and decrease the use of emergency care for minority patients.

While blacks (compared to whites) used less primary care and had more emergency care visits, race concordance was not a statistically significant predictor of either primary care or emergency room use. However, patients’ satisfaction with their primary care providers was associated with significantly fewer primary care and emergency care visits while trust in one’s provider was associated with more primary care visits.

The study findings suggest that the central premises of the race concordance hypothesis require further study to confirm the assumption that better patient – primary care provider relationships result in less utilization of more costly and resource-intensive forms of health care.

The study makes a valuable contribution by expanding the relatively small body of literature dedicated to exploring the impact of race concordance on health services utilization. Additionally, by virtue of researching the experience of Medicaid enrollees, the study controls for health insurance status.