This is an excerpt of the paper below, with the title above, focusing on the topic in question. For the original publication, refer to the second part of this post, please.
Attributes of patient-centered primary care associated with the public perception of good healthcare quality in Brazil, Colombia, Mexico and El Salvador
Health Policy and Planning (Oxford Academic)
Svetlana V Doubova, Frederico C Guanais, Ricardo Pérez-Cuevas, David Canning, James Macinko, Michael R Reich
13 February 2016
Executive Summary by
Joaquim Cardoso MSc.
Health Revolution — Foundation
Primary Care — Institute
June 24, 2022
Key Messages
- The primary care services of Brazil, Colombia, Mexico and El Salvador should evolve to provide patient-centered care and improve public opinion of primary care quality.
- The major gaps that these countries should bridge to improve public perception of quality are difficulties in communication with the primary care clinic, lack of coordination of care and lack of information to increase healthy lifestyle.
What is the problem?
- The Latin American region has an ongoing commitment to adopting primary care-based healthcare systems built on the principles of equity, solidarity and the right to the highest possible standard of health
- In the last decade, Brazil, Colombia, Mexico and El Salvador began to strengthen their primary care services through reforms that are rooted in the Alma Ata Declaration ( World Health Organization 1978) and were ratified in the Declaration of Montevideo of 2005
- From a health system perspective, in the LAC region these changes represent substantial progress toward the provision of primary care.
- However, the model of primary care is still paternalistic and disease-focused, rather than patient-centered ( Mainetti 1995; Salles 2002).
What is the solution?
The Picker-Commonwealth Program has proposed a comprehensive PCC model that takes into account the experiences of patients receiving healthcare across eight domains:
- (1) respect for patient-centered values, preferences and needs;
- (2) coordination and integration of healthcare across services;
- (3) information and education of patients to facilitate autonomy and self-care;
- (4) physical comfort;
- (5) emotional support;
- (6) involvement of family and friends in decision-making;
- (7) continuity of care; and
- (8) easy access to care ( Shaller 2007).
Abstract of the paper
- This study evaluated primary care attributes of patient-centered care associated with the public perception of good quality in Brazil, Colombia, Mexico and El Salvador.
- We conducted a secondary data analysis of a Latin American survey on public perceptions and experiences with healthcare systems.
- The primary care attributes examined were access, coordination, provider-patient communication, provision of health-related information and emotional support.
- A double-weighted multiple Poisson regression with robust variance model was performed. The study included between 1500 and 1503 adults in each country.
What are the results?
The results identified four significant gaps in the provision of primary care:
- not all respondents had a regular place of care or a regular primary care doctor (Brazil 35.7%, Colombia 28.4%, Mexico 22% and El Salvador 45.4%).
- The communication with the primary care clinic was difficult (Brazil 44.2%, Colombia 41.3%, Mexico 45.1% and El Salvador 56.7%).
- There was a lack of coordination of care (Brazil 78.4%, Colombia 52.3%, Mexico 48% and El Salvador 55.9%).
- Also, there was a lack of information about healthy diet (Brazil 21.7%, Colombia 32.9%, Mexico 16.9% and El Salvador 20.8%).
The public’s perception of good quality was variable (Brazil 67%, Colombia 71.1%, Mexico 79.6% and El Salvador 79.5%).
The primary care attributes associated with the perception of good quality were a primary care provider
- ‘who knows relevant information about a patient’s medical history’,
- ‘solves most of the health problems’,
- ‘spends enough time with the patient’,
- ‘coordinates healthcare’ and
- a ‘primary care clinic that is easy to communicate with’.
In conclusion, the public has a positive perception of the quality of primary care, although it has unfulfilled expectations; further efforts are necessary to improve the provision of patient-centered primary care services in these four Latin American countries.
- The primary care services of Brazil, Colombia, Mexico and El Salvador should evolve to provide patient-centered care and improve public opinion of primary care quality.
- The major gaps that these countries should bridge to improve public perception of quality are difficulties in communication with the primary care clinic, lack of coordination of care and lack of information to increase healthy lifestyle.
What are the implications for policy in primary care?
Despite the public’s positive perception of the quality of primary care in these four Latin American countries, it is clear that efforts can be made to improve the provision of patient-centered primary care.
Particularly, it is necessary to address significant gaps identified in the study:
- shortages of a regular place of primary care or regular doctor,
- difficulties in communication with the primary care clinic,
- lack of coordination of care and
- lack of information about healthy diet.
These four gaps were consistent among the countries studied.
- Addressing these gaps will require changes in incentives and organizational culture, especially in the management of public services (Roberts et al. 2004).
- Policy makers need to establish effective systems to provide regular monitoring and measurement of patients’ perceptions of the quality of primary care so that the impacts of changes can be assessed, and real improvements achieved.
ORIGINAL PUBLICATION (excerpted version)
Attributes of patient-centered primary care associated with the public perception of good healthcare quality in Brazil, Colombia, Mexico and El Salvador
Health Policy and Planning (Oxford Academic)
Svetlana V Doubova, Frederico C Guanais, Ricardo Pérez-Cuevas, David Canning, James Macinko, Michael R Reich
13 February 2016
Introduction
The Latin American region has an ongoing commitment to adopting primary care-based healthcare systems built on the principles of equity, solidarity and the right to the highest possible standard of health ( Macinko et al. 2007).
In the last decade, Brazil, Colombia, Mexico and El Salvador began to strengthen their primary care services through reforms that are rooted in the Alma Ata Declaration ( World Health Organization 1978) and were ratified in the Declaration of Montevideo of 2005 ( Macinko et al. 2007).
The Latin American region has an ongoing commitment to adopting primary care-based healthcare systems built on the principles of equity, solidarity and the right to the highest possible standard of health …
In the last decade, Brazil, Colombia, Mexico and El Salvador began to strengthen their primary care services through reforms …
Since 1998, Brazil has implemented the Family Health Strategy (FHS) through multidisciplinary primary care teams of health professionals responsible for the population living in a particular territory.
Each FHS team includes a physician, a nurse, a nurse assistant and up to six community health agents.
By 2014, the FHS covered over 120 million people (62% of the population) ( Macinko and Harris 2015).
In 1979, Mexico started a program to expand coverage of primary care for rural people ( Harrison 1991).
Today, the Ministry of Health has an extensive network of primary care clinics, and the Social Security institutions have a robust network of family medicine clinics.
Current primary care coverage reaches 92% of Mexico’s population ( Secretaría de Salud 2013).
In the 1980s, Colombia introduced a clear conception of primary healthcare in the government health plans.
In 2007, the Primary Health Care (PHC) became part of government policy (Law 1122 of 2007).
Recently, Law 1438 of 2012 positioned primary healthcare (PHC) into the core of the healthcare system, but without changing the structure and mechanisms for the flow of resources ( Apráez Ippolito and Sarmiento Limas 2014).
Since 1980, El Salvador has made significant efforts to improve primary care services.
In 2009, the government launched a comprehensive, integrated network of health services, as part of the plan to reform the public health system.
Community-oriented family health teams support these services that work in marginalized regions of the country.
The team includes a primary care physician, a nurse and community health workers ( Ventres 2013).
From a health system perspective, in the LAC region these changes represent substantial progress toward the provision of primary care.
However, the model of primary care is still paternalistic and disease-focused, rather than patient-centered ( Mainetti 1995; Salles 2002).
From a health system perspective, in the LAC region these changes represent substantial progress toward the provision of primary care.
However, the model of primary care is still paternalistic and disease-focused, rather than patient-centered ( Mainetti 1995; Salles 2002).
The US Institute of Medicine recognizes patient-centeredness as a core strategy for improving the quality of healthcare ( Institute of Medicine 2001).
The patient-centered care (PCC) perspective takes into account the view of users in the design, provision and evaluation of healthcare services.
The US Institute of Medicine recognizes patient-centeredness as a core strategy for improving the quality of healthcare … The patient-centered care (PCC) perspective takes into account the view of users in the design, provision and evaluation of healthcare services.
The Picker-Commonwealth Program has proposed a comprehensive PCC model that takes into account the experiences of patients receiving healthcare across eight domains:
- (1) respect for patient-centered values, preferences and needs;
- (2) coordination and integration of healthcare across services;
- (3) information and education of patients to facilitate autonomy and self-care;
- (4) physical comfort;
- (5) emotional support;
- (6) involvement of family and friends in decision-making;
- (7) continuity of care; and
- (8) easy access to care ( Shaller 2007).
The Picker-Commonwealth Program has proposed a comprehensive PCC model that takes into account the experiences of patients receiving healthcare across eight domains:
The patient’s perception of positive patient-physician communication and good quality of care has been associated with better physical and emotional health ( Stewart et al. 2000; Griffin et al. 2004; Hsiao and Boult 2008).
The sociodemographic characteristics, health status, culture, experience and perception of technical and non-technical aspects of healthcare, influence the patient’s perception of the quality of care ( Sofaer and Firminger 2005; Mohammed et al. 2014).
Most studies about patient perceptions of healthcare have been performed in the USA and other developed countries.
In 1998, the Commonwealth Fund launched an International Health Policy Survey in the USA, the UK, Canada, Australia and New Zealand aimed at measuring public perceptions and experiences with healthcare systems, including aspects of primary care. The Commonwealth Fund has repeated the survey several times and included more countries ( Donelan et al. 1999; Schoen et al. 2007, 2011). In 2011, 11 developed countries participated. The surveys have identified opportunities for healthcare improvement.
The Latin American region has few studies addressing patients’ experiences and perceptions of the quality of care.
Studies in Colombia (Jaramillo-Echeverri 2004) and Mexico ( Lazcano-Ponce et al. 2004; Doubova et al. 2009) have reported that patients require doctors to have better communication skills and capability to recognize their autonomy and the right to express their opinions and ask questions. A recent study in 17 Latin American countries reported that the proportion of people dissatisfied with healthcare varied by country. Dissatisfaction was highly correlated with difficult access to healthcare services and the cost of healthcare ( Kim et al. 2013).
It is worthwhile to build on the literature regarding patient experiences with primary care associated with perceptions of good quality in Latin America.
Documenting these experiences would inform policy makers about the gaps in PCC and its relationship with the perception of good quality.
The objective of the present study was to identify the PCC attributes associated with perceptions of good quality in Brazil, Colombia, Mexico and El Salvador, by analyzing survey responses of users of primary care services.
Methods
See the original publication
Study variables
The dependent variable was the participants’ perception of healthcare received at primary care facilities in the last year.
This variable was assessed by the question: ‘Overall, how do you rate the medical care that you have received in the past 12 months from your family doctor’s practice or clinic?’ The response options were: excellent, very good, good, fair, poor, not sure, decline to answer. The answers were consolidated into two categories: good (excellent, very good, good) and poor perception (fair, poor). Those who responded not sure or decline to answer were <1% and excluded from the analysis.
The study’s independent variables were the participants’ experiences with primary care providers (PCP) (the term PCP was defined to encompass family doctors and other health personnel working in primary care, such as nurses and other health professionals) regarding the following 10 PCC attributes:
- PCP knows relevant information about the patient’s medical history.
- PCP gives an opportunity to ask questions about recommended treatment.
- PCP spends enough time with the patient.
- PCP explains things in a way that is easy to understand.
- PCP helps the patient to coordinate or arrange his/her healthcare from other doctors and places.
- Patient perceives difficulties in communication with the primary care clinic during regular practice hours about a health problem.
- A nurse or another clinical staff (other than a doctor) is involved in primary healthcare.
- PCP who during a routine medical checkup in the past 2 years talked about an exercise or physical activity.
- PCP who during a routine medical checkup in the past 2 years spoke of a healthy diet and healthy eating.
- PCP who during a routine medical checkup in the past 2 years talked about things that worry the patient or cause stress.
The variables 1–5 had five options in a Likert scale response format: always, often, sometimes, rarely or not, not sure. These options were then divided into two categories: yes (always, often) and no (sometimes, rarely or not, not sure). For the variable ‘perceived difficulties in communication’ (6) the responses were: yes (very easy, easy), no (somewhat difficult, very difficult), and never tried to communicate with PC clinic. The variables 1 and 8–10 had a yes/no response format. The variables 8–10 were asked only if the person reported having a routine medical checkup during the last 2 years: those people without the check-up visit were coded as not applicable.
The study covariates were the participants’ characteristics: sex, age, schooling, chronic disease, self-rated health, health insurance (HI) and the visits to the PCP during the last year. We identified the participant as suffering from a chronic disease if he/she reported that a doctor has told him/her of having arthritis, asthma or chronic lung diseases, cancer, diabetes, heart disease, hypertension or depression.
The variable ‘general self-rated health’ was categorized as good (excellent, very good and good) and poor (fair, poor and not sure). The variable ‘type of HI’ was categorized as: without HI, private HI, social security/job-related/contributive HI and government HI (Seguro Popular/subsidized/Unified Health System HI). In Colombia and Mexico (4.1% and 21.5%, respectively), participants reported being affiliated with social security and government HI. For the purpose of this analysis, these participants were placed in the social security HI group. The variable of schooling defines the level of schooling for participants in Brazil, Colombia and Mexico; however, in El Salvador it describes the schooling of the head of the household.
Statistical analysis
See the original publication
Results
See the original publication
The Picker-Commonwealth Program has proposed a comprehensive PCC model that takes into account the experiences of patients receiving healthcare across eight domains:
- (1) respect for patient-centered values, preferences and needs;
- (2) coordination and integration of healthcare across services;
- (3) information and education of patients to facilitate autonomy and self-care;
- (4) physical comfort;
- (5) emotional support;
- (6) involvement of family and friends in decision-making;
- (7) continuity of care; and
- (8) easy access to care ( Shaller 2007).
The Picker-Commonwealth Program has proposed a comprehensive PCC model that takes into account the experiences of patients receiving healthcare across eight domains:
Discussion
The experiences and perceptions of users of primary care in Brazil, Colombia, Mexico and El Salvador reveal gaps in the quality and provision of primary care services.
The responses of participants showed that primary care services did not completely fulfill the main attributes of patient-centered primary care:
easy access, coordinated care, good provider-patient communication, provision of health-related information and education, and emotional support.
Countries with a strong primary care system have improved population health and reached more equitable health outcomes than countries that have health systems oriented toward specialty care ( Macinko et al. 2003).
Having a regular doctor or place for primary care is an important attribute of patient-centered primary care that has been increasingly emphasized ( Institute of Medicine 2001).
Individuals with a regular source of primary care have better access to healthcare than individuals without a regular source of care ( Lambrew et al. 1996).
Previous Commonwealth surveys carried out in developed countries in the general population ( Schoen et al. 2007) and in chronic patients ( Schoen et al. 2011) found that the overall percentage of people with regular place and/or regular doctor for primary care ranged from 80% in the USA to 100% in the Netherlands.
In our study, the percentages of people reporting that they had a regular place or doctor were lower than in developed countries (Brazil 64.3%, Colombia 71.6%, Mexico 78% and El Salvador 54.6%).
Countries with a strong primary care system have improved population health and reached more equitable health outcomes than countries that have health systems oriented toward specialty care ( Macinko et al. 2003).
This finding contrasts with the reports of progress in achieving universal coverage in these countries.
The contrast might signal that additional efforts should be made not only to reach universal coverage but also to inform the public that having HI means they have the right to a regular place and a regular doctor to receive medical services.
A significant number of people found it difficult to communicate with the primary care facility during regular practice hours. These results indicate poor first contact access and suggest a perceived unmet need of substantial magnitude.
The inclusion of people’s experiences, fulfillment of their expectations and taking into account their perception of quality may enhance the assessment of the quality of primary care ( Haddad et al. 2000; Jung et al. 2002).
The results stress that coordinated and comprehensive care was partially fulfilled.
A small proportion of respondents reported that the PCP coordinated the necessary care, spent enough time with them, provided recommendations to improve lifestyle and showed interest in talking about worrisome situations.
There was wide variation in the participants’ experiences regarding the perception that the ‘PCP explained things in a way that was easy to understand’, ‘gave an opportunity to ask’ and ‘solved most of the health problems’.
The Commonwealth surveys reported that 70–88% of participants answered that their primary care doctor spent enough time with them ( Schoen et al. 2007, 2011), whereas, in this survey, this attribute ranged from 32.1% in Brazil to 74.4% in Colombia.
This study had a common finding with the Commonwealth surveys that a major gap was observed in the variable ‘regular PCP who coordinates healthcare’ ( Schoen et al. 2007, 2011).
Despite the importance of physical activity, healthy diet and psychological wellbeing in preventing chronic diseases ( American Heart Association Scientific Statement 2006; Haskell et al. 2007), family doctors do not regularly provide counseling for healthy lifestyles.
Their routine advice is typically ineffective in improving dietary habits and promoting physical activity ( Lindholm et al. 1995; Lawlor and Hanratty 2001).
Our results confirmed that PCPs did not address healthy lifestyle counseling (ranging from 16.9% to 49.4%).
Effective patient-provider health communication influences people’s self-care, including their lifestyle.
The effectiveness of health communication depends on several features. These features are the sender (healthcare provider), the message (information), the receiver (patient), the channel (i.e. speech, printed information) and the form of communication (i.e. paternalistic, consumerist and mutualistic, which means shared decision-making) ( Berry 2007).
It is crucial to inform policy makers and health providers about their need to learn strategies to boost effective patient-provider communication.
Despite the importance of physical activity, healthy diet and psychological wellbeing in preventing chronic diseases ( American Heart Association Scientific Statement 2006; Haskell et al. 2007), family doctors do not regularly provide counseling for healthy lifestyles.
The perception and satisfaction of people with the services influence their compliance with the recommendations and the continuity of the patient-provider relationship ( Sans-Corrales et al. 2006).
We found that a high percentage of participants had a perception of good quality primary care.
The analysis of the independent variables of this study, however, indicates that there is asymmetry of information regarding the perception of quality that these people have, as there was a wide variation in the attributes of patient-centered primary care signaling that a substandard quality of care existed.
The figures about the perception of quality were similar to those reported from developed countries ( Schoen et al. 2007) and lower than those reported by Reyes-Morales et al. (2013) that were based on the analysis of data from 2012 National Health Survey in Mexico where 85% of participants reported a perception of good quality primary care.
Team-based primary care has the potential for sharing knowledge, shifting tasks among health professionals and improving people’s perception of process and quality of care ( Wagner 2000; Jesmin et al. 2012).
However, some negative aspects of this approach have been reported as well.
The negative aspects include limited access to primary care physicians due to the delegation of tasks to other health professionals such as a nurse or social worker ( Perry et al. 2005).
Respondents in these four countries perceived the participation of nurses and ancillary staff in primary care delivery differently.
In Mexico, having a nurse or another clinical staff involved in primary care was associated with a perception of good quality of care; whereas in Brazil, in which there is high participation of nurses and ancillary staff in the provision of primary care services, their presence was associated with a perception of lower quality.
Since 1994, Brazil has introduced primary healthcare services based on multidisciplinary teams that include physicians, nurses and community health workers.
In 2006, such teams were providing services to > 46% of the Brazilian population ( Harzheim et al. 2006).
Currently, several studies aimed at assessing the effect of these teams in Brazil are in progress ( Harzheim et al. 2006).
In the present study, some negative perceptions were identified. Brazilian participants reported more often that the primary care doctor lacked necessary information about him/her and did not spend enough time with him/her.
It is worth mentioning that in Brazil, the survey took place right before the massive protests over poor healthcare quality, which received widespread media coverage.
In Colombia, there are ongoing public discussions about a major reform to their national health system. These national circumstances would have some influence on the answers of participants.
Team-based primary care has the potential for sharing knowledge, shifting tasks among health professionals and improving people’s perception of process and quality of care ( Wagner 2000; Jesmin et al. 2012).
Study strengths and limitations
The statistical techniques can be considered a strength of this study. IP weights provide control against possible selection bias arising from truncation ( Hernán et al. 2004), and survey weights provide control against potential selection bias resulting from the sample inclusion probabilities, such as underrepresentation of some groups due to non-response and non-coverage ( Thompson 2008). Given the evidence of potential bias in the unweighted estimator, the weighted estimators strengthen our analysis.
The study also has several limitations.
First, this study is a secondary data analysis, which reduces the possibility of an in-depth exploration of other factors that can be associated with the public perception of good quality of primary care.
For example, we did not have information about providers’ characteristics, or about participants’ health literacy, which is a ‘patients’ ability to obtain, process and understand basic health information and services needed to make appropriate health decisions’ ( Agency for Healthcare Research and Quality 2007).
Effective patient-provider communication depends on the level of the patient’s health literacy. Patients with limited health literacy were less likely than those with adequate health literacy to report adequate patient-centered communication quality across seven communication items ( Wynia and Osborn 2010).
Finally, the four Latin American countries that we analyzed are middle-income countries that may not be comparable with Commonwealth Fund countries, which are richer.
Implications for policy in primary care
Despite the public’s positive perception of the quality of primary care in these four Latin American countries, it is clear that efforts can be made to improve the provision of patient-centered primary care.
Particularly, it is necessary to address significant gaps identified in the study:
- shortages of a regular place of primary care or regular doctor,
- difficulties in communication with the primary care clinic,
- lack of coordination of care and
- lack of information about healthy diet.
These four gaps were consistent among the countries studied.
Addressing these gaps will require changes in incentives and organizational culture, especially in the management of public services (Roberts et al. 2004).
Policy makers need to establish effective systems to provide regular monitoring and measurement of patients’ perceptions of the quality of primary care so that the impacts of changes can be assessed, and real improvements achieved.
About the authors and affiliations
Svetlana V Doubova,1,2 Frederico C Guanais,3 Ricardo Pe´ rez-Cuevas,4,*
David Canning,5 James Macinko6 and Michael R Reich7
1
Takemi Program in International Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue,
Boston, MA 02115, USA,
2
Epidemiology and Health Services Research Unit, CMN Siglo XXI, Mexican Institute of
Social Security, Av. Cuauhtemoc 330, Mexico City 06720, Mexico,
3
Division of Social Protection and Health, InterAmerican Development Bank, Dean Valdivia 148-Piso 10, Centro Empresarial Platinum Plaza, San Isidro Lima 27,
Peru,
4
Division of Social Protection and Health, Inter-American Development Bank, Reforma 222 Piso 11, Mexico
City 06726, Mexico,
5
Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665
Huntington Avenue, Boston, MA 02115, USA,
6
Departments of Health Policy and Management and Community
Health Sciences, UCLA Fielding School of Public Health, 650 Charles E. Young Dr. South, Center for Health
Sciences, Los Angeles, CA 90095–1772, USA and
7
Takemi Program in International Health, Department of Global
Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
Acknowledgement
This project was conducted with the support of the Takemi Program in International Health at Harvard T.H. Chan School of Public Health.
References and additional information
See original publication
Originally published at https://academic.oup.com.
Cite
Svetlana V Doubova, Frederico C Guanais, Ricardo Pérez-Cuevas, David Canning, James Macinko, Michael R Reich, Attributes of patient-centered primary care associated with the public perception of good healthcare quality in Brazil, Colombia, Mexico and El Salvador, Health Policy and Planning, Volume 31, Issue 7, September 2016, Pages 834–843,
