Pratiquer la responsabilité sociale en santé : de la théorie à la pratique. Une étude Delphi internationale.

INTRODUCTION: Health professionals’ social responsibility in health resists translation into skills that can be taught and implemented concretely in professional practice. PURPOSE OF THE RESEARCH: This study, conducted by the Réseau International Francophone pour la Responsabilité Sociale en Santé (RIFRESS), aims to develop a consensus on the components of doctors’ social responsibility in health from the perspective of experts in medical education. Its findings are intended to inform the creation of a skills profile. A three-round Delphi consensus method was used, with an open first round and closed second and third rounds. Mesydel software was used to organize the process and to do the qualitative analysis of the first round. SPSS was used for consensus analysis for rounds 2 and 3. RESULTS: Thirty-four experts responded to the study. During the first round, 62 codes emerged, grouped into 13 themes. From the initial analysis, 40 items were submitted for the Delphi round 2. Of these 40 items, 23 came out consensual after the second round, as did 13 of the 18 resubmitted items after the third. Examples of items that emerged as consensual are eco-responsibility, advocacy, defense of the common good, critical analysis of practice, and collaborative leadership. CONCLUSIONS: The present study represents a much-needed effort to concretely define the components of doctors’ social responsibility in health. Local context must be taken into account when using these findings. They can help to train tomorrow’s doctors to better meet the priority health needs of society in a profoundly changing world.

Health professionals and patients' perspectives on person-centred maternal and child healthcare in Burkina Faso.

CONTEXT: The person-centred approach (PCA) is a promising avenue for care improvement. However, health professionals in Burkina Faso (hereafter referred to as caregivers) seem unprepared for taking into consideration patients' preferences and values in the context of healthcare provision. OBJECTIVE: To understand the meaning attributed to PCA in the Burkina Faso context of care and to identify the challenges related to its adoption from the perspective of caregivers and women service users (hereafter referred to as patients). METHODS: An ethnographic qualitative research design was used in this study. We conducted 31 semi-directed interviews with caregivers and patients from Koudougou (Burkina Faso) healthcare facilities. We also carried out direct observation of consultations. Data thematic analyses are based on the person-centred approach analysis framework. RESULTS: According to the caregivers and patients interviewed, the PCA in maternal and child healthcare in Burkina Faso includes the following five components used in our analytical framework: i) pregnancy follow-up consultations extend beyond examining physical health issues (biopsychosocial component), ii) healthcare professionals' mood affects the caregiver-patient relationship as well as care delivery (the healthcare professional as a person), iii) patients expect to be well received, listened to, and respected (the patient as a person), iv) healthcare professionals first acknowledge that both themselves and patients have power, rights but also responsibilities (sharing power, rights and responsibilities of professionals and patients), and v) healthcare professionals who are open to involving patients in decision-making about their care and patients asking to have a say in the organization of services (therapeutic alliance). Implementing each of these themes comes with challenges, such as i) talking about health problems in the presence of other women, especially those related to sexuality, even though they are common to parturient women (biopsychosocial component); ii) offering psychotherapy to healthcare professionals (healthcare professional as a person); iii) taking into consideration patients' cultural and linguistic differences (the patient as a person); iv) raising awareness among patients about their right to ask questions and healthcare professionals' duty to answer them (sharing power, and rights and responsibilities of professionals and patients); v) accepting the presence of birth attendants while avoiding traditional practices that are contrary to scientific recommendations (therapeutic alliance). CONCLUSION: Despite some context-specific particularities, the PCA is not new in the context of health care in Burkina Faso. However, its implementation can pose a number of challenges. There is a need to train healthcare professionals with a view to being sensitive to these particularities. This may also require organizational adjustments so as to create the physical and sociocultural environments that are conducive to taking into account the patient's perspective.

Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial.

BACKGROUND: Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections. We evaluated the effect of DECISION+2, a shared decision-making training program, on the percentage of patients who decided to take antibiotics after consultation with a physician or resident. METHODS: We performed a randomized trial, clustered at the level of family practice teaching unit, with 2 study arms: DECISION+2 and control. The DECISION+2 training program included a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making. The primary outcome was the proportion of patients who decided to use antibiotics immediately after consultation. We also recorded patients' perception that shared decision-making had occurred. Two weeks after the initial consultation, we assessed patients' adherence to the decision, repeat consultation, decisional regret and quality of life. RESULTS: We compared outcomes among 181 patients who consulted 77 physicians in 5 family practice teaching units in the DECISION+2 group, and 178 patients who consulted 72 physicians in 4 family practice teaching units in the control group. The percentage of patients who decided to use antibiotics after consultation was 52.2% in the control group and 27.2% in the DECISION+2 group (absolute difference 25.0%, adjusted relative risk 0.48, 95% confidence interval 0.34-0.68). DECISION+2 was associated with patients taking a more active role in decision-making (Z = 3.9, p < 0.001). Patient outcomes 2 weeks after consultation were similar in both groups. INTERPRETATION: The shared decision-making program DECISION+2 enhanced patient participation in decision-making and led to fewer patients deciding to use antibiotics for acute respiratory infections. This reduction did not have a negative effect on patient outcomes 2 weeks after consultation. ClinicalTrials.gov trial register no. NCT01116076.

Training family physicians and residents in family medicine in shared decision making to improve clinical decisions regarding the use of antibiotics for acute respiratory infections: protocol for a clustered randomized controlled trial.

BACKGROUND: To explore ways to reduce the overuse of antibiotics for acute respiratory infections (ARIs), we conducted a pilot clustered randomized controlled trial (RCT) to evaluate DECISION+, a training program in shared decision making (SDM) for family physicians (FPs). This pilot project demonstrated the feasibility of conducting a large clustered RCT and showed that DECISION+ reduced the proportion of patients who decided to use antibiotics immediately after consulting their physician. Consequently, the objective of this study is to evaluate, in patients consulting for ARIs, if exposure of physicians to a modified version of DECISION+, DECISION+2, would reduce the proportion of patients who decide to use antibiotics immediately after consulting their physician. METHODS/DESIGN: The study is a multi-center, two-arm, parallel clustered RCT. The 12 family practice teaching units (FPTUs) in the network of the Department of Family Medicine and Emergency Medicine of Université Laval will be randomized to a DECISION+2 intervention group (experimental group) or to a no-intervention control group. These FPTUs will recruit patients consulting family physicians and residents in family medicine enrolled in the study. There will be two data collection periods: pre-intervention (baseline) including 175 patients with ARIs in each study arm, and post-intervention including 175 patients with ARIs in each study arm (total n = 700). The primary outcome will be the proportion of patients reporting a decision to use antibiotics immediately after consulting their physician. Secondary outcome measures include: 1) physicians and patients' decisional conflict; 2) the agreement between the parties' decisional conflict scores; and 3) perception of patients and physicians that SDM occurred. Also in patients, at 2 weeks follow-up, adherence to the decision, consultation for the same reason, decisional regret, and quality of life will be assessed. Finally, in both patients and physicians, intention to engage in SDM in future clinical encounters will be assessed. Intention-to-treat analyses will be applied and account for the nested design of the trial will be taken into consideration. DISCUSSION: DECISION+2 has the potential to reduce antibiotics use for ARIs by priming physicians and patients to share decisional process and empowering patients to make informed, value-based decisions.

Competencias médicas requeridas para el buen desempeño en Centros de Salud Familiares en Chile / A survey about the competences required by primary health physicians in Chile

Background: Primary health care is considering the cornerstone of health care in Chile. Its efficiency is strongly influenced by the quality and competences of physicians that are responsible for health care at this level. Aim: To define the features and competences that should have primary care physicians. Material and methods: A group of experts that could be physicians or other professionals working in primary health care were invited to answer electronically a structured questionnaire containing a list of 71 competences, for a basic and an expert level of physician, using the Delphi method. Competences were classifying as "desirable" or "indispensable". If there was lack of consensus in the importance given to a specific competence, the researchers defined its importance. Results: Thirty-eight professionals (50 percent physicians) were inviting to participate and 16 answered the questionnaire. The competence profile defined for basic physicians has 13 knowledge items, 24 skills and 16 attitudes. The figures for advanced physicians are 29 knowledge items, 37 skills and 20 attitudes. Conclusions: This list of competences should been considered by medical schools to adapt undergraduate training of future physicians.

[A survey about the competences required by primary health physicians in Chile]. / Competencias médicas requeridas para el buen desempeño en Centros de Salud Familiares en Chile.

BACKGROUND: Primary health care is considering the cornerstone of health care in Chile. Its efficiency is strongly influenced by the quality and competences of physicians that are responsible for health care at this level. AIM: To define the features and competences that should have primary care physicians. MATERIAL AND METHODS: A group of experts that could be physicians or other professionals working in primary health care were invited to answer electronically a structured questionnaire containing a list of 71 competences, for a basic and an expert level of physician, using the Delphi method. Competences were classifying as "desirable" or "indispensable". If there was lack of consensus in the importance given to a specific competence, the researchers defined its importance. RESULTS: Thirty-eight professionals (50% physicians) were inviting to participate and 16 answered the questionnaire. The competence profile defined for basic physicians has 13 knowledge items, 24 skills and 16 attitudes. The figures for advanced physicians are 29 knowledge items, 37 skills and 20 attitudes. CONCLUSIONS: This list of competences should been considered by medical schools to adapt undergraduate training of future physicians.