Informal Care in the Context of Long-term Health Care for the Elderly in Slovenia: a Qualitative Study.

BACKGROUND: Slovenia is an aging society. Social security expenditures for the elderly are rising steadily, and the majority of Slovenians are firmly convinced that the state must provide elder care. This situation means that informal caregivers face many challenges and problems in their altruistic mission. OBJECTIVES: To explore the experiences and feelings of informal caregivers and to provide an understanding of how informal caregivers support the elderly and what challenges and difficulties they face in Slovenian society. METHODS: The study is based on qualitative semi-structured interviews with 10 caregivers. In addition to descriptive statistics, we conducted a qualitative study using the qualitative content analysis method. RESULTS: We identified four themes among health caregivers' experiences with challenges and problems in providing long-term health care for the elderly. Caregivers pointed out that they are mostly left to themselves and their altruistic mission of giving informal long-term care to their elderly relatives and friends. Systemic regulation of the national public health care system is the source of many problems. CONCLUSION: Other social systems determine and limit the position of informal caregivers in Slovenia. This qualitative study should be understood as useful stepping-stone to future research and real improvement in this area.

Reasons for the low influenza vaccination rate among nurses in Slovenia.

AIM: This study aimed to identify nurses' views on influenza vaccination and factors that might explain why they do not receive influenza vaccinations, and to examine any ethical issues encountered in the vaccination process. BACKGROUND: All 27 European Union member states and 2 other European countries recommended influenza vaccinations for healthcare workers in 2014-15. Data show that the influenza vaccination rate among nurses in Slovenia is even lower than in other European countries. Slovenian study showed that 41.7% of the respondents had received both the pandemic and the seasonal vaccine. Doctors had the highest level of vaccine coverage, with 44.1%, followed by registered nurses at 23.4%, whereas the lowest level was found among nursing assistants and nursing technicians (17%) at a Ljubljana health clinic. METHODS: A qualitative study was carried out. Nineteen nurses who did not receive influenza vaccination took part in the study. Thematic interviews were conducted in December 2018. Interview transcripts were read, coded, reviewed and labelled by three independent researchers. The collected material was processed using qualitative content analysis. FINDINGS: Thirteen categories and four themes were identified and coded, which enabled an understanding of the nurses' views regarding influenza vaccination. Most of their experiences were positive in one way: they recognised the importance of vaccination and people's awareness of it. However, they did not obtain the influenza vaccine themselves. The main barriers to vaccination were doubt regarding the vaccine's effectiveness, the potential for side effects, the belief that young healthcare professionals are well protected and not at high risk, an overrated trust in their own immune systems, and the belief that pharmaceutical industry marketing was targeting them. The nurses suggested several ways that vaccination could be promoted and improved vaccination coverage achieved. These findings call attention to the importance of recognising both the need for targeted information for the nurses and the need for different approaches to healthcare provision.

Workplace Violence and Sanctioning of Family Medicine Physicians Due to the Rules of Health Insurance Funds in the Western Balkan.

INTRODUCTION: After family medicine's famous beginnings in the early 60's through introduction of the world's first family medicine specialization, with transitional changes and war also come changes in former Yugoslavia's healthcare systems. AIM: The primary aim of this article is to analyze frequency and causes of sanctioning of family physicians by Health insurance funds in the countries of former Yugoslavia. The secondary aim is to evaluate frequency and types of workplace violence family physicians experienced due to insurance boundaries for patients. METHODS: The comparative, cross-sectional survey was carried out from October 2017 to February 2018. Study participants were general practitioners' (GPs), family physicians (FPs) and those without a specialty designation but providing family medicine services in one of the five Western Balkans countries: Croatia, Slovenia, Serbia, Macedonia and Bosnia and Herzegovina (B&H). The questionnaire was designed for the purpose of the study. RESULTS: Forty-nine percent of participating physicians have been sanctioned by Health Insurance Fund and 77. 5% has been exposed to workplace violence. The most common type of violence was verbal (76.6%). Financial penalties according to the scale had the highest rates in Macedonia (73.9%) and Slovenia (43.9%). CONCLUSION: It is necessary to educate creators of healthcare policies, doctors and patients for the purpose of establishing partner relations which would lead to strengthening of primary healthcare, but also to a more efficient healthcare system.

ECCO Essential Requirements for Quality Cancer Care: Primary care.

BACKGROUND: ECCO Essential Requirements for Quality Cancer Care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to cancer patients. They are written by European experts representing all disciplines involved in cancer care. This paper concerns the integration of primary care into care for all cancers in Europe. Primary care integration.

Community orientation of general practitioners in 34 countries.

General practitioners (GPs) are frontline health workers. They should be sensitive to the health needs of the community in addition to caring for patients that visit their practice. Due to changes in demography, epidemiology, ecology and healthcare policy, a community orientation becomes more important. Our research question is: to what extent does community orientation of GPs vary between countries and GPs and how can this variation be explained? We use cross-sectional survey data from the QUALICOPC study, conducted among over 7000 GPs in 34 countries. Community orientation was measured through a scale constructed from three survey questions on whether GPs would take action when confronted with: repeated accidents in an industrial setting, frequent respiratory problems in patients living near a certain industry, and repeated cases of food poisoning in the local community. Independent variables are at healthcare system level and GP or practice level. Data were analysed using linear multilevel regression analysis. Community orientation varies between GPs and countries. Community orientation is more frequent in healthcare systems with a list system, among self-employed GPs, those using medical records to make overviews, and those more active in prevention and multidisciplinary cooperation. GPs in rural areas and areas with more people from ethnic minorities are more community oriented. Based on the variation between countries and GPs, we would like to raise awareness and underline the importance of multidisciplinary cooperation.

Assessing refugee healthcare needs in Europe and implementing educational interventions in primary care: a focus on methods.

The current political crisis, conflicts and riots in many Middle Eastern and African countries have led to massive migration waves towards Europe. European countries, receiving these migratory waves as first port of entry (POE) over the past few years, were confronted with several challenges as a result of the sheer volume of newly arriving refugees. This humanitarian refugee crisis represents the biggest displacement crisis of a generation. Although the refugee crisis created significant challenges for all national healthcare systems across Europe, limited attention has been given to the role of primary health care (PHC) to facilitate an integrated delivery of care by enhancing care provision to refugees upon arrival, on transit or even for longer periods. Evidence-based interventions, encompassing elements of patient-centredness, shared decision-making and compassionate care, could contribute to the assessment of refugee healthcare needs and to the development and the implementation of training programmes for rapid capacity-building for the needs of these vulnerable groups and in the context of integrated PHC care. This article reports on methods used for enhancing PHC for refugees through rapid capacity-building actions in the context of a structured European project under the auspices of the European Commission and funded under the 3rd Health Programme by the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA). The methods include the assessment of the health needs of all the people reaching Europe during the study period, and the identification, development, and testing of educational tools. The developed tools were evaluated following implementation in selected European primary care settings.

Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes.

Background: In order to provide effective primary care for refugees and to develop interventions tailored to them, we must know their needs. Little is known of the health needs and experiences of recently arrived refugees and other migrants throughout their journey through Europe. We aimed to gain insight into their health needs, barriers in access and wishes regarding primary health care. Methods: In the spring of 2016, we conducted a qualitative, comparative case study in seven EU countries in a centre of first arrival, two transit centres, two intermediate-stay centres and two longer-stay centres using a Participatory Learning and Action research methodology. A total of 98 refugees and 25 healthcare workers participated in 43 sessions. Transcripts and sessions reports were coded and thematically analyzed by local researchers using the same format at all sites; data were synthesized and further analyzed by two other researchers independently. Results: The main health problems of the participants related to war and to their harsh journey like common infections and psychological distress. They encountered important barriers in accessing healthcare: time pressure, linguistic and cultural differences and lack of continuity of care. They wish for compassionate, culturally sensitive healthcare workers and for more information on procedures and health promotion. Conclusion: Health of refugees on the move in Europe is jeopardized by their bad living circumstances and barriers in access to healthcare. To address their needs, healthcare workers have to be trained in providing integrated, compassionate and cultural competent healthcare.

Process quality indicators in family medicine: results of an international comparison.

BACKGROUND: The aim of our study was to describe variability in process quality in family medicine among 31 European countries plus Australia, New Zealand, and Canada. The quality of family medicine was measured in terms of continuity, coordination, community orientation, and comprehensiveness of care. METHODS: The QUALICOPC study (Quality and Costs of Primary Care in Europe) was carried out among family physicians in 31 European countries (the EU 27 except for France, plus Macedonia, Iceland, Norway, Switzerland, and Turkey) and three non-European countries (Australia, Canada, and New Zealand). We used random sampling when national registers of practitioners were available. Regional registers or lists of facilities were used for some countries. A standardized questionnaire was distributed to the physicians, resulting in a sample of 6734 participants. Data collection took place between October 2011 and December 2013. Based on completed questionnaires, a three-dimensional framework was established to measure continuity, coordination, community orientation, and comprehensiveness of care. Multilevel linear regression analysis was performed to evaluate the variation of quality attributable to the family physician level and the country level. RESULTS: None of the 34 countries in this study consistently scored the best or worst in all categories. Continuity of care was perceived by family physicians as the most important dimension of quality. Some components of comprehensiveness of care, including medical technical procedures, preventive care and health care promotion, varied substantially between countries. Coordination of care was identified as the weakest part of quality. We found that physician-level characteristics contributed to the majority of variation. CONCLUSIONS: A comparison of process quality indicators in family medicine revealed similarities and differences within and between countries. The researchers found that the major proportion of variation can be explained by physicians' characteristics.

Standpoints of Roma women regarding reproductive health.

BACKGROUND: Little is known about the reproductive health of Roma women in Slovenia. The aim of this study is to present the standpoints of Roma women regarding reproductive health, the degree to which primary healthcare services are available to Roma women and the reproductive health circumstances which lead most Roma women to decide to visit a gynaecologist. METHODS: A qualitative research study was carried out. Forty-four adult Roma women from the Hudeje/Vejar settlement in the Dolenjska region, Slovenia, took part in the research. The collected material was processed by means of inductive (qualitative) content analysis. The coding procedure was supported by the QDA software Atlas.ti. RESULTS: Eighteen categories and six themes were identified that enable with the relevant codes an understanding of the standpoints of Roma women regarding reproductive health. The research results showed that the cultural needs of Roma women should be taken into account in their comprehensive healthcare treatment. Roma women wish for equal treatment when health is in question, drawing attention to better communication and the problem of ethnic discrimination in medical facilities. Roma women also feel a need to be educated and to receive professional advice, such as appropriate lectures and/or workshops dealing with reproductive health that would ensure them a higher quality of life over time. CONCLUSIONS: The research results call attention to the necessity of recognising both the need to educate Roma women as well as the need for different approaches to the provision of healthcare services in the field of reproductive health with such a sensitive group of female inhabitants. It will be necessary to familiarise them with preventive programmes and to implement such programmes, to inform them of possible diseases and to encourage them in a friendly and easy-to-understand manner to regularly visit their gynaecologist.

A cross-sectional study of socio-demographic factors associated with patient access to primary care in Slovenia.

INTRODUCTION: Primary care (PC) is the provision of universally accessible, integrated, person-centred, comprehensive health and community services. Professionals active in primary care teams include family physicians and general practitioners (FP/GPs). There is concern in Slovenia that the current economic crisis might change the nature of PC services. Access, one of the most basic requirements of general practice, is universal in Slovenia, which is one of the smallest European countries; under national law, compulsory health insurance is mandatory for its citizens. Our study examined access to PC in Slovenia during a time of economic crisis as experienced and perceived by patients between 2011 and 2012, and investigated socio-demographic factors affecting access to PC in Slovenia. METHODS: Data were collected as a part of a larger international study entitled Quality and Costs of Primary Care in Europe (QUALICOPC) that took place during a period of eight months in 2011 and 2012. 219 general practices were included; in each, the aim was to evaluate 10 patients. Dependent variables covered five aspects of access to PC: communicational, cultural, financial, geographical and organizational. 15 socio-demographic factors were investigated as independent variables. Descriptive statistics, factor analysis and multilevel analysis were applied. RESULTS: There were 1,962 patients in the final sample, with a response rate of 89.6%. The factors with the most positive effect on access to PC were financial and cultural; the most negative effects were caused by organizational problems. Financial difficulties were not a significant socio-demographic factor. Greater frequency of visits improves patients' perception of communicational and cultural access. Deteriorating health conditions are expected to lower perceived geographical access. Patients born outside Slovenia perceived better organizational access than patients born in Slovenia. CONCLUSIONS: Universal medical insurance in Slovenia protects most patients from PC inaccessibility. However, problems perceived by patients may indicate the need for changes in the organization of PC.

The pattern of physical comorbidity and the psychosocial determinants of depression: a prospective cohort study on a representative sample of family practice attendees in Slovenia.

Objectives This study aims to present the patterns of physical comorbidity in depressed patients and factors strongly associated with depression in a representative sample of Slovenian family practice attendees.Methods Medical data was obtained for 911 general practice attendees. Of them, 221 (24.3%) were diagnosed as depressed. The depressive states of the subjects were evaluated using the Composite International Diagnostic Interview (CIDI). Physical comorbidity was assessed with a questionnaire covering the most common health problems in the Slovenian adult population. Several psycho-social factors were also analysed.Results Those variables significantly related to ICD depression were included in multivariate binary logistic regression analysis, adjusted by age, gender and education. The calculation included the chi-square, odds ratio (OR) with confidence interval (95% CI) and P-value. A P-value < 0.05 was marked as statistically significant.Conclusions There was no significant difference in the number of concurrent chronic diseases in depressed and non-depressed subjects. The risk of depression was increased by the presence of several concomitant factors. The burden of somatic co-morbidity was shown to be smaller than the impact of psychosocial determinants, which also acted as protective factors: the feeling of safety at home and the absence of problems in intimate relationships. The abuse of alcohol and drugs by a family member and current poor financial situation were strongly associated with depression. The impact of concurrent incontinence and chronic bowel disease was also important, though somewhat weaker.

The European primary care monitor: structure, process and outcome indicators.

BACKGROUND: Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care. METHODS: A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems). RESULTS: The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care. CONCLUSIONS: A standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.

Longstanding disease, disability or infirmity and depression in primary care.

CONTEXT: Current evidence suggests that depression is much more prevalent among those with chronic medical conditions compared to the general population. Depression will rank second to cardiovascular disease as a global cause of disability by 2020. With ageing of the population physicians are called upon to treat a higher percentage of patients with chronic medical illness. OBJECTIVE: To assess the prevalence and incidence of depression and likelihood for new-onset depression in patients with self-reported longstanding disease, disability or infirmity in the sample of primary care attendees. METHOD: Consecutive family medicine practice attendees aged 18 to 75 years were recruited and followed up after six months. Presence of longstanding disease, disability or infirmity was recorded. RESULTS: Prevalence of major depression was 8.9% in the group of patients reporting longstanding disease compared to 3.1% in the group without longstanding disease. Incidence of major depression after 6 months was 2.7% in the group with longstanding disease and 0.9% in the group without longstanding disease. For the patients with longstanding disease at the baseline it was almost 4 times more likely to have major depression after 6 months than for patients who did not report any longstanding disease at the baseline. CONCLUSION: The associations between longstanding disease and depression are important in primary care setting.

Impact of demographic factors on recognition of persons with depression and anxiety in primary care in Slovenia.

BACKGROUND: Research has repeatedly shown that family physicians fail to diagnose up to 70% of patients with common mental disorders. Objective of the study is to investigate associations between persons' gender, age and educational level and detection of depression and anxiety by their family physicians. METHODS: We compared the results of two independent observational studies that were performed at the same time on a representative sample of family medicine practice attendees in Slovenia. 10710 patients participated in Slovenian Cross-sectional survey and 1118 patients participated in a first round of a cohort study (PREDICT-D study). Logistic regression was used to examine the effects of age, gender and educational level on detection of depression and anxiety. RESULTS: The prevalence of major depression and Other Anxiety Syndrome (OAS) amongst family practice attendees was low. The prevalence of Panic Syndrome (PS) was comparable to rates reported in the literature. A statistical model with merged data from both studies showed that it was over 15 times more likely for patients with ICD-10 criteria depression to be detected in PREDICT-D study as in SCS survey. In PREDICT-D study it was more likely for people with higher education to be diagnosed with ICD-10 criteria depression than in SCS survey. CONCLUSION: People with higher levels of education should probably be interviewed in a more standardized way to be recognised as having depression by Slovenian family physicians. This finding requires further validation.

Attitudes to illness and the use of health services by economic immigrants in Slovenia.

AIM: To analyze the attitudes of immigrants from former Yugoslav republics to Slovenia toward illness, concerns about and perception of health status, and factors that influence their use of health services for the prevention and treatment of illness. METHODS: We used a qualitative approach, employing the ETHNIC (Explain, Treatment, Healers, Negotiation, Intervention, Collaboration) questionnaire. We analyzed data from interviews with 27 economic immigrants who consecutively came to a general practice office from May 15 to August 15, 2005. RESULTS: Qualitative analysis of the interview showed that health problems were largely understood as consequences of hard work, poor working and housing conditions, and stress. Fear of disability and concern about financial support for their family were important factors why they sought medical help. There were many financial and housing obstacles to leading a healthy lifestyle and following doctors' advice. Inadequate communication with health care professionals was also mentioned. Coworkers were an important source of support, whereas the worker-employer relation appeared to be a negative factor. CONCLUSION: Identifying factors that influence health care utilization and attitudes about illness is a first step toward improving health care among immigrants. Improving the sanitary and hygienic aspects of their lives and becoming familiar with their basic health problems will improve quality of treatment at the primary care level.

Older people's preferences for involvement in their own care: a qualitative study in primary health care in 11 European countries.

OBJECTIVE: The aim of the study was to explore the views of people aged over 70 years on involvement in their primary health care in 11 different European countries. METHODS: Older patients were asked about their views on patient involvement in a face-to-face interview. All interviews were audio-recorded, transcribed and analysed in accordance with the principles of 'qualitative content analysis'. An international code list was used. RESULTS: Four hundred and six primary care patients aged between 70 and 96 years were interviewed. Their views could be categorized into four major groups: doctor-patient interaction, GP related topics, patient related issues and contextual factors. CONCLUSION: People over 70 do want to be involved in their care but their definition of involvement is more focussed on the 'caring relationship', 'person-centred approach' and 'receiving information' than on 'active participation in decision making'. PRACTICE IMPLICATIONS: The desire for involvement in decision making is highly heterogeneous so an individual approach for each patient in the ageing population is needed. Future research and medical education should focus on methods and training to elicit older patients' preferences. The similar views in 11 countries suggest that methods for enhancing patient involvement in older people could be internationally developed and exchanged.