The influence of gender on the primary care management of diabetes in Tunisia

Background: Gender differences in access to high quality care for chronic illnesses have been suggested yet little work in this potentially vital area of health care inequality has been undertaken in Africa. We explored the influence of patient gender on the care of people with diabetes within a multi-method, national study of diabetes management in primary care in Tunisia. Methods:Methodologies used were quantitative (nationwide randomized study of 2160 medical records) and qualitative (participant observation, focus groups and interviews of patients and health care professionals) Results:Differences in patient characteristics, treatments prescribed, process and outcome data and access to care variables were demonstrated. The most striking disparity found was the high female to male ratio of patients attending for diabetes care (61.1%). A number of possible explanations for this emerged: Men were thought to under-attend for practical, financial and behavioural reasons whereas women were thought to have increased morbidity and potentially over-attend for social and psychological reasons. Conclusion:We have demonstrated a number of disparities in the care of men and women with diabetes in Tunisian primary care. In particular, a dual but related problem emerges from the data: more women than men attend for diabetes care and yet women do not get the same level of risk factor control as men. A number of local explanations for these disparities have emerged, which inform our analysis of the impact of gendered beliefs on diabetes care. Strategies to address these disparities will require a careful consideration of local beliefs and practices

Damm Sokkor! : identifying, exploring and testing the factors influencing the care of patients with diabetes in primary care in Tunisia

Background Quality of diabetes care is variable and sub-optimal worldwide. Few studies have been undertaken in the developing world to identify factors that influence care. Objectives To identify, explore and test the patient, health professional and organisational factors associated with the quality of care of patients with diabetes in primary care in Tunisia. Methods A multi-method study within an ethnographic framework. Qualitative methods include participant observation, semi-structured interviews and focus groups with health professionals and patients with diabetes. Content and ethnographic analyses were undertaken. Quantitative data were collected from a random sample of medical records of patients with diabetes from a nationwide sample of 48 randomly-selected health centres. Multivariate regression analyses were undertaken to identify associations with fifteen quality indicators and 57 potential explanatory factors. Results The mean age of the study population (n=2160) was 62.4years, mean duration of diabetes 8.4years, 62% were female and 94% had type 2 diabetes. The standard of care varied but some improvements were apparent since 2000. The three most important factors to emerge from the qualitative data were also significantly and independently associated with higher quality of care: availability of medication, clinician motivation and chronic disease clinics. Other important factors were financial, gender and adherence issues. The predominant theme that emerged from the ethnographic analysis was the perception that access to medication at the health centre is "the only thing that matters". Conclusion This study has provided a detailed, unique picture of diabetes care in primary care from a low/middle income country. Important themes that need to be addressed in order to successfully implement culturally-appropriate, quality improvement interventions are accessibility to medications, clinician motivation, patients' health beliefs and gender issues. It is recommended that strategies, such as the development of the role of paramedical staff, be implemented within the context of culturally-adaptable national programs.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Developing a career as a GP educationalist: contemporary challenges and workforce solutions

GP educationalists are crucial in training the future medical workforce and in developing and advancing the field of primary care medical education, yet opportunities in the UK are patchy and varied. In this article, a group of GP educationalists summarise the challenges facing the sustainability of this particular group of clinical academics and outline opportunities available at each career stage, from medical students through to senior GP educationalists. Recommendations to support the growth of this workforce include the development of a nationally recognised framework for GP educationalist careers, collaboration with professional and educational bodies and taking steps to level out opportunities in order to reduce existing inequity

Facilitators and barriers to teaching undergraduate medical students in general practice

CONTEXT Globally, primary health care is facing workforce shortages. Longer and higher-quality placements in primary care increase the likelihood of medical students choosing this specialty. However, the recruitment and retention of community primary care teachers are challenging. Relevant research was predominantly carried out in the 1990s. We seek to understand contemporary facilitators and barriers to general practitioner (GP) engagement with undergraduate education. Communities of practice (CoP) theory offers a novel conceptualisation, which may be pertinent in other community-based teaching settings. METHODS Semi-structured interviews were undertaken with 24 GP teachers at four UK medical schools. We purposively sampled GPs new to teaching, established GP teachers and GPs who had recently stopped teaching. We undertook NVivo-assisted deductive and inductive thematic analysis of transcripts. We used CoP theory to interpret data. RESULTS Communities of practice theory illustrated that teachers negotiate membership of three CoPs: (i) clinical practice; (ii) the medical school, and (iii) teaching. The delivery of clinical care and teaching may be integrated or exist in tension. This can depend upon the positioning of the teaching and teacher as central or peripheral to the clinical CoP. Remuneration, workload, space and the expansion of GP trainee numbers impact on this. Teachers did not identify strongly as members of the medical school or a teaching community. Perceptions of membership were affected by medical school communication and support. The findings demonstrate gaps in medical school recruitment. CONCLUSIONS This research demonstrates the marginalisation of primary care-based teaching and proposes a novel explanation rooted in CoP theory. Concepts including identity and membership may be pertinent to other community-based teaching settings. We recommend that medical schools review and broaden recruitment methods. Teacher retention may be improved by optimising the interface between medical schools and teachers, fostering a teaching community, increasing professional rewards for teaching involvement and altering medical school expectations of learning in primary care

Promoting general practice in medical schools. Where are we now?

In November 2016, the Medical Schools Council and Health Education England published a joint report chaired by Professor Val Wass: ‘By choice – not by chance’ to raise the profile of general practice as a positive career choice for medical students. We sought to evaluate the impact of the report by firstly, asking the views of Heads of GP teaching at UK medical schools whether and how the report has supported them in raising the profile of general practice and secondly, describing the initiatives developed by medical schools in a national survey. There was a perception reported by heads of GP teaching that the report has been highly influential in facilitating the promotion of general practice as a career to medical students. We describe multiple specific initiatives developed in response to the report’s recommendations. The national survey confirmed that whilst there is significant variation across medical schools in their response to the specific recommendations in the report, definite progress is being made. A number of areas that need particular consideration have been highlighted and we would recommend that future surveys are completed at appropriate time intervals to review further progress

‘They say’: medical students’ perceptions of General Practice, experiences informing these perceptions, and their impact on career intention—a qualitative study among medical students in England

Objectives The number of UK graduates choosing General Practice training remains significantly lower than the current numbers required to meet the demands of the service. This work aims to explore medical students’ perceptions of General Practice, experiences which lead to the development of these perceptions, and the ultimate impact of these on career intention. Design This mixed-methods, qualitative study used focus groups, semistructured interviews, longitudinal audio diary data and debrief interviews to explore and capture the experiences and perceptions of students in their first and penultimate years of university. Setting Three English medical schools. Participants Twenty students were recruited to focus groups from first and fourth/fifth year of study. All students in these years of study were invited to attend. Six students were recruited into the longitudinal diary study to further explore their experiences. Results This work identified that external factors, internal driving force and the ‘they say’ phenomenon were all influential on the development of perceptions and ultimately career intention. External factors may be split into human or non-human influences, for example, aspirational/inspirational seniors, family, peers (human), placements and ‘the push’ of GP promotion (non-human). Driving force refers to internal factors, to which the student compares their experiences in an ongoing process of reflection, to understand if they feel General Practice is a career they wish to pursue. The ‘they say’ phenomenon refers to a passive and pervasive perception, without a known source, whereby usually negative perceptions circulate around the undergraduate community. Conclusion Future strategies to recruit graduates to General Practice need to consider factors at an undergraduate level. Positive placement experiences should be maximised, while avoiding overtly ‘pushing’ GP onto students

Developing a career as a GP educationalist: contemporary challenges and workforce solutions

GP educationalists are crucial in training the future medical workforce and in developing and advancing the field of primary care medical education, yet opportunities in the UK are patchy and varied. In this article, a group of GP educationalists summarise the challenges facing the sustainability of this particular group of clinical academics and outline opportunities available at each career stage, from medical students through to senior GP educationalists. Recommendations to support the growth of this workforce include the development of a nationally recognised framework for GP educationalist careers, collaboration with professional and educational bodies and taking steps to level out opportunities in order to reduce existing inequity

Primary care management of diabetes in a low/middle income country: A multi-method, qualitative study of barriers and facilitators to care

<p>Abstract</p> <p>Background</p> <p>The management of patients with diabetes mellitus is complex. Some research has been done in developed countries to attempt to determine the factors that influence quality of care of patients with diabetes: Factors thus far postulated are usually categorised into patient, clinician and organisational factors. Our study sought to discover the main barriers and facilitators to care in the management of diabetes in primary care in a low/middle income country.</p> <p>Methods</p> <p>A qualitative study, based on reflexive ethnography using participant observation, semi-structured interviews of clinicians (10) and group interviews with paramedical staff (4) and patients (12) in three purposively sampled health centres, along with informal observation and discussions at over 50 other health centres throughout Tunisia. A content analysis of the data was performed.</p> <p>Results</p> <p>Over 400 potential barriers or facilitators to care of patients with diabetes in primary care in Tunisia emerged. Overall, the most common cited factor was the availability of medication at the health centre. Other frequently observed organisational factors were the existence of chronic disease clinics and clinicians workload. The most commonly mentioned health professional factor was doctor motivation. Frequently cited patient factors were financial issues, patient education and compliance and attendance issues. There were notable differences in the priority given to the various factors by the researcher, physicians, paramedical staff and the patients.</p> <p>Conclusion</p> <p>We have discovered a large number of potential barriers and facilitators to care that may potentially be influencing the care of patients with diabetes within primary care in Tunisia, a low/middle income country. An appreciation and understanding of these factors is essential in order to develop culturally appropriate interventions to improve the care of people with diabetes.</p

General practice and the Medical Licensing Assessment

From 2024/2025, all UK medical students will sit the Medical Licensing Assessment (MLA),1 a mandated national exam comprising: a written applied knowledge test (AKT) in single best answer (SBA) format; and a clinical and professional skills assessment (CPSA). Here we consider the implications for primary care, and for those involved in teaching primary care to medical undergraduates, including GPs and other primary care professionals

How to … grow a team in clinical education research

The Incubator for Clinical Education Research (ClinEdR) is a UK-wide network, established with support from the National Institute for Health and Care Research (NIHR), to lead initiatives to build capacity in the field. Our lived experiences as members of the NIHR ClinEdR Incubator and wider literature are woven into this ‘How to …’ paper, which outlines what to consider as you seek to grow and develop a ClinEdR team. This paper sets out pragmatic steps to grow an effective ClinEdR team that has a wider impact and mutual benefits for its members and their institution(s). Growing a ClinEdR team requires more than a dynamic character to bring people together. In our view, you can grow a ClinEdR team with other people through a structured, well-thought-out approach, in which its members develop through collaborative work to achieve a shared objective