Seksuaaliterveyspalvelut terveyskeskuksissa

Keskeiset seksuaaliterveyspalvelut raskauden ehkäisyneuvonta, raskaudenkeskeytyshoidon järjestäminen, sukupuolitautien tutkimus ja hoito sekä seksuaalineuvonta ovat monin osin kuuluneet julkisen perusterveydenhuollon palvelutarjontaan jo kauan. Terveyskeskuksissa toteutetun ehkäisyneuvonnan tulokset olivat hyviä 1990-luvun puoliväliin saakka, jolloin erityisesti nuorten raskaudenkeskeytykset alkoivat lisääntyä. Samanaikaisesti myös ilmoitettujen klamydiainfektioiden määrä kääntyi nousuun. Yhtenä mahdollisena epäsuotuisan kehityksen syynä on pidetty terveyskeskuksissa tarjottavien ennaltaehkäisevien palveluiden tarjonnan heikentymistä muun muassa väestövastuujärjestelmän yleistymisen ja 1990-luvun alun talouslaman myötä. Väitöskirjatyön tavoitteena oli tutkia terveyskeskusten keskeisten seksuaaliterveyspalveluiden, erityisesti ehkäisyneuvonnan, tarjontaa, palveluiden toteuttamistapoja ja niiden laatua Tampereen yliopistollisen sairaalan erityisvastuualueen terveyskeskuksissa. Tutkimusaineisto kerättiin alueen terveyskeskusten johtaville lääkäreille ja hoitotyön johtajille sekä ehkäisyneuvontatyötä tekeville lääkäreille ja hoitajille suunnatuilla lomakekyselyillä. Tulokset osoittivat, että palveluiden järjestämistavat terveyskeskuksissa olivat moninaisia ja että erityisesti ehkäisyneuvontapalveluita tarjottiin usein erilaisin järjestelyin. Ehkäisyneuvontaan pääsyä rajoittivat muun muassa pitkät odotusajat ja kesäsulut. Ehkäisyneuvontapalveluiden laadussa oli runsaasti vaihtelua niin palvelutarjonnan rakenteessa kuin työntekijöiden käytännöissäkin. Palvelurakenteiden hyvää laatua ennustivat johtavan hoitajan tai ylihoitajan sekä nimetyn terveyden edistämisen johtamisesta vastaavan henkilön olemassaolo. Väestövastuinen toimintatapa ei ollut yhteydessä laatuun tutkittujen rakenteiden tai prosessien tasoilla. Ehkäisyä aloitettaessa terveyskeskuksissa tehtiin yleisesti tarpeettoman paljon rutiinitutkimuksia. Yhdistelmähormoniehkäisyn käyttöön liittyvien ikärajojen ja vasta-aiheiden soveltamisessa todettiin puutteita. Tarjolla olevien ehkäisymenetelmien valikoima oli yleensä hyvä. Synnytyksen jälkeen lääketieteellisten ehkäisymenetelmien käyttö tavattiin aloittaa usein melko myöhään. Raskaudenkeskeytysasiakkaille pyrittiin useissa terveyskeskuksissa järjestämään lääkärin vastaanottoaika nopeasti. Sukupuolitautien osalta suurimmassa osassa terveyskeskuksia hoitajalla oli oikeus ohjata asiakas klamydiatutkimukseen ilman lääkärin lähetettä, mutta suunnitelmallinen klamydian seulonta ei ollut kovin yleistä. Tartunnan toteamisen yhteydessä vastuu kumppaneiden informoimisesta jäi tavallisesti potilaalle. Seksuaalineuvojakoulutuksen saaneita hoitajia työskenteli tutkimusajankohtana vain harvassa terveyskeskuksessa. Kokonaisuutena katsoen seksuaaliterveyspalveluiden tarjontaa terveyskeskuksissa voidaan pitää hyvänä. Toimintakäytännöt ja palveluiden laatu ovat kuitenkin varsin vaihtelevia ja useita palveluiden saavutettavuutta heikentäviä tekijöitä todettiin. Näyttöön perustuville hoitosuosituksille ja niiden tehokkaalle jalkauttamiselle näyttää olevan raskauden ehkäisyn alueella selvä tarve. Ehkäisyneuvonnassa voitaisiin siirtää painopistettä rutiinitutkimuksista seksuaalineuvonnan tarpeisiin vastaamiseen valtakunnallisen seksuaali- ja lisääntymisterveyden edistämisen toimintaohjelman 2007-2011 mukaisesti. Nuorten palveluiden kehittäminen on keskeinen haaste. Terveyskeskuksissa on tutkimuksen valossa tarvetta myös ammattilaisten säännönmukaiselle täydennyskoulutukselle, lääkäreiden ja hoitajien työnjaon tarkistamiselle sekä johtamisen kehittämiselle.In Finland, core sexual health services, defined as contraceptive counselling, abortion care, screening and treatment of sexually transmitted infections and sexual health counselling, are provided as part of publicly funded primary health care in municipal health centres. From a European perspective, teenage pregnancy and overall abortion rates are low in Finland. Nonetheless, the earlier positive trends in abortion and Chlamydia trachomatis infection rates have reversed since the mid-1990s, and this has raised the question whether the service provision system of health centres is adequate. A list-based personal doctor system was introduced to most of the country in the 1980-90's. Instead of earlier service provision in separate clinics, it was aimed that every physician offers preventive services (including family planning services) to his/her patients. It has been claimed that the number of specific family planning clinics was thereby diminished, resulting in inferior accessibility and quality of family planning services. The purpose of the study was to chart the provision of sexual health services in all health centres of the Expert Responsibility Area of Tampere University Hospital in Western Finland. In addition to describing the service structures and practices, quality of contraceptive service provision and its determinants were aimed to be explored as well as equity and equality of service provision. Data were gathered by conducting an online survey between September 2005 and January 2006 in the health centres (N = 63) of the study area. Emailed self-administered questionnaires were sent to chief physicians (response rate 78 %), directors of nursing (95 %), and physicians and nurses most closely involved in family planning in their health centres (68 % and 92 %). The statistical methods used were mostly descriptive. However, when assessing quality of contraceptive services and its determinants, Pearson´s chi-square test, Spearman´s rank correlation test and an ordered logit model were used. Finnish and international recommendations available in 2005 were the references for quality assessment. The results showed that sexual health services were arranged in health centres in various ways. Especially contraceptive counselling was organized in different settings, most often in connection with maternity care. In some health centres, long waiting times as well as breaks in family planning clinic services during summer impaired access to counselling. However, the time reserved for a consultation for contraception was sufficient in almost all health centres. Quality of contraceptive services varied substantially in the level of service structure as well as service processes. A chief nursing officer or leading nurse engaged in the health centre and an appointed person responsible for management of health promotion predicted good quality. Patient care organised with personal doctor system was not associated with quality of service structure or processes. Regarding clinical practices, there were several clinical and laboratory routines which were reported to be performed when initiating contraception. These practices were in line with Finnish recommendations available. Nevertheless, they were not evidence-based and they may even create medical barriers to access contraception. Some shortcomings were identified in applying age limits and contraindications when prescribing combined hormonal contraception. The contraceptive variety available in health centres was usually good. However, initiation of contraception with hormonal and intrauterine methods after childbirth seemed to be delayed unnecessarily. For clients seeking abortion, expedited access to a doctor´s consultation was arranged in the majority of health centres. Regarding sexually transmitted diseases, nurses were allowed to test for chlamydia independently without physician´s involvement in most health centres. On-site instructions for screening of chlamydia infection were available in only a few health centres. However, when initiating oral contraceptives or in the follow-up of their users, testing for chlamydia was performed fairly often. The most usual mode of contact tracing after diagnosis of chlamydia was asking the patient to contact his/her partners. Nurses with specific training in sexual health counselling were employed in only few health centres. Nurses discussed sexual health counselling issues with clients initiating contraception more actively than physicians. At community level, school nurses in secondary schools carried out sexuality education most often by giving lessons and by participating in planning of sexuality education. Equity and equality of sexual health service provision were considered somewhat inadequate from client´s point of view because of problems identified in accessing services and in variation of service quality. The special needs of adolescent clients were seldom met at the structural level of service provision. In general, provision of core sexual health services in health centres can be considered adequate. However, practice patterns and quality of services varied notably and several medical barriers to access were identified. It seemed that updating contraceptive counselling practices is challenging in primary care. Clearly, evidence-based clinical practice guidelines for contraceptive counselling with effective implementation are needed to support the counselling in health centres. Improving adolescents´ services in school health care, and in the largest health centres also by developing youth clinics, is one central challenge in the future. In many health centres, unnecessary routine investigations in contraceptive counselling could be dispensed. Instead, the focus could be shifted to supporting sexual health, as advised in the action programme for promotion of sexual and reproductive health 2007-2011. Based on the results, continuous medical education, evaluation of the distribution of work between physicians and nurses, and improving management of services are needed in primary care

Associations between study questionnaire-assessed need and school doctor-evaluated benefit of routine health checks : an observational study

Background In Finland, school doctors examine all children at predetermined ages in addition to annual health checks by school nurses. This study explored the association of study questionnaire-assessed need for and school doctor-evaluated benefit of routine health checks conducted by doctors. Methods Between August 2017 and August 2018, we recruited a random sample of 1341 children in grades 1 and 5 (aged seven and eleven years, respectively) from 21 elementary schools in four Finnish municipalities. Children mainly studying in special education groups or whose parents needed an interpreter were excluded. School nurses performed their health check as usual. Parents, nurses, and teachers then completed study questionnaires that assessed the concerns of parents, school nurses, and teachers regarding each child's physical, mental and social health. Doctors, blinded to the responses, routinely examined all the children. The primary outcome measures were (1) the need for a health check based on the study questionnaires and (2) the benefit/harm of the appointment as estimated by the doctors according to predetermined criteria, and (3) the patient-reported experience measures (PREMs) of benefit/harm of the appointment as estimated by the parents and children. We compared the need for a health check with the doctor-evaluated benefit using multilevel logistic regression. Results The participation rate was 75.5 %. According to all questionnaires, 20-25 % of the 1013 children had no need for a health check. The doctors regarded 410 (40.6 %) and the parents 812 (83.4 %) of the appointments as being beneficial. Respondents rarely reported harm. The children who were classified as needing a health check more often benefitted from the health check (assessed by the doctor) than children with no need for one (OR 3.53; 95 % CI 2.41-5.17). Conclusions The need for a health check is an important predictor of school-doctor evaluated benefit of the health check. This approach could allow school doctors to allocate time for the children who need them most.Peer reviewe

Associations between study questionnaire-assessed need and school doctor-evaluated benefit of routine health checks: an observational study

Background In Finland, school doctors examine all children at predetermined ages in addition to annual health checks by school nurses. This study explored the association of study questionnaire-assessed need for and school doctor-evaluated benefit of routine health checks conducted by doctors. Methods Between August 2017 and August 2018, we recruited a random sample of 1341 children in grades 1 and 5 (aged seven and eleven years, respectively) from 21 elementary schools in four Finnish municipalities. Children mainly studying in special education groups or whose parents needed an interpreter were excluded. School nurses performed their health check as usual. Parents, nurses, and teachers then completed study questionnaires that assessed the concerns of parents, school nurses, and teachers regarding each child's physical, mental and social health. Doctors, blinded to the responses, routinely examined all the children. The primary outcome measures were (1) the need for a health check based on the study questionnaires and (2) the benefit/harm of the appointment as estimated by the doctors according to predetermined criteria, and (3) the patient-reported experience measures (PREMs) of benefit/harm of the appointment as estimated by the parents and children. We compared the need for a health check with the doctor-evaluated benefit using multilevel logistic regression. Results The participation rate was 75.5 %. According to all questionnaires, 20-25 % of the 1013 children had no need for a health check. The doctors regarded 410 (40.6 %) and the parents 812 (83.4 %) of the appointments as being beneficial. Respondents rarely reported harm. The children who were classified as needing a health check more often benefitted from the health check (assessed by the doctor) than children with no need for one (OR 3.53; 95 % CI 2.41-5.17). Conclusions The need for a health check is an important predictor of school-doctor evaluated benefit of the health check. This approach could allow school doctors to allocate time for the children who need them most.</p

Steroidihormonien vaikutus estrogeenin indusoimaan differentaatioon kanan munatorvessa

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Seksuaaliterveyspalvelut terveyskeskuksissa

Keskeiset seksuaaliterveyspalvelut raskauden ehkäisyneuvonta, raskaudenkeskeytyshoidon järjestäminen, sukupuolitautien tutkimus ja hoito sekä seksuaalineuvonta ovat monin osin kuuluneet julkisen perusterveydenhuollon palvelutarjontaan jo kauan. Terveyskeskuksissa toteutetun ehkäisyneuvonnan tulokset olivat hyviä 1990-luvun puoliväliin saakka, jolloin erityisesti nuorten raskaudenkeskeytykset alkoivat lisääntyä. Samanaikaisesti myös ilmoitettujen klamydiainfektioiden määrä kääntyi nousuun. Yhtenä mahdollisena epäsuotuisan kehityksen syynä on pidetty terveyskeskuksissa tarjottavien ennaltaehkäisevien palveluiden tarjonnan heikentymistä muun muassa väestövastuujärjestelmän yleistymisen ja 1990-luvun alun talouslaman myötä. Väitöskirjatyön tavoitteena oli tutkia terveyskeskusten keskeisten seksuaaliterveyspalveluiden, erityisesti ehkäisyneuvonnan, tarjontaa, palveluiden toteuttamistapoja ja niiden laatua Tampereen yliopistollisen sairaalan erityisvastuualueen terveyskeskuksissa. Tutkimusaineisto kerättiin alueen terveyskeskusten johtaville lääkäreille ja hoitotyön johtajille sekä ehkäisyneuvontatyötä tekeville lääkäreille ja hoitajille suunnatuilla lomakekyselyillä. Tulokset osoittivat, että palveluiden järjestämistavat terveyskeskuksissa olivat moninaisia ja että erityisesti ehkäisyneuvontapalveluita tarjottiin usein erilaisin järjestelyin. Ehkäisyneuvontaan pääsyä rajoittivat muun muassa pitkät odotusajat ja kesäsulut. Ehkäisyneuvontapalveluiden laadussa oli runsaasti vaihtelua niin palvelutarjonnan rakenteessa kuin työntekijöiden käytännöissäkin. Palvelurakenteiden hyvää laatua ennustivat johtavan hoitajan tai ylihoitajan sekä nimetyn terveyden edistämisen johtamisesta vastaavan henkilön olemassaolo. Väestövastuinen toimintatapa ei ollut yhteydessä laatuun tutkittujen rakenteiden tai prosessien tasoilla. Ehkäisyä aloitettaessa terveyskeskuksissa tehtiin yleisesti tarpeettoman paljon rutiinitutkimuksia. Yhdistelmähormoniehkäisyn käyttöön liittyvien ikärajojen ja vasta-aiheiden soveltamisessa todettiin puutteita. Tarjolla olevien ehkäisymenetelmien valikoima oli yleensä hyvä. Synnytyksen jälkeen lääketieteellisten ehkäisymenetelmien käyttö tavattiin aloittaa usein melko myöhään. Raskaudenkeskeytysasiakkaille pyrittiin useissa terveyskeskuksissa järjestämään lääkärin vastaanottoaika nopeasti. Sukupuolitautien osalta suurimmassa osassa terveyskeskuksia hoitajalla oli oikeus ohjata asiakas klamydiatutkimukseen ilman lääkärin lähetettä, mutta suunnitelmallinen klamydian seulonta ei ollut kovin yleistä. Tartunnan toteamisen yhteydessä vastuu kumppaneiden informoimisesta jäi tavallisesti potilaalle. Seksuaalineuvojakoulutuksen saaneita hoitajia työskenteli tutkimusajankohtana vain harvassa terveyskeskuksessa. Kokonaisuutena katsoen seksuaaliterveyspalveluiden tarjontaa terveyskeskuksissa voidaan pitää hyvänä. Toimintakäytännöt ja palveluiden laatu ovat kuitenkin varsin vaihtelevia ja useita palveluiden saavutettavuutta heikentäviä tekijöitä todettiin. Näyttöön perustuville hoitosuosituksille ja niiden tehokkaalle jalkauttamiselle näyttää olevan raskauden ehkäisyn alueella selvä tarve. Ehkäisyneuvonnassa voitaisiin siirtää painopistettä rutiinitutkimuksista seksuaalineuvonnan tarpeisiin vastaamiseen valtakunnallisen seksuaali- ja lisääntymisterveyden edistämisen toimintaohjelman 2007-2011 mukaisesti. Nuorten palveluiden kehittäminen on keskeinen haaste. Terveyskeskuksissa on tutkimuksen valossa tarvetta myös ammattilaisten säännönmukaiselle täydennyskoulutukselle, lääkäreiden ja hoitajien työnjaon tarkistamiselle sekä johtamisen kehittämiselle.In Finland, core sexual health services, defined as contraceptive counselling, abortion care, screening and treatment of sexually transmitted infections and sexual health counselling, are provided as part of publicly funded primary health care in municipal health centres. From a European perspective, teenage pregnancy and overall abortion rates are low in Finland. Nonetheless, the earlier positive trends in abortion and Chlamydia trachomatis infection rates have reversed since the mid-1990s, and this has raised the question whether the service provision system of health centres is adequate. A list-based personal doctor system was introduced to most of the country in the 1980-90's. Instead of earlier service provision in separate clinics, it was aimed that every physician offers preventive services (including family planning services) to his/her patients. It has been claimed that the number of specific family planning clinics was thereby diminished, resulting in inferior accessibility and quality of family planning services. The purpose of the study was to chart the provision of sexual health services in all health centres of the Expert Responsibility Area of Tampere University Hospital in Western Finland. In addition to describing the service structures and practices, quality of contraceptive service provision and its determinants were aimed to be explored as well as equity and equality of service provision. Data were gathered by conducting an online survey between September 2005 and January 2006 in the health centres (N = 63) of the study area. Emailed self-administered questionnaires were sent to chief physicians (response rate 78 %), directors of nursing (95 %), and physicians and nurses most closely involved in family planning in their health centres (68 % and 92 %). The statistical methods used were mostly descriptive. However, when assessing quality of contraceptive services and its determinants, Pearson´s chi-square test, Spearman´s rank correlation test and an ordered logit model were used. Finnish and international recommendations available in 2005 were the references for quality assessment. The results showed that sexual health services were arranged in health centres in various ways. Especially contraceptive counselling was organized in different settings, most often in connection with maternity care. In some health centres, long waiting times as well as breaks in family planning clinic services during summer impaired access to counselling. However, the time reserved for a consultation for contraception was sufficient in almost all health centres. Quality of contraceptive services varied substantially in the level of service structure as well as service processes. A chief nursing officer or leading nurse engaged in the health centre and an appointed person responsible for management of health promotion predicted good quality. Patient care organised with personal doctor system was not associated with quality of service structure or processes. Regarding clinical practices, there were several clinical and laboratory routines which were reported to be performed when initiating contraception. These practices were in line with Finnish recommendations available. Nevertheless, they were not evidence-based and they may even create medical barriers to access contraception. Some shortcomings were identified in applying age limits and contraindications when prescribing combined hormonal contraception. The contraceptive variety available in health centres was usually good. However, initiation of contraception with hormonal and intrauterine methods after childbirth seemed to be delayed unnecessarily. For clients seeking abortion, expedited access to a doctor´s consultation was arranged in the majority of health centres. Regarding sexually transmitted diseases, nurses were allowed to test for chlamydia independently without physician´s involvement in most health centres. On-site instructions for screening of chlamydia infection were available in only a few health centres. However, when initiating oral contraceptives or in the follow-up of their users, testing for chlamydia was performed fairly often. The most usual mode of contact tracing after diagnosis of chlamydia was asking the patient to contact his/her partners. Nurses with specific training in sexual health counselling were employed in only few health centres. Nurses discussed sexual health counselling issues with clients initiating contraception more actively than physicians. At community level, school nurses in secondary schools carried out sexuality education most often by giving lessons and by participating in planning of sexuality education. Equity and equality of sexual health service provision were considered somewhat inadequate from client´s point of view because of problems identified in accessing services and in variation of service quality. The special needs of adolescent clients were seldom met at the structural level of service provision. In general, provision of core sexual health services in health centres can be considered adequate. However, practice patterns and quality of services varied notably and several medical barriers to access were identified. It seemed that updating contraceptive counselling practices is challenging in primary care. Clearly, evidence-based clinical practice guidelines for contraceptive counselling with effective implementation are needed to support the counselling in health centres. Improving adolescents´ services in school health care, and in the largest health centres also by developing youth clinics, is one central challenge in the future. In many health centres, unnecessary routine investigations in contraceptive counselling could be dispensed. Instead, the focus could be shifted to supporting sexual health, as advised in the action programme for promotion of sexual and reproductive health 2007-2011. Based on the results, continuous medical education, evaluation of the distribution of work between physicians and nurses, and improving management of services are needed in primary care

Steroidihormonien vaikutus estrogeenin indusoimaan differentaatioon kanan munatorvessa

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