Browsing by Organization "National Institute of Health and Welfare (THL, the former National Research and Development Centre for Welfare and Health (STAKES))"

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  • Larivaara, Meri (Helsingin yliopisto, 2012)
    Since the late 1990s Russia has seen rapid social change in terms of population decline and low fertility. The health service system has been reformed. A mandatory health insurance system has been constructed and the development of the private sector has taken place. In the field of reproductive health services attitudes towards maternity care, birth control, and termination of pregnancy have undergone considerable change. At the same time new technologies have become available. Access to reliable contraception has improved and the number of induced abortions has declined, but the use of unreliable birth control methods continues to be common practice. Previous studies have reported that many patients are dissatisfied with the quality of health services in the public sector. ---- Relatively little is known about reproductive health providers' knowledge, attitudes and practices concerning family planning. Information about providers' roles in reproductive health promotion is scarce and scattered. Previous literature points to missed opportunities in reproductive health counselling and low patient involvement in clinical decision-making. The objective of this study was to increase the current understanding of the obstacles that limit the extent and effectiveness of reproductive health counselling in the public sector out-patient services in urban Russia. The specific aims were (1) to describe how the delivery of women's reproductive health services is organised in St Petersburg, (2) to analyse the challenges in women's reproductive health services as perceived by health administrators and practising gynaecologists, (3) to analyse gynaecologists' views and practices concerning preventing, planning, and monitoring pregnancy, and (4) to examine gynaecologists' perceptions of the provider-patient relationship. The data of this study are qualitative, consisting of semi-structured interviews and observations. The data were collected between January and May 2005. The data collection consisted of four parts: (1) semi-structured background interviews with administrative personnel and medical professors (N=9), and managers of women's out-patient clinics (N=9), (2) a pilot study involving observations (N=3) and semi-structured interviews (N=2) at a women's out-patient clinic, (3) observations (N=17) and semi-structured interviews (N=12) at two women's out-patient clinics, and (4) visits and comparison interviews (N=4) at five women's out-patient clinics. The main method of data analysis was content analysis. The women's clinics provided a variety of services ranging from preventative gynaecological check-ups and contraceptive counselling to monitoring of pregnancies and treatment of gynaecological complaints. More than 40 per cent of the patient visits concerned monitoring pregnancy, whereas contraceptive counselling was the primary purpose of the visit in only a small number of cases. Women's clinics suffered from a low level of formal funding, which has resulted in user charges in breach of the mandatory health insurance legislation. The clinics had also developed commercial services to improve their financial situation. Many of the study participants were concerned about equal access to health services and the decline of health promotion. The gynaecologists were well-informed about the latest contraceptive methods and had a positive attitude towards promoting their use. They offered contraceptive counselling to many patients, but the coverage was not 100 per cent among women of reproductive age. The depth of contraceptive counselling varied considerably. In about two-thirds of the observed cases patient involvement was low and counselling was provider-centred, but in approximately a third of the cases patient preferences influenced the clinical decision-making process. Gynaecologists regarded the use of reliable contraception as a means of protecting future fertility and avoiding terminations and as a sign of responsible and morally respectable womanhood. Gynaecologists held a medicalised view of pregnancy planning, promoting gynaecological examinations and diagnostic tests before pregnancy. In practice they emphasised specialist knowledge and risk management in monitoring pregnancy, although they thought their work should ideally combine medical expertise and maternal caretaking. The practising gynaecologists felt that there were many gaps in the provider-patient relationship and that patients did not pay enough attention to reproductive health matters. The gynaecologists expressed patient-centred and holistic ideas about patient work in interviews, but patient involvement was limited during the observed clinical encounters. The gynaecologists emphasised medical authority in interviews, but they also wished for warm and trusting provider-patient relationships. The study results suggest that mandatory health benefit packages should be defined in detail and that reforms are needed to the compensation provided by mandatory health insurance to women's clinics. The results indicate that gynaecologists need continuing education in patient-centred counselling and treatment and in how to involve patients in clinical decision-making. The results point to several implications for future research including the need to broaden models of the provider-patient relationship to incorporate mutual liking and trust in the existing models of patient involvement.