What is Primary Health Care?

In studying health care delivery in informal settlements/slums we have found that people seek health care both in the slum communities and from the local hospital outpatients department. Are those who go to the hospital receiving primary care? The WHO definition is not of any help here because it defines primary care in a way that makes it indistinguishable from secondary care. It is ‘a whole-of-society approach’.[1] How silly; such an approach would include education, industrial policy trade, press freedom and a whole pile more. If a word means everything then it means nothing. It is ‘centred on the needs and preferences of individuals’. Well then, it includes the whole of health care – secondary, tertiary, quaternary, the lot. It ‘addresses the broader determinants of health’. And secondary care can’t do that? And then it goes on about rights without mentioning what happens when not all rights can be met. But one thing is important: at no point does the WHO definition state that primary care cannot be delivered in hospital. This means that service planners have a choice with respect to where they provide services to meet patient demand for reactive care. They can provide it in communities such as informal settlements, or they can strengthen hospital provision. In rich countries provision in communities and close to where people live is affordable and desirable. This might not be the case in urban areas in poor countries where care is usually abysmal according to our near complete systematic review. If people in local communities access care in hospital and are satisfied with it, then ensuring availability of high quality outpatients care may be optimal strategy in low-income cities.

— Richard Lilford, CLAHRC WM Director

Reference:

1. World Health Organization. Primary health care. 27 February 2019.

On Foetal Growth Charts – the WHO May Have Adopted the Correct Policy for the Wrong Reason

The journal ‘Science’ reports a controversy over two studies of foetal growth across countries [1] – the first study showed very similar growth rates across eight countries (Brazil, Italy, Oman, UK, USA, China, India, Kenya).[2] They conclude that a common threshold should be used in countries to identify slow-growing foetuses. The second study looks only at the socio-economically advantaged populations across ten countries, ranging from Norway and Denmark to India and Egypt.[3] It finds markedly different rates across countries among socio-economically advantaged segments of the population. So that would suggest the use of country-specific thresholds.
I am not so sure – I question the assumption that the search for the growth-retarded foetus should be based on a fixed proportion of the foetal population – say the slowest growing 5%. The risk of stillbirth is higher in the countries with slower foetal growth (e.g. India and Egypt), than in those with higher growth rates (e.g. Norway and Denmark). So the cut-off threshold for foetal growth as a screening test should, logically, be set at a higher point in high-risk countries than in lower-risk countries. If it is set to identify the ‘bottom’ 5% in low-risk countries it should be set at, say, 10% in high-risk countries. This suggests that the WHO (which recommends a universal chart on the basis of the first study above) has the correct solution for the wrong reason. The universal chart will identify a higher proportion of still-births in the high-risk countries – just what one would want.

— Richard Lilford, CLAHRC WM Director

References:

1. de Vrieze J. Big studies clash over fetal growth rates. Science. 2017; 355(6323): 336.
2. Papageorghiou AT, Ohuma EO, Altman DG, et al. International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal Study of the INTERGROWTH-21stProject. Lancet. 2014; 384: 869-79.
3. Kiserud T, Piaggio G, Carroli G, et al. The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight. PLoS Medicine. 2017.

Use of WHO Surgical Check List

We thank Mary Dixon-Woods for drawing our attention to an interesting article on the use of the fabled WHO surgical checklist.[1] Interesting because the topic is important and because the authors used a step wedge, cluster, experimental design as they introduced the intervention across different surgical specialities in two Norwegian hospitals. Step wedge designs need to avoid pitfalls of all cluster studies related to interaction between intervention and willingness to be recruited. The neat way out of this conundrum is to use routinely collected data and enter everyone in the cluster. That was done here. It is important to control for systematically later time periods in the intervention ‘cells’ of the step wedge and, again, the authors did so. So what did they find in this procedurally satisfactory study? A large and statistically significant intervention effect was observed. This is in keeping with many, but not all, previous studies of the conventional checklist.

My problem lies in the underlying hypothesis; as a previous surgeon I find the theoretical basis for the checklist unconvincing. In other words I start from a sceptical prior that is reluctantly being pulled towards a more optimistic estimate. Also, I fret over publication bias in the social science/service delivery literature, as discussed in a previous post. All the same a sceptic like me cannot ignore these positive results. So how may they work. Firstly, the word “checklist” may be a misnomer. It may just be a convenient focus around which to engender a positive and professional personal and team approach. This could explain why it sometimes works and sometimes does not. The idea here would be that it can’t work when: 1) attitudes are totally hostile, or 2) practice is already very good so there is little headroom for improvement. In that case it would be like any behavioural intervention – it will work among those who are receptive to improvement, but not yet improved. It is also possible that use of the checklist, even in a tokenistic way, will be effective in the very long term. Here I rely on the theory of cognitive dissonance.[2] People who start with ritualistic tokens of compliance are inclined to either stop complying or move their attitudes towards their outward actions, if I understand correctly. Comments welcome.

— Richard Lilford, CLAHRC WM Director

Reference:

1. Haugen AS, Søfteland E, Almeland S, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Ann Surg. 2015; 261 (5): 821-8.
2. Festinger L. A Theory of cognitive dissonance. Stanford, CA: Stanford University Press, 1957.