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Сухомлин Г.М., Ромаданова О.І., Сябренко Г.П., Шкляр А.С., Неєлова О.В., Панченко М.С., Кіча Н.В., Крилова О.Б., Сергеєва О.Ю. Методичні ас
31.07.2014, 18:02

Резюме
Сухомлин Г.М.1, Ромаданова О.І.2, Сябренко Г.П.1, Шкляр А.С.3, Неєлова О.В.2, Панченко М.С.2, Кіча Н.В.4, Крилова О.Б.2, Сергеєва О.Ю.2 Методичні аспекти реабілітації, як компоненту діяльності лікарів загальної практики / сімейної медицини.
Доведено, що оптимізація обсягів медичної допомоги, яка надається місцевими закладами ПМСД є провідним шляхом у вирішенні актуального питання підвищення ефективності охорони здоров’я сільського населення з оглядом на їх найзначнішу роль серед закладів охорони всіх рівнів у наданні медичної допомоги, як дорослому населенню, так і дітям. Заклади ПМСД в сільській місцевості обслуговують 73,3% первинних звернень за допомогою для дорослого населення та 62,8% первинних звернень по допомогу дітям, при цьому середній персонал відіграє поряд з сімейними лікарями важливу роль у наданні первинної допомоги (42,4% - допомогу дорослим та 24,4% - дітям).  Виявлено низький рівень відвідувань закладів ПМСД мешканцями сільських районів, як з реабілітаційно - профілактичною метою, так і з приводу захворювань, не зважаючи на те, що значна частка опитаних страждає на хронічні захворювання (57,2%), а досить велика кількість респондентів вважає стан свого здоров’я незадовільним (24,9%).
Ключові слова: реабілітація, сімейна медицина

Резюме
Сухомлин Г.Н., Ромаданова О.И., Сябренко Г.П., Шкляр А.С., Неелова О.В., Панченко Н.С., Кича Н.В., Крылова О.Б., Сергеева О.Ю. Методические аспекты реабилитации, как компоненты деятельности врачей общей практики/семейной медицины.
Доказано, что оптимизация объёмов медицинской помощи на первичном уровне является ведущим фактором в решении актуального вопроса повышения эффективности здравоохранения сельского населения. Учреждения обшей практики-семейной медицины в сельской местности обслуживают 73,3% первичных обращений взрослых и 62,8% первичных обращений детей, при этом средний персонал играет важную роль в первичной помощи (42,4% - первичных обращений взрослых и 24,4% - детей).  Выявлен низкий уровень поселений сельскими жителями как с реабилитационно – профилактической целью, так  и в святи с заболеваниями, несмотря на то, что значительная часть опрошенных имеют хронические заболевания (57,2%), а достаточно большое количество респондентов считает состояние здоровья неудовлетворительным (24,9%).
Ключевые слова: реабилитация, семейная медицина.

Summary
Sukhomlyn H.M., Romadanova О.І., Siabrenko H.P., Shklyar A.S., Neyеlova O.V., Panchenko М.S., Кіcha Н.V., Sergeeva О.Yu., Кrylova О.B. Methodological aspects of rehabilitation as the component of general practitioners’ activity / family medicine.
It has been proved that the optimization of medical care, provided by the local PHC institutions is the leading way in addressing the vital issue of improving the efficiency of health care for the rural population, taking into consideration their most significant role among other medical institutions of all levels in the provision of medical care to adults and children. Primary health care institutions in rural areas provide primary medical treatment in 73.3% cases, when the adult population is involved, and react to 62.8% cases of primary medical assistance to children. Along with family doctors, nursing staff plays an important role in providing primary medical assistance to 42.4% of adults and 24.4% of children. Low levels of visiting PHC facilities by the residents of rural areas have been observed, both for the rehabilitation and prevention reason and for the treatment of diseases, , despite the fact that a significant proportion of the respondents have chronic diseases (57.2%), and a sufficiently large number of respondents said poor health status (24, 9%).
Key words: rehabilitation, family medicine.

Рецензент: д.мед.н., проф. С.П. Шкляр

УДК 614.253+254]:35.083.53

1 Кіровоградський університет «Україна» МОН України

Kirovohrad University "Ukraine"

Кировоградский университет «Украина» МОН Украины

2 Харківська медична академія післядипломної освіти МОЗ України

Харьковская медицинская академия последипломного образования

Kharkov medical academy of Postgraduate Education

oksana.neelova78@gmail.com
3 Харківський національний медичний університет МОЗ України

Харьковский национальный медицинский университет

Kharkiv National Medical University 

serg_shklyar@ukr.net

4 Національна медична академія післядипломної освіти ім. П.Л. Шупика

Национальная медицинская академия последипломноого образования им. П.Л. Шупика

Shupyk National Medical Academy of Postgraduate Education

n_kicha@mail.ru

Introduction. In recent decades, virtually all European countries have been actively using the models of health care system reform, based on the strategies of implementation and development of primary health care service [2, 6]. According to the leading international and local researchers, primary health care system is recognized as the optimal organizational approach that creates the potential for efficient use of health care resources and provides affordable and high quality public health care service based on the principles of general medical practice [1,7]. Identifying the factors of negative impact on the introduction of organizational changes in health care is the basis for the justification of the ways of their elimination and adaptation to the local conditions [4, 5, 8, 9].

Conducting a survey is one of the methods to evaluate the effectiveness of the organization of health care system as a whole and its individual components.

The research objective was to study the quality of rural ambulatories of general practice and family medicine by conducting a medical and sociological study.

Research methodology. A standardized survey protocol for the residents of rural areas was developed to conduct the research. Taking into consideration the patients' opinion, the study of the quality of medicine was carried out with special emphasis on the following criteria: accessibility, continuity, professional competence, timeliness, security, scientific and technical level, interpersonal relations, and effectiveness. The questions aimed at assessing the aspects of quality of medical aid were developed in the form of closed questions with five answer options. Each of them was attributed with some value ranging from 1.0 (the maximum positive response and 100% quality) to 0.0 (completely negative or 0% quality). Intermediate responses were equal to 0.75 (75%), 0.5 (50%), and 0.25 (25%). Each of the answer options received verbal interpretation to facilitate understanding. Evaluation of the quality of medical care that the patients were provided with was complemented with the study of the frequency of medical consultations, particularly for the sake of prevention or treatment of diseases and for the purpose of examining people's health.

The study was conducted using the method of simultaneous continuous surveillance by anonymous questionnaires. The survey was conducted in 14 districts of the administrative region. The total amount of the surveyed people is 850 individuals. According to the type of a population poll, it was a combined cluster-zoned survey with introduced quotas depending on gender and type of settlement. All the respondents lived in the territory with family doctors working in primary health care (PHC) ambulatories where the nursing and obstetrician facilities had been reformed during the previous five years.

Data analysis was conducted using the 5R88 software; the data were transmitted to EXCEL and presented in tables. During the survey, 850 patients' questionnaires were analyzed after they had received medical care in the areas of primary health care facilities. The respondents included 48.0% men (408 patients) and 52% women (442 patients) within the age range of 18 to 88 years, which generally reflects the gender structure of the Kharkiv region residents. The largest share among the survey participants is constituted by the people aged 40-49 years - 207 people (24.35±1.5%), the number of the responses given by the people aged 29 reached 15.29±1,2% (130 patients), 30-39 years (17.65±1.3%, 150), 50-59 years (18.71±1.3%, 159 patients), over 60 years – 24.0±105% (204 patients).

Presentation of the results. In the socio-professional groups, the surveyed people occupied the following categories: 29.7±1.6% are retired, 26.5±1.5% are  employees, 23.7±1.5%  are workers and agricultural workers, 12.2±1.1% are unemployed, 17.8±1.3% are entrepreneurs, and 12.7±1.1% are students or pupils. It should be mentioned that the category of employees included the respondents, whose work did not involve physical labor. The proportion of the respondents, who had graduated from higher educational establishment, constituted 12.8±1.1%, whereas 36.8±1.9% had vocational education, which implied obtaining fully adequate responses to specific questions. Among the respondents, 72.8+1.5% were married and lived in a family; 11.8±1.1% of the respondents identified their status as single (not married), 5.4+0.8% respondents were divorced, and 10.0±1.1% were widowers. There were no children under 18 years old in the families of 16.5+1.3% respondents. 80.2±1.2% of the respondents indicated that one, two or three children lived in their families; 3.3±0.6% respondents had four or more children under 18 years old in the family. Distribution of the respondents on the basis of their financial security shows that 71.9+1.6% of the respondents have an average income per family member that is below the officially defined subsistence level. 26.2±1.5% of the respondents indicated that their average income per family member ranged from 350 to 700 hryvnias per month and 1.9±0.4% of the respondents said that their income was more than 700 hryvnias.

The frequency of people's asking for help is the factor which indirectly indicates the quality of health care, that is why one of the objectives of the study was to assess the subjective component of this index among the population. The frequency of medical assistance requests in cases of diseases and for the sake of prophylaxis were studied separately. The survey showed that a half (50.0+1.7%) of the respondents requested medical assistance because of the disease quite rarely - once a year. The rest of the respondents needed the service of medical institutions about once a quarter – 34.4±1,6% and once a month – 15.3±1.2%. Three respondents (0.4±0.2%) chose the option, which was interpreted as "Do not need medical assistance" or "Consult doctors less than once per year." There is a weak relationship between the frequency rate of visits to doctors for the purpose of disease treatment with the index of age (p=0.05, r=+0.1).

64.9+1.6% of the respondents attend medical institutions for the purpose of disease prevention once a year; 27.2+1.5% visit their doctors once a quarter, and 3.8+0.7% (32 people) address their doctor once a month. Answering the question, 4.1+0.7% of the respondents chose the category “Other”. In this case, 100% of the respondents, who had chosen this answer option, deciphered their response as "Do not appeal for doctor's help as a prophylactic measure." Thus, the results suggest that the level of appeals for help is rather low among the residents of the rural area, and it is especially vividly seen in case of visiting hospitals as a prophylactic measure. It is worth emphasizing that there is no significant difference between the frequency of visits to hospitals for treatment and prevention of diseases among the respondents, who revealed they had chronic diseases, and among the respondents, who said they did not suffer from them.

The survey showed that 62.7±1.8% of the respondents, who needed medical aid for their children, addressed the personnel of the local PHC facility. 38.4±1.7% of the respondents went directly to the doctor at these institutions. 24.4±1.5% addressed the nursing staff. The number of the respondents, who needed health care for their children and visited a narrow specialist at medical institutions of a higher level, was twice bigger (26.9±1.5%), if to compare it with the medical care provided to adult family members. This may indicate the lack of family doctors' skills in pediatrics and lack of patients' confidence in them. 2.5±0.5% of the respondents use medical services privately, 7.2±0.9% call an emergency service at once. Answering the question "Who do you first apply to if you need medical assistance for children", 0.7±0.2% of the respondents (6 people) chose the option named "Other".

One of the objectives of the study was to find out how the people estimated the quality of medical help provided in outpatient primary health care hospitals, which had been introduced instead of the nursing and obstetrician facilities. 11.8±1.1% of the respondents (100 people) rated the professional competence of doctors as "very high", 13.1±1.2% of the respondents (111 people) were absolutely satisfied with the professional quality of medical technicians. 25.8±1.5% of the respondents (219 people) considered the doctors to be well qualified, and 24.7±1.5% of the respondents (210 people) were absolutely satisfied with the professional level of the nursing staff. The largest part of the respondents considered professional training of the medical staff (the doctors and assisting staff) at primary health care institutions to be satisfactory (30.7±1.6% and 32.1±1.6% of the respondents, or 261 and 293 patients respectively). Accordingly, 27.2±1.5% and 27.6±1.5% of the respondents (231 and 235 people) considered the professional level of doctors and nurses to be low. 4.6±0.7% of the respondents (39 people) believed that professional qualities of the doctors were poor, and the corresponding indicator of the nursing personnel at the local primary health care facilities was 2.5±0.5% (21 people). The calculated indicator of the patients' integral assessment of the family doctors proficiency level is 53.2% and of the nursing staff – 54.6%.

According to the study of the physical accessibility of primary medical care for the residents of rural areas, it has been found that 24.2±1.5% of the respondents seek help from a family doctor at any time of the day regardless of working hours of the primary health care facility. 9.6±1.0% of the respondents can use the services of a doctor during the day, 24.9±1.5% of the patients consult a doctor during the working hours of an PHC facility. Thus 16.2±1.5% of the respondents indicated that they not always had the opportunity to immediately seek medical attention even during working hours and 24.9±1.5% emphasized that this possibility was virtually unavailable as a result of objective obstacles. Thus, the physical accessibility of medical care at the primary level is 48.0%. The results of the study show that 21.4±1.4% of the respondents spend up to 15 min waiting for a doctor's consultation at the medical clinic; 31.9±1.6% wait from 15 to 30 min; another 19.6±1.4% say they spend from 30 to 45 min to visit their doctor at the clinic; 6.9±0.9% respondents need about an hour, whereas 20.1±1.4% note that they have to wait for more than an hour. 39.2±1.7% of the patients claim that at home they usually wait for a doctor's visit for one hour, 21.4±1.4% spend from one to three hours waiting, 17.1±1.3% of the respondents indicate that their doctor visits them during the same day, and 12.6±1.1% of the respondents said that sometimes the doctor would come only the next day. 9.8±1.0% residents claim that the doctor visits them in a matter of two or three days. According to the provided data, the calculated integral indicator of the optimal time of waiting for a consultation at a PHC facility that has replaced nursing and obstetrician facilities is 56.9%, while the corresponding figure for the medical service at home is 66.9%.

9.2±1.0% of the respondents (78 people) are fully satisfied with the results of treatment. 36.5±1.7% of the respondents (310 people) consider the result of their treatment to be good; 24.7±1.5% of the patients (210 people) have some doubts whether everything possible is done to stabilize their health. 26.5±1.5% (225 people) think the results of the treatment are unsatisfactory, and 3.2±0.6% of the respondents (27 people) are completely dissatisfied with the treatment and its results in local PHC facilities. According to the residents of rural areas, the quality of medical care provided by the local PHC facilities is 59.2%. The most significant proposals made ​​by the respondents to improve the health care system are as follows: provide the staff of PHC facilities with higher medical education - 24.7%; improve the doctors' professional level - 22.9%; raise the qualification of the medical staff - 17.6%; improve the material and technical resources - 48.2%; provide medical institutions with free medications - 13.5%; provide periodic patient counseling by narrow specialists at a local level - 9.2%.

Conclusions.

1. It has been proved that the optimization of medical care, provided by the local PHC institutions is the leading way in addressing the vital issue of improving the efficiency of health care for the rural population, taking into consideration their most significant role among other medical institutions of all levels in the provision of medical care to adults and children. Primary health care institutions in rural areas provide primary medical treatment in 73.3% cases, when the adult population is involved, and react to 62.8% cases of primary medical assistance to children. Along with family doctors, nursing staff plays an important role in providing primary medical assistance to 42.4% of adults and 24.4% of children.

2. Low levels of visiting PHC facilities by the residents of rural areas have been observed, both for the rehabilitation and prevention reason and for the treatment of diseases, despite the fact that a large number of the respondents suffer from chronic diseases (57.2%), and quite a large number of respondents consider their health to be poor (24.9 %).

3. The main challenges in improving the quality of medical care are the poor level of material and technical base (the quality index is 34.8%), physical access to medical care (48.0 %), and the professional level of the medical staff (doctors - 53.2% and nursing staff - 54.6 %).

 Further study is considered perspective since the aggregate data help create conditions for managing the process of reforms from the viewpoint of public acclaim. The solution of these problems must take into account the subjective component of the quality and efficiency of family doctors, particularly in terms of taking rehabilitation measures more often.

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