Challenges in Implementation of the Primary Care Assessment

Challenges in Implementation of the Primary Care Assessment Tools in Vietnam Jeff Markuns MD Laura Goldman MD Kristin Shaw MPH Boston University Global Health Collaborative

Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Jeffrey Markuns, Laura Goldman, and Kristin Shaw have indicated they have no relevant financial relationships to disclose. 2

Learning Objectives • Describe the goals and objectives of the PCAT study • Explain the challenges of PCAT implementation in low-resource settings • Apply lessons learned to future research in primary care 3

Primary Care in Vietnam • 10, 000 commune health centers (CHCs) • Staffed by “general doctors” who work there right after medical school • Patients recognize low-quality and by-pass the commune level • BU GHC has been working to improve primary care in Vietnam, primarily through Family Medicine development, for 20 yrs 4

Development of Family Medicine • Family Medicine was declared a specialty by the MOH in 2000 • FM Departments developed at 6 medical schools • FM specialty training (CK 1) – FM “residency” to train, and retrain, CHC doctors – Over 600 FM CK 1 graduates since 2001 5

The Primary Care Assessment Tool (PCAT) Domains of Measurement First Contact Care Continuous Care Coordinated Care Comprehensive Care Family-Centered Care Community-Oriented Care Culturally Competent Care 6 • Family of tools designed to measure the main domains of primary care • Structural and behavioral sub-domains are measured for each

PCAT Instruments • Consumer (client) surveys – Adult and child versions • Facility surveys • Provider surveys • Systems-version survey 7

PCAT Feasibility Study: 2007 • 4 locations where CK 1 training was ongoing • Survey participants: – 41 CHC physicians: 58% CK 1, 42% no CK 1 – 104 CHC patients: 51% patients of CK 1, 49% patients of non-CK 1 s • Results and feasibility – No significant difference in provider domain scores – Consumer scores for continuous care, familycenteredness, and community- based care were higher in patients of CK 1 s 8

PCAT Adaption and Planning: 2008 -2013 • Formalized research relationship with international partners – Adapted research methodology based on needs of all partners – Applied for ethical approval at each research site • Pre-post evaluation of CK 1 trainees – 2008 (pre) and 2010 (post) – Later realized the pre-group was wrong 9

PCAT Implementation: 2014 -2015 3 provinces, 57 physicians, 3360 patients Quang Tri Province Dong Ha District Vinh Linh District Cam Lo District 6 Communes 4 Communes 3 Trained 3 Un-Trained 90 Households 180 Consumers 10 180 Consumers 2 Trained 2 Un-Trained 60 Households 120 Consumers

Preliminary Results • Preliminary results from 1 province • 2 of the 11 primary care domains were significantly different between patients of a FM doctor vs. patients of general doctor: – Coordination of care – Family centeredness 11

Challenges 12

Cultural Adaptation • Appropriate translation methods – The tool was not back-translated before the feasibility study • “Western” terms and concepts – “Is it easy to get an appointment for a general checkup at your CHC? ” – “When your CHC is open, can you get advice quickly over the phone if you need it? ” • Selection of household interviewee 13

Patient-Doctor Affiliation 1. Is there a doctor or place that you usually go if you are sick or need advice about your health? 2. Is there a doctor or place that knows you best as a person? 3. Is there a doctor or place that is most responsible for your health care? 14

External Factors • Infrastructure – Equipment and technology at CHCs is under-resourced • Policies – Roles and responsibilities of FM doctors are still being developed – New referral policy implemented in 2015 15

Next Steps • Validation study – Internal consistency of data • More in-depth data analysis – Analyze data from the other 2 provinces – Stratify data by CHCs with only 1 doctor 16

Questions? • Jeffrey Markuns, jmarkuns@bu. edu • Kristin Shaw, keshaw@bu. edu 17