Zeliha Aslı Öcek

Family medicine model in Turkey: a qualitative assessment from the perspectives of primary care workers

BackgroundA person-list-based family medicine model was introduced in Turkey during health care reforms. This study aimed to explore from primary care workers’ perspectives whether this model could achieve the cardinal functions of primary care and have an integrative position in the health care system.MethodsFour groups of primary care workers were included in this exploratory-descriptive study. The first two groups were family physicians (FP) (n = 51) and their ancillary personnel (n = 22). The other two groups were physicians (n = 44) and midwives/nurses (n = 11) working in community health centres. Participants were selected for maximum variation and 102 in-depth interviews and six focus groups were conducted using a semi-structured form.ResultsData analysis yielded five themes: accessibility, first-contact care, longitudinality, comprehensiveness, and coordination. Most participants stated that many people are not registered with any FP and that the majority of these belong to the most disadvantaged groups in society. FPs reported that 40-60% of patients on their lists have never received a service from them and the majority of those who use their services do not use FPs as the first point of contact. According to most participants, the list-based system improved the longitudinality of the relationship between FPs and patients. However, based on other statements, this improvement only applies to one quarter of the population. Whereas there was an improvement limited to a quantitative increase in services (immunisation, monitoring of pregnant women and infants) included in the performance-based contracting system, participants stated that services not among the performance targets, such as family planning, postpartum follow-ups, and chronic disease management, could be neglected. FPs admitted not being able to keep informed of services their patients had received at other health institutions. Half of the participants stated that the list-based system removed the possibility of evaluating the community as a whole.ConclusionsAccording to our findings, FPs have a limited role as the first point of contact and in giving longitudinal, comprehensive, and coordinated care. The family medicine model in Turkey is unable to provide a suitable structure to integrate health care services.

The change in capacity and service delivery at public and private hospitals in Turkey: A closer look at regional differences

BackgroundSubstantial regional health inequalities have been shown to exist in Turkey for major health indicators. Turkish data on hospitals deserves a closer examination with a special emphasis on the regional differences in the context of the rapid privatization of the secondary or tertiary level health services.This study aims to evaluate the change in capacity and service delivery at public and private hospitals in Turkey between 2001-2006 and to determine the regional differences.MethodsData for this retrospective study was provided from Statistical Almanacs of Inpatient Services (2001-2006). Hospitals in each of the 81 provinces were grouped into two categories: public and private. Provinces were grouped into six regions according to a development index composed by the State Planning Organisation. The number of facilities, hospital beds, outpatient admissions, inpatient admissions (per 100 000), number of deliveries and surgical operations (per 10 000) were calculated for public and private hospitals in each province and region. Regional comparisons were based on calculation of ratios for Region 1(R1) to Region 6(R6).ResultsPublic facilities had a fundamental role in service delivery. However, private sector grew rapidly in Turkey between 2001-2006 in capacity and service delivery. In public sector, there were 2.3 fold increase in the number of beds in R1 to R6 in 2001. This ratio was 69.9 fold for private sector. The substantial regional inequalities in public and private sector decreased for the private sector enormously while a little decrease was observed for the public sector. In 2001 in R1, big surgical operations were performed six times more than R6 at the public sector whereas the difference was 117.7 fold for the same operations in the same regions for the private sector. These ratios decreased to 3.6 for the public sector and 13.9 for the private sector in 2006.ConclusionsThe private health sector has grown enormously between 2001-2006 in Turkey including the less developed regions of the country. Given the fact that majority of people living in these underdeveloped regions are uninsured, the expansion of the private sector may not contribute in reducing the inequalities in access to health care. In fact, it may widen the existing gap for access to health between high and low income earners in these underdeveloped regions.

Public health education in Ege University Medical Faculty: Developing a community-oriented model

Background: Ege University Medical Faculty (EUMF) introduced a community-oriented curriculum in 2001. Aims: To evaluate the new public health education program in EUMF curriculum. Method: The study adopted triangulated methods. Quantitatively, a comparison of the students who were exposed to a community-oriented curriculum (Year 4 in 2007) was made with the students who were exposed to the traditional curriculum (Year 4 in 2005) in terms of their assessment of their achievement of our learning objectives. A total of 255 students in 2005 (80.7%) and 243 students in 2007 (81.5%) were surveyed using a questionnaire. Qualitatively, five focus group- and five individual interviews were performed with the 2007 cohort. Results: Except the one related to teamwork (p > 0.05) all learning objectives yielded significantly higher scores in the 2007 cohort than in the 2005 cohort (p < 0.05). The qualitative analysis supported the achievement of objectives in the 2007 cohort. The students appreciated the relevance of public health education with clinical subjects and interactive methods, but criticized didactic lectures and written assignments. Conclusions: A community-oriented approach is more effective in achieving a holistic approach to health problems. Improving community-based activities and assessment methods would be more successful in integrating population health into medical training.

The influence of a market-oriented primary care reform on family physicians’ working conditions: A qualitative study in Turkey

Background: Turkey has undergone a ‘Health transformation programme’ putting emphasis on the reorganization of primary care (PC) services towards a more market-oriented system. Objectives: To obtain a deep understanding of how family physicians (FPs) experienced the process of the reforms by focusing on working conditions. Methods: This phenomenological and qualitative research used maximum variation sampling and 51 FPs were interviewed in 36 in-depth and four focus-group interviews. Results: Thematic analysis of interviews provided seven themes: (1) change in the professional identity of PC physicians (physician as businessperson); (2) transformation of the physician–patient relationship in PC (into a provider–customer relationship); (3) job description and workload; (4) interpersonal relationships; (5) remuneration of FPs, (6) uncertainty about the future and (7) exhaustion. Most FPs felt that the Family medicine model (FMM) placed more emphasis on the business function of family practice and this conflicted with their professional characteristics as physicians. FPs complained that some of their patients behaved as extremely demanding consumers. Continuously increasing responsibilities and extremely high workload were commonly reported problems. Most participants described the negative incentives in the performance scheme as a degrading method of punishment. The main factor was job insecurity caused by contract-based employment. FPs described the point at which they are with terms such as exhaustion. Conclusion: By increasing workload and creating uncertainty about the future and about income, the PC reforms have led to working conditions, which has led to changes in the professional attitudes of physicians and their practice of medicine.

Evaluation of an intensive intervention programme to protect children aged 1–5 years from environmental tobacco smoke exposure at home in Turkey

The aim of this randomized-controlled trial was to evaluate the effectiveness of an intensive intervention to reduce childrens environmental tobacco smoke (ETS) exposure at their home compared with a minimal intervention. The target population of the study was the mothers of children aged 1-5 who lived in the Cengizhan district of Izmir in Turkey, who smoked and/or whose spouses smoked. It was found that at least one parent of a total of 182 children smoked and 80 of these mothers were taken into stratified sampling based on the number of the smoking parents. Mothers were visited at their homes. During the initial visit, they were educated and urine samples were taken from their children. Following this initial visit, mothers were randomized to the intensive intervention (n = 38) or the minimal intervention group (n = 40). The levels of cotinine in the intensive intervention (P = 0.000) and minimal intervention (P = 0.000) groups in the final follow-up were significantly lower than the initial levels. The proportion of mothers reporting a complete smoking ban at home in the final follow-up was higher in the intensive intervention group than the minimal intervention group (P = 0.000). The education provided during the home visits and the reporting of the urinary cotinine levels of the children were effective in lowering the childrens exposure to ETS at their home.

Reliable mortality statistics for Turkey: Are we there yet?

BackgroundThe Turkish government has implemented several reforms to improve the Turkish Statistical Institute Death Reporting System (TURKSTAT-DRS) since 2009. However, there has been no assessment to evaluate the impact of these reforms on causes of death statistics. This study attempted to analyse the impact of these reforms on the TURKSTAT-DRS for Turkey, and in the case of Izmir, one of the most developed provinces in Turkey.MethodsThe evaluation framework comprised three main components each with specific criteria. Firstly, data from TURKSTAT for Turkey and Izmir for the periods 2001–2008 and 2009–2013 were assessed in terms of the following dimensions that represent quality of mortality statistics (a. completeness of death registration, b. trends in proportions of deaths with ill-defined causes). Secondly, the quality of information recorded on individual death certificates from Izmir in 2010 was analysed for a. missing information, b. timeliness of death notifications and c. characteristics of deaths with ill-defined causes. Finally, TURKSTAT data were analysed to estimate life tables and summary mortality indicators for Turkey and Izmir, as well as the leading causes-of-death in Turkey in 2013.ResultsRegistration of adult deaths in Izmir as well as at the national level for Turkey has considerably improved since the introduction of reforms in 2009, along with marked decline in the proportions of deaths assigned ill-defined causes. Death certificates from Izmir indicated significant gaps in recorded information for demographic as well as epidemiological variables, particularly for infant deaths, and in the detailed recording of causes of death. Life expectancy at birth estimated from local data is 3–4 years higher than similar estimates for Turkey from international studies, and this requires further investigation and confirmation.ConclusionThe TURKSTAT-DRS is now an improved source of mortality and cause of death statistics for Turkey. The reliability and validity of TURKSTAT data needs to be established through a detailed research program to evaluate completeness of death registration and validity of registered causes of death. Similar evaluation and data analysis of mortality indicators is required at regular intervals at national and sub-national level, to increase confidence in their utility as primary data for epidemiology and health policy.