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Inicio Atención Primaria Commentary: Giving Fish and Teaching How to Fish. So Much Work, Oh Mother!
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Vol. 36. Issue 2.
Pages 69-70 (June 2005)
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Commentary: Giving Fish and Teaching How to Fish. So Much Work, Oh Mother!
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J.. Brasa
a Pediatra de Atenci??n Primaria, Centro de Salud de Poblenou, Barcelona, Spain.
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C Tapia Collados, V Gil Guillén, D Orozco Beltrán
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The public health is stressed, first and foremost due to underfunding. It is provided with a percentage of GDP lower than surrounding countries and it is expected to cover all demands, without limits. Including those of all the Europeans whose demands were rejected in their country of origin, with a higher GDP and a higher percentage of the GDP destined for health. And they are settled here.

And here comes the terrible classical binomial, underfunding versus over demand: queues for everything...from the telephone queue to ask for a visit, the queues in the waiting rooms, the delays in gaining access to the primary care team, the chronic abuses with long queues in casualties, unsustainable delays in seeing some specialists or some diagnostic techniques, which generate more ineffective visits which overload the doctor or the paediatrician, etc.

In view of this, studies emerge to try to reduce the queues. And they look for the factors which cause them, which are, obviously, numerous and varied. Some factors, minor ones, are somewhat vulnerable to change by the actions of the professionals, but others, the major ones, are not so, being due to structural or external factors "off scene."

In the profile of the use of health services, particularly in the case of paediatrics, many determining factors are found to be involved.1-3

If we look at both sides of the table, one has to distinguish between the determining factors pertaining to the user and those of the health professional.

Among the factors of the user we will distinguish several individual ones, such as clinical vulnerability (atopics, intolerants, hyperkinetics, hypoimmunes, chronics), age (hyperinfectivity, common at nursery age), or level of health education; as, for example, assistance is normally demanded for symptoms of discomfort, but almost never for prevention or education (healthy users as well as chronic patients). Almost always the demand due to problems is predominant in the health visit.

Other factors will depend on the family group4,5 such as, for example, the order in the number of children. The insecurities are greater with the first child, which is significant in a society with a predominance of anxious parents with only one child. The stability or anxiety of the mothers also is important, due to the frustration of their childhood feminine expectations (the little housewife) compared to the reality of worker + mother + child minder + household manager,6 often not complemented by the level of paternal dedication. And to this very generalised data, might be added the specific maternal illnesses.

It also depends on the degree of availability of particular support, babysitters or grandparents, which can be aggravated in single parent situations: here the appearance of febrile episodes will cause distress and social urgencies especially at nursery age.

The degree of stability and social support (especially during the first period, in the case of migration) is another element which determines possible maternal insecurity: cultural migration will added insecurities specific to family separation and the lack of social benefits.

In the case of an asymmetric relationship, as happens in a medical or paediatric clinic, the level of recognising and accepting the cognitive messages transmitted in the clinic (diets, prescriptions, advice) will vary depending on the emotional manner of its transmission (distant tone, objective, imperative, authoritarian, excluded or snubbed by the doctors or nurses).

Some very widespread phobias (fever-phobia, mucous-phobia, nutrition-phobia, etc) are of cultural environment origin, obviously multifactorial, but not always associated with maternal problems.7 In fact, there are several factors involved which might bring them on.

If we focus on the other side of the table, we will see some factors which depend on the health professional. Some will be individual and common to the paediatrician paediatric nurse, such as the erroneous and excessive application of some preventive programmes which generate over use by the patients.

Some insecure, stressed attitudes, with compulsive prescribing, often associated with a lack of dedication to education in self-help, can also generate over use (they consist of clear examples of the over prescribing of mucolytics, anti-diarrhoea drugs, or orexogenics which, without improving the clinical situation, facilitate over use).

On occasions, the over use by the patient simulates confidence and complicity with the health professional...until this manages to contain the banality and insecurity of the visits.

The personal experience of fatherhood/motherhood can provide a better understanding, a capacity to manage and empathise with the father/mother users.

Other determinants arise from the welfare environment, such as lack of time for decent care (here, we believe that the 10 minute campaign puts salt on the wound), the lack of objective regulators of the visit (price, ticket, etc), and the absence of clear clinic times, which can alleviate the urgency8 of many visits. The irregular distribution of workload in a team can be conducive to the contrived generation of compensatory over use.

Another distorting element is the transference of the distress and insecurity, either actively, due to the personality of the health professional, or passively (robot-like and emotionally disconnected) due to the overload of the service becoming chronic.

To this, is added the overload due to administrative visits (documents, certificates, prescriptions, etc) with no care justification.

Another element lies in the health culture of the health professionals: paediatric training, still not sufficiently widespread in the primary care scene, can give, especially in the younger professionals, an inadequate vision of care, which consists of the need for objectivity and high precision diagnosis in view of the demands, often confused, inexact and loaded with clear anxious projection. The scientific interest for the diagnosis does not improve the picture and the demands are repeated until the underlying insecurity is rectified.

Besides the multifactorial framework outlined up until now, it is true that some patients have abnormally repetitive or over user behaviour. In the interesting article which is included in this issue, this problem is seriously and methodologically reviewed, and it puts forward an interpretation and a proposed solution which well deserves to be discussed widely within primary care teams.

As in the joke about boats, in which everything was organised and only one person was rowing, we could conclude...that the rower has to row better and stronger. But over use is a sufficiently serious and chronic problem and at least countrywide, thus we should think about it from multiple approaches.

Bibliography
[1]
Variations in utilization of health services by children. Pediatrics. 1979;63:633-41.
[2]
An??lisis de la relaci??n entre morbilidad y nivel de demanda en atenci??n primaria pedi??trica. Un estudio sobre 1.359 ni??os. An Esp Pediatr. 1998;49:273-9.
[3]
??Es necesario que algunos pacientes nos visiten tan a menudo?: factores asociados con la utilizaci??n en pediatr??a de atenci??n primaria. Gac Sanit. 2000;14: 195-202.
[4]
Determinantes del uso de las consultas de pediatr??a: estudio de morbilidad infantil y variables maternas. Aten Primaria. 1999;23:132-6.
[5]
Factores familiares y nivel de demanda en atenci??n primaria pedi??trica. Rev Esp Pediatr. 1998;54:497-505.
[6]
Hiperfrecuentaci??n en las consultas: ??hay relaci??n con la personalidad de la madre? An Esp Pediatr. 2003;58:29-33.
[7]
Cultura sanitaria materna y utilizaci??n pedi??trica en atenci??n primaria. Aten Primaria. 1992;10:591-7.
[8]
Frecuentaci??n a los servicios de urgencias hospitalarios: relaci??n con la utilizaci??n de la atenci??n primaria en una poblaci??n pedi??trica. An Esp Pediatr. 1996;44:105-8.
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