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This paper reports the findings of a scoping review on the organisation and delivery of health improvement activities in general practice and the primary healthcare team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices and how individual practices and the primary healthcare team organise such public health activities and how these contribute to health improvement. Our focus was on health promotion and prevention activities and aimed to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary healthcare team. Many of the research studies reviewed had some details about the type, process, location or who provided the intervention. Little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches with practices engaging in both primary and secondary prevention. Although many GPs do not take a population approach and focus on individual patients some do see health promotion as an integral part of practice – whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Based on our analysis we conclude that there is insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care. [ABSTRACT FROM PUBLISHER]

Aim: The aim of this paper is to introduce the experience of applying public–private partnership (PPP) in providing primary health care (PHC) in East Azerbaijan Province (EAP), Iran. Background: Moving toward the Universal Health Coverage (UHC) involves using of all health-related resources. Certainly, one of the key strategies for achieving UHC is PPP. Since 2015, a PPP in PHC policy has begun in EAP as a major strategy for strengthening the health system and achieving UHC. Methods: In this case study, data were collected through interviews with stakeholders, document analysis, reviewing of health indexes and published studies. The data were analyzed using content analysis. Finding: PPP in PHC policy was designed and implemented in EAP with the aim of social justice, strengthening the health system and achieving UHC in the framework of health complexes (HCs). HCs provide a defined service package according to the contract. The reimbursement method is a combination of per capita, fee for services and bonus methods. Part of the payments is fixed and the other part is based on the pay for quality system and paid according to the results of monitoring and evaluation. According to the study results, the most important strength of the plan is to improve access to services, especially in marginalized areas. The main weakness is not providing infrastructures before the implementation of the plan, and the most important challenges are financial, political and organizational unsustainability and, sometimes, poor cooperation by the other organizations. The findings show that PPP in PHC in EAP is an effective strategy to provide social justice, implement family practice and achieve UHC. [ABSTRACT FROM AUTHOR]

This paper illustrates the development of Primary Health Care (PHC) public sector in Malaysia, through a series of health reforms in addressing equitable access. Malaysia was a signatory to the Alma Ata Declaration in 1978. The opportunity provided the impetus to expand the Rural Health Services of the 1960s, guided by the principles of PHC which attempts to address the urban–rural divide to improve equity and accessibility. The review was made through several collation of literature searches from published and unpublished research papers, the Ministry of Health annual reports, the 5-year Malaysia Plans, National Statistics Department, on health systems programme and infrastructure developments in Malaysia. The Public Primary Care Health System has evolved progressively through five phases of organisational reforms and physical restructuring. It responded to growing needs over a 40-year period since the Alma Ata Declaration in 1978, keeping equity, accessibility, efficiency and universal health coverage consistently in the backdrop. There were improvements of maternal, infant mortality rates as well as accessibility to health services for the population. The PHC Reforms in Malaysia are the result of structured and strategic investment. However, there will be continuing dilemma between cost-effectiveness and equity. Hence, continuous efforts are required to look at opportunity costs of alternative strategies to provide the best available solution given the available resources and capacities. While recognising that health systems development is complex with several layers and influencing factors, this paper focuses on a small but crucial aspect that occupies much time and energies of front-line managers in the health. [ABSTRACT FROM AUTHOR]

The Covid-19 pandemic has put policy systems to the test. In this paper, we unmask the institutionalized resilience of the Dutch health care system to pandemic crisis. Building on logics of crisis decision-making and on the notion of 'tact', we reveal how the Dutch government initially succeeded in orchestrating collective action through aligning public health purposes and installing socio-economic policies to soften societal impact. However, when the crisis evolved into a more enduring one, a more contested policy arena emerged in which decision-makers had a hard time composing and defending a united decision-making strategy. Measures have become increasingly debated on all policy levels as well as among experts, and conflicts are widely covered in the Dutch media. With the 2021 elections ahead, this means an additional test of the resilience of the Dutch socio-political and health care systems. [ABSTRACT FROM AUTHOR]

Background: Historically transgender adults have experienced barriers in accessing primary care services. In Ontario, Canada, health care for transgender adults is accessed through primary care; however, a limited number of practitioners provide care, and patients are often waiting and/or traveling great distances to receive care. The purpose of this protocol is to understand how primary care is implemented and delivered for transgender adults. The paper presents how the case study method can be applied to explore implementation of health services delivery for the transgender population in primary care. Methods: Case study methodology will be used to explore this phenomenon in different primary care contexts. Normalization Process Theory is used as a guide. Three cases known to provide transgender primary care and represent different Ontario primary care models have been identified. Comparing transgender care implementation and delivery across different models is vital to understanding how care provision to this population can be supported. Qualitative interviews will be conducted. Participants will also complete the NoMAD (NOrmalization MeAsure Development) survey, a tool measuring implementation processes. The tool will be modified to explore the implementation of primary care services for transgender individuals. Documentary evidence will be collected. Cross-case synthesis will be completed to compare the cases. Discussion: Findings will provide an Ontario perspective on the implementation and delivery of primary care for transgender adults in different primary care models. Results may be applicable to other primary care settings in Canada and other nations with similar systems. Barriers and facilitators in delivery and implementation will be identified. Providing an understanding and increasing awareness of the implementation and delivery of primary care may help to reduce the invisibility and disparities transgender individuals experience when accessing primary care services. Understanding delivery of care could allow care providers to implement primary care services for transgender individuals, improving access to health care for this vulnerable population. [ABSTRACT FROM AUTHOR]

Background: Nurses have the potential to make a real impact on the health and well-being of people and populations and contribute to the realisation of delivery of Universal Health Coverage. However, in many parts of the world, the education and practice of nursing and nurses' position in health care and society are restricted by a range of social, cultural, economic and political factors. In North Macedonia, the Ministry of Health in partnership with the WHO Country Office launched a primary healthcare strategy supporting the development of nurses in primary care to fulfil their full scope of service. Aims: To present information on the education, practice and position of nursing, in particular primary care nursing, in North Macedonia and to describe the ongoing initiatives to support the further development of nursing. Approach: Background documents reviewed, and visits to healthcare settings, organisations, interviews with individuals and groups and workshops undertaken in 2019–2020. Findings: Three key areas of development were identified: education of nurses, their service delivery and practice in primary care, and their position in health care and society, all underpinned by the need for workforce planning. The findings formed the basis of a 10-year plan: Making Change Happen: The Nursing and Midwifery Development Roadmap. Developments: To support the proposed primary care pilots, during the 2020/2021 COVID-19 pandemic, an on-line modular programme for primary care nurses was developed and delivered with the support of members drawn from The National Working Group for Moving Primary Care Nursing Forward in North Macedonia. Further work is planned to develop initial nurse education and to pilot changes in primary care. Conclusions: The launch of the primary healthcare strategy stimulated initiatives to improve the education, position and practice of primary care nursing. The COVID-19 pandemic required flexibility and changes to the original plans. [ABSTRACT FROM AUTHOR]

The objective of the paper is to estimate the number of patients presenting with chest pain suspected of acute coronary syndrome (ACS) in primary care and to calculate possible cost effects of a future clinical decision rule (CDR) incorporating a point-of-care test (PoCT) as compared with current practice. The annual incidence of chest pain, referrals and ACS in primary care was estimated based on a literature review and on a Dutch and Belgian registration study. A health economic model was developed to calculate the potential impact of a future CDR on costs and effects (ie, correct referral decisions), in several scenarios with varying correct referral decisions. One-way, two-way, and probabilistic sensitivity analyses were performed to test robustness of the model outcome to changes in input parameters. Annually, over one million patient contacts in primary care in the Netherlands concern chest pain. Currently, referral of eventual ACS negative patients (false positives, FPs) is estimated to cost €1,448 per FP patient, with total annual cost exceeding 165 million Euros in the Netherlands. Based on ‘international data’, at least a 29% reduction in FPs is required for the addition of a PoCT as part of a CDR to become cost-saving, and an additional €16 per chest pain patient (ie, 16.4 million Euros annually in the Netherlands) is saved for every further 10% relative decrease in FPs. Sensitivity analyses revealed that the model outcome was robust to changes in model inputs, with costs outcomes mainly driven by costs of FPs and costs of PoCT. If PoCT-aided triage of patients with chest pain in primary care could improve exclusion of ACS, this CDR could lead to a considerable reduction in annual healthcare costs as compared with current practice. [ABSTRACT FROM PUBLISHER]

Objective: To describe the time trends and socio-economic inequalities in infant and young child feeding practices in accordance with the Brazilian deprivation index (BDI). Design: This time-series study analysed the prevalence of multiple breast-feeding and complementary feeding indicators based on data from the Brazilian Food and Nutrition Surveillance System, 2008–2019. Prais–Winsten regression models were used to analyse time trends. Annual percent change (APC) and 95 % CI were calculated. Setting: Primary health care services, Brazil. Participants: Totally, 911 735 Brazilian children under 2 years old. Results: Breast-feeding and complementary feeding practices differed between the extreme BDI quintiles. Overall, the results were more favourable in the municipalities with less deprivation (Q1). Improvements in some complementary feeding indicators were observed over time and evidenced such disparities: minimum dietary diversity (Q1: Δ 47·8–52·2 %, APC + 1·44, P = 0·006), minimum acceptable diet (Q1: Δ 34·5–40·5 %, APC + 5·17, P = 0·004) and consumption of meat and/or eggs (Q1: Δ 59·7–80·3 %, APC + 6·26, P < 0·001; and Q5: Δ 65·7–70·7 %, APC + 2·20, P = 0·041). Stable trends in exclusive breast-feeding and decreasing trends in the consumption of sweetened drinks and ultra-processed foods were also observed regardless the level of the deprivation. Conclusions: Improvements in some complementary food indicators were observed over time. However, the improvements were not equally distributed among the BDI quintiles, with children from the municipalities with less deprivation benefiting the most. [ABSTRACT FROM AUTHOR]

Aim: This study piloted a digital self-help intervention facilitating healthy lifestyle for patients with mental health problems in primary care. Background: Patients with mental health problems show more unhealthy lifestyle behaviors than the general population and prior research indicates that healthy lifestyle behaviors can improve mental health. Methods: This pilot study assessed use of a self-help digital intervention for healthy lifestyle promotion and included an embedded randomized recruitment trial, where all patients were randomized to digital self-help plus treatment as usual (TAU) or to TAU only. Patients seeking help for mental health problems were recruited from two primary care clinics in Stockholm, Sweden, and offered participation in a healthy lifestyle promotion study via digital self-help. Outcome measures included use-related assessment of inclusion and follow-up rates at both clinics, participant characteristics, and intervention adherence. Secondary outcomes included depression (the Patient Health Questionnaire-9) and anxiety (the GAD-7) up to 10 weeks, and changes in alcohol and tobacco use, physical activity, and diet. Results: The study included 152 patients. The recruitment rate, initially low, increased after involving the clinicians more and maintaining more frequent contact with the patients. The 10-week missing data rate was 33/152 (22%). Participants were 70% (106/152) women, with a mean age of 42 years (SD = 14); fewer than half (38%, n = 58/152) had one or more high-risk unhealthy behaviors at inclusion. Psychiatric symptoms were moderate at baseline and declined in both groups after 10 weeks (d = 0.57–0.75). No between-group effects over time occurred on depression (b = 0.3 [95% CI −1.6, 2.2]; d = 0.06), anxiety (b = −0.7 [−2.5, 1.2]; d = 0.13), or lifestyle behaviors (b = 0.01 [−0.3, 0,3]; d = −0.01). Conclusions: Recruitment routines seemed to be decisive for reaching as many patients as possible. The relatively low rate of unhealthy lifestyle behaviors and small effect sizes suggests that the intervention may only suit patients at risk. Trial registration: ClinicalTrials.gov NCT03691116 (01/10/2018), focusing on the embedded trial. Retrospectively registered for the first clinic and prospectively for the second clinic. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to identify key policy objectives by investigating the perception of important stakeholders and affected professionals concerning relevance and feasibility of a successful primary care (PC) reform. Background: Since 2013, the Austrian PC system has been undergoing a reform process to establish multiprofessional primary care units. The reforms have various defined objectives and lack clear priorities. Methods: After the definition and consensus-based selection of 12 policy objectives, a cross-sectional online survey on their relevance and feasibility was distributed via email and social media to PC and public health networks. The survey was conducted in the period from January to February 2020. Results were analyzed descriptively, and further, Pearson Chi-Square Test or Fisher's Exact Test was performed for group comparison regarding respondents' characteristics. Open-ended responses were analyzed using qualitative content analysis. Findings: In total, 169 questionnaires were completed. A total of 46.3% of the responders had more than 20 years of professional experience (female: 60.5%). A mandatory internship in general practice, vocational training for general practice, and a modern remuneration system were the three top-rated policy objectives regarding relevance. A mandatory internship in general practice, specialization in general practice, and coding of services and diagnosis were assessed as the most feasible objectives. The group comparisons regarding working field, years of professional experience, age, and sex did not show any meaningful results in the evaluation of relevance and feasibility. Discussion: In the view of the study participants, easily obtainable objectives include adapting the duration and setting of internships for medical students, as well as mandatory vocational training for GP trainees. Further efforts are necessary to achieve complex objectives such as the adoption of a modern remuneration scheme and a comprehensive quality assurance program. Building capacity and creating team-oriented environments are also important aspects of a successful PC reform. [ABSTRACT FROM AUTHOR]

Aim: To explore how primary healthcare professionals (HCPs) tasked with facilitating primary healthcare service development with patient participation perceived their role. Introduction: Patient participation in health service development is a recognized means of ensuring that health services fit the public's needs. However, HCPs are often uncertain about how to involve patient representatives (PRs), and patient participation is poorly implemented. Inspired by the Promoting Action on Research Implementation in Health Services framework, we address the innovation (patient participation), its recipients (PRs, HCPs, supervisors, and senior managers), and its context (primary healthcare at a local and organizational level). Methods: We conducted semi-structured individual interviews with six HCPs working as internal facilitators in primary healthcare in four Norwegian municipalities. The data were analyzed by applying Braun and Clarke's reflexive thematic analysis. Findings: The themes show that to develop primary healthcare services with patient participation, facilitators must establish a network of PRs with relevant skills, promote involvement within their organization, engage HCPs favorable toward patient participation, and demonstrate to supervisors and senior managers its usefulness to win their support. Implementing patient participation must be a shared, collective responsibility of facilitators, supervisors, and senior management. However, supervisors and senior management appear not to fully understand the potential of involvement or how to support the facilitators. The facilitator role requires continuous and systematic work on multiple organizational levels to enable the development of health services with patient participation. It entails maintaining a network of persons with experiential knowledge, engaging HCPs, and having senior management's understanding and support. [ABSTRACT FROM AUTHOR]

Aim: To describe variation in task shifting from GPs to practice assistants/nurses in 34 countries and to explain differences by analysing associations with characteristics of the GPs and their practices and features of the health care systems. Background: Redistribution of tasks and responsibilities in primary care are driven by changes in demand, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill-mix of primary care teams. These developments are hampered by barriers between professional domains. Methods: Data were collected between 2011 and 2013 through a cross-sectional survey among approximately 7,200 general practitioners (GPs) in 34 countries. Task shifting is measured through a composite score of GPs' self-reported shifting of tasks. Independent variables at GP and practice level are as follows: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are as follows: demand for and supply of care, nurse prescribing, and professionalisation of practice assistants/nurses. Multilevel analysis is used to account for clustering of GPs in countries. Findings: Countries vary in the degree of task shifting. Regarding GP and practice characteristics, use of electronic health records and availability of support staff in the practice are positively associated with task shifting and GPs' working hours negatively, in line with our hypotheses. Age of the GPs is, contrary to our hypothesis, positively related to task shifting. These variables explain 11% of the variance at GP level. Two country variables are related to task shifting: a lower percentage of practices without support staff in a country and nurse prescribing rights coincide with more task shifting. The percentage of practices without support staff has the strongest relationship, explaining 73% of the country variation. [ABSTRACT FROM AUTHOR]

Introduction: The coronavirus (COVID-19) pandemic has impacted healthcare worldwide. It has altered service delivery and posed challenges to practitioners in relation to workload, well-being and support. Within primary care, changes in physicians' activities have been identified and innovative work solutions implemented. However, evidence is lacking regarding the impact of the pandemic on pharmacy personnel who work in primary care. Aim: To explore the impact of the pandemic on the working practice (including the type of services provided) and job satisfaction of pharmacists and pharmacy technicians within Scottish general practice. Due to the stressful nature of the pandemic, we hypothesise that job satisfaction will have been negatively affected. Methods: An online questionnaire was distributed in May–July 2021, approximately 15 months since initial lockdown measures in the UK. The questionnaire was informed by previous literature and underwent expert review and piloting. Analysis involved descriptive statistics, non-parametric statistical tests and thematic analysis. Results: 180 participants responded (approximated 16.1% response rate): 134 pharmacists (74.4%) and 46 technicians (25.6%). Responses indicated greater involvement with administrative tasks and a reduction in the provision of clinical services, which was negatively perceived by pharmacists. There was an increase in remote working, although most participants continued to have a physical presence within general practices. Face-to-face interactions with patients reduced, which was negatively perceived by participants, and telephone consults were considered efficient yet less effective. Professional development activities were challenged by increased workloads and reduced support available. Although workplace stress was apparent, there was no indication of widespread job dissatisfaction. Conclusion: The pandemic has impacted pharmacists and technicians, but it is unknown if changes will be permanent, and there is a need to understand which changes should continue. Future research should explore the impact of altered service delivery, including remote working, on patient care. [ABSTRACT FROM AUTHOR]

Background: The COronaVIrus Disease 2019 (COVID-19) pandemic has led to significant re-organisation of general practice in the United Kingdom and around the world. The general practice workforce has led changes to their services, often dealing with high levels of uncertainty. The way in which many practitioners consult has shifted significantly, and there has been an increase in the number of phone and online consultations. We know very little about how those working in general practice experienced the service reorganisation introduced in the first year of the COVID-19 pandemic. Aim: The aim of this project was to describe the changes in the delivery of general practice in the United Kingdom in the first year of the COVID-19 pandemic. Furthermore, to explore primary care practitioners' and managers' experiences of change within general practice during this time and investigate shifts in perceptions of professional identities. Method: We conducted a longitudinal qualitative study that captured narrative accounts from 17 primary care practitioners and managers across England and Scotland. Each participant submitted narrative accounts in the first year of the COVID-19 pandemic using self-recorded or written contributions, or via an interview if preferred. These were analysed using a grounded theory approach, with thematic coding used to construct common themes. Findings: Participants' narratives describe the challenges COVID-19 presented to general practice. Responses mirror the shifts in the pandemic and its management – from an initial sense of autonomy but uncertainty, to a period of stability and patients' increasing frustration. The re-organisation of general practice has affected practitioners' views of their work and their role as clinicians. Participants' narratives were framed profoundly by the importance of their relationships with patients. This analysis of practitioners' and managers' narratives highlights the need for further exploration of how to support the general practice workforce's well-being longer term in a context of increased demand and significant change. [ABSTRACT FROM AUTHOR]

Aim: To inform the primary care community about priorities for research in primary care as came up from the European project TO-REACH and to discuss transferability of service and policy innovations between countries. Background: TO-REACH stands for Transfer of Organizational innovations for Resilient, Effective, equitable, Accessible, sustainable and Comprehensive Health services and systems. This EU-funded project has put health systems and services research higher on the European agenda and has led to the current development of a European 'Partnership Transforming Health and Care Systems'. Methods: To identify research priorities, both qualitative and quantitative approaches were used. Policy documents and strategic roadmaps were searched, and priorities were mapped. Stakeholders were involved through national roundtable consultations and online consultations. Regarding transferability, we carried out a review of the literature, guided by a conceptual framework, and using a snowballing approach. Findings: Primary care emerged as an important priority from the inventory, as are areas that are conducive to strengthening primary care, such as workforce policies. The large variation in service organisation and policy around primary care in Europe is a huge potential for cross-country learning. However, the simple transfer of primary care service and policy arrangements from one health system to another has a big chance to fail, unless known conditions for successful transfer are taken into account and gaps in our knowledge about transfer are resolved. [ABSTRACT FROM AUTHOR]

This study focuses on the role of primary care in China's response to COVID-19. A retrospective, reflective approach was taken using data available to one of the authors who led the national community response to COVID-19, first in Wuhan and then multiple cities in ten provinces/municipalities across the country. At the peak of the pandemic, primary care providers shoulder various public health responsibilities and work in close partnerships with other key stakeholders in the local communities. Primary care providers keep playing a 'sentinel'/surveillance role in identifying re-emerging cases after the elimination of community transmissions of COVID-19. Critically, however, the pandemic once again highlights some key limitations of the primary care sector, including the lack of gatekeeping, limited capacity and weak integration between medical care and public health. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to assess the health outcome of four epidemic-prone infectious diseases, in the context of a Primary Health Care project implemented in a protracted refugee setting along the Thai–Myanmar border. Background: Refugees settled at the Thai–Myanmar border are fully dependent on support for health services, shelter, food, education, water, and sanitation. The Non-Governmental Organization Malteser International developed an integrated Primary Health Care program in close cooperation with trained camp residents over 25 years in the two settlements under its supervision. The project has been funded by the European Commission Civil Protection and Humanitarian Aid Operations (DG ECHO). Methods: This was a retrospective primary health care project evaluation. All-cause mortality; morbidity trends in malaria, lower respiratory tract infections (LRTIs), watery diarrhea, and dysentery; and health service utilization covering a time span of 18 years were assessed. Programmatic changes in the Primary Health Care (PHC) project and events with a potential effect on health of the target population were examined. Findings: Despite the continuous drain of trained health care workers, the volatile influx of refugees, and the isolated location of the two camps, the initial basic curative health care developed into an integrated and comprehensive PHC project including a SPHERE-compliant water, sanitation, and hygiene program. Malaria, LRTIs, watery diarrhea, and dysentery morbidity dropped twelve, three, two, and fivefold, respectively, over the 18-year period evaluated while the health services utilization dropped from 7.1 to 2.9 consultations per refugee/year. The international community may face situations where integration of refugees into the health services of the host country is not possible. In such a context, integrated and evidence-based PHC adequately funded and implemented by one health agency is an effective and relevant approach to reduce the infectious diseases burden under the constraints of semipermanent living conditions. [ABSTRACT FROM AUTHOR]

Mobile Health (mHealth) interventions have received a mix of praise and excitement, as well as caution and even opposition over recent decades. While the rapid adoption of mHealth solutions due to the COVID-19 pandemic has weakened resistance to integrating these digital approaches into practice and generated renewed interest, the increased reliance on mHealth signals a need for optimizing development and implementation. Despite an historically innovation-resistant medical ethos, mHealth is becoming a normalized supplement to clinical practice, highlighting increased demand. Reaching the full potential of mHealth requires new thinking and investment. The current challenge to broaden mHealth adoption and to ensure equity in access may be overcoming a "design purgatory," where innovation fails to connect to practice. We recommend leveraging the opportunity presented by the COVID-19 pandemic to disrupt routine practice and with a new focus on theory-driven replicability of mHealth tools and strategies aimed at medical education and professional organizations. [ABSTRACT FROM AUTHOR]

Background: Changes to the general practice (GP) contract in England (April 2019) introduced a new quality improvement (QI) domain. The clinical microsystems programme is an approach to QI with limited evidence in primary care. Aim: To explore experiences of GP staff participating in a clinical microsystems programme. Design and setting: GPs within one clinical commissioning group (CCG) in South East England. Normalisation process theory informed qualitative approach. Method: Review of all CCG clinical microsystems projects using pre-existing data. The Diffusion of Innovation Cycle was used to inform the sampling frame and GPs were invited to participate in interviews or focus groups. Ten practices participated; 11 coaches and 16 staff were interviewed. Results: The majority of projects were process-driven activities related to administrative systems. Projects directly related to health outputs were fewer and related to externally imposed targets. Four key elements facilitated practices to engage: feeling in control; receiving enhanced service payment; having a senior staff member championing the approach; and good practice–coach relationship. There appeared to be three key benefits in addition to project-specific ones: improved working relationships between CCG and practice; more cohesive practice team; and time to reflect. Conclusion: Small projects with clear parameters were more successful than larger ones or those spanning organisations. However, there was little evidence suggesting the key benefits were unique attributes of the microsystems approach and sustainability was problematic. Future research should focus on cross-organisational approaches to QI and identify what, if any, added value the approach provides. [ABSTRACT FROM AUTHOR]

Background: Cancer is the second leading cause of death worldwide. Lifestyle choices play an important role in the aetiology of cancer with up to 4 in 10 cases potentially preventable. Interventions delivered by healthcare professionals (HCPs) that incorporate risk information have the potential to promote behaviour change. Our aim was to develop a very brief intervention incorporating cancer risk, which could be implemented within primary care. Methods: Guided by normalisation process theory (NPT), we developed a prototype intervention using literature reviews, consultation with patient and public representatives and pilot work with patients and HCPs. We conducted focus groups and interviews with 65 HCPs involved in delivering prevention activities. Findings were used to refine the intervention before 22 HCPs completed an online usability test and provided further feedback via a questionnaire incorporating a modified version of the NoMAD checklist. Results: The intervention included a website where individuals could provide information on lifestyle risk factors view their estimated 10-year risk of developing one or more of the five most common preventable cancers and access lifestyle advice incorporating behaviour change techniques. Changes incorporated from feedback from the focus groups and interviews included signposting to local services and websites, simplified wording and labelling of risk information. In the usability testing, all participants felt it would be easy to collect the risk information. Ninety-one percent felt the intervention would enable discussion about cancer risk and believed it had potential to be easily integrated into National Health Service (NHS) Health Checks. However, only 36% agreed it could be delivered within 5 min. Conclusions: With the use of NPT, we developed a very brief intervention that is acceptable to HCPs in primary care and could be potentially integrated into NHS Health Checks. However, further work is needed to assess its feasibility and potential effectiveness. [ABSTRACT FROM AUTHOR]

Background: This study aimed to develop and test the feasibility of a primary care worker-led psychological intervention as the main feature of a collaborative stepped care for depression that is effective, affordable, culturally acceptable, tailored to patients' clinical condition and easily integrate-able into the primary care schedule in Nigeria. Methods: Using the Medical Research Council framework, in the first stage (modelling/theoretical development), experts reviewed and distilled evidence from literature to form the intervention components. In the second (formative) stage, local stakeholders were consulted on the practical application and feasibility of the proposed intervention. The third (piloting) stage involved testing for the clinical efficacy and acceptability of the components of the draft intervention Results: The final intervention components included a 2-stage screening (red-flagging and further evaluation), psychoeducation, low-intensity psychological therapy (problem-solving therapy for primary care), antidepressant prescription, proactive mobile telephony adherence support and referral to the mental health specialist if needed. At 3 months, 71.6% of depressed patients on the intervention improved. The intervention was perceived to be acceptable and useful by over 70% of health workers and clients and had high ratings (>70% score) by expert panels on intervention simplicity, facilitation strategies, and quality of delivery. Conclusions: The development and feasibility testing of our integrated intervention encompassed review of current literature, expert opinions and consultation with local stakeholders and end users. Our intervention package was largely deemed acceptable, relevant, useful, and feasible. Important lessons learnt with this process will help in future intervention developments. [ABSTRACT FROM AUTHOR]

Background: Various organizational-level attributes are being implemented in primary healthcare to improve healthcare delivery. There is a need to describe the distribution and nature of these attributes and explore differences across practices. Aim: The aim of this study was to better understand organizational attributes of primary care teams, focusing specifically on team composition, nursing roles, and strategies that support chronic disease management. Methods: We employed a cross-sectional survey design. Team composition, nursing roles, availability of health services, and chronic disease management activities were described using the 'Measuring Organizational Attributes of Primary Health Care Survey.' Findings: A total of 76% (n =26 out of 34) of practice locations completed the survey, including family health teams (FHT; n =21) and community health centers (CHC; n =4). Nurse practitioners (NPs) and registered nurses (RNs) were the most common non-physician providers, and CHCs had a greater proportion of non-physician providers than FHTs. There was overlap in roles performed by NPs and RNs, and registered practical nurses engaged in fewer roles compared with NPs and RNs. A greater proportion of FHTs had systematic chronic disease management services for hypertension, depression and Alzheimer's disease compared with CHC practices. The 'Measuring Organizational Attributes of Primary Health Care Survey' was a useful tool to highlight variability in organizational attributes across PHC practices. Nurses are prominent within PHC practices, engaging in a wide range of roles related to chronic disease management, suggesting a need to better understand their contributions to patient care to optimize their roles. [ABSTRACT FROM AUTHOR]

Aim: To compare the impact of three different approaches to primary care mental health on the prevalence of mental disorders. Background: Millions of people suffer from mental disorders. As entry point into the health service, primary healthcare plays an important role in providing mental health prevention and treatment. Methods: Random sample of households in three different areas of the city of Ribeirão Preto (state of São Paulo, Brazil) were selected, and 20 trained medical students conducted interviews using a mental health screening instrument, the Mini-Screening of Mental Disorders, and a socio-demographic datasheet. Primary care mental health was provided in each area through a specific approach. The influence of the area of residence and the socio-demographic variables on the prevalence of mental disorder was explored and analyzed by univariate binary logistic regression and then by a multiple logistic regression model. Findings: A total of 1545 subjects were interviewed. Comparison between the three areas showed a significantly higher number of people with mental disorders in the area covered by the primary care team that did not have physicians with specific primary care mental health training, even when this association was adjusted for the influence of age, education, and socio-economic status. Our results suggest that residing in areas with family physicians with mental health training is associated with a lower prevalence of mental disorders. [ABSTRACT FROM AUTHOR]

Aim: We sought to examine strength of primary care service delivery as measured by selected process indicators by general practitioners from 31 European countries plus Australia, Canada, and New Zealand. We explored the relation between strength of service delivery and healthcare expenditures. Background: The strength of a country’s primary care is determined by the degree of development of a combination of core primary care dimensions in the context of its healthcare system. This study analyses the strength of service delivery in primary care as measured through process indicators in 31 European countries plus Australia, New Zealand, and Canada. Methods: A comparative cross-sectional study design was applied using the QUALICOPC GP database. Data on the strength of primary healthcare were collected using a standardized GP questionnaire, which included 60 questions divided into 10 dimensions related to process, structure, and outcomes. A total of 6734 general practitioners participated. Data on healthcare expenditure were obtained from World Bank statistics. We conducted a correlation analysis to analyse the relationship between strength and healthcare expenditures. Findings: Our findings show that the strength of service delivery parameters is less than optimal in some countries, and there are substantial variations among countries. Continuity and comprehensiveness of care are significantly positively related to national healthcare expenditures; however, coordination of care is not. [ABSTRACT FROM AUTHOR]

BackgroundPrimary care faces unprecedented challenges. A move towards a more comprehensive, multi-disciplinary service delivery model has been proposed as a means with which to secure more sustainable services for the future. One seemingly promising response has been the implementation of physiotherapy self-referral schemes, however there is a significant gap in the literature regarding implementation.AimThis evaluation aimed to explore how the professionals and practice staff involved in the delivery of an in-practice physiotherapy self-referral scheme understood the service, with a focus on perceptions of value, barriers and impact.Design and settingA qualitative evaluation was conducted across two UK city centre practices that had elected to participate in a pilot self-referral scheme offering ‘physiotherapy-as-a-first-point-of-contact’ for patients presenting with a musculoskeletal complaint.MethodsIndividual and focus group interviews were conducted amongst participating physiotherapists, administration/reception staff, general practitioners (GPs) and one practice nurse (in their capacity as practice partner). Interview data were collected from a total of 14 individuals. Data were analysed using thematic analysis.ResultsThree key themes were highlighted by this evaluation. First, the imperative of effecting a cultural change – including management of patient expectation with particular reference to the belief that GPs represented the ‘legitimate choice’, re-visioning contemporary primary care as a genuine team approach, and the physiotherapists’ reconceptualisation of their role and practices. Second, the impact of the service on working practice across all stakeholders – specifically re-distribution of work to ‘unburden’ the GP, and the critical role of administration staff. Finally, beliefs regarding the nature and benefits of physiotherapeutic musculoskeletal expertise – fears regarding physiotherapists’ ability to work autonomously or identify ‘red flags’ were unfounded.ConclusionThis qualitative evaluation draws on the themes to propose five key lessons which may be significant in predicting the success of implementing physiotherapy self-referral schemes. [ABSTRACT FROM PUBLISHER]

BackgroundAlthough considerable attention has been paid to the use of quantitative methods in health research, there has been limited focus on decentralisation research using a qualitative-driven mixed method design. Decentralisation presents both a problematic concept and methodological challenges, and is more context-specific and is often multi-dimensional. Researchers often consider using more than one method design when researching phenomena is complex in nature.AimTo explore the effects of decentralisation on the provision of primary healthcare services.MethodsQualitative-driven mixed method design, employing three methods of data collections: focus group discussions (FGDs), semi-structured interviews (SSIs) and participant observations under two components, that is, core component and supplementary components were used. Four FGDs with health service practitioners, three FGDs with district stakeholders, 20 SSIs with health service users and 20 SSIs with national stakeholders were carried out. These were conducted sequentially. NVivo10, a data management program, was utilised to code the field data, employing a content analysis method for searching the underlying themes or concepts in the text material.FindingsBoth positive and negative experiences related to access, quality, planning, supplies, coordination and supervision were identified.ConclusionThis study suggests some evidence of the effects of decentralisation on health outcomes in general, as well as filling a gap of understanding and examining healthcare through a qualitative-driven mixed methods approach, in particular. Future research in the area of qualitative in-depth understanding of the problems (why decentralisation, why now and what for) would provoke an important data set that benefits the researchers and policy-makers for planning and implementing effective health services. [ABSTRACT FROM PUBLISHER]

AimTo compare the characteristics of mental health and physical health participants attending an exercise referral scheme (ERS) and investigate associations with their adherence to exercise.BackgroundWhile people referred to an ERS with a mental health diagnosis have similar initial rates of uptake as physical health participants, they are more likely to drop out. Comparisons of the groups to understand their differences and how these might impact on their adherence have been limited by the typically low numbers of mental health referrals in many schemes.MethodsRetrospective analysis of a participant cohort. Data were extracted on all participants enrolled over a 12- month period (n = 701) and included measurements at baseline, mid-point (13 weeks) and end of programme (20-26 weeks). Differences were explored between the mental health (n=141) and physical health (n=560) subcohorts, and between adherers and non-adherers in each group. Binomial logistic regression estimated the effect of group-level factors associated with adherence.FindingsMental health referrals were more likely to be younger, White and unemployed, and had a lower mean body mass index and lower proportion of participants with high blood pressure. They were also more likely to drop out. While occupation was associated with exercise adherence among the physical health group, no predictive factors were identified in the mental health group.ConclusionParticipants referred for mental health disorders are more likely to drop out of exercise referral schemes than those with physical health problems. While no factors were found to be predictive of their exercise adherence, an understanding of their distinguishing characteristics and attendance behaviour can guide in making better referral decisions concerning them and planning more appropriately tailored support. [ABSTRACT FROM PUBLISHER]

BackgroundPulmonary rehabilitation (PR), a programme of exercise, education and psycho-social support, is recommended for patients with chronic obstructive pulmonary disease but referral rates are relatively low compared with need.AimWorking with primary care clinicians (GPs and practice nurses) from eight practices, this project developed strategies for influencing clinician and patient behaviours as a means of increasing referral rates for PR.MethodsA participatory action research design was employed. Semi-structured questionnaires captured clinicians’ baseline knowledge of PR and their ideas for increasing referrals. Actionable changes were then recommended. Audits (at baseline, mid-point and end of project) were used to assess and initiate improvements in the quality of practice data about PR referrals. The impacts of these changes were explored via further clinician surveys (free text questionnaire). Semi-structured questionnaires, posted to patients eligible for PR, assessed their characteristics, and, where applicable, their views on PR referral processes and reasons for not wanting PR.FindingsThe baseline survey of clinicians (n=22) revealed inadequate knowledge about PR, particularly among GPs. Actionable changes recommended included in-house education sessions, changes to practice protocols, and ‘pop-ups’ and memory aids (mugs and coasters) to prompt clinician/patient discussions about PR. Audit findings resulted in changes to improve the quality and availability of coded information about patients eligible for PR. These changes, supported by clinicians (n=9) in the follow-up survey, aimed to facilitate and increase the quality of patient/clinician discussions about PR. Findings from the patient survey (n=126, response rate 25.7%) indicate that such changes will increase the uptake of PR as patients who accepted a referral for PR provided more positive feedback about their discussions with clinicians.ConclusionsThe strategies introduced were relatively easy to implement and the anticipated advantage is more patients accessing the health and quality of life benefits that PR offers. [ABSTRACT FROM PUBLISHER]

Background: Mental health service delivery models that are grounded in the local context are needed to address the substantial treatment gap in low- and middle-income countries.Aims: To present the development, and content, of a mental healthcare plan (MHCP) in Nepal and assess initial feasibility.Method: A mixed methods formative study was conducted. Routine monitoring and evaluation data, including client flow and reports of satisfaction, were obtained from patients (n = 135) during the pilot-testing phase in two health facilities.Results: The resulting MHCP consists of 12 packages, divided over community, health facility and organisation platforms. Service implementation data support the real-life applicability of the MHCP, with reasonable treatment uptake. Key barriers were identified and addressed, namely dissatisfaction with privacy, perceived burden among health workers and high drop-out rates.Conclusions: The MHCP follows a collaborative care model encompassing community and primary healthcare interventions. [ABSTRACT FROM AUTHOR]

Background: The large treatment gap for mental disorders in India underlines the need for integration of mental health in primary care.Aims: To operationalise the delivery of the World Health Organization Mental Health Gap Action Plan interventions for priority mental disorders and to design an integrated mental healthcare plan (MHCP) comprising packages of care for primary healthcare in one district.Method: Mixed methods were used including theory of change workshops, qualitative research to develop the MHCP and piloting of specific packages of care in a single facility.Results: The MHCP comprises three enabling packages: programme management, capacity building and community mobilisation; and four service delivery packages: awareness for mental disorders, identification, treatment and recovery. Challenges were encountered in training primary care workers to improve identification and treatment.Conclusions: There are a number of challenges to integrating mental health into primary care, which can be addressed through the injection of new resources and collaborative care models. [ABSTRACT FROM AUTHOR]

Aim: The purpose of this study is to evaluate an educational programme, 'Diabetes Connect: Connecting Professions', which was developed to enhance communication across primary care networks, to support best practice in clinical interventions and progress multidisciplinary team work to benefit patients in diabetes care. Methods: A total of 26 workshops were successfully delivered for 309 primary care professionals across the state of Queensland in Australia from November 2011. It consists of two separate, but complementary training elements: a series of online clinical education training modules and state-wide interprofessional learning workshops developed to enhance professional competencies. The evaluation design included completion of online surveys by the participants at two time points: first upon registering for the online modules or workshops; second, one week after attending a workshop. The survey included questions to evaluate the change in role performance measures. Findings: Overall, significant increases in participants' current knowledge, perceived ability to adopt this knowledge at work and willingness to change professional behaviour in the short term were observed. Conclusion: The study suggests that for maximum benefit both, workshop and online training, should be combined and made available widely. Future programmes should use a randomised trial design to test the delivery model. [ABSTRACT FROM AUTHOR]