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Introduction: Noncommunicable diseases (NCDs) are associated with high and rising burden of morbidity and mortality in sub-Saharan Africa, including Nigeria. Diabetes mellitus (DM) is among the leading causes of NCD-related deaths worldwide and is a foremost public health problem in Nigeria. As part of National policy, Nigeria has committed to implement the World Health Organization (WHO) Package of Essential Non-communicable Disease interventions for primary care. Implementing the intervention requires the availability of essential elements, including guidelines, trained staff, health management information systems (HMIS), equipment, and medications, in primary healthcare centers (PHCs). This study assessed the availability of the DM component of the WHO package, and the readiness of the health workers in these PHCs to implement a DM screening, evaluation, and management program to inform future adoption and implementation. Methods: This cross-sectional formative assessment adapted the WHO Service Availability and Readiness Assessment (SARA) tool to survey 30 PHCs selected by multistage sampling for readiness to deliver DM diagnosis and care in Abuja, Nigeria, between August and October 2021. The SARA tool was adapted to focus on DM services and the availability and readiness indicator scores were calculated based on the proportion of PHCs with available DM care services, minimum staff requirement, diagnostic tests, equipment, medications, and national guidelines/protocols for DM care within the defined SARA domain. Results: All 30 PHCs reported the availability of at least two full-time staff (median [interquartile range] = 5 [4–9]), which were mostly community health extension workers (median [interquartile range]) = 3 [1–4]. At least one staff member was recently trained in DM care in 11 PHCs (36%). The study also reported high availability of paper-based HMIS (100%), and DM screening services using a glucometer (87%), but low availability of DM job aids (27%), treatment (23%), and national guidelines/protocols (0%). Conclusion: This formative assessment of PHCs' readiness to implement a DM screening, evaluation, and management program in Abuja demonstrated readiness to integrate DM care into PHCs regarding equipment, paper-based HMIS, and nonphysician health workers' availability. However, strategies are needed to promote DM health workforce training, provide DM management guidelines, and supply essential DM medications. [ABSTRACT FROM AUTHOR]

Background: Mobile device-based cognitive screening has the potential to overcome the limitations in diagnostic precision and efficiency that characterize conventional pen and paper cognitive screening. Several mobile device-based cognitive testing platforms have demonstrated usability, but the usability of take-home mobile device-based cognitive screening in typical adult primary care patients requires further investigation. Methods: This study set out to test the usability of a prototype mobile device-based cognitive screening test in older adult primary care patients across a range of cognitive performance. Participants completed the St. Louis University Mental Status Examination (SLUMS) and then used a study-supplied mobile device application at home for 5 days. The application presented 7 modules lasting approximately 15 min. Participants completed the System Usability Scale (SUS) after using the application. Results: A total of 51 individuals participated, with a median (IQR) age of 81 (74–85) years. Cognitive impairment (SLUMS score < 27) was present in 30 (59%) of participants. The mean (95% Confidence Interval [CI]) SUS score was 76 (71–81), which indicates good usability. Usability scores were similar across ranges of cognitive impairment. A Lower SLUMS score predicted early withdrawal from the study with an area under the receiver operating characteristic curve (95% CI) of 0.78 (0.58–0.97). Conclusion: Take-home mobile device-based cognitive testing is a usable strategy for many older adult primary care patients. Depending on patient preferences and abilities, it could be part of a flexible cognitive testing and follow-up strategy that includes mobile device-based testing in healthcare settings and pen-and-paper cognitive testing. [ABSTRACT FROM AUTHOR]

Primary health care (PHC) has increased in global relevance as it has been demonstrated to be a useful strategy to promote community access to health services. Multilateral organizations and national governments have reached a consensus regarding the basic principles of PHC, but the application of these varies from country to country due to the particularities of local health systems. This article aims to review and summarize PHC strategies and the configuration of health networks in Latin American and Caribbean countries. The review was carried out using keywords in at least 9 databases. Papers in languages other than English, Portuguese, and Spanish were excluded, while non-refereed articles and regional gray literature were incorporated. As a result, 1,146 papers were identified. After three instances of analysis, 142 articles were selected for this investigation. Data were analyzed according to an analysis by theme. The evidence collected on health reforms in the region reflects the need to intensify care strategies supported by PHC and care networks. These must be resilient to changes in the population's needs and must be able to adapt to contexts of epidemiological accumulation. [ABSTRACT FROM AUTHOR]

Background: The National Health Service (NHS) and general practice are increasingly adopting digital services. These services can impact both positively and negatively upon patient experiences, and access to digital services is not equal amongst all groups. Within a wider project examining digital facilitation (the Di-Facto study) our team conducted a patient survey amongst English primary care practices aiming to investigate patient views of what supports uptake and use of web-based services. This paper reports on the analysis of the free-text responses from the patient survey. Methods: The Di-Facto patient survey was distributed to practices in eight clinical commissioning groups (CCGs) in England between 2021–2022. We examined free-text responses to two questions relating to access to primary care web-based and support for web-based services. We used qualitative reflexive thematic analysis based on a six-stage process to analyse responses. Results: Of the 3051 patients who responded to the Di-Facto survey, 2246 provided a free-text response. We present our findings in two major themes: systems and structures and their impact on use of web-based services, and 'what works for me', a description of how respondents described what worked, or did not work in terms of their interactions with web-based services. Respondents described how the technology, such as poor practice website design, confusion over multiple digital apps, data security and concerns about eConsultation offerings impacted on use of web-based services. Respondents described practice level barriers, such as a lack of or inconsistent provision, which prevented optimal use of web-based services. Respondents described personal and technical barriers that impacted on their use of digital services, and described which web-based services worked well for them. Respondents felt that web-based services were not a replacement for face-to-face interactions with a doctor. Conclusions: This analysis of free-text responses from a large patient survey highlights the system, practice, and person level barriers and facilitators to use of digital services in primary care. With an increasing push towards digital solutions in NHS primary care, practices should consider the design, rollout and communication of their web-based services to support patient access. [ABSTRACT FROM AUTHOR]

Introduction: The significance of Primary Healthcare Centers (PHCCs) in fostering health equity and enhancing health outcomes cannot be overstated, especially in low and middle-income countries. This paper's primary area of interest is to create evidence and innovation for PHCs, with a particular emphasis on underserved groups. Thus, the study aimed to investigate the state of primary health care in Nigeria, with a particular emphasis on best practices, challenges to best practices, and quality of care., Methodology: A cross-sectional quantitative study was conducted to collect secondary data from 29 primary healthcare facilities. The data was collected using staff and facility activity indicators over a year (2022). Descriptive statistics and chi-square tests were used to analyze the collected data., Result: Our study data showed that all of the PHCCs have service rosters that can be utilized for follow-up with patients. About 85 (84.1%) respondents have reported that deliveries were taken by the reporting midwife, and 55 (54.5%) respondents indicated that their facilities provided on-the-job training to their staff. This is considered as the best practice in the facility. However, the majority of the PHCCs (71.3%) lacked assessment teams, which was found to have a negative impact on the quality of healthcare provided at these facilities (p < 0.05)., Conclusion: Our study underscores the pressing need for primary healthcare services in Nigeria. Government authorities and healthcare providers must take action to overcome the challenges of limited capacity, service delivery, and quality of care. By adopting effective strategies and ensuring access to primary healthcare, citizens' health outcomes can be greatly enhanced. Thus, it is essential to revamp and optimize healthcare facilities to establish an efficient healthcare system that caters to the needs of all citizens., (© 2024. The Author(s).)

Background: Primary care is an essential pillar of health systems. Many countries have implemented different policies to improve access to primary care. However, persistent challenges remain. This paper offers a critical analysis of the evolution of primary care coverage in Portugal, focusing on the number of patients without an assigned general practitioner (GP)., Methods: We collected and analyzed publicly available data from 2009 to 2023 to decompose primary care coverage in three components: the number of patients enrolled in primary care units (demand-side effect), the number of GPs measured in full-time equivalent (supply-side effect), and the average number of patients on each GP's list (patient-to-GP ratio, capturing a productivity effect). We provide national and local level estimates for these three components., Results: Between 2009 and 2023, there was an overall decline in the number of patients enrolled in primary health care units. Concurrently, there was also a net decrease of GPs measured in full-time equivalent. Additionally, there was a progressive reduction in the average number of patients on each GP's list. The rise in the number of patients without an assigned GP is attributed not only to a reduction in the number of physicians, but also to a decrease in the patient load per doctor., Conclusions: Hiring additional GPs may not suffice to enhance coverage. Achieving higher coverage may imply revisiting patient load per doctor or considering alternative care models. Understanding the challenges related to GP coverage is critical for improving the efficiency of primary care., (© 2024. The Author(s).)

Background: The optimisation of patients in primary care is a prime opportunity to manage patient care within the community and reduce the burden of referrals on secondary care. This paper presents a quality improvement clinical programme taking place within an NHS Primary Care Network as part of the wider Leicester Leicestershire Rutland integrated chronic kidney disease programme., Method: Patients are optimised to guidelines from the National Institute for Health and Care Excellence, by a primary care clinical team who are supported by nephrology consultants and nephrology pharmacists. Multidisciplinary team meetings take place with secondary care specialists and primary care staff. Learning is passed to the community clinicians for better patient treatment locally., Results: A total of 526 patients were reviewed under this project.The total number of referrals to secondary care which were discharged following first outpatient appointment, reduced from 42.9% to 10%. This reduction of 32.9% represents the optimisation of patient cases through this quality improvement project. Patients can be optimised and managed within the community, reducing the number of unnecessary referrals to secondary care., Conclusion: This programme has the potential to offer significant improvement in patient outcomes when expanded to a larger patient base. Medicine management and the use of clinical staff are optimised in both primary and secondary care., (© 2024. The Author(s).)

Introduction: Community-driven research in primary healthcare (PHC) may reduce the chronic disease burden in Indigenous peoples. This systematic review assessed the cultural safety of reports of research on PHC use by Indigenous peoples from four countries with similar colonial histories., Methods: Medline, CINAHL and Embase were all systematically searched from 1st January 2002 to 4th April 2023. Papers were included if they were original studies, published in English and included data (quantitative, qualitative and/or mixed methods) on primary healthcare use for chronic disease (chronic kidney disease, cardiovascular disease and/or diabetes mellitus) by Indigenous Peoples from Western colonial countries. Study screening and data extraction were undertaken independently by two authors, at least one of whom was Indigenous. The baseline characteristics of the papers were analyzed using descriptive statistics. Aspects of cultural safety of the research papers were assessed using two quality appraisal tools: the CONSIDER tool and the CREATE tool (subset analysis). This systematic review was conducted in accordance with the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool., Results: We identified 35 papers from Australia, New Zealand, Canada, and the United States. Most papers were quantitative (n = 21) and included data on 42,438 people. Cultural safety across the included papers varied significantly with gaps in adequate reporting of research partnerships, provision of clear collective consent from participants and Indigenous research governance throughout the research process, particularly in dissemination. The majority of the papers (94%, 33/35) stated that research aims emerged from communities or empirical evidence. We also found that 71.4% (25/35) of papers reported of using strengths-based approaches by considering the impacts of colonization on reduced primary healthcare access., Conclusion: Research on Indigenous PHC use should adopt more culturally safe ways of providing care and producing research outputs which are relevant to community needs by privileging Indigenous voices throughout the research process including dissemination. Indigenous stakeholders should participate more formally and explicitly throughout the process to guide research practices, inclusive of Indigenous values and community needs., (© 2024. The Author(s).)

Background: Changes in demographics with an older population, the illness panorama with increasing prevalence of non-communicable diseases, and the shift from hospital care to home-based care place demand on primary health care, which requires multiprofessional collaboration and team-based organization of work. The COVID-19 pandemic affected health care in various ways, such as heightened infection control measures, changing work practices, and increased workload., Objectives: This study aimed to investigate the association between primary care practices' organization, and quality and safety changes during the COVID-19 pandemic., Design: Data were collected from 38 countries in a large online survey, the PRICOV-19 study. For this paper, the participating practices were categorized as "Only GPs", comprising practices with solely general practitioners (GPs) and/or GP trainees, without any other health care professionals (n = 1,544), and "Multiprofessional," comprising practices with at least one GP or GP trainee and one or more other health professionals (n = 3,936)., Results: Both categories of practices improved in infection control routines when compared before and during the COVID-19 pandemic. A larger proportion of the multiprofessional practices changed their routines to protect vulnerable patients. Telephone triage was used in more "Multiprofessional" practices, whereas "Only GPs" were more likely to perform video consultations as an alternative to physical visits. Both types of practices reported that the time to review new guidelines and scientific literature decreased during the pandemic. However, both had more meetings to discuss directives than before the pandemic., Conclusions: Multiprofessional teams were keener to introduce changes to the care organization to protect vulnerable patients. However, practices with only GPs were found to be more aligned with video consultations, perhaps reflecting the close patient-doctor relationship. In contrast, telephone triage was used more in multiprofessional teams., (© 2024. The Author(s).)

Background: Staff shortages limit access to health services. The bidirectional benefits of allied health clinical placements are understood in the domains of student learning, health service delivery, and future workforce development. Still, the benefits to current workforce outcomes remain unknown. This review provides insights into the effects of allied health student placements in acute and primary care settings, particularly on healthcare staff's knowledge and procedural skills., Methods: This search was based on the integrative review process established by Whittemore and Knafl in 2005. In October 2023, the first author (MH) searched five major electronic databases: Medline-EBSCO, PubMed, CINAHL, Embase, and Scopus. The CLUSTER model was used to track additional references. The first three authors (MH, SM, and SC) were involved in screening, quality appraisal, and synthesis of the studies. Data were thematically synthesised and analysed., Results: MeSH headings and keywords were used in key search areas: health education, health professional training, clinical placements, and allied health professions. The systematic search yielded 12 papers on allied health student placements across various healthcare settings in rural and metropolitan areas, with no high-quality methodologies measuring student placements' impact on staff knowledge and skills. Four main themes were identified from the analysis: meaningful student integration in service delivery, targeted educational support to healthcare staff, development of staff procedural skills and confidence, and the mechanisms of why student placements work in this aspect., Conclusions: This review suggests that offering allied health student placement could be a promising approach to supporting rural healthcare staff in performing patient assessments and treatments proficiently and collaboratively. However, this requires further investigation to confirm., (© 2024. The Author(s).)

Background: Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single 'situational' missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more 'enduring' multiple missed appointments in primary care and the role this has in producing health inequalities., Methods: We conducted a realist review of the literature on multiple missed appointments to identify the causes of 'missingness.' We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation., Results: Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is 'for them'; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place., Conclusions: Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care., (© 2024. The Author(s).)

Background: Exposure to domestic and family violence is a pervasive form of complex trauma and a major global public health problem. At the frontline of the health system, primary healthcare practitioners are uniquely placed to support individuals with experiences of trauma, yet their views on trauma-informed primary care are not well understood. This systematic review of qualitative literature sought to explore primary healthcare practitioners' perspectives on trauma-informed primary care. Methods: Eight databases were searched up to July 2023. Studies were included if they consisted of empirical qualitative data, were conducted in general practice or equivalent generalist primary healthcare settings, and included the perspectives of primary healthcare practitioners where they could be distinguished from other participants in the analysis. Thematic synthesis was used for analysis. Results: 13 papers met inclusion criteria, representing primary care settings from the United States, Canada, Australia, and Norway. Three key themes were developed: Changing the paradigm, Building trust, and Navigating the emotional load. Findings shed light on how primary healthcare practitioners perceive and strive to practise trauma-informed primary healthcare and the challenges of navigating complex, trauma-related work in the primary care environment. Conclusions: This review supports the need for recognition of the value of primary care in supporting patients with histories of trauma and violence, the development of interventions to mitigate the emotional load worn by primary healthcare practitioners, and further work to develop a deep and consistent understanding of what trauma-informed primary care encompasses. [ABSTRACT FROM AUTHOR]

Background: Co-occurring physical and mental health conditions are common, but effective and sustainable interventions are needed for primary care settings. Purpose: Our paper analyzes the effectiveness of a Solution-Focused Brief Therapy (SFBT) intervention for treating depression and co-occurring health conditions in primary care. We hypothesized that individuals receiving the SFBT intervention would have statistically significant reductions in depressive and anxiety symptoms, systolic blood pressure (SBP), hemoglobin A1C (HbA1c), and body mass index (BMI) when compared to those in the control group. Additionally, we hypothesized that the SFBT group would have increased well-being scores compared to the control group. Methods: A randomized clinical trial was conducted at a rural federally qualified health center. Eligible participants scored ≥ 10 on the Patient Health Questionnaire (PHQ-9) and met criteria for co-occurring health conditions (hypertension, obesity, diabetes) evidenced by chart review. SFBT participants (n = 40) received three SFBT interventions over three weeks in addition to treatment as usual (TAU). The control group (n = 40) received TAU over three weeks. Measures included depression (PHQ-9) and anxiety (GAD-7), well-being (Human Flourishing Index), and SFBT scores, along with physical health outcomes (blood pressure, body mass index, and hemoglobin A1c). Results: Of 80 consented participants, 69 completed all measures and were included in the final analysis. 80% identified as female and the mean age was 38.1 years (SD = 14.5). Most participants were white (72%) followed by Hispanic (15%) and Black (13%). When compared to TAU, SFBT intervention participants had significantly greater reductions in depression (baseline: M = 18.17, SD = 3.97, outcome: M = 9.71, SD = 3.71) and anxiety (baseline: M = 14.69, SD = 4.9, outcome: M = 8.43, SD = 3.79). SFBT intervention participants also had significantly increased well-being scores (baseline: M = 58.37, SD = 16.36, outcome: M = 73.43, SD = 14.70) when compared to TAU. Changes in BMI and blood pressure were not statistically significant. Conclusion: The SFBT intervention demonstrated efficacy in reducing depressive and anxiety symptoms and increasing well-being but did not affect cardio-metabolic parameters over a short period of intervention. Trial Registration: The study was pre-registered at ClinicalTrials.gov Identifier: NCT05838222 on 4/20/2023. *M = Mean, SD = Standard deviation. [ABSTRACT FROM AUTHOR]

Background: Cognitive impairment and dementia are frequently under-recognized. Health system strategies anchored in primary care are essential to address gaps in timely, comprehensive diagnosis. The goal of this paper is to describe the adaptation of a tablet-based brain health assessment (TabCAT-BHA) intervention and the study protocol to test its effectiveness in improving the detection of cognitive impairment, including dementia. Methods: This mixed-methods, pragmatic, cluster randomized, hybrid effectiveness-implementation trial is being conducted in two 18-month waves with 26 Kaiser Permanente Southern California primary care clinics, with 13 serving as intervention clinics and 13 as usual care clinics. Patients 65 years and older with memory concerns (n ~ 180,000) receiving care at the 26 clinics will be included in the analyses. Primary care clinics are provided the following practice supports as part of the TabCAT-BHA intervention: brief education and training on neurocognitive disorders and study workflows; digital tools to assess cognitive function and support clinician decision making and documentation; and registered nurse support during the work-up and post-diagnosis periods for primary care providers, patients, and families. The intervention was adapted based on engagement with multiple levels of clinical and operational leaders in the healthcare system. Effectiveness outcomes include rates of cognitive impairment diagnosis in primary care and rates of completed standardized cognitive assessments and specialist referrals with incident diagnoses. Implementation outcomes include acceptability-appropriateness-feasibility, adoption, and fidelity. Results: We identified seven themes organized by system-, provider-, and patient-level domains that were used to adapt the TabCAT-BHA intervention. Accordingly, changes were made to the provider education, diagnostic work-up, and post-diagnostic support. Results will be reported in fall of 2027. Conclusions: Our engagement with multiple primary and specialty care clinical and operational leaders to adapt the TabCAT-BHA intervention to these primary care clinics has informed the protocol to evaluate the intervention's effectiveness for improving the detection of cognitive impairment, including dementia, in an integrated healthcare system. Trial Registation: Clinicaltrials.gov: NCT06090578 (registered 10/24/23). [ABSTRACT FROM AUTHOR]

Background: Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease., Objective: The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process., Methods: A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023., Results: Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early., Conclusions: This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services., (© 2024. Crown.)

Background: Community health worker programmes have the potential to contribute critically towards universal health coverage. However, CHWs globally have often continued to operate on the periphery of the health care system, viewed as a non-essential cadre. This results in a workforce that often remains disempowered and under-supported. This paper presents evidence from a study conducted in a rural part of South Africa, to better understand issues of CHW prioritisation, integration, and empowerment. Methods: We applied an analytical lens based on empowerment theory and conducted a secondary analysis of qualitative data emerging from a sub-study of a cRCT evaluating the effectiveness of supportive supervision for CHWs within a large-scale national CHW programme. The cRCT was conducted between 2017 and 2022, and 39 CHWs were included in the study. Results: We organised our findings across the four domains of structural empowerment; information, resources, support, and opportunity, and mapped these domains against the domains of psychological empowerment. Our findings show how CHWs are still working in the periphery of the healthcare system. Without sufficient prioritisation, high level-support from national and district governments, and sufficient investments in programmatic domains—such as training, equipment, and supportive supervision—it is likely that the CHW cadre will continue to be seen as informal health care workers. Conclusions: CHW empowerment could be a lever to potentially transform the current health system towards universal coverage; however, this process can only happen with sufficient high-level prioritization and investment. [ABSTRACT FROM AUTHOR]

Background: Early identification and treatment of chronic disease is associated with better clinical outcomes, lower costs, and reduced hospitalisation. Primary care is ideally placed to identify patients at risk of, or in the early stages of, chronic disease and to implement prevention and early intervention measures. This paper evaluates the implementation of a technological intervention called Future Health Today that integrates with general practice EMRs to (1) identify patients at-risk of, or with undiagnosed or untreated, chronic kidney disease (CKD), and (2) provide guideline concordant recommendations for patient care. The evaluation aimed to identify the barriers and facilitators to successful implementation. Methods: Future Health Today was implemented in 12 general practices in Victoria, Australia. Fifty-two interviews with 30 practice staff were undertaken between July 2020 and April 2021. Practice characteristics were collected directly from practices via survey. Data were analysed using inductive and deductive qualitative analysis strategies, using Clinical Performance - Feedback Intervention Theory (CP-FIT) for theoretical guidance. Results: Future Health Today was acceptable, user friendly and useful to general practice staff, and supported clinical performance improvement in the identification and management of chronic kidney disease. CP-FIT variables supporting use of FHT included the simplicity of design and delivery of actionable feedback via FHT, good fit within existing workflow, strong engagement with practices and positive attitudes toward FHT. Context variables provided the main barriers to use and were largely situated in the external context of practices (including pressures arising from the COVID-19 pandemic) and technical glitches impacting installation and early use. Participants primarily utilised the point of care prompt rather than the patient management dashboard due to its continued presence, and immediacy and relevance of the recommendations on the prompt, suggesting mechanisms of compatibility, complexity, actionability and credibility influenced use. Most practices continued using FHT after the evaluation phase was complete. Conclusions: This study demonstrates that FHT is a useful and acceptable software platform that provides direct support to general practice in identifying and managing patients with CKD. Further research is underway to explore the effectiveness of FHT, and to expand the conditions on the platform. [ABSTRACT FROM AUTHOR]

Background: There is limited research examining the views of general practice pharmacists (GPPs) on their role and their impact in general practice. The aim of this study was to explore GPPs' views regarding this role and its potential impact within general practice in Northern Ireland (NI). Methods: A paper-based self-administered questionnaire was mailed to 319 general practices in NI in 2022, directed to the GPP who spent most time at the practice. A variety of closed and open questions were included in six sections. Responses to closed questions were analysed descriptively whilst open question responses were analysed using content analysis. To ascertain associations between variables (e.g. GPP prescribing status, working arrangements and aspects of collaboration with GPPs), Fisher's exact test was employed with an a priori significance level of p < 0.05. Results: 155 responses were received equating to a response rate of 48.5%. Most participants (72.3%) were female, independent prescribers (71%), and 64.5% were currently using their independent prescriber qualification. Services that were provided by most GPPs were medication reconciliation (99.4%) and medication reviews (97.4%). The most common method of communication between GPPs and general practitioners (GPs) was face-to-face (89.0%). Telephone was the most common method of communication between GPPs, community pharmacists (97.4%) and patients (98.7%). Most GPPs (> 80%) showed positive attitudes towards collaboration with GPs and those who worked in multiple practices were more likely to agree with the Attitudes Towards Collaboration Instrument for pharmacists (ATCI-P) statements compared to those who worked in a single practice (p < 0.05). Less than 40% (36.8%) of GPPs agreed that patients were aware of the role they provided. The majority of GPPs (80.6%) expressed positive views on their impact on primary care. Analysis of the free-text comments revealed the need for more GPP patient-facing activities, GPP-specific training, and promotion of the GPP role. Conclusion: The findings indicated that GPPs had largely positive views about their role and their impact on primary care. The results may be helpful for practices and service commissioners. Further research is necessary to explore the perspectives of patients regarding the role of the GPP and to enhance patients' awareness of the GPP. [ABSTRACT FROM AUTHOR]

Background: This study involved a scoping review to explore factors influencing dental hygienist demand and supply in high-income countries. Methods: A six-stage scoping review was conducted with separate search strategies tailored to four databases (MEDLINE, CINAHL, Google Scholar, and Google) plus a targeted scan of dental hygienist organization websites. This yielded 2,117 unique citations, leading to 148 articles included in the review. Results: Nearly half of the articles (47%) focused on the United States, with 11% on Canada. Most articles (91%) were in English, alongside 13 in Korean and one in French. Journal articles comprised 62% of the publications, followed by reports/working papers (11%) and websites (11%). Other types included conference abstracts, policy briefs, and presentation slides. Content-wise, 47% were original research, with analysis articles (14%), commentaries (11%), and reviews (8%) also present. The articles were coded into three main categories: workforce characteristics/projections, factor-specific analyses, and workforce opportunities. The articles on workforce characteristics covered demographic, geographic, and employment aspects of dental hygienists, along with projections for supply and demand using simulation modelling and geospatial analyses. Factor-specific articles investigated the (1) working environment, (2) policy/regulatory/training environment, (3) job/career satisfaction and related human resource issues, and (4) scope of practice. The third key category of articles highlighted opportunities for expanding the workforce through alternative models in different sectors/settings (e.g., public health, primary care, long-term care, hospitals, mobile outreach, and non-clinical roles including research, education and leadership) and for a range of vulnerable or underserved populations (e.g., geriatric and pediatric populations, persons with disabilities, those living in rural/remote areas, Indigenous peoples, and incarcerated people). Conclusions: This review provides a comprehensive documentation of the current state of the dental hygienist workforce, compiling factors affecting demand and supply, and highlighting opportunities for the dental hygienist workforce in Canada and other high-income countries. The findings offer a foundation for future research, highlighting the need for more focused and rigorous reviews and underscoring the necessity of high-quality studies to verify the effectiveness of various interventions and policies. This is crucial to address dental hygienist workforce challenges and ensure the sustainability and effectiveness of oral health care delivery. [ABSTRACT FROM AUTHOR]

Background: In Rwanda, nurses manage all primary care at health centres, and therefore are their clinical reasoning skills important. In this study, a web-based software that allows the creation of virtual patient cases (VP cases) has been used for studying the possibility of using VP cases for the continuous professional development of nurses in primary health care in Rwanda. Previous studies in pre-service education have linked VP cases with the enhancement of clinical reasoning, a critical competence for nurses. This study investigated the feasibility of continuous professional development through VP cases to further train in-service nurses in clinical reasoning. Method: The study used a pre-post test design. Initially, seventy-six participants completed a questionnaire as part of the pre-test phase, subsequently invited to engage with all four VP cases, and finally responded to the post-test questionnaire evaluating clinical reasoning skills. Fifty-six participants successfully completed the entire study process and were considered in the analysis. The primary outcomes of this study were evaluated using a paired t-test for the statistical analysis. Results: The results show that the mean score of clinical reasoning increased significantly from the pre-test to the post-test for all four illness areas (p < 0.001). The study findings showed no statistically significant difference in participants' scores based on demographic factors, including whether they worked in urban or rural areas. Conclusion and recommendation: Utilizing VP cases appears to significantly enhance the continuous professional development of nurses, fostering a deliberate learning process that enables them to reflect on how they manage cases and, in turn, refine their clinical reasoning skills. This study strongly recommends incorporating VP cases in the continuous professional development of nurses at the primary health level (health centers). This is especially pertinent in a context where nurses are required to perform diagnostic processes similar to those employed by physicians. [ABSTRACT FROM AUTHOR]

Background: Primary care professionals encounter difficulties coordinating the continuum of care between primary care providers and second-line specialists and adhere to practice guidelines pertaining to diabetic foot ulcers management. Family medicine groups are providing primary care services aimed to improve access, interdisciplinary care, coordination and quality of health services, and reduce emergency department visits. Most professionals working in family medicine groups are primary care physicians and registered nurses. The aim of this study was to develop and validate an interprofessional decision support tool to guide the management of diabetic foot ulcers for primary care professionals working within the family medicine group model. Methods: A one-page decision tool developed by the research team was validated by an expert panel using a three-round Delphi protocol held between December 2019 and August 2021. The tool includes 43 individual actions and a care pathway from initial presentation to secondary prevention. Data collection was realized with both paper and electronic questionnaires, and answers were compiled in an electronic spreadsheet. Data was analyzed with use of descriptive statistics, and consensus for each item was defined as ≥ 80% agreement. Results: Experts from 12 pre-identified professions of the diabetic foot ulcer interdisciplinary care team were included, 39 participants out of the 59 invited to first round (66.1%), 34 out of 39 for second (87.2%) and 22 out of 34 for third (64.7%) rounds. All items included in the final version of the decision support tool reached consensus and were deemed clear, relevant and feasible. One or more professionals were identified to be responsible for every action to be taken. Conclusions: This study provided a comprehensive decision support tool to guide primary care professionals in the management of diabetic foot ulcers. Implementation and evaluation in the clinical setting will need to be undertaken in the future. [ABSTRACT FROM AUTHOR]

Background: In response to the COVID-19 pandemic, the World Health Organization established a number of key recommendations such as educational activities especially within primary care practices (PCPs) which are a key component of this strategy. This paper aims to examine the educational activities of PCPs during COVID-19 pandemic and to identify the factors associated with these practices across 38 countries. Methods: A "Patient Education (PE)" score was created based on responses to six items from the self-reported questionnaire among PCPs (n = 3638) compiled by the PRICOV-19 study. Statistical analyses were performed on 3638 cases, with PCPs with missing PE score values were excluded. Results: The PE score features a mean of 2.55 (SD = 0.68) and a median of 2.50 (2.16 – 3.00), with a maximum of 4.00, and varies quite widely between countries. Among all PCPs characteristics, these factors significantly increase the PE score: the payment system type (with a capitation payment system or another system compared to the fee for service), the perception of average PCP with patients with chronic conditions and the perception of adequate governmental support. Conclusion: The model presented in this article is still incomplete and requires further investigation to identify other configuration elements favorable to educational activities. However, the results already highlight certain levers that will enable the development of this educational approach appropriate to primary care. [ABSTRACT FROM AUTHOR]

Background and objective: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. Methods: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. Results: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. Conclusions: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage. [ABSTRACT FROM AUTHOR]

Primary Health Care (PHC) is the most equitable and cost-effective way to enhance the health of populations and improve health security and is a requirement for achieving universal health coverage (UHC). Vital to advancing the PHC agenda is effective global health partnerships, particularly with Global Health Initiatives (GHIs) which provide financial support for improving population health. Despite progress, GHI support at times remained parallel to rather than embedded in national health strategies. To improve the impact of GHI support, World Health Organization (WHO) member states requested specific guidance to better align GHI support to national health strategies and PHC principles. We present the PHC-GHI Toolbox as a comprehensive set of resources for use by countries to apply the PHC approach to development of plans for securing and optimally utilizing funding received from GHIs, such as Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM); and the Global Financing Facility (GFF) as well as other donors. The PHC-GHI Toolbox includes a PHC resource database, GHI-specific overviews, a database of health system strengthening (HSS) investments, COVID-19 funding rapid assessment tool, and a focal point database for identifying expert technical assistance. This paper describes the process undertaken for Toolbox development and outlines its potential applications. [ABSTRACT FROM AUTHOR]

Background: Having a sufficient and well-functioning health workforce is crucial for reducing the burden of disease and premature death. Health workforce development, focusing on availability, recruitment, retention, and education, is inseparable from acceptability, motivation, burnout, role and responsibility, and performance. Each aspect of workforce development may face several challenges, requiring specific strategies. However, there was little evidence on barriers and strategies towards comprehensive health workforce development. Therefore, this review explored barriers and strategies for health workforce development at the primary health care level around the world. Methods: A scoping review of reviews was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews. The article search was performed in Google Scholar, PubMed, Web of Science, and EMBASE. We used EndNote x9 for managing the collected articles, screening processes, and citation purpose. The scoping review included any kind of review articles on the application of health workforce development concepts, such as availability, recruitment, retention, role and responsibility, education and training, motivation, and burnout, with primary health care and published in English anywhere in the world. Based on the concepts above, barriers and strategies for health workforce development were identified. The findings were synthesized qualitatively based on the building blocks of the health system framework. The analysis involved specific activities such as familiarization, construction of the thematic framework, indexing, charting, and interpretation. The results were presented in texts, tables, and figures. Results: The search strategies yielded 7,276 papers were found. Of which, 69 were included in the scoping review. The most frequently cited barriers were financial challenges and issues related to health care delivery, such as workloads. Barriers affecting healthcare providers directly, including lack of training and ineffective teamwork, were also prominent. Other health system and governance barriers include lack of support, unclear responsibility, and inequity. Another notable barrier was the shortage of health care technology, which pertains to both health care supplies and information technology. The most common cited effective strategies were ongoing support and supervision, engaging with communities, establishing appropriate primary care settings, financial incentives, fostering teamwork, and promoting autonomous health care practice. Conclusions: Effective leadership/governance, a robust health financing system, integration of health information and technology, such as mobile health and ensuring a consistent supply of adequate resources are also vital components of primary health care workforce development. The findings highlight the importance of continuous professional development, which includes training new cadres, implementing effective recruitment and retention mechanisms, optimising the skill mix, and promoting workplace wellness. These elements are essential in fostering a well-trained and resilient primary health care workforce. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic immensely impacted care provision, including quality of care in general practice. This paper aimed: (1) to assess how Belgian general practices acted upon the six dimensions of quality of care during COVID-19; (2) to study differences between the three Belgian regions; and (3) to benchmark the performance of the Belgian practices against the performance in other European countries. Methods: The data collected from 479 Belgian practices during 2020–2021 using an online survey as part of the international cross-sectional PRICOV-19 study were analyzed. Hereby, descriptive statistics, chi-squared tests, and binary logistic regression analyses were performed. Thirty-four survey questions related to the six dimensions of quality of care were selected as outcome variables. The adjusted regression models included four practice characteristics as covariates: practice type, being a teaching practice for GP trainees, multidisciplinarity of the team, and payment system. Results: Belgian practices made important organizational changes to deliver high-quality care during COVID-19. Most practices (n = 259; 56.1%) actively reached out to vulnerable patients. Limitations to the practice building or infrastructure threatened high-quality care in 266 practices (55.5%). Infection prevention measures could not always be implemented during COVID-19, such as using a cleaning protocol (n = 265; 57.2%) and providing a separate doctor bag for infection-related home visits (n = 130; 27.9%). Three hundred and sixty practices (82.0%) reported at least one safety incident related to a delayed care process in patients with an urgent condition. The adjusted regression analysis showed limited significant differences between the Belgian regions regarding the quality of care delivered. Belgian practices demonstrated varied performance compared to other European countries. For example, they excelled in always checking the feasibility of isolation at home but reported more patient safety incidents related to timely care than at least three-quarters of the other European countries. Conclusions: Future studies using different design methods are crucial to investigate which country and practice characteristics are associated with delivering high-quality care. [ABSTRACT FROM AUTHOR]

Background: Adaptation to climate change (CC) is a priority for Small Island Developing States (SIDS) in the Caribbean, as these countries and territories are particularly vulnerable to climate-related events. Primary health care (PHC) is an important contributor to CC adaptation. However, knowledge on how PHC is prepared for CC in Caribbean SIDS is very limited. The aim of this paper is to discuss health system adaptation to climate change, with a focus on PHC. Methods: We explored the perspectives of PHC professionals in Dominica on PHC adaptation to climate change. Focus group discussions (FGDs) were conducted in each of the seven health districts in Dominica, a Caribbean SIDS, between November 2021 and January 2022. The semi-structured interview guide was based on the Essential Public Health Functions: assessment, access to health care services, policy development and resource allocation. Data coding was organized accordingly. Results: Findings suggest that health care providers perceive climate change as contributing to an increase in NCDs and mental health problems. Climate-related events create barriers to care and exacerbate the chronic deficiencies within the health system, especially in the absence of high-level policy support. Healthcare providers need to take a holistic view of health and act accordingly in terms of disease prevention and health promotion, epidemiological surveillance, and ensuring the widest possible access to healthcare, with a particular focus on the environmental and social determinants of vulnerability. Conclusion: The primary health care system is a key stakeholder in the design and operationalization of adaptation and transformative resilience. The Essential Public Health Functions should integrate social and climate and other environmental determinants of health to guide primary care activities to protect the health of communities. This study highlights the need for improved research on the linkages between climate events and health outcomes, surveillance, and development of plans informed by contextual knowledge in the SIDS. [ABSTRACT FROM AUTHOR]

Background: Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa. Methods: We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert. Results: Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants. Conclusions: Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) Clinical trials registration: Clinicaltrials.gov ID: BFC157/19, August 2019. [ABSTRACT FROM AUTHOR]

Background: With the onset of the COVID-19 pandemic and the large uptake in virtual care in primary care in Canada, the care of patients with type 2 diabetes has been greatly affected. This includes decreased in-person visits, laboratory testing and in-person assessments such as blood pressure (BP). No studies have investigated if these changes persisted with pandemic progression, and it is unclear if shifts impacted patient groups uniformly. The purpose of this paper was to examine changes in diabetes care pre, early, and later pandemic across different patient groups. Methods: A repeated cross-sectional design with an open cohort was used to investigate diabetes care in adults with type 2 diabetes for a 6-month interval from March 14 to September 13 over three consecutive years: 2019 (pre-pandemic period), 2020 (early pandemic period), and 2021 (later pandemic period). Data for this study were abstracted from the University of Toronto Practice-Based Research Network (UTOPIAN) Data Safe Haven, a primary care electronic medical records database in Ontario, Canada. Changes in diabetes care, which included primary care total visits, in-person visits, hemoglobin A1c (HbA1c) testing, and BP measurements were evaluated across the phases of the pandemic. Difference in diabetes care across patient groups, including age, sex, income quintile, prior HbA1c levels, and prior BP levels, were assessed. Results: A total of 39,401 adults with type 2 diabetes were included in the study. Compared to the 6-month pre-pandemic period, having any in-person visits decreased significantly early pandemic (OR = 0.079 (0.076–0.082)), with a partial recovery later pandemic (OR = 0.162 (95% CI: 0.157–0.169). Compared to the pre-pandemic period, there was a significant decrease early pandemic for total visits (OR = 0.486 (95% CI: 0.470–0.503)), HbA1c testing (OR = 0.401 (95% CI: 0.389–0.413)), and BP measurement (OR = 0.121 (95% CI: 0.116–0.125)), with partial recovery later pandemic. Conclusions: All measures of diabetes care were substantially decreased early pandemic, with a partial recovery later pandemic across all patient groups. With the increase in virtual care due to the COVID-19 pandemic, diabetes care has been negatively impacted over 1-year after pandemic onset. [ABSTRACT FROM AUTHOR]

Background: The world population is ageing rapidly. Rehabilitation is one of the most effective health strategies for improving the health and functioning of older persons. An understanding of the current provision of rehabilitation services in primary care (PC) is needed to optimise access to rehabilitation for an ageing population. The objectives of this scoping review are a) to describe how rehabilitation services are currently offered in PC to older persons, and b) to explore age-related differences in the type of rehabilitation services provided. Methods: We conducted a secondary analysis of a scoping review examining rehabilitation models for older persons, with a focus on PC. Medline and Embase (2015–2022) were searched to identify studies published in English on rehabilitation services for people aged 50 +. Two authors independently screened records and extracted data using the World Health Organization (WHO)'s operational framework, the Primary Health Care Systems (PRIMASYS) approach and the WHO paper on rehabilitation in PC. Data synthesis included quantitative and qualitative analysis. Results: We synthesised data from 96 studies, 88.6% conducted in high-income countries (HICs), with 31,956 participants and identified five models for delivering rehabilitation to older persons in PC: community, home, telerehabilitation, outpatient and eldercare. Nurses, physiotherapists, and occupational therapists were the most common providers, with task-shifting reported in 15.6% of studies. The most common interventions were assessment of functioning, rehabilitation coordination, therapeutic exercise, psychological interventions, and self-management education. Environmental adaptations and assistive technology were rarely reported. Conclusions: We described how rehabilitation services are currently provided in PC and explored age-related differences in the type of rehabilitation services received. PC can play a key role in assessing functioning and coordinating the rehabilitation process and is also well-placed to deliver rehabilitation interventions. By understanding models of rehabilitation service delivery in PC, stakeholders can work towards developing more comprehensive and accessible services that meet the diverse needs of an ageing population. Our findings, which highlight the role of rehabilitation in healthy ageing, are a valuable resource for informing policy, practice and future research in the context of the United Nations Decade of Healthy Ageing, the Rehab2030 initiative and the recently adopted WHA resolution on strengthening rehabilitation in health systems, but the conclusions can only be applied to HICs and more studies are needed that reflect the reality in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Background: Back pain is the number one condition contributing to years lived with disability worldwide, and one of the most common reasons for seeking primary care. Research on this condition in the ageing population is sparse. Further, the heterogeneity of patients with back pain complicates the management in clinical care. It is possible that subgrouping people with similar characteristics would improve management. This paper aimed to identify latent classes based on demographics, pain characteristics, psychosocial behavior, and beliefs and attitudes about back pain, among older patients seeking primary care with a new episode of back pain, and to examine if there were differences regarding the classes' first point-of-contact. Methods: The study was part of the international BACE (Back complaints in elders) consortium and included 435 patients aged ≥ 55 years seeking primary care (general practitioners, physiotherapists, and chiropractors) in Norway from April 2015 to March 2020. A latent class analysis was performed to identify latent classes. The classes were described in terms of baseline characteristics and first point-of-contact in primary care. Results: Four latent classes were identified. The mean age was similar across groups, as were high expectations towards improvement. Class 1 (n = 169, 39%), the "positive" class, had more positive attitudes and beliefs, less pain catastrophizing and shorter duration of current pain episode. Class 2 (n = 31, 7%), the "fearful" class, exhibited the most fear avoidance behavior, and had higher mean pain intensity. Class 3 (n = 33, 8%), the "distressed" class, had the highest scores on depression, disability, and catastrophizing. Finally, class 4 (n = 202, 46%), the "hopeful" class, showed the highest expectations for recovery, although having high pain intensity. The identified four classes showed high internal homogeneity, sufficient between-group heterogeneity and were considered clinically meaningful. The distribution of first point-of-contact was similar across classes, except for the positive class where significantly more patients visited chiropractors compared to general practitioners and physiotherapists. Conclusions: The identified classes may contribute to targeting clinical management of these patients. Longitudinal research on these latent classes is needed to explore whether the latent classes have prognostic value. Validation studies are needed to evaluate external validity. Trial registration: Clinicaltrials.gov NCT04261309. [ABSTRACT FROM AUTHOR]

Background: Despite the United States Preventive Services Task Force recommendation to screen adults for unhealthy alcohol use, the implementation of alcohol screening in primary care remains suboptimal. Methods: A pre and post-implementation study design that used Agile implementation process to increase screening for unhealthy alcohol use in adult patients from October 2021 to June 2022 at a large primary care clinic serving minority and underprivileged adults in Indianapolis. Results: In comparison to a baseline screening rate of 0%, the agile implementation process increased and sustained screening rates above 80% for alcohol use using the Alcohol Use Disorders Identification Test – Consumption tool (AUDIT-C). Conclusions: Using the agile implementation process, we were able to successfully implement evidence-based recommendations to screen for unhealthy alcohol use in primary care. [ABSTRACT FROM AUTHOR]

Background: General practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about 'models of paramedic working in general practice' in different UK contexts to understand their impact. Methods: The rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories. Results: Empirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models. Conclusions: Variability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various 'models of paramedic working' in different contexts. [ABSTRACT FROM AUTHOR]

Background: Access of all people to the healthcare they need, without financial hardship is the goal of Universal Health Coverage (UHC). As UHC initiatives expand, assessing the needs of vulnerable populations can reveal gaps in the system which may be covered by relevant policies. In this study we (i) identify the met and unmet primary healthcare needs of the poorest population of Khyber Pakhtunkhwa province (KP), Pakistan, and (ii) explore why the gaps exist. Methods: We used Leveque's Framework of Patient-centred Access to Healthcare to examine unmet primary healthcare (PHC) needs and their underlying causes for the poorest population in four districts of Khyber Pakhtunkhwa province, Pakistan. Using a triangulation mixed methods design, we analysed data from a quantitative household survey of744 households, 17 focus group discussions with household members and, 11 interviews with healthcare providers. Results: Our results show that indicate that despite service utilization, PHC needs were not met, primarily due to prohibitively high costs at each stage of access. Furthermore, gaps in outreach and information (approachability), and varying availability of medicines and diagnostics at facilities (appropriateness) the supply side as well as difficulties in navigating the system (inability to perceive) and adhering to prescriptions (inability to engage) on the demand side, also led to unmet PHC needs. Going beyond utilization, our findings highlight that engagement with care is an important determinant of met needs for vulnerable populations. Conclusion: Social health protection policies can contribute to advancing UHC for primary care. However, in our setting, enhancing communication and outreach, addressing gender and age disparities, and improving quality of care and health infrastructure are necessary to fully meet the needs of the poorest populations. Highlights: • The primary health needs of the poorest population of Khyber Pakhtunkhwa remain largely unmet or are met with difficulties, across the care-seeking pathway. • Major contributors to unmet primary healthcare needs in the study area are: low outreach, crowded facilities and, varying availability of medicines and diagnostics at facilities on the supply side, and difficulties in navigating care and inability to afford prescribed care on the demand side. • Social Health Protection is a crucial tool for advancing Universal Health Coverage and improving primary healthcare, however these needs cannot be met without quality service provision and outreach from facilities. • Levesque's framework of access to care (2013) can be effectively employed to identify broad-based unmet needs and assess gaps in primary healthcare systems. [ABSTRACT FROM AUTHOR]

Background: Despite major primary health care (PHC) reforms in China with the 2009 launch of the National Essential Public Health Service Package, the country experiences many challenges in improving the management of non-communicable diseases in PHC facilities. "EMERALD" is a multifaceted implementation strategy to strengthen the management of hypertension and type-2 diabetes mellitus (T2DM) in PHC facilities. The study aims to: (1) examine the effectiveness of EMERALD in improving hypertension and T2DM management; (2) evaluate the implementation of the interventions; and (3) use the study findings to model the long-term health economic impact of the interventions. Methods: The EMERALD intervention components include: (1) empowerment for PHC providers through training and capacity building; (2) empowerment for patient communities through multi-media health education; and (3) empowerment for local health administrators through health data monitoring and strengthening governance of local PHC programs. An interrupted time series design will be used to determine the effectiveness of the interventions based on routinely collected health data extracted from local health information systems. The primary effectiveness outcome is the guideline-recommended treatment rates for people with hypertension and T2DM. Secondary effectiveness outcomes include hypertension and T2DM diagnosis and control rates, and enrolment and adherence rates to the recommended care processes in the National Essential Public Health Service Package. A mixed-methods process evaluation will be conducted to evaluate the implementation of the interventions, including the reach of the target population, adequacy of adoption, level of implementation fidelity, and maintenance. Qualitative interviews with policy makers, health administrators, PHC providers, and patients with hypertension and/or T2DM will be conducted to further identify factors influencing the implementation. In addition, health economic modelling will be performed to explore the long-term incremental costs and benefits of the interventions. Discussion: This study is expected to generate important evidence on the effectiveness, implementation, and health economic impact of complex PHC interventions to strengthen the primary care sector's contribution to addressing the growing burden of non-communicable diseases in China. Trial registration: The study has been registered on Chinese Clinical Trial Registry at https://www.chictr.org.cn/ (Registration number ChiCTR2400082036, on March 19th 2024). [ABSTRACT FROM AUTHOR]

The need for equitable access to primary healthcare services in the current global context has attracted widespread attention, prompting nations to continuously enhance their grassroots medical service levels. In response, China launched the "Healthy China" initiative, which prioritizes the enhancement of national health as a core goal of the healthcare system and uses this opportunity to deepen reforms aimed at strengthening primary care. However, in remote and rural areas, the optimization of medical resource allocation and the achievement of balanced service development remain critical challenges owing to limited resources. This study selected Liannan Yao Autonomous County, which is situated in the northwestern corner of Guangdong Province, as a case study due to its remote mountainous location, underdeveloped economy, and minority region characteristics. Through field research and interviews, this study thoroughly explored the needs of both supply and demand, factoring in elements such as the service capability of healthcare facilities and residents' travel thresholds to enhance the two-step floating catchment area model, thus making it more applicable to remote villages. By integrating electric bikes and cars, which are the primary means of transportation in rural areas, this study conducted a thorough analysis and comparison of the accessibility of medical services in Liannan Yao Autonomous County (Liannan County). The results reveal significant disparities in healthcare accessibility, an uneven distribution of medical resources, and varying impacts of transportation conditions and facility service capabilities on accessibility. Notably, the study revealed that improving transportation conditions alone has limited effects in rural areas; the key lies in balancing medical service capabilities and the rationality of overall layouts. From the perspectives of equity and efficiency, this study employs the equitable coverage model and the efficiency-driven model to construct two scenarios, comparing accessibility changes in Liannan County under both conditions and proposing strategies to improve the spatial layout of local healthcare facilities. This research not only deepens the understanding of healthcare service accessibility in rural areas but also provides a scientific basis for optimizing resource allocation and enhancing primary medical services, offering valuable guidance and reference for Liannan County and other similar rural regions. [ABSTRACT FROM AUTHOR]

Background: The introduction of the COVID-19 vaccine influenced discussions to explore integrating COVID-19 vaccination into routine immunization (RI) programs. Subsequently, the WHO Strategic Advisory Group Experts (SAGE) on immunization plausibly advised countries to leverage the COVID-19 vaccination rollout as a transformative opportunity to establish a resilient immunization system, through an integrated immunization system, resulting in strengthened primary healthcare services. Objective: This study assessed the enablers and barriers to integrating COVID-19 vaccination into the routine immunization programme in Ekiti state, Nigeria. Methods: This study utilized a qualitative research approach to obtain information from 40 participants selected purposively across the primary healthcare facilities, LGA, and state levels. A three-tier approach was employed to select the LGAs. At the same time, In-depth interviews were conducted to elicit relevant information on the assessment of enablers and barriers to integrating COVID-19 vaccination into routine immunization through an interview guide. All the audio interview files were transcribed into English Language, coded, and presented using a thematic approach. Results: A total of 40 healthcare workers across Ekiti state were selected to participate in this study. Our study found the enablers of integrating COVID-19 into routine immunization to include demand generation and social mobilization, health education, health workers training, data validation, financing, and supervision. However, rumors, demand for incentives, Adverse Events Following Immunization (AEFI), manpower shortage, poor internet network services, and bad road networks were reported as barriers to integrating COVID-19 vaccination into routine immunization in Ekiti state. Conclusion: While the enablers of integrating COVID-19 vaccination into routine immunization may outweigh its barriers, it is pertinent to know that the efforts towards integrating COVID–19 vaccination in the RI Program is a call to all stakeholders to ensure sustainability. The identified barriers in the study must be addressed to ensure a strengthened health system. Therefore, achieving a successful integration and uptake of vaccination/immunization is anchored on driving demand generation, social mobilization, health education, availability of healthcare workers, integrated supervision, and financing. [ABSTRACT FROM AUTHOR]

Purpose: Understanding the technical efficiency of health facilities is essential for an optimal allocation of scarce resources to primary health sectors. The COVID-19 pandemic may have further undermined levels of efficiency in low-resource settings. This study takes advantage of 2019 and 2020 data on characteristics of health facilities, health services inputs and output to examine the levels and changes in efficiency of Ghanaian health facilities. The current study by using a panel dataset contributes to existing evidence, which is mostly based on pre-COVID-19 and single-period data. Methods: The analysis is based on a panel dataset including 151 Ghanaian health facilities. Data Envelopement Analysis (DEA) technique was used to estimate the level and changes in efficiency of health facilities across two years.. Results: The results show a net increase of 26% in inputs, influenced mostly by increases in temporary non-clinical staff (131%) and attrition of temporary clinical staff and permanent non-clinical staff, 40% and 54% respectively. There was also a net reduction in output of 34%, driven by a reduction in in-patient days (37%), immunization (11%), outpatients visits and laboratory test of 9%. Nowithstanding the COVID-19 pandemic, the results indicate that 59 (39%) of sampled health facilities in 2020 were efficient, compared to 48 (32%) in 2019. The results also indicate that smaller-sized health facilities were less likely to be efficient compared to relatively bigger health facilities. Conclusion: Based on the findings, it will be essential to examine factors that accounted for efficiency improvements in some health facilities, to enable health facilities lagging behind to learn from those on the efficiency frontier. In addition, the findings emphasise the need for CHAG to work with health facility managers to optimise inputs allocation through a redistribution of staff. Most importantly, the findings are suggestive of the resilience of CHAG health facilities in responding to a health shock such as the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Polypharmacy and inappropriate drug use are associated with adverse health outcomes in older people. Collaborative interventions between geriatricians and general practitioners have demonstrated effectiveness in improving clinical outcomes for complex medication regimens in home-dwelling patients. Since 2012, Norwegian municipalities have established municipal in-patient acute care (MipAC) units, designed to contribute towards reducing the number of hospital admissions. These units predominantly serve older people who typically benefit from multidisciplinary approaches. The primary objective of this study is to evaluate the effect of cooperative medication reviews conducted by MipAC physicians, supervised by geriatricians, and in collaboration with general practitioners, on health-related quality of life and clinical outcomes in MipAC patients ≥ 70 years with polypharmacy. Additionally, the study aims to assess the carbon footprint of the intervention. Methods: This is a randomized, single-blind, controlled superiority trial with 16 weeks follow-up. Participants will be randomly assigned to either the control group, receiving usual care at the MipAC unit, or to the intervention group which in addition receive clinical medication reviews that go beyond what is considered usual care. The medication reviews will evaluate medication appropriateness using a structured but individualized framework, and the physicians will receive supervision from geriatricians. Following the clinical medication reviews, the MipAC physicians will arrange telephone meetings with the participants' general practitioners to combine their assessments in a joint medication review. The primary outcome is health-related quality of life as measured by the 15D instrument. Secondary outcomes include physical and cognitive functioning, oral health, falls, admissions to healthcare facilities, and mortality. Discussion: This study aims to identify potential clinical benefits of collaborative, clinical medication reviews within community-level MipAC units for older patients with polypharmacy. The results may offer valuable insights into optimizing patient care in comparable municipal healthcare settings. Trial registration: The study was registered prospectively on ClinicalTrials.gov 30.08.2023 with identifier NCT06020391. [ABSTRACT FROM AUTHOR]

Background: Community health workers (CHWs) remain an underutilized resource in social risk diagnostics in the primary care setting. This process evaluation study seeks to assess the role of CHWs in social risk screening, referral, and follow-up through process mapping to identify barriers to the process for future quality improvement efforts. Methods: Researchers at the Arizona Prevention Research Center (AzPRC) engaged with two Federally Qualified Health Centers (FQHCs) in two of Arizona's major urban areas to evaluate their internal processes for social risk screening and intervention. The Consolidated Framework for Implementation Research (CFIR) was used to direct a process mapping exercise to visually describe the workflow, gaps, and barriers to identifying and addressing social risk. Results: The process unveiled key areas for health system improvements in the community setting, the organizational setting, and in the implementation of social risk screening, referral, and follow-up. Further, process maps highlight the potential resources needed for effective CHW integration to address social risk in the primary care setting. Conclusions: Our findings demonstrate the importance of organizational tools, such as process mapping, to assist primary care settings in evaluating internal processes for quality improvement in addressing social risk and in effectively integrating the CHW workforce. Subsequent research will evaluate rates of social risk screening, referral, and follow-up within all of Arizona's FQHCs and propose models for CHW integration to address social risk in primary care and strengthen social risk screening reach and effectiveness. [ABSTRACT FROM AUTHOR]

Background: Tajikistan has embarked on health reforms to orient the health system towards primary health care (PHC). The health labour market analysis (HLMA) was initiated by the Ministry of Health with the World Health Organization (WHO) on policy questions related to the PHC workforce team. This article presents the results with focus on family doctors as a critical part of the PHC team, providing lessons for strengthening family medicine and PHC in the European Region and central Asia. Methods: The HLMA framework was used to guide the analysis. The data for analysis were provided by the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan. Descriptive means were used to analyse the data. A Technical Working Group guided the process. Results: There has been an increase in the number of health workers in the country over the last 7 years. However, there is a huge shortage of family doctors when compared with norms, with decreasing family doctor densities over the last 7 years. Family doctors have the highest vacancy rates among specialists and also constitute the highest proportion of specialists who migrate. There is inequitable distribution of doctors across the regions. Overall number of enrolments and graduates in family medicine are declining. Although salaries in PHC are higher than in hospitals, the overall health workforce salaries are lower than the national average. While there have been efforts to retain and attract doctors to PHC in rural and remote regions, challenges exist. The attraction of doctors to narrow specialties may be leading to undermining PHC and family medicine. While the optimal skill-mix and availability of nurses provide an opportunity to strengthen multi-disciplinary teams at the PHC level, shortages and unequal distribution of doctors are affecting health services coverage and health indicators. Conclusions: Application of the HLMA framework has helped identify the bottlenecks in the health labour market flows and the possible explanations for them. The policy considerations emerging out of the HLMA have contributed to improving evidence-based planning for retention and recruitment of the PHC workforce, improvements in medical and nursing education, and higher investments in the PHC workforce and particularly in family doctors. Implementation of the Action Plan will require political commitment, financial resources, strong inter-sectoral collaboration, stakeholder management, and cross-country learning of best practices. Through this process, Tajikistan has shown the way forward in implementing the Central Roadmap for health and well-being in Central Asia and the Framework for Action on the Health and Care Workforce in the WHO European Region. [ABSTRACT FROM AUTHOR]

Background: Countries with formal policies for palliative care, and advanced and integrated practices in this field, such as Portugal, face challenges in achieving excellence in care, particularly in home-based assistance. Issues include care coordination among providers, confusion regarding the roles of each health care professional in the network, and a lack of monitoring and evaluation of actions. Our objective was to analyze the implementation of palliative care in primary health care in Portugal. Methods: We conducted a qualitative, descriptive, and exploratory study in Portugal involving health care professionals with experience in palliative care. The data were collected through semistructured interviews and focus groups between March and October 2023. Eighteen health care professionals participated. We used the Alceste software for lexicographic analysis. The research was authorized by an Ethics Committee. Results: Four classes were identified; classes 1 and 2, comprising 77% of the corpus, addressed the study objectives. Participants highlighted inequitable access, strategic development plans with unattainable short-term goals; and low literacy. They emphasized the importance of legislation, professional training initiatives for generalist palliative care at home, and early referral. Home-based challenges included professionals' lack of exclusive dedication, absence of 24/7 coverage, and unavailability of capable family caregivers. The networks' response to hospital admissions and patient transitions from hospital to home, with access to the specialized team, was also inadequate. Conclusions: Health care professionals aim to increase patients' time spent at home, reduce emergency department visits, and minimize hospitalizations by leveraging the resources of the national palliative care network. In addition to investments to sustain network implementation and legally guaranteed palliative care rights, the country must focus on measurable indicators for evaluating and monitoring actions, providing better guidance in the short, medium, and long term. [ABSTRACT FROM AUTHOR]

Background: Geriatric assessment (GA) is a multidimensional process that disrupts the primary health care (PHC) referral system. Accessing consistent data is central to the provision of integrated geriatric care across multiple healthcare settings. However, due to poor-quality data and documentation of GA, developing an agreed minimum data set (MDS) is required. Therefore, this study aimed to develop a GA-MDS in the PHC referral system to improve data quality, data exchange, and continuum of care to address the multifaceted necessities of older people. Methods: In our study, the items to be included within GA-MDS were determined in a three-stepwise process. First, an exploratory literature search was done to determine the related items. Then, we used a two-round Delphi survey to obtain an agreement view on items to be contained within GA-MDS. Finally, the validity of the GA-MDS content was evaluated. Results: Sixty specialists from different health geriatric care disciplines scored data items. After, the Delphi phase from the 230 selected items, 35 items were removed by calculating the content validity index (CVI), content validity ratio (CVR), and other statistical measures. Finally, GA-MDS was prepared with 195 items and four sections including administrative data, clinical, physiological, and psychological assessments. Conclusions: The development of GA-MDS can serve as a platform to inform the geriatric referral system, standardize the GA process, and streamline their referral to specialized levels of care. We hope GA-MDS supports clinicians, researchers, and policymakers by providing aggregated data to inform medical practice and enhance patient-centered outcomes. [ABSTRACT FROM AUTHOR]

Background: Healthcare workers (HCWs) including community health extension workers (CHEWs) in the Federal Capital Territory, Nigeria participated in a hypertension training series following the Extension for Community Healthcare Outcomes (ECHO) model which leverages technology and a practical peer-to-peer learning framework to virtually train healthcare practitioners. We sought to evaluate the patient-level effects of the hypertension ECHO series. Methods: HCWs from 12 of 33 eligible primary healthcare centers (PHCs) in the Hypertension Treatment in Nigeria Program (NCT04158154) were selected to participate in a seven-part hypertension ECHO series from August 2022 to April 2023. Concurrent Hypertension Treatment in Nigeria Program patient data were used to evaluate changes in hypertension treatment and control rates, and adherence to Nigeria's hypertension treatment protocol. Outcomes were compared between the 12 PHCs in the ECHO program and the 21 which were not. Results: Between July 2022 and June 2023, 16,691 PHC visits were documented among 4340 individuals (ECHO: n = 1428 [33%], non-ECHO: n = 2912 [67%]). Patients were on average (SD) 51.5 (12.0) years old, and one-third were male (n = 1372, 32%) with no differences between cohorts in either characteristic (p ≥ 0.05 for both). Blood pressures at enrollment were higher in the ECHO cohort compared to the non-ECHO cohort (systolic p < 0.0001 and diastolic p = 0.0001), and patients were less likely to be treated with multiple medications (p < 0.0001). Treatment rates were similar at baseline (ECHO: 94.0% and Non-ECHO: 94.7%) and increased at a higher rate (interaction p = 0.045) in the ECHO cohort over time. After adjustment for baseline and within site variation, the difference was attenuated (interaction p = 0.37). Over time, control rates increased and medication protocol adherence decreased, with no differences between cohorts. Staffing levels, adult patient visits, and rates of hypertension screening and empanelment were similar between ECHO and non-ECHO cohorts (p ≥ 0.05 for all). Conclusions: The ECHO series was associated with moderately increased hypertension treatment rates and did not adversely affect staffing or clinical capacity among PHCs in the Federal Capital Territory, Nigeria. These results may be used to inform strategies to support scaling hypertension education among frontline HCWs throughout Nigeria, and use of the ECHO model for CHEWs. Trial Registration: The Hypertension Treatment in Nigeria Program was prospectively registered on November 8, 2019 at www.clinicaltrials.gov (NCT04158154; https://clinicaltrials.gov/ct2/show/NCT04158154). [ABSTRACT FROM AUTHOR]

Background: Youth mental health is a growing concern in research, practice, and policy. Practice standards, guidelines, or strategies provide an invisible infrastructure that fosters equity, quality, and safety, potentially addressing inconsistencies and more effectively attending to the mental wellness of Black youth as a particular population of concern. This scoping review aimed to address the following question: What standards exist for the delivery of mental health services to Black youth in community, primary care, and educational settings? Due to a limited initial search yield on publications about standards for the delivery of mental health services for Black youth population, our goal was then to identify and map mental health standards, recommendations, or guidelines for the delivery of mental health services using the same settings to all youth. Methods: Searches were conducted in various databases, including PubMed/MEDLINE, PsycINFO, Embase, SocINDEX, CINAHL, Gender Studies Database, Social Services Abstracts, Sociological Abstracts, Scopus, Web of Science, and Google Scholar. Screening was independently conducted by two reviewers, with disagreements resolved by a third. Information extraction was performed by two independent reviewers. Results: Out of the 2,701 screened publications, 54 were included in this scoping review. Among them, 38.9% were published between 2020 and 2023, with 40.7% originating from the United States of America, 20.4% from the United Kingdom, and 13% from Canada. Concerning the settings, 25.9% of the publications focused on primary care, 24.1% on health care services, 20.4% on educational settings, and 3.7% on the community. Additionally, 25.9% were classified as general because recommendations were applicable to various settings. Attention-deficit/hyperactivity disorder (11.1%) was the most frequently considered specific condition, followed by autism spectrum disorder (9.3%) and depression (9.3%). However, 31.5% of the included references addressed mental health in general. Only three references provided specific recommendations for the Black population. Conclusions: Recommendations, guidelines, or standards for Black youth mental health services in community, primary care, or educational settings are scarce and limited to North American countries. This scoping review emphasizes the need to consider ethnicity when developing guidelines or standards to improve racial equity and reduce disparities in access to mental health services. [ABSTRACT FROM AUTHOR]

Background: The onset of the COVID-19 pandemic drove a rapid and widespread shift to virtual care, followed by a gradual return to in-person visits. Virtual visits may offer more convenient access to care for some, but others may experience challenges accessing care virtually, and some medical needs must be met in-person. Experiences of the shift to virtual care and benefits of in-person care may vary by immigration experience (immigration status and duration), official language level, and age. We examined use of virtual care and return to in-person visits in the Canadian province of British Columbia (BC), comparing patterns by age and across immigration groups, including length of time in Canada and language level (official languages English and French) at time of arrival. Methods: We used linked administrative health and immigration data to examine total primary care visits (virtual or in-person) and return to in-person visits during the COVID-19 pandemic (2019/20–2021/2) in BC. We examined the proportion of people with any primary care visits and with any in-person visits within each year as measures of access to primary care. We estimated the odds of any primary care visits and any in-person visits by immigration group and official language level assessed prior to arrival: non-immigrants, long-term immigrants, recent immigrants (< 5 years) with high assessed official language level and recent immigrants (< 5 years) with low assessed official language level (assessed prior to arrival), stratified by age. Results: In general, changes in access to primary care (odds of any visits and odds of any in-person visits) were similar across immigration groups over the study period. However, we observed substantial disparities in access to primary care by immigration group among people aged 60 + , particularly in recent immigrants with low official language level (0.42, 0.40–0.45). These disparities grew wider over the course of the pandemic. Conclusion: Though among younger adults changes in access to primary care between 2019–2021 were similar across immigration groups, we observed significant and growing inequities among older adults, with particularly limited access among adults who immigrated recently and with low assessed official language level. Targeted interventions to ensure acceptable, accessible care for older immigrants are needed. [ABSTRACT FROM AUTHOR]

Background: Relative to country-specific epidemiological trends, Kuwait experiences a far greater burden of type 2 diabetes among its population. Information behaviours form a significant component of self-care management for patients diagnosed with type 2 diabetes, however this remains an understudied aspect of disease management. This study aims to investigate the information behaviours of patients with type 2 diabetes in Kuwait, and characterise the methods employed to manage their disease. Methods: This qualitative study employed a grounded theory method. Semi-structured interviews were conducted with twenty-seven participants over three phases of data collection in primary, secondary and tertiary healthcare settings across Kuwait. These were complemented by in-depth interviews to detail the information behaviours of these participants. The interviews were translated where appropriate, transcripts, and analysed through qualitative coding to synthesise the information behaviour patterns. Results: The findings demonstrated that living with type 2 diabetes involved a range of developmental and transformative stages, including changes to the patients' emotional state, reconstruction of their lifestyle and identity, and changes in the ways they find and use information. Living with the chronic condition was viewed as a dynamic and transitional process, where patients' information behaviours continually changed throughout the process across various identifiable stages. This dynamic pattern was reflected most prominently across the participants' behavioural needs, sources and information-seeking patterns. Conclusion: Patients with type 2 diabetes continuously adapted their information behaviours to optimise the self-management of their condition across a relatively predictable pattern. Greater understanding of these behaviours across a wider population would improve the provision of clinical care for patients with diabetes. [ABSTRACT FROM AUTHOR]

Background: Chronic, non-malignant diseases (CNMD) like chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia in advanced stages are very burdensome for patients. Timely palliative care with strong collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams can reduce symptom burden, hospitalization rates, hospitalization costs and overall healthcare costs. The KOPAL-study on strengthening interprofessional collaboration for patients with palliative care needs tested the effect of an intervention comprising of a SPHC nurse assessment and an interprofessional case conference. This qualitative evaluative study explores patients', proxies' and their associates' motivation to participate in the KOPAL-study and views on the (benefits of the) intervention. Methods: We interviewed 13 male and 10 female patients as well as 14 proxies of patients with dementia and six associates of study participants using a semi-structured interview guide. All interviews were digitally recorded, transcribed verbatim and analysed with deductive-inductive qualitative content analysis. Results: Motivation for participation was driven by curiosity, the aim to please the GP or to support research, respectively to help other patients. Few interviewees pointed out to have expected positive effects for themselves. The nurse visit was evaluated very positively. Positive changes concerning health care or quality of life were reported sparsely. Most study participants did not prepare for the SPHC nurse assessment. They had no expectations concerning potential benefits of such an assessment, the interdisciplinary case conference and an early integration of palliative care. The majority of interviewees reported that they did not talk about the nurse visit and the interprofessional case conference with their GPs. Conclusion: Our results lead to the conclusion that SPHC nurses can serve as an advocate for the patient and thereby support the patients' autonomy. GPs should actively discuss the results of the interdisciplinary case conference with patients and collaboratively decide on further actions. Patient participation in the interdisciplinary case conference could be another way to increase the effects of the intervention by empowering patients to not just passively receive the intervention. Trial registration: DRKS00017795 German Clinical Trials Register, 17Nov2021, version 05. [ABSTRACT FROM AUTHOR]

Background: Primary health care is the first point of contact for patients from refugee backgrounds in the Australian health system. Sociocultural factors, including beliefs and value systems, are salient determinants of health literacy and access to primary health care services. Although African refugees in Australia have diverse sociocultural backgrounds, little is known about the influence of sociocultural factors on their experiences of accessing primary health care services. Guided by the theoretical framework of access to health care, this study examined from the perspective of African refugees how culturally and religiously conditioned, constructed and bound health beliefs, knowledge and practices influence their experiences of access to, acceptance and use of primary health care services and information in Australia. Methods: This exploratory, qualitative study involved 19 African refugees from nine countries living in New South Wales, Australia. Semi-structured interviews were conducted and recorded using Zoom software. The interviews were transcribed verbatim and analysed using a bottom-up thematic analytical approach for theme generation. Results: Four main themes were identified. The themes included: participants' experiences of services as inaccessible and monocultural and providing information in a culturally unsafe and insensitive manner; the impact of the clinical care environment; meeting expectations and needs; and overcoming access challenges and reclaiming power and autonomy through familiar means. The findings generally support four dimensions in the access to health care framework, including approachability, acceptability, availability and accommodation and appropriateness. Conclusion: African refugees experience significant social and cultural challenges in accessing primary health care services. These challenges could be due to a lack of literacy on the part of health services and their providers in servicing the needs of African refugees. This is an important finding that needs to be addressed by the Australian health care system and services. Enhancing organisational health literacy through evidence-informed strategies in primary health systems and services can help reduce disparities in health access and outcomes that may be exacerbated by cultural, linguistic and religious differences. [ABSTRACT FROM AUTHOR]

Introduction: Adolescent mothers require trauma- and violence-informed care during the perinatal period due to trauma histories and ongoing violence as a result of pregnancy. Nurses and midwives play a critical role in caring for adolescent mothers in primary healthcare settings in Rwanda in the perinatal period. Purpose: To explore the experiences of nurses and midwives working with adolescent mothers in selected primary healthcare settings in Rwanda to inform the delivery of trauma- and violence- informed care. Methods: This study utilized an interpretive description qualitative approach and was conducted in eight primary healthcare settings in Rwanda. Twelve nurses and midwives working in perinatal services and four heads of health centers participated in in-depth individual interviews. Data were analyzed thematically. Results: The analysis revealed four main themes and 11 (sub-themes): (a) relational practice (being creative and flexible, "lending them our ears"); (b) individual challenges of providing care to adolescent mothers (lack of knowledge to provide care related to gender-based violence, and gendered experience); (c) factors contributing to workarounds (inflexible guidelines, lack of protocol and procedures, lack of nurses' and midwives' in service training, and the physical structure of the perinatal environment); and (d) vicarious trauma (living the feelings, "I carry their stories home," and hypervigilance in parenting). Conclusion: Nurses and midwives find caring for adolescent mothers challenging due to their unique needs. These needs require them to be creative, adaptable, and attentive listeners to better understand their challenges. These practitioners face difficulties such as insufficient specific knowledge related to, for example, gender-based violence, inflexible guidelines, and a lack of protocols and training. Additionally, in the perinatal environment attention to the needs of practitioners in those settings is often lacking, and many nurses and midwives report experiencing vicarious trauma. Consequently, there is a pressing need for guidelines and protocols specifically tailored for the care of adolescent mothers. Ongoing trauma- and violence- informed care training and professional education should be provided to enhance the ability of nurses and midwives to care for adolescent mothers and prevent re-traumatization and mitigate vicarious trauma effectively. [ABSTRACT FROM AUTHOR]