Guidelines for interprofessional practice in rehabilitation at primary health care level

Health care is costly and there is need for rational use of health care resources for the world to achieve universal health coverage (UHC). The preventive Primary Health Care (PHC) service is cheaper than the Secondary Health Care (SHC). PHC is strengthened through gatekeeper system, so the emphasis on the PHC for cost control is self-explanatory. This study aimed at determining the efficiency and organizational arrangements using human resources for health (HRH), laboratory services and supply of drugs as the performance indicators that determined rational use of resources in Machakos County, Kenya. This was a convergent parallel mixed methods cross-sectional study that employed qualitative and quantitative data collection techniques. The study targeted facility health managers in charges and policy implementers namely the Chief Officer of health, the Director of Prevention and PHC and the Medical Superintendents and patients seeking health care. A response rate of 83%was achieved (n=83), of whom 84.3% were nurses and 15.7% diploma medicine practitioners. Over (70%) of the health facilities had less than 3professional health workers. Exactly 75% of the community-based self-referrals cases would be treated at PHC level. Self referrals were largely due to patients’ perceived need for laboratory services (53.8%) and medicines (60%). On the contrary, 89.6% of the residents of Machakos County, Kenya were informed about PHC services, 91.7% were accessible to PHC and 93.7% had faith in health care providers at PHC level. The HRH, diagnostic equipment and essential drugs were not the main reasons for self-referrals, but perceived needs for drugs and laboratory services. The inverse and disproportionate attendances of patients at both PHC and SHC levels caused dissonance in service delivery and subsequent inefficiency in service delivery in Machakos County, Kenya. Proper supervision and implementation of referral policy available at county level should be emphasized.

BackgroundIn Kenya, cardiovascular diseases (CVDs) accounted for more than 10% of total deaths and 4% of total Disability-Adjusted Life Years (DALYs) in 2015 with a steady increase over the past decade. The main objective of this paper was to review the existing policies and their content in relation to prevention, control and management of CVDs at primary health care (PHC) level in Kenya.MethodsA targeted document search in Google engine using keywords “Kenya national policy on cardiovascular diseases” and “Kenya national policy on non-communicable diseases (NCDs)” was conducted in addition to key informant interviews with Kenyan policy makers. Relevant regional and international policy documents were also included. The contents of documents identified were reviewed to assess how well they aligned with global health policies on CVD prevention, control and management. Thematic content analysis of the key informant interviews was also conducted to supplement the document reviews.ResultsA total of 17 documents were reviewed and three key informants interviewed. Besides the Tobacco Control Act (2007), all policy documents for CVD prevention, control and management were developed after 2013. The national policies were preceded by global initiatives and guidelines and were similar in content with the global policies. The Kenya health policy (2014–2030), The Kenya Health Sector Strategic and Investment Plan (2014–2018) and the Kenya National Strategy for the Prevention and Control of Non-communicable diseases (2015–2020) had strategies on NCDs including CVDs. Other policy documents for behavioral risk factors (The Tobacco Control Act 2007, Alcoholic Drinks Control (Licensing) Regulations (2010)) were available. The National Nutrition Action Plan (2012–2017) was available as a draft. Although Kenya has a tiered health care system comprising primary healthcare, integration of CVD prevention and control at PHC level was not explicitly mentioned in the policy documents.ConclusionThis review revealed important gaps in the policy environment for prevention, control and management of CVDs in PHC settings in Kenya. There is need to continuously engage the ministry of health and other sectors to prioritize inclusion of CVD services in PHC.

Leadership and governance are key components of health systems, nevertheless research into leadership and governance of mental healthcare at the Primary Health Care (PHC) level is probably the least well researched and understood part of these systems. As part of assessing the integration of mental health at the PHC level in Ghana, the leadership and governance organisation and structures to ensure supervision and coordination were examined. A concurrent triangulation mixed-methods design involving both quantitative and qualitative research methods approach was adopted. The quantitative data were collected through a questionnaire, self-administered or interviewer administered, on 1010 respondents with 830 completed (response rate 82%). Key informant interviews and focus group discussions were used to collect the qualitative data. Thematic content analysis utilising NVivo 12 was applied for the qualitative field data. Stata SE16 was used for quantitative data. Data triangulation strategy was used to report the qualitative and quantitative results. The study showed that leadership and governance of mental health at the PHC level were partially developed, with a composite mean score of 2.53, due to the modest level of awareness of the Mental Health Law, inadequate functioning and coordination of mental health units, low private sector participation in mental health care services, and low levels of monitoring, supervision, and evaluation. This affected the integration of mental health at the PHC level, which was also gauged as low. The study concludes that despite the presence of legislation and policy aiming to achieve decentralised and integrated mental health services at the PHC level, mental health care is still a low-level priority within the health care system in Ghana and tends to operate within a silo. The study recommends that more practical and concerted leadership of mental health at the regional and district levels is required to drive decentralisation and integration at these levels.

Introduction: Scorpion envenomation is a life-threatening paediatric emergency. Prazosin-an alpha-1 blocker is the gold standard therapy for scorpion envenomation. Many children with scorpion envenomation were under-treated at Primary Healthcare (PHC) and Secondary Healthcare (SHC) level because of lack of awareness about prazosin therapy. If prazosin is started earlier at PHC and SHC level, complications and mortality can be reduced. Aim: To conduct sensitisation programme for PHC and SHC doctors regarding the management of paediatric emergencies including scorpion envenomation, and to evaluate the effectiveness of sensitisation programme on prazosin therapy for scorpion envenomation at PHC and SHC level. Materials and Methods: This non concurrent clinical trial consisted of training PHC and SHC doctors at the Department of Paediatrics, Government Dharmapuri Medical College Hospital, Tamil Nadu, India for a period of two years (January 2018-December 2019). After the training, children aged 1 month-12 years with features of scorpion envenomation referred from PHC and SHC to this tertiary care centre, during January 2021-September 2021 were evaluated. The data regarding initiation of prazosin therapy at PHC and SHC level and the clinical profile, complications and outcome at tertiary care level were noted. The present study parameters were compared with previous study on scorpion envenomation, done before the sensitisation programme in the same centre, and the data were compared. Results: Training was given to 120 medical officers of PHC and SHC. Sixty-two children, with scorpion envenomation referred from PHC and SHC, were included in the study. A total of 7 (10%) children brought to the tertiary care centre directly were excluded. Prazosin therapy was initiated in 43 (69.3%) children at PHC and SHC level before referral. Initiation of prazosin within four hours of scorpion sting was done in 45 (72.6%). Common symptoms were pain {42 (68%)}, diaphoresis {26 (42%)} and salivation {25 (40%)}. Cold peripheries, myocarditis and pulmonary oedema were noted in 24 (39%), 4 (6%) and 6 (10%) children, respectively. Dobutamine and Non Invasive Ventilation (NIV) were needed in 13 (21%) and 11 (18%) cases, respectively. When compared to the observations pretraining, peripheral circulatory failure (76% to 39%) (p=0.019), pulmonary oedema (27% to 10%) (p=0.010), myocarditis (17% to 6%) (p=0.039), ionotrope support (41% to 21%) (p=0.024), and NIV (39% to 18%) (p<0.003) were significantly reduced. There was no mortality. Conclusion: Following the sensitisation programme, initiation of prazosin for scorpion envenomation at PHC and SHC level significantly improved. Complications like myocarditis, pulmonary oedema, need for inotropes and ventilator support decreased significantly.

BackgroundThere is a recognised need for rehabilitation services at primary health care (PHC) level. In addition, there are clear policies (international and national) and guidelines for use by healthcare planners in South Africa to implement rehabilitation services. Although rehabilitation services are provided on the primary platform, its operationalisation has not been in an integrated manner. Clarity on the level of integration within existing PHC rehabilitation service delivery is required for its inclusion in a reengineered PHC.AimThe study explored the extent to which rehabilitation services are integrated into PHC service delivery based on the expressed reality of rehabilitation professionals.SettingThe Johannesburg Metropolitan District of Gauteng, South Africa.MethodsIn-depth interviews with 12 PHC rehabilitation professionals were completed to elicit their experiences with PHC rehabilitation services.ResultsThe theme the current state of rehabilitation services – ‘this is the reality; you need to do what you need to do’ along with its two subcategories, was generated from this study. The theme describes the expressed reality of suboptimal, underdeveloped and poorly integrated rehabilitation services within the Johannesburg Metropolitan District. Rehabilitation service providers have adapted service delivery by including isolated components of rehabilitation integration models, but this has not yielded an integrated service.ConclusionRehabilitation services although recognised as a crucial service in PHC must be critically analysed and adapted to develop integrated service delivery models. There should be a shift from selected coping mechanisms to targeted, integrated services.ContributionThe study describes PHC rehabilitation services and explores best practice models for integrated service planning and delivery.

Increasing functional limitations and disabilities have raised the need for comprehensive rehabilitation services at the primary healthcare (PHC) level, particularly in low- and middle-income countries. To support the integration of these services into PHC in South Africa, assessing outcomes from the service users' perspectives is essential. This study examined service users' views on their PHC rehabilitation outcomes in a Metropolitan District of Gauteng, South Africa. The aim was to understand perceived changes in activity limitations and participation restrictions following the rehabilitation intervention. A quantitative survey design, including self-rating measurements and structured interviews, was employed. Thirty-eight rehabilitation service users from eight clinics and community health centres were purposively sampled. Participants rated their pre- and post-rehabilitation levels of difficulty in activity limitations and participation restrictions, with open-ended questions providing additional insights. Data analysis used descriptive statistics, quantitative content analysis, and non-parametric tests. Significant improvements in mobility, self-perception, and quality of life were reported by both adult and child service users. Caregivers of child service users also noted positive experiences (p = 0.019) in community, social, and civic life. This study highlights the perceived positive changes experienced by PHC rehabilitation service users in addressing functional limitations and disabilities. It underscores the effectiveness of integrated rehabilitation service delivery in improving user outcomes. The findings offer valuable insights into how rehabilitation interventions enhance functional abilities, social participation, and overall well-being. By focusing on activity limitations and participation restrictions from service users' perspectives, this study supports the priority of providing person-centred rehabilitation services at the PHC level.

The low health outcomes and inequities problems in developing countries are due to ineffective gate keeping at the Primary Health Care (PHC) level, non-adherence to policy and dysfunctional health infrastructure. This study was conducted at 100 PHC centres sampled using Taro Yamane formula, in Machakos County, Kenya, from March to May 2015. It involved 8 gender-based focus group discussions (FGDs) with patients and their caretakers. Qualitative and quantitative data were collected from emancipated children and adults aged 15-65 years excluding the disabled due to data integrity issues. The Statistical Package for Social Science (SPSS) version 20.0 and Atlas.ti 7 software were used for data analysis. Correlation was done using the Spearman rho test and significance was set at <0.05. A questionnaire return rate of 83% was achieved of whom 84.3% were nurses (p<0.001) nurses and 15.7% were diploma holders in clinical medicine (clinical officers). The health workers were young (P<0.001) and married (p<0.001). A proportional relationship (rho=0.383, p< .001) existed between the number of out-patients received and cases referred to hospitals. Most gatekeepers were ignorant (p=0.04) about the Policy on the patients’ referral yet they did not officially refer patients (80.7%). Most (63.5%) of the hospitals receiving self-referrals did not ask for referral letters. Policy and referral letters were found to be necessary (p=0.004). The gatekeepers’ non-adherence to policy, lack of laboratory services and shortages of drugs contributed to self-referral by patients, creating a burden on the resources for healthcare, resulting in inefficiency at the PHC level. This study recommends a review of the gatekeeping system at the PHC level, capacity building, quality assurance, redefinition and strengthening of the office of the gatekeepers, regularization of supplies and reinforcement of the patient referral policy, staff motivation and best practices in customer care.

To assess knowledge and practice of primary eye care among primary healthcare workers known as community health extension workers in Funtua district of Nigeria. Cross-sectional mixed method study among health workers employed in government-owned primary healthcare facilities. Quantitative data were obtained using self-administered questionnaires and checklists, while qualitative data by modified Delphi technique, role plays and observation. A score of 1 was given for each correct answer, while a total score of ≥60% was considered 'good'. Eighty three of 88 health workers participated (94%) in the questionnaire survey; while 16 of them were selected for the qualitative survey. Good scores regarding the knowledge of common eye diseases were obtained by 68.7%, but only 26.4% of them could identify their most important features. Participants could undertake 3 of 5 steps in visual acuity testing. Skills in recognising common eye diseases and their management were weak; while practice was often not according to the guidelines. Community health extension workers displayed good knowledge of common eye diseases. Areas of weakness are recognition and interpretation of eye signs, and practice rarely follows the guidelines. Preventive medicine was neglected; community health extension workers require practical retraining and supervision to achieve integration of primary eye care into primary healthcare services.

Despite the 1990 reforms to the health system in Namibia, mental health still receives low priority. Coupled with limited resources, health policies are directed at addressing communicable and life-threatening diseases. On the primary health care (PHC) level, health care services are either completely absent or, at best, fragmented. Therefore, an assessment of the implementation of the mental health policy that was launched in 2005 in the Oshana region of Namibia was undertaken in order to assess the extent to which the mental health policy had been implemented. The aim of the study was to explore and describe the extent of implementation and identify the challenges faced by nurses in PHC settings. A quantitative, explorative, descriptive design was used, where a total of 42 nurse from 13 health facilities in the Oshana region were conveniently included in the study. Data were collected using a self-administered questionnaire that included both open and closed-ended items. The study found that health care workers on the ground were expected to implement the policy, without have been provided with the crucial tools for implementing it, such as training, implementation guidelines, supervision, infrastructure to support the services and the materials needed to provide the services. In addition, although 77% of the research participants had received training in mental health, none expressed confidence in delivering mental health services on a PHC level. As a result, such services are not available in 94% of the health facilities in the region. This finding supports Gilson et al.’ s (2008) bottom-up model of policy implementation, which holds that in order to implement a policy fully and successfully, sufficient resources for implementation at multiple levels are required The findings call for articulated plans to address the challenges experienced in mental health policy implementation in Namibia in order to allow for the early identification of the burden associated with mental disorders.

The past decade witnessed momentum toward redesigning the U.S. health care system with the intent to improve quality of care. To achieve and sustain this change, health professions education must likewise reform to prepare future practitioners to optimize their ability to participate in the new paradigm of health care delivery. Recognizing that interprofessional education (IPE) is gaining momentum as a crucial aspect of health care professions training, this article provides an introduction to IPE programs from three different academic health centers, which were developed and implemented to train health care practitioners who provide patient-centered, collaborative care. The three participating programs are briefly described, as well as the processes and some lessons learned that were critical in the process of adopting IPE programs in their respective institutions. Critical aspects of each program are described to allow comparison of the critical building blocks for developing an IPE program. Among those building blocks, the authors present information on the planning processes of the different institutions, the competencies that each program aims to instill in the graduates, the snapshot of the three curricular models, and the assessment strategies used by each institution. The authors conclude by providing details that may provide insight for academic institutions considering implementation of IPE programs.

BackgroundChronic kidney disease (CKD) is a significant public health concern in KwaZulu-Natal (KZN), exacerbated by a high burden of HIV, diabetes and hypertension, and compounded by socioeconomic barriers that limit access to preventative healthcare. With KZN accounting for 20% of South Africa’s dialysis patients, strengthening CKD management at the primary healthcare (PHC) level is crucial.AimThe study used a qualitative phenomenological approach to explore healthcare providers’ (HCPs) lived experiences with CKD management in PHC settings in KZN, focusing on perceived barriers, facilitators and implementation realities.MethodA qualitative phenomenological approach was used to explore the lived experiences of HCPs managing CKD in PHC settings in KZN, South Africa. Through semi-structured interviews, the study examined perceived barriers, facilitators and real-world challenges influencing the implementation of CKD interventions and guideline adherence.ResultsThe study uncovered five key themes reflecting HCPs experiences with CKD guideline implementation at the PHC level: inconsistent guideline awareness and adherence, inadequate training, challenges in early detection because of limited resources, the importance of team-based care and patient involvement, and broader systemic and community-level barriers. Participants underscored the need for improved training, resource allocation and integrated care approaches.ConclusionImplementation gaps stem from limited awareness, inadequate training and systemic barriers. Strengthening early detection, capacity building and team-based care is key to improving CKD management in PHC.ContributionThe study offers practical insights into implementation challenges, guiding policymakers and PHC managers in enhancing CKD care in resource-limited settings.

BackgroundHypertension remains the top global cause of disease burden. Decision support systems (DSS) could provide an adequate and cost-effective means to improve the management of hypertension at a primary health care (PHC) level in a developing country, nevertheless evidence on this regard is rather limited.MethodsDevelopmentofDSSsoftware was based on an algorithmic approach for (a) evaluation of a hypertensive patient, (b) risk stratification (c) drug management and (d) lifestyle interventions, based on Indian guidelines for hypertension II (2007). The betatestingofDSSsoftware involved a feedback from the end users of the system on the contents of the user interface. Softwarevalidation and piloting was done in field, wherein the virtual recommendations and advice given by the DSS were compared with two independent experts (government doctors from the non-participating PHC centers).ResultsThe overall percent agreement between the DSS and independent experts among 60 hypertensives on drug management was 85% (95% CI: 83.61 - 85.25). The kappa statistic for overall agreement for drug management was 0.659 (95% CI: 0.457 - 0.862) indicating a substantial degree of agreement beyond chance at an alpha fixed at 0.05 with 80% power. Receiver operator curve (ROC) showed a good accuracy for the DSS, wherein, the area under curve (AUC) was 0.848 (95% CI: 0.741 - 0.948). Sensitivity and specificity of the DSS were 83.33 and 85.71% respectively when compared with independent experts.ConclusionA point of care, pilot tested and validated DSS for management of hypertension has been developed in a resource constrained low and middle income setting and could contribute to improved management of hypertension at a primary health care level.

BackgroundMental health-related stigma is a global public health concern and a major barrier to seeking care. In this study, we explored the role of stigma as a barrier to scaling up mental health services in primary health care (PHC) centres in Lebanon. We focused on the experiences of Healthcare Providers (HCPs) providing services to patients with mental health conditions (MHCs), the views of policy makers, and the perceptions of stigma or discrimination among individuals with MHCs. This study was conducted as part of INDIGO-PRIMARY, a larger multinational stigma reduction programme.MethodsSemi-structured qualitative interviews (n = 45) were carried out with policy makers (n = 3), PHC management (n = 4), PHC staff (n = 24), and service users (SUs) (n = 14) between August 2018 and September 2019. These interviews explored mental health knowledge, attitudes and behaviour of staff, challenges of providing treatment, and patient outcomes. All interviews were coded using NVivo and a thematic coding framework.ResultsThe results of this study are presented under three themes: (1) stigma at PHC level, (2) stigma outside PHC centres, and (3) structural stigma. SUs did not testify to discrimination from HCPs but did describe stigmatising behaviour from their families. Interestingly, at the PHC level, stigma reporting differed among staff according to a power gradient. Nurses and social workers did not explicitly report incidents of stigma but described patients with MHCs as uncooperative, underscoring their internalized negative views on mental health. General practitioners and directors were more outspoken than nurses regarding the challenges faced with mental health patients. Mental health professionals revealed that HCPs still hold implicitly negative views towards patients with MHCs however their attitude has improved recently. Our analysis highlights five layers of stigma affecting SUs.ConclusionThis qualitative study reveals that stigma was still a key concern that affects patients with MHC. SUs reported experiencing overt stigmatising behaviour in the community but less explicit discrimination in a PHC setting. Our findings emphasise the importance of (1) combatting structural stigma through legal reform, (2) addressing interpersonal stigma, (3) committing PHC management to deliver high quality mental health integrated services, and (4) reducing intrapersonal stigma by building public empathy.

IntroductionThe weak health system is viewed as a major systematic obstacle to address the rising burden of non-communicable diseases (NCDs) in resource-poor settings. There is little information about the health system challenges and opportunities in organizing NCD services. This study examined the health system challenges and opportunities in organizing NCD services for four major NCDs (cervical cancer, diabetes mellitus, cardiovascular diseases, and chronic respiratory illnesses) at the primary healthcare (PHC) level in Bangladesh.MethodsUsing a qualitative method, data were collected from May to October 2021 by conducting 15 in-depth interviews with local healthcare providers, 14 key informant interviews with facility-based providers and managers, and 16 focus group discussions with community members. Based on a health system dynamics framework, data were analyzed thematically. Information gathered through the methods and sources was triangulated to validate the data.ResultsOrganization of NCD services at the PHC level was influenced by a wide range of health system factors, including the lack of using standard treatment guidelines and protocols, under-regulated informal and profit-based private healthcare sectors, poor health information system and record-keeping, and poor coordination across healthcare providers and platforms. Furthermore, the lack of functional referral services; inadequate medicine, diagnostic facilities, and logistics supply; and a large number of untrained human resources emerged as key weaknesses that affected the organization of NCD services. The availability of NCD-related policy documents, the vast network of healthcare infrastructure and frontline staff, and increased demand for NCD services were identified as the major opportunities.ConclusionDespite the substantial potential, the health system challenge impeded the organization of NCD services delivery at the PHC level. This weakness needs be to addressed to organize quality NCD services to better respond to the rising burden of NCDs at the PHC level.

Background Emergency care at a primary health care (PHC) level must be strengthened to reduce overall mortality and morbidity in any country. Developing recommendations for improvement in this area should take into consideration the context and nuances of the current emergency care system and primary health care context. Contribution to policy from the experts in the cross-cutting fields of PHC and emergency care is lacking. Objectives This study aims to evaluate the strengths and weaknesses of emergency care in primary health settings and develop consensus-based recommendations for the strengthening of emergency care at this level. Methods Using a modified Delphi technique, data were collected from various data sources to evaluate the strengths and weaknesses of emergency care at PHC level, from which recommendation statements were developed. These recommendations were proposed to a panel of experts using a Delphi survey to build consensus on 14 recommendations to strengthen emergency care at PHC level. Results Ten experts were recruited to participate (n = 10) with a response rate of 90% in round II and 80% in round III of Delphi. Recommendations broadly addressed the areas of education and training in emergency care, the role and placement of various actors, leadership in emergency care and the development of a national plan for emergency care. Consensus was reached in round II for 97.61% of the statements and after modification based on open-ended comments, 98.21% consensus was reached in round III. Conclusion Strengthening emergency care at primary and subsequent levels of health care requires a coordinated effort and mandate from authority in order to effect real change.