Community Health Care Centers Research Articles

Provincial Maternal and Child Information System in Inner Mongolia, China: Descriptive Implementation Study.

After the implementation of 2- and 3-child policies, the rising proportion of high-age and high-risk pregnancies put enormous pressure on maternal and child health (MCH) services for China. This populous nation with an increasing population flow imperatively required the support of large-scale information systems for management. Municipal MCH information systems were commonly applied in developed cities of eastern provinces in China. However, implementation of provincial MCH information systems in relatively low-income areas is lacking. In 2020, the implementation of a regional maternal and child information system (RMCIS) in Inner Mongolia filled this gap. This paper aimed to demonstrate the construction process and evaluate the implementation effect of an RMCIS in improving the regional MCH in Inner Mongolia. We conducted a descriptive study for the implementation of an RMCIS in Inner Mongolia. Based on the role analysis and information reporting process, the system architecture design had 10 modules, supporting basic health care services, special case management, health support, and administration and supervision. Five-color management was applied for pregnancy risk stratification. We collected data on the construction cost, key characteristics of patients, and use count of the main services from January 1, 2020, to October 31, 2022, in Inner Mongolia. Descriptive analysis was used to demonstrate the implementation effects of the RMCIS. The construction and implementation of the RMCIS cost CNY 8 million (US $1.1 million), with a duration of 13 months. Between 2020 and 2022, the system recorded 221,772 registered pregnant women, with a 44.75% early pregnancy registry rate and 147,264 newborns, covering 278 hospitals and 225 community health care centers in 12 cities. Five-color management of high-risk pregnancies resulted in 76,975 (45.45%) pregnancies stratified as yellow (general risk), 36,627 (21.63%) as orange (relatively high risk), 156 (0.09%) as red (high risk), and 3888 (2.30%) as purple (infectious disease). A scarred uterus (n=28,159, 36.58%), BMI≥28 (n=14,164, 38.67%), aggressive placenta praevia (n=32, 20.51%), and viral hepatitis (n=1787, 45.96%) were the top factors of high-risk pregnancies (yellow, orange, red, and purple). In addition, 132,079 pregnancies, including 65,018 (49.23%) high-risk pregnancies, were registered in 2022 compared to 32,466 pregnancies, including 21,849 (67.30%) high-risk pregnancies, registered in 2020. The implementation of an RMCIS in Inner Mongolia achieved the provincial MCH data interconnection for basic services and obtained both social and economic benefits, which could provide valuable experience to medical administration departments, practitioners, and medical informatics constructors worldwide.

135. Piloting a Quality Improvement Package for Adolescent Sexual and Reproductive Health Care in Community Health Centers: Getting to Quality for Teens (Q4T)

135. Piloting a Quality Improvement Package for Adolescent Sexual and Reproductive Health Care in Community Health Centers: Getting to Quality for Teens (Q4T)

Experiences of primary health care practitioners dealing with emergencies - 'We are on our own'.

Primary health care (PHC) focuses on health promotion and disease prevention; however, acute episodes and emergencies still occur at this level of care. The World Health Organization (WHO) proposes strengthening emergency care at a PHC level as a way of lessening the burden of disease on the overall health system. It is not known how health care practitioners at the PHC level experience management of emergencies. To explore and describe the experiences of PHC practitioners dealing with emergencies at PHC facilities in Gauteng, South Africa. The study was conducted in the District Health Services of Gauteng province in South Africa, including clinics, community health care centres and district hospitals. Using a qualitative approach, semi-structured interviews were conducted with a purposively selected sample of professional nurses and doctors from various levels of the district health care system. Data were transcribed and analysed using qualitative thematic analysis. Various themes were identified related to the individual confidence and competence of the PHC practitioner, the team approach, the process of role and task allocation and the need for training. The study provided a voice for the needs of health care practitioners dealing with emergencies at the PHC level. The designing of a targeted and contextually appropriate approach to emergency care training of health care practitioners in the PHC setting that improves team dynamics and team performance, is recommended.Contribution: The insights of PHC practitioners dealing with emergencies contribute contextual relevance to any strategic improvement of care at this level.

A prospective analysis of optimal total weight gain ranges and trimester-specific weight gain rates for Chinese pregnant women

BackgroundGestational weight gain (GWG) criteria recommended by the Institute of Medicine may not be appropriate for Asians. Our aims are to investigate the association between GWG and adverse pregnancy outcomes, and to propose optimal total GWG and rates of GWG for Chinese women.MethodsProspective data of 51,125 mother-child pairs from 27 hospitals and community health care centers from Guizhou, Yunnan and Sichuan provinces in China between 2014 and 2018 were analyzed. Generalized Additive Models were performed to determine the associations of GWG with the risk of aggregated adverse outcomes (gestational diabetes mellitus, preeclampsia, cesarean delivery, stillbirth, preterm birth, macrosomia, large for gestational age, and small for gestational age). The range that did not exceed a 2.5% increase from the lowest risk of aggregated adverse outcomes was defined as the optimal GWG range.ResultsAmong all participants, U-shaped prospective association was found between GWG and the risk of aggregated adverse pregnancy outcomes. The optimal GWG range of 8.2–13.0 kg was proposed for underweight, 7.3–12.5 kg for normal weight, and 2.0–9.4 kg for overweight/obese women. Meanwhile, a higher GWG rate in the first two trimesters than that in the last trimester was suggested, except for overweight/obese women. After stratified by maternal age, mothers ≥35 years were suggested to gain less weight compared to younger mothers.ConclusionsTo keep a balance between maternal health and neonatal growth, optimal GWG ranges based on Asia-specific BMI categories was suggested for Chinese women with different pre-gravid BMIs and maternal ages.

Challenges faced by nurses in managing patients with foot pathologies at primary healthcare clinics in Johannesburg-South Africa

BackgroundFoot health (podiatric) services remain inaccessible in many primary healthcare clinics across South Africa. As first-line contact practitioners at primary health care clinics, nurses manage all patients, including those presenting with foot pathologies. Anecdotal evidence suggests that nurses have challenges and are limited in their capability to assess the foot. In most cases, they do not assess the foot as part of the routine patient assessment. The primary aim of this study was to investigate the challenges nurses face in managing patients presenting with foot pathologies at primary healthcare clinics. MethodsThe study used a qualitative design to explore nurses' challenges in managing patients presenting with foot complaints. A purposive sampling strategy was used to select participants from primary health care clinics in Johannesburg to participate in a focus group discussion. Data were analysed using Giorgi's qualitative thematic analysis to reveal themes based on similarities and relationships between the collected data. ResultsSix PHC nurses participated in the focus group discussion. Participants confirmed challenges in managing patients presenting with foot pathologies. These include poor guidelines, limited training, consultation times, and a lack of defined referral pathways for patients with foot pathologies. Nurses indicated that due to challenges at the PHC level, foot assessment is not a mandatory part of patient assessment. All participants agreed on the need for structured foot health services. ConclusionPrimary healthcare nurses have challenges in managing patients with foot pathologies. There is a need for structured foot health services and training for nurses to coordinate care for this patient group effectively. Further studies should establish the need and demand for podiatric services to distribute the limited podiatry resources equitably, such as placement of podiatrists at community healthcare centres which serve as the first referral point for primary healthcare clinics.

Care Continuity, Telehealth Use, and Quality of Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic: Repeated Cross-sectional Study

Background Community health centers (CHCs) pivoted to remote chronic care services during the COVID-19 pandemic. While care continuity is associated with improved care quality and patients’ experiences, telehealth’s impact on these relationships is unclear. Objective We aimed to examine the association among care continuity, telehealth use, and quality of diabetes or hypertension care in CHCs before and during the COVID-19 pandemic. Methods We collected electronic health record data from a cohort of 20,792 patients with diabetes or hypertension with ≥2 visits per year from March to December 2019 and 2020 among 166 California CHCs in the OCHIN Accelerating Data Value Across a National Community Health Center Network Collaborative. Logistic regression models estimated the association between care continuity (modified, modified continuity index [MMCI]) and telehealth adoption and blood pressure or hemoglobin A1c (HbA1c) testing. Generalized linear regression models for 2019 and 2020 estimated the association between MMCI and blood pressure or HbA1c, exploring telehealth as a mediator. Results Patients experienced reduced care continuity (2019: MMCI=0.71, SD 0.28; 2020: MMCI=0.63, SD 0.36; P<.001) and more blood pressure (99.99% vs 99.75%) and HbA1c (53.38% vs 48.99%) assessments in 2019 vs 2020. Telehealth accounted for 0.33% of 2019’s visits and 9.55% of 2020’s visits. MMCI scores were associated with higher odds of telehealth use in 2020 (odds ratio [OR] 1.96; P<.001). MMCI (2019: OR 1.72, P<.001; 2020: OR 1.66, P<.001) and telehealth use (2019: OR 2.44, P<.001; 2020: OR 6.82, P<.001) were associated with greater HbA1c testing. MMCI was associated with lower HbA1c values in 2020 (–0.40, P=.01) and lower systolic (2019: –1.64, P=.045; 2020: –2.40, P=.001) and diastolic (2019: –1.24, P=.007; 2020: –1.33, P=.001) blood pressure. MMCI and telehealth were not associated with HbA1c values in 2019. In 2020, telehealth mediated the relationship between MMCI and HbA1c testing (percent mediated 59%), but not between MMCI and other study outcomes. Conclusions Care continuity facilitates telehealth use and enables resilient performance on process measures. Elucidating how care continuity influences telehealth adoption may provide insights about implementing patient-centered innovations.

Patients' satisfaction on primary healthcare services in China and its associated factors during COVID-19 pandemic: A cross-sectional study.

The provision of a satisfactory service by community healthcare centres in China plays an important role in the prevention and control of communicable diseases, especially during the COVID-19 pandemic. However, there is a lack of study in this field. This study aimed to determine the level of patient satisfaction with primary healthcare services in China and its associated factors during the COVID-19 pandemic. This cross-sectional study was conducted at 10 primary healthcare clinics in Xi'an, China. The 18-Item Patient Satisfaction Questionnaire was used for data evaluation and SPSS version 23.0 for data analysis. A total of 315 patients were recruited. The overall patient satisfaction score was 26.1±3.1. In the multiple linear regression analysis, the highly educated patients had a higher patient satisfaction score than the low-educated patients (β=1.138, 95% confidence interval=0.135-2.141, P=0.026). The overall patient satisfaction level of the patients who attended community healthcare centres in Xi'an was high. The patients with a higher educational level showed a higher patient satisfaction level than did those with a lower educational level.

Pharmacist-led clinical medication review service in primary care: the perspective of general practitioners

BackgroundAn advanced level medication review service (CMR) is systematically reimbursed and available nationwide in Slovenian primary care since 2016. CMR is performed by clinical pharmacists (CP). Close collaboration with general practitioner (GP) is required as they perform patient selection and make clinical decisions regarding patient’s medication.MethodsA prospective observational study was conducted in 2018 aiming to evaluate the perspective of GPs on the implementation of pharmacist-led medication review service in Community Health Care Centre Ljubljana, Slovenia. GPs of the patients, who provided written informed consent were invited for the interviews. The semi-structured interview consisted of 5 open ended questions addressing reasons for referral of the patients, implementation of CP recommendations and the GPs’ perspective of the service in general. Interviews were audio recorded with GPs written consent, transcribed verbatim and inductive content analysis was performed in NVivo11 Pro.ResultsIn total 38 interviews with 24 GPs were performed. The emerged themes were nested under 3 main domains representing Donabedian model of quality healthcare – structure, process, outcomes. The service structure is built on broad pharmacotherapy knowledge as the main CP competency, good accessibility, and complementarity of healthcare professions. Patients are mainly referred to the CMR due to polypharmacotherapy, however in majority there is a more in-depth reason behind (e.g., adverse events, etc.). Lack of time to recognize eligible patients and additional workload to study and implement the recommendations present the major challenges in the service process and therefore low number of referrals. CPs recommendations are mostly accepted, although the implementation time varies. When recommendation addresses medicines prescribed by a clinical specialist, the CMR report is forwarded to them for decision regarding implementation. The empowerment of the patients in medicines use was emphasized as the major benefit of the CMR, which consequently supports and enhances the quality of GP’s patient care. Transferability of recommendations to similar cases and high satisfaction with the service of GPs and patients, were mentioned.ConclusionGPs experiences with CMR are encouraging and supportive and present a base for further growth of the service.

Factors Associated With Blood Pressure Control Among Patients in Community Health Centers

Understanding the multilevel factors associated with controlled blood pressure is important to determine modifiable factors for future interventions, especially among populations living in poverty. This study identified clinically important factors associated with blood pressure control among patients receiving care in community health centers. This study includes 31,089 patients with diagnosed hypertension by 2015 receiving care from 103 community health centers; aged 19-64 years; and with ≥1 yearly visit with ≥1 recorded blood pressure in 2015, 2016, and 2017. Blood pressure control was operationalized as an average of all blood pressure measurements during all the 3 years and categorized as controlled (blood pressure <140/90), partially controlled (mixture of controlled and uncontrolled blood pressure), or never controlled. Multinomial mixed-effects logistic regression models, conducted in 2022, were used to calculate unadjusted ORs and AORs of being in the never- or partially controlled blood pressure groups versus in the always-controlled group. A total of 50.5% had always controlled, 39.7% had partially controlled, and 9.9% never had controlled blood pressure during the study period. The odds of being partially or never in blood pressure control were higher for patients without continuous insurance (AOR=1.09; 95% CI=1.03, 1.16; AOR=1.18; 95% CI=1.07, 1.30, respectively), with low provider continuity (AOR=1.24; 95% CI=1.15, 1.34; AOR=1.28; 95% CI=1.13, 1.45, respectively), with a recent diagnosis of hypertension (AOR=1.34; 95% CI=1.20, 1.49; AOR=1.19; 95% CI=1.00, 1.42), with inconsistent antihypertensive medications (AOR=1.19; 95% CI=1.11, 1.27; AOR=1.26; 95% CI=1.13, 1.41, respectively), and with fewer blood pressure checks (AOR=2.14; 95% CI=1.97, 2.33; AOR=2.17; 95% CI=1.90, 2.48, respectively) than for their counterparts. Efforts targeting continuous and consistent access to care, antihypertensive medications, and regular blood pressure monitoring may improve blood pressure control among populations living in poverty.

Diabetes and Hypertension Prevention and Control in Community Health Centers: Impact of the Affordable Care Act.

Access to care significantly improved following the implementation of the Patient Protection and Affordable Care Act. Since its implementation, the number of uninsured Americans has significantly decreased. Medicaid expansion played an important role in community health centers, who serve historically marginalized populations, leading to increased clinic revenue, and improved access to care. As the continuous Medicaid enrollment provision established during the pandemic ended, and states have to make decisions about their program eligibility, exploring the impact of Medicaid expansion on the detection, and management of hypertension and diabetes could inform these decisions. We summarized the effect of Medicaid expansion on community health centers and their patients specific to hypertension and diabetes from existing literature. These studies suggest the beneficial impact of the Affordable Care Act and acquiring insurance on diabetes and hypertension disease detection, treatment, and control for patients receiving care in community health centers. Overall, these studies suggest the clear importance of health insurance coverage, and notably insurance stability, on diabetes and hypertension control.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Settings for an Underserved Population: A Feasibility Pilot Study.

Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care. To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings. This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up. 93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic. Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants.

The Effect of Integrated Religious Cognitive Behavioral Therapy (IRCBT) on Psychological Symptoms of Women with Breast Cancer

Breast cancer exacerbates psychological problems and raises existential concerns, and decreases hope and quality of life. The aim of the study was to investigate the efficacy of integrated religious cognitive behavioral therapy (IRCBT) on psychological symptoms among Iranian women with breast cancer. A total sample of 178 patients referred to the community healthcare centers in Mashhad (Iran) was selected. Patients were randomly assigned to experimental and control groups. For the experimental group, eight 120-min sessions of IRCBT were administered. All patients completed the Symptom Checklist-25 (SCL-25). At baseline, there was no significant difference between the two groups on the SCL-25 subscales scores. After the intervention, the mean scores on all subscales of the SCL-25 in the experimental group were significantly lower than the control group, except for the obsessive-compulsive, somatization, and neuroticism subscales. The IRCBT may be useful for improving negative psychological symptoms among Iranian women with breast cancer. Keywords: IRCBT, Psychological symptoms, Breast cancer, Religion, Iran

The Correlation Between the Husband's Support and the Psychological Well-Being of Pregnant Adolescents

Background: Teenage pregnancy can be defined by the occurrence of pregnancy in girls aged 10-19 years who still have emotional instability. This emotional instability can affect the psychological well-being of pregnant adolescents, which will cause disturbances in their pregnancy; therefore, the husband's support is needed so that mothers can feel security and comfort in their pregnancy to achieve maternal and fetal health in the womb. Objective: To determine the correlation between husband's support and psychological well-being in pregnant adolescents. Method: This study used a quantitative method with a cross-sectional design. The sampling technique used total sampling with a total sample of 30 respondents. The study was conducted in the Moga Health Care Center Pemalang Regency, Central Jawa Province, Indonesia. Data analysis used is univariate analysis to determine the frequency distribution of respondent characteristics (age, number of pregnancies and education), and bivariate analysis to determine the relationship between independent variables (husband's support) with the dependent variable (psychosocial condition of adolescent pregnant women) Results: This study shows a significant correlation between husband's support and the psychological well-being of pregnant adolescents in the Moga Community Health Care Center, with a p-value of 0.000. Conclusion: Pregnant women who lack a husband's support will be at risk of experiencing psychological well-being in their pregnancy, especially pregnant adolescents.

Factors associated with falls in patients with knee osteoarthritis: A cross-sectional study.

Falls represent an important adverse effect associated with knee osteoarthritis and result in a significant financial burden on the healthcare system. Therefore, identification of fall predictors is essential to minimize fall incidence. However, few studies have investigated falls and fall predictors, particularly focused on the fear of falls and proprioception. In this study, we investigated significant fall predictors in patients with knee osteoarthritis in Malang, Indonesia. Our findings may serve as useful guidelines to develop geriatric fall prevention programs. This cross-sectional survey using purposive sampling was performed between April and July 2021 and included 372 participants. We recorded the following data: sociodemographic and medical history questionnaire responses, visual analog scale scores, Hopkins falls grading scale scores, Fall Efficacy Scale-International scores, proprioception test findings, knee injury and osteoarthritis outcome score (KOOS), range of motion (ROM), chair stand test and the timed up and go test performance. Data were analyzed using the chi-square and t tests, and multivariate logistic regression to determine significant fall predictors. Multivariate logistic regression analysis showed a lower risk of falls in patients with better proprioception and ROM than in the other groups (odds ratio 0.55 vs 0.96). The risk of falls was higher in patients with higher KOOS symptoms, fear of falls, diagnosis of low back pain and diabetes mellitus, and increased body mass index than in the other groups (odds ratio 1.41, 2.65, 1.27, 3.45, and 1.10, respectively. Our study shows that knee proprioception and ROM serve as protective factors against falls, whereas KOOS symptoms, fear of falls, low back pain, diabetes mellitus, and body mass index were associated with a high risk of falls, with diabetes mellitus and fear of falls being the most significant risk factors. These findings may be useful to policy makers to develop a fall prevention program that can be implemented in community health care centers across Indonesia to deliver individualized, person-centered care and improve fall prevention strategies through a systematic process comprising evaluation, intervention, and monitoring to minimize fall risk.

Construction of the Hybrid Agile Management Model in Public Health Services in Indonesia

Community health care centers (Puskesmas) sometimes view management as ancillary, unimportant tasks. Traditional management issues in which services are separated into distinct journeys, each reliant on fulfilling previous steps without response or recurrence, can be onerous for governance frameworks with rigid structures. Management issues can be prevented by modifying how the service and organizational structure are managed. In such circumstances, an agile strategy can be advantageous. According to the guiding idea of the agile principle, agile will adjust to the requirements and quirks of the workplace in which it is implemented, especially in the various operations of government agencies. The Hybrid Agile Model of Public Health Service proposes a new, flexible management structure for local government service units based on the growth of human resources and continuous cultural change, without ignoring the routine activities of such bodies in making them more reliable and efficient. The model and its implementation procedure, tested at Puskesmas in South Sulawesi, Indonesia, have been described in depth.&#x0D; Keywords: agile health service, hybrid agile management, human resource management, organizational culture, traditional organizational management.

Association of Parent Preventive Care with their Child's Recommended Well-Child Visits.

Receipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs). To understand if there is an association between parent preventive care and their children's well-child visits. We used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n=363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents. We included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR]=1.06; 95% CI=1.03-1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR=1.07; 95% CI=1.04-1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR=1.11; 95% CI=1.03-1.19) compared to neither receiving preventive care. These findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.

Why adult patients on antiretroviral therapy miss clinical appointments in rural villages of Limpopo Province, South Africa: An exploratory study.

Missing clinical appointments while on antiretroviral therapy (ART) is associated with poor adherence to treatment and an increased risk of poor immunological outcomes. This study explored the reasons why adults missed clinical ART appointments. The study was conducted in community healthcare centres (CHCs) with high rates of missed appointments by ART patients. An explorative qualitative research design was used for this study. The population comprised all adult patients on ART who had missed their clinic appointments. The simple random sampling method was used to select sample healthcare centres with high absenteeism from the district health information system. Furthermore, a purposive systematic sampling technique was used to sample ART patients who had missed more than two appointments in a year. Thirty-seven patients were interviewed, as determined by data redundancy, using in-depth individual unstructured interviews, as guided by the following central question: 'How is it for you to miss your clinic appointments?' Tesch's eight steps were used to analyse the data. Participants cited a lack of family support, financial constraints, nondisclosure of HIV status at the workplace and a lack of patient involvement in scheduling appointments as reasons for nonadherence to ART appointments. Missed appointments disrupt the functionality of healthcare systems and negatively impact the quality of patient's care. Patients missing appointment are likely to interrupt HIV care and run a risk of clinical and immunological failure. This study contributes to knowledge as to why patients on ART miss appointments. It will also provide practical guidance to come up with a strategy that will reduce missing appointments and to improve adherence to treatment and health outcomes of patients on ART.

Effect of Dolutegravir on Plasma Glucose Among Human Immunodeficiency Virus Patients in a Community Health Center Setting.

BackgroundDolutegravir has become one of the initial backbones in antiretroviral therapy regimens for most patients with HIV in several recent clinical guidelines. However, dolutegravir has been associated with severe cases of hyperglycemia and the new-onset of diabetes in multiple case reports and clinical trials. A community health center noticed an increasing number of new-onset hyperglycemia incidences in patients on dolutegravir.MethodRetrospective chart review of patients who started on dolutegravir or dolutegravir combination regimen (Triumreq®, Juluca®, GlaxoSmithKline (GSK), Research Triangle Park, NC) between the dates of January 1st, 2013 and January 1st, 2018 who have been treated in community healthcare centers. Baseline blood sugar and/or hemoglobin A1C before starting dolutegravir, at three to six months of treatment, and at the end of the study were compared between subjects. Four hundred twenty-two subjects were enrolled.ResultsDolutegravir had little effect on plasma glucose among 72% of the subjects (n=305). However, 7% of the subjects (n=28) on dolutegravir treatment with no glucose intolerance met the criteria for prediabetes at three to six months of therapy. One of the subjects had developed diabetes three to six months after dolutegravir was initiated. In addition, at the end of the study, 13% of patients developed prediabetes (n=56) and 1.4% developed diabetes (n=6). Among the 24 subjects that had diabetes before dolutegravir was initiated, 83% required intensification of their diabetes regimen.ConclusionDolutegravir may cause a moderate increase in plasma sugar after three to six months of therapy. Further increases in plasma sugar have been noticed in up to 13% of subjects meeting the criteria for prediabetes. Due to the existence of confounding variables, patients with diabetes should not be switched from dolutegravir.

Inequality of Low Air Quality-Related Health Impacts among Socioeconomic Groups in the World of Work.

This research aimed to assess the perceptions of air quality and health symptoms caused by low urban air quality among vulnerable socio-economic groups in the world of work in Bangkok, Thailand through a questionnaire survey of 400 workers of both formal and informal sectors in the five districts with different socio-economic characteristics and levels of air pollution. The findings showed symmetry between air quality-monitoring data and health symptoms of different socio-economic groups but asymmetry between air quality-monitoring data and people’s perceptions of air quality in their areas. It also showed inequalities of low air quality-related health impacts on socio-economic groups in the world of work. People working near the streets, highways, and industrial zones tended to have more health symptoms related to low air quality, and informal sector workers faced more health risks than formal sector workers. The study appeals for effective air pollution communication to enhance the public and informal sector worker population’s literacy of air pollution, the sources of air pollution and its critical health impacts, and the available and sufficient primary care organizations and community health care centers to address work-related health needs to reach the informal sector worker population.

Improving primary care antimicrobial stewardship by implementing a peer audit and feedback intervention in Cape Town community healthcare centres.

The increasing prevalence of antibiotic resistance is a major threat to public health. Primary care, where 80% of antibiotics are consumed, is a pivotal setting to direct antimicrobial stewardship (AMS) efforts. However, the ideal model to improve antibiotic prescribing in primary care in low-resource settings is not known. To implement a multidisciplinary audit and feedback AMS intervention with the aim to improve appropriate antibiotic prescribing at primary care level. The intervention was implemented and monitored in 10 primary care centres of the Cape Town metropole between July 2017 and June 2019. The primary and secondary outcome measures were monthly adherence to a bundle of antibiotic quality process measures and monthly antibiotic consumption, respectively. Multidisciplinary audit and feedback meetings were initiated and integrated into facility clinical meetings. Two Excel tools were utilised to automatically calculate facility audit scores and consumption. Once a month, 10 antibiotic prescriptions were randomly selected for a peer review audit by the team. The prescriptions were audited for adherence to a bundle of seven antibiotic process measures using the standard treatment guidelines (STG) and Essential Medicines List (EML) as standard. Concurrently, primary care pharmacists monitored monthly antibiotic consumption by calculating defined daily doses (DDDs) per 100 prescriptions dispensed. Adherence and consumption feedback were regularly provided to the facilities. Learning collaboratives involving representative multidisciplinary teams were held twice-yearly. Pre-, baseline and post-intervention periods were defined as 6 months before, first 6 months and last 6 months of the study, respectively. The mean overall adherence increased from 19% (baseline) to 47% (post intervention) (p<0.001). Of the 2 077 prescriptions analysed, 33.7% had an antibiotic prescribed inappropriately. No diagnosis had been captured in patient notes, and the antibiotic chosen was not according to the STG and EML in 30.1% and 31.7% of cases, respectively. Seasonal variation was observed in prescribing adherence, with significantly lower adherence in winter and spring months (adjusted odds ratio 0.60). A reduction of 12.9 DDDs between the pre- and post-intervention periods (p=0.0084) was documented, which represented a 19.3% decrease in antibiotic consumption. The study demonstrated that peer reviewed audit and feedback is an effective AMS intervention to improve antibiotic prescribing in primary care in a low-resource setting. The intervention, utilising existing resources and involving multidisciplinary engagement, may be incorporated into existing quality improvement processes at facility level, to ensure sustainable change.