Community-based Primary Health Care Research Articles

Strategies for involving patients and the public in scaling initiatives in health and social services: A scoping review.

Scaling in health and social services (HSS) aims to increase the intended impact of proven effective interventions. Patient and public involvement (PPI) is critical for ensuring that scaling beneficiaries' interests are served. We aimed to identify PPI strategies and their characteristics in the science and practice of scaling in HSS. In this scoping review, we included any scaling initiative in HSS that used PPI strategies and reported PPI methods and outcomes. We searched electronic databases (e.g., Medline) from inception to 5 February 2024, and grey literature (e.g., Google). Paired reviewers independently selected and extracted eligible reports. A narrative synthesis was performed and we used the PRISMA for Scoping Reviews and the Guidance for Reporting Involvement of Patients and the Public (GRIPP2). We included 110 unique reports out of 24,579 records. In the past 5 years, the evidence on PPI in scaling has increased faster than in any previous period. We found 236 mutually nonexclusive PPI strategies among 120 scaling initiatives. Twenty-four initiatives did not target a specific country; but most of those that did so (n = 96) occurred in higher-income countries (n = 51). Community-based primary health care was the most frequent level of care (n = 103). Mostly, patients and the public were involved throughout all scaling phases (n = 46) and throughout the continuum of collaboration (n = 45); the most frequently reported ethical lens regarding the rationale for PPI was consequentialist-utilitarian (n = 96). Few papers reported PPI recruitment processes (n = 31) or incentives used (n = 18). PPI strategies occurred mostly in direct care (n = 88). Patient and public education was the PPI strategy most reported (n = 31), followed by population consultations (n = 30). PPI in scaling is increasing in HSS. Further investigation is needed to better document the PPI experience in scaling and ensure that it occurs in a meaningful and equitable way. Two patients were involved in this review. They shared decisions on review questions, data collection instruments, protocol design, and findings dissemination. Open Science Framework on 19 August 2020 (https://osf.io/zqpx7/).

Clinical Psychologists’ Experiences of “Community Service” in South Africa: Community-Based Service Learning and Primary Healthcare

Many South African master’s degree programmes in Clinical Psychology integrate community psychology training modules into the first year (M1) of the coursework. Such modules often incorporate community-based service learning (CBSL) to equip trainees for work in primary healthcare settings. After completing their M1 year, trainees complete a year’s internship (M2) in a psychiatric setting, followed by a mandatory third year of “community service”, before being able to register for independent practice. This raises questions about the preparation of trainees for this additional year, including its links with CBSL and the provision of primary healthcare. The aim of this study was to investigate the clinical psychologists’ experiences of and settings for community service, and resonances with and contrasts to CBSL. The data were collected through an online survey accessing reflections of trainee clinical psychologists from five South African universities (n = 12), who had recently completed, or were currently completing, their community service. The data were analysed by template analysis. The resonances in the findings seem to be linked to the trainees’ relational and attitudinal skills and concepts related to community psychology, refined and applied during their M1 year. The contrasts in the themes illustrate the predominance of traditional clinical placements during community service, with their associated demands linked to dominant clinical practice. In conclusion, this study indicates that community service settings for clinical psychologists are seldom well linked to primary healthcare or based in community settings. Recommendations are made for CBSL in the M1 year and for expanding the settings of community service more widely into primary healthcare.

Deconstructing subjective unmet healthcare needs: a South Korean case study with policy implications.

Despite widespread efforts by many countries to reduce the prevalence of unmet healthcare needs within their populations, there remains a scarcity of research systematically exploring the components of these needs. This study aims to deconstruct subjective unmet healthcare needs into two distinct components: the experience of subjective healthcare needs (the "Needs" component) and the experience of unmet needs contingent on those healthcare needs (the "Unmet" component). This analysis utilizes data from 13,359 adults aged 19 or older, collected through the 2018 Korea Health Panel survey, with the aim of minimizing the influence of the coronavirus disease 19 pandemic. The two dependent variables are the experience of subjective healthcare needs and whether these needs have been met. The independent variables include 15 socio-demographic, health, and functional characteristics. The study employs both a population proportion analysis and a multivariable bivariate probit model with sample selection. In South Korea, 11.6% (CI [confidence interval] = 11.0-12.3%) of the population experienced subjective unmet healthcare needs. Upon deconstructing these, 96.7% (CI = 96.2-97.1%) of the population exhibited the Needs component, and 12.0% (CI = 11.4-12.7%) displayed the Unmet component. Each independent variable showed different associations between the two components. Furthermore, effective interventions targeting the characteristics associated with each component could reduce the proportion of the population experiencing subjective unmet healthcare needs from 11.6 to 4.0%. South Korea faces a significant challenge due to the considerable prevalence of subjective unmet healthcare needs. To address this challenge effectively, the universal healthcare coverage system should adapt its approach based on the characteristics associated with both the Needs and Unmet components of subjective unmet healthcare needs. To achieve this goal, it is highly recommended that the government prioritize strengthening community-based primary healthcare, which currently suffers from insufficient resources.

Access to primary health care: perspectives of primary care physicians and community stakeholders

BackgroundAction on the social determinants of health is important to strengthen primary health care and promote access among underserved populations. We report on findings from stakeholder consultations undertaken at one of the Canadian sites of the Innovative Models Promoting Access-to-Care Transformation (IMPACT) program, as part of the development of a best practice intervention to improve access to primary health care. The overarching objective of this qualitative study was to understand the processes, barriers, and facilitators to connect patients to health enabling community resources (HERs) to inform a patient navigation model situated in primary care.MethodsFocus groups and interviews were conducted with primary care physicians, and community health and social service providers to understand their experiences in supporting patients in reaching HERs. Current gaps in access to primary health care and the potential of patient navigation were also explored. We applied Levesque et al., (2013) access framework to code the data and four themes emerged: (1) Approachability and Ability to Perceive, (2) Acceptability and Ability to Seek, (3) Availability and Accommodation, and Ability to Reach, and (4) Appropriateness.ResultsDeterminants of access included patient and provider awareness of HERs, the nature of the patient-provider relationship, funding of HERs, integration of primary and community care services, and continuity of information. Participants’ perspectives about the potential scope and role of a patient navigator provided valuable insight for the development of the Access to Resources in the Community (ARC) navigation model and how it could be embedded in a primary care setting.ConclusionAdditional consultation with key stakeholders in the health region is needed to gain a broader understanding of the challenges in caring for primary care patients with social barriers and how to support them in accessing community-based primary health care to inform the design of the ARC intervention.

Perspectives of community and facility stakeholders on community health workers in rural Malawi.

Community health workers (CHWs) bridge the primary health care (PHC) system and communities by providing care in the household. In Malawi, few studies have examined the perspective of users of household-level CHW services, in remote areas, to understand CHW's role in community-based PHC. To explore perspectives of community and facility stakeholders on the enablers and challenges of the CHW role in community-based PHC in Neno District. The study was conducted in the Neno District health facilities, namely, Ligowe, Dambe, Chifunga, and Zalewa. We conducted eight focus group discussions (FGDs) with purposively sampled community members and conveniently sampled facility stakeholders. Data were transcribed and analysed thematically through an adapted COM-B model of behaviour change. Three main themes of perceived behaviour change within the CHW role were identified: (1) capacity - the CHW programme aids health education and promotion within the community; (2) opportunity - the CHW programme facilitates community-based PHC and linkage to the facility; and (3) motivation - the CHW programme enablers and challenges in providing community-based PHC. Community health workers enrich community-based PHC delivery through health education, timely access to care, and linking communities to the facility. Optimising workload and programme support is critical for the help of CHWs. Further studies are required to address programme and cultural challenges to enhance positive health-seeking behaviours.Contribution: This study provides contextual knowledge for further research on bringing together spiritual and formal health practices and considering the cultural background when planning for health interventions in remote areas.

Measuring quality-of-care in treatment of young children with attention-deficit/hyperactivity disorder using pre-trained language models.

To measure pediatrician adherence to evidence-based guidelines in the treatment of young children with attention-deficit/hyperactivity disorder (ADHD) in a diverse healthcare system using natural language processing (NLP) techniques. We extracted structured and free-text data from electronic health records (EHRs) of all office visits (2015-2019) of children aged 4-6 years in a community-based primary healthcare network in California, who had ≥1 visits with an ICD-10 diagnosis of ADHD. Two pediatricians annotated clinical notes of the first ADHD visit for 423 patients. Inter-annotator agreement (IAA) was assessed for the recommendation for the first-line behavioral treatment (F-measure = 0.89). Four pre-trained language models, including BioClinical Bidirectional Encoder Representations from Transformers (BioClinicalBERT), were used to identify behavioral treatment recommendations using a 70/30 train/test split. For temporal validation, we deployed BioClinicalBERT on 1,020 unannotated notes from other ADHD visits and well-care visits; all positively classified notes (n = 53) and 5% of negatively classified notes (n = 50) were manually reviewed. Of 423 patients, 313 (74%) were male; 298 (70%) were privately insured; 138 (33%) were White; 61 (14%) were Hispanic. The BioClinicalBERT model trained on the first ADHD visits achieved F1 = 0.76, precision = 0.81, recall = 0.72, and AUC = 0.81 [0.72-0.89]. Temporal validation achieved F1 = 0.77, precision = 0.68, and recall = 0.88. Fairness analysis revealed low model performance in publicly insured patients (F1 = 0.53). Deploying pre-trained language models on a variable set of clinical notes accurately captured pediatrician adherence to guidelines in the treatment of children with ADHD. Validating this approach in other patient populations is needed to achieve equitable measurement of quality of care at scale and improve clinical care for mental health conditions.

30 by 2030 campaign

Primary Health Care (PHC) is a cornerstone of universal health coverage (UHC). To prevent diseases and holistically treat people, community-based primary healthcare systems need to be strengthened. PHC is an approach that aims to address physical, mental, and social health and well-being, and to provide comprehensive care for a person's health needs throughout life rather than focus on treating a specific set of diseases. To achieve this approach, we must strengthen horizontal PHC systems and encourage vertical programmes, including disease-specific programmes, to be developed, integrated, and implemented in the context of integrated Primary Health Care.
 In early 2020 the WHO Collaborating Centre on Family Medicine and Primary Health Care launched the 30by2030 campaign (https://www.30by2030.net), whereby signatories are asking donors of vertical disease-oriented projects to invest at least 30% of their budgets for vertical programs in strengthening coordinated and integrated primary health care. The initiative is a pull of efforts of different organizations such as Wonca: World Organisation of Family Doctors, The Network: Towards Unity for Health (TUFH), African Forum for Primary Health Care, European Forum for Primary Care, PRIMAFAMED network, among others.
 The 30 by 2030 has two aims: the first one is to inform and raise awareness of the impact of vertical programs on health systems. Most of the private and external funds, which represent one-third of the total spending of PHC, are channelled through programmes that focus on the health problems of specific population subgroups (e.g., HIV, tuberculosis, malaria) which also leads to inequity by disease. The second aim is to call for international donors to assign 30% of their vertical top-down, disease-oriented budgets to strengthen primary healthcare services through coordination, increased human resources and improved infrastructure.

Impact of a community-based primary healthcare programme on childhood diphtheria-tetanus-pertussis (DPT3) immunisation coverage in rural northern Ghana

BackgroundChild healthcare services such as diphtheria-tetanus-pertussis (DPT3) vaccination are known to reduce childhood mortality and morbidity. However, inequalities in access to these services in developing countries continue to constrain global efforts aimed at improving child health. This study examines the impact and equity effect of a community-based primary healthcare programme known as the Ghana Essential Health Intervention Programme (GEHIP) on improving the uptake of childhood DPT3 immunisation coverage in a remote rural region of Ghana.MethodsUsing baseline and end-line household survey data collected from mothers, the effect of GEHIP’s community-based healthcare programme on DPT3 immunisation coverage is evaluated using difference-in-differences multivariate logistic regression models. Household wealth index and maternal educational attainment were used as equity measures.ResultsAt end-line, both intervention and comparison districts recorded increases in DPT3 immunisation coverage although intervention districts had a relatively higher coverage than comparison districts (90% versus 88%). While children resident in intervention areas had slightly higher rates than children resident in comparison areas, regression results show that this difference was not statistically significant (DiD = 0.038, p-value = 0.102). There were also no significant equity disparities in the coverage of DPT3 vaccination for both household wealth index and maternal educational attainment.ConclusionDPT3 vaccination coverage in both study arms met the global vaccine action plan targets. However, because estimated effects are not significantly higher among treatment area children than among comparison districts counterparts, no equity/inequity effects of the community-based healthcare programme on DPT 3 coverage is evident.

Substantial Shift in Palliative Care from Hospice to Community and Its Integration into Community-Based Primary Health Care

In 1967 Cicely Saunders founded St. Christopher’s Hospice. Then, Saunders’ hospice model of palliative care promoted palliative care movement in the world. World Health Organization (WHO) adopted this hospice model, but WHO has gradually improved palliative care and integrated it into community-based comprehensive care. This review focuses on the recent substantial shift in palliative care from hospice to community and WHO’s leadership in integration of palliative care into primary health care. We summarized Saunders’ hospice model, WHO’s improved model in 2002 and the complemented model proposed by the International Association for Hospice & Palliative Care (IAHPC) in 2019. Then, we delineated the development steps of WHO’s integration of palliative care into primary health care. We also showed integration of supportive care in cancer and existential therapy/care into primary health care. Thus, various limitations of Saunders’ hospice model (palliative care for patients with cancer only at the terminal stage and Christian religious care) have been overcome by WHO’s integrated primary health care model that provides care for noncommunicable (including cancer) and communicable diseases during all the continuity of care. Further education and training of the participants in community-based primary health care are required to address all the needs of patients and families in community.

Evaluation of a stroke rehabilitation training programme for community-based primary healthcare.

Family caregiver training is an integral part of stroke rehabilitation programmes and is associated with improved caregiver and stroke survivor outcomes. In the Cape Winelands District, a low-resourced rural community-based setting in South Africa, stroke survivors and family caregivers mostly rely on assistance from community health workers (CHWs), despite their lack of stroke-specific rehabilitation training. To evaluate the implementation and immediate effects of a bespoke, 16 session, 21 h stroke rehabilitation training programme for CHWs to better support family caregivers. Two cooperative inquiry groups participated in participatory action research to design and develop the programme. This article reports on the implementation of this programme. Inquiry group members directly observed the training, obtained written and verbal feedback, interviewed CHWs and observed them in the community. Consensus on their learning was achieved after reflection on their experience and observations. Learning of the cooperative inquiry groups was categorised into the effect on community-based care, the training programme's design and development, how training was delivered and implications for service delivery. Community health workers empowered caregivers and stroke survivors and enabled access to care, continuity, coordination and person-centredness. The need for experiential learning and a spiral curriculum was confirmed. Therapists needed a different set of skills to deliver training. A systems approach and effective leadership were needed to enable community health workers to use their new skills. The stroke rehabilitation training programme demonstrated potential for integration into service delivery and equipping CHWs to support family caregivers and stroke survivors. Further evaluation of the programme's effectiveness and scale-up is needed. Evidence of an intervention to train CHWs to support stroke survivors and family caregivers.

Risk of Bias Mitigation for Vulnerable and Diverse Groups in Community-Based Primary Health Care Artificial Intelligence Models: Protocol for a Rapid Review.

The current literature identifies several potential benefits of artificial intelligence models for populations' health and health care systems' efficiency. However, there is a lack of understanding on how the risk of bias is considered in the development of primary health care and community health service artificial intelligence algorithms and to what extent they perpetuate or introduce potential biases toward groups that could be considered vulnerable in terms of their characteristics. To the best of our knowledge, no reviews are currently available to identify relevant methods to assess the risk of bias in these algorithms. The primary research question of this review is which strategies can assess the risk of bias in primary health care algorithms toward vulnerable or diverse groups? This review aims to identify relevant methods to assess the risk of bias toward vulnerable or diverse groups in the development or deployment of algorithms in community-based primary health care and mitigation interventions deployed to promote and increase equity, diversity, and inclusion. This review looks at what attempts to mitigate bias have been documented and which vulnerable or diverse groups have been considered. A rapid systematic review of the scientific literature will be conducted. In November 2022, an information specialist developed a specific search strategy based on the main concepts of our primary review question in 4 relevant databases in the last 5 years. We completed the search strategy in December 2022, and 1022 sources were identified. Since February 2023, two reviewers independently screened the titles and abstracts on the Covidence systematic review software. Conflicts are solved through consensus and discussion with a senior researcher. We include all studies on methods developed or tested to assess the risk of bias in algorithms that are relevant in community-based primary health care. In early May 2023, almost 47% (479/1022) of the titles and abstracts have been screened. We completed this first stage in May 2023. In June and July 2023, two reviewers will independently apply the same criteria to full texts, and all exclusion motives will be recorded. Data from selected studies will be extracted using a validated grid in August and analyzed in September 2023. Results will be presented using structured qualitative narrative summaries and submitted for publication by the end of 2023. The approach to identifying methods and target populations of this review is primarily qualitative. However, we will consider a meta-analysis if quantitative data and results are sufficient. This review will develop structured qualitative summaries of strategies to mitigate bias toward vulnerable populations and diverse groups in artificial intelligence models. This could be useful to researchers and other stakeholders to identify potential sources of bias in algorithms and try to reduce or eliminate them. OSF Registries qbph8; https://osf.io/qbph8. DERR1-10.2196/46684.

A time-motion study of community health workers delivering community-based primary health care in Neno District, Malawi

IntroductionCommunity health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi.MethodsWe conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood’s median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks.ResultsWe observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05).ConclusionThis study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.

Equity in maternal healthcare utilisation in Ghana: Do community-based primaryhealth care programmes matter?

Improving equity in the use of maternal health services in rural and remote communities is critical to meeting the Sustainable Development Goals targets on maternal and child health. This study examines the effect of a community-based primary healthcare strengthening programme on improving the utilisation of antenatal care (ANC4+), skilled delivery and health facility delivery. Baseline and endline survey data of women of reproductive age for intervention and comparison districts were used to examine the equity impact of the Ghana Essential Health Interventions Programme (GEHIP) on antenatal care visits, skilled delivery and health facility delivery. The Wagstaff extension of the concentration index and regression models are used to assess equity effects of the programme on the utilisation of these services by wealth index and educational attainment. Coverage rates increased for both intervention and comparison districts, but were generally higher in intervention districts than comparison districts at endline (90% vs. 88% for ANC4+, 88% vs. 84% for skilled delivery and 93% vs. 88% for health facility delivery). Only ANC4+ showed a statistically significant positive treatment effect of the intervention (Dif-in-Dif = 0.071, p-value = 0.010). Equity analysis showed a mixed picture with intervention districts achieving significant equity improvement for skilled delivery for both wealth index and maternal education but only education equity for health facility delivery, while comparison districts achieved both wealth and education equity improvements for two indicators (health facility delivery and skilled delivery). No significant equity/inequity effects were found for ANC4+. Efforts to improve community-based healthcare access have been associated with improved coverage of maternal health services; however, the effect on improving equity in service coverage is mixed. Results indicate a need to extend community-based primary health care development beyond general improvements in access to ensure equity in the coverage of maternal and child health services that such programmes provide.

Detection of Speech-Language Delay in the Primary Care Setting: An Electronic Health Record Investigation.

The purpose of this study is to determine the rate and age at first identification of speech-language delay in relation to child sociodemographic variables among a pediatric primary care network. We analyzed a deidentified data set of electronic health records of children aged 1- to 5-years-old seen between 2015 and 2019 at 10 practices of a community-based pediatric primary health care network. Primary outcomes were numbers (proportions) of patients with relevant ICD-10 visit-diagnosis codes and patient age (months) at first documentation of speech-language delay. Regression models estimated associations between outcomes and patient characteristics, adjusting for practice affiliation. Of 14,559 included patients, 2063 (14.1%) had speech-language delay: 68.4% males, 74.4% with private insurance, and 96.1% with English as a primary household language. Most patients (60%) were first identified at the 18- or 24-month well-child visit. The mean age at first documentation was 25.4 months (SD = 9.3), which did not differ between practices reporting the use of standardized developmental screener and those using surveillance questionnaires. Regression models showed that males were more than twice as likely than females to be identified with speech-language delay (adjusted odds ratio [aOR] = 2.05, 95% CI: [1.86-2.25]); publicly insured were more likely than privately insured patients to be identified with speech-language delay (aOR = 1.48, 95% CI: [1.30-1.68]). Females were older than males at first identification (+1.2 months, 95% CI: [0.3-2.1]); privately insured were older than military insured patients (private +3.3 months, 95% CI: [2.2-4.4]). Pediatricians in this network identified speech-language delays at similar rates to national prevalence. Further investigation is needed to understand differences in speech-language delay detection across patient subgroups in practices that use developmental screening and/or surveillance.

Understanding the theoretical underpinnings of preventative early parenting interventions: A theory-based evaluation

Early parenting programmes which promote nurturing care for children aged 0–3 years are popular in community-based primary health care settings. However, little research has explored the causal and theoretical assumptions underpinning these programmes. This paper outlines a programme theory evaluation which was conducted to explore the change principles inherent in a complex early parenting intervention, the parent and infant programme, which aims to support parents and infants aged 0–2 years. A documentary analysis and qualitative interviews ( n = 19) with key stakeholders were undertaken to describe programme components, outline intervention objectives and identify the mechanisms assumed to be important to programme success. The interpretation of the findings was informed by the Consolidated Framework for Implementation Research, within which we explore and describe the theoretical perspectives that underpin the programme and guide its operationalisation and delivery. The importance of attending to the causal mechanisms underlying early parenting interventions is outlined.

Addressing coloniality of power to improve HIV care in South Africa and other LMIC.

We describe the appropriateness and potential for effectiveness of three strategic approaches for improving HIV care in South Africa: community-based primary healthcare, local/community-based stakeholder engagement, and community-engaged research. At their core, these approaches are related to overcoming health inequity and inequality resulting from coloniality of power's heterogenous structural processes impacting health care in many low- and middle-income countries (LMIC). We turn to South Africa, a middle-income country, as an example. There the HIV epidemic began in the 1980s and its ending is as elusive as achieving universal healthcare. Despite impressive achievements such as the antiretroviral treatment program (the largest in the world) and the country's outstanding cadre of HIV experts, healthcare workers and leaders, disadvantaged South Africans continue to experience disproportionate rates of HIV transmission. Innovation in global public health must prioritize overcoming the coloniality of power in LMIC, effected through the imposition of development and healthcare models conceived in high-income countries (HIC) and insufficient investment to address social determinants of health. We advocate for a paradigm shift in global health structures and financing to effectively respond to the HIV pandemic in LMIC. We propose ethically responsive, local/community-based stakeholder engagement as a key conceptual approach and strategy to improve HIV care in South Africa and elsewhere. We join in solidarity with local/community-based stakeholders' longstanding efforts and call upon others to change the current status quo characterized by global public health power concentrated in HIC.

The Colocation Model in Community Cancer Care: A Description of Patient Clinical and Demographic Attributes and Referral Pathways.

Cancer disparities are well documented among Black, Indigenous, and People of Color, yet little is known about the characteristics of programs that serve these populations. Integrating specialized cancer care services within community settings is important for addressing the needs of historically marginalized populations. Our National Cancer Institute-Designated Cancer Center initiated a clinical outreach program incorporating cancer diagnostic services and patient navigation within a Federally Qualified Health Center (FQHC) to expedite evaluation and resolution of potential cancer diagnoses with the goal of collaboration between oncology specialists and primary care providers in a historically marginalized community in Boston, MA. Sociodemographic and clinical characteristics were analyzed from patients who were referred to the program for cancer-related care between January 2012 and July 2018. The majority of patients self-identified as Black (non-Hispanic) followed by Hispanic (Black and White). Twenty-two percent of patients had a cancer diagnosis. Treatment and surveillance plans were established for those with and without cancer at a median time to diagnostic resolution of 12 and 28 days, respectively. The majority of patients presented with comorbid health conditions. There was a high prevalence of self-reported financial distress among patients seeking care through this program. These findings highlight the wide spectrum of cancer care concerns in historically marginalized communities. This review of the program suggests that integrating cancer evaluation services within community-based primary health care settings offers promise for enhancing the coordination and delivery of cancer diagnostic services among historically marginalized populations and could be a method to address clinical access disparities.

A stroke rehabilitation training program for community-based primary health care, South Africa.

With an increasing burden of stroke and a lack of access to rehabilitation services in rural South African settings, stroke survivors rely on untrained family caregivers for support and care. Community health workers (CHWs) support these families but have no stroke-specific training. To describe the development of a contextually appropriate stroke training program for CHWs in the Cape Winelands District, South Africa. Twenty-six health professionals and CHWs from the local primary healthcare services participated in action research over a 15-month period from September 2014 to December 2015. The groups participated in two parallel cooperative inquiry (CI) groups. The inquiry followed the cyclical steps of planning, action, observation and reflection. In this article, the planning step and how the CI groups used the first three steps of the analyse, design, develop, implement, evaluate (ADDIE) instructional design model are described. The CHWs' scope of practice, learning needs, competencies and characteristics, as well as the needs of the caregivers and stroke survivors, were identified in the analysis step. The program design consisted of 16 sessions to be delivered over 20 h. Program resources were developed with appropriate technology, language and instructional methodology. The program aims to equip CHWs to support family caregivers and stroke survivors in their homes as part of their generalist scope of practice. The implementation and initial evaluation will be described in a future article. The study developed a unique training program for CHWs to support caregivers and stroke survivors in a resource-constrained, rural, middle-income country setting.

Continuity of Care in Primary Care for Young Children With Chronic Conditions.

1) To assess continuity of care (CoC) within primary-care practices for children with asthma and autism spectrum disorder (ASD) compared to children without chronic conditions, and 2) to determine patient and clinical-care factors associated with CoC. Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0-1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits. Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean=0.58, SD 0.21) and ASD (M=0.57, SD=0.20) than Controls (M=0.66, SD=0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR=0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR=0.77, CI, 0.74-0.81; aOR=0.64, CI, 0.59-0.69). After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.

Chronic diseases of lifestyle curriculum: Students' perceptions in primary health care settings.

Community-based primary health care (PHC) forms the foundation of healthcare in South Africa. Medical programmes need to equip future health practitioners to face the challenges of the rising burden of chronic diseases of lifestyle (CDL) in different communities. Community-based education (CBE) contributes to developing knowledge, skills and attitudes appropriate to the challenges experienced in the PHC context. To explore medical students' perceptions of the current CDL curriculum and related programmes during CBE rotations. The study was conducted among fourth- and fifth-year medical students at the University of the Free State, South Africa. Focus group discussions were conducted and data were analysed thematically. Themes included perceptions of the CDL curriculum, relevance thereof for the PHC setting and barriers and challenges to implementing PHC programmes. This study identified foundational CDL content that needs to be incorporated or revisited at strategic points. Participants identified the need to contextualise educational programmes and focus on affordable, culturally acceptable and holistic healthcare prevention strategies. Barriers and challenges included high patient load, resource constraints, the lack of continuous care and focus on communicable diseases. Community-based education rotations were described as meaningful opportunities to develop professional attributes, competencies and skills. This study identified foundational concepts to consider at key points throughout the curriculum. Incorporating creative and reflective learning activities in CDL modules can prepare students for the realities of PHC settings.Contribution: This study provides insight into medical students' perceptions of the CDL curriculum and informs future curriculum content for CDL modules.