Local Primary Care Clinics Research Articles

The impact of COVID-19 on referrals among general practitioners and specialists in Shanghai, China.

The COVID-19 pandemic has impacted patient's visits to general practitioners (GPs). However, it is unclear what the impact of COVID-19 has been on the interaction among the local primary care clinics, the GP Department within the hospital and specialists. The interaction among GPs referring to hospital-based specialists and specialists to local doctors was determined, comparing pre-pandemic 2019 and 2020 during the pandemic. Reduced referrals from GPs to specialists were consistent with the reduction in specialist referrals back to the local doctors, which dropped by approximately 50% in 2020, particularly in the two most common chronic conditions (hypertension and diabetes mellitus). Reduced referral of patients from local clinics to Tongren Hospital is probably due to the extensive online training provided to the local GPs to become more competent in handling local patients via telehealth. Our data provide some insight to assist in combatting the pandemic of COVID-19, offering objective evidence of the impact of COVID-19 on patient management by GPs.

Abstract 15893: A Quality Improvement Project of Increasing Utilization of SGLT2i in Patients With Heart Failure Within a Veterans Affairs Health System Through an Interdisciplinary Approach in the Primary Care Setting

Introduction: Given the astounding beneficial effects of SGLT2i in patients with heart failure, they continue to be underutilized especially in the outpatient setting. Our project looked at increasing empagliflozin usage in patients with heart failure, preserved and reduced ejection fraction, at James A Haley VA Hospital (JAHVA). Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to increase utilization of empagliflozin in patients with heart failure. We created an actionable database using ICD codes for heart failure to identify eligible heart failure patients who were not on SGLT2i categorized by local primary care clinics at the JAHVA. We split up the responsibilities between clinic pharmacists and primary care physicians to safely start patients on SGLT2i from February to April 2023. Primary care physicians focused on patients scheduled for clinic during this period while pharmacists were responsible for patients not scheduled for clinic. Results: Our initial data showed only 19% of the 3,352 patients were on SGLT2i at JAHVA. From February to April 2023, we started 224 patients on empagliflozin with heart failure (preserved and reduced ejection fraction). We increased utilization by 13% in three months from 19% to 32% at JAHVA. Primary care physicians accounted for 46% of drug initiation while pharmacists accounted for 20% of new prescriptions. Cardiology providers prescribed 27% of all SGLT2i with 7% started by endocrinology or nephrology. Some of the characteristics of our sample included patients with an average age of 70 years old, 35% without diabetes, 50% with preserved heart failure. Conclusion: Our multi-disciplinary team approach involving pharmacists increased the utilization of SGLT2i in patients with heart failure through an actionable dashboard. Next steps for this project include improving the database to include other GDMT to further optimize medications.

CE-452772-3 SELF-PULSE EXAM FOR ATRIAL FIBRILLATION SCREENING: A RANDOMIZED CONTROLLED TRIAL

Atrial fibrillation (AF), the most commonly treated cardiac arrhythmia, is associated with significant morbidity including the potential for stroke. Because AF is often asymptomatic, there is growing interest in AF screening. Trials of AF screening using external monitors, smartwatches, or other personal electronic devices have shown that screening increases detection of AF. Due to the cost and low yield of screening with insufficient evidence of clinical benefit, the US Preventative Services Task Force has not recommended comprehensive screening for AF at the current time. However, no study has evaluated whether teaching patients to detect irregularity on self-pulse exam is a feasible and effective screening tool for AF. To conduct a randomized controlled trial of self-pulse exam for detection of AF in patients who would be at high risk for stroke. We recruited 524 patients with no history of AF or atrial flutter (AFL) who would be at high risk for stroke (CHADS2VASC score ≥ 2 in men or ≥3 in women) for participation in a study of self-pulse exam for detection of AF. Participants were recruited from local primary care and cardiology clinics and randomized to either usual care or to viewing a 5-minute educational video designed to teach patients to self-detect pulse irregularity. Participants were asked to self-check twice daily for 14 days. Those detecting an abnormal pulse were then offered a confirmatory 14-day external cardiac monitor. The primary endpoint was time to detection of AF or AFL and patients were followed for one year. The one-year rate of AF or AFL detection was increased (5.5% vs. 2.4%, p=0.07), while time to AF/AFL diagnosis (121.8 days vs. 140.6 days, p=0.07, Figure) and time to anticoagulation initiation (127.8 days vs. 239.0 p=0.3) were decreased in the intervention vs. control groups, respectively. Multivariate analysis demonstrated a significant independent association of the intervention with rate of detection of AF/AFL (OR 3.04, p=0.04) and decreased time to detection of AF/AFL (HR 9.75, p=0.01), after adjusting for potential confounders. Patients can be taught a self-pulse exam via a simple educational video. This easily implemented screening tool is independently associated with a greater than three-fold increased rate of detection of AF/AFL, as well as significantly decreased time to AF/AFL diagnosis.

Active vs Traditional Methods of Recruiting Children for a Clinical Trial in Rural Primary Care Clinics

To our knowledge, there are no published randomized clinical trials of recruitment strategies. Rigorously evaluated successful recruitment strategies for children are needed. To evaluate the feasibility of 2 recruitment methods for enrolling rural children through primary care clinics to assess whether either or both methods are sufficiently effective for enrolling participants into a clinical trial of a behavioral telehealth intervention for children with overweight or obesity. This cluster-randomized clinical trial of 2 recruitment methods was conducted at 4 primary care clinics in 4 separate states. Each clinic used both recruitment methods in random order. Clinic eligibility criteria included at least 40% pediatric patients with Medicaid coverage and at least 100 potential participants. Eligibility criteria for children included a rural home address, age 6 to 11 years, and body mass index at or above the 85th percentile. Recruitment began February 3, 2020, and randomization of participants occurred on August 17, 2020. Data were analyzed from October 3, 2021, to April 21, 2022. Two recruitment methods were assessed: the active method, for which a list of potential participants seen within the past year at each clinic was generated through the electronic health record and consecutively approached by research staff based on visit date to the clinic, and the traditional method, for which recruitment included posters, flyers, social media, and press release. Clinics were randomized to the order in which the 2 methods were implemented in 4-week periods, followed by a 4-week catch-up period using the method found most effective in previous periods. For each recruitment method, the number and proportion of randomized children among those who were approached was calculated. A total of 104 participants were randomized (58 girls [55.8%]; mean age, 9.3 [95% CI, 9.0-9.6] years). Using the active method, 535 child-parent dyads were approached and 99 (18.5% [95% CI, 15.3%-22.1%]) were randomized. Using the traditional method, 23 caregivers expressed interest, and 5 (21.7% [95% CI, 7.5%-43.7%]) were randomized. All sites reached full enrollment using the active method and no sites achieved full enrollment using the traditional method. Mean time to full enrollment was 26.3 (range, 21.0-31.0) days. This study supports the use of the active approach with local primary care clinics to recruit children with overweight and obesity from rural communities into clinical trials. ClinicalTrials.gov Identifier: NCT04142034.

Cervical cancer screening management practices and prevention in uMsunduzi Local Municipality primary care clinics.

Although cervical cancer is preventable, it remains the most feared and second most common cancer in women worldwide, as well as the leading cause of cancer deaths in many low- and middle-income countries, including South Africa. Numerous studies conducted globally, in Africa and in South Africa revealed a knowledge gap about cervical cancer and its preventive strategies, including cervical cancer screening, among nurses and the general population. The purpose was to investigate and describe nurses' knowledge and management practices regarding cervical cancer screening in uMsunduzi Local Municipality, KwaZulu-Natal. The study was directed by a positivism paradigm. A quantitative research approach and nonexperimental descriptive design was used in this study. Probability random sampling was used, and a self-administered questionnaire was used to collect data. Eighty-three professional nurses participated in the study. The study discovered that professional nurses working in selected clinics in uMsunduzi Local Municipality, KwaZulu-Natal, had a high level of knowledge about cervical cancer and its screening. Nonetheless, despite the high level of knowledge demonstrated, the level of practice remained low. Cervical cancer morbidity and mortality have long been a major health concern in South Africa's general population. The study found that PNs are knowledgeable about cervical cancer screening; conversely, practice was low. This paper includes recommendations for future research, nursing practice, nursing education and the Department of Health. This study contributed vastly to the body of knowledge in managing cervical cancer screening practices, particularly in health promotion and prevention of diseases at primary care level.

Substance Use Disorder Treatment Providers' Knowledge and Opinions Toward Testing and Treatment of Chronic Hepatitis C in Rural North Carolina.

Poor access to care has made western North Carolina vulnerable to an outbreak of hepatitis C viral infection (HCV), particularly among persons who inject drugs (PWID). As substance use disorder (SUD) treatment providers could potentially improve linkage to HCV testing and treatment, we sought to understand SUD providers, clinic and client characteristics; referral patterns; HCV knowledge; willingness to participate in additional trainings; and local linkage-to-care pathways for treatment of substance use and HCV. Online survey data were collected from 78 SUD providers serving PWID in eight western rural North Carolina counties. Providers' attitudes toward working with HCV+ clients were very positive. One-third of providers reported a low fund of knowledge regarding HCV, HCV treatment, and financial assistance opportunities. Non-prescribing providers rarely initiated discussions about HCV testing/treatment, but were receptive to training. Respondents indicated that HCV testing and treatment were best delivered at local health departments or primary care clinics but were open to other venues where PWID access care. The vast majority of prescribing and non-prescribing providers expressed interest in obtaining training in HCV treatments, how to obtain HCV medications and topics on advanced liver disease. Data from prescribing and non-prescribing SUD providers suggest opportunities to develop or expand integrated care models for HCV testing/treatment in PWID in rural Appalachian North Carolina.

Meeting Needs of Pediatric Patients in Grades K-12 with Telehealth: A Case Study

Viewers will gain a deep understanding of school setting and challenges schools can meet medical needs. Topics will include FERPA and HIPAA rules and regulations, proper consent for medical care in schools, understanding how enrollment and engagement affects access, reimbursement challenges and engagement with local resources and primary care clinics to identify gaps in care.

Supportive supervision from a roving nurse mentor in a community health worker programme: a process evaluation in South Africa

BackgroundMany low and middle- income countries (LMICs) are repositioning community health worker (CHW) programmes to provide a more comprehensive range of promotive and preventive services and referrals to the formal health service. However, insufficient supervision, fragmented programmes, and the low literacy levels of CHWs often result in the under-performance of the programmes. We evaluate the impact of a roving nurse mentor working with CHW teams proving supportive supervision in a semi-rural area of South Africa.MethodsWe conducted a longitudinal process evaluation, using in-depth interviews, focus groups and observations prior to the intervention, during the intervention, and 6 months post-intervention to assess how the effects of the intervention were generated and sustained. Our participants were CHWs, their supervisors, clients and facility staff members and community representatives.ResultsThe nurse mentor operated in an environment of resource shortages, conflicts between CHWs and facility staff, and an active CHW labour union. Over 15 months, the mentor was able to (1) support and train CHWs and their supervisors to gain and practice new skills, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs’ activities, resulting in improved service provision. Towards the end of the intervention the direct employment of the CHWs by the Department of Health and an increase in their stipend added to their motivation and integration into the local primary care clinic team. However, given the communities’ focus on accessing government housing, rather than better healthcare, and volatile nature of the communities, the nurse mentor was not able to establish a collaboration with local structures.ConclusionsA roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors to support CHWs activities. A roving nurse mentor can contribute to the knowledge and skills development of the CHWs and enhance the capacity of junior supervisors. However, the long-term sustainability of the effects of intervention is dependent on CHWs’ formal employment by the Department of Health.

Primary Care Evolution: Clinic Staff and Patient Perspectives of the Rapid Upscale of Virtual Primary Care during the COVID‐19 Pandemic

Research ObjectiveThe Veterans Health Administration (VA) offers virtual care options including telephone and video‐based care to supplement face‐to‐face visits, with the goal of expanding access to care for Veterans. Across the Rocky Mountain Regional (RMR) VA Health Care System, virtual care had been used selectively prior to the COVID‐19 pandemic, but since March 2020, it has been systematically expanded. Perceptions of this rapid implementation from patients, providers and primary care clinic staff, are largely unknown. The objective of this evaluation is to better understand these perspectives.Study DesignWe conducted a rapid exploratory qualitative evaluation to understand perceptions and impact of the swift upscale of virtual care on local primary care clinic staff and patients who received virtual care. Five‐question structured surveys were distributed to clinic staff electronically prior to participation in a semi‐structured focus group. Focus groups were scheduled, facilitated, recorded, transcribed, and analyzed by the research team, utilizing rapid analysis process with modified consensus review. Ten‐question semi‐structured patient interviews were conducted among a cohort of patients who received virtual primary care from four identified clinics. Guides were created by the research team and informed by Practical Robust Implementation and Sustainability Model (PRISM) to focus on clinic staff and patient perspectives of virtual care and the rapid upscale and on contextual factors. Data were analyzed descriptively and thematically.Population StudiedWe studied four primary care clinics delivering virtual care within RMR. Clinical staff included providers, nurse care managers, licensed practical nurses, and medical support assistants. Out of the 47 focus group participants, 45% also participated in electronic surveys. All patients were men aged 33 to 76. 40% self‐identified as “White, not Hispanic or Latino”, 40% declined to identify, and 20% identified as “Black or African American, not Hispanic or Latino”.Principal FindingsPreliminary survey data from clinic staff suggest expanded virtual care options provide the same or slightly higher quality of care, efficiency and patient‐centeredness when compared to face‐to‐face care (3.1, 3.4, and 3.1 respectively on 1–5 Likert scale). Themes from clinic staff focus groups included (not limited to): unintended consequences of rapid upscale, concerns with workload increase, and uncertainty with patient suitability for virtual care. Data from patient interviews suggest satisfaction with both virtual and face‐to‐face care, with concerns regarding uncertainty of network privacy with virtual care usage and interest in self‐scheduling to improve patient satisfaction.ConclusionsPrimary care clinic staff perceive virtual care as providing the same or higher quality of care, efficiency and patient‐centeredness when compared to face‐to face but remain concerned about potential unintended consequences of the rapid scale up of virtual care implementation. Patients report satisfaction with both virtual and face‐to‐face primary care, with questions regarding network safety and self‐scheduling to improve experience.Implications for Policy or PracticeVirtual Care is an important option for primary care, however perceptions of utilization during a rapid scale up from patients and clinic staff should be considered in future planning. This study provides insight into the impact of the rapid upscale of virtual care and adds perspectives on usage to further inform future program development with appropriate contextual factor consideration.

Efficacy of Wolbachia-Infected Mosquito Deployments for the Control of Dengue

BackgroundAedes aegypti mosquitoes infected with the wMel strain of Wolbachia pipientis are less susceptible than wild-type A. aegypti to dengue virus infection.MethodsWe conducted a cluster-randomized trial involving releases of wMel-infected A. aegypti mosquitoes for the control of dengue in Yogyakarta, Indonesia. We randomly assigned 12 geographic clusters to receive deployments of wMel-infected A. aegypti (intervention clusters) and 12 clusters to receive no deployments (control clusters). All clusters practiced local mosquito-control measures as usual. A test-negative design was used to assess the efficacy of the intervention. Patients with acute undifferentiated fever who presented to local primary care clinics and were 3 to 45 years of age were recruited. Laboratory testing was used to identify participants who had virologically confirmed dengue (VCD) and those who were test-negative controls. The primary end point was symptomatic VCD of any severity caused by any dengue virus serotype.ResultsAfter successful introgression of wMel into the intervention clusters, 8144 participants were enrolled; 3721 lived in intervention clusters, and 4423 lived in control clusters. In the intention-to-treat analysis, VCD occurred in 67 of 2905 participants (2.3%) in the intervention clusters and in 318 of 3401 (9.4%) in the control clusters (aggregate odds ratio for VCD, 0.23; 95% confidence interval [CI], 0.15 to 0.35; P=0.004). The protective efficacy of the intervention was 77.1% (95% CI, 65.3 to 84.9) and was similar against the four dengue virus serotypes. The incidence of hospitalization for VCD was lower among participants who lived in intervention clusters (13 of 2905 participants [0.4%]) than among those who lived in control clusters (102 of 3401 [3.0%]) (protective efficacy, 86.2%; 95% CI, 66.2 to 94.3).ConclusionsIntrogression of wMel into A. aegypti populations was effective in reducing the incidence of symptomatic dengue and resulted in fewer hospitalizations for dengue among the participants. (Funded by the Tahija Foundation and others; AWED ClinicalTrials.gov number, NCT03055585; Indonesia Registry number, INA-A7OB6TW.)

Non-gestational choriocarcinoma as a cause of heavy menstrual bleeding-potential: Primary care detection

Choriocarcinoma is a malignant trophoblastic disease. It can be divided into gestational and non-gestational type. Gestational choriocarcinoma consists of less than 1% of total endometrial malignancy, and usually is diagnosed via histopathological examination preceding a suspected molar pregnancy. In contrast to gestational choriocarcinoma, only a few cases of primary non-gestational choriocarcinoma were reported in literature reviews. The reported locations for primary non-gestational choriocarcinoma were ovarian and uterine cervix. Due to its low incidence, this disease is often overlooked leading, to delayed diagnosis. In primary care practice, heavy menstrual bleeding is a common presentation. Further evaluations, such as full blood count, ultrasound pelvis or hysteroscopy are usually required. We would like to report a case of potentially earlier detection of non-gestational choriocarcinoma in a 52 years old lady who was presented with heavy menstrual bleeding for a duration of one year. Her symptom persisted despite receiving medical treatment in a few local primary care clinics. She was admitted to a tertiary hospital for symptomatic anaemia which required blood transfusion. Further evaluations, (i.e., laboratory tests, ultrasound, Computed Topography (CT) scan, bone scan, hysteroscopy and laparotomy total abdominal hysterectomy and bilateral salphingo-oophorectomy (TAHBSO) and histological examination) concluded a diagnosis of primary non-gestational choriocarcinoma of fundal uterus with lung metastasis.
 Bangladesh Journal of Medical Science Vol.19(4) 2020 p.755-759

COVID-19 pandemic and shortage of personal protective equipment in Tokyo clinics.

Dear Editor, Clinicians worldwide are aware of the shortage of personal protective equipment (PPE) in their daily practice in the wake of the coronavirus disease 2019 (COVID-19) pandemic.1, 2 This PPE shortage has forced health-care staff to reuse single-use masks, clean face shields with bleach wipes, or use substitutes, which may expose health-care workers to danger.2 Peace Winds Japan (a non-governmental organization) decided to donate PPE to local clinics from their stockpiles for disaster relief, since local primary care clinics play important roles in frontline triage and referral of symptomatic COVID-19 patients. In order to distribute PPE to local clinics in Tokyo, the most affected area in Japan as of late April 2020, Peace Winds Japan conducted a survey to gain information on the shortage of medical supplies. Online questionnaires were implemented using Google Forms, and the link to the questionnaires was sent to members of Tokyo Medical Association on 17 April 2020. Due to the limited amount of PPE available for donation, registration was limited to 125 facilities on a first-come, first-serve basis and was closed the same day. On 17 April 2020, when the survey was conducted, the total number of patients with COVID-19 was 9,845 nationwide in Japan, including 2,792 patients in Tokyo.3 Of the 125 registered clinics, the median number of outpatient visits per day was 50 (interquartile range, 37.5-70). The PPE shortage status is shown in Table 1. Surprisingly, at the time of the survey, PPE was unavailable in approximately half of the clinics. The proportion of clinics with PPE shortages (remaining supply ≤50 pieces) for treating COVID-19 patients were 72.8%, 65.6%, 83.2%, and 79.2% for isolation gowns, vinyl aprons, face shields, and goggles for eye protection, respectively. In addition, 66.4% of facilities had shortages (remaining supply ≤100 pieces) of surgical masks, which is a minimal requirement for protection against respiratory droplets. In general, in outpatient clinics, donning an N95 respirator is not required when aerosol-producing procedures are not performed. However, the stock of PPE, even surgical masks and gloves for standard precautions, was critically low. In addition, there was a shortage of gowns and eye protection needed to treat patients with suspected COVID-19. The present data are limited to local health-care systems; however, it also highlights the serious shortage of PPE at clinics in Tokyo during the pandemic. Despite attempts, many facilities had difficulties obtaining additional supplies, as usual suppliers were dependent on imports from abroad. It is necessary to secure supplies that are not imported to prepare for future pandemics. To face PPE shortages, strategies to minimize the need for PPE are important, as described in the WHO report.4 The use of acrylic and vinyl partitions in addition to telemedicine are other important approaches. We thank Dr. Hiroyuki Kobayashi and the Tokyo Medical Association for their efforts in this study. Approval of the research protocol: N/A. Informed consent: N/A. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None.

Oral and dental health and health care for Māori with type 2 diabetes: A qualitative study.

Type 2 diabetes mellitus (T2DM) and periodontal disease are two highly prevalent, directly and independently associated long-term conditions that disproportionately impact Indigenous Māori in New Zealand (NZ). Although poorly understood, a number of social and biological mechanisms connect these conditions. This qualitative study explored experiences of T2DM and oral and dental (hereafter oral/dental) health; access to oral/dental health care; whether participants' experiences supported or challenged existing evidence; and sought suggestions for improving oral/dental health in a high-deprivation rural area of Northland, NZ. Participants (n=33) meeting the study criteria: self-identified Māori ethnicity, aged≥18-years with glycated haemoglobin (HBA1c) >65mmol/L were recruited via the local primary care clinic in September-December 2015; two left the study prior to data collection. During face-to-face semi-structured interviews, participants (n=31) were asked How does diabetes affect your teeth? and When did you last access dental care? Kaupapa Māori (KM) theory and methodology provided an important decolonizing lens to critically analyse the fundamental causes of Indigenous health inequities. Independent analysis of qualitative data by three KM researchers identified four themes: access barriers to quality care; pathways to edentulism; the 'cost' of edentulism; and, unmet need. Results contributed towards informing Mana Tū-an evidence-based KM programme for diabetes in primary care-to be introduced in this and other communities from 2018. Oral health is integral to diabetes management, and vice versa. Subsidized specialist referrals for oral-dental health care for Māori with T2DM could improve glycaemic control and diabetes outcomes and reduce diabetes-related complications among this population.

Strengthening Linkages Between Public Health and Health Care in Nebraska.

IntroductionEffective collaboration between public health and the health care system is essential for connecting medical and community health–related resources and improving population health. We investigated the linkages between local health departments and primary care clinics in Nebraska.MethodsWe conducted a mixed-method study by using semistructured in-person and telephone interviews and surveys in 2017 and 2018 with directors of 19 Nebraska local health departments. Interviews and surveys assessed activities and programs that health departments implemented or planned with clinics in their jurisdictions. Barriers, benefits, and opportunities for building the linkages were identified.ResultsStrong linkages existed between local health departments and primary care clinics. Linkages focused on the control and prevention of chronic diseases and on traditional public health programs, including screening for cancer and other chronic diseases, vaccinations, worksite wellness programs, home visits, clinic and medication assistance referrals, health message development, electronic health records data analyses, staff education, and improvements in policies and procedures. The most frequently reported barrier was funding, and the most frequently reported benefit was patient behavior change. The opportunity most frequently reported was chronic disease health coaching.ConclusionExtensive linkages exist between Nebraska local health departments and the health care systems in their areas. Additional funding, effective workforce management, community needs assessments, and program evaluation can support joint initiatives to address community health priorities.

882-P: Overcoming Family and Cultural Challenges for Chinese American Patients with Diabetes: Provider Guidelines

Despite unique cultural beliefs regarding health and family roles for Chinese immigrants, limited clinical guidance is available for primary care providers to addresses T2DM in this population. Our aim was to articulate cultural and family challenges in T2DM and detail clinical guidance for clinicians. Method: As part of a CBPR intervention trial, interdisciplinary Chinese and American researchers, community partners, and a Chinese American CAB created clinical recommendations based on: a) evidence on Chinese health beliefs and practices, b) prior interpretive study of this population by our research team and c) practical clinical wisdom of community partners: a Community Health Center and a historically significant social service agency serving new Chinese immigrants. Results: A structured clinical guideline (in Chinese and English) highlighted cultural and family challenges to T2DM management, and potential provider responses. Cultural health challenges included (partial list): Chinese health metaphors centered on balance versus control; dietary preferences that contradicted diabetes diets; respect for authority inhibiting querying health providers; face concerns constraining illness disclosure and family support requests; communal concerns that prioritized relationships over diabetes adherence; and preferences for authoritative versus collaborative health care approaches. Provider guidelines included: employing Chinese health metaphors (balance); highlighting self-care as a form of family care; flexibly providing both directive medical advice and encouraging patient agency, and normalizing diabetes as a chronic but not disabling condition. Dissemination of guidelines to local primary care clinics has been positively reviewed. Implications: Caring for ethnically diverse populations is demanding for diabetes providers and evidence-based guidelines for culturally tailored care is warranted. Disclosure C.A. Chesla: None. K.M. Chun: None. C.M. Kwan: None. Funding National Institute of Nursing Research (R01NR009111)

The experience of gestational diabetes for indigenous M\u0101ori women living in rural New Zealand: qualitative research informing the development of decolonising interventions

BackgroundAlthough early detection and management of excess rates of gestational diabetes mellitus (GDM) among Indigenous women can substantially reduce maternal and offspring complications, current interventions seem ineffective for Indigenous women. While undertaking a qualitative study in a rural community in Northland, New Zealand about the complexities of living with diabetes, we observed a common emotional discourse about the burden of diabetic pregnancies. Given the significance of GDM and our commitment to give voice to Indigenous Māori women in ways that could potentially inform solutions, we aimed to explore the phenomenon of GDM among Māori women in a rural context marked by high area-deprivation.MethodA qualitative and Kaupapa Māori methodology was utilised. A sub-sample of women (n = 10) from a broader study designed to improve type 2 diabetes mellitus (T2DM) who had experienced GDM or pre-existing diabetes during pregnancy and/or had been exposed to diabetes in utero were interviewed. Participants in the broader study were recruited via the local primary care clinic. Experiences of GDM, in relation to their current T2DM, was sought. Narrative data was analysed for themes.ResultsIntergenerational experiences informed perceptions that GDM was an inevitable heritable illness that “just runs in the family.” The cumulative effects of deprivation and living with GDM compounded the complexities of participant’ lives including perceptions of powerlessness and mental health deterioration. Missed opportunities for health services to detect and manage diabetes had ongoing health consequences for the women and their offspring. Positive relationships with healthcare providers facilitated management of GDM and helped women engage with self-management.ConclusionMāori women living with T2DM were clear that health providers had failed to intervene in ways that would have potentially slowed or prevented progression of GDM to T2DM. Participants revealed missed opportunities for appropriate diagnostic testing, treatment and health promotion programmes for GDM. Poor collaboration between health services and social services meant psychosocial issues were rarely addressed and the cycle of intergenerational poverty and disadvantage prevailed. These data highlight opportunities for extended case management to include whānau (family) engagement, input from social services, and evidence-based medicine and/or long-term management and prevention of T2DM.

Assessment of Diabetes Distress in Appalachian Ohio

Diabetes rates in southeastern Ohio are more than double the national average (19.9% vs. 9.4%). Here, people battle a poverty rate 1.5 times that of the U.S. average, and suffer from higher unemployment, lower educational achievement, poorer health, and lower access to care. Despite the high presence of social determinants of health, the impact of diabetes is understudied and one critical outcome that has not been addressed is diabetes distress. We conducted a cross-sectional survey study with 121 students, faculty, and staff at a large university in Appalachian Ohio (A1C=7.3±1.4%, age=36±17years; female=60%; white=86%; type 2 diabetes=54%; duration=10±9 years, 48%=college degree or more). Diabetes distress was assessed using the Diabetes Distress Scale for type 2 diabetes and for type 1 diabetes; depressive symptoms were assessed using the Patient Health Questionnaire-9. Of the 65 type 2 diabetes participants, 34% (n=19) reported moderate to severe diabetes distress, with 48% (n=31) experiencing moderate to severe distress on the Regimen subscale. Among the 56 type 1 participants, 26% (n=15) reported moderate to severe diabetes distress, with 51% (n=28) experiencing moderate to severe distress on the Powerlessness subscale. Multiple regression analyses found high scores of diabetes distress (standardized b= 0.62, p=0.03) were independently associated with higher A1C levels after controlling for depressive symptoms (standardized b=0.01, p=79), age (standardized b= -0.03, p=0.14) and gender (standardized b=0.75, p<=.08). This model accounted for 29% of the variation in A1C. Multiple regression analyses using the same model found no association between type 2 diabetes, distress, and A1C; the lack of significance may be explained by well-educated, working adults with private insurance. Next steps include recruiting type 1 and type 2 patients from local specialty and primary care clinics to enhance representativeness. These data will help providers individualize clinical approaches for patient’s diabetes distress level. Disclosure E.A. Beverly: None. E.H. Guseman: None. K.A. Cook: None. A.M. Healy: None.

Development of an item bank of health literacy questions appropriate for limited literacy public sector patients in South Africa

ABSTRACTThe majority of current health literacy measures emanate from high-income countries. In South Africa, there is no appropriate measure available for use by the diverse public sector population, many of whom have some literacy limitations. The objective was to develop a bank of questions for this population informed by a broader definition of health literacy, which acknowledges both traditional cognitive skills and explores the influence of the collective social environment on health literacy. Thirty questions for the Item Bank were developed to ensure cultural, contextual and educational appropriateness, and were continuously subjected to critical review by an expert consultant panel. Patients (n = 120) were recruited from a local primary care clinic and individually interviewed with the assistance of an interpreter to collect data on the Item Bank, Multidimensional Screener of Functional Health Literacy (MSFHL) and sociodemographics. The mean Item Bank score was 55% ± 11.3%. A high 82.5% was categorized as having either inadequate or marginal health literacy. Skills-based questions, particularly numeracy questions, were poorly answered. A significant education effect was established with 8/30 questions. The Procedural knowledge domain had the lowest score, but was not significantly different to the Access and Factual domain scores. The questions afforded preliminary insight into health literacy in a previously unstudied population and clearly demonstrated the need to include questions that did not rely solely on cognitive skills. Study findings provided an ideal base for further question refinement to generate a health literacy measure suitable for this population.

Impact of nurse-delivered community-based CD4 services on facilitating pre-ART care in rural South Africa.

BackgroundHIV testing, diagnosis and treatment programs have expanded globally, particularly in resource-limited settings. Diagnosis must be followed by determination of treatment eligibility and referral to care prior to initiation of antiretroviral treatment (ART). However, barriers and delays along these early steps in the treatment cascade may impede successful ART initiation. New strategies are needed to facilitate the treatment cascade. We evaluated the role of on site CD4+ T cell count phlebotomy services by nurses in facilitating pre-ART care in a community-based voluntary counseling and testing program (CBVCT) in rural South Africa.MethodsWe retrospectively evaluated CBVCT services during five continuous time periods over three years: three periods when a nurse was present on site, and two periods when the nurse was absent. When a nurse was present, CD4 count phlebotomy was performed immediately after HIV testing to determine ART eligibility. When a nurse was absent, patients were referred to their local primary care clinic for CD4 testing. For each period, we determined the proportion of HIV-positive community members who completed CD4 testing, received notification of CD4 count results, as well as the time to test completion and result notification.ResultsBetween 2010 and 2013, 7213 individuals accessed CBVCT services; of these, 620 (8.6 %) individuals were HIV-positive, 205 (33.1 %) were eligible for ART according to South African national CD4 count criteria, and 78 (38.0 % of those eligible) initiated ART. During the periods when a professional nurse was available to provide CD4 phlebotomy services, HIV-positive clients were significantly more likely to complete CD4 testing than during periods when these services were not available (85.5 % vs. 37.3 %, p < 0.001). Additionally, when nurses were present, individuals were significantly more likely to be notified of CD4 results (60.6 % vs. 26.7 %, p <0.001). The time from HIV screening to CD4 test completion was also significantly shorter during nurse presence than nurse absence (median 8 days (IQR 4–19) vs. 35 days (IQR 15–131), p < 0.001).ConclusionsThese findings indicate that in addition to CBVCT, availability of on site CD4 phlebotomy may reduce loss along the pre-ART care cascade and facilitate timely entry into HIV care.

Sleep time and pattern of adult individuals in primary care in an Asian urbanized community: A cross-sectional study.

Sleep norms vary between individuals, being affected by personal, communal, and socioeconomic factors. Individuals with sleep time which deviate from the population norm are at risks of adverse mental, cardiovascular, and metabolic health. Sleep-related issues are common agenda for consultation in primary care. This study aimed to determine the sleep time, pattern, and behavior of multiethnic Asian individuals who attended public primary care clinics in an urban metropolitan city-state.Standardized questionnaires were assistant-administered to adult Asian individuals who visited 2 local public primary care clinics in north-eastern and southern regions of Singapore. The questionnaire included questions on demographic characteristics, self-reported sleep time, patterns, and behavior and those originated from the American National Sleep Foundation Sleep Diary. The data were collated, audited, rectified, and anonymized before being analyzed by the biostatistician. Individuals with 7 h sleep time or longer were deemed getting adequate sleep. Chi-squared or Fisher exact test was used to test the association between the demographic and behavioral variables and sleep time. Next, regression analysis was performed to identify key factors associated with their sleep time.A total of 350 individuals were recruited, with higher proportion of those of Chinese ethnicity reporting adequate sleep. Almost half (48.1%) of those who slept <7 h on weekdays tended to sleep ≥7 h on weekends. More individuals who reported no difficulty falling asleep, had regular sleep hours and awakening time, tended to sleep adequately. Those who slept with children, studied, read leisurely, used computer or laptops in their bedrooms, drank caffeinated beverages or smoked had inadequate sleep. Those who perceived sufficient sleep and considered 8 h as adequate sleep time had weekday and weekend sleep adequacy.Sleep time varied according to ethnicity, employment status, personal behavior, and perception of sleep sufficiency. Awareness of sleep time and pattern allows the local physicians to contextualize the discussion of sleep adequacy with their patients during consultation, which is a prerequisite to resolve their sleep-related issues.