Primary Care Area Research Articles

Nurses' first encounters with parents of new-born children--public health nurses' views of a good meeting.

The nurse's view of the first meeting with parents of new-born children ma have consequences for the quality of future contact. A good start will lay a soli foundation for a lasting relationship, and have an affect on the nurse's work to support parents and children and to promote health. We do not know wha nurses mean by a 'good meeting'. The aim of this study was to discover how nurses view the first meeting as a general preventive measure aimed at all parents and their new-born children. Four focus groups interviews were held with nurses from different primary health care areas in the county of Skåne, southernmost Sweden. Analysis of the content in the transcribed interview texts disclosed eight subcategories: good contact/reciprocal relationship; willingness to listen; guest/ equal roles; time/peace and quiet; the family in its environment; socio-cultural aspects; confirmation/support; and individual advice. Three categories were established: creating trust; creating a supportive climate; and creating a picture of the family's life situation. The home visit was seen as an important way to establish trust and obtain a picture of the family's life situation, which was in turn essential for creating a supportive climate.

Trends in the misuse of androgenic anabolic steroids among boys 16?17 years old in a primary health care area in Sweden

Objective - To evaluate the effects of an appearance programme in preventing the misuse of androgenic anabolic steroids among male adolescents in a primary health care area in Sweden. Methods - Attitudes to steroid hormones among 16-17 years old male and female adolescents are discussed. A well-established anonymous multiple-choice questionnaire was answered by 921 adolescents and statistically analysed. Results - The misuse of androgenic anabolic steroids tended to decrease after the intervention. Conclusions - The misuse of androgenic anabolic steroids did not increase, and even tended to decrease, after the intervention, indicating that drug-abuse among male adolescents can be decreased through discussions about appearance and attitudes. Repeat and prospective studies have to be done before this intervention programme can be generalised.

Prevalencia de la obesidad en la población atendida en asistencia primaria de Girona, 1995–1999

ObjectivesTo estimate the prevalence of obesity and overweight in the population of Girona (Spain) between 1995 and 1999 and to divide the prevalences in geographical areas according to age and sex. MethodsHeight and weight were directly measures in 24,554 health care consumers older than 14 years (10,595 men and 13,959 women) treated in four primary health care areas: Girona 1, Girona 4, Salt and Camprodon and in one primary health care center in the province of Girona. Body mas index (BMI) was calcuted by dividing weight in kilograms bye height in meters squared. Obesity was defined as grades II and III of Garrow's index (BMI ≥ 30 kg/m2) and overweight as degree I (25 kg/m2 ≥ BMI < 30 kg/m2). Because the sample was not randomized, the prevalences were adequately weighted. The comparison between prevalences in two different primary health care areas for each sex (in the same Garrow's index and age group) was carried out using a parametric test of differences in proportions (Student's t-test). A hierarchical logistic regression was used to compare prevalences in the same grade Garrow's index, controlling for age and sex. ResultsThe prevalence of obesity was estimated as 15.6% in men aged from 20-74 years (from 14.0% in Girona 1 to 22.4% in Camprodon) and 17.5% for women (15.6% in Girona 1, 22.7% in Camprodon). The weighted mean was 16.7%. The prevalence of overweight was 44% in men and 33% in women and the weighted mean was 37.8%. The prevalence of obesity was graduated with statistically significant differences between Girona 1, Salt, Girona 4, Camprodon and Sils. ConclusionsThe estimates of the prevalences of obesity and overweight obtained in this study were closer to those of other studies in similar populations than previously believed. Inde-ed, the prevalences may be similar to those of the European Union and, in some age groups, to those of the United States.

Validez del diagnóstico clínico de carcinoma basocelular en atención primaria

To measure the validity of the clinical diagnosis of the basal cell carcinoma (BCC) in primary care. Cross-sectional study. Primary health care Area 8 in Madrid. PATIENTS AND ITNERVENTIONS: A study was carried out on a group of patients that had been histopathologically diagnosed of BCC and on another that had received any of the most frequent differential diagnoses. A sample estimate was made with the most unfavourable situation of a sensitivity and a specificity of 50%, a precision of 5%, a confidence of 95% and losses of 20%. It was estimated that 962 cases were necessary. The histopathological diagnosis (gold standard) were compared to the clinical diagnosis. Sensitivity, specificity, predictive values, likelihood ratios and global value were estimated. 963 patients were included of which 7.6% were lost 890 cases were studied, 491 with BCC and 399 with differential diagnoses. The most frequent location of BCC was the face (65.8%). Sensitivity was 27.5% (95% CI, 23.531.5%), specificity 90.5% (95% CI, 87.5-93.5%), the global value of 55.7% (95% CI, 52.7-58.7%), positive predictive value, 78.0% (95% CI, 72.084.0%) and negative predictive value 50,3% (95% CI, 46.354.3%). Validity was moderate with low sensitivity and very low positive predictive value, the latter estimated for its expected prevalence. The clinical diagnosis of BCC in primary health care must be complemented with other diagnostic tests.

Impacto económico de la implantación de un programa de cirugía menor en atención primaria

To value the economic impact of implantation (establishment) of a minor surgery programme within health area of primary care in Albacete (Spain). Primary care (PC). Observational, cross-sectional and retrospective study. Interventions and measurements. It has been recorded some patients operated on subsidiary minor surgery pathologies in the three health centers of Albacete area that participated in pilot experience from 1 November 1997 to 30 October 1998. It has been calculated the fixed costs corresponding to sanitary staff and the repayment of chirurgical area daily. As well, it were calculated the costs corresponding to disposable and not disposable equipment. It were analysed costs in function of intervention and the total cost were compared with the cost it would have supposed if it would carried out in specialized private centers according to up to dated fees of 1998 insurance companies. During the study interval were operated on 185 patients with an average age of 64,5 years (SD +/- 21,4) with a slight predominance of women. All pathologies treated were benign, 39 cases were abscess, 38 were nail pathology, and 35 were foreign bodies removed.Cost were calculated on the basis of time of one year. Total cost of minor surgery programme were 1.234.440 Pts (7715 Euros) whereas if it would have carried out at specialized level it supposed between 2621450 Pts (15755.23 Euros) and 4440000 Pts (26684.94 Euros). In our study, the minor surgery programme in primary care diminish the cost in comparison with private specialized level, at the same time as reducing standby list in specialities like surgery or dermatology.

Validez de un indicador de calidad de prescripción farmacológica en pacientes con hiperlipemia

The computer system for billing prescriptions (SIFAR in Spanish) enables indicators to be extracted for the study and follow-up of the use of medicines in the INSALUD primary care areas. Concretely, we studied the indicator referring to pensioners consumption of lipid-lowering drugs (PCLL), not validated, and whose value is expected to drop as quality increases. The objective was to calculate the correlation of the indicator of prescription of lipid-lowering drugs on the SIFAR with the proportion of lipid-lowerers prescribed correctly for pensioners (PCP). A descriptive study of correlation between two indicators of drug prescription. Four health districts in Madrid. The prescriptions of 49 general practitioners, chosen at random on the basis of three strata defined by the value of the indicator, were studied. Each doctor filled out a protocol of data for each pensioner patient to whom he/she prescribed a lipid-lowerer during the study period. The PCLL and PCP indicators were compared through the correlation of Spearman. 6,779 prescriptions for 1,125 patients were collected from the 49 participating doctors. The mean percentage of lipid-lowerers correctly prescribed was 31.9%, figure that rose to 77.5% when the LDL value was not specified. The correlation between the PCLL and the PCP was near zero. The PCLL indicator of the SIFAR does not discriminate quality in lipid-lowering drug prescription to people over 64.

The California Physician Assistant Workforce: A 10-Year Perspective

Educators and policy-makers concerned about primary-care workforce issues in California have conducted surveys with physician assistants (PAs) to learn more about their locations, practice features, and the extent to which they provide care for underserved populations. Method: In 1998, a statewide survey was administered to all PA licensees (2,938) in California. This survey was similar to one administered in 1988 to 1,263 PAs. Results of the two surveys were compared. These results also were compared with results from the 1998 national census conducted by the American Academy of Physician Assistants (AAPA). The 1998 California survey also included all nurse practitioner (NP) licensees, allowing comparison between state PAs and NPs. Results: A 58% response from PAs in the 1998 study revealed that the California PA workforce increased by 65% between 1988 and 1998. Minority PAs increased by 7%. California had 20% more minority PAs compared to the PA workforce nationally. Sixty-one percent of California PAs were practicing in the primary-care specialties, compared with 54% in the national census. In 1998, 54% of California PAs reported substantial involvement (more than 15% of their patients) with Medicaid recipients, 34% with the uninsured, 71 % with minorities, and 50% with patients who spoke limited English. These percentages increased substantially over the 10-year comparison period. When compared with NPs in the California study, PA licensees were fewer in number (7,341 vs. 2,938), and PAs were of greater ethnic diversity (29% minority compared to 18% among NPs). NPs were more likely than PAs to practice in the primary-care specialties (75% vs. 61%). A significant percentage of both groups (39%) practiced in underserved settings and reported similar levels of involvement with underserved groups of patients. More of the PAs than NPs (16% vs. 12%) were in state-designated rural areas, and more PAs than NPs (21% vs. 17%) were in federally designated Health Professional Shortage Areas (HPSAs). Conclusion: California PAs, along with their NP colleagues, are growing in numbers and increasingly practicing primary care in areas of need and with underserved populations.

Australia's national mental health strategy

Aim: To inform Fellows on aspects of the work being carried out in the Commonwealth's Mental Health Branch.Method: The goals, background and processes used in the Mental Health Branch are compared with the perspective of psychiatrists in private or public practice settings, and with the population-based approach in public health. The author's appointment in 1999 and again in 2000 as Clinical Adviser in Mental Health has provided this opportunity.Findings: The Mental Health Branch continues to have outstanding leadership and administrative abilities. It is internationally recognised for the quality of its programmes, exemplified by its influential publications, the National Survey of Mental Health and Well-being and the recent visit of the US Surgeon General. The Branch's broad strategy is to focus on three levels: the general population of all ages, with particular reference to mental health literacy, prevention and promotion; the mental health component in general practice and other areas of primary care...

Freight trains and supernovas: the use of a sorting task to determine patterns within long-term frequent attendance to general practitioners

Little is understood about the patterns in which frequent attenders consult primary care over time, or about the clinical or behavioural reasons for doing so. The aim of this study was to use a sorting task to identify the important features of patterns of attendance to general practitioners generated by frequent attenders over a period of 44 months. A total of 12 experts performed a sorting task on consulting patterns of the 100 most frequent attenders from one general practice in Leeds. A similarity matrix was constructed which was then subjected to cluster analysis. A range and diversity of patterns was clearly demonstrated within the data. The determining factors of the groupings by the experts included frequency, regularity, bursts of consultations, patterns of consulting after bursts, periods of not consulting, and seasonal or annual trends. The cluster analysis provided six final clusters, the largest of which had no fixed or classifiable pattern of attendance. The other five clusters were ‘regular without bursts’, ‘supernovas’, ‘gap and prolonged burst’, ‘bursts and sporadic attending’ and ‘regular as clockwork’. Distinct patterns of frequent attendance exist, and it seems likely that the clinical and behavioural reasons underpinning such behaviours differ. This work furthers our understanding of the way in which frequent attenders consult, and the results have implications both for general practice and for future research. The methodology described may have applications in other areas of primary care and biomedical research.

Estudio del impacto de un boletín farmacoterapéutico en un área de atención primaria

To evaluate the impact of the recommendations in the bulletin of pharmacotherapeutic information on the prescription of iron salts by the area's doctors. Intervention study with control group. Two primary care areas in Asturias. Intervention group: 93 doctors from area 3. 59 doctors from area 7. In March 97 an informative bulletin was issued recommending the use of ferrous salts rather than ferric salts and was sent to all area 3's doctors. The PFe2 indicator was calculated: defined daily dose percentage of ferrous salts out of total iron salts in three time periods: January-March '97 (t1), April-June '97 (t2) and January-March '98 (t3). In the intervention group, the PFe2 value increased progressively in the three periods. There were significant differences between t1 and t3 (mean increase: 6.0%, 95% CI: 1.9%-10.1%, p = 0.004) and between t2 and t3 (mean increase: 4.5%, 95% CI 0.8%-8.3%, p = 0.017), whereas the differences were not significant between t1 and t2 (mean increase 1.5%, 95 CI 1.3%-4.2%, p = 0.296). The respective values for the controls only showed significant differences for variation in periods t2 and t3 (mean increase: 2.0%, 95% CI 0.2%-3.8%, p = 0.017). 1. The bulletin issued in the area had a favourable impact. 2. This impact could only be seen in the medium term, not in the short term.

The Development of Indigenous Substance Misuse Services in Australia: Beliefs, Conflicts and Change

The aim of this paper is to overview earlier and recent issues in the field of Indigenous substance misuse intervention from its beginning to more recent developments. The overview will specifically analyse developments, advancements and change in the area of tertiary intervention or 'rehabilitation' as it is commonly referred to by Indigenous people. First, the paper will focus on Indigenous historical and theoretical constructs that have impacted on the development of Indigenous notions of 'rehabilitation' or intervention. Indigenous interpretations of the disease model of alcoholism, particularly the Alcoholics Anonymous philosophy, is analysed as well as the socio-cultural beliefs associated with those models. Second, conflicts with the mainstream management of substance misuse intervention are overviewed. Third, the paper highlights the complexity of more recent evolution of the services and discusses possible options for change. Attention is also devoted to Indigenous alternative interpretations of intervention and their relevance to the area of secondary intervention. Recent developments in the area of primary health care and their potential towards further improvement is also considered as well as obstacles to those changes.

Profesionales y gestores ante la comunicación interna en el Programa de Salud Maternoinfantil de Andalucía

To find the views of primary health area directors and of professionals in health centres (HC) in Andalusia on internal communication within the Mother-Child Health Programme introduced in this autonomous community. Descriptive study that uses qualitative and quantitative methodology. Primary care (PC) areas and HC in Andalusia, between July 1994 and February 1995. 51 PC area directors and 91 HC professionals. Self-administered questionnaire (directors) and focus groups (professionals) were used. Analysis by non-parametric tests compared averages and analysed discourse contents. Internal communication was an important weakness in the Mother-Child Health Programme and in PC in general. There were important differences between the perceptions of directors and professionals in relation to the guidelines of the Mother-Child Programme. As such, in all the area administrations it was affirmed that there were programme objectives agreed with the professionals, and transmission channels for these objectives between the area and the centres, although these were transmitted in writing in under 25% of the areas. However, professionals thought that the objectives and guidelines of the programme were unclear and ill-defined. In addition, the view that the annual objectives are not negotiated was quite common. Internal communication in PC is a considerable weakness in HC management. The professionals perceive considerable conflicts of interest between them and the organisation's directors.

Impacto de diversos objetivos relacionados con el uso racional del medicamento en un área de atención primaria

To evaluate the impact of the application of objectives relating to the rational use of medication and to assess the possible effect of these objectives on pharmaceutical expenditure. A non-randomised intervention study with control. Santiago de Compostela Primary Care (PC) Area. After the inclusion and exclusion criteria were applied, both the intervention group (IG) and the control group (CG) consisted of 31 doctors. Those in the IG belonged to the reformed PC model, whereas those in the CG did not. Four blocks of objectives on the rational use of medication were included in the Pact signed by reformed-model doctors and the management. The study lasted three years (1996-1998) for the objective of lowering the prescription of low-therapeutic-utility (LTU) drugs, and two years (1997-1998) for lowering the prescription of antihypertensives, Triflusal and quinolones. The difference between both groups was 1.7 fewer packs of LTU drugs per 1000 users and per day in the IG (95% CI, 0.9-2.6) and 1768 pesetas less (95% CI, 801-2733). These differences were still greater among pensioners. The difference between the two groups in terms of total pharmaceutical cost was 7379 pesetas less in the IG (95% CI, 708-14,049) than in the CG. The differences between the groups for the remaining objectives (antihypertensives, Triflusal and quinolones) in no case reached statistical significance. The pharmaceutical objectives of the pact were partly achieved: a drop in LTU drug prescription was seen, with an indirect reduction in overall expenditure, but no differences were found in the prescription of antihypertensives, triflusal or quinolones.

Recién nacido de riesgo neurológico en el año 2000. Recomendaciones para el seguimiento, incorporación de nuevos instrumentos

Perinatal mortality has dropped markedly in recent years. However, there is still a considerable prevalence of neurological sequelas. Symptoms may present during the first months of life or later. Thus it is necessary to follow-up children with a clinical history of risk of neurological disorders. The various programmes for follow-up show slight variations in criteria of inclusion, calendar and methods of evaluation. We report the results of our follow-up of children at risk: long and short term sequelae in children of very low birth-weight and their correlation with neuroimaging findings. We review the use of some investigations (clinical examination, cranial ultrasound, CAT, magnetic resonance, EEG, visual and auditory evoked potentials and different biological, hemodynamic and nerve damage markers. It is necessary to: 1. Restrict the criteria for inclusion in hospital follow-up programmes; 2. Match a suitable investigative calendar to the pathology of the newborn baby; 3. Coordinate with the pediatricians of primary care areas and centres of early health care; 4. Use specific instruments for detection of mild sequelae at an earlier age; 5. Prolong follow-up at least until the age of 6-7 years old, and 6. To seek new biological markers to allow early detection of brain damage.

Análisis de un programa de detección precoz de cáncer de mama en una zona rural

To find the results of a breast cancer early-detection programme run in a rural area, in terms of the activities corresponding to primary care. Cross-sectional, observational study. Rural district in Primary Care Area 11, Madrid. The programme was run in this area between 1st February and 31st March 1999. Women from 50 to 64, both inclusive, who had been called for a mammography. Inclusion in the breast cancer early-detection programme and open telephone survey of those who did not take part to find the reasons for not taking part in the randomised sample. In the period mentioned, 3902 women were called for screening (60.07% of all women between 50 and 64. The rest will be called in a second round in the year 2000). 2099 women attended for mammography (participation index 53.79%), with the following results: 5 (0.24%) highly likely to be malignant; 6 (0.29%) probably malignant; 172 (8.19%) probably benign; 1393 (66.36%) found to be benign; 438 (20.87%) negative; and 85 (4.05%) who needed further evaluation. The main reasons why 46.21% of the women called did not attend for mammography were: they had had one recently (29.9%); could not attend (22.7%); did not want to have one (17.5%); had not received the notification (17.5%). The participation rate was acceptable, with fewer malignant cases found than in other programmes. It would be important to call again those women who could not attend.

Families' Medical Self-Care Management in a Primary Health Care Area in Sweden

Medical self-care (MSC) is the range of activities undertaken to promote or restore health when dealing with a medical problem (MP). The aim of the study was to map out families' MPs and how these were managed in terms of reactive and restorative MSC. In a primary health care area in Sweden, 93 consecutive families were interviewed by telephone eight times during a four-month period. The instruments used were structured questions and illness diaries about MPs, which were analysed using descriptive statistics. In total, 621 MPs were reported and the most common complaints were ear-nose-throat problems. The mean number of MPs and mean duration of days for children were 1.9 and 13, for mothers 1.7 and 15, and for fathers 0.9 and 7.0, respectively. In five percent of all MP cases the families tried to manage their MPs by reading medical books and pharmacy brochures. In one-fifth of the MPs the families tried non-medical treatments comprising both external and internal application. The hospital's department of...

Establishing a research team in general practice

The integration of multiprofessional teaching, training and audit within general practice has demonstrated that service and academic practice are not necessarily mutually exclusive. This recognition is now leading to the development of research teams within traditional service-orientated general practices. The many unresearched and under-researched areas in primary care provide an opportunity for nursing and other professionals to combine clinical and academic practice. This article describes the process of establishing a multiprofessional research team in a non-academic practice in the South West of England. It focuses on the issues required to achieve the team’s aims, which include the development of research expertise; publication of projects; successful application of project-based grants; and the development of a research culture within primary health care. The challenges addressed and the lessons learned in the first year since its inception are outlined.

Promoting medical self-care: evaluation of a family intervention implemented in the primary health care by pharmacies.

Medical self-care is the range of behaviours undertaken by people to promote or restore health when dealing with a medical problem. The aim of the study was to evaluate medical self-care effects of a family intervention implemented in primary health care by pharmacies, in terms of non-professional and professional involvement. The intervention was implemented in one of two primary health care areas during a 4-month period and involved consecutive families acting as an intervention (IG, n = 94) or a control (CG, n = 93) group. Eight telephone interviews were conducted with each family. The families were asked about complaints of illness, how long they prevailed and how they were treated. The results showed (P < 0.05-0.0001) that the IG had more medical problems (931 versus 621) compared with the CG, were less hospitalized (4 versus 10), stayed at home more to take care of sick children (84 versus 40), read more medical brochures (121 versus 31), tried more non-medical treatments (228 versus 116), and had fewer visits to the department of paediatrics but more visits to primary health care (69 and 98 versus 90 and 68). Due to the non-randomization procedure, some caution with regard to generalization of the results must be taken, but they are in concordance with established knowledge of the usefulness of medical self-care. The results indicate that a brief intervention for families can change the use of health authorities. It therefore seems meaningful to implement the intervention in a more comprehensive way in the primary health care setting, while at the same time trying to implement it as a large-scale randomized experimental study, comprising aspects such as the individual's need for care, the use of the right organization level and the assessment of economic costs and savings.

Prevalence of depressive symptoms and mood disorders in primary care: a Spanish rural study.

5-10% of primary care patients present a classification diagnosis of Major Depression, 5-10% of Dysthymia and 20% "depressive symptoms only". We tried to obtain the prevalence of depressive symptoms in a Spanish primary care area (11,667 adult inhabitants, Seville). a randomized sample of 221 people (SE = 0.0025, a = 0.05) was initially examined using the Beck Depression Inventory (BDI). The patients with a BDI > 16 were considered as "cases" and were extensively examined using the "Schedules for Clinical Assessment in Neuropsychiatry" (SCAN). Our prevalence of depressive symptoms was higher than that reported in international studies with similar BDI cutting-scores. Class-linked vulnerability could play an important aetiological role. Prevalences of Major Depression and Dysthymia were similar to other reports using structured diagnostic interviews. The cases were usually lower-class females, and they also presented medium or high psychosocial disability. Depressive symptoms and mood disorders in Primary Care represent an unsolved health care problem today.

Health promotion in primary health care nursing: the development of quality indicators

This paper describes the development of indicators of quality in the health promo tion work of primary health care nurses through a study commissioned by the Health Education Authority (HEA). The study commenced with a review of the accident- prevention literature in primary health care nursing and three in-depth workshops with locality-based project teams consisting of commissioners of primary health care nursing services, primary health care nurses themselves, and their managers. Potential indicators of quality were identified from the literature and explored further within the workshops. The second phase of the study involved refining and testing the relevance of the indicators in practice through stakeholder interviews and the third phase focused on case studies of six areas of primary health care nursing prac tice. Client perspectives were actively sought and ten consumer-focused process indicators emerged. These have the potential to provide measures of quality in health promotion activities undertaken by primary health care nurses.