Community Primary Care Research Articles

Development, spread and impact of primary care and musculoskeletal communities of practice to assist rapid translation of evidence into practice

Embedding research into practice is challenging. Barriers include: a shortage of time, lack of understanding of the evidence and a poor support in the clinical setting. A community of practice (CoP) model has been used to address these issues. Three 'Evidence into Practice' groups use a CoP model to assist the rapid translation of evidence into practice in primary and secondary care settings. We describe how a CoP model supports the functions, operations and outputs of three 'Evidence into Practice Groups'. A CoP model is used to engage a broad range of clinicians, researchers, managers, patients and librarians in the complex process of acquiring research knowledge and then translating knowledge into practice. The CoP principles of Domain, Community and Practice are used to describe three 'Evidence into Practice Groups' who cater for different elements of the care and academic sector and engage a range of professional groups. This includes primary and secondary care engaging professionals such as general practitioners (GP), practice nurses, allied health professionals, researchers and librarians. All groups are clinically led, academically supported and follow similar processes to identify the best evidence and translate it into practice. As the groups reflect the context in which they work they have different operational arrangements for example frequency and time of meetings. The CoP model enabled three 'Evidence into Practice Groups' over time to: engage over 180 clinical and academic staff; answer 130 clinical questions; improve clinical care, gain funding for two randomised controlled trials (enrolled over n=7000 participants) and identify areas for further research, quality improvement audit and training. The CoP model encourages the rapid translation of evidence into practice by engaging staff to identify areas of clinical concern in their own context, thereby stimulating their interest and involvement. This creates a meaningful link between research and practice. Clinical leadership and the CoP model ensure that practice change is quick and efficient. This model can be replicated at scale. Consideration needs to be given to the key ingredients to achieve impact.

Demonstration of automated non-adherence and service disengagement risk monitoring with active follow-up for severe mental illness.

Medication cessation and service disengagement often precedes relapse in people with severe mental illnesses but currently specialist mental health services only become involved after a relapse. Early detection of non-adherence is needed to enable intervention to avert relapse. This paper aims to demonstrate how digitally automated non-adherence risk monitoring from Medicare data with active follow-up can work and perform in practice in a real-world mental health service setting. AI2 software is an automated risk monitoring tool to detect non-adherence using Medicare data. It was implemented prospectively in a cohort of 354 registered patients of a community mental health clinic between July 2019 and February 2020. Patients flagged as at risk by the software were reviewed by two clinicians. We describe the risks automatically flagged for non-adherence and the clinical responses. We examine differences in clinical and demographic factors in patients flagged at increased risk of non-adherence. In total, 46.7% (142/304) were flagged by the software as at risk of non-adherence, and 22% (31/142) received an intervention following clinician review of their case notes. Patients flagged by the software were older in age and had more prior mental health treatment episodes. More alerts were associated with patients who had been transferred from the mental health service to the care of their general practitioners, and those with more alerts were more likely to receive a follow-up intervention. Digitally automated monitoring for non-adherence risk is feasible and can be integrated into clinical workflows in community psychiatric and primary care settings. The technology may assist clinicians and services to detect non-adherence behaviour early, thereby triggering interventions that have the potential to reduce rates of mental health deterioration and acute illness relapse.

The North Karelia Project (1972-1997) and the Origins of the Community Approach to Cardiovascular Disease Prevention.

Community-based risk factor modification is today an established approach to chronic disease control and public health practice. This article analyzes the shaping of the North Karelia Project (NKP), an early and influential formulation of the community approach that focused on coronary heart disease prevention in Finland. Instead of targeting only high-risk individuals, NKP aimed to change the culture of the local community. On the basis of archival material and interviews, I first trace the multiple origins of the notion of community in NKP, which combined "internal" factors (local risk factor distribution, the role given to the social environment in chronic disease prevention) and "external" influences (regional origin of the initiative, World Health Organization and national policy concepts of community control and primary health care). Second, I describe the shape of the community intervention in NKP. The project foregrounded social relationships as a way to educate the public and influence norms guiding individual behaviors while subordinating environmental changes of a more structural nature.

Prescriber perspectives on low-value prescribing: A qualitative study.

Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood. To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians. Qualitative study using semi-structured interviews. Academic and community primary care practices within University of Pittsburgh Medical Center health system. Sixteen primary care physicians. We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing. We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable. Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

Factors Associated With Residential Relocation and Effects on Early Childhood Development in a Low-Income Home Visitation Population.

Residential relocation (RR) is associated with behavior problems and cognitive delays in school-age children. Little is known regarding effects of RR on early childhood development. The data from this study were collected from 2011 to 2016 through the Cincinnati Home Injury Prevention and Literacy Promotion Trial. The purpose of the current study was to identify factors associated with RR and determine effects of RR on early childhood development in a cohort of mother/child dyads (n = 424). High RR was relocating ≥ 3 times over the 24-month study period. Differences in baseline characteristics and early childhood development, measured by the Ages and Stages Questionnaire (ASQ) and MacArthur Bates Communicative Development Inventory, according to relocations, were estimated by negative binomial regression and logistic regression, respectively. Participants moved on average 1.46 times over 24months. Relocations decreased by 0.05 for each year of increasing maternal age. Mothers with college degrees moved 0.72 fewer times than those with a high school diploma or less. Mothers living alone moved 0.47 fewer times than their counterparts. Mothers who could not count on someone to loan them $1000 and those with food insecurity more (0.41) than their counterparts(0.50). Odds of scoring in the bottom-tertile for the communication domain of the ASQ was significantly higher in those relocating ≥ 3 times. High RR was associated with concern for delayed language development at 24-month follow-up in some, but not all models. Early intervention may be more successful if primary care physicians and community health professionals collaborate to link families at risk of high RR to relevant community based resources.

Teaching Baccalaureate Nursing Students to Practice in Primary Care Settings.

The Affordable Care Act of 2010 emphasized the importance of primary care and preventative services as core components to promote the health of the U.S. A unique program was created for baccalaureate nursing students to provide learning and practice experiences in primary practice sites that emphasized chronic disease prevention and management, including mental health and substance abuse services. Students were selected using a holistic approach. Students were selected to participate in the project. A community leadership advisory board was created. Students were assigned to the Veteran Administration's primary care clinics for their clinical experiences. This project is well-developed to increase the knowledge of present and future RNs, interprofessional providers and educators, researchers, and policy makers in community-oriented primary care. [J Nurs Educ. 2021;60(3):129-135.].

Improving Diabetes Education in Mexican American Older Adults.

Lack of culturally sensitive, age-specific diabetes education in Mexican American older aged people may contribute to deficits in diabetes knowledge, self-management, and glycemic control. This quality improvement initiative applied evidence-based, culturally competent, age-specific education to improve health outcomes. A one-group, pretest/posttest design guided this project in a primary care community clinic. Mexican American adults >60 years, with type 2 diabetes mellitus (T2DM; N = 12) received 3 months of biweekly innovative classes including: healthy Mexican foods; family involvement; Spanish interpreter using simultaneous earphone technology; and interactive, bilingual, large-print materials. Paired sample t tests compared diabetes knowledge, self-management, and A1C levels. There was a significant improvement in preeducation and posteducation outcomes: knowledge, t(11) = -7.969, p = .000; d = 2.32, self-management, t(11) = -7.930, p = .000; d = 2.43, and A1C levels, t(11) = 6.434, p = .000; d = 0.78. Culturally competent, language-friendly innovation, age-specific T2DM education can positively impact knowledge, self-management behaviors, and glycemic values in older aged Mexican American people.

Caregivers' experiences of medication management advice for people living with dementia at discharge.

Caregivers of people living with dementia play an essential role in managing medications across transitions of care. Adequate caregiver medication management guidance at hospital discharge is important to ensure optimal outcomes from medication use. This qualitative study explores the experiences and perspectives of caregivers about the medication management guidance provided at hospital discharge. A qualitative approach using semi-structured, telephone interviews was conducted with 31 caregivers of people with dementia across Australia. Purposive sampling was used to ensure maximum variation of diverse experiences and perspectives. Caregivers' experiences of medication guidance for people with dementia at discharge were described in three themes including: (a) inadequate information about medication management at discharge; (b) limited caregiver engagement in medication management decisions; and (c) difficulties ensuring medication supply post discharge. Most participants indicated they would like to be included in discussions at discharge. However, participation was influenced by caregivers being overwhelmed by discharge processes; proactively seeking information on medication-related harm; and belief in advocacy as part of their caregiver role. Caregivers reported they would like to receive a tailored medication list for people with dementia which included information on medications that may impact on the patient's cognition, and for hospital staff to communicate with both the community pharmacist and primary care physician, to improve co-ordination post transition. In our study of caregivers of people with dementia, we identified key recommendations to facilitate regular participation of people living with dementia and their caregiver around medication guidance at discharge.

Challenges and opportunities in addressing social determinants of child health in Cambodia: perspectives and experience of frontline providers in two health districts.

ObjectivesOther forces related to socio-economic and cultural factors, besides biomedical and behavioural fields, also influence health but receive little attention in health research. This study aims to illuminate social determinants of health and to identify challenges and opportunities in addressing social determinants of child health (SDCH) in rural Cambodia.MethodsThis is a qualitative study based on interviews of frontline primary health care providers, health officials, local authorities and community volunteers in two health districts in Cambodia. The data were supplemented by secondary data on different aspects of the districts and Cambodia.ResultsPoverty, lack of basic commodities and adverse social conditions remained problems for population health. While access to health services was considered adequate, households and communities had several major risk exposures. Challenges in addressing SDCH were the high prevalence of social and household adverse conditions, and the lack of training of providers, of information about social services, of effective coordination and of trust in public services. Opportunities were present, including social services being existent albeit poor functioning, the traditional practice of social inquiry, existing frontline providers being open to further information and training, existing subnational coordination bodies at district and provincial levels, and use of evidence in planning and resource allocation.ConclusionAddressing SDCH requires broad and coordinated efforts of stakeholders from multiple sectors. Among the prerequisites are to leverage the existing structures and mechanisms, training primary health care providers and providing them with adequate information about local resources and available supports. Improving social care services and infrastructures requires strong coordination, planning and adequate resource allocation.

A gratitude intervention to improve clinician stress and professional satisfaction: A pilot and feasibility trial.

Resilience training combined with medical system changes have the potential to reduce clinician burnout. We sought to estimate effects and assess feasibility of a brief gratitude intervention for primary care clinicians. This was a pre-test/post-test single group intervention design with longitudinal follow-up. Volunteer participants were from either a primary care community engagement conference or worked at one of two clinical sites in a Western mid-size city. Eligible clinicians held an MD/DO or NP/PA degree and currently worked at least 0.50 FTE in a primary care clinical practice and were willing and able to participate in the initial group session and complete weekly journaling. The gratitude intervention consisted of an in-person 90-minute group psychoeducation and skills-building workshop, followed by an 8-week daily gratitude journal exercise. The primary outcomes were related to resilience, including coping self-efficacy, clinician autonomy, and self-care behaviors. The secondary outcomes were the feasibility and acceptability of the intervention, as well as career satisfaction, and types and frequency of things for which clinicians were grateful in their daily work. The intervention was brief, feasible, and of interest to clinicians. Statistically significant improvements were seen in most outcome measures at both 4 and 8 weeks follow-up, with the exception of gratitude, which also increased, but not significantly so. Gratitude categories mentioned most frequently were support platforms at work (47%) and sense of competence (42%). The intervention had positive effects on resilience and is a promising brief intervention for clinicians experiencing stress. Larger experimental designs are needed.

Medical Education for What?: Neoliberal Fascism Versus Social Justice.

In her 2018 book, What the Eyes Don’t See, Dr. Mona Hanna-Attisha wrote that it is the duty of doctors to speak out against injustice. In fact, no other physician or institution in Flint had done the research and spoken out, as a whistleblower, against the poisoning of Flint’s children by Michigan government. Why had Dr. Hannah-Attisha? Unfortunately, in the absence of a medical education system that teaches community-oriented primary health care in the tradition of the 1978 Alma Ata Declaration, there is little reward in doing so. This article focuses on three movements that are challenging medical education orthodoxy: 1) primary health care 2) the medical humanities and 3) “Study Up your Town” medicine. How can we create a radical health pedagogy – one that draws the links between several pandemics raging across the planet: capitalist collapse, climate disruption, Covid-19, racism, and an emergent neoliberal fascism – to enable doctors, health professionals and citizens to see them as all of one piece? Medical educators must employ critical pedagogy to create legions of “constructive troublemakers” who challenge the social-structural obstacles that are driving millions to premature death. We have reached the “end times.” A new “planet medicine” is finally emerging.

Palliative care needs among patients with advanced illnesses in Bhutan

BackgroundPalliative care improves the quality of lives of patients and families affected by advanced illnesses through the prevention and relief of suffering. While palliative care is well established in developed countries, it is inadequate or non-existent in most developing countries. Palliative care is an emerging concept in Bhutan, a tiny Himalayan Kingdom. A small community palliative care service is available in the national referral hospital with three dedicated inpatient palliative care beds. This study explored the needs for palliative care among patients diagnosed with advanced illnesses and is a component of a larger project aimed to inform a suitable palliative care model for the country.MethodsThis is a cross-sectional descriptive study. A survey, using a structured questionnaire including the EORTC QLQ-C30, was carried out among patients with advanced illness in hospitals, primary care units and communities across the country. Purposeful and snowball sampling strategies were used to recruit study participants.ResultsSeventy (76%), out of 93 eligible patients, agreed to participate in the survey. Participants reported low to moderate scores on physical, role, emotional, cognitive and social functioning, a moderate score for the global health/ quality of life scale and moderately high (worse) scores in symptoms including fatigue, pain, insomnia, loss of appetite and the financial impact from the disease.ConclusionsThe symptom burden experienced by patients affected by advanced illnesses demonstrates the need for palliative care in Bhutan. These findings will help inform the development of a public health-focused palliative care model, modified to the Bhutanese context, as recommended by the World Health Organization.

Promoting social capital, self-management and health literacy in older adults through a group-based intervention delivered in low-income urban areas: results of the randomized trial AEQUALIS

BackgroundEvidence is scarce on how to promote health and decrease cumulative inequalities for disadvantaged older people. Downstream complex interventions focusing on intermediate factors (self-management, health literacy and social capital) may have the potential to mitigate the inequitable impacts of social determinants in health. The aim of the AEQUALIS study was to assess the effectiveness of a group-based intervention to improve self-perceived health as indicator of health inequality.MethodsPragmatic randomised clinical trial addressed to older adults (≥ 60 years) living in urban disadvantaged areas with low self-perceived health. The intervention was delivered in primary care settings and community assets between 2015 and 2017 and consisted in 12 weekly sessions. The primary outcome was self-perceived health assessed in two ways: with the first item of the SF-12 questionnaire, and with the EQ-5D visual analog scale. Secondary outcomes were health-related quality of life, social capital, self-management, mental health and use of health services. Outcomes were assessed at baseline, post intervention and follow-up at 9 months after the end of the intervention.Results390 people were allocated to the intervention group (IG) or the control group (CG) and 194 participants and 164 were included in the data analysis, respectively. Self perceived health as primary outcome assessed with SF-12-1 was not specifically affected by the intervention, but with the EQ-5D visual analog scale showed a significant increase at one-year follow-up only in the IG (MD=4.80, 95%CI [1.09, 8.52]). IG group improved health literacy in terms of a better understanding of medical information (− 0.62 [− 1.10, − 0.13]). The mental component of SF-12 improved (3.77 [1.82, 5.73]), and depressive symptoms decreased at post-intervention (− 1.26 [− 1.90, − 0.63]), and at follow-up (− 0.95 [− 1.62, − 0.27]). The use of antidepressants increased in CG at the follow-up (1.59 [0.33, 2.86]), while it remained stable in the IG.ConclusionsThis study indicates that a group intervention with a strong social component, conducted in primary health care and community assets, shows promising effects on mental health and can be used as a strategy for health promotion among older adults in urban disadvantaged areas.Trial registrationClinicalTrials.gov, NCT02733523. Registered 11 April 2016 - Retrospectively registered

Community as Medicine: A Trauma-Informed Yoga Program for Multi-Cultural Female Immigrants Identified in the Primary Care Setting

Introduction: The immigrant population in Maine represents a unique group of patients with complicated health care needs due to cultural, linguistic, and systemic barriers. We sought to bridge gaps in health access for immigrant women by expanding and integrating community resources through the development and evaluation of a trauma-informed yoga class. Methods: A needs assessment via a focus group with immigrant women revealed barriers to care and community health needs. Health partners of the immigrant community were identified via word of mouth and a Google search. Yoga participants were recruited in the primary care clinic and by community outreach. Participants underwent program evaluation, which informed development of the program. Results: Over 16 months, 52 immigrant women participated in the class. Participants reported reduced social isolation, improved mood, and chronic physical pain. We reduced common barriers to attendance, such as cost, childcare, and transportation. Funding was obtained via the Innovation Cohort and private donations. Discussion: A group-based yoga class promoted community building among participants. Alleviation of systemic barriers and collaboration between community partners and primary care providers was critical for success. Conclusions: The model for this program may guide further community-based wellness options for immigrant communities in Maine.

The community health impasse: What can family physicians learn about integration of social determinants of health from the challenges, diversity, and worldview of primary healthcare practices located in Southern India?

Context:As social position rises, health improves. Alma Ata set the stage for community-oriented primary care (COPC), and family medicine is perfectly positioned to integrate Social Determinants of Health. India presents a unique environment for innovations in family medicine.Aims:This study aimed to (1) assess the ability of different primary care practices to address the social determinants of health (SDoH); (2) identify key obstacles and supports; and (3) provide practical insights to family physicians and other primary care providers (PCPs) for the integration of SDoH and clinical primary care.Settings and Design:A diverse sample of primary healthcare practices were selected in southern India for investigation. Data collection involved observation and informal interviews.Methods and Material:The researchers used general observation and informal interviews to collect data. Investigators used a basic interview guide to structure conversations and formal journal entries were recorded immediately following each visit.Statistical Analysis Used:Thematic analysis was conducted with NVIVO software to categorize major themes.Results:Seventeen primary healthcare practices were observed; eleven were formally enrolled for interviews. Four inputs and three outputs of socially oriented primary care practices were identified. The inputs include leadership style, appropriate staffing, funding structures, and patient panels. Social interventions, community contact, and treasuring community empowerment were the major outputs.Conclusions:Community health lies at the heart of strengthening primary healthcare. Establishing practices that bridge the gap between clinical primary care and SDoH initiatives need to be prioritized. This study fosters agency for family physicians and PCPs to engage with local communities and lead the path toward this integration.

Table of Contents

The Australian Journal of Primary Health is published by CSIRO PUBLISHING on behalf of the Australian Institute for Primary Care and School of Public Health, La Trobe University in association with the Primary and Community Health Network. The Journal is a refereed, international journal designed to publish articles on a range of issues influencing community health services and primary health care. The focus of the Australian Journal of Primary Health is on the integration of theory and practice in primary health utilising perspectives from a range of disciplines. The Journal publishes research articles, policy reports and analyses, book reviews, case reports, the views of practitioners, consumers, carers, students, and special interest groups, and descriptions of professional practice initiatives in the field of primary health care

Campaign letter for RPS elections 2021: Rizwan Din on championing the role of pharmacists and technicians

I am passionate about developing and championing the role of pharmacists and technicians. With a background in community pharmacy and primary care, I believe I will be able to provide a unique insight to the board if elected. Previous RPS boards have made good progress and this needs to be continued and re-aligned with what […]

Impact of dementia education and training on health and social care staff knowledge, attitudes and confidence: a cross-sectional study

ObjectivesThe aim of this study was to establish the impact of dementia education and training on the knowledge, attitudes and confidence of health and social care staff. The study also...

Scrub typhus: An under-reported and emerging threat - hospital based study from central and eastern Uttar Pradesh, India.

Scrub typhus is a zoonotic rickettsial disease that is transmitted by the bite of the larval stage (chiggers) of trombiculid mites. The aim of this study was to determine the existence of scrub typhus in central and eastern Uttar Pradesh, India in patients with acute febrile illness (AFI) presenting to a super specialty tertiary level institute. This prospective hospital-based study was conducted for a period of one year, from August 2018 to July 2019. About 2-5 mL of blood samples, along with clinical, epidemiological, and demographic data from a total of 125 patients presenting with acute febrile illness to outpatient and inpatient departments, were collected. ELISA testing tested the sera from blood samples for IgM antibodies against scrub typhus. Samples were also tested for dengue, leptospirosis, malaria and typhoid. During the study period, out of a total of 125 samples collected, 20% were found positive for IgM antibodies against scrub typhus. Demographically higher positivity was found in males, older age group, and in rural area. Rainfall was found to be important epidemiological parameter for presence of scrub typhus. Co-infection with dengue, leptospirosis and malaria was found. Scrub typhus is found to be an important cause of acute febrile illness. It is necessary to include it in differential diagnosis of AFI cases even in absence of eschar. Diagnostic facilities of this as a screening test should be started in primary care centers or community health centers of rural areas of districts of central and eastern Uttar Pradesh, India.

Engagement of nurse practitioners in primary health care in northern British Columbia: a mixed-methods study.

Background:Nurse practitioners (NPs) have been regulated primary care providers in British Columbia since 2005; however, many practices and contributions of NPs, especially those in northern or rural regions, remain unarticulated in primary health care. The objective of this study was to evaluate NP practices in the context of providing primary health care in northern BC.Methods:This was a qualitative-dominant mixed-methods study. We recruited NP participants working in northern BC; recruitment and data collection occurred between April and June 2018. Participants completed the validated 28-item Primary Health Care Engagement (PHCE) Scale to assess their perceptions of their workplace with 8 attributes of primary health care (quality improvement, community participation, patient-centred care, accessibility, intersectoral team, interdisciplinary collaboration, continuity and population orientation). We also interviewed NPs about their everyday practice. Transcribed data from the interviews were analyzed interpretively.Results:In total, 13 of 30 (43%) eligible NPs participated in the survey and interview. The PHCE Scale results showed that all NPs perceived their workplaces to be highly engaged in patient-centred care, but none reported their workplaces as accessible. Interview data were organized into 5 headings which described how NPs see patients who are medically and socially complex, address inequities in access, practice collaboratively, address local service gaps and improve patient abilities to access care.Interpretation:In interprofessional primary health care teams, NPs are key members and attend to both direct patient care and broader social conditions affecting health. Nurse practitioners can help accelerate advancements to deliver responsive community-based primary health care.