Primary Care Context Research Articles

Using community-based participatory research methods to build the foundation for an equitable integrated health data system within a Canadian urban context

Health inequalities amplified by the COVID-19 pandemic have disproportionately affected racialized and equity-deserving communities across Canada. In the Municipality of Peel, existing data, while limited, illustrates that individuals from racialized and equity-deserving communities continue to suffer, receive delayed care, and die prematurely. In response to these troubling statistics, grassroots community advocacy has called on health systems leaders in Peel to work with community and non-profit organizations to address the critical data and infrastructure gaps that hinder addressing the social determinants of health in the region. To support these advocacy efforts, we used a community-based participatory research approach to understand how we might build a data collection ecosystem across sectors, alongside community residents and service providers, to accurately capture the data about the social determinants of health. This approach involved developing a community engagement council, defining the problem with the community, mapping what data is actively collected and what is excluded, and understanding experiences of sociodemographic data collection from community members and service providers. Guided by community voices, our study focused on sociodemographic data collection in the primary care context and identified which service providers use and collect these data, how data are used in their work, the facilitators and barriers to data use and collection. Additionally, we gained insight into how sociodemographic data collection could be respectful, safe, and properly governed from the perspectives of community members. From this study, we identify a set of eight recommendations for sociodemographic data collection and highlight limitations. This foundational community-based work will inform future research in establishing data governance in partnership with diverse and equity-deserving communities.

Evaluating A Multicomponent Chronic Disease Management Pilot Intervention among Korean Patients with Hypertension and Diabetes.

A local clinic-based chronic disease management intervention including care planning, education about disease management, monitoring, and evaluation of the achievement of objects was introduced in Korea in 2019. We evaluated the effect of the intervention on medication adherence in patients with hypertension and diabetes. In 2019, a one-year retrospective case-control group study design was performed using data from the National Health Insurance Service in Korea. Propensity score matching was used to control for selection bias. Medication adherence, calculated by medication possession rate, was the dependent variable. We conducted multivariate logistic regression analyses to examine the association between participation in the intervention and medication adherence, adjusting for covariates. A control group was set as a reference for participation in the full/partial component intervention. The proportions of participants in the full component intervention in the experimental group were 43.2% and 42.6% for patients with hypertension or diabetes, respectively. Both these groups tended to be more medication adherent than their counterparts (hypertension OR: 1.23, 95% CI 1.03-1.45, diabetes OR: 1.64, 95% CI: 1.24-2.17). Institutionalizing a comprehensive chronic disease management program using multidisciplinary teams in the primary care context is crucial. Also, it is necessary to refine reimbursement payment systems.

A systematic review of shared decision making training programs for general practitioners

BackgroundShared decision making (SDM) has been presented as the preferred approach for decisions where there is more than one acceptable option and has been identified a priority feature of high-quality patient-centered care. Considering the foundation of trust between general practitioners (GPs) and patients and the variety of diseases in primary care, the primary care context can be viewed as roots of SDM. GPs are requesting training programs to improve their SDM skills leading to a more patient-centered care approach. Because of the high number of training programs available, it is important to overview these training interventions specifically for primary care and to explore how these training programs are evaluated.MethodsThis review was reported in accordance with the PRISMA guideline. Eight different databases were used in December 2022 and updated in September 2023. Risk of bias was assessed using ICROMS. Training effectiveness was analyzed using the Kirkpatrick evaluation model and categorized according to training format (online, live or blended learning).ResultsWe identified 29 different SDM training programs for GPs. SDM training has a moderate impact on patient (SMD 0.53 95% CI 0.15–0.90) and observer reported SDM skills (SMD 0.59 95%CI 0.21–0.97). For blended training programs, we found a high impact for quality of life (SMD 1.20 95% CI -0.38-2.78) and patient reported SDM skills (SMD 2.89 95%CI -0.55-6.32).ConclusionSDM training improves patient and observer reported SDM skills in GPs. Blended learning as learning format for SDM appears to show better effects on learning outcomes than online or live learning formats. This suggests that teaching facilities designing SDM training may want to prioritize blended learning formats. More homogeneity in SDM measurement scales and evaluation approaches and direct comparisons of different types of educational formats are needed to develop the most appropriate and effective SDM training format.Trial registrationPROSPERO: A systematic review of shared-decision making training programs in a primary care setting. PROSPERO 2023 CRD42023393385 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023393385.

Effectiveness of a home-based pulmonary rehabilitation maintenance programme: the Rehab2Life study protocol

Pulmonary rehabilitation (PR) is the bedrock of non-pharmacological treatment for people with COPD. Nonetheless, it is well described in the literature that unless the patient changes his behaviour, the benefits of PR programmes will decline in six to twelve months after finishing the programme. Therefore, maintenance programmes can address the problem of PR programmes’ effect loss over time.Community care units can provide multidisciplinary care in the current Portuguese primary health care context. These units have an interdisciplinary team that aims to develop competencies in COPD patients to self-manage the disease.This study aims to test the effectiveness of a 12-month home-based PR programme (Rehab2Life) compared to usual care through a single-blind randomised controlled trial with two parallel groups. The Rehab2Life programme includes two distinct phases. The first is an 8-week PR programme delivered to both groups, and the second is a PR maintenance programme delivered to the intervention group after the initial eight weeks. The control group receive the usual care and regular appointments. The primary outcome is functional capacity, and secondary outcomes are dyspnea, Health-Related Quality of Life (HRQoL), number of exacerbations, symptoms burden, anxiety and depression symptoms, and physical activity.We expect to observe that the home-based PR programme brings clinically relevant benefits to the participants at the end of the first eight weeks and that, at 12 months after the maintenance phase of the programme, benefits are less dissipated than in the control group. We expect to identify the characteristics of the patients who benefit the most from home-based programmes.The trial was registered on 7 April 2022 at ClinicalTrials.gov (NCT05315505).

Accuracy evaluation of a point-of-care testing device for lipid levels in a primary care context

Accuracy evaluation of a point-of-care testing device for lipid levels in a primary care context

Psychometric Evaluation of a Tablet-Based Tool to Detect Mild Cognitive Impairment in Older Adults: Mixed Methods Study.

With the rapid aging of the global population, the prevalence of mild cognitive impairment (MCI) and dementia is anticipated to surge worldwide. MCI serves as an intermediary stage between normal aging and dementia, necessitating more sensitive and effective screening tools for early identification and intervention. The BrainFx SCREEN is a novel digital tool designed to assess cognitive impairment. This study evaluated its efficacy as a screening tool for MCI in primary care settings, particularly in the context of an aging population and the growing integration of digital health solutions. The primary objective was to assess the validity, reliability, and applicability of the BrainFx SCREEN (hereafter, the SCREEN) for MCI screening in a primary care context. We conducted an exploratory study comparing the SCREEN with an established screening tool, the Quick Mild Cognitive Impairment (Qmci) screen. A concurrent mixed methods, prospective study using a quasi-experimental design was conducted with 147 participants from 5 primary care Family Health Teams (FHTs; characterized by multidisciplinary practice and capitated funding) across southwestern Ontario, Canada. Participants included health care practitioners, patients, and FHT administrative executives. Individuals aged ≥55 years with no history of MCI or diagnosis of dementia rostered in a participating FHT were eligible to participate. Participants were screened using both the SCREEN and Qmci. The study also incorporated the Geriatric Anxiety Scale-10 to assess general anxiety levels at each cognitive screening. The SCREEN's scoring was compared against that of the Qmci and the clinical judgment of health care professionals. Statistical analyses included sensitivity, specificity, internal consistency, and test-retest reliability assessments. The study found that the SCREEN's longer administration time and complex scoring algorithm, which is proprietary and unavailable for independent analysis, presented challenges. Its internal consistency, indicated by a Cronbach α of 0.63, was below the acceptable threshold. The test-retest reliability also showed limitations, with moderate intraclass correlation coefficient (0.54) and inadequate κ (0.15) values. Sensitivity and specificity were consistent (63.25% and 74.07%, respectively) between cross-tabulation and discrepant analysis. In addition, the study faced limitations due to its demographic skew (96/147, 65.3% female, well-educated participants), the absence of a comprehensive gold standard for MCI diagnosis, and financial constraints limiting the inclusion of confirmatory neuropsychological testing. The SCREEN, in its current form, does not meet the necessary criteria for an optimal MCI screening tool in primary care settings, primarily due to its longer administration time and lower reliability. As the number of digital health technologies increases and evolves, further testing and refinement of tools such as the SCREEN are essential to ensure their efficacy and reliability in real-world clinical settings. This study advocates for continued research in this rapidly advancing field to better serve the aging population. RR2-10.2196/25520.

The Effectiveness of the Chronic Disease Self-Management Program in Improving Patients' Self-Efficacy and Health-Related Behaviors: A Quasi-Experimental Study.

The Stanford Chronic Disease Self-Management Program (CDSMP) is a valuable educational resource for supporting patients' self-management behaviors. However, no evidence supporting its effectiveness in the Saudi Arabian population exists. Therefore, this study aimed to evaluate the effectiveness of the 6-month CDSMP in individuals with chronic conditions in Saudi Arabia within a primary care context. A quasi-experimental design was conducted in 110 adults living with ≥1 chronic disease in Saudi Arabia. The patients in the experimental group (n = 45) participated in a six-session CDSMP, whereas those in the control group (n = 65) continued their usual care. Baseline and 6-month assessments were conducted using relevant questionnaires to assess outcome measures. Analysis of covariance revealed that the participants who underwent the CDSMP had significantly higher self-efficacy levels in managing their conditions (F = 9.80, p < 0.01) and a greater tendency to adopt healthy behaviors to successfully manage their chronic illnesses (F = 11.17, p < 0.01). The participants who underwent the CDSMP also showed significant improvements in all health-related outcomes compared with those in the control group (p < 0.01). These findings indicated that the program had a positive effectiveness in self-efficacy, self-management behaviors, and health-related outcomes among adults with chronic diseases in Saudi Arabia. The CDSMP may be integrated into primary care settings to help patients successfully manage their chronic conditions.

Building a digital tool to support focused acceptance and commitment therapy practitioners in New Zealand primary care: A qualitative exploration of user needs to guide software feature development

Mental health service scalability needs to be improved to meet the growing global demand. The scalability of Focused Acceptance and Commitment Therapy (fACT), a popular evidence-based brief behavioural intervention used in primary care contexts, could be improved through the development and implementation of a digital tool that supports practitioners to overcome service-delivery problems within their practice context.Through semi-structured in-depth interviews with 12 fACT practitioners, we examined the service-delivery problems that they face within the New Zealand primary care context and identified organisational factors which may be contributing to these problems. From these interviews, six key themes emerged: (1) The brief model works for most clients but is not suitable for every client, (2) practitioners often struggle to access culturally appropriate fACT congruent exercises and psychoeducation material, (3) practitioners feel that they need additional training to maintain good model fidelity, (4) short session times can negatively impact model delivery, (5) public health employed practitioners have high workloads and are often unable to refer clients to secondary or crisis services, and (6) fACT practitioners are unable to effectively follow up with their clients post-session.This study is part of a broader project aimed at developing an adjunctive digital tool to support the delivery of fACT in New Zealand primary care. These interviews will help us to understand the problems practitioners face in this service-delivery context, identify context-specific factors that may be causing these problems, and offer insights into the necessary features of an engaging digital tool designed to improve model scalability.

Laying the Groundwork: A Pilot Study Exploring Improved Endometriosis Management Strategies in Primary Healthcare.

To evaluate if a brief educational intervention for primary health care staff regarding endometriosis gives sustainable knowledge of endometriosis symptoms and if a brief questionnaire for women seeking care for common symptoms is feasible in the Swedish primary care context. Pilot study. 3 primary care centres (PCCs) in Sweden. Exploring knowledge among staff about endometriosis at baseline and 3 months after an information workshop. Evaluation of feasibility of a brief questionnaire for women seeking care for common symptoms For PCC personnel: knowledge about endometriosis at baseline and after 3 months. For patient questionnaire: whether adequate, understandable, acceptable, and feasible. Females in primary care centre waiting room, and staff members at participating PCCs. The knowledge level of endometriosis was improved or sustained after 3 months compared to baseline among staff at PCCs. Over 90% of the patients stated that the questionnaire was adequate, understandable, acceptable, and feasible. We found that an educational programme improved the staff's knowledge about endometriosis. The programme together with the patient questionnaire could be a way to enhance knowledge about endometriosis among PCCs. This combined effort might facilitate earlier detection and treatment of women with endometriosis.

IDEAL: Maintaining PHC-focused training in a MBChB programme through a COVID-induced innovation.

Responding to the need for authentic clinical training for students in the context of coronavirus disease 2019 (COVID-19), the Stellenbosch University Faculty of Medicine and Health Sciences developed an innovative 12-week longitudinal, integrated rotation for pre-final-year medical students, the Integrated Distributed Engagement to Advance Learning (IDEAL) rotation. This saw 252 students being placed across 30 primary and secondary healthcare facilities in the Western and Northern Cape provinces. With a focus on service learning, the rotation was built on experiences and research of members of the planning team, as well as partnership relationships developed over an extended period. The focus of student learning was on clinical reasoning through being exposed to undifferentiated patient encounters and the development of practical clinical skills. Students on the distributed platform were supported by clinicians on site, alongside whom they worked, and by a set of online supports, in the form of resources placed on the learning management systems, learning facilitators to whom patient studies were submitted and wellness supporters. Important innovations of the rotation included extensive distribution of clinical training, responsiveness to health service need, co-creation of the module with students, the roles of learning facilitators and wellness supporters, the use of mobile apps and the integration of previously siloed learning outcomes. The IDEAL rotation was seen to be so beneficial as a learning experience that it has been incorporated into the medical degree on an ongoing basis.Contribution: Longitudinal exposure of students to undifferentiated patients in a primary health care context allows for integrated, self-regulated learning. This provides excellent opportunities for medical students, with support, to develop both clinical reasoning and practical skills.

Evidence-based management and the nurse's decision-making process

The managerial decision-making process is a competence of nurses in the hospital and primary care context, which makes them a highly requested professional for solving problems involving the unit and the care provided to the user. Such a process must be informed by evidence, with a view to achieving the best results. To discuss the use of scientific evidence by nurses in the health management process. An integrative literature review, carried out in the PubMed/MEDLINE, LILACS, BDENF, and SciELO databases, through the DeCS/MESH "Evidence-Based Nursing" AND "Health Management" OR "Evidence-Informed Policy", 694 studies were identified and 07 were included. Evidence-based decision-making is important for the delivery of effective and cost-effective public health services, this decision-making process consists of the integration of the best available research evidence, along with consideration of local context, community and policy preferences, professional experience, and resources in public health decision-making. It is, therefore, crucial to improve the quality of management decisions, consequently improving service delivery, and increasing effectiveness and efficiency, in addition to contributing to patient safety. It is concluded that evidence-based management is essential to improve the quality of management decisions and, therefore, to improve the optimization and allocation of resources in the health system.

A study of the impact of an interprofessional education module in Vietnam on students' readiness and competencies.

The literature puts forward a range of challenges of interprofessional education (IPE) related to its planning, initiation, implementation, and especially to IPE assessment. The present study aims to map changes in students' readiness and interprofessional collaboration competence (IPCC) in implementing an innovative IPE module. Potential differences in impact related to the health education programs and IPCC scores resulting from self-, peer-, and tutor assessments will also be analysed. A pre-post design was adopted. The student's readiness for interprofessional learning was assessed using the Readiness for Interprofessional Learning Scale, and the student's IPCC score was calculated based on self-, peer-, and tutor assessments with the interprofessional collaborator assessment rubric. Students' mean post-test readiness scores and mean post-test IPCC scores were significantly higher than the total and subscales/domain pre-test scores (p<0.01). No significant within-subject differences were observed in students' readiness total or subscale scores when comparing health educational programs. However, significant differences were observed in students' mean total IPCC scores between programs (p<0.01). Significant differences in students' average IPCC scores were found when comparing self-, peer- and tutor assessment scores in six domains (p<0.01). Also, significant correlations between peer and tutor assessment scores were observed (p<0.01). The IPE module, designed and implemented to focus on patient-centred practice within a primary care context, positively impacted students' readiness and IPCC development. These results offer insights to expand the implementation of the IPE module to all health educational programs.

Fostering positive affective exercise experiences and affect-related competencies for a physically active lifestyle: The FEEL project

Introduction&#x0D; Interventions targeting physical inactive individuals have not yielded sufficient impact yet. This may be attributed to two reasons: Firstly, affective processes during physical activity (PA) are often inadequately acknowledged (e. g. shame, feeling bad; Hohberg et al. 2022). Secondly, individuals are often not empowered to PA that positively influences affective wellbeing and mental health (Sudeck &amp; Pfeifer, 2016). The FEEL project addresses these two deficiencies by developing a program promoting pleasant experiences, affect regulation competence, wellbeing and consequently PA.&#x0D; The program is grounded in Ekkekakis et al.’s (2021) conceptual framework on affective exercise experiences and their antecedent appraisals. It consists of [a] an instructor workshop focused on creating an inclusive, socially supportive atmosphere. Additionally, the program features [b] group exercise sessions covering topics such as attentional focus, preferred intensity, and flexible goal setting. Experiential learning is employed during these sessions, encouraging participants to engage not only physically but also to reflect on and in action. Finally, the program incorporates [c] a PA counseling session, during which participants individual motives for exercise are assessed, and suitable activities are discussed (Schorno et al., 2022).&#x0D; Methods&#x0D; We plan a multicenter randomized controlled trial to investigate the impact of the 6-8 week FEEL program. Inactive individuals (meeting less than 75% of recommended PA guidelines) in the age of 16 to 35 will take part in the study. Participants will be recruited via schools, universities, companies, and social work institutions. Around 300 people will be assigned to either the intervention or control group. The control group will undergo a standard fitness program (usual care). The primary outcomes positive affective exercise experiences, affect regulation competence, wellbeing and PA will be measured pre- (0 weeks), post-intervention (6 weeks) and at follow-up (12 weeks). After piloting the FEEL program in April 2024, the main study will start in fall 2024.&#x0D; Discussion&#x0D; This study explores the impact of a multifaceted intervention in a primary care context. It may provide valuable insights for effective considerations of affective processes and related competencies in PA programs. Should the FEEL program showcase positive effects, there may be interest in extending its implementation in diverse settings (e.g., rehabilitation).&#x0D; References&#x0D; Ekkekakis, P., Zenko, Z., &amp; Vazou, S. (2021). Do you find exercise pleasant or unpleasant? The Affective Exercise Experiences (AFFEXX) questionnaire. Psychology of Sport and Exercise, 55, Article 101930. https://doi.org/10.1016/j.psychsport.2021.101930&#x0D; Hohberg, V., Kreppke, J.‑N., Cody, R., Guthold, R., Woods, C., Brand, R., Dunton, G., Rothman, A., Ketelhut, S., &amp; Nigg, C. (2022). What is needed to promote physical activity? Current Issues in Sport Science, 7, Article 005 https://doi.org/10.36950/2022ciss005&#x0D; Schorno, N., Gut, V., Conzelmann, A., &amp; Schmid, J. (2022). Effectiveness of individual exercise and sport counseling based on motives and goals: A randomized controlled trial. Journal of Sport and Exercise Psychology, 44(2), 103-115. https://doi.org/10.1123/jsep.2021-0018&#x0D; Sudeck, G., &amp; Pfeifer, K. (2016). Physical activity-related health competence as an integrative objective in exercise therapy and health sports – Conception and validation of a short questionnaire. Sportwissenschaft, 46, 74–87. https://doi.org/10.1007/s12662-016-0405-4

A qualitative interview study of patients' attitudes towards and intention to use digital interventions for depressive disorders on prescription.

Depressive disorders are an emerging public health topic. Due to their increasing prevalence, patients with depressive disorders suffer from the lack of therapeutic treatment. Digital health interventions may offer an opportunity to bridge waiting times, supplement, or even substitute in-person treatment. Among others, the Unified Theory of Acceptance and Use of Technology (UTAUT) explains that actual technology use is affected by users' behavioural intention. However, patients' perspectives on digital interventions are rarely discussed within the specific context of primary care provided by general practitioners (GP) and need further exploration. A qualitative study design with semi-structured interviews was used to explore DTx-acceptance of patients with mild or moderate depression (n = 17). The audio-recorded interviews were transcribed verbatim, coded, and thematically analysed by qualitative content analysis. Patients' performance expectancies reveal that DTx are not perceived as a substitute for face-to-face treatment. Effort expectancies include potential advantages and efforts concerning technical, motivational, and skill-based aspects. Moreover, we identified health status and experience with depressive disorders as other determinants and potential barriers to patients' DTx acceptance: Difficult stages of depression or long-time experience are perceived hurdles for DTx use. GPs' recommendations were just partly relevant for patients and varied according to patients' consultancy preferences. But still, GPs have a crucial role for access due to prescription. GPs' influence on patients' DTx acceptance varies between three situations: (1) pre-use for consultation, (2) pre-use for access and (3) during DTx-use. Further, GPs' guidance could be especially relevant for patients during DTx-use in routine care. The UTAUT-based exploration suggests that acceptance determinants should be considered independently and embedded in personal and situational aspects. DTx require a healthcare professional to prescribe or diagnose the disease, unlike other digital offerings. We identified prescription- and depression-related determinants, exceeding existing theoretical constructs. GPs' guidance can compensate for some barriers to DTx use e.g., by increasing commitment and motivational support to strengthen patients' acceptance. We argue for a multidimensional integration of acceptance determinants for further development of health technology acceptance research. Future research should specify how DTx can be integrated into routine care to strengthen user acceptance.

Healthcare Professionals' Perceptions about the Implementation of Shared Decision-Making in Primary Care: A Qualitative Study from a Virtual Community of Practice.

The incorporation of shared decision making (SDM) is a central part of empowerment processes, as it facilitates greater activation on the part of patients, increasing the likelihood of them gaining control over their healthcare and developing skills to solve their health problems. Despite these benefits, there are still difficulties in the implementation of SDM among healthcare professionals due to internal and external factors related to the context and health systems. To explore primary care professionals (PCPs)' perceptions of the SDM model, based on their preconceptions and experience in clinical practice. A framework analysis was conducted on qualitative data derived from a virtual community practice forum, within a cluster-randomized clinical trial developed in the e-MPODERA project. The most important points in the opinions of the PCPs were: exploring the patients' values, preferences and expectations, providing them with and checking their understanding of up-to-date and evidence-based health information. The analysis revealed three themes: determinants of the implementation process of SDM, lack of consistency and dilemmas and benefits of PCP active listening, motivation and positive expectations of SDM. In our initial analysis, we examined the connections between the categories of the TDC model and its application in the primary care context. The categories related to the model reflect the theoretical understanding of professionals, while those related to perceptions of its application and use show certain discrepancies. These discrepancies could indicate a lack of understanding of the model and its real-world implications or insufficient commitment on the part of professionals or the organization to ensure its effective implementation. Specific targeted training that addresses knowledge, attitudes and practice may resolve the aforementioned findings.

Twin studies as an innovative approach to address research questions in cancer care within primary care settings

This paper proposes the utilisation of twin studies as a novel and powerful methodological approach to investigate critical research questions pertaining to cancer prevention, screening, diagnosis, treatment and survivorship within...

The dilemma of the split between theory and reality as experienced by primary healthcare professionals: a mixed methods study of evidence-based practice in a primary care context

BackgroundPrimary care depends upon a good information flow across professional and structural boundaries to provide the best care for patients. Previous research has mainly focused on Evidence-Based Practice (EBP) within specific professions. Mapping of pan-professional experiences of and attitudes to EBP in publicly funded clinical practice is necessary to deepen the understanding of EBP and its implementation. Thus, this study aimed to investigate healthcare professionals’ experiences of and attitudes towards working in accordance with EBP in primary care.MethodsThe study used a convergent mixed methods design divided into two strands: a quantitative enquiry tool (Evidence-Based Practice Attitude Scale, EBPAS) and a set of qualitative interviews analysed by means of qualitative content analysis. Both strands included all primary care employees with patient interaction in the studied county (n = 625), including doctors, nurses, physiotherapists, psychologists and assistant nurses. Out of the original 625 healthcare professionals, 191 finished the first strand and 8 volunteered for the second strand (2 nurses, 2 physiotherapists, 1 psychiatrist and 3 doctors).ResultsThe EBPAS value of 2.8 (max 4) indicated a generally positive attitude towards EBP amongst the population, which was also evident in the interviews. However, there were additional experiences of not having the ability or resources to engage in EBP. This was illustrated by the theme that emerged from the qualitative content analysis: “The dilemma of the split between theory and reality”. Due to the organisational and managerial focus on efficiency rather than quality of care, there were few or no incentives for promoting individual educational or research development.ConclusionsAlthough the general attitude towards EBP is positive, experiences of practising it differ. There is a need to increase knowledge of EBP concepts, requirements and implementation in the clinical setting. The absence of opportunities to do research and collegial debate about new ways of finding and implementing research-based evidence results might influence the quality of care.

Professionals' experiences of what affects health outcomes in the sick leave and rehabilitation process-A qualitative study from primary care level.

To explore frontline employees' experiences of how to create a purposeful sick leave and rehabilitation process (SRP) with the best interest of patients' long-term health in focus. Qualitative design based on focus group interviews in a primary care context in Region Västra Götaland, Sweden. Strategically selected professionals from different SRP organizations discussed sick leave outcomes and the rehabilitation process. Analysis was performed with Systematic text condensation. General practitioners (n = 6), rehabilitation coordinators and/or healthcare professionals from primary healthcare (n = 13), caseworkers from the Social Insurance Agency, the Employment Agency, and Social Services (n = 12). The outcome of the SRP was described to depend upon the extent to which the process meets patients' bio-psycho-social needs. Aspects considered crucial were: 1) early bio-psycho-social assessments, including medical specialist consultations when needed, 2) long-term realistic planning of sick leave and rehabilitation alongside medical treatment, 3) access to a wide range of early rehabilitative and supportive interventions, including situation-based, non-medical practical problem solving, and 4) trusting relationships over time for all involved professions and roles to maximize process quality and person-centeredness. A gap between the desired scope of the SRP and existing guidelines was identified. Interviewees perceived that successful outcomes from the sick leave and rehabilitation process in a primary care context depend on consensus, person-centeredness, and relationship continuity for all involved professions. An extended process scope and relationship continuity for all involved professionals were suggested to improve process outcomes.

The transformative journey of community health workers in implementing a lifestyle intervention in Brazil: A qualitative study.

Community health workers (CHWs) stand as critical frontline agents within the Brazilian healthcare system. In this qualitative study, we examined the impact of a community-based behavioral change intervention spearheaded by CHWs. The intervention focused on promoting healthy behaviors - physical activity, nutrition, and emotional well-being - among individuals aged 50 and older living in a rural community in Brazil. The intervention was designed, implemented, and evaluated in close collaboration with CHWs and local administrators. The implementation of the intervention unfolded in two waves, each lasting 12 months. Interviews with CHWs, health administrators, and intervention participants conducted at post-intervention and 6-year follow-up centered on CHWs as delivery agents and examined the implementation of the intervention in primary care contexts around adoption, implementation, and long-term maintenance. Inductive analysis revealed four themes that highlight CHWs' motivation to take active roles in health promotion and overcoming challenges such as unfamiliarity with new roles or limited training. In addition, enhanced community bonds, job satisfaction, and trust in CHWs gained through the intervention, empowered CHWs to realize their potential and importance. Another important area relates to the CHWs' ability to leverage their deep community ties and cultural insights to enhance the intervention's significance. CHWs' participation in the program also led to personal benefits and self-care practices, setting an example for the community they serve. This study underscores the positive impact of a community-based intervention led by CHWs. Such programs have the potential for nationwide dissemination, leveraging the CHWs' widespread presence and deep community integration.

The impact of health maintenance organizations on improving cardiac surgery outcomes.

California is one of a few states with mandatory reporting of mortality after coronary artery bypass graft (CABG) surgery. The Affordable Care Act restructured Medicaid, preferentially penalizing patients experiencing poverty because payments to hospitals for isolated surgical events overshadow payments to primary care clinicians. We propose outcomes are superior when hospital networks organize surgical episodes within the context of primary care inside that same network. We listed factors impacting outcomes after CABG. CABG surgery outcome depends upon the integration of issues beginning years preoperatively and extending for decades. Therefore, we studied one health maintenance organization (HMO) from 2009 to 2020 compared to surrounding individual hospitals. We divided 58 hospitals in Northern California in 2009 according to income and population. To focus on changes introduced because of COVID-19, we compared a public database for the subset in 2009 for any relationship between poverty in a zip code and low volumes of CABG in that area to overall mortality in 2020. First, we defined low-income zip codes as those with a higher rate of poverty than the state average or with a lower per capita average income, per Census Bureau. Second, low volume was defined as a population under 165,000 because a hospital adjacent to a larger community can easily transfer care, sharing surgeons and processes. Third, we defined low volume as fewer than 180 CABG per year. Our qualitative evidence synthesis reveals that informal communication and hospital HMO policies improve CABG outcomes. In our small pilot data, Chi-square analysis showed higher crude mortality rates in 1507 CABG in 17 low-income low-volume hospitals versus 8163 CABG in the other 41 Northern California hospitals (2.72% vs 1.69%, p = 0.0064). Low-income low-volume hospitals had a relative mortality risk of 1.61 (95% CI: 1.14-2.27). These hospitals had a mean mortality rate of 3.79%, readmission 11.12%, and stroke 1.84%. A patient undergoing CABG in a low-income low-volume hospital has a 61% higher chance of dying. The number needed to treat analysis shows that one life can potentially be saved for every 97 patients referred to another institution. We describe features of an HMO that contribute to up to fourfold lower mortality rates.