Primary Care Level Research Articles

Barriers Related to Antenatal Care Utilization at Primary Health Care Level in Pregnant Women of Hazro District Attock

Background: Maternal and newborn mortality is a global public health issue. Pakistan is lagging much behind in target of improving maternal and child health due to underutilization of antenatal care services. Aim: To determine utilization of the ANC services by pregnant women and barriers in utilization of ANC services at primary health care level of Hazro District Attock. Methods: This cross-sectional study was conducted in Hazro of District Attock, Pakistan with sample size of 425 pregnant women in their third trimester selected by simple random sampling technique over a period of six months from Jan 2021 to Jun 2021. A structured Questionnaire was used for the data collection regarding the barriers related to utilization of antenatal care services by interview. Analysis was done using SPSS version 23. Results: The mean age of women was 27.76±5.41 years with 75.8% were from rural side. In socioeconomic status 60.5% women had high, 33.4% had middle and 6.1% had low status of socioeconomic. The complete utilization of antenatal cares were observed in 62.8% women. We found distance of health care facility (p=0.006), transport availability (p=0.0001), cost of transport (p=0.0001), availability of personnel and services (p=0.006), ambulance availability (p=0.006) and working hours of health care facility (p=0.004) as a main barriers. Practical implication: The results of current study will help in providing MCH services at door step with proper planning to minimize the barriers in utilization of ANC services for the community. Conclusions: We conclude that Utilization of MCH services by pregnant women at primary care level in Hazro of District Attock was low i.e. 62.8%. The barriers in the utilization of MCH services at PHC level were financial poverty crisis, distance of antenatal care facility, transport availability, cost of transport, poor medical facilities, absence of ambulance and working hours are important barriers in seeking and availing antenatal care services. Keywords: ANC services, pregnant women, barriers, utilization, primary health care level, District Attock

Translation, cross-cultural adaptation, and validation of a Latin American Spanish version of the ID Migraine screening test.

To translate, culturally adapt, and validate a version of the ID Migraine into Latin American Spanish. Although still considered a common diagnosis, half of the patients with migraine in Latin America experience diagnostic delay. The ID Migraine is a test developed in 2003 as a valuable tool for the early diagnosis of migraine at the primary care level; however, there is no validated Spanish or culturally adapted version for the Spanish-speaking population. This is an analytical, translation, and test-validation study. We performed back translation and cross-cultural adaptation. The Latin American Spanish version ID Migraine MX was applied to headache clinic patients from March 2021 to January 2022 to perform a validation process against the gold standard: blinded expert diagnosis according to the International Classification of Headache Disorders, 3rd edition (ICHD-3), criteria. One hundred seventeen patients from the headache clinic of the National Institute of Neurology and Neurosurgery of Mexico City were screened. We found 62/117 (53%) patients positive for screening with ID Migraine MX, and 47/117 (40%) positive for migraine according to ICHD-3 criteria. A sensitivity (95% CI) of 0.91 (0.80-0.97), specificity of 0.73 (0.61-0.82), positive predictive value of 0.694 (0.57-0.794), and negative predictive value of 0.93 (0.83-0.97) were obtained. The positive likelihood ratio was 3.38 (2.27-4.99), and the negative likelihood ratio was 0.12 (0.04-0.30). After calling the patients 1 month after the first interview, the calculated Kappa test-retest was 0.75 (p = 0.001). A translated and cross-culturally adapted version into Spanish of the ID Migraine was obtained, with a diagnostic performance similar to the original instrument. Clinicians may use this test at the first level of care to reduce the rate of misdiagnosis and the time from onset of symptoms to diagnosis and treatment of migraine.

#4951 NON-ADHERENCE TO CARDIOMETABOLIC DRUGS AS ASSESSED BY LS-MS/MS IN URINE AND ITS ASSOCIATION WITH RENAL AND CARDIOVASCULAR OUTCOMES IN T2DM

Abstract Background and Aims Cardiovascular and renal complications have a detrimental impact on the prognosis and quality of life of patients with type 2 diabetes mellitus (T2DM). Guidelines recommend combination drug therapy to prevent or delay these complications[1]. However, non-adherence to medication is common and a barrier to successful disease management[2]. Most previous studies on adherence and outcome used indirect methods to assess adherence[3]. In this study we used liquid chromatography-tandem mass spectrometry (LC-MS/MS), a direct and objective adherence measure, to asses adherence to cardiometabolic drugs in a large real-world cohort of individuals with T2DM and analyzed non-adherence in the context of cardiovascular and renal outcomes. Method 1125 eligible PROVALID participants were included. PROVALID is a prospective observational cohort study of patients with T2DM followed annually at the primary health care level. Urine samples from the PROVALID biobank were screened for 79 cardiometabolic drugs and metabolites thereof by LC-MS/MS. An individual was classified as fully adherent when markers for all prescribed drugs were detected, partially non-adherent when at least a marker for one drug was detected and totally non-adherent when no marker for any prescribed drug was detectable. In order to assess outcome by adherence we defined a cardiovascular (myocardial infarction, stroke, and cardiovascular death) and a renal (ESKD, renal death, sustained 40% reduction in eGFR to < 60 ml/min per 1.73 m², sustained progression of albuminuria) composite endpoint. Results The mean age was 64.2 (±8.9) years and 46.1% were female. The mean duration of T2DM was 11.4 (±7.9) years. The mean HbA1c was 7.1 (±1.1)%, the mean eGFR was 77.6 (±23.6) ml/min/1.73 m2 and mean albuminuria 67.3 (±287.9) mg/g creatinine. Participants were prescribed 5.4 (±2.0) cardiometabolic drugs on average. Based on the results of LC-MS/MS measurements, 56.3% were totally adherent, 42.0% were partially adherent, and 1.7% were totally non-adherent to screened cardiometabolic drugs. Adherence was highest to antiplatelet and glucose lowering drugs and lowest to lipid lowering drugs (totally adherent individuals 90.1%, 89.2% and 70.7%, respectively). Non-adherent patients had a longer history of T2DM (12.3 ± 8.5 vs. 10.7 ± 7.5, p = 0.003) and a higher number of prescribed drugs (5.8 ± 2.1 vs. 5.1 ± 1.9, p < 0.001). Age per se had no influence on adherence, however the number of prescribed medications had more impact on adherence in younger patients (Fig. 1). Ex-smokers were more likely to be adherent than current or never-smokers (odds ratio 1.4, p-value = 0.014). Patients who were adherent to lipid lowering drugs had significantly lower LDL (82.4 ± 29.8 vs. 111.4 ± 39.7 mg/dl, p < 0.001). A trend for lower HbA1c with adherence to glucose-lowering drugs and lower systolic blood pressure with adherence to antihypertensive drugs could be observed, however these differences were not statistically significant. In the longitudinal analysis, worse cardiovascular prognosis was especially seen with non-adherence to antiplatelet drugs and worse renal outcome especially with non-adherence to antihypertensive drugs (Fig. 2). Conclusion Our analysis confirms that non-adherence, especially partial non-adherence, to cardiometabolic drugs is common in T2DM. A higher incidence of cardiovascular events was observed with non-adherence to antiplatelet drugs, whereas non-adherence to antihypertensive drugs was associated with a higher renal event rate.

Cribado de la retinopatía diabética mediante teleoftalmología en una zona básica de salud rural

ObjectiveTo investigate the prevalence of diabetic retinopathy in a rural health basic area, and to establish the type, the severity degree and the relationship with sex and with another cardiovascular risk factors. DesignCross-sectional or prevalence descriptive study. LocationRural health basic area in Spain. Primary health care level. Participants500 patients over 18 years old with diabetes. Main measurementsStudy of the retina through retinography under mydriasis, according to the Joslin Vision Network protocol, with the incorporation of a diagnostic reading center. Correlation of the existence and severity of the retinopathy with the cardiovascular risk factors –smoking, hypertension and hyperlipidemia– and the characteristics of the diabetes –type, evolution time, treatment, metabolic control and renal function–. ResultsThe findings showed a 16.4% prevalence, with no significant differences between both sexes. The variables smoking and high blood pressure were related to the existence of retinopathy, and the variable years of diabetes evolution was correlated to both the existence and the severity of the retinopathy. In the study, 9.6% of the affected people were preferentially referred to the ophthalmologists because of sight-threatening retinopathy, and 6.8% of the people studied were referred due to other ophthalmological pathologies. ConclusionsIt is possible to do the ophthalmological follow-up of 82% of the population with diabetes in primary health care, involving its professionals and team-working with the ophthalmologists. It is paramount to consider diabetic retinopathy within the global context of the person with diabetes, relating diabetic retinopathy with the other microvascular complications and cardiovascular diseases.

Manifold effects of Probiotics on Inflammation, Cognition, Dementia , Depression and Anxiety : A Traditional/Narrative Review - Possible choice of Non-pharmacological therapy at the level of primary care

Probiotics are microorganisms that can be included inthe diet or taken as supplements. They are widelyaccessible and available at low cost to variouspopulations all over the world. This study aims togather both supporting and contradicting informationfrom previous studies and additionally discuss theharmful effects of probiotics. Probiotics may offeressential early intervention to lessen the severity ofinflammation, cognitive decline, and mood problems bymodifying the gut-brain axis in the body. They work onmultiple systems, so it is necessary to thoroughlyinvestigate their effects and efficacy throughrandomized control trials in order to developtherapeutic, affordable, and widely accessiblealternative treatment options from them for some ofthe most prevalent health problems. A thorough searchwas performed on various databases (PubMed,ScienceDirect, and Google Scholar) using keywords andnineteen studies that fit the inclusion/exclusion criteriawere deemed relevant.

ROSUVASTATINE TREAMENT IN A BIG UKRAINIAN COHORT OF PATIENTS WITH TYPE 2 DIABETES

Objective: Diabetes mellitus (DM) remains one of the most important cardiovascular risk factors significantly worsening the prognosis in patients with hypertension and dyslipidemia. The leading role among drugs for the treatment of such patients is played by statins with their powerful influence on the development and progression of atherosclerosis and its complications. We used the OZIRKA study database and performed additional subanalysis to study the effects of rosuvastatin in patients with diabetes and dyslipidemia. To study the effect of Ozalex (rosuvastatin) on lipid and cholesterol levels in patients with lipid metabolism disorders and hypercholesterolemia and DM. Design and method: A prospective open population study on a primary care level. Recruitment of patients was conducted from March to December 2019. The analysis of the study data was conducted from June to November 2020. All patients attended in total 3 visits. Results: A total of 20,000 patients from all over Ukraine were included in the study. The full follow-up period was completed by 18,100 patients, of whom 17,530 had all the necessary data, and they were included in the final analysis. The mean follow-up period was 2.2 months. Approximately 13% of patients included in the study had DM type 2. We observed a significant reduction in total cholesterol, LDL and triglyceride levels in patients with diabetes. In addition, there was a tendency to increase the level of HDL in this group of patients. In general, it can be noted that there was a significant improvement in lipid profile in patients with diabetes - the level of total cholesterol decreased by 28%, LDL cholesterol by 34%, and triglycerides by 24%. Administration of rosuvastatin did not impair glucose control in any way in the group of patients with DM, moreover, even in the group of people without DM there was no negative effect of rosuvastatin on fasting glucose level. Conclusions: In general, we can recommend rosuvastatin in a dose of 10 to 20 mg as an optimal start of statin therapy at the stage of primary care for patients with DM.

Abstract 13: Barriers to Diagnostic Follow-Up for Women With a Suspicious Clinical Breast Examination at the Primary Health Center in Uttar Pradesh State in India: A Qualitative Study

Abstract Purpose: The purpose of this study was to understand key barriers to diagnostic follow-up for women with a suspicious clinical breast examination (CBE) at the primary care level in Uttar Pradesh (UP) state in India. We also explored acceptability of the use of mHealth strategies to address barriers to CBE follow up for women. Methods: We conducted 28 in-depth individual interviews with key stakeholders involved in the Breast Health Initiative in Lucknow district, UP. Primary health facilities in rural and urban settings were purposively selected based on the number of CBE screening exams conducted in the last year and the number of women with a suspicious CBE identified. We interviewed six women with a suspicious CBE at the primary health facility who did not have diagnostic follow-up, six community health workers (ASHAs), six healthcare providers from primary health facilities and four district or state-level health decisionmakers. Interviews were audio-recorded and transcribed verbatim. Coding and thematic analysis will proceed once translation of the full dataset of transcripts is complete. Results: Preliminary analyses of qualitative interviews found that cancer stigma and fear are significant barriers to both breast screening and follow-up of an abnormal CBE. Male providers and long waits at the district hospital are barriers to completing confirmatory diagnostic exams. Providers maintain that, despite community education and outreach efforts by ASHAs, lack of awareness of breast cancer and the importance of follow-up for abnormal CBE remains a barrier to early detection. Conclusion: Knowledge barriers, cultural barriers, and health system barriers challenge women’s ability to follow recommendations for diagnostic follow-up of an abnormal CBE in Uttar Pradesh, India. Multi-level strategies are needed to address these barriers. Our findings will help inform the content and approach of an mHealth patient navigation strategy that could include patient education, reminders, patient tracking, and care coordination. Citation Format: Erica Liebermann, Gulnoza Usmanova, Nadeem Akhtar, Shivani Agrawal, Vaibhav Patwardhan, Parag Bhamare, Somesh Kumar. Barriers to Diagnostic Follow-Up for Women With a Suspicious Clinical Breast Examination at the Primary Health Center in Uttar Pradesh State in India: A Qualitative Study [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 13.

Behaviour and perception of parents on irrational use of antibiotics in children at primary care level

Objective:To investigate the perception of antibiotics, the frequency of inappropriate antibiotic use, and the factors that lead to inappropriate antibiotic use by parents who apply to primary healthcare organizations.Methods:This cross-sectional study included 973 parents who applied to primary healthcare centers. We analyzed basic concepts related to antibiotics prescribed for their children, antibiotic administration, and antibiotic resistance, as well as parents' knowledge and attitudes towards antibiotic use, and their experiences, practices, and perceptions related to purchasing antibiotics without prescription.Results:In the past one year, 78.9% of the parents gave antibiotics to their children at least once, and 39.1% gave antibiotics three or more times. Some of the participants (7.1%) reported having forced the physician to prescribe antibiotics and purchased antibiotics without a prescription (13.2%). The knowledge about antibiotics and awareness about antibiotic resistance were found to be more frequent; among parents who had university degrees, higher income levels, two or fewer children, social insurance and negative behaviours were lower in those who received information about antibiotics from healthcare professionals. The probability of taking antibiotics without prescription was lower in that of with higher income level (OR0.460; 95%CI0.219-0.965), and the probability of forcing antibiotic prescription was higher in those with 3 or more children (OR6.94; 95%CI2.37-20.26). The score obtained from the awareness of antibiotic resistance sub-dimension was found to negatively affect the behavior of forcing antibiotic prescription (OR0.852; 95%CI0.732-0.993) but the score obtained from the behaviour sub-dimension was positively affect this behaviour (OR1.136; 95%CI1.011-1.276).Conclusions:Inappropriate antibiotic use appears to be a problem with negative perception, lack of knowledge and socioeconomic dimension. Studies should be conducted to increase antibiotic knowledge in parents and to expand the scope of social insurance.

Quality improvement intervention to increase colorectal cancer screening at the primary care setting: a cluster-randomised controlled trial

BackgroundApproximately 81% of deaths in Argentina are from chronic non-communicable diseases and 21% caused by cancer. Colorectal cancer (CRC) is the second most frequent cancer in Argentina. Even though CRC...

Risk factors for osteoporosis among postmenopausal women in a Nigerian teaching hospital.

Osteoporosis is a progressive bone disease characterized by a reduction in bone mass and density, leading to bone fragility and an increased risk of sustaining fractures. Several studies have shown that the risk for osteoporosis increases with age and after menopause. A cross-sectional study was undertaken of 422 postmenopausal women at the Family Medicine Clinic of the Lagos State University Teaching Hospital (LASUTH). Variables such as socio-demographic characteristics, anthropometric indices, and lifestyle habits of participants were assessed. In addition, bone mineral density was measured using a validated portable dual-energy X-ray absorptiometry scanner. The results of the bone mineral density were analyzed based on T-scores. The mean age of the study subjects was 59.8± ±6.4 years, while the mean age at menopause was 50.15 ± 4.1 years. The majority of the subjects were obese (41.5%), while the prevalence of osteoporosis and osteopenia was 15.1% and 30.6%, respectively. The use of oral steroids was associated with osteoporosis (P < 0.05). We recommend regular bone mineral density screening of postmenopausal women at the primary care level for early diagnosis and treatment of osteoporosis to prevent fragility fractures.

To queue or not to queue: Facility managers and mental health care users' experiences of integrated health care in a rural South African district.

A key feature of South Africa's state health care strategy since 1994 has been the development and expansion of services towards integrated health care at primary health care level. Within the new system, emphasis has been on the integration of patients with mental health care needs with other patients where multiple health conditions and needs would be addressed simultaneously. As part of a larger study into mental health care in a predominantly rural district, we investigated the experiences of facility managers and mental health service users in rural clinics within the system of care. We were interested both in their views as to the advisability of the integrated model and the ways in which they managed any challenges they may have experienced within the system at local level. Data were collected through once-off semi-structured interviews with facility managers and mental health care service users to gather qualitative information. Narratives were transcribed and translated into English. Transcriptions were imported to Atlas.ti 22 and analysed through Thematic Analysis. The integration of mental health care into routine primary health services poses challenges to treatment delivery and to patients who come for treatment. Our study also suggests resegregating mental health care as a possible solution to facilitate service delivery and treatment to service users. This research provided first insights into facility managers' and service users' views of integrated mental health care at primary health care level in this district. While mental health care services have been expanded and integrated into primary health care over recent years, the system may not have been as streamlined as in other parts of the country. The integration of mental health into primary health care can pose various challenges to facilities, health care providers, and mental health service users. Managers in these constrained circumstances have observed that resegregating mental health care from physical treatment, as in the past, may be deemed more effective for health care provision and reception. Generalised integration of mental health treatment with physical care should be approached with caution unless there is wider scale provisioning and greater organisational change.

Mental healthcare services in Kenyan counties: a descriptive survey of four counties in Western Kenya

BackgroundThe government of Kenya has made progressive efforts towards improving mental health services in the country. However there is little documentation of mental health services in the counties that would support actualization of the legislative frameworks in the context of a devolved healthcare system. This study sought to document existing mental health services within 4 counties in Western Kenya.MethodsWe conducted a cross sectional descriptive survey of four counties using the World Health Organization, Assessment Instrument for Mental Health Systems (WHO-AIMS). Data was collected in 2021, with 2020 being the year of reference. We collected data from the facilities offering mental healthcare within the counties as well as from County health policy makers and leaders.ResultsMental healthcare was provided at higher level facilities within the counties, with minimal structures at primary care facilities. No county had a stand-alone policy on mental health services or dedicated budget for mental healthcare. The national referral hospital, within Uasin-Gishu county, had a clear mental health budget for mental health. The national facility in the region had a dedicated inpatient unit while the other three counties admitted patients in general medical wards but had mental health outpatient clinics. The national hospital had a variety of medication for mental health care while the rest of the counties had very few options with antipsychotics being the most available. All the four counties reported submitting data on mental health to Kenya health information system (KHIS). There were no clearly defined mental healthcare structures in the primary care level except for funded projects under the National referral hospital and the referral mechanism was not well defined. There was no established mental health research in the counties except that which was affiliated to the national referral hospital.ConclusionIn the four counties in Western Kenya, the mental health systems are limited and not well structured, are faced with limited human and financial resources and there is lack of county specific legistrative frameworks to support mental healthcare. We recommend that counties invest in structures to support provision of quality mental healthcare to the people they serve.

Epidemiological and Therapeutic Aspects of the Single Visit Approach in the Management of Precancerous Lesions of the Cervix in Guinea Conakry in 2022

<i>Objective:</i> to evaluate the epidemiological and therapeutic aspects of the single visit approach in the management of precancerous lesions of the cervix in the CECAP sites of Conakry in 2022. <i>Methodology</i>: This was a multicenter cross-sectional descriptive study, using retrospective data at the six CECAP sites from July 1 to Conakry. Three data collection tools: the individual form, a screening register, and a monthly summary sheet or reporting template, were used to track key single-visit service variables: the number of women screened using VIA, proportion of women screened positive for VIA and proportion of women screened VIA positive who received cryotherapy on the same day, KoBo Collect served the collections and the analysis was carried out by the software EPI info version 7.2 6. <i>Results</i>: during our three-month study, in the six pilot sites of Conakry, 786 women were screened, of whom 3.18% (25/786), had IVA+, 62.5% benefited from cryotherapy the same day, it was postponed in 37.5% of cases, the program did not train providers in the management of large lesions, which is one of the limitations of our study. <i>Conclusion</i>: Visual inspection with acetic acid is a simple test, requiring minimal infrastructure and expense, little provider training. The integration of VIA with cryotherapy at the primary care level in the communal medical centers of the city of Conakry, could constitute a feasible program for the prevention of cervical cancer in Guinea.

Blood Pressure Association with the 8-Item Morisky Medication AdherenceScale in Hypertensive Adults from Low-Resource Primary Care Settings: Results from a Prospective Cohort Nested within a Randomised Controlled Trial.

One of the self-report adherence scales most widely used is the 8-item Morisky Medication Adherence Scale (MMAS-8). To evaluate construct validity and reliability of the MMAS-8 in hypertensive adults from low-resource settings within the public primary care level in Argentina. Prospective data from hypertensive adults under antihypertensive pharmacological treatment that participated in the "Hypertension Control Program in Argentina" study was analyzed. Participants were followed at baseline, 6, 12 and 18 months. Based on MMAS-8, adherence was defined as low (score < 6), medium (score 6 to < 8) and high (score of 8). 1214 participants were included in the analysis. In comparison to low adherence, high adherence category was associated with a reduction of - 5.6 mmHg (CI 95%: - 7.2; - 4.0) in systolic blood pressure (BP) and - 3.2 mmHg (CI 95%: - 4.2; - 2.2) in diastolic BP; and with a 56% higher likelihood to have controlled BP (p < .0001). Among those participants with baseline score ≤ 6, two points increase in MMAS-8 along follow-up showed a tendency to reduce BP in almost all-time points and a 34% higher likelihood of having controlled BP at the end of the follow-up (p = 0.0039). Cronbach's alpha total-item values in all time-points were higher than 0.70. Higher MMAS-8 categories were positively associated with BP reduction and higher likelihood of BP control over time. Internal consistency was acceptable and in line with previous studies.

Experience of establishing a lifestyle medicine clinic at primary care level- challenges and lessons learnt

On an international level, for more than 30 years, Lifestyle Medicine (LSM) Practice has had a great impact on both health Promotion and disease prevention. A practice which on a national KSA level, we are in eager need to adopt, due to the high prevalence of chronic diseases and unhealthy lifestyles. The establishment of the LSM clinic inside the Wazarat Health Center (WHC) more than one and half year ago, was a great advancement towards offering very important preventive and promotive services for people in real high need to these underutilized main elements in Primary Health Care (PHC) features. We identified quality oriented Key Performance Indicators and the clinically important outcomes for our patients. Our initial data showed great achievement on both fronts. We are currently studying the satisfaction of our customers and working on improving their level of health awareness and help seeking behavior. Furthermore, we are looking to benchmark our results. From our pilot project in WHC, we are preparing for an expansion plan to branch out other Primary Care centers in the Riyadh area to serve more people, and we aim to share the experience with other similar services and within the PHC centers allover KSA.

A long but fruitful journey: From clinical psychoanalysis to public mental health in Chile

AbstractThe authors, both professors of psychiatry, trained as psychoanalysts according to the standards of the International Psychoanalytic Association (IPA), recount 30 years of conceptual and empirical research work for the construction of a model of brief and adaptive psychodynamic psychotherapy applicable at the Primary Health Care level. The many milestones of this journey are reviewed, starting with the difficulties and obstacles encountered when pursuing this task within IPA institutions. Once the authors decided to conduct the task outside the analytic institution, they created two training programs for psychodynamic therapists and a research group in psychotherapy, all of which have attained excellence. This effort gave birth to several institutions that are still in operation, such as the Chilean and Latin American chapters of the Society for Psychotherapy Research, the Chilean Congress of Psychotherapy, the PhD Program in Psychotherapy, and finally the Millennium Institute for Research and Personality (MIDAP). In its 8 years of existence, MIDAP has become a national and Latin American reference center for research in Mental Health, aimed at implementing preventive and psychotherapeutic interventions in vulnerable populations at the primary health care and community level. The article ends with a description of the main components and the final process of the construction of the Protocol of Psychotherapeutic Competences for the Treatment of Depression in Primary Health Care level.

Medicine and the Law

The South African (SA) medical internship training programme model was recently revised to extend training into the primary care platform. In this article, we reflect on the experiences of training under the new model from an intern perspective. We use these reflections to make recommendations to the Health Professions Council of SA on how to further improve the training model by implementing systems that guide and empower the intern doctor practising at a primary level of care.

Strategies on critical levels and nodes to improve self-management in people with cardiovascular risk factors in COVID-19 pandemic conditions

Chile faced the Sars-Cov-2 pandemic, which coexisted with food-nutritional problems related to non-communicable diseases (NCDs). Due to this context, individuals with chronic conditions had less chance to receive medical attention due to the restructuring of the public health system. The present study aimed to identify strategies that integrate the individual, community, and structural levels to improve health control in habitual and critical situations. The study included individuals attending the Cardiovascular Health Program (Programa de Salud Cardiovascular) at the primary care level in the capital city of Santiago during the COVID-19 pandemic. Nine hundred forty individuals attending the Cardiovascular Health Program answered a 40-question telephonic interview. With the results of the analysis (convergence analyses, the complement of quantitative and qualitative results), we performed a seminar with key stakeholders from the Ministry of Health and the primary care level. Our study describes integrative strategies that include the individual level, the community level, and structural aspects. These strategies may improve healthcare management among people with NCDs and could be helpful to face interruptions of health benefits and improve health control in everyday and critical situations. The strategies include three levels: 1) Cardiovascular Health Program redesign; 2) facing health attendance discontinuities, and 3) structural measures. It is necessary to re-evaluate primary care policies in light of these proposed strategies for sharing responsibility and empowering users about their abilities.

Commentary on Laffan et al expert consensus for equitable care for VWD.

In a recent issue of Haemophilia, Laffan et al. report ‘An expert consensus to define how higher standards of equitable care for von Willebrand disease can be achieved in the United Kingdom and Republic of Ireland.’’1 This project aimed to generate recommendations to improve equitable access to care for VWD patients. A modified Delphi approach was used and clear criteria for stopping and consensus were defined. Ultimately, eight recommendations were derived and include four that specifically address standardised and improved history taking about bleeding events, especially heavy menstrual bleeding, as well as additional recommendations focused on care delivery, better evidence for prophylaxis, and equity in terms of time to diagnosis and quality of life assessments. The expert authors are to be applauded for this effort and their focus on gender bias in the bleeding disorder community. A few points raised by this study merit additional discussion. The health care providers included were predominantly Haematologists, with Nurse Specialists as the second most common group; only one Obstetrician was included. Most respondents were from England and Ireland. Notably, a very high level of consensus was achieved after only one round of voting, which while reassuring, is not surprising given the relative homogeneity of the group. VWD patients interact with many parts of the health care system, and as a community, we need to turn our focus outward to other providers if we intend to truly improve the time to diagnosis and care. We also need to consider the specific challenges facing those living in low and middle-income countries, as the solutions must be tailored to the available resources and cultural settings. Certainly, the foundation of change needs to involve rejecting sexist attitudes towards individuals with bleeding disorders and valuing the lived experiences of patients. Along those lines, the patient voice must be included in future efforts directed at improving equitable access to care. We need to listen to patients and patient organizations to understand their priorities and tailor our approaches appropriately. Failure to do so could perpetuate the current state of inequity, no matter how well-meaning the intentions. As an example, the ongoing focus of many national and international organizations on hemophilia (as evidenced by the very names of these organisations) creates a barrier for VWD patients and healthcare providers. Women have been telling us for years that they feel poorly represented within Hemophilia Treatment Centres and by Hemophilia-focused patient organisations.2-4 It is time we listen and act. Of note, the recommendation with the lowest consensus at 80% was ‘Patients should always be involved in treatment options for their VWD’—clearly, there is work left to do to truly achieve patient-centred care. The authors include a detailed discussion of the barriers to care, which are many, especially at the primary care level. Engaging with primary care practitioners (PCP), who are often the first point of contact for someone with bleeding symptoms, seems an additional critical step in creating a functional and integrated system to diagnose and manage these patients. The value of multi-disciplinary clinics has been recognised, but in contrast to these being specialist centred, the inclusion of PCP in these models of care could be considered. Lastly, as highlighted by the authors, the quality of evidence for critical aspects of the care of VWD patients, such as prophylaxis, is poor. Although there are many barriers to performing these studies including the multiple types and subtypes of VWD as well as the numerous bleeding symptoms experienced by patients, the need for high-quality evidence is clear. In the recently published ASH (American Society of Hematology) ISTH (International Society on Thrombosis and Hemostasis) NHF (National Hemophilia Foundation) WFH (World Federation of Hemophilia) VWD Management Guidelines, all 12 recommendations were conditional, due to the lack of high-quality evidence.5 Laffan et al. appropriately identify the need for future studies to further develop the evidence base on which we base management decisions for VWD patients. Paula James receives research funding from Bayer and consultancy fees from Band/Guardian Therapeutics and Star/Vega Therapeutics. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Spinal Cord Injury: Extent of Disability, Complications, and Management of Patients in The Community – An Overview for Primary Care Physicians

In terms of mortality and morbidity, spinal cord injury (SCI) is the second most frequent severe traumatic event globally, behind traumatic brain injury. SCI causes physical, psychological, social, and financial dysfunction not only to patients but also to their families. This review aims to highlight the most common potentially reversible medical issues faced by patients affected by SCI in the community so that they could be addressed early at the primary care level. In this narrative review, the leading causes of morbidity following SCI including cardio-pulmonary complications, bowel, and bladder-related complications and autonomic dysreflexia are presented with recommendations for their management. We explore the management of bone health-related, pressure injury-related complications and psychosocial aspects of care, and present recommendations to improve the quality of life of patients with SCI. Early detection and management of complications of SCI at the primary care level will help reduce the financial costs and psychosocial burden of this major cause of long-term disability.