Primary Care Level Research Articles

Barriers to Follow-Up of an Abnormal Clinical Breast Examination in Uttar Pradesh, India: A Qualitative Study.

To understand key barriers to diagnostic follow-up for women with an abnormal clinical breast examination (CBE) at the primary care level in the Uttar Pradesh state in India. We also explored acceptability of mobile phones to address barriers to CBE follow-up for women. We conducted 28 semistructured in-depth interviews with 12 women with an abnormal CBE at the primary health facility who did not have diagnostic follow-up, four community health workers, nine health care providers from health facilities in rural and urban settings, and three state-level decision makers. Interviews were audiorecorded, transcribed verbatim, and translated from Hindi to English. Thematic analysis was conducted using Dedoose qualitative software. Themes were organized by multilevel barriers to follow-up. Key barriers to CBE follow-up included knowledge, fear, and stigma about breast cancer; women's health not being prioritized in the family; discomfort seeing male providers; and difficulty navigating the diagnostic facility. Despite community education and outreach efforts by community health workers (known as Accredited Social Health Activists), lack of awareness of breast cancer and the importance of follow-up for abnormal CBE remains a barrier to early detection. Despite widespread access to mobile phones, perceived acceptability varied among stakeholders regarding mobile phone use for breast health education and communication with clients. Knowledge, cultural, and health system barriers challenge women's ability to follow recommendations for diagnostic follow-up of an abnormal CBE. Multilevel and gender-responsive strategies are needed to address these barriers. Our results suggest that mobile phones could be used to further improve breast health awareness, patient navigation, and tracking, and further research is needed.

Effectiveness of influenza vaccines in children aged 6 to 59 months: a test-negative case-control study at primary care and hospital level, Spain 2023/24.

During 2023/24, all children aged 6 to 59 months were targeted for seasonal influenza vaccination in Spain nationally. Using a test-negative case-control design with sentinel surveillance data, we estimated adjusted influenza vaccine effectiveness (IVE) against any influenza type to be 70% (95% confidence interval (CI): 51 to 81%) for primary care patients with acute respiratory illness (ARI) and 77% (95% CI: 21 to 93%) for hospitalised patients with severe ARI. In primary care, where most subtyped viruses (61%; 145/237) were A(H1N1), adjusted IVE was 77% (95% CI: 56 to 88%) against A(H1N1)pdm09.

Situational analysis of maternal and infant mortality in Kazakhstan

Background. Previous studies from Western countries have shown an association between maternal and infant mortality and sociomedical problems. The social environment, which influences the health status of mothers and infants, is a function of the economic resources and forms of production of different regions. This study, for the first time, includes the study of preventable mortality from Pregnancy, childbirth, and the perinatal period, and Congenital malformations in Kazakhstan in the context of regions. For 2015-2019, maternal mortality decreased by 16.5% in Kazakhstan. However, since the start of the pandemic in 2020, the maternal mortality ratio has increased by 2.7 times, highlighting the urgent need for action. This study aims to provide the latest maternal and infant mortality policy and analyze their mortality ratios. The findings of this study have the potential to significantly impact healthcare policies and practices, making a substantial contribution to the field of maternal and child health. Methods. The regulatory documents related to maternal and child health in the Kazakhstan health system were appraised over the last ten years. To identify changes in avoidable mortality ratio trends for the period 2011-2021, joinpoint regression was used to calculate the average annual percentage change for every age group using the JoinPoint Regression Program, Version 4.9.1.0. Results. Crude mortality associated with pregnancy, childbirth, and the postpartum period was high in the 30-34 age group from 2015 to 2018. From 2019 to 2021, there has been an increase in mortality in the 35-39 age group from 0.48 (95% CI: - 0.06; 1.03) to 4.37 (95% CI: 2.83; 5.91) per 100,000 women. In general, there is a twofold increase in mortality in the period from 2018 to 2021. Treatable mortality from pregnancy, childbirth, and puerperium fluctuated between 0.34 and 0.37 from 2015-2019, after which it rose to 1.07 in 2021 per 100.000 population. The highest increase can be seen in Atyrau, South and East Kazakhstan, Karagandy, and Almaty regions. The treatable mortality decreased in Kyzylorda and Akmola regions in the 2015-2021. Conclusion. Several regions need to increase efforts to reduce maternal mortality, which remains high nationally compared to OECD countries. This is the first study to examine the prevention of deaths from pregnancy, childbirth, and the perinatal period, as well as the development of birth defects in Kazakhstan by region, which helps physician decision-makers reconsider possible approaches to providing care at the primary health care level.

Catalyzing Change: Assessing Inner Setting Context of Cervical Cancer Prevention Efforts in Loreto, Peru, Prior to Transition from VIA to HPV Screen-and-Treat.

The objective of this study was to understand health care providers' perspectives regarding the facilitators of and barriers to the success of the former Pap and VIA-based cervical cancer program in Iquitos, Peru, using the Consolidated Framework for Implementation Research (CFIR) to inform the transition to the HPV screen-and-treat intervention. By exploring the pre-implementation organizational context, or inner setting, through the opinions of those who would implement the HPV-based intervention at the patient care level, this research lays the foundation to assess readiness before implementation and understand what's necessary to design contextually appropriate and sustainable interventions in LMIC settings. We conducted 19 semi-structured interviews with health professionals (12 nurse-midwives, 4 doctors, and 3 laboratory technicians) who administered the former Pap- and VIA-based cervical cancer EDT program. Providers identified information gaps between the primary level of care, where cervical cancer screening occurs, and the hospital level of care, where diagnosis and treatment occurs. These gaps, which were caused in part by fragmented, antiquated, and overlapping data systems, resulted in the loss of patients between levels of care. Participants also noted a lack of trained personnel and basic materials. Some providers found their way around these gaps by facilitating informal information exchanges among providers to ensure women were not lost to follow-up. PPC relied on these findings and other data from INSPIRE Phase 1 to implement a HPV-based screen-and-treat program that dramatically increased screening and treatment; however, challenges remain regarding resources and sustainability related to HPV technology.

Student perspectives on designing and implementing an interprofessional education module in chronic disease management at primary care level in Vietnam

PurposeThis study explored students' perspectives on designing and implementing the new clinical interprofessional education (IPE) module for chronic disease management at the primary care level in the Vietnamese context.Design/methodology/approachStudents from seven different university-level healthcare programmes participated in a cross-sectional survey Course Experience Questionnaire-based study. Additionally, two open-ended questions were presented to gather qualitative data, mapping student perspectives. Statistical analyses and thematic analyses were performed.FindingsThe results show that students agree with quality statements about IPE design features, such as good teaching, clear goals and standards, appropriate workload, appropriate assessment and a blended learning approach. Answers to the open-ended comments pointed out the strengths of the IPE module in providing opportunities for interprofessional learning, improving interprofessional collaboration competencies, real-life interprofessional collaboration practice and continuous feedback from tutors. Students also reported weaknesses in the IPE module, including a lack of feedback on the care plan and logistics of the IPE module.Originality/valueStudents positively recognise key design features of the IPE module, combining classroom activities with standardised patient simulations, clinical practice and home visits. Chronic disease management at the primary care level is a suitable context for training students to work interprofessionally. The strengths and weaknesses identified by students could help in the redesign and future implementation of the IPE module in the Vietnamese context. They could inspire practices in Southeast Asian medical education and beyond.

Improving possible serious bacterial infection (PSBI) management in young infants when referral is not feasible: lessons from embedded implementation research in Ethiopia and Kenya

BackgroundSepsis is a leading cause of neonatal mortality, despite the availability of effective treatment of possible serious bacterial illness (PSBI), including when referral to a hospital is not feasible. Gaps in access and delivery worsened during COVID-19. We conducted embedded implementation research in Ethiopia and Kenya aimed at mitigating the impact of COVID-19 and addressing various implementation challenges to improve PSBI management.MethodsThe implementation research projects were implemented at the subnational level in Ethiopia and Kenya between November 2020-June 2022 (Ethiopia) and December 2020-August 2022 (Kenya). Guided by the implementation research frameworks, both projects conducted mixed formative quantitative and exploratory research from April to May 2021, followed by summative evaluations conducted between June and July 2022. Frameworks encompassed Consolidated Framework for Implementation Research (CFIR), Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM), as well as health systems framework that incorporates cascades of care and World Health Organization Health Systems Building Blocks. Results were synthesized across the projects through document review and sharing cross-project measures and strategies through a project community of practice.ResultsDespite differences in settings across the projects, cross-cutting facilitators included community health worker program and support, and existence of guidelines for PSBI management at primary care levels. Barriers included community attitudes towards seeking care for sick newborns, COVID-19 risks and fear, and lack of health care worker competence. Country-specific contextual barriers included supply chain issues, civil conflict (Ethiopia), and labor strikes (Kenya). Strategies chosen to mitigate barriers and support implementation and sustainability in both settings included leveraging community health workers to address resistance to care-seeking, health workers’ training, COVID-19 infection prevention measures, stakeholder engagement, and advocacy to integrate PSBI management into existing programs, policies, and training. Other strategies addressing emerging project-specific barriers, included improving follow-up through a community health desk and PSBI mobile app (Kenya) and supply chain strengthening (Ethiopia). Both projects improved PSBI management coverage, increased adoption and uptake, and informed national policy changes supporting potential for sustainability.ConclusionsPragmatic embedded implementation research effectively supports the identification of barriers and mapping to strategies designed to increase effective coverage of PSBI management when referral is not feasible during the COVID-19 pandemic. Despite differences in context, cross-cutting strategies identified could inform broader scale-up in the region, including during future health system shocks.

Systematic review: Comparative analysis of international approaches to the organisation of emergency departments at the primary health care level

The study aims to review the different systems of emergency care in North American, European, and Pan-Asian countries and to perform a comparative analysis of these modes of organisation. The emergency care systems of Kyrgyzstan, Germany, the United States of America, the United Kingdom, South Korea, Turkey and the United Arab Emirates were analysed, and it was determined that the Anglo-American and Franco-German model of emergency care is currently dominant in the world. The main difference with the system built in Kazakhstan is that ambulance brigades in the above countries consist of nursing staff, in these countries there is a double triage of patients at the stage of call and the stage of distribution of patients in the emergency department, and the last main difference is that the emergency department in Kazakhstan is organised based on an emergency room and does not include intensive care, dynamic observation, there is no diagnostic unit and palliative care unit. Another difference is the training of non-medical services in the comparison countries, such as police and firefighters, who have the necessary basic skills to provide emergency care. This study will help in the future to use foreign experience in the organisation of emergency care in the Republic of Kazakhstan, which may have a positive impact on the quality and speed of emergency care

Health Promoting Behaviors among Reproductive Age Women in Serbia: The Results from a National Health Survey.

Certain lifestyle characteristics, such as dietary patterns, physical activity, and maintenance of recommended body weight, low-risk alcohol consumption and non-smoking are associated with the lower likelihood for the development of chronic-non communicable disease in the general population. These lifestyles are called health promoting behaviors (HPBs). We aimed to examine the prevalence of the HPBs among the women of reproductive age in Serbia and the factors associated with the compliance with four or more of these behaviors. The study was the secondary analysis of the data from the National Health survey in Serbia from 2019 that examined social, health status, mental health (using PHQ-8) and lifestyle characteristics of the general population in Serbia. The prevalence of compliance with four or more HPBs was 22%. Among the HPBs the most frequent was a non-risky alcohol consumption reported by 2585 participants (99.2%), followed by normal weight (2018-69.2%) and non-smoking (1469-69%), daily fruit and vegetables intake (969-33.2%) and sufficient aerobic PA (216-7.9%). Multivariate logistic regression analysis with four or more HPBs as an outcome variable showed that the association of compliance with four or more HPBs with tertiary education (OR 1.91, 95% CI: 1.32-2.76) use of prescription medications (OR: 0.62, 95% CI: 0.44-0.87) and score on PHQ-8 (OR: 0.88, 95% CI: 0.79-0.98). There is a need for deeper promotion of health-related behaviors among all educational and vocational groups, including health promotion activities at the primary health care level, which is available to the entire population.

The effects of physical activity prescription on mental health: Evidence from primary care

While the benefits of physical activity on health are well documented, in high-income countries 1 in 3 adults do not reach the recommended levels. Thus, policy makers have developed interventions to promote physical activity. The aim of this research is to evaluate the effectiveness of physical activity prescription on mental health outcomes, by studying an intervention that prescribes physical activity at the primary care level in Catalonia (PAFES). This intervention specifically targets the adult population with high cardiovascular risk. We use data from the Health Survey of Catalonia (2011–2016) and exploit the variation in the number of trained General Practitioners that prescribe physical activity. Our results show that physical activity prescription reduces the probability of suffering from poor mental health. This effect is mainly driven by females within the targeted population. We also explore the main effect (or the output) of the intervention. While PAFES increases the probability of patients undertaking high-level physical activity, it does not affect rates of sedentarism or minutes walked per day. Results are consistent when using alternative mental health outcome measures, including self-reported depression and anxiety. We conclude that the prescription of physical activity not only contributes to the improvement of physical health but is also a useful tool to help preserve mental wellbeing.

The impact of the nurse practice environment, workload, and professional support on job outcomes and standards of care at primary health care clinics in South Africa: A structural equation model approach

BackgroundThere is substantial evidence on the associations between a positive nurse practice environment and improved nurse and patient outcomes, as well as the factors that mediate these associations, in high-income countries and in hospital settings. The knowledge gaps in African and primary health care settings motivated this empirical study. ObjectiveThe objective of this study was to examine the impact of the dimensions of the nurse practice environment, specifically human resource management, foundations for nursing care, and participation in clinic affairs, on job outcomes and standards of care. DesignA cross-sectional study was conducted between November 2021 and June 2022. Setting180 primary health care clinics in two South African provinces of Gauteng and North West. Participants665 nurses of all categories. MethodsA causal model was developed with pathways between the nurse practice environment dimensions and the outcomes of job satisfaction, intention to leave, and standards of care. A set of standardised instruments was used to measure the study variables. Using structural equation modelling, workload and professional support were tested as potential mediators between the nurse practice environment and the outcome variables. ResultsThe nurses scored the domain of foundations for nursing care 71.2 out of 100 on average, indicating high agreement, while the mean scores for nurses’ participation in clinic affairs and human resources management were lower at 68.0 and 61.7 respectively. Although nurses expressed moderate satisfaction with professional support (67.7), they were less satisfied with their workload (52.2). The mean score of overall job satisfaction was moderate (58.9), with 53.8 % of the nurses reporting that they intended leaving the clinic where they were working. Thirty-six percent intended leaving the nursing profession, indicating low intention to stay. The final mediation model was judged to fit the data adequately based on goodness-of-fit indices, confirming that workload and professional support had a mediating role between the nurse practice environment dimensions of interest and both nurses’ job outcomes and standards of care. ConclusionsWe have highlighted the value of supportive practice environments, effective workload management, and enhanced professional support in improving nurses’ job outcomes and satisfaction with standards of care. Improving nurses’ practice environments at primary health care level may have a wide-ranging impact on the performance of the health system. Therefore, primary health care facility managers should ensure that workload is distributed equitably, professional support for nurses is enhanced, and the overall work environment is improved.

Centering The Voices of People Living with Multimorbity to Develop Visual Dashboards to Facilitate Structured Medication Reviews: The Role of Patient and Public Involvement and Engagement in the DynAIRx Study

The use of Artificial Intelligence in healthcare has the potential to enhance the experiences of both patients and healthcare practitioners (Rajpurker et al., 2022). In an effort to streamline Structured Medication Reviews (SMRs) and to support medication optimization, The Artificial Intelligence (AI) for dynamic prescribing optimization and care integration in multimorbidity (DynAIRx) is a project which seeks to apply AI extracted from clinical records to improve the lives of people who are living with multimorbidity. SMRs were introduced at the primary care level to holistically support complex multimorbid patients’ health journeys and who are considered to be polypharmacy (at least five medications daily). However, there has been poor integration of health records across systems, and limited guidance on how to identify people who need yearly SMR. Without appropriate monitoring a patient’s medication, their polypharmacy may worsen (NICE, 2017); negatively impacting a patient’s overall health. Using AI and statistical approaches to predict the risk of poor outcomes, DynAIRx will produce visual dashboards for healthcare providers to use to facilitate reviews of medications for patients requiring SMRs. A Public Advisory Steering Group, comprised of individuals with lived multimorbidity experiences or carers of people with multimorbid conditions sits at the heart of DynAIRx. The steering group is designed to ensure co-production is implemented throughout each work package. This presentation presents DynAIRx as a case study on how to develop and implement PPIE as user/partnership-centered approach to AI research in healthcare and potential implications of including the public’s perspectives on the larger product.

Preparedness of Nursing Homes: A Typology and Analysis of Responses to the COVID-19 Crisis in a French Network.

Preparing healthcare systems for emergencies is crucial to maintaining healthcare quality. Nursing homes (NHs) require tailored emergency plans. This article aims to develop a typology of French private NHs and study their early COVID-19 responses and mortality outcomes. We conducted a cross-sectional survey among NHs of a French network consisting of 290 facilities during the first wave of the COVID-19 pandemic. A Hierarchical Clustering on Principal Components (HCPC) was conducted to develop the typology of the NHs. Association tests were used to analyze the relationships between the typology, prevention and control measures, COVID-19 mortality, and the satisfaction of hospitalization requests. The 290 NHs vary in size, services, and location characteristics. The HCPC identified three clusters: large urban NHs with low levels of primary care (Cluster 1), small rural NHs (Cluster 2), and medium urban NHs with high levels of primary care (Cluster 3). The COVID-19 outcomes and response measures differed by cluster, with Clusters 1 and 2 experiencing higher mortality rates. Nearly all the NHs implemented preventive measures, but the timing and extent varied. This typology could help in better preparing NHs for future health emergencies, allowing for targeted resource allocation and tailored adaptations. It underscores the importance of primary care territorial structuring in managing health crises.

Assessing and Comparing Musculoskeletal Knowledge and Red Flag Identification Skills: A Cross-Sectional Study of Physical Therapists and Primary Care Physicians

Background: Musculoskeletal disorders are one of the most common health issues often managed at the level of primary health care. Enabling physical therapists to be first-contact practitioner for patients with musculoskeletal disorders could improve patient access, expedite management, enhance outcomes and reduce costs. However, this role requires a high level of musculoskeletal knowledge and the ability to detect red flags. Objectives: To assess and compare the musculoskeletal knowledge and abilities to identify red flags between physical therapists and primary care physicians (PCPs). Methods: A cross-sectional study was undertaken using an electronic survey assessed participants’ musculoskeletal knowledge and ability to identify red flags. Study participants included physical therapist and PCPs practicing at Ministry of Health hospitals and/or primary care centers in Riyadh, Saudi Arabia. Results: A total of 60 physical therapists and 76 PCPs participated. Good knowledge levels (total score ≥ 75%) were found for 7% of physical therapists compared to 18% of PCPs, and moderate knowledge levels (total score 60-75%) were found in 70% of physical therapists compared to 62% of PCP participants (P=.003). Conclusion: Physical therapists and PCPs demonstrated an overall moderate level of musculoskeletal knowledge and the ability to identify red flags. The results suggest that with further education on red flags identification, physical therapists in Saudi Arabia could potentially act as first-contact practitioners for patients with musculoskeletal conditions.

Epidemiological Pattern and Case Fatality Rate among COVID-19 Patients during First and Second Wave of Pandemic in Madhesh Province, Nepal

Background & Objectives: Evaluating multi-wave patterns of COVID-19 infection, hospitalization, and mortality across spatial scales can inform public health strategies for future pandemics. However, there is limited understanding of these patterns in developing countries, including Nepal. This study aimed to analyze epidemiological patterns, fatality rates, and factors associated with severe outcomes during the first and second waves of COVID-19 in Madhesh Province, Nepal. Materials and Methods: This retrospective cross-sectional study used provincial health records from Madhesh Province, covering April 9, 2020, to December 15, 2021, to analyze 37,551 positive COVID-19 cases and 1,037 deaths across two waves. The study examined changes in COVID-19-related deaths, with data on demographics, residence, isolation sites, treatment hospitals, care levels, and testing laboratories. The frequency and percentage of the variables were presented. The case fatality rate (CFR) for different categories were calculated. Additionally, the case fatality rate ratio (CFRR) for the first wave against second wave was obtained. Finally, case fatality risk ratios with 95% confidence intervals were presented. A p-value of <0.05 was set as statistically significant. Results: The case fatality rate (CFR) for COVID-19 was significantly higher in the second wave, especially among the elderly (≥47 years), and in institutional isolation (7.82%). Tertiary level care and private hospitals consistently showed higher CFRs. Furthermore, the multivariable analysis of risk ratios (RR) for COVID-19 case fatality in revealed that the 25–34 year age group had the highest RR (2.39). Similarly, males had a higher RR (1.42) than females, and institutional isolation had a substantially higher RR (93.33) compared to home isolation. Primary level care RR (28.11) and government hospitals RR (4.32) showed a higher risk. Place of residence also impacted the RR, with Sarlahi (7.68) having higher. Conclusion: A significant increase in COVID-19 case fatality rates during the second wave, particularly among the elderly and those in institutional isolation. Higher mortality was observed in tertiary hospitals and among those who were tested in private laboratories, with substantial variations in risk ratios based on age, isolation type, and place of residence.

The importance of continuing medical education on cardiopulmonary resuscitation of health care professionals at the level of primary health care – experience of the Health Center of Osijek-Baranja County

The importance of continuing medical education on cardiopulmonary resuscitation of health care professionals at the level of primary health care – experience of the Health Center of Osijek-Baranja County

Degenerative Cervical Myelopathy Awareness in Primary Care: UK National Cross-Sectional Survey of General Practitioners.

Degenerative cervical myelopathy (DCM) is a progressive neurological condition, characterized by spinal cord injury secondary to degenerative changes in the spine. Misdiagnosis in primary care forms part of a complex picture leading to an average diagnostic delay of 2 years. This leads to potentially preventable and permanent disability. A lack of awareness secondary to deficits in postgraduate education may contribute to these delays. This study aims to assess the awareness of DCM in the setting of general practice. General practitioners completed a quantitative web-based cross-sectional questionnaire. The 17-item questionnaire captured data regarding demographics, subjective awareness, and objective knowledge. The questionnaire was disseminated via professional networks, including via practice managers and senior practice partners. Incentivization was provided via a bespoke DCM fact sheet for those that completed the survey. A total of 54 general practitioners representing all 4 UK nations responded to the survey. General practitioners most commonly self-assessed that they had "limited awareness" of DCM (n=24, 51%). General practitioners felt most commonly "moderately able" to recognize a case of DCM (n=21, 46%). In total, 13% (n=6) of respondents reported that they would not be at all able to recognize a patient with DCM. Respondents most commonly reported that they were "moderately confident" in their ability to triage a patient with DCM (n=19, 41%). A quarter of respondents reported no prior introduction to DCM throughout their medical training (n=13, 25%). The mean score for knowledge-based questions was 42.6% (SD 3.96%) with the lowest performance observed in patient demographic and clinical recognition items. General practitioners lack confidence in the recognition and management of DCM. These findings are consistent with the diagnostic delays previously described in the literature at the primary care level. Further work to develop and implement educational interventions to general practitioner practices is a crucial step to improving patient outcomes in DCM.

Advancing geospatial preconception health research in primary care through medical informatics and artificial intelligence

Established life course approaches suggest that health status in adulthood can be influenced by events that occurred during the prenatal developmental period. Yet, interventions such as diet and lifestyle changes performed during pregnancy have had a small impact on both maternal and offspring health outcomes. Currently, there is a growing body of literature that highlights the importance of maternal health before conception (months or years before pregnancy occurs) for the future health of offspring. While some studies have explored factors such as maternal body composition, nutrition, and lifestyle in this area, location-based environmental and socioeconomic exposures before conception may also contribute to future offspring health. In this line, the study of a patient's geographic history presents a promising avenue. To foster research in this direction, the integration of geospatial health, medical informatics and artificial intelligence techniques offers great potential. Importantly, novel sources of big health data sets such as electronic health records registered at the primary care level provide a unique framework due to its inherent longitudinal nature. Nonetheless, a number of privacy, ethical, and technical challenges need to be overcome for this kind of longitudinal analysis to mature and succeed. In the long-term, we support the vision of incorporating a patient's geographic history into her clinical history to equip clinicians with useful contextual information to explore.

Design and Proof of Concept of a Web-Based Questionnaire to Identify Patients at Risk for HIV and HCV Infection.

Despite remarkable improvement in the human immunodeficiency virus (HIV) and hepatitis C virus (HCV) care continuum, the rate of late diagnosis of HIV and HCV in high-income countries remains unacceptably high. Testing relies mainly on primary care physicians' identification of risk factors. We aimed to adapt an analogic to an online questionnaire to help HIV and HCV screening and perform a pilot study to assess its accuracy and acceptability. We used the Delphi method to adapt a previously validated analogical questionnaire to a user-friendly online tool. It aimed to identify participants who should be screened for HIV or HCV and those who should be referred for pre-exposure prophylaxis (PrEP). We then designed a proof-of-concept pilot study from July to October 2022 to test its feasibility and suitability for use on a larger scale and to assess its accuracy in identifying patients at risk for HIV or HCV or with indication for PrEP. The final questionnaire consisted of 37 questions. A total of 142 participants provided informed consent, and 102 completed the questionnaire: 41 random patients recruited at the primary care level, 10 participants recently diagnosed with HIV, 20 participants with HIV on follow-up, 21 participants from the PrEP program, and 10 patients diagnosed with HCV. The tool adequately indicated the need for testing in more than 98% of participants with confirmed HIV/HCV infections or in the PrEP program. Furthermore, it adequately assessed PrEP referral in 94% of participants already on PrEP or with known HIV infection. Participants were highly satisfied with the tool, and 98% of them recommended its use. A self-administered web-based tool to identify patients who should be tested for HIV or HCV or referred to PrEP could simplify patient selection and help reduce late diagnosis.

Evaluation of an electricity-independent method for IS2404 Loop-mediated isothermal amplification (LAMP) diagnosis of Buruli ulcer in resource-limited settings.

Buruli ulcer (BU) caused by Mycobacterium ulcerans (MU) is a devastating necrotic skin disease. PCR, recommended for confirmation of BU by WHO, requires an adequately equipped laboratory, therefore often delaying timely diagnosis and treatment of BU patients in remote settings. Loop-mediated isothermal amplification (LAMP) is a PCR-based protocol for isothermal amplification of DNA that has been suggested for diagnosis of BU in low-resource settings. This is an exploratory diagnostic test evaluation study, with an embedded qualitative sub-study. Its aims are two-fold: First, to evaluate a simple rapid syringe-based DNA extraction method (SM) in comparison with a more elaborate conventional DNA extraction method (CM), followed by a LAMP assay targeting IS2404 for the detection of MU, either using a commercially available pocket warmer (pw) or a heat block (hb) for incubation. Second, to complement this by exploring the diagnostic workflow for BU at a community-based health centre in an endemic area in rural Ghana as an example of a potential target setting, using interviews with researchers and health care workers (HCWs). Diagnostic test evaluation results are discussed in relation to the requirements of a target product profile (TPP) for BU diagnosis and the target setting. A protocol using SM for DNA extraction followed by IS2404 PCR (IS2404 PCRSM) was able to identify MU DNA in 73 out of 83 BU clinical specimens submitted for diagnosis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of IS2404 PCRSM were 90.12%, 100%, 100% and 65.21% respectively, as compared to the reference standard IS2404 PCR in combination with a standard extraction protocol for mycobacterial DNA. Evaluation of the LAMP assay on 64 SM DNA extracts showed a sensitivity, specificity, PPV and NPV of 83.6%, 100%, 100% and 50%, respectively, using either pocket warmer (pwLAMPSM) or heat block (hbLAMPSM) for incubation of the reaction, as compared to the same reference standard. The limit of detection of pwLAMPSM was found to be 30 copies of the IS2404 target. Interview findings explored barriers to BU diagnosis and treatment, including perceptions of the disease, costs, and availability of transport. Participants confirmed that a diagnosis at the PoC, in addition to screening based on clinical criteria, would be advantageous in order to prevent delays and loss to follow-up. The high diagnostic and analytic accuracy of the pwLAMP, evaluated by us in combination with a syringe-based DNA extraction method, supports its potential use for the rapid detection of MU in suspected BU samples at the community or primary health care level without reliable electricity supply. Further optimization needs include a lysis buffer, evaluation directly at the PoC and/or other sites, assessing staff training requirements and quality control.

Family out-of-pocket expenditure for type 2 diabetes mellitus care and percentage of family income.

Type 2 diabetes has economic implications involving family income and out-of-pocket spending. Determine family out-of-pocket expenditure for type 2 diabetes mellitus care and percentage of family income. Study of family out-of-pocket spending in families with patients with type 2 diabetes treated at primary care level. Out-of-pocket expenses included expenses for transportation, food-drinks, and external medications. Family income corresponded to the total economic income contributed by family members. The percentage of out-of-pocket spending in relation to family income was identified with the relationship between these two variables. Statistical analysis included averages and percentages. The annual family out-of-pocket expenditure on transportation was $2,621.24, the family out-of-pocket expenditure on food and beverages was $1,075.67, and the family out-of-pocket expenditure on external medications was $722.08. The total annual family out-of-pocket expense was $4,418.89 and corresponds to 4.73% of family income. The family out-of-pocket expense in the family with a patient with diabetes mellitus 2 was $4,418.89 and represents 4.73% of the family income.