Prevention In Primary Care Research Articles

Effectiveness of different interprofessional collaborative processes to optimize type-2 diabetes prevention in routine Primary Care: the PREDIAPS implementation trial

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Training Psychologists in Integrated Primary Care and Child Maltreatment: Trainee and Supervisor Perspectives on Lessons Learned.

Psychologists are key team members in the delivery of integrated behavioral healthcare. Healthcare reform has supported a shift toward a team-based, interdisciplinary model of service delivery, with increasing emphasis on primary care services, prevention, and health promotion. In conjunction with this shift has been a greater focus on psychosocial problems and social determinants of health, particularly childhood adversity. Psychologists in primary care are uniquely positioned to advance efforts to prevent and ameliorate childhood adversity, which are essential to improving care for underserved populations and reducing health disparities. Targeted training efforts are needed to increase the number of psychologists equipped to work in primary care settings with underserved populations. This paper provides an overview of a training program designed to provide psychology trainees with specialized training in both integrated primary care and child maltreatment. The overarching goal of the program is to provide trainees with the skillset to work within integrated primary care settings and the expertise needed to further efforts to address and prevent child maltreatment, as well as childhood adversity more broadly, to improve outcomes for underserved populations. The paper reviews strengths, challenges, and lessons learned from this program.

Improving care for sexually transmitted infections.

IntroductionRising rates of reported sexually transmitted infections (STIs) in the US and Europe are a public health priority and require a public health response. The diagnosis and treatment of STIs have been the cornerstone of STI control and prevention for many decades and, historically, publicly funded STI clinics have played a central role in the provision of STI care. Innovations in non‐invasive diagnostic techniques, especially nucleic acid amplification tests in the mid‐1990s, have facilitated the expansion of STI testing and treatment outside traditional STI clinics, including primary care, family planning, school‐based health, outreach, corrections, emergency departments and HIV prevention and care settings. As a result, the continued need for categorical STI clinics has been debated. In this Commentary, we discuss how practice can be improved at each level of STI care.Discussion STI practice improvement plans should be tailored to the strengths of each care setting. Thus, in primary care, the focus should be on improving STI screening rates, the provision of hepatitis B and human papillomavirus vaccines and, in jurisdictions where this is legal, expedited partner therapy for gonorrhoea and chlamydia. Extragenital (pharyngeal and rectal) testing for gonorrhoea and chlamydia should be available in settings serving populations more vulnerable to STI acquisition at these anatomical sites, including men who have sex with men. In family planning settings with a mostly female patient population, there are opportunities to serve male partners with both contraceptive and STI services. STI screening rates can also be improved in other settings serving populations at increased risk for STIs, including school‐based clinics, emergency departments, correctional health facilities and providers of HIV care and prevention. These improvements are predominantly logistical in nature and not dependent on extensive STI clinical expertise. While some providers in these settings may have the clinical knowledge and skills to evaluate symptomatic patients, many do not, and STI speciality clinics must be available for consultation and referral and evolve from “safety net” providers of last resort to STI centres of excellence.ConclusionsA tailored practice improvement plan can be envisioned to achieve an optimally functioning STI care continuum.

Engaging Young Men in the HIV Prevention and Care Continua: Experiences From Young Men of Color Who Have Sex With Men.

Sexual minority individuals experience barriers to receiving equitable health care. Research also indicates that young men who have sex with men (YMSM), particularly young men of color, have limited engagement in the HIV care continuum and there are significant disparities across the continuum. This study aims to uncover how providers can engage YMSM of color in all forms of care, including primary care and HIV prevention through an HIV prevention continuum. This qualitative study reports data from the Healthy Young Men's Cohort Study; a total of 49 YMSM participated in the eight focus groups. This study provides a description of YMSM's overall health concerns, experiences with health care, and under what circumstances YMSM seek care. We then present a model describing the salient characteristics of a HIV prevention continuum for YMSM of color and provide clear areas for education, intervention, and policy change to support better overall health for YMSM of color.

NP20 Starting Early: Expansion of a Primary Care-Based Early Child Obesity Prevention Program

Objective Determine “Starting Early Program” (StEP) impacts on infant feeding practices and weight and develop expanded prenatal and pre-school StEP interventions. Description We conducted a randomized controlled trial testing the efficacy of StEP, a comprehensive early child obesity prevention program using prenatal and pediatric primary care to target low-income, Hispanic families. English/Spanish speaking pregnant Hispanic women were enrolled in the third trimester to standard primary care control group vs. StEP intervention group (prenatal/postpartum nutrition counseling, and nutrition and parenting support groups coordinated with well-child visits until child age three years). Expanded prenatal and preschool StEP curricula for women beginning in the first trimester and children aged 3-5 years were developed. Evaluation Intervention outcomes assessed at child age 3, 10, 19 months and 2, 3, 4 and 5 years. Maternal infant feeding and activity practices assessed using 24-hour diet recalls and validated surveys. Measured child weight for age z-scores (WFAz) determined from CDC growth charts. Intent to treat analyses and within group analyses for intervention dose impacts were conducted. We randomized 533 low-income women into the original trial. 88%, 78%, 74%, 76% and 75% of mother-infant pairs completed assessments at 3, 10, and 19 months, and 2 and 3 years. Intervention pairs had healthier feeding and activity practices (more exclusive breastfeeding, tummy time; less cereal in the bottle, excess milk intake and non-responsive feeding styles). By age two, intervention group infants had lower WFAz than controls (0.62(1.11) vs. 0.85(1.17); P = .046). Median number of sessions attended was 7.0(SD3.5)/12. High attendance reduced the odds of being overweight (AOR 0.42, P = .02). To date, a new expanded prenatal cohort is being enrolled in the 1st trimester (goal n = 200); 309 pairs from the original cohort enrolled for continuation, 4- and 5-year assessments on-going. Conclusion and Implications StEP intervention infants had healthier feeding practices and lower weight at two years, with dose dependent reduction in overweight. Findings demonstrate a scalable system to potentially augment obesity prevention in primary care for at-risk families.

Socioeconomic inequalities in healthcare utilisation in Indonesia: a comprehensive survey-based overview

ObjectiveMonitoring inequality in healthcare utilisation is essential to reduce persistent inequalities in health in lower-middle income countries. This study aimed to assess socioeconomic inequalities in the utilisation of primary care,...

Primary Care Women’s Health Screening: A Case Study of a Community Engaged Human Centered Design Approach to Enhancing the Screening Process

To apply a Human Centered Design (HCD) approach to co-designing a comprehensive women's health screening tool with community partners. Evidenced-based health screenings for behaviors and risks are important tools in primary health care and disease prevention, especially for women. However, numerous barriers limit the effective implementation of comprehensive health screenings, and often lead to excluding important risks such as intimate partner violence (IPV). Utilizing a human centered design approach (HCD), Mountain Area Health Education Center (MAHEC, NC USA) developed a community co-designed 9-topic health screening for women. Key end-users were recruited to participate in the design process, including women who identified IPV as a health issue in their community, Spanish speaking women, domestic violence program organizers, and MAHEC staff. A total of 21 participants collaborated during three design sessions on two specific goals: 1) creating a comprehensive women's health screening tool from the existing tools that were in use in our clinics at the time, and 2) incorporating IPV screening. Through the HCD sessions, participants highlighted the impact of what they termed "Triple T: time, trust and talk" on the effectiveness of women's health screening. Our co-designed women's health screening tool is a first step towards addressing screening barriers from both primary care provider's and community women's perspectives. Future research will explore the facilitators of and barriers to implementing the tools in different primary care settings. Future work should also more systematically examine whether and how screening processes may reinforce or contribute to women's feelings of being stereotyped, and how screening processes can be designed to avoid stereotype threat, which has the potential to reduce the effectiveness of screenings intended to promote women's health.

The incidence of malnutrition between 1 and 5 years of age on the basis of the preventive primary care data

Introduction Malnutrition inhibits children from normal development and leads to irreversible consequences with respect to mental and physical performance. Materials and methods We analysed the aggregate data in the 2013–2015 reports of regional visiting nurses on the nutritional status of Hungarian children at the ages of 1, 3, and 5 years. In the regions of Hungary, stratum-specific proportions were calculated with 95% confidence intervals for the proportion of children with lower than a 10th percentile score. Results The proportions of malnutrition among children whose score was below the 10th percentile nationwide were 8.14% [8.03%–8.25%] at age 1, 6.87% [8.03%–8.25%] at age 3, and 5.68% [5.59%–5.78%] at age 5. In all three age groups, the proportion of children below the 10th percentile was significantly lower in the Central Hungarian region than in the national reference proportion and in Northern Hungary and the Southern Great Plain. Discussion and conclusions These results indicate that Hungary’s incidence of malnutrition is no better than the worldwide average. To improve this situation, Hungarian healthcare professionals must at least begin following a precise, standardized protocol for the compulsory assessment of nutritional status in the framework of their reporting on the primary care of children.

Lifestyle interventions for cancer prevention in primary care: Differences between family physicians and nursing professionals.

Prevention offers the most cost-effective long-term strategy for cancer control. The objective of this study was to ascertain opinions, attitudes, and professional practices towards cancer prevention among primary care professionals and to assess differences between family physicians (FP) and nursing professionals (NP). A cross-sectional study was performed in 2012 in the Community of Madrid. A random sample of 3586 professionals received an online questionnaire about opinions/attitudes, training, and interventions in cancer prevention. The chi-square test was used to analyse the association of the profession with all the variables. Factors associated with the usual practice of individual, group, and community interventions were analysed using multivariate logistic regression, with separate models for FP and NP. The response rate was 39.4% (N=1413). Approximately 90% of the participants attributed "sufficient/high" utility to individualized counselling. NP attributed higher utility to group and community interventions than FP (70.1% vs 60.1% and 64.9% vs 57.7%, respectively, P-value<0.01). The usual practice of group and community interventions was more frequent among NP. The practice of group and community interventions was associated with knowledge of resources for prevention, specific training in group interventions, and the utility attributed to these methods. Among FP, the ability to dispense effective health advice and the utility attributed to this advice were associated with the usual practice of the three interventions. Group and community interventions are rarely practised, especially among FP. Actions targeting improved ability and knowledge could lead to higher involvement in the promotion of health. It would also be necessary to intervene in the examination of the utility of such interventions.

Influences on general practitioner referral to allied health professionals for fall prevention in primary care.

To explore influences on referral for fall prevention from general practitioners (GPs) to allied health professionals (AHPs) to better equip AHPs engage with GPs regarding fall prevention. Qualitative, semi-structured interviews with GPs (n=24), practice nurses (n=3) and AHPs (n=15) and field notes were analysed inductively using constant comparative methods. Three main themes regarding influences on GP referral to AHPs for fall prevention were identified as follows: GPs' knowledge of AHPs; The "reliable and good" AHP; and Patient feedback-Patient choice. Three-way communication and trust between GP, patient and AHP underpinned each of these themes. Strategies for encouraging GP referral include AHPs personally contacting GPs to explain their services; writing to GPs about every patient seen; and being aware that interprofessional relationships are based on trust and take time to develop. GPs and AHPs are encouraged to communicate directly rather than relying on patients to convey verbal information.

Iranian Primary Healthcare providers` Perspectives on Providing Pre-hospital Emergency Services in Primary Levels of Healthcare System: A Qualitative Study

Background and purpose: Due to the important role of emergencies and accidents as mainspring of mortality and morbidity, providing emergency services must be taken into account at all levels of health system. The aim of this study was to investigate the perspectives of healthcare providers on providing pre-hospital emergency services and its challenges in primary healthcare (PHC) levels in Golestan Province, northern Iran.Materials and Methods: The researchers conducted 31 interviews totally (n=21 community health workers and n=10 family physicians) using semi-structured and in-depth interviews in Golestan Province, north of Iran in the year 2014. All interviews were digitally recorded and transcribed. The collected data was then analyzed through qualitative content analysis.Results: In total, three categories were identified related to emergency services in the primary healthcare system, including 1) Different status of providing primary preventive and emergency care in primary healthcare levels, 2) Need to develop the emergency services in health houses, and 3) Challenges of providing appropriate emergency services in the primary levels of healthcare system, such as lack of physical and human resources, weakness in monitoring and education system, inadequate skills, motivation in health team, heavy workload, and insufficient cooperation with other related organizations.Conclusion: The primary levels of healthcare system were not properly serviced in emergencies. They were also faced with numerous challenges that necessitate health policy makers to plan for promoting and providing required services at this level of healthcare system.

Secondary prevention after stroke/transient ischemic attack: A randomized audit and feedback trial.

The clinical benefits of use of secondary preventive pharmacotherapy in ischemic stroke/TIA have been previously demonstrated. A potential target for facilitating the use of recommended medications is primary care physicians. Therefore, we carried out an audit and feedback intervention aimed at primary care centers. The aim was to improve the use of secondary preventive stroke medications and diagnosis recording in ischemic stroke/TIA. The intervention consisted of structured, healthcare database-derived quality reports on secondary preventive medication use and diagnosis recording, sent in 2015 to half of the primary care centers in Stockholm County, with information specific to each primary care center. Medication dispensation (primary outcome) for statins, antihypertensives, antiplatelets, and anticoagulants, as well as diagnosis recording (secondary outcome), was compared between intervention centers and control centers in the 18months following the intervention. Outcome data were derived from the healthcare databases of Stockholm County (VAL). Dispensation of medications to the 12766 patients analyzed in the study was high. Over 77% of patients used antihypertensives and antithrombotics, and 65%-68% used statins. After the intervention, no differences in medication dispensation were seen between the intervention and control centers, even after adjusting for potential confounders. A simple audit and feedback intervention directed toward physicians in primary care did not improve medication dispensation to ischemic stroke/TIA patients 18months later. Any future audit and feedback intervention aimed at improving adherence to guidelines for secondary prevention in primary care should consider multiple and continuous reminders, the graphical appeal, and widening the recipients to include patients.

Guest Editorial: AI Enabled Connected Health Informatics

The articles in this special section provide a snapshot of the latest research advancements in all aspects of connected health and informatic systems where artificial intelligence has been evident, including sensing, transfer, storage and analytics of biomedical data. These articles capture the end-to-end view of solutions that use automated informatics to address single ormultiple scenarios of health engineering such as primary care, preventive care, predictive technologies, hospitalization, home care, and occupational health.

Reliability of routinely collected anthropometric measurements in primary care

BackgroundMeasuring body mass index (BMI) has been proposed as a method of screening for preventive primary care and population surveillance of childhood obesity. However, the accuracy of routinely collected measurements has been questioned. The purpose of this study was to assess the reliability of height, length and weight measurements collected during well-child visits in primary care relative to trained research personnel.MethodsA cross-sectional study of measurement reliability was conducted in community pediatric and family medicine primary care practices. Each participating child, ages 0 to 18 years, was measured four consecutive times; twice by a primary care team member (e.g. nurses, practice personnel) and twice by a trained research assistant. Inter- and intra-observer reliability was calculated using the technical error of measurement (TEM), relative TEM (%TEM), and a coefficient of reliability (R).ResultsSix trained research assistants and 16 primary care team members performed measurements in three practices. All %TEM values for intra-observer reliability of length, height, and weight were classified as ‘acceptable’ (< 2%; range 0.19% to 0.70%). Inter-observer reliability was also classified as ‘acceptable’ (< 2%; range 0.36% to 1.03%) for all measurements. Coefficients of reliability (R) were all > 99% for both intra- and inter-observer reliability. Length measurements in children < 2 years had the highest measurement error. There were some significant differences in length intra-observer reliability between observers.ConclusionThere was agreement between routine measurements and research measurements although there were some differences in length measurement reliability between practice staff and research assistants. These results provide justification for using routinely collected data from selected primary care practices for secondary purposes such as BMI population surveillance and research.

A Guide for Designing Student-Led, Interprofessional Community Education Initiatives About HIV Risk and Pre-Exposure Prophylaxis.

There is room for innovation in medical education regarding HIV and modern biomedical preventive strategies such as pre-exposure prophylaxis (PrEP). Previously described undergraduate medical curricular modules address care for HIV patients but do not include PrEP. A graduate medical curriculum concerning HIV has also been described but misses the opportunity for early introduction of HIV risk prevention, an element of primary preventive care. The guiding framework described here provides one mechanism to begin addressing this gap and fosters interprofessional collaboration among students through community engagement. We assembled a team of 11 first-year students (medical, physician assistant, podiatry, pharmacy, and health care psychology). The team collaborated to create a training module about HIV risk and PrEP access in Lake County, Illinois. A biopsychosocial perspective on HIV risk and PrEP was employed as the guiding framework. The student team presented the module to care teams at the Lake County Health Department and to the university campus through interactive workshops. Participating students completed a self-reflection instrument. Responses were positive in terms of student enjoyment and attainment of new knowledge regarding HIV risk and PrEP. Students also self-reported competency in a selected group of Interprofessional Education Collaborative competencies. Narrative responses were analyzed for context. Student responses suggest that this activity is effective in providing education about HIV risk and PrEP. The framework is novel in that it requires research and modification at each site of implementation. Furthermore, as an extracurricular element, its implementation is flexible.

The Optimal Short Version of Montreal Cognitive Assessment in Diagnosing Mild Cognitive Impairment and Dementia

ObjectivesWhile various short variants of the Montreal Cognitive Assessment (MoCA) have been developed, they have not been compared among each other to determine the most optimal variant for routine use. This study evaluated the comparative performance of the short variants in identifying mild cognitive impairment or dementia (MCI/dementia). DesignBaseline data of a cohort study. SettingAlzheimer's Disease Centers across the United States. ParticipantsParticipants aged ≥50 years (n = 4606), with median age 70 (interquartile range 65-76). MeasuresParticipants completed MoCA and were evaluated for MCI/dementia. The various short variants of MoCA were compared in their performance in discriminating MCI/dementia, using areas under the receiver operating characteristic curve (AUCs). ResultsAll 7 short variants of MoCA had acceptable performance in discriminating MCI/dementia from normal cognition (AUC 87.7%-91.0%). However, only 2 variants by Roalf et al (2016) and Wong et al (2015) demonstrated comparable performance (AUC 88.4-88.9%) to the original MoCA (AUC 89.3%). Among the participants with higher education, only the variant by Roalf et al had similar AUC to the original MoCA. At the optimal cut-off score of <25, the original MoCA demonstrated 84.4% sensitivity and 76.4% specificity. In contrast, the short variant by Roalf et al had 87.2% sensitivity and 72.1% specificity at its optimal cut-off score of <13. Conclusions/implicationsThe various short variants may not share similar diagnostic performance, with many limited by ceiling effects among participants with higher education. Only the short variant by Roalf et al was comparable to the original MoCA in identifying MCI or dementia even across education subgroups. This variant is one-third the length of the original MoCA and can be completed in <5 minutes. It provides a viable alternative when it is not feasible to administer the original MoCA in clinical practice and can be especially useful in nonspecialty clinics with large volumes of patients at high risk of cognitive impairment (such as those in primary care, geriatric, and stroke prevention clinics).

AMA’s Incoming President to Deliver Distinguished Psychiatrist Lecture

AMA’s Incoming President to Deliver Distinguished Psychiatrist Lecture

Older Immigrants' Access to Primary Health Care in Canada: A Scoping Review.

ABSTRACTAging and immigration have significantly shaped the population composition in Canada, where immigrants make up increasingly large proportions of the older adult population. This scoping review examines the existing knowledge surrounding older immigrants' access to, and utilization of, primary care physicians, who play a pivotal role in the delivery of primary care, preventive care, and mental health care. We applied Arksey and O'Malley's five-stage framework to search databases for Canadian-based, peer-reviewed English-language articles on the topic and examined 31 articles in detail. Three focus areas emerged: access and utilization of primary care, health promotion and cancer screening, and utilization of mental health services. Older immigrants face intertwining access barriers related to health literacy, language, culture, health beliefs, spatial inequality, and structural circumstances. The review provides a thorough understanding of the status of access to care among older immigrants in Canada, and yields policy implications to address their unmet health needs.

A randomized controlled trial of suicide prevention training for primary care providers: a study protocol

BackgroundSuicide is a national public health crisis and a critical patient safety issue. It is the 10th leading cause of death overall and the second leading cause of death among adolescents and young adults (15–34 years old). Research shows 80% of youth who died by suicide saw their primary care provider within the year of their death. It is imperative that primary care providers develop the knowledge and skills to talk with patients about distress and suicidal thoughts, and to assess and respond in the context of the ongoing patient - primary care provider relationship.MethodsThis study examines the effectiveness of simulation on suicide prevention training for providers-in-training by comparing two conditions: 1) a control group that receives online teaching on suicide prevention in primary care via brief online videos and 2) an experimental group that includes the same online teaching videos plus two standardized patient (SP) interactions (face-to-face and telehealth, presentation randomized). All SP interactions are video-recorded. The primary analysis is a comparison of the two groups’ suicide prevention skills using an SP “test case” at 6-month follow-up.DiscussionThe primary research question examines the impact of practice (through SP simulation) over and above online teaching alone on suicide prevention skills demonstrated at follow-up. We will assess moderators of outcomes, differences among SP simulations (i.e., face-to-face vs. telehealth modalities), and whether the experimental group’s suicide prevention skills improve over the three SP experiences.Trial registrationThe study was registered on Clinical Trials Registry (clinicaltrials.gov) on December 14, 2016. The Trial Registration Number is NCT02996344.

Epidemiology of haemodialysis patients and haemodialysis performance in Nauru.

There is limited literature on haemodialysis in island countries in the Central Pacific. The primary aim of this study was to report on the epidemiology of haemodialysis patients and haemodialysis performance in Nauru. We obtained registry data from the haemodialysis unit in Nauru to calculate the incidence rate, prevalence, and survival probability of haemodialysis patients in Nauru. We also reviewed medical records from January 2015 to February 2017 to evaluate the haemodialysis performance in Nauru. In total, 177 patients received long-term haemodialysis in the Nauru dialysis unit from 1987 to 2017. The 1-year, 2-year, and 5-year survival probabilities during the 30-year study period were 76.5%, 58.3% and 25.9%, respectively. From 2011 to 2014, the incidence rate and prevalence of treated end-stage renal disease in Nauru were significantly higher than Australia. From 2015 to 2017, there were 36 patients with a median age of 55 years who received long-term haemodialysis. Of these, 25 patients (69.4%) had diabetes. The median haemoglobin, serum albumin, and urea reduction ratio were 9.6 mg/dL, 35 g/L, and 64.7%, respectively. Multivariate analysis showed that lower serum albumin and lower urea reduction ratio were associated with mortality. To our knowledge, this is the first study to report the haemodialysis status in Nauru. The epidemiology of haemodialysis patients in Nauru is unique in the Central Pacific. Improvement of primary health care in disease detection and prevention of progression should be considered to decrease the need for dialysis and optimise the care of haemodialysis patients in Nauru.