Implementation Of Primary Health Care Research Articles

Experiences, benefits and challenges of the use of geoprocessing for the development of primary health careExperiências, benefícios e desafios do uso de geoprocessamento para o desenvolvimento da atenção primária à saúde

RESUMENObjetivoRevisar las consecuencias empíricas del uso de geoprocesamiento en la gestión de los servicios de atención primaria de salud (APS), con el propósito de difundir los beneficios del uso de esta tecnología, así como precisar los desafíos que deben ser superados para su contribución en el desarrollo de la APS.MétodosSe realizó una revisión sistemática de estudios primarios publicados en español, inglés o portugués, entre los años 2000 y 2017. En primer lugar, se efectúa una revisión general de la producción académica por continente y tipo de objetivo. En una segunda etapa, se seleccionan los estudios que experimentaron y evaluaron el uso de geoprocesamiento en forma empírica, donde se revisan beneficios concretos y genéricos, así como las limitaciones.ResultadosSe identificaron 134 artículos en la primera etapa de selección, la mitad de ellos provenientes del continente americano. Tan solo nueve estudios cumplieron con los requisitos de la segunda etapa; sin embargo, demostraron que el uso de geoprocesamiento genera beneficios que van más allá de los beneficios técnicos, con limitaciones factibles de ser superadas.ConclusionesAun cuando los beneficios del uso de geoprocesamiento han sido ampliamente discutidos, son escasos los estudios que han evaluado su implementación en APS en forma empírica. Experiencias prácticas, que podrían ser fácilmente reproducidas en otras comunidades, demuestran que su uso continuo podría aumentar la capacidad de respuesta a las metas de APS, así como a las propias metas del desarrollo sostenible.

Expansion of family medicine in Latin America: challenges and lines of actionExpansão da medicina familiar na América Latina: desafios e linhas de ação

RESUMENEste documento tiene por objetivos resumir los desafíos actuales de la medicina familiar en América Latina y proponer posibles líneas de acción para consolidar su desarrollo. En los últimos 40 años, los sistemas de salud de la Región de las Américas han encarado reformas cuyos resultados fueron negativos en términos de equidad, y la atención primaria de la salud, lejos de ser aquella estrategia destinada a reducirla, se restringió a una política focal y selectiva. En este contexto, las propuestas técnicas de expansión de las plazas de formación en medicina familiar y su inserción en las carreras de Medicina, han carecido de coherencia y de una dirección política clara, por lo que su falta de eficacia puede leerse como un síntoma de estas reformas incompletas. Al respecto, la Confederación Iberoamericana de Medicina Familiar realizó recomendaciones sobre el compromiso político de los gobiernos para asegurar la estructura y el financiamiento necesarios, consolidar el modelo de medicina familiar como mecanismo de instrumentación de la atención primaria de la salud, la jerarquización de los programas de formación, las condiciones laborales de los médicos de familia y la certificación profesional, entre otras. Estas recomendaciones técnicas, sin acción política coherente y oportuna, no serán más exitosas que los intentos previos.

Primary health care in the Region of the Americas 40 years after the Alma-Ata DeclarationAtenção primária à saúde na Região das Américas 40 anos após a Declaração de Alma-Ata

RESUMENEn este artículo se reseña la evolución de las propuestas y acuerdos regionales desde la Declaración de Alma-Ata (1978) hasta la Estrategia de Salud Universal y se destaca la vigencia de los planteamientos esenciales de la estrategia de atención primaria, que hoy se expresan en las propuestas de fortalecimiento del primer nivel de atención y la generación de redes integradas de servicios de salud. Se recuerda, también, el carácter contextual de la implementación de la estrategia en el marco de situaciones nacionales complejas a través de algunos hitos de los últimos 40 años. Se describen los factores que frenan la implementación de la atención primaria de salud (APS), así como los avances y desafíos emergentes que hoy en día enfrentan los sistemas de salud en varios países. Se reafirma que solo mediante un fuerte primer nivel articulador y resolutivo, cercano, inserto en la comunidad y accesible, es posible avanzar hacia el ejercicio del derecho a la salud para todos y se aboga por la generación de propuestas prácticas para relanzar la estrategia de APS a 40 años de la Declaración de Alma-Ata.

Remembering Alma-Ata: challenges and innovations in primary health care in a middle-income city in Latin America.

ABSTRACTThe year 2018 is an opportune time to explore health system reforms and primary health care (PHC) in Brazil, given the anniversaries of the Alma-Ata Declaration (40 years) and of the Constitution of Brazil (30 years), the basis of the Unified Health System (SUS). In this context, health system analysis in the municipal setting is an important instrument for acknowledging achievements and innovations, as well as weaknesses and threats. Due to the principle of decentralization of SUS, municipalities have assumed a leadership role in health policy development and implementation. The cities also come first in expressing the failures of the health system and the consequences of austerity measures. Thus, analysis of health system transformations at the municipal level are fundamental to studying PHC achievements and gaps.This report identifies the challenges and innovations of PHC implementation in Curitiba, beginning with a brief history of the city's health system development. The city was a pioneer in linking urban planning with health system design, improving access to health care, and obtaining better health outcomes over the past 30 years. This report covers those years, as well as the challenges and strategies implemented during the most recent political cycle (2013 – 2016). There are substantial lessons that can be garnered from the experience of this middle-income city in Latin America, lessons that may be useful as the region moves toward the Sustainable Development Goal of Universal Health Coverage by 2030.

Assessing the role of appropriate primary health care on the use of dental services by Brazilian low-income preschool children.

This cross-sectional study aimed to assess the association between the quality of primary health care (PHC) and the use of dental services by preschoolers served by the Family Health Strategy (FHS), controlling for socio-demographic determinants and perceived need. The sample encompassed 438 children aged 3-5 years, enrolled in 19 FHS facilities in Ponta Grossa, Paraná State, Brazil. Individual level variables were collected by interviewing parents or caregivers at home. They answered a questionnaire on socioeconomic conditions, oral hygiene habits and use of dental services. Parental perception of child's oral health related quality of life, as perceived need, was assessed by the Brazilian version of Early Childhood Oral Health Impact Scale (ECOHIS). Normative need was assessed by oral examinations, according to guidelines standardized by the World Health Organization. The contextual level factor was defined as the extent of implementation of PHC in the facilities. Managers responded to PCATool-Brazil, a validated questionnaire which measures the extent of PHC. Dentists answered to a version of PCATool, which was adapted and pretested for dental services. Multilevel analysis, based on Andersen's behavioral model, fitted the adjustment of "having ever consulted a dentist" to contextual and individual covariates. We observed high prevalence of dental caries. Almost half of the sample had had dental appointments in life. Social gradients were observed for the use of dental services. Although it was not able to eliminate the impact of adverse social conditions, higher levels of PHC attributes in dental services favored the effective use of such services by low-income children.

Challenges of Primary Health Care Implementation from a Human Rights Approach

Este articulo tiene por objetivo reconocer los lineamientos y desafios que plantea la implementacion de la (Atencion Primaria de la Salud) APS desde el enfoque de Derechos Humanos. A estos efectos se parte de una revision y analisis del surgimiento del concepto de Atencion Primaria de la Salud (APS), sus concepciones, modo de implementacion e interrelaciones con el sistema de salud, el derecho a la salud y el contexto socio-politico, economico y cultural. A partir de este analisis se concluye que: a) la implementacion de la APS desde el enfoque de Derechos Humanos implica no solo reconocer a la APS como una estrategia sanitaria, un principio que guia y orienta las acciones en salud y organiza los niveles de atencion sino tambien como una herramienta eminentemente politica y social de constitucion de ciudadania y por lo tanto

The interface between primary and secondary care in dentistry in the Unified Health System (SUS): an integrative systematic review

Secondary care in dentistry in Brazil has scarce and broadly underutilized resources. The challenge is to organize the interface between primary health care (PHC) and secondary care in order to consolidate the population's access to specialist dental care in the Unified Health System (SUS). This article seeks to analyze national publications in Portuguese and English on the interface between secondary health care and primary health care in dentistry from the perspective of comprehensive care in the SUS. It is an integrative review, considering the publications of the following databases: SciELO (Scientific Electronic Library Online), LILACS (Latin American and Caribbean Literature) WEB OF SCIENCE, SCOPUS, PubMed (International Literature on Health Sciences) and GOOGLE SCHOLAR. The search located 966 articles, of which 12 were used in full. Coverage of the oral health teams (ESB) in the family health strategy (ESF), primary health care implementation in a structured way, access to secondary health care, counter-referral to PHC, development of indicators and socioeconomic conditions and inequalities in the distribution of dental specialist centers (CEO) are factors that influence the integrity of oral health care in the SUS.

Diagnostic performance and clinical feasibility of a point-of-care test for respiratory viral infections in primary health care.

BackgroundInappropriately high levels of antibiotics are still prescribed in primary health care for respiratory tract infections (RTIs). Access to diagnostic point-of-care tests (POCTs) for RTIs might reduce this over-prescription.ObjectiveThe purpose of our study was to determine the diagnostic performance and clinical feasibility of a recently developed diagnostic POCT for respiratory viruses, the mariPOC®, in a Dutch primary healthcare setting.MethodsIn patients with RTI symptoms presenting to a family practice during the 2015–2016 winter season, we determined the test’s sensitivity and specificity relative to polymerase chain reaction (PCR) testing performed in a laboratory. The clinical feasibility of the POCT was evaluated by interviewing general practitioners (GPs).ResultsOne or more respiratory viruses were detected in 54.9% of the patients (n = 204). For influenza A virus (n = 24), sensitivity of the POCT was 54.2% and specificity was 98.9%; for influenza B virus (n = 18), sensitivity was 72.2% and specificity 99.5%; and for respiratory syncytial virus (RSV) (n = 12), sensitivity was 50.0% and specificity 100%. In samples with higher viral load, sensitivity was 85.7% for influenza A, 78.6% for influenza B and 85.7% for RSV. The availability of a diagnostic test for respiratory viruses was appreciated by both patients and GPs.ConclusionsOur study shows that diagnostic POCTs for respiratory viruses might contribute to a precise and evidence-based diagnosis of RTIs and could positively influence prescription of antibiotics by GPs. However, before implementation in primary healthcare, diagnostic accuracy of the POCT needs improvement and it is impact on clinical decision making should be further assessed.

Financial Burden of Out-of-Pocket Expenditures for Primary Health Care in Hilly Areas of Garhwal Region, Uttarakhand, North India.

High total health expenditures via Out-of-Pocket (OOP) as formal user fees and informal payments put India in challenging situation to achieve towards universal health coverage. To assess the (OOP) expenditure and its determinants among outpatient in primary care settings of Uttarakhand, North India. A hospital based cross-sectional study was conducted in a Outpatient Department of Urban Health Training Centre, Srinagar, Uttarakhand, India and Rural Health Training Centre, Kritinagar, Uttarakhand in 2015. A total of 200 patients were enrolled in the study using random sampling. Questionnaire covering costs like: travel cost, drug cost, investigation cost, and others was used for measuring OOP expenditure incurred toward health care by patients. Of the total 200 patients, 43.5% were males and 56.5% were females with mean age 40.36 (SD 19.45) in years. Average annual family income was 11718.5 INR±13457.3 INR. Of the total study subjects, 42.5% were unskilled or had no occupation (unemployed, student, and homemaker). The majority (68.5%) had travelled less than or equal to 10 km to reach the health facility. About 50% of the study subjects presented with communicable diseases and 20% with non-communicable diseases. The health expenditure of the outpatient revealed that major part of the expenditure is the direct cost of the treatment, including registration fee, drugs, and investigation. Mean OOP expenditure for drugs and investigations was 509 INR and 673.1 INR, respectively. Mean total out-of-patient expenditure was 303.1 INR. The proportion of monthly family income spent on out-of-patient expenditure was 2.58%. The implementation of primary health care needs to be further strengthened in order to improve access of public sector hospitals for curative care.

Claustrofobia territorial y sus consecuencias en el campo de la Salud

The development and implementation of Primary Health Care (PHC) in Chile, is manifested discursively oriented to the space of health promotion and prevention of the disease, a contradictory issue with what is observed in practice, consolidating a space enclosed in the which health teams are delimeted and prone to treat the disease. This essay proposes a critical analysis regarding the articulation between the understanding of health as an expression of the unicausal and biological disease, in addition to Public Policies implemented from a central space, manifesting discursively the intersectoral action in health as a preponderant factor regarding the task in the field of health. Considering these aspects, it is concluded that the understanding of the processes of health, illness, attention and neglect are not part of the permanent task in the field of health, there is tension and conditioning associated with the implementation of central and homogeneous public policies, inaddition to an IAH not observable in a substantive way in the usual deployment of health teams in dialogue with other sectors, which consolidates a scenario of territorial claustrophobia that determines a deepening of socio-sanitary territorial inequities.

VP159 Strengthening Primary Health Care In Nigeria By Patient Involvement

INTRODUCTION:The Health system in Nigeria is structured into three tiers which include tertiary health care, secondary health care and primary health care (PHC). The latter forms the grassroots system of delivering basic health services to communities in both rural and urban centers. However PHC in Nigeria have been affected by poor service delivery. This has resulted in underuse of PHC due to the acceptance and utilization of health services delivered through this system. This research seek to bridge the gap of inequality, reaffirm that implementing PHC is a human right/duty and fosters patient and consumer involvement for economic, social and environmental sustainability of PHC.METHODS:A qualitative method of research was adopted using a participatory research model. The relative data was sourced secondarily from recent findings (July 2015) carried out in seventy-three primary health centers across Anambra State, Benue State, Kaduna State, Plateau State and Federal Capital Territory (FCT) of Nigeria. Issues that were examined included: client perspective and community involvement, status of available services, utilization and service delivery, and infrastructure and human resource capacities. The respondent of 294 client/service user population from interview were recorded and analyzed.RESULTS:The assessment showed client dissatisfaction to services being provided. In most centers, National Primary Health Care Development Agency (NPHCDA) requirements like availability of basic functional equipment, well trained health workers, patient record system, and access to water and sanitation were not met. Most of the facilities visited reported to be disconnected from the health system due to supportive supervision.CONCLUSIONS:Conclusively, the interest of the underserved Nigerian could be advocated for through local committees of consumer organizations. Their involvement will have an impact in PHC evaluation, policy making, and implementation of action plans aimed at improving PHC services.

An evaluation of the competencies of primary health care clinic nursing managers in two South African provinces

BackgroundManagerial competencies to enhance individual and organisational performance have gained currency in global efforts to strengthen health systems. Competent managers are essential in the implementation of primary health care (PHC) reforms that aim to achieve universal health coverage.ObjectiveTo evaluate the competencies of PHC clinic nursing managers in two South African provinces.DesignA cross-sectional study was conducted in two South African provinces. Using stratified random sampling, 111 PHC clinic nursing managers were selected. All supervisors (n=104) and subordinate nurses (n=383) were invited to participate in the survey on the day of data collection. Following informed consent, the nursing managers, their supervisors, and subordinate nurses completed a 40-item, 360-degree competency assessment questionnaire, with six domains: communication, leadership and management, staff management, financial management, planning and priority setting, and problem-solving. Standard deviations, medians, and inter-quartile ranges (IQRs) were computed separately for PHC nursing managers, supervisors, and subordinate nurses for competencies in the six domains. The Tinsley and Weiss index was used to assess agreement between each of the three possible pairs of raters.ResultsA 95.4% response rate was obtained, with 105 nursing managers in Gauteng and Free State completing the questionnaires. There was a lack of agreement about nursing managers’ competencies among the three groups of raters. Overall, clinic nursing managers rated themselves high on the five domains of communication (8.6), leadership and management (8.67), staff management (8.75), planning and priority setting (8.6), and problem-solving (8.83). The exception was financial management with a median score of 7.94 (IQR 6.33–9.11). Compared to the PHC clinic managers, the supervisors and subordinate nurses gave PHC nursing managers lower ratings on all six competency domains, with the lowest rating for financial management (supervisor median rating 6.56; subordinate median rating 7.31).ConclusionThe financial management competencies of PHC clinic nursing managers need to be prioritised in continuing professional development programmes.

Learning from doing: the case for combining normalisation process theory and participatory learning and action research methodology for primary healthcare implementation research.

BackgroundThe implementation of research findings is not a straightforward matter. There are substantive and recognised gaps in the process of translating research findings into practice and policy. In order to overcome some of these translational difficulties, a number of strategies have been proposed for researchers. These include greater use of theoretical approaches in research focused on implementation, and use of a wider range of research methods appropriate to policy questions and the wider social context in which they are placed. However, questions remain about how to combine theory and method in implementation research. In this paper, we respond to these proposals.DiscussionFocussing on a contemporary social theory, Normalisation Process Theory, and a participatory research methodology, Participatory Learning and Action, we discuss the potential of their combined use for implementation research. We note ways in which Normalisation Process Theory and Participatory Learning and Action are congruent and may therefore be used as heuristic devices to explore, better understand and support implementation. We also provide examples of their use in our own research programme about community involvement in primary healthcare.ConclusionsNormalisation Process Theory alone has, to date, offered useful explanations for the success or otherwise of implementation projects post-implementation. We argue that Normalisation Process Theory can also be used to prospectively support implementation journeys. Furthermore, Normalisation Process Theory and Participatory Learning and Action can be used together so that interventions to support implementation work are devised and enacted with the expertise of key stakeholders. We propose that the specific combination of this theory and methodology possesses the potential, because of their combined heuristic force, to offer a more effective means of supporting implementation projects than either one might do on its own, and of providing deeper understandings of implementation contexts, rather than merely describing change.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1587-z) contains supplementary material, which is available to authorized users.

Community health workers, recipients’ experiences and constraints to care in South Africa – a pathway to trust

ABSTRACTCommunity health workers (CHWs) affiliated with community-based organisations are central to the implementation of primary health care in district health services in South Africa. Here, we explore factors that affect the provision of and access to care in two provinces – Gauteng and Eastern Cape. Drawing on narratives of care recipients and the CHWs who support them, we illustrate the complex issues surrounding health maintenance and primary care outreach in poor communities, and describe how the intimate interactions between providers and recipients work to build trust. In the study we report here, householders in Gauteng Province had poor access to health care and other services, complicating the impoverished circumstances of their everyday lives. The limited resources available to CHWs hindered their ability to meet householders’ needs and for householders to benefit from existing services. CHWs in the Eastern Cape were better able to address the needs of poor householders because of the organisational support available to them. Based on an ethos of integrated and holistic care, this enabled the CHWs to address the recipients’ context-related needs, and health and medical needs, while building greater levels of trust with their clients.

Promotion of a primary healthcare philosophy in a community-based nursing education programme from the students’ perspective

Background. Community-based education (CBE) serves as a primordial instrument in the implementation of primary healthcare (PHC). Learning experiences in community-based settings provide students with learning opportunities, as they are actively engaged in PHC-associated activities in under-resourced communities. Many nursing schools in higher education integrated and implemented a CBE programme with an end-goal of becoming healthcare practitioners who are responsive to the needs of the community. Objectives. To establish how PHC philosophy is promoted through a community-based nursing education programme. Methods. The study was non-experimental and cross-sectional with a quantitative approach and was done at a selected higher education institution in KwaZulu-Natal, South Africa. A total of 118 participants were selected using the non-probability convenience sampling technique. A self-report questionnaire was distributed to the participants; 91 questionnaires were completed and returned – a response rate of 73.3%. Ethical clearance was obtained from the University of KwaZulu-Natal Ethics Review Committee. Participation was voluntary, informed consent was obtained, and other ethical principles were respected. Data were analysed with the Statistical Package for Social Sciences (SPSS). Descriptive and analytical analysis was used to analyse the data. Results. The participants reported exposure to community-based learning from the first until the fourth year of their study programme. Participants (69.9%) indicated that their learning activities had involved members of the community. The community-based learning projects, which mostly promoted a PHC philosophy, included prevention of illness, injuries and social problems (90.1%), health promotion (89%) and engaging communities in community-based learning activities to promote their self-reliance and self-determination (76.9%). Conclusion . Findings revealed that the community-based learning experiences of students promoted a PHC philosophy and that underprivileged community settings provided a rich learning environment.

Abstract: Promotion of Primary Health Care Philosophy in a Community-Based Nursing Education Program: Students’ Perspective

Abstract Background Community-based education (CBE) serves as a primordial instrument in the implementation of Primary Health Care (PHC). Learning experiences in community-based settings provide the students with opportunities to learn by means of being actively engaged in primary health care associated activities to under-resourced communities (Mtshali, 2009, 2005; World Health Organization ,2011a; World Health Organization, 2011b). International Council of Nurses (ICN) (2009) and World Health Organization (1993) recommends this educational approach as means of implementing PHC and responsive education. In response, many of the nursing schools in higher education integrated and implemented a community-based education programme with an end goal of becoming healthcare practitioners who are responsive to the needs of the community and promoting PHC. Aim This study explored how Primary Health Care philosophy is promoted through a community-based nursing education program. Methodology A non-experimental, cross-sectional study with a quantitative approach was carried out at a selected higher education institution in KwaZulu-Natal. A total of 118 participants were selected using the non-probability convenience sampling technique. A self-report questionnaire was distributed to the participants and 91 questionnaires were completed and returned with a response rate of 73.3%. Ethical clearance was obtained from the University of KwaZulu-Natal Ethics Review Committee. The participation was voluntary and informed consent was obtained and other ethical principles were respected. Data were analyzed descriptively and analytically with the Statistical Package for Social Sciences (SPSS). Results The participants reported exposure to community-based service learning (CBSL) throughout their study program. Findings revealed that 69.9% of participants indicated that their learning activities had involved members of the community. The community-based learning projects which mostly promoted a primary health care philosophy ranged from prevention of illness, injuries and social problems (90.1%); health promotion (89%) and engaging communities in community-based learning activities to promote their self-reliance and self-determination (76.9%). The findings indicated that 98.9% had positive perceptions about CBE and overall 79.5% of participants strongly perceived CBE as a tool to promote PHC philosophy. Conclusion The findings of the study revealed that the community-based learning experiences of students promoted primary health care philosophy and that underprivileged community settings provided a rich learning environment. Community -Based Service Learning should be included in nursing education programs as a responsive educational approach in order to prepare graduates who are competent and willing to work in, and serve underserved communities. Key words : nursing education, community-based education, community-based learning, primary health care, community-service learning

Factors militating against effective implementation of primary health care (PHC) system in Nigeria

Objectives: This study aimed to evaluate the factors that militate against effective implementation of a primary health care (PHC) system in Nigeria. Materials and Methods: The study was conducted at four selected PHC centers in Enugu State from November 2014 to January 2015. The primary health center was chosen by systemic sampling from about eight primary health centers in Enugu metropolis. The sixteen-item questionnaire was elaborated with the Likert scale. Data retrieved were collected with the aid of a structured study pro forma and analyzed using SPSS Version 18. Results: A total of 169 health workers were recruited from four primary health centers. The mean age of all participants was 38.42 years standard deviation (SD) = 9.8, while the male: Female ratio was 2:1. Among the subjects, 59% were aged 30-39 years. Existing equipment and manpower on one hand and job security and salary on the other hand are negative factors in the implementation of PHC; the respondents believed that adequate supply of gloves, needles, bandages, good access to drugs and medications, a good cold chain system, and full implementation of immunization programs all exist in PHC centers. Adequate community participation, culture and religion, access to safe and clean water, and steady electricity, on the other hand, are nonexistent in the PHC centers in the study. Conclusions: The PHC centers studied showed that much remains to be desired, especially in terms of manpower, communication, and the remuneration of health workers.

A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce?

BackgroundThis debate discusses the potential merits of a New Graduate Nurse Transition to Primary Health Care Program as an untested but potential nursing workforce development and sustainability strategy. Increasingly in Australia, health policy is focusing on the role of general practice and multidisciplinary teams in meeting the service needs of ageing populations in the community. Primary health care nurses who work in general practice are integral members of the multidisciplinary team – but this workforce is ageing and predicted to face increasing shortages in the future. At the same time, Australia is currently experiencing a surplus of and a corresponding lack of employment opportunities for new graduate nurses. This situation is likely to compound workforce shortages in the future. A national nursing workforce plan that addresses supply and demand issues of primary health care nurses is required. Innovative solutions are required to support and retain the current primary health care nursing workforce, whilst building a skilled and sustainable workforce for the future.DiscussionThis debate article discusses the primary health care nursing workforce dilemma currently facing policy makers in Australia and presents an argument for the potential value of a New Graduate Transition to Primary Health Care Program as a workforce development and sustainability strategy. An exploration of factors that may contribute or hinder transition program for new graduates in primary health care implementation is considered.SummaryA graduate transition program to primary health care may play an important role in addressing primary health care workforce shortages in the future. There are, however, a number of factors that need to be simultaneously addressed if a skilled and sustainable workforce for the future is to be realised. The development of a transition program to primary health care should be based on a number of core principles and be subjected to both a summative and cost-effectiveness evaluation involving all key stakeholders.

Meta-regression analyses to explain statistical heterogeneity in a systematic review of strategies for guideline implementation in primary health care.

This study is an in-depth-analysis to explain statistical heterogeneity in a systematic review of implementation strategies to improve guideline adherence of primary care physicians in the treatment of patients with cardiovascular diseases. The systematic review included randomized controlled trials from a systematic search in MEDLINE, EMBASE, CENTRAL, conference proceedings and registers of ongoing studies. Implementation strategies were shown to be effective with substantial heterogeneity of treatment effects across all investigated strategies. Primary aim of this study was to explain different effects of eligible trials and to identify methodological and clinical effect modifiers. Random effects meta-regression models were used to simultaneously assess the influence of multimodal implementation strategies and effect modifiers on physician adherence. Effect modifiers included the staff responsible for implementation, level of prevention and definition pf the primary outcome, unit of randomization, duration of follow-up and risk of bias. Six clinical and methodological factors were investigated as potential effect modifiers of the efficacy of different implementation strategies on guideline adherence in primary care practices on the basis of information from 75 eligible trials. Five effect modifiers were able to explain a substantial amount of statistical heterogeneity. Physician adherence was improved by 62% (95% confidence interval (95% CI) 29 to 104%) or 29% (95% CI 5 to 60%) in trials where other non-medical professionals or nurses were included in the implementation process. Improvement of physician adherence was more successful in primary and secondary prevention of cardiovascular diseases by around 30% (30%; 95% CI -2 to 71% and 31%; 95% CI 9 to 57%, respectively) compared to tertiary prevention. This study aimed to identify effect modifiers of implementation strategies on physician adherence. Especially the cooperation of different health professionals in primary care practices might increase efficacy and guideline implementation seems to be more difficult in tertiary prevention of cardiovascular diseases.

Faith and Health: Past and Present of Relations between Faith Communities and the World Health Organization

Relationships between faith communities and international multi-lateral or-ganizations can be complicated. While there is potential for synergy between the two, different values often characterize the approach of each. The history of these relationships is illustrative. This review describes collaboration between the World Health Organization (WHO) and faith-based organizations (FBOs) in the implementa-tion of primary health care, the role of spirituality in health, community responses to the HIV pandemic, and definitions of Quality of Life containing spiritual dimen-sions. However, important gaps persist in the appreciation and measurement of the contribution of faith communities to health assets on the part of governments and the WHO. FBOs can still draw from the nine points developed in the 1960s as a time-tested viable agenda for current and future operations.