Primary Health Settings Research Articles

Measuring the performance of the Mental Health Continuum-Short Form (MHC-SF) in a primary care youth mental health service

Mental health is regarded as more than the absence of mental health difficulties, with clinical and research focus moving towards measurement of well-being. The Mental Health Continuum-Short Form (MHC-SF) was developed to assess overall and emotional, social and psychological well-being. Little is known about the use of the MHC-SF with young people engaging with mental health services. The current pilot study sought to examine the performance of the MHC-SF in an Irish primary care youth mental health service for 12-25 year olds. A sample of 229 young people (female n=143; male n=85, unknown n=1) aged 12-24 years (M=15.87, SD=2.51) who completed the MHC-SF prior to commencing their first intervention session in Jigsaw participated in this study. The psychometric properties of the MHC-SF were investigated using confirmatory factor analysis (CFA) and Cronbach's alpha for internal consistency. CFA supported the three-factor structure of the MHC-SF for emotional, social, and psychological well-being, and very good internal consistency was observed. Findings provide evidence for the psychometric properties of the MHC-SF in a primary care youth mental health setting, and suggest that the MHC-SF's three-factor structure is valid for use in this context. Limitations and recommendations for future research are discussed.

The impact of MIH/HSPM on the carious lesion severity of schoolchildren from Talca, Chile.

Decamarcated hypomineralised lesions of enamel include those developmental defects that are related to MIH, HSPM or any other demarcated opacities of systemic origin. The present study's aims are to determine MIH/HSPM prevalence, caries lesion severity and their association in a sample of 6-12-year-old schoolchildren from Talca, Chile. The sample (N = 577) was derived from selected primary schools in urban Talca. A full dental examination was performed at the school by one calibrated examiner. Socio-demographic data and caries experience (DMFT/dmft/merged ICDAS II and PUFA/pufa) were measured in primary and permanent dentitions. MIH/HSPM was assessed using a modified EAPD protocol. Binary and multilevel binary regression analyses were calculated. The prevalence of MIH/HSPM or other demarcated hypomineralised lesions was 24.4%. MIH and HSPM was 15.8% and 5%, respectively. The presence of HSPM predicted MIH (OR 3.7; 95% CI 1.65-8.15) when corrected by demographic factors. Of the children examined, 35% had no teeth with a score greater than ICDASII Code 0 and 26% had one or more severe carious lesions (Code C). Toothwise multilevel binary regression analyses demonstrated that teeth with MIH/HSPM (OR 3.70) from low-SES children (OR 1.93) had higher odds for carious lesions compared with defect-free teeth from high-SES participants. MIH/HSPM lesions were associated with carious lesion occurrence and increased disease severity. The prevalence of MIH and HSPM was similar to other reports. Increased awareness of MIH/HSPM in schools and primary health settings may help to identify children at risk early.

Body dysmorphic disorder and its relationship to sexuality, impulsivity, and addiction

This study sought to examine the prevalence of probable body dysmorphic disorder (BDD) in a university sample and its associated physical and mental health correlates. A 156-item anonymous online survey was distributed via email to a randomly chosen subset of 10,000 university students, at a large public university. The survey queried current use of alcohol and drugs, psychological and physical status, academic performance, sexual behaviors, and questionnaire-based measures of impulsivity and compulsivity.A total of 3,459 participants (59.1% female) completed the survey and were included in the analysis. The overall prevalence of BDD was 1.7% (n = 59). Compared to students without BDD, those with BDD were significantly more likely to endorse symptoms of compulsive sexual behavior, depression, PTSD, and anxiety. Questionnaire-based measures revealed higher levels of both compulsivity and impulsivity associated with BDD.BDD appears to be common in young adults, and is associated with specific mental health comorbidities, as well as both impulsive and compulsive traits. Clinicians should be aware of the presentation of BDD and screen for it in primary care and mental health settings.

Preventing intergenerational trauma transmission: A critical interpretive synthesis.

To synthesise and critically interpret literature of relevance to intervening in intergenerational transmission of relational trauma within parent-infant relationships. Intergenerational trauma is a discrete process and form of psychological trauma transmitted within families and communities. Intergenerational trauma can be transmitted through attachment relationships where the parent has experienced relational trauma and have significant impacts upon individuals across the lifespan, including predisposition to further trauma. Critical interpretive synthesis (CIS) was used. CIS is an inductive qualitative process that generates new theory grounded within reviewed literature. The review commenced by systematically searching for literature on interventions for intergenerational trauma. As the core theoretical construct emerged, elements that may contribute to preventing intergenerational trauma were identified iteratively and influenced further searching. In the final synthesis, 77 articles were included from the fields of intergenerational trauma, trauma interventions and attachment interventions. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The key construct is that prevention of intergenerational trauma transmission is the key intervention. The two contributing constructs were identified as "resolving parental trauma" and "actively supporting parent-infant attachment." Prevention is the most effective intervention approach for intergenerational transmission of trauma. Prevention requires trauma-specific interventions with adults and attachment-focused interventions within families. Preventative strategies need to target individual, relationship, familial, community and societal levels, as addressing and preventing trauma requires a multipronged, multisystemic approach. Systematic trauma-informed attachment-focused interventions in health and social service settings are recommended. There are opportunities to provide multifocal individual and relational interventions within existing services that work with parents to help prevent the likelihood and impact of transmission of intergenerational relational trauma within families. Nurses are well placed to provide preventative interventions in mental health, early childhood and primary health settings.

Collaborative Primary Mental Health Education for Correctional Nurses.

Whitireia New Zealand and the Department of Corrections have worked collaboratively since 2008 in developing and delivering primary mental health (PMH) training for registered correctional nurses, specifically focused on assessment and brief interventions applicable to a primary health setting. The PMH training program was undertaken and evaluated by Department of Correction nurses between 2009 and 2016. Significant improvements in PMH learning outcomes were noted among 396 participants, while 98% applied knowledge gained from the PMH workshops to their practice. This highly successful educational collaboration has enhanced nurses' knowledge and skills in recognizing and managing PMH issues within the prison environment.

Clients' perceptions of the therapeutic relationship in the treatment of anorexia nervosa: qualitative findings from an online questionnaire.

The therapeutic relationship plays a unique and pivotal role in the treatment and recovery of individuals with mental illness. The aim of the questionnaire was to understand clients' perceptions of the factors affecting the formation of the therapeutic relationship during treatment or recovery from self-reported anorexia nervosa. Former or current individuals diagnosed with anorexia nervosa, 18 years and over, were invited to participate in an online questionnaire developed by the researchers. Eating disorder organisations in Australia and the United Kingdom advertised the study and provided the link to the online questionnaire. The questionnaire collected both quantitative and qualitative data, with quantitative data analysed using descriptive statistics and qualitative data using conventional content analysis. Findings revealed only 25% of participants (n=33) believed treatment providers listened and understood (to a great extent) their concerns during treatment and 30.08% (n=40) did not have sufficient trust or confidence in providers. The four qualitative themes identifying factors affecting therapeutic relationships are described. Healthcare providers working in acute and primary health settings should persevere with the development and maintenance of the therapeutic relationship in adults with anorexia nervosa. An investment in this relationship will be the catalyst driving motivation to change.

Viewpoint: Why you should provide HIV pre-exposure prophylaxis (PrEP) at your college health center

By providing HIV pre-exposure prophylaxis, or PrEP (a single daily oral pill), in a primary care college health setting, clinical providers can make a dramatic contribution to the current and long-term health and well-being of the students they see. This viewpoint article describes the approach taken to instituting primary care PrEP services at two college health programs. It delineates which students might benefit from PrEP and how to prescribe/monitor PrEP over time. Additionally, common barriers to PrEP are reviewed, including concerns about affordability, and the concerns that the use of PrEP will encourage risky sexual activity. Implementation strategies are discussed, including identifying a clinic champion, partnering with knowledgeable colleagues, and developing an educational campaign.

46.2 Providing Infant and Early Childhood Education and Consultation Through Project Echo™

Primary care physicians are in an important position to be able to contribute to positive change in the outcomes of at-risk infants and young children. This session will examine the expansion of an infant and early childhood mental health education and consultation program at a university setting using telecommunications. The goals of this project are to expand the reach of infant and early childhood consultation into a variety of primary care and community mental health settings, as well as to educate the primary care and mental health community on the behavioral and emotional health of infants and young children and their families.

Implementing single-item screening for drug use in a Veterans Health Administration outpatient setting

ABSTRACTBackground: Unhealthy drug use is a concern in many settings, including military and veteran populations. In 2013, the Veterans Health Administration (VHA) medical center in Bedford, Massachusetts, started requiring routine screening for unhealthy drug use in outpatient primary care and mental health settings, using a validated single question. Methods: This study used descriptive and multivariable analyses of VHA electronic records for patients eligible for the screening program (N = 16,118). The study assessed first-year rates and predictors of screening and of positive screens, both for drug use and for unhealthy alcohol use, for which screening was already required. Results: During the first year, 70% of patients were screened for unhealthy drug use and 84% were screened for unhealthy alcohol use. In multivariable analyses, screening for drug use was more likely for patients who had 8 or more days with VHA visits or were aged 40 or over. Patients with a prior drug use disorder diagnosis were much less likely to be screened. Three percent of patients screened for unhealthy drug use had a positive screen, and 14% of those screened for unhealthy alcohol use had a positive screen. Strong predictors of a positive drug use screen included a prior-year diagnosis of drug use disorder, any mental health clinic visits, younger age, or being unmarried. Conclusions: The drug screening initiative was relatively successful in its first-year implementation, having screened 70% of eligible subjects. However, it failed to screen many of those most likely to screen positive, thereby missing many opportunities to address unhealthy drug use. Future refinements should include better training clinicians in how to ask sensitive questions and how to address positive screens.

Privately practicing nurse practitioner services in Australia and patient access to care: Results from realist interviews.

To facilitate the expansion of nurse practitioners working in community and primary health settings, legislative changes were enacted in 2010. These led to privately practicing nurse practitioners (PPNPs) being enabled to provide care subsidized through the Australian Government Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. Little is known about the impact of this legislation on patient access to care in Australia. To explore how, why and in which contexts PPNP services in Australia impact on patient access to care. Semistructured interviews using realist evaluation were undertaken with 20 participants, selected through stratified sampling using geographic criteria (State/territory in which practicing) and dividing the sample representatively between those who worked solely in private practice and those who worked in both private and public practice. Thematic analysis of qualitative data was undertaken. Findings suggest that PPNPs have increased access to care for patients, predominantly in community and primary health settings. In increasing access to care, PPNPs have the potential to reduce hospital and general practitioner attendance, thereby potentially reducing the ever-increasing demand for health care.

Use of the WHO's Perceived Well-Being Index (WHO-5) as an efficient and potentially valid screen for depression in a low income country.

Introduction: Depression is associated with negative social, economic, and family outcomes and the majority of individuals with depression in low and middle income countries (LMICs) are untreated. A critical first step in bridging the treatment gap is accurate, feasible, and culturally appropriate screening to identify those who need treatment. The WHO's Perceived Well-Being Index (WHO-5) well-being instrument can potentially meet the screening needs of LMICs in primary care and community-based settings. This study tested the feasibility and validity of this tool to identify depression among adult parents of young children in Addis Ababa, Ethiopia. Successful identification and treatment of depression in parents extends benefits to children and families. Method: The WHO-5 was translated to Amharic and administered to 849 adults and compared with simultaneous administration of the well-established PHQ-9 instrument. Feasibility was assessed and analyses evaluated frequency of positive screens for depression, internal consistency, sensitivity and specificity of the WHO-5, and sociodemographic correlates of depression. Results: The prevalence of probable depression was similar as assessed by the PHQ-9 (17.3%) and the WHO-5 (18.5%). The internal consistency of the WHO-5 was strong (Cronbach's alpha = .83). WHO-5 agreement with the PHQ-9 was moderate; sensitivity and specificity were strong. Correlates of depression included unemployment and financial status. Discussion: The study provides promising evidence to support use of the WHO-5 to identify depression in Ethiopia. Feasibility was good, and it was culturally and linguistically acceptable. The results suggest that minimally trained community health and education workers in countries like Ethiopia could use the WHO-5 effectively in primary health and education settings. (PsycINFO Database Record

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study.

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe.Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective.Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings.Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation.Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

Managing information gaps on caregivers of psychotic patients in primary health settings of Yogyakarta, Indonesia.

Background: Information gaps hinder the management of psychotic patients. Incorporating mental health services into primary care might solve the problem. Health workers can be trained to provide psycho-education for caregivers of psychotic patients.Methods: This study was a two stage experimental study. In the first stage, 43 health workers were trained to provide a psycho-education for caregivers of psychotic patients. Next, 10 health workers were selected to provide the psycho-education. Participants were family caregivers of psychotic patients (n = 113) randomly assigned to control and intervention groups. Pre- and post-tests were conducted to assess the results. Statistical analyses were conducted using paired t tests and analysis of covariance (ANCOVA).Results: The intervention group scored higher for Knowledge of Psychosis at post-test. Both groups showed significant increase of knowledge (paired t tests: P<0.001; P<0.001; respectively) and the increases were not significantly different between the groups (ANCOVA: P=0.057).Conclusion: Psycho-education was applicable in primary care settings. Training primary care health workers is a feasible method to address information gaps in the management of mental health problems.

Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain.

As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.

Gambling and its clinical correlates in university students

Objective: This study sought to examine the prevalence of gambling disorder (GD) in a university sample and its associated physical and mental health correlates.Methods: A 156-item anonymous online survey was distributed via random email generation to a sample of 9449 university students. Current use of alcohol and drugs, psychological and physical status and academic performance were assessed, along with questionnaire-based measures of impulsivity and compulsivity. Positive screens for GD were based upon individuals meeting DSM-5 criteria.Results: A total of 3421 participants (59.7% female) were included in the analysis. The overall prevalence of GD was 0.4%, while an additional 8.4% reported subsyndromal symptoms of GD. GD was significantly associated with past-year use of cocaine, heroin/opiate pain medications, sedatives, alcohol and tobacco. Those with GD were more likely to have generalized anxiety, PTSD and compulsive sexual behavior. Questionnaire-based measures revealed higher levels of both compulsivity and impulsivity associated with disordered gambling.Conclusions: Some level of gambling symptomatology is common in young adults and is associated with alcohol and drug use, as well as impulsive and compulsive behaviors. Clinicians should be aware of the presentation of problematic gambling and screen for it in primary care and mental health settings.

Managers’ Perceptions of the Availability of Medicines in the Free State District Health Services

The purpose of this study was to explore and to describe perceptions of pharmaceutical service managers and district managers regarding factors influencing the availability of medicines within the district health services of the Free State province. A qualitative, descriptive, exploratory and contextual research design was followed. Data collection was conducted through two focus group discussions consisting of pharmaceutical managers and district health services managers, respectively. The collected data were organised and analysed by means of an inductive model where the data that were relevant to the topic had to be grouped into appropriate and meaningful categories. This was enhanced by the use of XSight, a software package developed for the analysis of qualitative data. The research results demonstrate that there is inadequate availability of medicine in district health services due to various factors, including a shortage of pharmacists and pharmacist assistants in the primary health setting, lack of delegation, red tape in the procurement of medicines, and lack of an electronic medicine procurement and monitoring system. The study made recommendations on how to improve medicine availability within the district health services.

Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: a systematic review.

During the last decade, teamwork has been addressed under the rationale of interprofessional practice or collaboration, highlighted by the attributes of this practice such as: interdependence of professional actions, focus on user needs, negotiation between professionals, shared decision making, mutual respect and trust among professionals, and acknowledgment of the role and work of the different professional groups. Teamwork and interprofessional collaboration have been pointed out as astrategy for effective organization of health care services as the complexity of healthcare requires integration of knowledge and practices from differente professional groups. This integration has a qualitative dimension that can be identified through the experiences of health professionals and to the meaning they give to teamwork. The objective of this systematic review was to synthesize the best available evidence on the experiences of health professionals regarding teamwork and interprofessional collaboration in primary health care settings. The populations included were all officially regulated health professionals that work in primary health settings: dentistry, medicine, midwifery, nursing, nutrition, occupational therapy, pharmacy, physical education, physiotherapy, psychology, social work and speech therapy. In addition to these professionals, community health workers, nursing assistants, licensed practical nurses and other allied health workers were also included. The phenomena of interest were experiences of health professionals regarding teamwork and interprofessional collaboration in primary health care settings. The context was primary health care settings that included health care centers, health maintenance organizations, integrative medicine practices, integrative health care, family practices, primary care organizations and family medical clinics. National health surgery as a setting was excluded. The qualitative component of the review considered studies that focused on qualitative data including designs such as phenomenology, grounded theory, ethnography, action research and feminist research. A three-step search strategy was utilized. Ten databases were searched for papers published from 1980 to June 2015. Studies published in English, Portuguese and Spanish were considered. Methodological quality was assessed using the Qualitative Assessment and Review Instrument developed by the Joanna Briggs Institute. All included studies received a score of at least 70% the questions in the instrument, 11 studies did not address the influence of the researcher on the research or vice-versa, and six studies did not present a statement locating the researcher culturally or theoretically. Qualitative findings were extracted using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Qualitative research findings were pooled using a pragmatic meta-aggregative approach and the Joanna Briggs Institute Qualitative Assessment and Review Instrument software. This review included 21 research studies, representing various countries and healthcare settings. There were 223 findings, which were aggregated into 15 categories, and three synthesized findings: CONCLUSIONS: This review shows that health professionals experience teamwork and interprofessional collaboration as a process in primary health care settings; its conditions, consequences (benefits and barriers), and finally shows its determinants. Health providers face enormous ideological, organizational, structural and relational challenges while promoting teamwork and interprofessional collaboration in primary health care settings. This review has identified possible actions that could improve implementation of teamwork and interprofessional collaboration in primary health care.

Understanding the implementation of ‘sick day guidance’ to prevent acute kidney injury across a primary care setting in England: a qualitative evaluation

ObjectivesThe study sought to examine the implementation of sick day guidance cards designed to prevent acute kidney injury (AKI), in primary care settings.DesignQualitative semistructured interviews were conducted and comparative analysis...

Integrating HIV Preexposure Prophylaxis (PrEP) Into Routine Preventive Health Care to Avoid Exacerbating Disparities.

More than 3 decades since its emergence in the United States, HIV continues to spread and disproportionately affect socially marginalized groups. Preexposure prophylaxis (PrEP), a highly effective prevention strategy federally approved since 2012, could fundamentally alter the course of the epidemic. However, PrEP's potential has not been fully realized, in part because health care providers have been slow to adopt PrEP in clinical practice and have been selective in their discussion of PrEP with patients. This nonstandardized approach has constrained PrEP access. PrEP access has not only been inadequate but also inequitable, with several groups in high need showing lower rates of uptake than do their socially privileged counterparts. Recognizing these early warning signs that current approaches to PrEP implementation could exacerbate existing HIV disparities, we call on health professionals to integrate PrEP into routine preventive health care for adult patients-particularly in primary care, reproductive health, and behavioral health settings. Drawing on the empirical literature, we present 4 arguments for why doing so would improve access and access equity, and we conclude that the benefits clearly outweigh the challenges.

Estudio de la hiperfrecuentación en un distrito de atención primaria

ObjectiveTo describe the distribution of frequent attenders (FA) through the different primary care practices in Cordoba-Guadalquivir Health District (Córdoba, Spain). MethodsAn ecological study was performed, including data from 2011 to 2015. Defining FA as those subjects who made12 or more appointments per year; independently analysed for nursing, general practice and paediatrics. Prevalence of frequent attendance and FA/professional ratio were used as dependent variables. Demographic characteristics from district population, number of health professionals and use of general facilities were also examinated. Aiming to understand FA distribution, primary health settings were classified according to facility size and environmental location (urban, suburban and rural). ResultsThe mean prevalence for FA was 10.86% (0.5 SE) for nursing; general practice 21.70% (0.7 SE) and for paediatrics 16.96% (0.7 SE). FA/professional ratios for the different professional categories were: 101.07 (5.0 SE) for nursing, 239.74 (9.0 SE) for general practice and 159.54 (9.8 SE) for paediatrics. ConclusionsA major part of primary health care users make a high number of consultations. From this group, women overuse nursing and general practitioner services more compared to men. A higher prevalence of FAs was observed in smaller settings, in rural areas. Although taking the FAs:professional ratio as the bar, medium-size practices are more highly overused.