Primary Health Care Population Research Articles

Deployment of Tablet‐based Cognitive Assessment Tool (TabCAT) for detecting cognitive impairment in elderly Primary Health Care Population in Southeast Nigeria

Deployment of Tablet‐based Cognitive Assessment Tool (TabCAT) for detecting cognitive impairment in elderly Primary Health Care Population in Southeast Nigeria

Deployment of Tablet‐based Cognitive Assessment Tool (TabCAT) for detecting cognitive impairment in elderly Primary Health Care Population in Southeast Nigeria

AbstractBackgroundCognitive assessment should be actively incorporated into the clinical evaluation of patients in Primary Health Care (PHC) settings. This is because of the imminent demand with the changing demographics especially in low‐ and middle‐income countries (LMICs) concerning dementia and Alzheimer’s disease.MethodA cross‐sectional mixed‐method descriptive study was conducted to evaluate the useability and performance of a tablet‐based cognitive assessment tool (TabCAT) for use in geriatric primary healthcare settings in southeast Nigeria.ResultIn our study involving 207 participants, with an average age of 64.69 years, educational levels varied, with 51.8% having primary education, 41.2% secondary, and 6.6% tertiary. The research found that education had a significant positive impact on associative memory, processing speed, executive function, language skills, and visuospatial skills (p<0.001). Rural residents exhibited higher scores in associative memory, processing speed, executive function, language, and visuospatial skills (p<0.000). However, gender and location did not show significant contributions to cognitive performance across the examined domains.ConclusionThere is an urgent need to deploy and routinely conduct cognitive assessments in primary healthcare clinics for elderly patients for early detection of cognitive changes to improve healthy living.

THE CARE SCENARIO IN PRIMARY HEALTH CARE FOR THE BLACK POPULATION

This research aims to analyze inequalities in access to health care for the black population in Primary Health Care (PHC) in Brazil, highlighting the impact of structural and institutional racism on care practices. The overall objective is to analyze the current scenario of care and health promotion in primary care for the black population. The research methodology was a qualitative and descriptive literature review. The research shows that PHC, although it is the gateway to the Unified Health System (SUS), often fails to equitably meet the needs of the black population, resulting in worse health and quality of life indicators. The conclusion points out that it is urgent to implement inclusive public policies and anti-racist practices, in addition to promoting the continued training of health professionals with a focus on the specificities of the health of the black population. The active participation of this population in the formulation of policies and the encouragement of research on their health conditions are essential to promote comprehensive and equitable health.

Levels of plasma 25-hydroxy vitamin D and risk of developing type 2 diabetes in a large Danish primary health care population.

Plasma levels of Vitamin D (25(OH)D) have been suggested as a predictor for developing type 2 diabetes. The purpose of this study was therefore to investigate if a measurement of plasma 25(OH)D could predict the development of type 2 diabetes in a cohort of 222,311 individuals from primary healthcare in Denmark. The CopD-study database containing data from the Copenhagen General Practitioners Laboratory on blood tests conducted from April 2004 to January 2012 was used for identification of the study population. Incident type 2 diabetes was then defined as having at least two redeemed prescriptions of antidiabetics or at least two hospital contacts due to type 2 diabetes or one redeemed prescription and one hospital contact regarding type 2 diabetes. A total of 222,311 individuals were included in the study, of whom 7652 (3.4%) developed type 2 diabetes during the follow-up period of minimum one year. Individuals who developed type 2 diabetes had a significantly lower median 25(OH)D level than persons in the non-diabetes group. The hazard ratio for development of type 2 diabetes increased by 15% per 10nmol/L decrease in 25(OH)D level. In this study of 222,311 persons from primary health care in Denmark, we found a clear inverse relationship between 25(OH)D and the risk of developing type 2 diabetes. Further studies should be conducted to clarify the mechanisms behind the relationship between 25(OH)D and type 2 diabetes and the effect of oral vitamin D supplementation on the development of type 2 diabetes.

Herbal Medicine- A Friend or a Foe of Cardiovascular Disease.

Herbal remedies are used by 80% of the Asian population in primary health care as per WHO. According to current research, the herbal medicine market was valued at nearly USD 166 billion in 2021 and is expected to reach approximately USD 348 billion by 2028. Increased incidence of chronic conditions such as diabetes, asthma, coronary artery disease, osteoarthritis, has fueled the growing interest in traditional herbal and plant-derived treatments among researchers. In addition, rural communities in developing nations have renewed interest in herbal treatments due to lower cost and easy availability. Aim of the paper is to highlight the role of five of more commonly used herbal medicines that are Ginkgo biloba, Garlic, Flaxseed, Ginseng, Salvia miltiorrhiza in cardiovascular disorders. A PubMed search was done using the keywords Herbal Medicine, Ginkgo biloba, Garlic, Flaxseed, Ginseng, Salvia miltiorrhiza. Articles which were available for free access were utilized. No formula inclusion or exclusion criteria was followed. A total of 42 papers were included for the study. Although there have been encouraging outcomes with the use of these herbal medications, many of these products are poorly monitored and are yet to be studied in detail regarding their adverse effects. Moreover, these medicinal products are known to interact with various drugs. To compete with the expanding pharmaceutical industry, more medicinally helpful herbal items must be used and scientifically validated.

High red meat consumption among PNPLA3 polymorphism carriers is associated with NAFLD in a multi-center cross-sectional study.

Patatin-like phospholipase domain-containing 3 gene (PNPLA3) polymorphism has been implicated in susceptibility to non-alcoholic fatty liver disease (NAFLD), with evidence for potential interaction with nutrition. However, the combination of meat consumption with genetic polymorphism has not been tested. Therefore, this study aims to test the association between the joint presence of PNPLA3 rs738409 G-allele with high meat consumption and NAFLD in populations with diverse meat consumption. A cross-sectional study among Israeli screening and Brazilian primary healthcare populations. Food consumption was assessed by a food-frequency questionnaire. PNPLA3 polymorphism was defined as homozygous (GG) or heterozygous (GC). Inconclusive/probable NAFLD was defined as a fatty liver index (FLI) ≥ 30 and probable NAFLD as FLI ≥ 60. The sample included 511 subjects from the screening and primary healthcare populations (n = 213 and n = 298, respectively). Genetic polymorphism (homozygous GG or heterozygous GC) combined with high consumption of total meat, red and/or processed meat, unprocessed red meat, and processed meat was associated with the highest odds for inconclusive/probable NAFLD (OR = 2.75, 95%CI 1.27-5.97, p = 0.011; OR = 3.24, 1.43-7.34, p = 0.005; OR = 2.92, 1.32-6.47, p = 0.008; OR = 3.16, 1.46-6.83, p = 0.003, respectively), adjusting for age, gender, BMI, alcohol consumption, carbohydrate, and saturated fat intake. In addition, genetic polymorphism combined with high processed meat consumption was associated with the highest odds for probable NAFLD (OR = 2.40, 95%CI 1.04-5.56, p = 0.040). High red meat intake may confer a greater risk for NAFLD among PNPLA3 polymorphism carriers. Prospective studies are needed to confirm these findings and consider minimizing red and processed meat consumption among PNPLA3 polymorphism carriers.

Long COVID Symptoms in Non-Hospitalised Patients: A Retrospective Study.

The COVID-19 pandemic has presented numerous challenges to healthcare systems. As the number of affected individuals continues to rise, it is crucial to find preventive, diagnostic, and therapeutic approaches. This study aims to describe different COVID-19 sequelae within a Primary Health Care population. A retrospective cohort study was conducted in adults diagnosed with COVID-19 from March 2020 to April 2022, excluding pregnant women, minors, nursing home residents, hospitalizations, and deaths. Data was gathered from surveillance records on the Trace COVID-19® platform, a pre-set original questionnaire (which included the Portuguese version of the World Health Organization's Quality of Life Assessment Instrument), and, if needed, patient electronic health records. Information on sociodemographic and clinical characteristics of acute COVID-19 was collected along with long COVID symptoms. This study included 284 patients, aged 19 to 99 years old. The five most prevalent acute COVID-19 symptoms were fever (50.0%), tiredness (48.2%), myalgias (44.7%), dry cough (37.7%) and odynophagia (36.3%). Symptoms related to the neurological system (23.2%) and tiredness (22.9%) were the most prevalent in long COVID symptoms. Acute tiredness and arthralgia were associated with all long COVID outcomes. The associations between acute COVID-19 symptoms with long COVID outcomes were stronger for anosmia [OR = 5.07, 95% confidence interval (CI) 2.49 - 10.36, p < 0.001] on a neurological chapter, acute tiredness for long lasting tiredness (OR = 4.07, 95% CI 2.07 - 8.02, p = 0.041), fatigue for muscles and/or bones chapter (OR = 7.55, 95% CI 3.06 - 18.66, p < 0.001), tiredness on an endocrine/hormonal chapter (OR = 6.54, 95% CI 2.37 - 18.04, p < 0.001), dyspnea for respiratory symptoms (OR = 5.67, 95% CI 1.92 - 16.74, p = 0.002) and fever for stomach or intestine symptoms (OR = 8.06, 95% CI 2.55 - 25.47, p < 0.001). Almost all quality of life dimensions were negatively associated with the number of long COVID symptoms. A higher number of acute symptoms, as well as the presence of specific COVID-19 symptoms were associated with reported symptoms ≥ 12 weeks after infection. In the studied population, an increased number of symptoms in both acute and long COVID had a significant negative impact on the perception of overall quality of life. The identification of these relationships could provide a new perspective for post-COVID care.

Defecation symptoms in primary health care patients with irritable bowel syndrome

Background The objectives of the present study were to (a) measure the prevalence of defecation symptoms in IBS, (b) investigate the relationship between stool consistency and defecation symptoms in IBS, and (c) investigate the association of defecation symptoms with health-related quality of life (HRQL) and self-reported stress in patients with IBS cared for in a primary health care setting. Methods Ten primary health care centres joined the study. 282 patients with IBS as well as 372 non-IBS controls filled in gastrointestinal symptom diaries prospectively for two weeks as well as the Perceived Stress Scale-14 (PSS14) and the EuroQol barometer to measure perceived stress and HRQL, respectively. Results Incomplete evacuation was present in 51% vs. 21% of the stools among the IBS patients and the non-IBS controls, respectively. The need to strain during defecation was existing in 41% vs. 33% of the stools for the IBS patients and the non-IBS controls, respectively. Urgency was experienced in 37% of the stools in the IBS patients compared with 18% of the stools in the non-IBS controls. Patients with IBS experienced in a significant higher degree of overlapping symptoms per stool (p < 0.001 to p = 0.007). The occurrence of all defecation symptoms in the same patient was related to decreased HRQL, and increased stress (p = 0.001 to p < 0.001). Conclusions An overlap between IBS and symptoms from the anorectal region related to defecation was found in a primary health care population. Defecation symptoms are very common in primary care IBS-patients, it co-occurs with increased self-perceived stress, and decreased HRQL.

Incidence and prevalence of alopecia areata in the Australian primary care setting: A retrospective analysis of electronic health record data.

Alopecia areata (AA) is a common immune-mediated non-scarring hair loss, with a worldwide incidence between 0.57% and 3.8%. The incidence and prevalence of AA in the Australian general population have not been previously reported. To describe the incidence and prevalence of AA in Australia using primary care data. A secondary objective was to identify common demographic characteristics, comorbidities and treatment patterns among Australians living with AA. We analysed electronic health record data captured from a national clinical practice management software over a 10-year index period between 2011 and 2020 calendar years, inclusive. The incidence of new-onset AA and the prevalence of active records with AA were estimated. Differences in incidence by sociodemographic groups, and patterns of treatment were also evaluated. There were 976 incident AA records. The incidence of new-onset AA in the total study cohort was 0.278 per 1000 person-years (95% CI 0.26-0.295). By age, the incidence was highest in the 19- to 34-year-old age bracket (0.503 per 1000 person-years: 95% CI 0.453-0.554). AA incidence was lower among females than males (IRR 0.763, p < 0.001, 95% CI 0.673-0.865). Among active records, 520 were prevalent AA records. AA point prevalence at 31/12/2020 was 0.13% (1.26 per 1000 persons; 95% CI 1.15-1.37). This is the first study to describe the epidemiology (incidence and point prevalence) and management of AA in the Australian primary health-care population through large-scale database analysis. Incidence and prevalence findings were consistent with earlier estimates from other regions.

On the forms, contributions and impacts of community mobilisation involved with Kerala's COVID-19 response: Perspectives of health staff, Local Self Government institution and community leaders.

Kerala, a south Indian state, has a long and strong history of mobilisation of people's participation with institutionalised mechanisms as part of decentralisation reforms introduced three decades ago. This history formed the backdrop of the state's COVID-19 response from 2020 onwards. As part of a larger health equity study, we carried out an analysis to understand the contributions of people's participation to the state's COVID-19 response, and what implications this may have for health reform as well as governance more broadly. We employed in-depth interviews with participants from four districts of Kerala between July and October, 2021. Following written informed consent procedures, we carried out interviews of health staff from eight primary health care centres, elected Local Self Government (LSG, or Panchayat) representatives, and community leaders. Questions explored primary health care reforms, COVID responses, and populations left behind. Transliterated English transcripts were analysed by four research team members using a thematic analysis approach and ATLAS.ti 9 software. For this paper, we specifically analysed codes and themes related to experiences of community actors and processes for COVID mitigation activities. A key feature of the COVID-19 response was the formation of Rapid Response Teams (RRTs), groups of lay community volunteers, who were identified and convened by LSG leaders. In some cases, pre-pandemic 'Arogya sena' (health army) community volunteer groups were merged with RRTs. RRT members were trained and supported by the health departments at the local level to distribute medicine and essential items, provided support for transportation to health facilities, and assisted with funerary rites during lockdown and containment period. RRTs often comprised youth cadres of ruling and opposition political parties. Existing community networks like Kudumbashree (Self Help Groups) and field workers from other departments have supported and been supported by RRTs. As pandemic restrictions eased, however, there was concern about the sustainability of this arrangement as well. Participatory local governance in Kerala allowed for the creation of invited spaces for community participation in a variety of roles as part of the COVID 19 response, with manifest impact. However, the terms of engagement were not decided by communities, nor were they involved more deeply in planning and organising health policy or services. The sustainability and governance features of such involvement warrant further study.

Associations between education level, blood-lipid measurements and statin treatment in a Danish primary health care population from 2000 to 2018

Objective To examine whether education level influences screening, monitoring, and treatment of hypercholesterolemia. Design Epidemiological cohort study. Setting Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre. Subjects Cholesterol blood test results ordered by general practitioners in Greater Copenhagen were retrieved from 2000-2018. Using the International Standard Classification of Education classification, the population was categorized by length of education in three groups (basic education; up to 10 years, intermediate education; 11-12 years, advanced education; 13 years or more). The database comprised 13,019,486 blood sample results from 653,903 patients. Main Outcome Measures Frequency of lipid measurement, prevalence of statin treatment, age and comorbidity at treatment initiation, total cholesterol threshold for statin treatment initiation, and achievement of treatment goal. Results The basic education group was measured more frequently (1.46% absolute percentage difference of total population measured [95% CI 0.86%–2.05%] in 2000 and 9.67% [95% CI 9.20%–10.15%] in 2018) over the period compared to the intermediate education group. The advanced education group was younger when receiving first statin prescription (1.87 years younger [95% CI 1.02–2.72] in 2000 and 1.06 years younger [95% CI 0.54–1.58 in 2018) compared to the intermediate education group. All education groups reached the treatment goals equally well when statin treatment was initiated. Conclusion Higher education was associated with earlier statin prescription, although the higher educated group was monitored less frequently. There was no difference in reaching treatment goal between the three education groups. These findings suggest patients with higher education level achieve an earlier dyslipidemia prevention intervention with an equally satisfying result compared to lower education patients. Key Points Little is known about the role of social inequality as a possible barrier for managing hypercholesterolemia in general practice. Increasing education level was associated to less frequent measurement and less frequent statin treatment. Patients with higher education level were younger, and less comorbidity at first statin prescription. Education level had no effect on frequency of statin treatment-initiated patients reaching the treatment goal was found.

A Atenção Primária à Saúde no Brasil e a população LGBTI+: uma revisão integrativa

ABSTRACT This article mainly focuses on the healthcare attention provided to the LGBTI+ population in Primary Healthcare within the Brazilian context. To achieve this, we sought to analyze the literature produced on the experiences of healthcare attention to the LGBTI+ population in Primary Healthcare in Brazil through an integrative literature review and thematic content analysis to identify, analyze, and report patterns within the researched data. The studies were classified and ordered according to the year of publication, region of the country, methodology used, and participant status. Although the researched period began in 2012, publications were only recorded in 2015. Between the years 2016 and 2019, there was an increase in the number of published studies related to the theme of this research. The decrease in publications in 2020 may be related to the reduction of activities due to the COVID-19 pandemic. It is also concluded that moral and religious factors have a strong impact on prejudice and discrimination, and there are reports in the literature of healthcare professionals being anchored in cultural teachings, family influence, and social groups that do not accept sexual and gender diversity, contributing to the distancing of the LGBTI+ population from the healthcare services offered by Unified Health System (SUS).

Knowledge, self-efficacy and professional practices related to the Dietary Guidelines for the Brazilian population in primary health care

Resumo Introdução fatores individuais parecem estar relacionados à utilização de novas recomendações e mudanças de prática profissional para ações de promoção à saúde. Objetivo avaliar a relação entre conhecimento, autoeficácia (AE) e utilização das recomendações do Guia Alimentar Brasileiro (GAB) nas práticas de equipes de Núcleos de Apoio à Saúde da Família (NASF-AB). Método recorte transversal de pós-intervenção de um ensaio comunitário controlado envolvendo 26 profissionais de saúde. Conhecimento e AE em utilizar as recomendações do GAB foram coletados por escalas validadas autoaplicáveis. A utilização do GAB na prática profissional foi mensurada mediante observação da rotina de trabalho dos NASF-AB e preenchimento de escala validada sobre as recomendações do GAB. Todos os escores variaram de 0 a 100. Resultados as pontuações médias nos escores de conhecimento, AE e utilização do GAB foram de 83,07 (DP = 18,29), 63,36 (DP = 19,07) e 4,33 (DP = 8,03), respectivamente. Houve correlação positiva e moderada entre AE e escore de utilização do GAB (r = 0,45; p = 0,03). Conhecimento sobre o GAB obteve fraca correlação com o escore de utilização (r = 0,34; p = 0,11). Diferença significativa foi obtida entre as médias do escore de utilização do GAB no grupo de elevada AE (5,13; p = 0,004; DP =1,55), em relação ao de baixa AE (3,40; p = 0,059; DP = 1,69), independentemente da categoria profissional. Conclusão neste estudo, a AE demonstrou estar moderadamente correlacionada com a adoção de novas práticas profissionais.

The health of the black population in Primary Health Care: a misunderstanding that legitimizes inequality in times of COVID-19

RESUMO A Atenção Primária à Saúde constitui o eixo regulador do cuidado no Sistema Único de Saúde. A sua compreensão é condição para que as ações sejam resolutivas. Este artigo propõe refletir sobre a compreensão da Atenção Primária à Saúde entre gestores, profissionais, usuários e as implicações das iniquidades em saúde vivenciadas pela população negra no contexto da Covid-19. Realizou-se pesquisa qualitativa em três municípios que foram entrevistadas 58 pessoas. A análise mostrou a incompreensão da Atenção Primária à Saúde. Gestores e profissionais a associam apenas a ações de prevenção de doenças e disponibilização de serviços. Os usuários associam ao acesso a serviços, e relacionam a má qualidade da assistência ao pertencimento racial e de classe. A incompreensão da Atenção Primária à Saúde pelos atores envolvidos na sua operacionalidade compromete a assistência da população negra com relação à Covid-19, bem como em outras demandas.

Healthcare for LGBTQIA+ population in Primary Health Care: a scoping review

RESUMO A população LGBTQIA+ ainda enfrenta diversas dificuldades no acesso aos serviços de saúde e na obtenção efetiva de cuidado e assistência. Este artigo apresenta uma análise da produção bibliográfica acadêmica sobre o acesso da população LGBTQIA+ aos serviços de Atenção Primária à Saúde (APS) no Brasil. Para isso, foi realizada uma revisão de escopo, que visa identificar estudos sobre temas em relação aos quais revisões de literatura ainda são escassas e na qual diferentes desenhos de estudo são possíveis. No que se refere aos resultados, observou-se uma produção científica ainda incipiente sobre o acesso da população LGBTQIA+ na APS. Identificou-se que, apesar das conquistas políticas, adquiridas por meio da luta dos movimentos sociais, o processo de saúde dessa população ainda é permeado por uma lógica heteronormativa que desconsidera as identidades e as orientações de gênero e, consequentemente, institui importantes barreiras de acesso aos serviços de saúde.

Physical-mental multimorbidity in a large primary health care population in Stockholm County, Sweden.

Multimorbidity of mental and physical disorders may be common. Our objectives were to estimate the prevalence of mental disorders and determine physical-mental multimorbidity relationships adjusted for sex and age within a primary care population in Region Stockholm, Sweden. From 2.4 million Region Stockholm inhabitants, we included adult patients with ≥1 primary care consultation from 2013 through 2017. We clustered 40 physical diagnoses into 9 categories and grouped mental disorders into mild-moderate (i.e., depression, anxiety, stress disorder, sleep disturbance) or severe (i.e., bipolar disorder, schizophrenia). Of 1 105 065 patients, mean age was 49 years, 56% were females, and nearly one-third had a mental disorder (97% mild-moderate). Adjusted odds ratios (AOR) for mild-moderate and severe mental disorders were highest in patients with alcohol abuse (AOR=3.7, 95% CI 3.6-3.8; AOR=7.2, 95% CI 6.7-7.6, respectively) vs. those with no abuse. Higher odds for either level of mental comorbidity occurred in patients with chronic heart failure (CHF), cerebrovascular disease, Transient ischemic attack (TIA), Chronic obstructive pulmonary disease (COPD), Gastroesophageal reflux disease- irritable bowel syndrome (GERD-IBS), chronic pain, dementia, nicotine dependence, and Parkinson's disease. For mild-moderate mental disorders, AOR in males was highest (1.45) at age 28 and was below 1.0 after age 46; AOR in females was highest (1.30) at age 38 and was below 1.0 after age 38. For severe mental disorders, AOR was below 1.0 after age 58 in males and after age 62 in females. Physical-mental multimorbidity was common in primary care patients in Sweden, with the highest odds occurring in those who were female, younger, and/or had an alcohol abuse disorder.

Determinants of sun exposure time among Sri Lankan pregnant women.

Introduction: Sun exposure becomes extremely important for primary prevention of vitamin D deficiency (VDD) for high-risk populations who do not receive supplemental vitamin D. The present study investigated the determinants of sun exposure time and its association to vitamin D among Sri Lankan pregnant women in a primary health care population from the Colombo District.Methods: This is part of a cross-sectional study of 383 third trimester pregnant mothers from primary healthcare (PHC) units in the Colombo District in Western Sri Lanka. A newly developed interviewer-administrated questionnaire was used as the main study instrument. In addition, a venous blood sample was collected for 25(OH)D levels. The univariate and multivariate analysis examined the determinants of sun exposure time. One-way ANOVA and Tukey post hoc test described the association between sun exposure time and vitamin D level.Results: Most (56.9%) had &lt;30 minutes of sun exposure per day. Low sun exposure time observed with Moor ethnicity (OR:7.45, 95% CI: 3.764, 14.741, p&lt;0.001), lower parity (OR:0.53, 95%CI: 0.369, 0.753, p&lt;0.001) and higher educational level (OR: 3.10, 95% CI: 1.606, 5.976, p=0.001). Women who spent ≥30 minutes exposed to sun between 9am to 3pm [F(3,373)=10.1, p&lt;0.001] had higher vitamin D levels.Conclusions: Educational level, parity, and ethnicity are important determinants of sun exposure time. A significantly lower serum vitamin D is demonstrated in pregnant women with exposure time &lt;30 minutes. This evidence will allow health personnel to individualize the advice to improve vitamin D-related sun exposure behaviour in this population who are not routinely supplemented with vitamin D.

A collaborative care package for depression comorbid with chronic physical conditions in South Africa

IntroductionA task-sharing collaborative care model for integrated depression care for South Africa’s burgeoning primary health care population with chronic conditions was developed and tested through two pragmatic cluster randomized controlled trials. One trial focused on patients with hypertension and was located in one district where a collaborative care model was co-designed with district stakeholders. The other trial, focused on patients on antiretroviral treatment, was located in the same district site, with the addition of a second neighbouring district, without adaptation of the original model. This paper describes the package used to implement this model, and implementation outcomes across the two sites, and summarises lessons and challenges.MethodsThe Template for Intervention Description and Replication (TIDieR) framework, adapted for complex health systems interventions, was used to describe components of the package. Additional elements of ‘modifications made’ and ‘actual implementation’ introduced in the ‘Getting messier with TIDieR’ framework, were used to describe implementation outcomes in terms of reach, adoption and implementation across the two trial districts.ResultsIn the absence of a co-design process to adapt the model to the context of the second site, there was less system level support for the model. Consequently, more project employed human resources were deployed to support training of primary care nurses in identification and referral of patients with depression; and supervise co-located lay counsellors. Referrals to co-located lay counselling services were more than double in the second site. However, uptake of counselling sessions was greater in the first site. This was attributed to greater in-vivo supervision and support from existing mental health specialists in the system. There was greater reliance on online supervision and support in the second site where geographical distances between clinics were larger.ConclusionThe need for in-country co-designed collaborative care models, and ‘implementation heavy’ implementation research to understand adaptations required to accommodate varying in-country health system contexts is highlighted.

Clinical characteristics and risk for severe COVID-19: a systematic review

COVID-19 has evolved into a serious clinical condition, especially in patients with comorbidities. However, the literature has diverged in relation to the main characteristics of patients prone to severe evolution. Objective: This study aimed to understand different variables that may be associated with the clinical management of COVID-19 for a better clinical response and prognosis. Methods: This is a systematic review in which the search in PubMed, Cochrane, EMBASE and LILACS databases. A manual and gray literature search on Google Scholar was also conducted. There was no country or region restriction and only studies in Portuguese, English and Spanish were included. Results: Of the 21 studies included in Primary Health Care (PHC) for eligibility, five studies from five countries involving 27,754 patients were analysed and, of the four eligible studies, one study was included for secondary care. Overall, the mean age of the COVID-19 population in PHC was around 41 years old, the number of cases was higher for females and, there was no difference between the groups without and with exposure, sex (ρ=0.322) and age (ρ=0.395). More than half of the patients had symptoms and, 47% had comorbidities. Heart diseases were the most prevalent among them. Approximately 79% of those infected had non-essential occupation. There was evidence that non-essential occupation was associated with infected individuals (ρ=0.002). Conclusions: This review identified that there may be greater vulnerability to contamination and aggravation of COVID-19 in female individuals, with adult age in non-essential activity, presence of chronic non-communicable diseases.

Describing a complex primary health care population to support future decision support initiatives.

Developing decision support tools using data from a health care organization, to support care within that organization, is a promising paradigm to improve care delivery and population health. Descriptive epidemiology may be a valuable supplement to stakeholder input towards selection of potential initiatives and to inform methodological decisions throughout tool development. We additionally propose that to properly characterize complex populations in large-scale descriptive studies, both simple statistical and machine learning techniques can be useful. To describe sociodemographic, clinical, and health care use characteristics of primary care clients served by the Alliance for Healthier Communities, which provides team-based primary health care through Community Health Centres (CHCs) across Ontario, Canada. We used electronic health record data from adult ongoing primary care clients served by CHCs in 2009-2019. We performed traditional table-based summaries for each characteristic; and applied three unsupervised learning techniques to explore patterns of common condition co-occurrence, care provider teams, and care frequency. There were 221,047 eligible clients. Sociodemographics: We described 13 characteristics, stratified by CHC type and client multimorbidity status. Clinical characteristics: Eleven-year prevalence of 24 investigated conditions ranged from 1% (Hepatitis C) to 63% (chronic musculoskeletal problem) with non-uniform risk across the care history; multimorbidity was common (81%) with variable co-occurrence patterns. Health care use characteristics: Most care was provided by physician and nursing providers, with heterogeneous combinations of other provider types. A subset of clients had many issues addressed within single-visits and there was within- and between-client variability in care frequency. In addition to substantive findings, we discuss methodological considerations for future decision support initiatives. We demonstrated the use of methods from statistics and machine learning, applied with an epidemiological lens, to provide an overview of a complex primary care population and lay a foundation for stakeholder engagement and decision support tool development.