Primary Health Care Services Research Articles

Supporting Patients' Use of Digital Services in Primary Health Care in England: Synthesis of Evidence From a Mixed Methods Study of "Digital Facilitation".

General medical practitioners and other staff at primary care medical practices have an important role in facilitating patient access to online services in the National Health Service in England. These services range from online ordering of repeat prescriptions to conducting online consultations with health care professionals. We have defined "digital facilitation" as that range of processes, procedures, and personnel that seeks to support patients in their uptake and use of online services. We report how we have synthesized the evidence from a mixed methods study of digital facilitation in primary care in England. The study's objectives were to identify, characterize, and explore the benefits and challenges of different models of digital facilitation in general medical practices in England and to design a framework for evaluation of the effectiveness and costs of digital facilitation interventions. Our study comprised scoping review of literature, survey of staff in general practices, survey of patients, and ethnography at case study practices plus stakeholder interviews. We compiled a triangulation matrix of the findings from individual work packages through an iterative process whereby each work package's results were first analyzed separately and were then cumulatively combined across work packages in 3 successive workshops. From the resulting matrix, we developed a program theory and an implementation theory and constructed a framework for evaluations of digital facilitation in primary care. The final step of the synthesis process was to discuss the results with national and regional National Health Service stakeholders. Triangulation yielded a combined set of findings summarized within 11 thematic groupings: 3 setting the scene within which digital facilitation takes place, and 8 related to different types of digital facilitation, their implementation, and effectiveness. Some thematic groupings were evident in the findings of all 4 of the research work packages; others were not addressed in all the work packages but were evident from those where they were addressed. Throughout the synthesis, there were no instances where findings from one work package contradicted the findings of another. Findings either reinforced each other or offered complementary or additional insights. The discussion at the stakeholder meeting held at the end of the study resulted in the research team clarifying some findings but not changing any of them. Digital facilitation can take many forms, though much of what is currently done in primary care practices in England is reactive and passive. Clear lines of responsibility, digital tools and platforms that work well for patients and practice staff, and investment in staff time and training are all needed if digital facilitation is to deliver on its promise. We propose a framework for future evaluations of the effectiveness and costs of digital facilitation interventions.

Patient pathways in primary health care – an interview study across various health care personnel in a Canadian and a Norwegian county

BackgroundDue to demographic changes in the Western world governments emphasize the need for viable solutions, e.g. through decentralization of specialist health care services and better coordination within and between health care services. Both Norway and Canada have been through health care reforms and initiatives aiming to improve continuity and coordination of services. Organizational change to primary care in both countries encompasses both team-based service delivery involving allied health professionals, and new blended payment models. The objective of this study was to explore patient pathways in primary healthcare from various health personnel’s perspectives, and across various primary care organizations in Norway and Canada.MethodsThe study had a qualitative design, including interviews with physicians, nurses and managers (n = 19) in primary care, from a county in Norway and a region in Canada. Data were analyzed with a thematic approach, in line with recommendations from Braun & Clarke.ResultsThree themes were identified: 1) Structural challenges, 2) Towards a more specialized primary health care and 3) Dedication could improve continuity. Findings indicate that coordinating health care services was assumed difficult due to different health care levels, funding systems, managements, electronic record systems and organizations. Hospitals were assumed more task oriented, while primary health care services were considered more care oriented, and this challenged the coordination across organizations. Primary care services were perceived to be more and more specialized, also representing a threat for coordination and continuity. Health care personnel in both countries perceived that dedicated personnel for each patient could improve information flow and continuity across services.ConclusionsAchieving continuity and coordination of health care services seems challenging. Integration strategies seem essential for reducing silo thinking and fragmentation of health care services.

Childhood Maltreatment and Revictimization in Young Adulthood: Is Problematic Substance Use a Mediator? A Linked Survey-Register Data Study.

Victims of childhood maltreatment often experience revictimization later in life. However, there is scant knowledge of the explanatory mechanisms that generate this phenomenon. Problematic substance use is a maladaptive coping strategy that may increase the risk of revictimization after maltreatment. We used linear regressions and mediation analyses to investigate the explanatory role of problematic substance use in the association between childhood maltreatment and violent revictimization in young adulthood. We analyzed linked survey-register data on a sample of senior high school graduates in Norway (n = 3,156) who were followed longitudinally until ages 32 to 33 (2021). Ordinary least squares regression analyses showed that childhood maltreatment was associated with both problematic substance use and violent revictimization, adjusted for a wide range of covariates. Moreover, problematic substance use was associated with an increased risk of violent revictimization in young adulthood. Mediation analyses showed that about one eighth (12.0%) of the association between childhood maltreatment and violent revictimization was mediated by problematic substance use. Sensitivity tests indicated that the mediation may be susceptible to unmeasured confounding. Thus, it is unclear whether the mediating role of problematic substance use can be interpreted causally within a counterfactual framework. In conclusion, reducing problematic substance use among victims of childhood maltreatment may mitigate the risk of violent revictimization later in life. Early detection and tailored treatment of problematic substance use could be one way to prevent violent revictimization following childhood maltreatment. Therefore, equitable access to primary and specialized healthcare services is essential, both for victims of maltreatment and individuals with habits of (borderline) problematic substance use. However, the majority of the maltreatment-revictimization pathway (88.0%) is not statistically explained by substance use, which implies that other mechanisms are also at play.

Challenges in oral health practice in Somalia: a call for regulatory strengthening and inclusion into primary healthcare services

BackgroundOral diseases remain a significant public health problem worldwide despite being largely preventable. Oral disorders such as dental caries, periodontal diseases, and oral cancers are highly prevalent chronic conditions that negatively impact quality of life. The oral health practice in Somalia has been evolving over the years, we therefore explored the challenges of oral health practice in a security-constrained poorly regulated environment to guide policy development.MethodsWe conducted a descriptive cross-sectional study among 15 oral health practitioners in Somalia. Using in-depth interviews, we gathered data on challenges working in private dental clinics and governmental institutions. Additionally, we gathered data on gender, age, marital status, profession, country of graduation, current location of practice, and years of clinical experience. Because the participants worked in different cities, we conducted interviews over the phone and recorded them. The data were analyzed via thematic analysis.ResultsIn this study, 9 of the participants were men and the median age was 29 years. Most of the participants (10) were dentists and remaining were dental specialists. The findings on challenges fall under four broad thematic areas: (1) Patient-related challenges; low patient literacy, preference for dental quacks, delay in seeking oral care, and dental phobia. (2) Institutional-related challenges: limited access to basic oral health services, oral health not an integral part of primary health care, and unregulated private dental clinics resulting in unqualified quacks practising as private caregivers. (3) Societal-related challenges, the absence of community-oriented preventive oral health services and low prioritization of oral health. (4) Personal-related challenges: female dentists in this study faced challenges related to the preference of male dentists and the shortage of oral health specialists in the country.ConclusionThis study reveals the need for the establishment and strengthening of regulation of oral services and its inclusion into the basic primary service package provided to the populace. It also calls for community enlightenment and more investment in dental health care in Somalia.Clinical trial numberNot applicable.

Integration of family planning into the primary health care in Ethiopia: results from national assessment

BackgroundFamily planning (FP) is part of Ethiopia’s essential health service package. However, integrating FP into other health care services is a relatively new concept. Integrated service can minimize missed opportunities and allow health workers to provide FP services and Reproductive, Maternal, Newborn, Child, Adolescent, and Nutrition (RMNCAH-N) services simultaneously. Thus, the objective of this study was to assess the levels of FP integration into maternal and child health (MCH) services at primary health care service delivery units in Ethiopia.MethodsThis was a facility-based cross-sectional study conducted from July to October 2022. We conducted a nationally representative survey of primary health care (PHC) facilities selected from seven regions and two-city administrations in Ethiopia to assess the current level of FP integration across four service delivery units (antenatal care unit, postnatal care unit, post-abortion care unit, and immunization unit) of the facilities. We collected data from selected health facilities through interview with health facility managers, healthcare providers in the selected service units, clients seeking health services, and extraction of data from facility records. We employed descriptive analysis, and categorized the degree of FP integration according to the FP information and services provided in the selected service delivery units.ResultsThis national FP integration survey included 122 health facilities (39 primary hospitals, 42 health centers, and 41 health posts) from seven regions and two city administrations. The study found a huge discrepancy regarding FP counselling given at ANC, PNC, PAC, and immunization service delivery units as reported by health care providers and clients. The proportion of PNC and immunization clients who received FP counselling was higher at health post compared to hospitals and health centers. Moreover, the proportion of PAC clients who received FP information was higher in primary hospitals compared to health centers.ConclusionData from facility records and provider interviews showed significant FP integration within ANC, PNC, and immunization units of PHC facilities. However, client exit interviews indicated low FP counselling integration. Facility records revealed few PNC and PAC clients received contraceptives in the past year. The study found high FP counselling and provision of at least one short- or long-acting contraceptive at PNC and PAC units. No facility offered contraceptives at immunization units, indicating missed FP integration opportunities.

Spatial accessibility and equity of primary healthcare in Zhejiang, China

BackgroundEnhancing the accessibility and equity of primary healthcare (PHC) is a crucial objective of China’s healthcare reform. However, spatial barriers remain a significant factor contributing to the inequitable access to PHC services among residents.ObjectiveThis study aims to quantify the spatial accessibility (SA) and evaluate the equity of PHC resources in a pilot province for healthcare reform, and its municipalities, thereby providing insights that can be generalized to the broader context of China.MethodsThe study used the navigation function provided by Gaode Map to estimate the time it takes for residents to visit PHC institutions. The two-step floating catchment area (2SFCA) method, weighted by a Gaussian function, was employed to measure the SA of PHC institutions, general practitioners (GPs), and beds across various residential areas. The Gini coefficient was utilized to assess disparities in SA among different regions. Additionally, Getis-Ord Gi* analysis was conducted to visualize these spatial disparities.ResultsThe study analyzed 25,601 residential and 1,451 healthcare points in Zhejiang Province, revealing significant disparities in SA of PHC. Urban residents reached PHC institutions faster than rural ones (7.05 ± 4.7 min vs. 9.17 ± 7.78 min, P < 0.001). Within 30 min, 98.4% of residential points and 99.1% of the population accessed PHC institutions. Disparities in PHC resources were notable, with Lishui having the highest SA for institutions and GPs, and Shaoxing for beds. Equity assessment showed high inequity for institutions (Gini 0.553), moderate for beds (Gini 0.497), and reasonable for GPs (Gini 0.332)​. Getis-Ord Gi* analysis demonstrated that areas further from urban centers were more likely to exhibit clusters of hotspots or cold spots.ConclusionThe study highlights substantial disparities in SA of PHC and equity across Zhejiang, underscoring the need for strategic resource distribution. Future research should include diverse transportation modes and more precise demand point data to enhance understanding of accessibility dynamics.

Primary care research on hypertension: A bibliometric analysis using machine-learning

Hypertension is one of the most important chronic diseases worldwide. Hypertension is a critical condition encountered frequently in daily life, forming a significant area of service in Primary Health Care (PHC), which healthcare professionals often confront. It serves as a precursor to many critical illnesses and can lead to fatalities if not addressed promptly. Our study underscores the importance of this critical issue by analyzing articles related to hypertension in the PHC research area from the Web of Science Core Collection using bibliometric methods and machine learning techniques, specifically topic analyses using the latent Dirichlet allocation method. The analysis was conducted using Python Scikit-learn, Gensim, and Wordcloud Libraries, the VosViewer program, and the Bibliometrix R Biblioshiny library. Our findings revealed a steady increase in publication output in hypertension-related research. Analysis shows that hypertension-related research in the PHC research area is clustered into 8 groups: (1) management of hypertension in PHC, risk factors, and complications; (2) psychiatric disorders and hypertension; (3) pediatric and pregnancy hypertension; (4) environmental factors and living conditions; (5) sex and age effects on hypertension; (6) COVID-19 and hypertension; (7) behavioral risk factors, quality of life, and awareness; and (8) current treatment methods and guidelines. Research on hypertension has focused intensively on kidney disease, obesity, pregnancy, cardiovascular risk, heart disease, calcium channel blockers, body mass index, amlodipine, mortality, risk factors, hyperlipidemia, depression, and resistant hypertension. This study represents the first and comprehensive bibliometric analysis of hypertension in the PHC research area. Annual publication volumes have steadily increased over the years. In recent years, topics such as social determinants, patient attendance, self-management, diabetes mellitus, COVID-19, telemedicine, type 2 diabetes, and noncommunicable diseases have garnered significant interest in the field of PHC services.

Breaking barriers: a qualitative exploration of healthcare access for crack cocaine users in Limerick

Background of studyCrack cocaine use in Ireland began to emerge as a significant problem in the early 2000s, with prevalence increasing from 2016 onwards. Services such as harm reduction, treatment/rehabilitation, primary healthcare and social services are available to crack cocaine users in Ireland. However, research addressing specific barriers to accessing these services remains limited. Internationally, while research on healthcare access barriers for crack cocaine users exists, it predominantly focuses on user perspectives. This paper uses a dual-perspective approach to investigate access challenges from both service user and service provider viewpoints, promoting a more patient-centred, holistic approach to service provision.MethodologyThe study is qualitative and used semi-structured interviews and a focus group to obtain study data. Levesque’s conceptual framework for healthcare access underpins this study. Data were analysed using thematic analysis.ResultsThe study highlighted barriers to healthcare access such as the inadequacy of services to support those with dual diagnosis. However, an advancement has been made through the establishment of specialised dual diagnosis teams and community dual diagnosis services in Ireland. Stigma from health care providers further hindered people from seeking help, highlighting the significance of ongoing efforts in Ireland to address stigma. Systemic factors such as distrust in services, stringent requirements and insufficient knowledge of user needs hamper timely access to care, underlining the need for more adaptive responses.ConclusionThe study underlines the need for a tailored approach to enhancing access to health care for crack cocaine users in Ireland. Facilitating collaboration among health care providers, fostering partnerships with educational institutions/communities, and implementing policy changes are essential in creating a supportive environment that promotes help-seeking in Ireland.

Development and evaluation of a caregiver checklist for primary care.

Family caregivers serve vital functions in older adults' health care, but their own needs are not systematically assessed in routine care delivery. The present study employed a user-centered approach to develop and evaluate a pragmatic checklist to support proactive identification and discussion of caregivers' concerns in primary care. Checklist development proceeded according to a preestablished methodology involving domain identification, item generation, overall construction, and revision. The checklist subsequently underwent formal evaluation by 25 subject matter experts (SMEs), including primary care clinicians, family caregivers, and health services researchers who assessed the checklist's content validity and appraised its overall utility, ease of use, and mode of administration. The checklist showed excellent content validity. None of the items were found to be superfluous, indicating that the checklist covered relevant content domains. Subject matter experts reported that the checklist was easy to use, just the right length, and would be helpful in identifying and prompting a discussion about caregivers' needs. Their preferences regarding how the checklist should be administered were variable. Minor revisions to the checklist focused on enhancing its applicability to caregivers from low- and middle-income families and those from underrepresented backgrounds. Results indicate that the checklist is an appropriate tool for identifying caregivers' needs and concerns. Findings lay the groundwork for pilot testing in primary care to confirm the checklist's clinical feasibility and evaluate its preliminary impact on family-centered care quality and outcomes for primary care clinics. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Multimodal intervention based on physical exercise, mindfulness, behaviour change and education to improve pain and health in patients with chronic primary low back pain: a study protocol of the HEALTHYBACK randomised controlled trial

The HEALTHYBACK trial is based on a multimodal intervention to determine the effectiveness of a supervised physical exercise, mindfulness, behaviour change and pain neuroscience education programme on several health variables...

Exploring the inequality in fine-grained primary healthcare accessibility in Macau based on high-resolution geospatial data under the 15-minute city framework

Primary healthcare (PHC) acts as a cornerstone of public health. The 15-min city concept, advocating convenient access to essential urban services such as PHC within a 15-min walk, has gained traction globally. However, there remains a lack of understanding regarding the 15-min accessibility to PHC services, crucial for physically vulnerable individuals requiring regular medical attention. Previous healthcare accessibility studies often use the traditional floating catchment area (FCA) method, which overlooks demand and service supply inflation within catchment areas, potentially leading to inaccuracies in accessibility estimates. This study addresses the gap in understanding fine-grained 15-min accessibility to PHC services by employing an enhanced two-step floating catchment area (E2SFCA) method, which considers the inflation effect. Additionally, our study incorporates hot spot analysis (Getis-Ord Gi∗), bivariate local Moran's I (Bi-LISA), and the Gini index to reveal inter- and intra-parish accessibility inequalities across the 7 parishes in Macau. Findings highlight Nossa Senhora de Fátima parish as having the highest concentration of low-income public housing estates and significant inter- and intra-parish 15-min PHC accessibility inequalities. This emphasizes the need for policymakers to consider integrating PHC facilities when developing public housing estates for low-income residents.

Utilization of Primary Health Care Services in Qayyarah City Northern Iraq

Utilization of Primary Health Care Services in Qayyarah City Northern Iraq

The Strategies to Improve Primary Health Care Services: A Scoping Review

Context: Evaluation of health policies and identification of their challenges are vital for improving and implementing reforms in the healthcare system. The present study was conducted to identify interventions aimed at improving primary healthcare (PHC) services in Iran. Evidence Acquisition: This research utilizes a scoping review to examine reform interventions in PHC services across 10 selected countries: Qatar, Oman, Turkey, Georgia, Armenia, United Arab Emirates, Saudi Arabia, Bahrain, Kazakhstan, and Kuwait. The study covers areas such as the PHC delivery system, human resource management, financial mechanisms, and the framework of community participation and intersectoral collaboration from 2010 to 2022. Results: The main reform strategies for PHC systems in the reviewed countries included the establishment of family medical centers with nurse support as a comprehensive strategy for service provision in public health centers; providing comprehensive and quality healthcare service packages including maternal and child health, infectious disease immunization, chronic disease monitoring, and dental care services; health education; access to essential medications; improvement of electronic health services; implementation of health promotion and continuous prevention programs; capacity enhancement; and a greater focus on health screening programs and grading of healthcare centers. Conclusions: The major findings from the reviewed countries indicate that healthcare policymakers focus on providing preventive care services, reducing maternal and child mortality, and increasing life expectancy. Programs such as referral systems, service grading, and the adoption of electronic health services are part of their reform agenda.

Utilization Patterns of Primary Healthcare Services Among Different Demographic Groups in the Kingdom of Saudi Arabia

This study investigates the utilization patterns of primary healthcare services across various demographic groups in the Kingdom of Saudi Arabia (KSA) between 2010 and 2014. Employing a descriptive methodology, the research analyzes data from the Saudi Ministry of Health and case studies to identify trends and disparities in healthcare access and utilization. The findings reveal significant variations based on age, gender, socioeconomic status, and geographic location, highlighting the need for targeted interventions and policies to improve healthcare equity and access in KSA. Recommendations include expanding healthcare infrastructure in underserved areas, implementing community outreach programs, enhancing data collection and analysis to inform evidence-based decision-making, and developing policies that address the unique needs of different demographic groups.

Does access to and use of primary healthcare services influence health insurance uptake? A mixed-methods study in the Wa Municipality, Ghana

ABSTRACT Purpose This study explored access to quality primary healthcare services under Ghana's National Health Insurance Scheme (NHIS), its impact on NHIS enrolment, and the implications for attaining Universal Health Coverage (UHC). Methods A sequential explanatory mixed-method research design was employed using a multistage sampling technique. We collected data from 413 insured individuals and 47 healthcare facilities for quantitative community-level analysis using questionnaires. Purposive sampling was used to select 17 healthcare providers and 20 insured key informants for qualitative investigation using interview guides. Quantitative data were analyzed using descriptive statistics, independent t-tests, and binary logistic regression. Qualitative data were thematically analyzed to explain the quantitative findings. Results The results indicated a positive association between outpatient and inpatient services, maternal healthcare, and laboratory testing. Maternal healthcare and laboratory diagnostics positively influenced the renewal of NHIS membership. Binary logistic regression revealed that access to, and utilization of PHC services significantly increased the likelihood of NHIS membership renewal, influenced by healthcare system factors such as service availability, acceptability, and affordability. Conclusion Our findings suggest that policymakers must enhance the NHIS with improved service delivery to attain UHC in Ghana.

Perceptions and Expectations of Midwives and Women Regarding Prenatal Care within the Scope of Primary Health Care Services in Türkiye.

One of the Sustainable Development Goals is to reduce the global maternal mortality rate. Antenatal care is a crucial component in achieving this goal. The aim of our study is to reveal the perceptions and expectations of midwives and women regarding antenatal care. In this qualitative study, Husserl's philosophy of phenomenology was adopted to emphasize the knowledge of experiences. One-to-one in-depth interviews were conducted with 31 participants - 15 midwives and 16 women - who received antenatal care in Türkiye. Each interview was recorded and transcribed verbatim. The data obtained from the research were analyzed using traditional content analysis, resulting in five main themes and ten sub-themes. The main themes were "Lack of knowledge/awareness," "Midwifery in Antenatal Care Services," "Practices within the Scope of Antenatal Care," "Factors Hindering Receiving Antenatal Care," and "Expectations from Antenatal Care." The women participating in the research could not define the concept of "Antenatal care" and did not consider the service they received during pregnancy as antenatal care. It was determined that midwives could not provide quality antenatal care services to women for various reasons. Midwives should raise women's awareness about antenatal care, which includes examination, treatment, education, and counselling. In addition, the areas of need of primary health care services should be determined, and necessary improvements should be made.

Patient satisfaction with rehabilitation services following traumatic brain injury: a quality registry study.

To examine factors associated with patient satisfaction with rehabilitation services received after traumatic brain injury. Cross-sectional study. Persons with mild to severe traumatic brain injury (n = 1,375) registered in the "Oslo TBI Registry - Rehabilitation" quality register at Oslo University Hospital from 1 January 2018-31 July 2022. Sociodemographics, injury-related variables, patient-reported outcome measures, global functioning, and rehabilitation-related variables were recorded at hospital outpatient visits. The patients reported satisfaction with services received at the outpatient clinic and in primary healthcare at the final follow-up. Multivariable logistic regression models were applied to examine factors associated with patient satisfaction. Of 316 patients, 83% reported satisfaction with services received at the hospital outpatient clinic. Belief in recovery (odds ratio [OR] = 2.73), shorter time to follow-up (OR = 0.39), and lower symptom burden (OR = 0.96) significantly increased satisfaction. Among 283 patients, 62% reported satisfaction with services in primary healthcare, where belief in recovery (OR = 2.90), shorter time to follow-up (OR = 0.50), higher age (OR = 1.04), and higher number of rehabilitation services received in primary healthcare (OR = 1.32) significantly increased satisfaction. Across service levels, the strongest associated factors for satisfaction were belief in recovery and shorter time to follow-up, suggesting that timely delivery of traumatic brain injury-related specialized services could increase overall satisfaction.

Nutritional guidance needs and influence factors for gastric cancer survivors in primary healthcare setting: a cross-sectional survey.

This study aimed to build a comprehensive understanding of the nutritional guidance needs of gastric cancer survivors in the primary healthcare setting that could be fulfilled by community health service centers as part of their primary healthcare services. Gastric cancer survivors were invited to participate in a questionnaire-based survey by convenience sampling method from the community health center. Relationships between nutritional demand and potential influence factors were examined by a multivariable logistic regression model. A total of 200 gastric cancer survivors were recruited from the community health service center in Shanghai, China, from whom we obtained 194 valid questionnaires, resulting in a 97.0% response rate. Of these gastric survivor participants, 48 individuals (24.7%) expressed a need for nutritional guidance administered by community health service centers, whereas 146 participants (75.3%) held the perspective that such guidance was unnecessary. Preferences for nutritional guidance included having a dietitian as the provider (68.8%), home-based engagement (72.9%), face-to-face consultation (68.8%), individual counseling (87.5%), and beginning immediately post-discharge (89.6%). A notable reluctance (66.7%) towards financial contribution was also observed. After adjusting for confounders, participants with higher income level (odds ratio (OR) = 4.45, 95% confidence interval (CI) = 1.39-15.50), history of food intake reduction (OR = 14.96, 95% CI = 3.49-82.28), and gastrointestinal symptoms (OR = 4.40, 95% CI = 1.35-14.33) were more likely to seek nutritional guidance. Gastric cancer survivors have a certain need for nutritional guidance administered by primary health service centers. Personal guidance by the primary health service center should be provided to gastric cancer survivors to support their dietary and nutritional intake needs. There is a need to develop and implement nutritional guidance programs in community health service centers as part of their primary healthcare services for gastric cancer survivors.

Childhood dead-before-arrival, our experience at a tertiary hospital in Southern Nigeria: a clarion call to stakeholders in the health sector

Dead-Before-Arrival (DBA) is a term used to describe patients who have no sign of life at the time of presentation to the hospital. There is a dearth of information about this cohort of children at most healthcare service delivery points. In fact, these children are also never captured in most of our national and local healthcare data. This research is aimed at sharing our experience on DBA at the Children’s Emergency Room of a tertiary hospital in the South-South geopolitical region of Nigeria, by determining the prevalence, probable disease cause, and pattern of DBA among children presenting at our facility. This is a cross-sectional study that used a standardized verbal autopsy instrument to ascertain the details of all the children aged 1 month to 17 years who were cases of DBA at the Children’s Emergency Room of the University of Benin Teaching Hospital, Benin City, Edo State, Nigeria, over 24 months (January 2018 to December 2019). Socio-demographic characteristics, symptoms before demise, treatment received, and suspected cause(s) of death were documented. The prevalence of DBA was compared to the in-hospital mortality during the period. A total of 96 (3.2%) compared to 144 (4.9%) in-hospital of the 2,914 emergency admissions were cases of DBA, with a 2:1 male-to-female ratio. The age group of 1-6 months had the highest proportion (41.7%). Children under two were 62.5% and 81.3% were under-fives. Infections such as diarrhea, bronchopneumonia, and sepsis were the most common suspected causes of death, followed by non-infectious causes such as perinatal asphyxia, Chronic Kidney Disease (CKD), cyanotic congenital heart disease, drowning, and electrocution. Cases of DBA were significantly lower than in-hospital mortality (144 cases) during the study period (3.2% vs 4.9%) The DBA prevalence as recorded in this hospital-based study may be the tip of the iceberg compared to what happens in the community. Making our primary and secondary health care services more accessible, affordable, and optimally functional may help reduce the burden of DBA.

Implementation outcomes from a randomized, controlled trial of a strategy to improve integration of behavioral health and primary care services

BackgroundIntegrating behavioral health services in primary care is challenging; a toolkit approach to practice implementation can help. A recent comparative effectiveness randomized clinical trial examined the impact of a toolkit for improving integration on outcomes for patients with multiple chronic conditions. Some aspects of behavioral health integration improved; patient-reported outcomes did not. This report evaluates the implementation strategy (Toolkit) using Proctor’s (2011) implementation outcomes model.MethodsUsing data from the 20 practices randomized to the active (toolkit strategy) arm (education, redesign workbooks, online learning community, remote coaching), we identified 23 measures from practice member surveys, coach interviews, reports, and field logs to assess Toolkit acceptability, appropriateness, feasibility, and fidelity. A practice survey score was high (met expectations) if its average was ≥ 4 on a scale 1-5; all other data were coded dichotomously, with high = 1.ResultsRegarding acceptability, 74% (14) of practices had high scores for willingness of providers and staff to use the Toolkit and 68% (13) for quality improvement teams liking the Toolkit. For appropriateness, 95% (19) of practices had high scores for the structured process being a good match and 63% (12) for the Toolkit being a good match. Feasibility, measured by Toolkit prerequisites, was scored lower by site members at project end (e.g., provider leader available as champion: 53% of practices) compared to remote coaches observing practice teams (74%). For “do-ability,” coaches rated feasibility lower for practices (e.g., completion of workbook activities: 32%) than the practice teams (68%). Fidelity was low as assessed across seven measures, with 50% to 78% of practices having high scores across the seven measures.ConclusionsExisting data from large trials can be used to describe implementation outcomes. The Toolkit was not implemented with fidelity in at least one quarter of the sites, despite being acceptable and appropriate, possibly due to low feasibility in the form of unmet prerequisites and Toolkit complexity. Variability in fidelity reflects the importance of implementation strategies that fit each organization, suggesting that further study on contextual factors and use of the Toolkit, as well as the relationship of Toolkit use and study outcomes, is needed.Trial registrationClinicalTrials.gov NCT02868983; date of registration: 08/15/2016.