Public Primary Care Clinics Research Articles

The relationship between decline of the sexual life and postpartum depression among women with antenatal depression

Several factors are associated with sexual satisfaction during the postpartum period. However, there is a lack of studies among low-income women with depression during the previous pregnancy. The aim of the present study was to estimate the prevalence of Decline of Sexual Life (DSL) and its relationship with postpartum depression (PPD), at 6 to 9 months after childbirth, in a primary care sample of mothers who had antenatal depression. We performed a cross-sectional, secondary analysis from a cluster, with 356 postpartum women from public primary care clinics in São Paulo, Brazil. The main outcome measure was the women's perception of DSL after pregnancy/delivery. The main exposure variable was PPD assessed with the Patient Health Questionnaire. A questionnaire evaluated self-perception of partner relationship and obstetric and socio-demographic maternal characteristics. Crude and adjusted Prevalence Ratios, with 95% confidence intervals, were calculated using Poisson regression. DSL occurred in 25.0% of postpartum women. In the multivariable analysis, PPD was associated with DSL and self-perception of partner relationship. In conclusion, DSL is common among postpartum women with a history of antenatal depression. The screening of sexual problems after childbirth should include assessment of PPD and perception of partner relationship, both variables amenable to interventions.

The Association Between Beliefs and Adherence to Inhaled Controller Medication Among Older Adults with Asthma: A Cross-Sectional Study in Primary Care.

BackgroundWhile illness perceptions and medication beliefs have been shown to be associated with inhaled corticosteroid (ICS) adherence in younger adults with asthma, their impact on older adults is less understood. This study aimed to determine the prevalence of ICS adherence among older Asian adults and to assess the association between ICS adherence, illness perceptions and medication beliefs.MethodsA questionnaire survey on older multi-ethnic Asian patients, aged ≥60 years, with physician-diagnosed asthma, was conducted in two Singapore public primary care clinics. The scores of the Medication Adherence Report Scale for asthma (MARS) were computed to determine the adherence to ICS alone or in combination with LABA. Illness perceptions and medication beliefs were assessed by the scores from the Brief-Illness Perception Questionnaire (B-IPQ) and Beliefs about Medications Questionnaire (BMQ), respectively. Logistic regression analyses were used to identify factors associated with ICS adherence.ResultsAnalyses of 323 participants (57% males; Chinese 73.7%, Malay 12.7%, Indian 12.4%; mean age 71.5 years) showed that 40.9% of them had good adherence to ICS (mean MARS score≥4.5). Good adherence to ICS was associated with perception of asthma as a chronic illness (OR=1.22; 95% CI=1.10–1.35; p<0.001), belief of ICS as an essential medication (2.67; 1.76–4.06; p<0.001) and fewer concerns about its use (0.39; 0.26–0.60; p<0.001). Patients on combined ICS-LABA therapy had higher adherence (2.50; 1.41–4.44; p=0.02) than those on ICS monotherapy.ConclusionFour in ten older patients with asthma were adherent to ICS. Perception of medication necessity, chronicity of illness, concerns and use of ICS-LABA medication were associated with adherence.

The Association Between Health Literacy and Quality of Life and Its Associated Factors Among Adults with Type 2 Diabetes Mellitus in Public Primary Care Clinic

Introduction: Low health literacy (HL) is one of the contributing factors that leads to negative diabetic outcome. Quality of life (QOL) is a state of complete physical, mental and social wellbeing. There is limited evidence on association of HL and QOL among type 2 diabetes mellitus (T2DM), therefore the objectives of this study were to identify the HL and QOL status, to determine the association between HL and QOL and factors associated with QOL among T2DM patients. Methods: This was a cross sectional study involving patients with T2DM from two public primary care clinics. HL and QOL were measured using translated and validatedHLS – Asia Q16 and DQoL-BCI questionnaires respectively among T2DM patients. Results: The mean HL score was 12.39 (3.34), 17.7 % had “inadequate HL”, 25.7% had “problematic HL” and 56.6% had “sufficient HL”. The mean DQoL-BCI score was 32.09 (6.51). Lower QOL level was negatively associated with age (b -0.140; CI: -0.190, - 0.090; p&lt;0.001), not obese (b -1.476; CI: -2.605, - 0.347; p&lt;0.011), and HL level (b -0.425; CI: -0.59, - 0.259; p&lt;0.001). Lower QOL level was positively associated with uncontrolled glycaemic status (HbA1c &gt;6.5%)(b 1.308; CI: -0.042, 2.659; p&lt;0.058), treatment with insulin (b 4.163; CI:1.538, 6.788; p&lt;0.002) and combination treatment of insulin and oral hypoglycaemic agents (OHA) (b 2.450; CI:1.145, 3.756; p&lt;0.001). Conclusions: This study demonstrated that age, body mass index, HL, glycaemic control, treatment with OHA and insulin were significantly associated with QOL. This suggest the importance of identifying high risk patients with poor QOL for targeted intervention.

Intra-cluster correlation coefficients in primary care patients with type 2 diabetes and hypertension

IntroductionThere are few sources of published data on intra-cluster correlation coefficients (ICCs) amongst patients with type 2 diabetes (T2D) and/or hypertension in primary care, particularly in low- and middle-income countries. ICC values are necessary for determining the sample sizes of cluster randomized trials. Hence, we aim to report the ICC values for a range of measures from a cluster-based interventional study conducted in Malaysia.MethodBaseline data from a large study entitled Evaluation of Enhanced Primary Health Care interventions in public health clinics (EnPHC-EVA: Facility) were used in this analysis. Data from 40 public primary care clinics were collected through retrospective chart reviews and a patient exit survey. We calculated the ICCs for processes of care, clinical outcomes and patient experiences in patients with T2D and/or hypertension using the analysis of variance approach.ResultsPatient experience had the highest ICC values compared to processes of care and clinical outcomes. The ICC values ranged from 0.01 to 0.48 for processes of care. Generally, the ICC values for processes of care for patients with hypertension only are higher than those for T2D patients, with or without hypertension. However, both groups of patients have similar ICCs for antihypertensive medications use. In addition, similar ICC values were observed for clinical outcomes, ranging from 0.01 to 0.09. For patient experience, the ICCs were between 0.03 (proportion of patients who are willing to recommend the clinic to their friends and family) and 0.25 (for Patient Assessment of Chronic Illness Care item 9, Given a copy of my treatment plan).ConclusionThe reported ICCs and their respective 95% confidence intervals for T2D and hypertension will be useful for estimating sample sizes and improving efficiency of cluster trials conducted in the primary care setting, particularly for low- and middle-income countries.

Prevalence and factors associated with adherence to anti-hypertensives among adults with hypertension in a developed Asian community: A cross-sectional study

Introduction: Poor adherence to anti-hypertensive medications (AHM) results in hypertension treatment failure. Understanding and addressing the factors associated with adherence to AHM may potentially improve health outcomes. This study aimed to assess the prevalence and factors associated with patients’ adherence to AHM in a developed Asian community. Methods: An assistant-administered questionnaire survey was conducted on multi-ethnic Asian adults aged 31–80 years with essential hypertension based on their electronic health records (EHR) at a public primary-care clinic. Data on their demographic characteristics, clinical measurements of blood pressure and body mass index, co-morbidities and prescriptions from the EHR, along with the Medication Adherence Report Scale-5 scores were collated, audited and analysed. A MARS-5 score of &lt;25 indicated poor adherence. Logistic regression was used to identify factors associated with adherence to AHM. Results: Data of 395 patients were analysed. Of these, 179 (45.3%) had poor adherence to at least one AHM. Bivariate analysis showed that poor adherence was significantly associated with lower mean age (59 years old vs. 63 years old), higher mean clinic diastolic blood pressure (76 mmHg vs. 73 mmHg) and higher mean weight (70.4 kg vs. 67.4 kg). Logistic regression showed that patients with no co-morbidities (such as diabetes mellitus, dyslipidaemia, stroke and ischaemic heart disease) had better medication adherence (MA; odds ratio=1.98; 95% confidence interval 1.14–3.45; p=0.02). There was no significant MA difference between the classes, dose frequency and number of AHM. Conclusion: Almost half of the patients had poor adherence to at least one AHM. Co-morbidity significantly influenced their MA. Attention should be directed to patients with co-morbidities to assess their AHM adherence.

Effectiveness of the EMPOWER-PAR Intervention on Primary Care Providers’ Adherence to Clinical Practice Guideline on the Management of Type 2 Diabetes Mellitus: A Pragmatic Cluster Randomised Controlled Trial

AIM: The objective of this study was to evaluate the effectiveness of the EMPOWER- participatory action research (PAR) intervention, a multifaceted strategy based on the chronic care model (CCM) on primary care providers (PCP)’ adherence to type 2 diabetes mellitus (T2DM) clinical practice guideline (CPG) in the Malaysian primary care setting.&#x0D; METHODS: This was a pragmatic cluster randomized controlled trial –PAR conducted in ten public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. The outcome measure was the absolute change in the proportion of PCP’s adherence to T2DM CPG captured using the “Indicators of Care Pro forma,” based on the recommendation by the Malaysian CPG on the Management of T2DM. Data were collected from the patients’ medical records, at baseline and at 1-year follow-up; and were analyzed using mixed method model.&#x0D; RESULTS: A total of 888 patients were recruited at baseline; 471 were in the intervention and 417 were in the control group. There was no significant demographic difference between the two groups at baseline except for ethnicity. At 1-year, 455 (96.6%) and 406 (97.3%) patients in the intervention and control groups completed the study, respectively. There were significant improvements in the absolute change in the proportion of PCPs’ adherence to T2DM CPG in the intervention group compared to the control group at 1-year follow-up in several indicators of care. These included the recording of BMI (0.6% vs. −1.8%, p&lt;0.001); performing foot examination (2.4% vs. 0.6%, p&lt;0.001); performing funduscopy/fundus photography (1.5% vs. 0.3%, p&lt;0.001); monitoring renal profile (0.9% vs. −0.6%, p=0.001); measuring urine protein (1.2% vs. 0.6%, p&lt;0.001), and giving lifestyle modification and self-management advice (1.2% vs. −0.3%, p&lt;0.001) in the intervention versus control groups, respectively.&#x0D; CONCLUSION: The EMPOWER-PAR intervention has been proven to be effective in improving the PCPs’ adherence to T2DM CPG in several indicators of care. Findings from this study provided objective evidence of the effectiveness of multifaceted intervention based on the CCM in the Malaysian public primary care setting.&#x0D; TRIAL REGISTRATION: Registered with: ClinicalTrials.gov: NCT01545401. Date of registration: 1st March 2012.

Assessing Tobacco Cessation Needs Among Persons Living With HIV in Brazil: Results From a Qualitative Interview Study.

With regard to tobacco cessation, persons living with HIV (PLWH) are an underserved population, given the high prevalence of use and lack of evidence-based cessation programs tailored to this population. This study examined barriers and facilitators to tobacco use and cessation among PLWH in southern Brazil. We interviewed a total of 36 PLWH: 26 current smokers, of whom eight had a previous diagnosis of pulmonary TB, and 10 former smokers. Motivations for smoking included anxiety relief, social influence, and habitual behaviors. Motivations to quit included bad smell/taste and consequences/symptoms. Barriers to cessation included cost of pharmacological aids, distance to treatment, and reluctance to seek tobacco cessation services at the public primary care clinics due to confidentiality concerns. Participants favored individual or group interventions, no-cost pharmacologic aids, and assured confidentiality. There are specific contextual factors associated with tobacco cessation among PLWH in Brazil, which have important clinical, research, and policy implications.

Knowledge, attitudes and practices with regard to sugar sweetened beverages and taxation among people with type 2 diabetes mellitus in the Caribbean island of Barbados – A cross sectional survey in primary care

AimsBarbados implemented a 10% tax on sugar sweetened beverages (SSBs) in 2015. We aimed to determine knowledge, attitudes and practices towards SSB consumption and taxation among people with type 2 diabetes (T2D) attending public sector primary care clinics in Barbados. MethodsPeople with T2D attending public sector clinics completed a survey including the Beverage Intake Questionnaire (BEVQ-15). Waist circumference was measured. ResultsOf 384 participants (34.6% male, median age 67 years, interquartile range 60–74 years, African descent 97.6%) 45.9% had diabetes diagnosed for >10 years, 30.7% used insulin, 31.8% had not seen a dietician since diabetes diagnosis, and 62.2% had abdominal obesity. Most (91.1%) thought that consuming SSB was unhealthy and 91% felt that reducing intake would be easy. Only 44.7% favoured the current 10% tax and 29.7% favoured a 20% tax. The median daily SSB consumption was 26.6ml (IQR 3.0–53.2). Responses did not differ by age, gender or abdominal obesity status (p>0.5). Weight loss was being attempted by 45.6% and 21.1% with and without abdominal obesity respectively (p<0.0001). ConclusionsWhile most felt SSB consumption is harmful and the median reported consumption contributes few calories to the diet, a minority supported the current tax.

The prevalence and factors associated with sarcopenia among community living elderly with type 2 diabetes mellitus in primary care clinics in Malaysia.

Sarcopenia is a recognised geriatric syndrome but few studies address its associated factors among elderly with type 2 diabetes mellitus (T2DM) in South East Asia. This study aimed to determine the prevalence of sarcopenia and its associated factors among the elderly with T2DM in public primary care clinics in Malaysia. This study utilised data from a longitudinal study of 506 adults with T2DM aged ≥60 years. Data on socio-demography, clinical and functional status, diet and levels of physical activity (PA) were collected. Sarcopenia was defined using Asian Working Group for Sarcopenia criteria and its associated factors were analysed using multiple logistic regression. The proportion of elderly with T2DM with sarcopenia was 28.5%. Those aged ≥70 years (β = 0.73;OR = 2.07; 95%CI = 1.24, 3.48; p = 0.006), men (β = 0.61; OR = 1.84; 95%CI = 1.12, 3.02; p = 0.017), with ≥10 years duration of diabetes (β = 0.62; OR = 1.85; 95%CI = 1.11, 3.09; p = 0.018), not using insulin sensitizers (β = -1.44; OR = 0.24; 95%CI = 0.08, 0.71; p = 0.010), using less than 5 medications (β = 0.68; OR = 1.98; 95%CI = 1.17, 3.36; p = 0.011), low body mass index (BMI) (β = -2.43; OR = 0.09; 95%CI = 0.05, 0.17; p<0.001), and engaging in low (β = 0.77; OR = 2.15; 95%CI = 1.07, 4.35; p = 0.032) and moderate physical activities (β = 0.80; OR = 2.23; 95%CI = 1.07, 4.66; p = 0.033) were associated with sarcopenia. Factors that predicts sarcopenia such as level of physical activity and body mass index were among the modifiable factors that could be used in developing future strategies to prevent or delay the progression of sarcopenia among elderly with T2DM to improve their health status.

Understanding the Turning Point of Patients with Diabetes.

BackgroundThe patient’s intention to engage in diabetes care is the hallmark of role acceptance as a health manager and implies one’s readiness to change. The study aimed to understand the process of having the intention to engage in diabetes care.MethodsA qualitative study using narrative inquiry was conducted at a public primary care clinic. Ten participants with type 2 diabetes of more than a 1-year duration were selected through purposive sampling. In-depth interviews were conducted using a semi-structured protocol guide and were audio-taped. The interviews were transcribed and the texts were analyzed using a thematic approach with the Atlas.ti ver. 8.0 software (Scientific Software Development GmbH, Berlin, Germany).ResultsThree themes emerged from the analysis. The first theme, “Initial reactions toward diabetes,” described the early impression of diabetes encompassing negative emotions, feeling of acceptance, a lack of concern, and low level of perceived efficacy. “Process of discovery” was the second overarching theme marking the journey of participants in finding the exact truth about diabetes and learning the consequences of ignoring their responsibility in diabetes care. The third theme, “Making the right decision,” highlighted that fear initiated a decision-making process and together with goal-setting paved the way for participants to reach a turning point, moving toward engagement in their care.ConclusionOur findings indicated that fear could be a motivator for change, but a correct cognitive appraisal of diabetes and perceived efficacy of the treatment as well as one’s ability are essentially the pre-requisites for patients to reach the stage of having the intention to engage.

Enhancing the triage and cohort of patients in public primary care clinics in response to the coronavirus disease 2019 (COVID-19) in Hong Kong: an experience from a hospital cluster.

The current COVID-19 outbreak has been characterised by the World Health Organisation (WHO) as a pandemic, as of 11 March 2020.1 The rapid spread and severity of the disease represents a global threat. Despite being geographically very close to the mainland China, where there were more than 80 000 confirmed cases, Hong Kong had successfully contained the number of confirmed cases to the relatively small number of 936 as of 7 April 2020. Among the confirmed cases, 538 (57.5%) were imported cases, 163 (17.4%) were local or possibly local cases, and 235 (25.1%) were close contacts of confirmed cases. Around 6% of patients had serious disease requiring intensive care, and four patients (0.4%) have died from the disease.2 Success in controlling the outbreak so far is likely due to proactively implemented government policies on travel and border controls; school and temporary work suspension; high level of public vigilance including the practice of wearing face mask in public areas;3 and good infection control in healthcare settings.4 In primary care settings, the prompt detection and effective triage and cohort of potentially infected patients are essential to prevent nosocomial infections among patients, healthcare workers, and visitors.5 ### The risks of COVID-19 in public primary care clinics in Hong Kong In Hong Kong, there are 73 General Outpatient Clinics (GOPCs) under the management of the Hospital Authority (HA), providing subsidised primary care services for patients with both episodic illnesses and chronic diseases. All healthcare workers in GOPCs received regular training and audit on infection control, including the proper use of personal protective equipment (PPE). During emergency response level for epidemic or pandemic of serious infectious disease, enhanced measures for infection prevention and control would be implemented, including: reinforcement of standard, contact, droplet, and airborne precautions (when performing aerosol generating procedures) for patient care; universal masking; provision of alcohol-based hand rub at convenient …

Association between intensive glycemic control and mortality in elderly diabetic patients in the primary care: A retrospective cohort study

ObjectiveTo examine the association between the most recent HbA1c values and the mortality of elderly Type 2 Diabetic (T2DM) patients managed in the public primary care setting and to explore the associating risk factors. DesignRetrospective cohort study. SubjectsAll T2DM patients aged 65 or above, who attended a public primary care clinic for regular follow up from 01/01/2012 to 31/12/2012 were included. Their follow up status till 31/12/2017 was reviewed. Those who were deceased on or before 31/12/2017 were matched randomly with controls that were alive in the same cohort for comparison. Main Outcome MeasuresPatients’ demographics, smoking status, duration of T2DM, biochemical parameters including the most recent HbA1c, lipid profile, renal function test, drug profile, co-morbidities and all-cause mortality were retrieved from Hospital Authority’s CDARS and CMS systems. ResultsBoth high (>8.0%) and low (<6.5%) HbA1c values were associated with increased odd ratio of all-cause mortality among T2DM elderly patients treated in the primary care. There was a 3-fold increase in odd ratio when the HbA1c reading was very low (<6.0%). Associated risk factors for all-cause mortality in elderly T2DM patients included smoker status, lower BMIs, and higher LDL levels and use of sulphonylureas. ConclusionsGlycemic target for elderly T2DM patients should be approached cautiously. Over-aggressive treatment may lead to increased mortality among elderly T2DM patients.

Incidence of and Risk factors for Mild Cognitive Impairment in Chinese Older Adults with Multimorbidity in Hong Kong

The aim of our study was to identify the incidence rate of and the risk factors for mild cognitive impairment (MCI) among Chinese older adults with multimorbidity in primary care in Hong Kong. Older adults aged 60 years and above with multimorbidity were recruited from the public primary care clinics in Hong Kong. Incidence rates were calculated with the person-years. Cox proportional hazard regression models were used to predict the risk factors for MCI. Sensitivity analysis was performed using multiple imputation. Among 462 participants included in the main analysis, 45 progressed from normal to MCI with an incidence rate of 80.9 cases per 1000 person-years. Older age (HR 2.82, 95% CI 1.26–6.28) and being single (HR 2.15, 95% CI 1.11–4.19) were risk factors for developing MCI in the multivariable regression model. A total of 660 participants were included in the sensitivity analysis, with an MCI incidence of 114.4 cases per 1000 person-years. Older age and being single remained to be risk factors for MCI among older adults with multimorbidity. There may be a high incidence of MCI among Chinese older adults with multimorbidity in primary care in Hong Kong. Future larger studies need to confirm the prevalence and incidence of MCI among primary care Chinese patients.

Lower Urinary Tract Symptoms: Prevalence and Factors Associated with Help-Seeking in Male Primary Care Attendees.

BackgroundLower urinary tract symptoms (LUTS) are common among elderly men. However, seeking help for this problem is mostly delayed until complications arise. Primary care clinics serve as the first point of contact for a person’s health needs throughout their life. This study aimed to determine the prevalence of LUTS among primary care attendees, and the factors that influence seeking medical intervention at primary care clinics.MethodsUsing a universal sampling technique, 460 male patients aged 60 and above visiting an urban based public primary care clinic were recruited. An interviewer administered the questionnaire which used International Prostate Symptoms Score and International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms-Quality of Life.ResultsThe prevalence of any LUTS and clinically significant LUTS were 89.8% and 20.5%, respectively. Among the 385 participants who completed the study, only 41.8% had consulted a doctor for LUTS. Among those with moderate/severe symptoms only 57.6% had sought medical intervention. Multiple logistic regression analysis showed that the presence of more than two comorbidities (P=0.004; odds ratio [OR], 4.695; 95% confidence interval [CI], 1.632–13.508) and quality of life (P=0.002; OR, 1.271; 95% CI, 1.091–1.481) were independent factors significantly associated with seeking help.ConclusionPrevalence of LUTS among elderly men undergoing primary care is high, but more than half of the patients had not sought medical attention. Increasing comorbidities and impact on quality of life influenced elderly men with LUTS to seek help.

Assessment of willingness to Tele-monitoring interventions in patients with type 2 diabetes and/or hypertension in the public primary healthcare setting

BackgroundTele-monitoring (TM) is remote monitoring of individuals via info-communication technology, enabling them and their relatives or care-providers to recognize their health status conveniently. TM will be successful only if the individuals, often patients with medical conditions, are willing to accept and adopt it in their daily lives. This study aimed to determine the prevalence of willingness of patients with type 2 diabetes mellitus (T2DM) and/or hypertension towards the use of TM, and the factors influencing their uptake.MethodsA cross-sectional survey was conducted at two public primary care clinics (polyclinics) in north-eastern Singapore, where TM had not been implemented. After the patients with T2DM and/or hypertension consented after fulfilling the eligibility criteria, they were first introduced to the concept of TM using pictogram and explanation by the investigators. Data on their demography, clinical parameters, technological literacy and acceptance of TM based on the Health Information Technology Acceptance Model (HITAM) were subsequently collected, computed, analyzed, followed by regression analyses to identify the factors associated with their willingness to use TM.ResultsAmong 1125 eligible multi-ethnic Asian patients approached, 899 of them completed the assisted questionnaire survey, yielding a response rate of 79.9%. Their mean age was 58 ± 8 years, females 51.3% and Chinese 69.3%. Overall, 53.0% of the patients were willing to use TM. Personal beliefs on technology (OR = 3.54, 95%CI = 2.50–4.50, p < 0.001), prior technology utility (OR = 3.18, 95%CI = 1.57–6.42, p = 0.001), Patient’s requirements to be accompanied (OR = 1.48, 95% CI = 1.054–2.082, P = 0.03) Cost considerations (OR = 2.96, 95% CI = 2.257–3.388, P < 0.01) and technological literacy (OR = 2.77, 95%CI = 2.05–3.38, p < 0.001) were associated with willingness to use TM.ConclusionSlightly over half of the patients were willing to use TM. Factors such as age, ethnicity, technological literacy, beliefs and previous utility of technology of the patients have to be addressed before implementing TM in primary care.

How Spillovers from Appointment Reminders Improve Health Clinic Efficiency

Missed clinic appointments present a significant burden to health care through disruption of care, inefficient use of staff time and wasted clinical resources. Short message service (SMS) appointment reminders show promise to improve clinics’ management through timely appointment cancellations and efficient re-scheduling, but evidence from large-scale interventions is missing. We study a nationwide SMS appointment reminder program in Chile for chronic disease patients at public primary care clinics. Using longitudinal clinic-level data we find that after two years the program increased clinics’ total number of visits per by 5.1% on average. The program did not change the number of visits by chronic patients eligible to receive the reminder, but it instead increased visits by other patients, ineligible to receive reminders in clinics that adopted the program by 7.4% on average. These results suggest that the appointment reminder systems increased clinics’ ability to care for more patients through timely cancellations and re-scheduling.

Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial.

Poor adherence to medications is more prevalent for chronic obstructive pulmonary disease (COPD) than for other chronic conditions and is associated with unfavorable health outcomes. Few interventions have successfully improved adherence for COPD medications; none of these use unlicensed health care personnel. We explored the efficacy of lay health coaches to improve inhaler adherence and technique. Within a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from urban, public primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive 9 months of health coaching or usual care. Outcome measures included self-reported adherence to inhaled controller medications in the past 7 days and observed technique for all inhalers. We used generalized linear models, controlling for baseline values and clustering by site. Baseline adherence and inhaler technique were uniformly poor and did not differ by study arm. At 9 months, health-coached patients reported a greater number of days of adherence compared with usual care patients (6.4 vs 5.5 days; adjusted P = .02) and were more likely to have used their controller inhalers as prescribed for 5 of the last 7 days (90% vs 69%; adjusted P = .008). They were more than 3 times as likely to demonstrate perfect technique for all inhaler devices (24% vs 7%; adjusted P = .01) and mastery of essential steps (40% vs 11%; adjusted P <.001). Health coaching may provide a scalable model that can improve care for people living with COPD.

Factors associated with level of shared decision making in Malaysian primary care consultations

ObjectiveTo measure the level of shared decision-making (SDM) in primary care consultations in Malaysia, a multicultural, middle-income developing country. MethodsA cross-sectional study was conducted in an urban, public primary care clinic. Convenience sampling was used to recruit participants, and audio-recorded consultations were scored for SDM levels by two independent raters using the OPTION tool. Univariate and multivariate analysis was conducted to determine factors significantly associated with SDM levels. Results199 patients and 31 doctors participated. Mean consultation time was 14.3 min (+ SD 5.75). Patients’ age ranged from 18 to 87 years (median age of 57.5 years). 52.8 % of patients were female, with three main ethnicities (Malay, Chinese, Indian). The mean OPTION score was found to be 7.8 (+ SD 3.31) out of 48. After a multivariate analysis, only patient ethnicity (β= -0.142, p < 0.05) and increased consultation time (β = 0.407, p < 0.01) were associated with higher OPTION scores. ConclusionsPatients in Malaysia experience extremely poor levels of SDM in general practice. Higher scores were associated with increased consultation time and patient ethnicity. Practice implicationsMalaysian general practitioners should aim to develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities.

The mediating role of sleep quality in the association between nocturia and health-related quality of life

BackgroundEven though the negative impacts of nocturia on sleep quality and health-related quality of life (HRQOL) have been documented in previous research, their interrelationship has been poorly studied. This study aimed to explore whether nocturia would affect sleep quality, which in turn affects HRQOL.MethodsParticipants aged 40 and above were randomly recruited from a Hong Kong public primary care clinic. Participants were asked to report the average number of nocturia (waking up at night to void) pisodes per night over a 1-month period. The Pittsburgh Sleep Quality Index (PSQI) and the 12-Item Short Form Health Survey version 2 (SF-12 v2) were administered. The mediation analysis was tested using multistage regression approach and bootstrap method.ResultsOf the 500 subjects who completed the survey, 31.2% reported symptomatic nocturia (having ≥2 nocturia episodes per night), and 60.4% experienced poor sleep quality (a PSQI global score > 5). Respondents with symptomatic nocturia had a poorer HRQOL in the domains of physical functioning (PF), role physical (RP) and social functioning (SF), general health (GH), vitality (VT) and physical component summary (PCS) of the SF-12 v2 than those without. Compared with the respondents without poor sleep quality, those with poor sleep quality had poorer HRQOL across all domains and summaries of the SF-12 v2. Mediation analysis found that sleep quality fully mediated the association between nocturia and the PF, RP and SF domains of the SF-12 v2, respectively, and partially mediated the association between nocturia and the GH, VT and PCS domains of the SF-12 v2, respectively.ConclusionsWe found that sleep quality mediated the association between nocturia and HRQOL. To enhance the HRQOL of patients with nocturia, clinicians should not only focus on nocturia symptoms, but also on their sleep quality.

Job satisfaction of public and private primary care physicians in Malaysia: analysis of findings from QUALICO-PC

BackgroundJob satisfaction of doctors is an important factor determining quality and performance of a health system. The aim of this study was to assess job satisfaction among doctors of the public and private primary care clinics in Malaysia and evaluate factors that could influence the job satisfaction rating.MethodsThis study was part of the Quality and Costs of Primary Care (QUALICOPC) Malaysia, a cross-sectional survey conducted between August 2015 and June 2016 in Malaysia. Data was collected from doctors recruited from public and private primary care clinics using a standardised questionnaire. Comparisons were made between doctors working in public and private clinics, and logistic regression analysis was used to determine factors influencing the likelihood of job satisfaction outcomes.ResultsA total of 221 doctors from the public and 239 doctors from the private sector completed the questionnaire. Compared to private doctors, a higher proportion of public doctors felt they were being overloaded with the administrative task (59.7% vs 36.0%) and part of the work does not make sense (33.9% vs 18.4%). Only 62.9% of public doctors felt that there was a good balance between effort and reward while a significantly higher proportion (85.8%) of private doctors reported the same. Over 80% of doctors in both sectors indicated continued interest in their job and agreed that being a doctor is a well-respected job. Logistic regression analysis showed public-private sector and practice location (urban-rural) to be significantly associated with work satisfaction outcomes.ConclusionA higher proportion of public doctors experienced pressure from administrative tasks and felt that part of their work does not make sense than their colleague in the private sector. At the same time, the majority of private doctors reported positive outcome on effort-and-reward balance compared to only one third of public doctors. The finding suggests that decreasing administrative workload and enhancing work-based supports might be the most effective ways to improve job satisfaction of primary care doctors because these are some of the main aspects of the job that doctors, especially in public clinics, are most unhappy with.