Public Primary Health Care System Research Articles

Jabula Uzibone: Protocol for an Implementation Study of Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Healthcare System (Preprint)

Jabula Uzibone: Protocol for an Implementation Study of Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Healthcare System (Preprint)

Reflections of nurses and primary healthcare managers on integrating hospital at home into public primary healthcare services: a Norwegian focus group study

Background Hospital at home (HaH) is an innovative approach to healthcare delivery that brings specialized services to patients’ homes. HaH services are typically available in urban areas where hospitals can easily reach nearby patients. An integrated care model that utilizes the public primary healthcare system may extend HaH services to include patients residing further away from hospitals. However, there is limited evidence of primary healthcare employees’ views on integrating HaH care into primary healthcare services. This study aimed to explore the reflections of primary healthcare employees on integrating HaH care into primary healthcare services. Methods Ten focus group interviews were conducted with homecare nurses and managers of primary healthcare services in five municipalities in Mid-Norway. Reflexive thematic analysis was used to analyze the data. Results The analysis resulted in three key themes regarding the integration of HaH care into primary healthcare. Participants discussed how they capture the distinctiveness of HaH care within the primary healthcare landscape. Moreover, they identified that the introduction of HaH care reveals opportunities to address challenges. Lastly, the study uncovered a strong primary healthcare commitment and a sense of professional pride among the participants. This resilience and dedication among primary healthcare employees appeared as an incentive to make the integration of HaH work. Conclusions This study offers valuable insights into integrating HaH into primary healthcare services, highlighting opportunities to address challenges. The resilience and dedication of primary healthcare employees underscore their commitment to adapting to and thriving with HaH care. To establish a sustainable HaH care model, it is important to address geographical limitations, consider the strain on providers, maintain robust relationships, enhance funding, and formalize decision-making processes.

LGBTQI+ Experiences of HIV Management Services at Primary Healthcare Facilities in Gauteng Province, South Africa

Lesbian, gay, bisexual, transgender, queer, intersex, and plus (LGBTQI+) people are still discriminated against in South Africa, irrespective of their protection by the constitution of South Africa. The study explores the experiences of LGBTQI+ people when accessing HIV management services at public primary healthcare (PHC) facilities in Gauteng Province. Interpretive phenomenological analysis (IPA) was used. Data were collected through in-depth face-to-face interviews with six individuals who self-identified as LGBTQI+. The interviews were audio recorded with the permission of the participants. The data were transcribed verbatim and analyzed using the IPA framework. The findings indicate that LGBTQI+ people are marginalized, discriminated against, and stigmatized in the public PHC system, exposing them to unequal access to healthcare services. The heterocentric system disadvantages them from accessing specific HIV management services and appropriate preventive commodities. The study concludes that gender diversity, inclusion and sensitivity in healthcare provision, and specific LGBTQI+ training for healthcare providers, are crucial components of ensuring LGBTQI+ people’s access to quality HIV management services.

Community pharmacy and primary health care - Types of integration and their applicability: A narrative review.

There is an urgent need for health care systems to be more efficient and efficacious. An approach to integrate public and private provider organizations such as community pharmacies and public primary health care (PHC) merits consideration. The objective of this review was to identify the types of integration in health care settings and discuss their applicability to the potential integration of community pharmacy and PHC. A narrative review using Medline, Scopus and SciELO databases was performed in which terms related to health were combined with terms related to integration. Levels and Types of integration: 14 types of integration were identified (two in breadth, seven as enablers and five in system levels). A model was created which classifies and assigns the types of integration to the different levels of the health system and to the breadth, intensity, and enablers of the integration process. Due to the nature of community pharmacy and PHC system, a horizontal integration at the micro level, supported by meso and macro levels policy, is suggested. The different elements of intensity and enablers can significantly influence the process. The application of principles, concepts and types of integration suggest that it might be feasible and practical to integrate community pharmacies and PHC. However, the conflictive historical context would need to be overcome with appropriate policy and incentives.

Informal Providers-Ground Realities in South Asian Association for Regional Cooperation Nations: Toward Better Cancer Primary Care: A Narrative Review.

South Asian Association for Regional Cooperation (SAARC) nations are a group of eight countries with low to medium Human Development Index values. They lack trained human resources in primary health care to achieve the WHO-stated goal of Universal Health Coverage. An unregulated service sector of informal health care providers (IPs) has been serving these underserved communities. The aim is to summarize the role of IPs in primary cancer care, compare quality with formal providers, quantify distribution in urban and rural settings, and present the socioeconomic milieu that sustains their existence. A narrative review of the published literature in English from January 2000 to December 2021 was performed using MeSH Terms Informal Health Care Provider/Informal Provider and Primary Health Care across databases such as Medline (PubMed), Google Scholar, and Cochrane database of systematic reviews, as well as World Bank, Center for Global Development, American Economic Review, Journal Storage, and Web of Science. In addition, citation lists from the primary articles, gray literature in English, and policy blogs were included. We present a descriptive overview of our findings as applicable to SAARC. IPs across the rural landscape often comprise more than 75% of primary caregivers. They provide accessible and affordable, but often substandard quality of care. However, their network would be suitable for prompt cancer referrals. Care delivery and accountability correlate with prevalent standards of formal health care. Acknowledgment and upskilling of IPs could be a cost-effective bridge toward universal health coverage and early cancer diagnosis in SAARC nations, whereas state capacity for training formal health care providers is ramped up simultaneously. This must be achieved without compromising investment in the critical resource of qualified doctors and allied health professionals who form the core of the rural public primary health care system.

Ten-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Macrovascular and Microvascular Complications and All-Cause Mortality: A Population-Based Cohort Study.

The Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) is a protocol-driven, risk-stratified, and individualized management program offered by a multidisciplinary team in addition to usual care for primary care patients with diabetes. This study aimed to evaluate the effectiveness of RAMP-DM for preventing complications and mortality over 10 years. A population-based, prospective cohort study of adult patients with type 2 diabetes managed in the Hong Kong public primary health care system between 2009 and 2010 was conducted. RAMP-DM participants and usual care patients were matched using one-to-one propensity score matching and followed for 10 years. Risks of macrovascular and microvascular complications and all-cause mortality were estimated by Cox proportional hazards regression. A total of 36,746 patients (18,373 in each group) were included after propensity score matching, with a median follow-up of 9.5 years and 306,802 person-years. RAMP-DM participants had significantly lower risks of macrovascular (hazard ratio [HR] 0.52, 95% CI 0.50-0.54) and microvascular (HR 0.68, 95% CI 0.64-0.72) complications and all-cause mortality (HR 0.45, 95% CI 0.43-0.47) than patients who received usual care only. However, the effect of RAMP-DM on macrovascular and microvascular complications attenuated after the 9th and 8th year of follow-up, respectively. RAMP-DM participants also showed better control of hemoglobin A1c, blood pressure, triglycerides, and BMI and a slower decline in renal function. Significant reductions in diabetes-related complications and all-cause mortality were observed among RAMP-DM participants over a 10-year follow-up, yet the effect of preventing complications attenuated after 8 years.

Measuring Organizational Culture in Ethiopia's Primary Care System: Validation of a Practical Survey Tool for Managers.

Organizational culture has been widely recognized as predictive of health system performance and improved outcomes across various healthcare settings. Research on organizational culture in healthcare has been largely conducted in high-income settings, and validated scales to measure this concept in primary healthcare systems in low- and middle-income country (LMIC) settings are lacking. Our study aimed to validate a tool to measure organizational culture in the context of the Ethiopian Primary Healthcare Transformation Initiative (PTI), a collaborative of the Federal Ministry of Health (FMoH) and the Yale Global Health Leadership Initiative to strengthen primary healthcare system performance in Ethiopia. Following established survey development and adaptation guidelines, we adapted a 31-item US-based organizational culture scale using (1) cognitive interviewing, (2) testing with 1176 district and zonal health officials from four regions in Ethiopia, and (3) exploratory factor analysis (EFA). Based on the results of cognitive interviewing, an adapted 30-item survey was piloted. The factor analyses of 1034 complete surveys (88% complete responses) identified five constructs of the scale which demonstrated strong validity and internal consistency: learning and problem solving, psychological safety, resistance to change, time for improvement, and commitment to the organization. Of the 30 a priori items, 26 items loaded well on the five constructs (loading values 0.40-0.86), and 4 items failed to load. Cronbach alpha coefficients were 0.86 for the scale as a whole and ranged from 0.65 to 0.90 for the subscales. The five-factor solution accounted for 62% of total variance in culture scores across respondents. Through validation and factor analyses, we generated a 26-item scale for measuring organizational culture in public primary healthcare systems in LMIC settings. This validated tool can be useful for managers, implementers, policy-makers, and researchers to assess and improve organizational culture in support of improved primary healthcare system performance.

Primary care provider notions on instituting community-based geriatric support in Uganda

BackgroundUnderstanding of the most economical and sustainable models of providing geriatric care to Africa’s rising ageing population is critical. In Uganda, the number of old adults (60 years and above) continues to rise against absence of policies and guidelines, and models for providing care to this critical population. Our study explored public primary health care provider views on how best community-based geriatric support (CBGS) could be instituted as an adaptable model for delivering geriatric care in Uganda’s resource-limited primary public health care settings.MethodsWe interviewed 20 key informants from four districts of Bukomansimbi, Kalungu, Rakai, and Lwengo in Southern Central Uganda. Respondents were leads (in-charges) of public primary health units that had spent at least 6 months at the fore said facilities. All interviews were audio-recorded, transcribed verbatim, and analysed based on Hsieh and Shannon’s approach to conventional manifest content analysis.ResultsDuring analysis, four themes emerged: 1) Structures to leverage for CBGS, 2) How to promote CBGS, 3) Who should be involved in CBGS, and 4) What activities need to be leveraged to advance CBGS? The majority of the respondents viewed using the existing village health team and local leadership structures as key to the successful institutionalization of CBGS; leveraging community education and sensitization using radio, television, and engaging health workers, family relatives, and neighbors. Health outreach activities were mentioned as one of the avenues that could be leveraged to provide CBGS.ConclusionProvider notions pointed to CBGS as a viable model for instituting geriatric care in Uganda’s public primary healthcare system. However, this requires policymakers to leverage existing village health team and local governance structures, conduct community education and sensitization about CBGS, and bring onboard health workers, family relatives, and neighbors.

Potential drug therapy problems: identification and associated factors among Primary Health Care users

Cardiovascular diseases (CVD) and diabetes mellitus (DM) are chronic non-communicable diseases with high prevalence. Several factors contribute to its lack of control, especially those related to pharmacotherapy, often leading to problems related to the use of medication (DTP). Objective: To identify potential DTPs for the treatment of CVD and DM, as well as associated factors, using big data from users of the Unified Health System (SUS) in a municipality. Methods: A cross-sectional study was carried out based on big data of patients for whom at least one medication was dispensed in SUS pharmacies in the primary healthcare network in April 2019 (n = 4,800). Potential DTPs involving the treatment of CVD or DM were identified based on data on medications dispensed, demographic and clinical characteristics. To classify these potential PRMs, the Pharmacotherapy Workup method was used. Logistic regression analyzes were performed to identify factors associated with identifying at least one potential MRP. Results: The results showed that 25% of the population had at least one potential DTP, with a total of 1,914 potential PRMs being identified. In the multivariate model, age group was statistically associated with the identification of at least one potential DTP. Conclusions: This study allows tracing the frequency of important potential DTPs and associated factors, pointing out some priorities that must be addressed by the public primary health care system, supporting the planning of the implementation of drug therapy management services aimed at the studied population.

Risk factor management of type 2 diabetic patients in primary care in the Scandinavian countries between 2003 and 2015

AimsTo observe and report population demography, comorbidities, risk factor levels and risk factor treatment in a sample of individuals treated for type 2 diabetes in primary care in Norway, Sweden and Denmark. MethodsRetrospective observational cohort using extraction of data from electronic medical records linked with national health care registries. ResultsSixty primary care clinics participated with annual cross-sectional data (2003 to 2015). In 2015 the sample consisted of 31,632 individuals. Mean age (64.5–66.8 years) and proportion of women (43–45%) were similar. The prevalence of cardiovascular disease in 2015 was 40.7%, 41.6% and 38.0% for Norway, Sweden and Denmark, respectively and 84% to 89% of patients were receiving a pharmacological anti-diabetic treatment. More Danish patients reached targets for HbA1c and LDL cholesterol, while more patients in Sweden and Denmark met the blood pressure target of <130/80 mmHg as compared to Norway. ConclusionsIn three comparable public primary health care systems we found a high prevalence of cardiovascular disease and differences in risk factor treatment and attainment of risk factor goals. With recent guideline changes there is potential for further prevention of diabetes complications in primary care in the future.

Design of a cluster-randomized trial of the effectiveness and cost-effectiveness of metformin on prevention of type 2 diabetes among prediabetic Mexican adults (the PRuDENTE initiative of Mexico City)

IntroductionType 2 diabetes (T2D) is a global epidemic, and nations are struggling to implement effective healthcare strategies to reduce the burden. While efficacy studies demonstrate that metformin can reduce incident T2D by half among younger, obese adults with prediabetes, its real-world effectiveness are understudied, and its use for T2D prevention in primary care is low. We describe the design of a pragmatic trial to evaluate the incremental effectiveness of metformin, as an adjunct to a simple lifestyle counseling. MethodsThe “Prevención de la Diabetes con Ejercicio, Nutrición y Tratamiento” [Diabetes Prevention with Exercise, Nutrition and Treatment; PRuDENTE, (Spanish acronym)] is a cluster-randomized trial in Mexico City's public primary healthcare system. The study randomly assigns 51 clinics to deliver one of two interventions for 36 months: 1) lifestyle only; 2) lifestyle plus metformin, to 3060 patients ages 30–65 with impaired fasting glucose and obesity. The primary endpoint is incident T2D (fasting glucose ≥126 mg/dL, or HbA1c ≥6.5%). We will also measure a range of implementation-related process outcomes at the clinic-, clinician- and patient-levels to inform interpretations of effectiveness and enable efforts to refine, adapt, adopt and disseminate the model. We will also estimate the cost-effectiveness of metformin as an adjunct to lifestyle counseling in Mexico. DiscussionFindings from this pragmatic trial will generate new translational knowledge in Mexico and beyond, both with respect to metformin's real-world effectiveness among an ‘at-risk’ population, and uncovering facilitators and barriers to the reach, adoption and implementation of metformin preventive therapy in public primary care settings. Trial registrationThis trial is registered at Clinicaltrials.gov (NCT03194009).

Availability of Analgesic and Anti-Inflammatory Medicines in Primary Health Care

Objective: To describe and analyze the availability and factors related to the presence of analgesics and non-steroidal anti-inflammatory drugs in the Brazilian public primary healthcare system. Material and Methods: This was a cross-sectional study that evaluated 17,903 health units that participated in the National Program for Primary Care Access and Quality Improvement (2013-2014). The dependent variable was defined as the presence of metamizole, ibuprofen, and acetaminophen in a sufficient amount. The independent variables included the type of primary health care unit, the presence of a medication disposal area, the number of physicians, nurses, and dental practitioners; and the number of primary care units with family and oral health teams. For statistical analysis, unadjusted and adjusted Odds Ratio (OR) (95% CI) were presented. Results: The three medicines were available in 62.4% of the units. Regarding Health Clinics, the Basic Health Units (OR= 1.31, CI95% 1.18-1.44), Polyclinic (OR= 2.00, 95% CI, 1.15 -3.48), and others (OR= 1.37; 95% CI 1.14-1.63) had higher chances of availability of all three drugs. The presence of a disposal area (OR = 1.64, 95% CI 1.51-1.77) and the number of physicians (OR= 1.04, 95% CI 1.00-1.08), nurses (OR= 1.08, 95% CI 1.03- 1.13), and dental practitioners (OR= 1.09, 95% CI 1.04-1.14) increased the availability odds of the analyzed drugs in the service. Conclusion: The structure of the healthcare units and the higher number of professionals were positively associated with the availability of these drugs.

Stakeholder Engagement in the Translation of a Hypertension Control Program to Guatemala's Public Primary Health Care System: Lessons Learned, Challenges, and Opportunities

BackgroundThere is an urgent need to define appropriate intervention strategies to control blood pressure in low- and middle-income countries. In 2018, a program proven effective in Argentina was translated to Guatemala's public primary health care system in rural and primarily indigenous communities. ObjectivesThis paper describes the stakeholder engagement process used to adapt the program to the Guatemalan rural context prior to implementing a type II hybrid effectiveness-implementation trial and shares lessons learned. MethodsWe identified key differences in the 2 contexts that are relevant to translating the intervention to the Guatemalan context. Alongside interviews and focus group discussions, we conducted consultation workshops in July and August 2018, applying a participatory translation process involving patients, family members, community members, health care providers, and Ministry of Health officials. The process consisted of multiple meetings in Guatemala City, as well as meetings in each of the 5 departments where the study will be implemented, and 1 district per department. During the workshops, we presented the evidence-based experience from Argentina and then focused on the challenges and recommended solutions that the participants identified for each of the intervention's 6 components. The process concluded with a meeting in which the research team and Ministry of Health officials defined specific details of the intervention. ResultsThe outcome of the process is an adapted approach appropriate to integrate into Guatemala's public primary health care system in the trial phase. The approach considers the challenges and recommended strategies for each of the 6 intervention components. ConclusionsWe identified lessons learned, challenges, and opportunities during the adaptation process. Findings will inform ongoing stakeholder engagement during the study implementation and future scale-up and efforts to translate evidence-based hypertension control strategies to low- and middle-income countries globally.

Development and validation of measurement tools for user experience evaluation surveys in the public primary healthcare facilities in Greece: a mixed methods study

BackgroundThe public primary healthcare system in Greece has not been fully developed and is delivered by urban and rural health centers, outpatient departments in public hospitals and the recently established first-contact and decentralized local primary care units. The aim of this study was to develop a valid and reliable measurement tool for conducting periodic user experience evaluation surveys in public Primary HealthCare facilities in Greece such as outpatient clinics of public hospitals and health centers.MethodsA mixed methods approach was applied. In particular, the methodology of developing and validating the tools included three steps: (a) establishment of the theoretical background/literature review, (b) qualitative study: development of the tools items and establishment of the face validity and (c) quantitative study: pilot testing and establishment of the structural validity and estimation of the internal consistency of the tools. Two patient focus groups participated in qualitative study: one visiting health centres and the other visiting the outpatient clinics of public hospitals. Quantitative study included 733 Primary Health Care services’ users/patients and was conducted during August–October 2017. Exploratory and confirmatory factor analysis was performed to check for structural validity of the tools, while Cronbach’s alpha coefficients were estimated to check for reliability.ResultsConfirmatory factor analysis confirmed almost perfectly the presumed theoretical model and the following six factors were identified through the tools: (a) accessibility (three items, e.g. opening hours), (b) continuity and coordination of care (three items, e.g. doctor asks for medical history), (c) comprehensiveness of care (three items, e.g. doctor provides advices for healthy life), (d) quality of medical care (four items, e.g. sufficient examination time), (e) facility (four items, e.g. comfortable waiting room) and (f) quality of care provided by nurses and other health professionals (four items, e.g. polite nurses).ConclusionsWe have developed reliable and valid tools to measure users’ experiences in public Primary HealthCare facilities in Greece. These tools could be very useful in examining differences between different types of public Primary Health Care facilities and different populations.

Diagnostic accuracy and reliability of the neurological and arterial tests according to the IWGDF guidelines in the diagnosis of diabetic peripheral neuropathy and peripheral arterial disease in type 2 diabetic patients attending the primary health care

Objective: To determine the diagnostic accuracy and reliability of the neurological test (NT) and the arterial test (AT) according to the International Working Group on the Diabetic Foot (IWGDF) guidelines in the diagnosis of diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD), respectively, using variables such as sensitivity (Se), specificity (Sp), positive predictive value (PPV), and positive likelihood ratio (PLR) in type 2 diabetic patients attending the primary health care. Materials and methods: One hundred (100) type 2 diabetic patients were chosen from the public primary health care system, and evaluated by a primary physician in a private diabetic foot unit. The NT was represented by the tactile-vibratory sensitivity and the AT by the ankle-brachial index according to the IWGDF guidelines. They were compared to standard neurological and arterial tests called Michigan Neuropathy Screening Instrument and Duplex Doppler Ultrasound, respectively, and performed by a diabetic foot specialist. Results: The NT showed an Se and Sp of 100 % and 94 % for the DPN, and the AT showed an S and E of 67.3 % and 83.2 % for the PAD, as well as a high PPV. The PLR was good in the NT, but poor in the AT. Conclusions: Accuracy and reliability of the NT and AT according to the IWGDF guidelines were adequate to diagnose DPN and PAD, respectively, in type 2 diabetic patients attending the primary health care, whose values were very similar to other studies’ but affected by local factors.

Sickness certification in Singapore’s public primary healthcare system: A cross-sectional analysis

Objectives:Sickness absenteeism has been rising in Singapore with sickness certification commonly performed by primary care physicians. The Primary Care Survey 2014 reported increased primary care demand driven by a rapidly ageing population and the prevalence of chronic disease. This article aims to determine the magnitude of outpatient sickness certification in all the polyclinics in Singapore and identify the demographic characteristics and factors influencing the taking of sick leave by the local multi-ethnic Asian patients.Design:A one-week, cross-sectional survey using computer-assisted interviews with age-stratified, systematically sampled patients was conducted at all 18 polyclinics in 2014. Sick leave data was then extracted from each polyclinic’s administrative system. Data was analysed with logistic regression to determine statistically significant factors.Results:The sickness certification rate was 22.6% during the study period with a weighted average duration of 1.42 days. Sickness certification was most associated with the younger age group (17–20 years; adjusted odd ratio (AOR) = 9.51), an acute condition (AOR = 24.8) and those living in 1–2 room public housing (AOR = 4.72). Among employees, those working in manufacturing industries had the most association with sickness certification while the finance and insurance industry had the least. An acute upper respiratory tract infection was the most frequent diagnosis for those who obtained medical certificates (38.7%).Conclusion:A medical certificate was issued in almost one-quarter of consultations in Singapore polyclinics. Sickness certification was predominated by short-term absence for acute conditions. Characterisation of sickness absenteeism among employees serves as a benchmark for future studies. Mitigation measures were discussed while exclusion of private primary care clinics probably led to an underestimation of the magnitude of sickness certification.

Contacting dropouts from type 2 diabetes care in public primary health care: description of the patient population

Objective: To characterize dropouts from type-2 diabetes (T2D) care in communal primary health care.Design: An observational study.Setting: In a Finnish city, patients with T2D who had not contacted the public primary health care system during the past 12 months were identified with a computer based search and contacted by a trained diabetes nurse.Subjects: Dropouts from T2D treatment.Main outcome measures: Demographic factors, laboratory parameters, examinations, medications, and comorbidities.Results: Of the patients with T2D, 10% (n = 356) were dropouts and 60% of them were men. Median HbA1c was 6.5 (QR for 25% and 75%: 6.0, 7.7) %, (45 [42,61] mmol/mol). Of the dropouts, 14% had HbA1c ≥ 9.0% (75 mmol/mol), and these patients were younger than the other dropouts (mean age 54.4 [SD 10.8] years vs. 60.6 [9.4] years, p < 0.001). Median low-density lipoprotein (LDL) cholesterol level was 2.8 (QR 2.1, 3.4) mmol/l. Median systolic blood pressure (BP) was 142 (QR 130, 160) mm Hg. Median diastolic BP was 86 (78, 94) mm Hg. Of the dropouts, 83% had comorbidities and 62% were prescribed metformin as a treatment.Conclusions: Ten percent of T2D patients were dropouts of whom those with a poor glycaemic control were younger than the other dropouts. BP and LDL cholesterol concentrations were non-optimal among the majority of the dropouts. Metformin was prescribed less frequently to the dropouts than is usual for T2D patients. The comorbidities were equally common among the dropouts as among the other T2D patients.KEY POINTS Which kinds of patients are dropouts from type-2 diabetes care is not known.• One-tenth of the patients with T2D were dropouts and they generally had good glycaemic control.• Blood pressure and LDL cholesterol concentrations were non-optimal among the majority of the dropouts.• Fourteen percent of these dropouts had HbA1c > 9% (75 mmol/mol) and they were more often younger than the other dropouts.

Poor availability of skilled birth attendants in Nigeria: a case study of enugu state primary health care system.

Background:The Government of Enugu State plans to offer free perinatal services at the primary health care (PHC) centers in order to improve perinatal outcomes in the state, but it was not clear whether there are skilled birth attendants (SBAs) at the PHC level to implement the program.Aims:To determine whether there are sufficient numbers of SBAs in the public PHC system in Enugu State of Nigeria.Subjects and Methods:This cross-sectional survey involved enumeration of health workers who worked at each public PHC facility in Enugu State and included verification of the qualifications and trainings of each health worker. Data analysis was performed with the help of Stata statistical package version 13 and results were presented in tables and as simple proportions.Results:There were 55 nurses and no midwife or doctor in the 152 PHC clinics studied. This number represents 0.36 nurses per health facility or about 9% (i.e., 55/608) of a minimum of 608 SBAs required for 24-h perinatal services at the 152 PHC clinics. There were 1233 junior community health extension worker/community health extension workers (JCHEW/CHEWs), averaging 8.1 JCHEW/CHEWs per PHC clinic.Conclusions:Enugu State has an acute shortage of SBAs. We recommend employment of qualified SBAs and in-service training of the JCHEW/CHEW and nurses to upgrade their midwifery skills. Incorporation of competency-based midwifery training into the pre-service training curricula of nurses and JCHEW/CHEW would provide a more sustainable supply of SBAs in Enugu state.

Protecting the underscreened women in developed countries: the value of HPV test.

BackgroundPoor attendance to cervical cancer (CC) screening is a major risk factor for CC. Efforts to capture underscreened women are considerable and once women agree to participate, the provision of longitudinal validity of the screening test is of paramount relevance. We evaluate the addition of high risk HPV test (HPV) to cervical cytology as a primary screening test among underscreened women in the longitudinal prediction of intraepithelial lesions grade 2 or worse (CIN2+).MethodsWomen were included in the study if they were older than 39 years and with no evidence of cervical cytology in the previous five years within the Public Primary Health Care System in Catalonia (Spain). 1,832 underscreened women from eight public primary health areas were identified during 2007–2008 and followed-up for over three years to estimate longitudinal detection of CIN2+. Accuracy of each screening test and the combination of both to detect CIN2+ was estimated. The risk of developing CIN2+ lesions according to histology data by cytology and HPV test results at baseline was estimated using the Kaplan–Meier method.ResultsAt baseline, 6.7% of participants were HPV positive, 2.2% had an abnormal cytology and 1.3% had both tests positive. At the end of follow-up, 18 out of 767 (2.3%) underscreened women had a CIN2+, two of which were invasive CC. The three-year longitudinal sensitivity and specificity estimates to detect CIN2+ were 90.5% and 93.0% for HPV test and 38.2% and 97.8% for cytology. The negative predictive value was >99.0% for each test. No additional gains in validity parameters of HPV test were observed when adding cytology as co-test. The referral to colposcopy was higher for HPV but generated 53% higher detection of CIN2+ compared to cytology.ConclusionsUnderscreened women had high burden of cervical disease. Primary HPV screening followed by cytology triage could be the optimal strategy to identify CIN2+ leading to longer and safe screen intervals.

Utilidad de la ecografía portátil en el cribado del aneurisma de aorta abdominal y de la ateromatosis de aorta abdominal

Background and objectiveTo determine the prevalence of abdominal aortic aneurysm (AAA) and abdominal aortic atheromatosis (AA-At) using a hand-held ultrasound by a general practitioner in the public Primary Health Care system. Patients and methodPilot study that prospectively studied a cohort of men over 50 years with cardiovascular risk factors: active smokers, former smokers, or hypertensive patients, attended in primary health care center. The general practitioner completed an ultrasonography training in an Ultrasound Unit under supervision of experienced radiologists using an standard ultrasound equipment and hand-held ultrasound (VScan®, General Electric, USA). One hundred and six patients participated in the study and all imaging data recorded were blindly evaluated by a radiologist in order to establish the concordance in the interpretation of images between general practitioner and radiologist. The kappa index was calculated to study the agreement on the presence or absence of AAA and AA-At. ResultsWe observed a prevalence of 5.88% of AAA. Kappa index for concordance in AAA diagnosis was absolute (κ=1.0), with a sensitivity and specificity of 100%. Otherwise, the general practitioner identified 59 patients (58.4%) with AA-At, while radiologist identified 39 (38.6%) in the image review, with moderate concordance (κ=.435), sensitivity 89.74% and specificity 57.14%. Hypercholesterolemia (odds ratio [OR] 2.61; 95% confidence interval [95% CI] 0.92-7.39) and diabetes mellitus (OR 3.35; 95%CI 0.89-12.55) were independent risk factors for AA-At development in logistic regression. ConclusionsAfter an adequate training in ultrasonography, hand-held ultrasound is a useful tool for AAA screening in Primary Care. Its simplicity, security, validity, cost-effectiveness and acceptance by the general population, makes it a feasible tool for cardiovascular risk assessment.