Routine Primary Health Care Research Articles

Evaluating the effect of ward-based outreach teams on primary healthcare performance in North West Province, South Africa: A plausibility design using routine data

Background. North West Province (NWP), South Africa, was an early adopter of the primary healthcare (PHC) ward-based outreach team (WBOT) strategy and has made considerable progress in implementing it. Given the interest in and expectations of greater investment in WBOTs, assessing their impact on and contribution to PHC outputs and health outcomes is becoming increasingly important. Objectives. To describe the application of a plausibility evaluation design for assessing the contribution of WBOTs to PHC performance in NWP, comparing changes in coverage, utilisation and outcome indicators in facilities with and without WBOTs. Methods. Routine data from the District Health Information System on both WBOTs and PHC facilities for the period 2011/12 (prior to implementation) to 2014/15 (3 years after implementation began) were extracted. Analysis involved the following three steps: ( i ) selection of indicators sensitive to community-based action; ( ii ) data cleaning; and ( iii ) comparison of the degree of change in median indicator values between 2011/12 and 2014/15 in facilities with and without WBOTs (a difference-in-differences analysis). Results. Changes in indicator values in facilities were grouped into four categories: ( i ) indicators where there was greater (statistically significant) improvement in facilities with WBOTs (couple year protection rate, measles immunisation coverage in children aged <1 year, incidence of children aged <5 years with severe diarrhoea with dehydration); ( ii ) indicators that declined or worsened, but less so in facilities with WBOTs at statistically significant levels (antenatal first visits as a percentage of children born in that year, PHC utilisation rate of children aged <5 years); ( iii ) indicators that improved in all facilities with no significant difference between facilities with and without WBOTs (antenatal attendance before 20 weeks, prophylactic vitamin A coverage to children aged 12 - 59 months); and ( iv ) indicators that remained unchanged in all facilities (immunisation coverage in children aged <1 year, postnatal mother visits at 6 days, cervical cancer screening coverage in women aged ≥30 years, PHC utilisation rate of children aged ≥5 years). Conclusion. Notwithstanding the limitations of routine data and the need to approach the findings with caution, this analysis suggests that WBOTs plausibly had some positive effects on the overall performance of the PHC system. We propose a methodology to monitor the performance of WBOTs using routine PHC indicators that programme managers could apply elsewhere.

Effective translation of a type-2 diabetes primary prevention programme into routine primary care: The PreDE cluster randomised clinical trial

AimsWe assessed the effectiveness of a Type 2 diabetes mellitus (T2D) prevention programme in routine primary health care (PHC) in high-risk patients. MethodsPhase IV cluster clinical trial involving 14 PHC centres in the Basque Health Service were randomised to the DE-PLAN educational healthy lifestyle promotion programme or standard care. All non-diabetic 45- to 70-year-old PHC attendees considered at high risk of T2D (FINDRISC ≥ 14 points) were eligible. The primary outcome was the 24-month cumulative incidence of T2D confirmed by oral glucose tolerance testing. Secondary outcomes were self-reported physical activity and dietary changes at 12 months in a subsample. ResultsOf the 4170 patients screened, 2128 (51%) were considered high risk, but 355 (33%) and 459 (43.6%) refused to participate in the control and intervention groups, respectively. Of all eligible non-diabetic patients, 634 and 454 were included in the control and intervention arms, 545 (85.9%) and 411 (90.5%) completed the follow-up. Intention-to-treat cumulative incidences of T2D were 12.1% (77/634) in the control group and 8.4% (38/454) in intervention group, with an absolute difference of 3.8% (95% CI: 0.18%–7.4%, p = 0.045) and a relative risk reduction of 32% (0.68; 95% CI: 0.47–0.99, p = 0.048) in favour of the intervention. Intervention patients were 1.83-fold more likely to meet recommended physical activity levels at 12 months (95% CI: 1.06–3.17, p = 0.03). ConclusionsThe DE-PLAN programme was effective in reducing T2D incidence in PHC high-risk patients. Research on implementation strategies to improve its feasible and sustainable adoption, reach and public health impact is warranted.

\u201cI can\u2019t bend it and it hurts like mad\u201d: direct observation of gout consultations in routine primary health care

BackgroundGout is the most common form of inflammatory arthritis and is associated with considerable co-morbidity. It is usually managed in the primary care setting with a combination of lifestyle modification and pharmacological therapy. This study describes patterns of communication about gout observed in interactions between patients and primary care practitioners during routine consultations.MethodsSecondary analysis of video-recordings of individual healthcare consultations between patients and a range of primary care practitioners (including general practitioners, practice nurses, podiatrists and dietitians) from an archived database. Consultations that included any discussion about gout were eligible for inclusion (n = 31) and were not restricted to those where gout was the main presenting complaint. The consultation transcripts were analysed using a qualitative inductive approach from clinical and linguistic perspectives and supplemented with visual observation of the interactions.ResultsTwo main themes emerged from the data; the importance of gout and ‘telling’ versus ‘listening’ in consultations. The first theme had two distinct strands; gout as an incidental part of the consultation and the impact of gout on patients. A trend towards more didactic practitioner communication encompassed by the second theme occurred at many different consultation points including diagnosis, in more general post-diagnosis discussion, and when discussing biochemical test results and lifestyle advice. In contrast, when discussion about treatment with medicines occurred a tendency towards a greater degree of listening to patients was observed.ConclusionOur observation of the communication patterns in these consultations illustrates an inherent complexity of gout consultations in primary care. Gout may be more important to patients than is often apparent to practitioners in routine consultations. Consultation management needs to take into account the impact of the condition and the balance of information provided around lifestyle advice versus long-term management with medicines.

Expenditure tracking and review of reproductive maternal, newborn and child health policy in Pakistan.

Since 2001 substantial resources have been allocated to the reproductive, maternal, newborn and child health sector (RMNCH) in Pakistan. Many new programmes have been started and coverage of some existing programmes has been extended to un-served and rural areas. Despite these efforts the Millennium Development Goals (MDGs) 4 and 5 were not achieved (2000-15). Maternal Mortality Ratio was reduced to 170 per 100 000 live births (target 100) by 2013 at an annual reduction rate of 3.6% (1990-2013). Against the target of 46 per 1000 live births, the Under Five Mortality Rate was reduced to 81 per 1000 live births by 2015 at an annual reduction rate of 2.1% (1990-2015). We evaluated the comparative expenditures for the RMNCH sector and analysed impact of public expenditures on the use of the public facilities for the RMNCH services. Expenditure on RMNCH increased by 181% (2000-10), reaching PKR 628.79 billion (US$9.67 billion). The Share of the RMNCH expenditure in the total health expenditure increased from 16 to 21% (2005-10). The share of official development assistance for the RMNCH increased from 36 to 51% (2003-10). Equity was modestly achieved with a greater proportion of the poor using public facilities for the childhood diarrhoea (Concentration Index -0.06 in 2001-02 to - 0.11 in 2010-11) and reduction in the proportion of the rich using the public health facilities for institutional births (Concentration Index 0.30 in 2001-02 to 0.25 in 2010-11). Overall the RMNCH disease control programmes focused on vertical primary health approach and targeted the district health system in the un-served areas. Our findings confirm that diseconomies of scale, donor dependence and supply side perspective could only result in a modest progress towards achieving the MDGs. We call for urgent attention of the policy makers for the integration of the vertical and the routine primary health care and reliance on indigenous sustainable healthcare financing. We also recommend acknowledging economic perspective on health policy and health programmes.

The implementation of health promotion in primary and community care: a qualitative analysis of the \u2018Prescribe Vida Saludable\u2019 strategy

BackgroundThe impact of lifestyle on health is undeniable and effective healthy lifestyle promotion interventions do exist. However, this is not a fundamental part of routine primary care clinical practice. We describe factors that determine changes in performance of primary health care centers involved in piloting the health promotion innovation ‘Prescribe Vida Saludable’ (PVS) phase II.MethodsWe engaged four primary health care centers of the Basque Healthcare Service in an action research project aimed at changing preventive health practices. Prescribe Healthy Life (PVS from the Spanish “Prescribe Vida Saludable) is focused on designing, planning, implementing and evaluating innovative programs to promote multiple healthy habits, feasible to be performed in routine primary health care conditions. After 2 years of piloting, centers were categorized as having high, medium, or low implementation effectiveness. We completed qualitative inductive and deductive analysis of five focus groups with the staff of the centers. Themes generated through consensual grounded qualitative analysis were compared between centers to identify the dimensions that explain the variation in actual implementation of PVS, and retrospectively organized and assessed against the Consolidated Framework for Implementation Research (CFIR).ResultsOf the 36 CFIR constructs, 11 were directly related to the level of implementation performance: intervention source, evidence strength and quality, adaptability, design quality and packaging, tension for change, learning climate, self-efficacy, planning, champions, executing, and reflecting and evaluating, with —organizational tracking added as a new sub-construct. Additionally, another seven constructs emerged in the participants’ discourse but were not related to center performance: relative advantage, complexity, patients’ needs and resources, external policy and incentives, structural characteristics, available resources, and formally appointed internal implementation leaders. Our findings indicate that the success of the implementation seems to be associated with the following components: the context, the implementation process, and the collaborative modelling.ConclusionsIdentifying barriers and enablers is useful for designing implementation strategies for health promotion in primary health care centers that are essential for innovation success. An implementation model is proposed to highlight the relationships between the CFIR constructs in the context of health promotion in primary care.

Association between bacterial vaginosis and partner concurrency: a longitudinal study

ObjectivesThe study aimed to test if there was an association between prevalent bacterial vaginosis (BV) and women reporting that their partner had other partners at the same time (partner concurrency)....

Sparking, supporting and steering change: grounding an accountability framework with viewpoints from Nigerian routine immunization and primary health care government officials

Existing accountability efforts in Nigeria primarily serve as retrospective policing. To enable accountability to guide change prospectively and preemptively, we drew from a literature review to develop a framework that highlights mutually reinforcing dimensions of accountability in health systems along three counterbalancing axes. The axis of power sparks change by wielding 'sticks' that curb the potential abuse of power, but also by offering 'carrots' that motivate constructive agency. The axis of ability supports change by enabling service delivery actors with formal rules that appropriately expand their authority to act, but also the informal norms and inputs for improved performance. Last, the axis of justice orients the strategic direction of change, balancing political representation, community ownership and social equity, so that accountability measures are progressive, rather than being captured by self-interests. We consulted Nigerian government officials to understand their viewpoints on accountability and mapped their responses to our evolving framework. All government officials (n = 36) participating in three zonal workshops on routine immunization filled out questionnaires that listed the top three opportunities and challenges to strengthening accountability. Thematically coded responses highlighted dimensions of accountability within the axes of ability and power: clarifying formal roles and responsibilities; transparency, data and monitoring systems; availability of skilled health personnel that are motivated and supervised; addressing informal norms and behaviours; and availability of inputs regarding funding and supplies. Other dimensions of accountability were mentioned but were not as critical from their viewpoints: managerial discretion; sanctions and enforcements; political influence and community engagement. Strikingly, almost no respondents mentioned social equity as being an important aspect of accountability, although a few mentioned broad development concerns that reflected community perspectives. Reframing accountability as a means of sparking, supporting and steering change can highlight different dimensions of health systems that need reform, particularly depending on the positionality of the viewpoints consulted.

Community and clinic-based screening for curable sexually transmissible infections in a high prevalence setting in Australia: a retrospective longitudinal analysis of clinical service data from 2006 to 2009.

Background In response to the high prevalence of sexually transmissible infections (STIs) in many central Australian Aboriginal communities, a community-wide screening program was implemented to supplement routine primary health care (PHC) clinic testing. The uptake and outcomes of these two approaches were compared. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) community and clinic screening data for Aboriginal people aged 15-34 years, 2006-2009, were used. Regression analyses assessed predictors of the first test occurring in the community screen, positivity and repeat testing. A total of 2792 individuals had 9402 tests (median: four per person) over 4 years. Approximately half of the individuals (54%) were tested in the community and clinic approaches combined, 29% (n=806) in the community screen only and 18% (n=490) in the clinic only. Having the first test in a community screen was associated with being male and being aged 15-19 years. There was no difference between community and clinic approaches in CT or NG positivity at first test. More than half (55%) of individuals had a repeat test within 2-15 months and of these, 52% accessed different approaches at each test. The only independent predictor of repeat testing was being 15-19 years. STI screening is an important PHC activity and the findings highlight the need for further support for clinics to reach young people. The community screen approach was shown to be a useful complementary approach; however, cost and sustainability need to be considered.

Integrating a Parenting Intervention With Routine Primary Health Care: A Cluster Randomized Trial.

More than 200 million children globally do not attain their developmental potential. We hypothesized that a parent training program could be integrated into primary health center visits and benefit child development. We conducted a cluster randomized trial in the Caribbean (Jamaica, Antigua, and St Lucia). Fifteen centers were randomly assigned to the control (n = 250 mother-child pairs) and 14 to the intervention (n = 251 mother-child pairs) groups. Participants were recruited at the 6- to 8-week child health visit. The intervention used group delivery at 5 routine visits from age 3 to 18 months and comprised short films of child development messages, which were shown in the waiting area; discussion and demonstration led by community health workers; and mothers' practice of activities. Nurses distributed message cards and a few play materials. Primary outcomes were child cognition, language, and hand-eye coordination and secondary outcomes were caregiver knowledge, practices, maternal depression, and child growth, measured after the 18-month visit. Eight-five percent of enrolled children were tested (control = 210, intervention = 216). Loss did not differ by group. Multilevel analyses showed significant benefits for cognitive development (3.09 points; 95% confidence interval: 1.31 to 4.87 points; effect size: 0.3 SDs). There were no other child benefits. There was a significant benefit to parenting knowledge (treatment effect: 1.59; 95% confidence interval: 1.01 to 2.17; effect size: 0.4). An innovative parenting intervention, requiring no additional clinic staff or mothers' time, was integrated into health services, with benefits to child cognitive development and parent knowledge. This is a promising strategy that merits further evaluation at scale.

Integrating a Parenting Intervention With Routine Primary Health Care: A Cluster Randomized Trial

Integrating a Parenting Intervention With Routine Primary Health Care: A Cluster Randomized Trial

Clinical Practice Models for the Use of E-Mental Health Resources in Primary Health Care by Health Professionals and Peer Workers: A Conceptual Framework.

BackgroundResearch into e-mental health technologies has developed rapidly in the last 15 years. Applications such as Internet-delivered cognitive behavioral therapy interventions have accumulated considerable evidence of efficacy and some evidence of effectiveness. These programs have achieved similar outcomes to face-to-face therapy, while requiring much less clinician time. There is now burgeoning interest in integrating e-mental health resources with the broader mental health delivery system, particularly in primary care. The Australian government has supported the development and deployment of e-mental health resources, including websites that provide information, peer-to-peer support, automated self-help, and guided interventions. An ambitious national project has been commissioned to promote key resources to clinicians, to provide training in their use, and to evaluate the impact of promotion and training upon clinical practice. Previous initiatives have trained clinicians to use a single e-mental health program or a suite of related programs. In contrast, the current initiative will support community-based service providers to access a diverse array of resources developed and provided by many different groups.ObjectiveThe objective of this paper was to develop a conceptual framework to support the use of e-mental health resources in routine primary health care. In particular, models of clinical practice are required to guide the use of the resources by diverse service providers and to inform professional training, promotional, and evaluation activities.MethodsInformation about service providers’ use of e-mental health resources was synthesized from a nonsystematic overview of published literature and the authors’ experience of training primary care service providers.ResultsFive emerging clinical practice models are proposed: (1) promotion; (2) case management; (3) coaching; (4) symptom-focused treatment; and (5) comprehensive therapy. We also consider the service provider skills required for each model and the ways that e-mental health resources might be used by general practice doctors and nurses, pharmacists, psychologists, social workers, occupational therapists, counselors, and peer workersConclusionsThe models proposed in the current paper provide a conceptual framework for policy-makers, researchers and clinicians interested in integrating e-mental health resources into primary care. Research is needed to establish the safety and effectiveness of the models in routine care and the best ways to support their implementation.

Negotiating sexuality in home care settings: older lesbians and bisexual women's experiences

There is evidence that lesbians and bisexual women often face prejudice and stigma when accessing routine primary healthcare services. However, limited research to date has examined their experiences outside of primary healthcare contexts or the perspectives of older healthcare users. This paper presents findings from a qualitative study of older lesbians and bisexual women in Ontario who accessed publicly-funded home care services. In qualitative in-depth interviews, 16 women responded to questions about their decision making around disclosure of their sexuality, home care workers' reactions to disclosure and their experiences of receiving care. The thematic analysis of participants' responses demonstrated that they experienced isolation and ongoing anxiety, as well overt and subtle examples of heterosexism and discrimination. However, there was also evidence of participants' resilience and resistance to heteronormativity and sexual minority stress. These findings have implications for our understanding of lesbians' and bisexual women's healthcare experiences and for policy recommendations.

The Impact of Polio Eradication on Routine Immunization and Primary Health Care: A Mixed-Methods Study

Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC).Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review.Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year.Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.

100: Non-Dairy Milk Consumption is Associated with Lower Serum 25-Hydroxyvitamin D in Early Childhood

Vitamin D fortification of cow's milk is the main dietary source of vitamin D in early childhood. The consumption of non-dairy milk, such as plant-based milk beverages and goat's milk is increasing. Vitamin D fortification of non-dairy milk is voluntary in North America. We hypothesize that the consumption of non-dairy milk may be associated with lower 25-hydroxyvitamin D in early childhood. For our primary objective, we aimed to determine if there is an association between daily volume of non-dairy milk consumption and serum 25-hydroxyvitamin D in healthy young Canadian children. For our secondary objective we aimed to explore whether cow's milk consumption modifies this relationship. Children attending one of seven pediatric or family medicine primary care practices were recruited during routine primary healthcare. For our primary analysis, a multiple linear regression model was developed to test the association between daily volume of non-dairy milk consumption and 25-hydroxyvitamin D, adjusted for age, gender, z-BMI, season, vitamin D supplementation, skin pigmentation, and daily outdoor play time. To explore whether cow's milk modifies this relationship, the interaction between non-dairy milk and cow's milk consumption was included in this model. A total of 2831 children were included in the analysis. Mean age was 2.9 years, 53% were male, 53% were taking a vitamin D containing supplement, 87% of children were consuming cow's milk and 13% of children consumed non-dairy milk daily. In the univariate analysis, each cup of non-dairy milk consumed per day was associated with a 2.3 nmol/L (P=0.005, 95% CI 1.0, 4.9) lower mean 25-hydroxyvitamin D concentration. Multiple linear regression, adjusted for clinically relevant covariates, revealed that each additional 250 ml cup of non-dairy milk was associated with a 3.8 nmol/L (95% CI 1.0 to 8.6; P=0.01) lower 25-hydroxyitmian D among children who drink cow's milk, and a non-significant increase in 25-hydroxyvitmain D of 0.3 nmol/L (95% CI −3.0 to 3.1; P=0.6) among children who do not drink cow's milk. Non-dairy milk consumption is associated with a lower 25-hydroxyvitamin D level in early childhood. This relationship appears to be modified by cow's milk consumption, suggesting that consumption of lower vitamin D containing non-dairy milk may be replacing consumption of higher vitamin D containing cow's milk.

101: Meat and Iron-Rich Food Consumption in Healthy Canadian Infants

Iron is an essential micronutrient for normal growth and cognitive development in early childhood. After the first six months of life, iron requirements rise rapidly and infants exclusively fed breast milk beyond six months are at risk for developing iron deficiency. In 2005, Health Canada recommended that iron-rich foods be introduced at six months of age, emphasizing that naturally iron-rich foods such as meat or meat alternatives be infant's first complementary foods, rather than iron-fortified infant cereal. In 2012, Health Canada advised that infants be offered iron-rich foods two or more times per day. Little is known about the meat consumption patterns among infants and young children in Canada. To describe the meat consumption patterns in healthy Canadian children and examine the association between meat consumption and sociodemographic factors. A cross-sectional study of healthy children, aged six months to five years, seen for routine primary health care between December 2008 and December 2012 was conducted through a practice-based research network. Meat consumption and sociodemographic factors were measured using standardized parent-completed survey instruments. Adjusted logistic regression was used to determine the independent variables associated with meat consumption. A total of 4614 healthy children (median age 25 months) were included. Most children (94%) consumed meat over a three-day period. Adjusted logistic regression analysis identified the odds of eating meat increased by 6.5% (95% CI 4.9 to 8.2) with each additional month of age. Children of African, Caribbean, Indian-Caribbean ethnicity (OR 0.4 [95% CI 0.2 to 0.8]; P=0.007), South Asian ethnicity (OR 0.4 [95% CI 0.2 to 0.7]; P=0.005), Latin American ethnicity (OR=0.4, 95% CI 0.2 to 0.8, P=0.009) and North American Aboriginal or Oceania ethnicity (OR 0.5 [95% CI 0.3 to 0.9]; P=0.03) were less likely to eat meat. Only 71% consumed at least two servings of meat or other iron-rich foods daily as per Health Canada recommendations. Children from lower income families were less likely to eat meat according to Health Canada recommendations (OR 0.6 [95% CI 0.4 to 0.7]; P<0.001). Poultry was the meat most frequently consumed (83% poultry, 65% red meat, 62% eggs, 41% fish and 6% shellfish). Most infants and young children eat meat, however almost one third do not eat meat according to the Health Canada recommendations. Eating meat or meat alternatives less than two times per day was associated with a lower family income. The association between poor meat consumption and iron deficiency in this cohort is a focus of future investigation.

Factors influencing the introduction of physical activity interventions in primary health care: a qualitative study.

The introduction of efficacious physical activity (PA) interventions in routine primary health care (PHC) is a complex process. Understanding factors influencing the process can enhance the development of successful introduction strategies. The aim of this qualitative study was to explore stakeholders' perceptions on factors influencing the introduction, i.e., adoption, implementation, and continuation, of PA interventions in PHC. Twenty-eight semistructured interviews were held with intervention managers, PHC advisors, intervention providers, and referring general practitioners of five PA interventions delivered in PHC. A theoretical framework on the introduction of innovations in health care was used to guide the data collection. Influencing factors were identified using thematic analysis. Stakeholders reported preconditions for the introduction of PA interventions in PHC (e.g., support, resources, and networks and collaborations), in addition to characteristics of PA interventions (e.g., compatibility, flexibility, and intervention materials) and characteristics of PHC professionals (e.g., knowledge, positive attitudes, and beliefs about capabilities) perceived to enhance the introduction process. Furthermore, they proposed strategies for the development of PA interventions (e.g., involvement of future stakeholders, full development, and refinement) and strategies to introduce PA interventions in PHC (e.g., training, assistance, and reinforcement). The majority of the influencing factors were discussed specifically in relation to one or two stages. This study presents an overview of factors that are perceived to influence the introduction of PA interventions in PHC. It underscores the importance of taking these factors into account when designing introduction strategies and of giving special attention to the distinct stages of the process.

Design of the e-Vita diabetes mellitus study: effects and use of an interactive online care platform in patients with type 2 diabetes (e-VitaDM-1/ZODIAC-40)

BackgroundDue to ongoing rise in need for care for people with chronic diseases and lagging increase in number of care providers, alternative forms of care provision and self-management support are needed. Empowering patients through an online care platform could help to improve patients’ self-management and reduce the burden on the healthcare system.MethodsAccess to laboratory results and educational modules on diabetes will be offered through a platform for subjects with type 2 diabetes mellitus treated in primary care. Differences in socio-demographic and clinical characteristics between subjects expressing interest vs. disinterest to use the platform will be explored. Platform usage will be tracked and compared. Patient satisfaction and quality of life will be measured by validated questionnaires and economic analyses will be performed.DiscussionThis study is designed to assess the feasibility of use of an online platform in routine primary healthcare for subjects with type 2 diabetes mellitus in the Netherlands, and to study effects of use of the platform on treatment satisfaction, quality of life and clinical parameters. Although providing access to a online platform is not a novel intervention, usage and effects have not yet been studied in this patient population.Trial registrationTrial registration: NCT01570140.

Setting priorities for mental health care in Nepal: a formative study

BackgroundThere is an urgent need to address the massive treatment gap for mental health problems, especially in low income settings. Packages of care integrated in routine primary health care are posited as a strategy to scale-up mental health care, yet more needs to be known about the most feasible and effective way to go about this.MethodsThe study follows a combined methods design that includes engaging an expert panel in a priority setting exercise, running workshops to develop a Theory of Change and conducting in-depth qualitative interviews and focus group discussions with key stakeholders. The results of each research step were taken forward to inform the subsequent one.ResultsThere was strong endorsement for a system of care that encompasses both the perspectives of health facility and the community. Issues related to increasing access and demand, guaranteeing a sustainable supply of psychotropic medicine, adequate human resourcing, and ensuring positive family involvement came up as priority areas of attention.ConclusionThe study underlines many of the known barriers in developing mental health services. At the same time it provides a distinct pathway and concrete recommendations for overcoming these challenges in Nepal.

Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial

BackgroundThe European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.Methods/designIn a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.DiscussionEffective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.Trial registrationClinicalTrials.gov. Trial identifier: NCT01501552

Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care

BackgroundThe impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings.Methods/DesignThis protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts.DiscussionThe study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis.