Urban Primary Care Setting Research Articles

Uncovering the hidden burden: A mixed methods study on the implementation of depression screening among persons with type 2 diabetes mellitus seeking health care in an urban primary health center of South India

BACKGROUND: Diabetes is linked with depression, but screening rates for depression are low, indicating a need for periodic assessments among those with diabetes. The study aimed to determine depression prevalence and associated factors in persons with type 2 diabetes mellitus (T2DM) in an urban primary care setting of Karnataka, as well as implementation challenges in depression screening for persons with T2DM as perceived by healthcare providers. MATERIAL AND METHODS: A mixed-methods study was performed for 6 months in 2022–2023 at an Urban Primary Health Centre (UPHC) in Bengaluru. The sample size was calculated to be 110, and convenience sampling was applied to select persons with T2DM. The participants were screened for depression using Patient Health Questionnaire-9. Key informant interviews were performed among various health care providers of the UPHC. Data were captured using EpiCollect Version 5.0. Univariate logistic regression was performed to find the factors associated with depression. RESULT: Of the 110 participants, 60 (54.5%) screened positive for depression. Men had 0.474 (95% Confidence Intervals—CI: 0.126, 1.782) lesser odds of depression when compared with women (P = 0.269). Those with comorbidities had 1.975 more odds (95% CI: 0.538, 7.252) when compared with absence of comorbidities (P = 0.305). Statistically significant associations were not found with any of the factors. Key facilitators for screening were willingness to implement screening, empathetic attitude, and awareness of mental health, whereas the challenges included lack of training in mental health assessment and patient reluctance to adhere to treatment due to stigma. CONCLUSION: The study found that 54.5% of persons with T2DM seeking heath care at the UPHC screened positive for depression. Several challenges in implementing depression screening for T2DM in primary care settings were noted.

Intra-rater and Inter-rater Reliability of the Commander Pressure Algometer in Greek Patients With Chronic Neck Pain.

Introduction Non-specific chronic neck pain (NSCNP) is a musculoskeletal disorder that affects 45%-54% of the general population. There is a strong correlation between patient-reported pain and mechanical pain pressure threshold (PPT) measured with an algometer. Purpose This study aims to investigate the intra- and inter-rater reliability of the Commanderalgometer in Greek NSCNP patients, in an urban primary care setting. Methods Thirty-three patients (22 women and 11 men) suffering from NSCNP (>3 months), the majority (42.4%) between the ages of 50 years and 59 years and overweight, were measured bilaterally both at the neck (mastoid, trapezius head-insertion and mid-portion, C5-C6 facet, insertion of levator scapula) and at the control areas (mid-deltoid and tibialis anterior) using the Commanderalgometer. Measurements were taken twice over a span of six days, by two raters, in a primary care setting. Intraclass correlation coefficient (ICC) statistics were used asmeasures of reliability (p = 0.05). Results Intra-rater reliability was "moderate to good" for both raters. ICCvalues for PPT at the seven bilaterally measured sites varied between 0.67 and 0.86 for the first rater (p ≤ 0.001) and 0.64 and 0.82 for the second rater (p ≤ 0.003). The inter-rater reliability was "moderate to excellent" (ICC = 0.68-0.92) in the first measurement (T1) and "moderate to good" (ICC = 0.68 to 0.89) in the second measurement (T2). Conclusion This study supports the intra- and inter-rater reliability of the Commander algometer in detecting reliably the mechanical PPT, in Greek NSCNP patients, as measured according to the procedures and methodology followed throughout this study.

Obstructive sleep apnea risk among adults with type 2 diabetes mellitus in an urban primary care setting of Mangalore, India.

Obstructive sleep apnea (OSA) is an under-evaluated and under-treated problem, particularly among individuals with type 2 diabetes mellitus (T2DM). Therefore, in this study, we aim to determine the risk of OSA among adults with T2DM residing in an urban area of Mangalore and to elucidate the determinants of OSA among the study participants. A cross-sectional study was conducted for a period of 2 months among adult patients (≥ 18 years) with T2DM seeking health care at a primary care setting located in an urban area of Mangalore. Face-to-face interviews were conducted using a semi-structured proforma. STOP-BANG questionnaire was used to assess the risk of OSA among the study participants. The measurements, such as height, weight, and neck circumference, were conducted using standard techniques. The mean age of the study participants was 58.12 ± 11.60 years. The majority, (58.30%), were males, and 45.0% reported a family history of T2DM. A total of 108 (60.0%) experienced loud snoring while asleep, while 149 (82.80%) experienced tiredness during daytime. The mean body mass index (BMI) was 24.64 ± 4.9 kg/m2, while a neck circumference of >40 cms was found in 28.90%. A total of 69 (38.30%) had a high risk of OSA with a STOP-BANG score ranging from 5 to 8, while 71 (39.40%) had a score ranging from 3 to 4 (intermediate risk). The statistically significant associations were found between age >50 years, male gender, and diabetes for ≥ 7 years and high risk of OSA (P < 0.001). More than a third of the study participants had a high risk of OSA. Age > 50 years, male gender, and diabetes for ≥7 years were the factors associated with OSA.

Short report: Integrated evaluations for autism spectrum disorder in pediatric primary care clinics.

Primary care providers often screen for autism during well child visits in the first few years of life and refer children for diagnostic evaluations when needed. However, most children do not receive a diagnosis until years later which delays access to services. Racism, socioeconomic status, and other systemic inequalities that limit access to health care further delay diagnostic evaluations. Mental health clinicians who work in primary care clinics can help address barriers to accessing diagnostic evaluation services once they are recommended by their primary care provider. However, mental health clinicians who work in primary care typically do not have training in diagnosing autism. The goal of this study was to evaluate a program training mental health professionals working in an urban primary care setting, primarily serving Black and Latinx families insured by Medicaid, to provide autism diagnostic evaluations. Two hundred and fifty children completed evaluations through the Autism in Primary Care (APC) program. The wait time to access an evaluation through APC was significantly shorter than through standard avenues of care (e.g. referring to a separate autism clinic). Referring primary care providers and caregivers endorsed high levels of satisfaction with the program. Conducting autism evaluations in primary care settings offers a promising opportunity to improve earlier diagnosis and treatment access for families, reduce inequities in care, and increase caregiver and child well-being.

Person-Centred Diabetes Care: Examining Patient Empowerment and Diabetes-Specific Quality of Life in Slovenian Adults with Type 2 Diabetes.

Patient empowerment is crucial for promoting and strengthening health. We aimed to assess patient empowerment and diabetes-specific health-related quality of life (HRQoL) in adults with type 2 diabetes (T2D). A multi-centre, cross-sectional survey was conducted among adults with T2D in urban and rural primary care settings in Slovenia between April and September 2023. The survey utilised convenience sampling and included sociodemographic and clinical data, the Diabetes Empowerment Scale (DES), and the Audit of Diabetes-Dependent QoL (ADDQoL). The study included 289 people with T2D and a mean age of 67.2 years (SD 9.2). The mean overall DES score was 3.9/5 (SD 0.4). In a multivariable linear regression model, higher empowerment was significantly associated with residing in a rural region (p = 0.034), higher education (p = 0.028), and a lack of comorbid AH (p = 0.016). The median overall ADDQoL score was -1.2 (IQR [-2.5, -0.6]). The greatest negative influence of diabetes on HRQoL was observed in the domain 'Freedom to eat', followed by 'Freedom to drink', 'Leisure activities', and 'Holidays'. Despite high empowerment among adults with T2D, the condition still imposes a personal burden. Integrated primary care models should prioritise the importance of implementing targeted interventions to enhance diabetes empowerment, address comorbidities, and improve specific aspects of QoL among individuals with T2D.

IJCM_349A: Uncovering the hidden burden: a mixed-methods study on the implementation of depression screening among persons with Type 2 Diabetes Mellitus in an urban primary care setting

Background: Diabetes is linked with depression, but screening rates for depression are low, indicating a need for periodic screening among those with diabetes Objective: The study aims to determine depression prevalence and associated factors in persons with Type-2 Diabetes Mellitus (T2DM) in an urban primary care setting of Karnataka, as well as implementation challenges in depression screening for persons with T2DM as perceived by healthcare providers Methodology: We carried out a mixed-methods study over a period of six months at an Urban Primary Health Centre (UPHC) in Bengaluru. Depression screening was carried out in 110 persons with T2DM using Patient Health Questionnaire-9. Key Informant Interviews were carried out among various health care providers of the UPHC. Data was captured using EpiCollect Version 5.0. Univariate logistic regression was carried out to find the factors associated with depression. Results: Of the 110 participants, 60 (54.5%) screened positive for depression. Duration of diabetes (95% CI=0.203,0.943; P=0.035); presence of comorbidities (Odds Ratio=3.226; 95% CI=1.362,7.638; P=0.008), presence of complications (Odds Ratio=3.000; 95% CI=1.341,6.713; P=0.008) were found to be significantly associated with depression. The key facilitators for screening were willingness to implement screening, empathetic attitude, and awareness of mental health whereas the challenges included lack of training in mental health assessment and patient reluctance to adhere to treatment due to stigma. Conclusion: More than half the study participants screened positive for depression, with significant associations found between depression and duration of diabetes, comorbidities, and complications. Several challenges in implementing depression screening for T2DM in primary care settings were noted.

IJCM_3A: Child Sex Ratio – Declining trend and it’s determinants: a qualitative community- based study in a selected urban primary care setting, Puducherry.

Background: Child sex ratio (CSR) is defined as the number of females consistent with thousand males in the age group of zero to six years. This serves as a valuable indicator for measuring socio-economic development in a particular region. Objective: To understand community perspectives on gender preference at birth and its potential influence on the decreasing Child Sex Ratio in a selected urban primary care setting in Puducherry, aiming to identify key determinants contributing to the observed declining trend. Methodology: A qualitative study was conducted among residents of the 4 wards under the care of JIPMER Urban Health Centre, Puducherry. Participants were purposively selected among mothers, family members attending well baby clinic at the centre and frontline health workers. Two FGDs involving 8-10 participants were conducted till saturation of information is achieved. Collected data was transcribed in verbatim format. Descriptive manual content analysis was conducted to draw the categories and themes. Results: The qualitative study on Child Sex Ratio revealed that there is a prevailing inclination towards expecting female children. Moreover, the study found no evidence of gender selection practices at present. Participants mentioned awareness of schemes such as “CM Cares for the empowerment of newborn girl child” as contributing factors to these attitudes and behaviors. Gender revealment is found inadvertently in government and private hospitals in the studied population. Conclusion: The study region exhibits a declining CSR, and there is no evidence of gender selection practices at present in the selected region. While improving female literacy and economic standing is essential, it alone is insufficient for enhancing the overall life prospects of female children.

Self-reported pain severity and use of cannabis and opioids in persons with HIV in an urban primary care setting in Northern California: A cross-sectional study.

Persons with HIV (PWH) experience high levels of pain. We examined the relationship of pain severity with use of cannabis and prescription opioids among PWH. This cross-sectional study evaluated associations between self-reported pain (moderate/severe vs mild/none) and cannabis and prescription opioid use in a primary care sample of PWH enrolled in an alcohol use treatment study at Kaiser Permanente, San Francisco. Prevalence ratios (PR) for moderate/severe pain associated with cannabis, opioid use, or both in the prior 30 days were obtained from Poisson regression models. Adjusted models included race/ethnicity, education, employment, HIV ribonucleic acid levels, depression, and anxiety. Overall, 614 PWH completed baseline questionnaires from May 2013 to May 2015, among whom 182/614 (29.6%) reported moderate/severe pain. The prevalence of moderate/severe pain varied by substances: 19.1% moderate/severe pain among study participants who reported neither cannabis or opioids, 30.2% for cannabis alone, 41.2% for opioids alone, and 60.9% for those reporting both substances. In adjusted models, compared with PWH who reported neither substance (reference), prevalence of moderate/severe pain was higher for those using cannabis alone (PR 1.54; 95% CI 1.13-2.09), opioids alone (PR 1.96; 95% CI 1.31-2.94), and those reporting both (PR 2.66; 95% CI 1.91-3.70). PWH who reported opioid and/or cannabis use were more likely to report moderate/severe pain compared with PWH who did not report use of these substances. To improve patient care, it is vital to assess patients' approaches to pain management including substance use and target appropriate interventions to reduce pain in PWH.

Multiple Behavioral Risk Factors As Assets for Chronic Disease Prevention: Observations From Urban Primary Care Settings in Crete, Greece.

This study aimed to assess the health profile of patient-attendees visiting primary healthcare (PHC) practice settings in the midst of the COVID-19 pandemic and to explore the relationships between multiple behavioral risk factors (MBRFs) and consultation-driven health information. Multiple behavioral risk factors involve a variety of unhealthy behaviors that are associated with an increased prevalence of non-communicable diseases (NCDs). The study design was based on a dataset analysis, afterward exploring the feasibility and diagnostic capacity of respiratory morbidity aspects from a study previously conducted. The study dataset contained information regarding socio-demographic characteristics, health habits, clinical information, and reported comorbidities from 183 primary care patient-attendees. A categorical regression analysis was performed, using as a numeric variable the multiple MBRFs (clustering of 0to four factors) in order to examine relationships with the basic and clinical characteristics of the patient-attendees. Based on this secondary analysis, it was found that the prevalence of MBRFs is quite common among patient-attendees visiting urban PHC facilities. The prevalence of current smoking, sleep deprivation, increased body weight, and medium/high perceived stress levels were 33.9%, 52.5%, 83.1%, and 35.0%, respectively. An increased occurrence of MBRFs might be significantly predicted by the lower age of patient-attendees (b = -0.221, p = 0.05), by the absence of gray hair at an early age (b = -0.144, p = 0.042), by the physical discomfort during activities (b = 0.191, p = 0.017), or by the lower oxygen saturation (b = -0.184, p = 0.004). Diabetes mellitus (25.1%) was the most prevalent condition, followed by bronchial asthma (18.6%) and depression (15.8%). Lower age, absence of premature hair whitening, physical discomfort during activities, and lower oxygen saturation are linked with an increased occurrence of MBRFs, leading to a neglected way of living. Those factors could be used to alert researchers, policymakers, and PHC professionals to act accordingly in order to prevent or early diagnose NCDs.

Positive PTSD Screening and Its Health Correlates in Patients With HIV in Urban Primary Care Settings.

Posttraumatic stress disorder (PTSD) is underdiagnosed and undertreated in primary care, especially among African American individuals. The current study assessed documentation rates of PTSD and clinical health correlates among 135 predominantly African American patients with HIV and positive PTSD screens in a primary care unit. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and a retrospective chart review of 135 patients with HIV were conducted. On the PCPTSD-5 (cut point of 3), approximately one half of patients (49.6%; n = 67) had probable PTSD; however, only 11.9% of patients (n = 16) had a chart diagnosis of PTSD. A positive PTSD screen was associated with higher rates of depression and insomnia, but not anxiety, alcohol use, drug use, or pain in patients with HIV. Multi-morbidity of HIV, major depression, and positive PTSD screens was associated with increased risk for asthma, number of medical diagnoses, depression, insomnia, and anxiety. Findings highlight the need for trauma-informed care in primary care settings for people with PTSD and HIV. Larger samples are warranted to further explore health correlates of PTSD. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 25-36.].

COVID-19 mRNA Vaccination Trends Among Immunocompromised Patients.

Immunocompromised patients are at increased risk of contracting severe COVID-19 infection. The purpose of this study was to assess COVID-19 vaccination trends of immunocompromised patients at a large, urban primary care setting. A retrospective chart review of immunocompromised patients who had a visit between 1/1/2021 and 5/15/2022 at Thomas Jefferson University's Department of Family and Community Medicine (DFCM) was conducted. Patient charts were reviewed for demographics, number of visits to the DFCM, immunocompromising diagnoses, and COVID-19 mRNA vaccination status, including vaccination type and number of vaccine doses received. Descriptive statistics were calculated. Paired t tests were conducted to assess relationships between immunocompromised patients with ≥3 mRNA vaccine doses and those with ≤2 mRNA vaccine doses. A total of 887 patients were included. Most patients were Black (66.7%), above the age of 50 (82.1%), and male (55.9%). Solid tumor cancers (62.6%) and HIV/AIDS (23.8%) were the most represented immunocompromising diagnoses. Overall, 556 patients received ≥3 mRNA vaccine doses (62.7%) and 331 patients received ≤2 mRNA vaccine doses (37.3%). Eighty-three patients (9.4%) had no COVID-19 vaccines on record. Of the 591 Black patients, 248 (42%) received ≤2 mRNA vaccine doses. Despite the majority of the sample receiving ≥3 mRNA vaccine doses, disparities in vaccination rates exist, especially when comparing White and Black patients. Vaccination rates in immunocompromised patients should be improved, and primary care providers should prioritize outreach efforts focusing on patient-centered COVID-19 vaccine education in these populations.

Hypertension prevalence, coding and control in an urban primary care setting in the UK between 2014 and 2021.

Hypertension is a leading preventable cause of mortality, yet high rates of undiagnosed and uncontrolled hypertension continue. The burden falls most heavily on some ethnic minorities and the socially deprived, with the COVID-19 pandemic having further widened inequalities. We sought to determine the prevalence and predictors of unmeasured blood pressure (BP), uncoded elevated BP and uncontrolled hypertension in primary care across 2014-2021. A population-based cohort study using data from all 41 general practices in a socioeconomically diverse inner-city borough. BP measurements, sociodemographic, lifestyle and clinical factors were extracted from anonymized primary care data. Hypertension and BP control were defined using NICE guidelines. Associations between patient characteristics and hypertension outcomes were identified using logistical regression modelling. Of 549 082 patients, 39.5% had unmeasured BP; predictors included male sex [AOR 2.40, 95% confidence interval (95% CI) 2.26-2.43] and registration in the pandemic years. Of 71 970 adults with elevated BP, 36.0% were uncoded; predictors included obesity (AOR 2.51, 95% CI 2.42-2.60) and increasing age. Of 44 648 adults on the hypertension register, 46.8% had uncontrolled hypertension; predictors included black ethnicity compared to white (AOR 1.54, 95% CI 1.41-1.68) and cardiovascular co-morbidities (AOR 1.23, 95% CI 1.21-1.25). Social deprivation was only weakly or not significantly associated with hypertension outcomes. The burden of uncoded elevated BP and uncontrolled hypertension is high. Obesity and male sex were associated with uncoded elevated BP and uncontrolled hypertension. Black ethnicity was associated with uncontrolled hypertension. Initiatives are needed to optimize hypertension coding and control, with an emphasis on specific population subgroups.

Unmet Social Needs and Pediatric Asthma Severity in an Urban Primary Care Setting.

Community-level social determinants of health impact asthma outcomes among children; however, individual patient's priorities are not often included in designing social care interventions. Identifying connections between patient-prioritized unmet social needs and asthma severity status may allow for improved patient-centered approaches to asthma management. In this analysis, we examined the association between unmet social needs and asthma severity in an urban population of children. We hypothesized that those with a greater number of unmet social needs would report a more severe asthma status. We conducted a secondary analysis of 4887 patients screened for unmet social needs and asthma severity status. Bivariate associations and adjusted logistic regression modeling were used to assess the association between unmet social needs and asthma severity. Persistent asthma severity status was associated with several unmet social needs, including housing quality and stability, lack of money for food, transportation, and healthcare costs. In the multivariable analysis, having 3 or more unmet social needs was associated with a 59% greater odds of persistent asthma status (CI, 1.18-2.14; P=.002), and having 2 unmet social needs was associated with a 33% greater odds of persistent asthma status (CI, 1.00-1.78; P=.05). Unmet social needs were associated with asthma severity status, with a greater number of unmet social needs associated with greater odds of severe asthma status. Additional studies are warranted to further evaluate the temporal relationship between unmet social needs and how they may compound one another in their relationship with asthma severity.

Childhood Vaccination Practices and Parental Hesitancy Barriers in Rural and Urban Primary Care Settings.

The purpose of our study was to identify primary care providers' (PCPs') practices in promoting childhood vaccination and their perceptions regarding barriers to vaccination in a primarily rural state. In January-May 2022, we conducted a mail and online survey of PCPs across Montana (n = 829). The survey included modules on routine immunizations in children 0-2 years old and COVID-19 vaccination in children 5-17 years old. The survey response rate was 36% (298/829). We categorized PCPs as working in rural (n = 218) or urban areas (n = 80), based on Rural-Urban Commuting Area codes. We then compared responses between rural and urban PCPs using chi-square tests. Urban PCPs (90-94%, depending on vaccine) stocked routinely recommended vaccines more frequently than rural PCPs (71-84%), but stocked the COVID-19 vaccine less often than rural PCPs (44% vs. 71%, respectively, p < 0.001). A higher percentage of rural providers reported parental beliefs that vaccine-preventable diseases are not severe enough to warrant vaccination (48% vs. 31%, p = 0.01) and concerns that vaccination will weaken their child's immune system (29% vs. 6%, p < 0.001). More rural (74%) compared to urban (59%) PCPs identified a social media campaign from local health departments promoting early childhood vaccinations as an effective strategy to increase childhood vaccination rates (p = 0.01). We identified key differences in some childhood vaccination practices and barriers between rural and urban PCPs. Interventions to increase rural vaccination rates could include increasing the number of providers stocking all recommended vaccines, identifying strategies to address parents' concerns regarding vaccine necessity, and collaborations with public health departments.

Confirmation of guideline-defined hepatitis C screening strategies within the 'Check-Up35+' examination in the primary care setting.

Screening strategies for undiagnosed infections are fundamental for hepatitis C virus (HCV) elimination. We previously investigated HCV prevalence and screening strategies in an urban primary care setting. IV drug abuse, blood transfusion before 1992, immigration, or elevated ALT were identified as risk factors in a post hoc analysis and diagnosed 83% of unknown HCV-RNA-positive cases by screening only 26% of the population. We aimed to validate prospectively the proposed screening algorithm in two independent urban and rural cohorts and to analyse for potential differences. Anti-HCV and ALT were included in a routine check-up together with a questionnaire covering risk factors. HCV-RNA was analysed in anti-HCV-positive individuals. In urban and rural areas, 4323 and 9321 individuals were recruited. The anti-HCV prevalence was 0.56% and 0.49%, and 0.1% of patients were HCV-RNA-positive in both regions. Fifty-two anti-HCV positive patients including eight HCV-RNA-positive cases were unaware of the infection (number needed to screen to detect one unknown anti-HCV-positive individual: 262). At least one of the three aforementioned risk factors or elevated serum ALT was present in 3000 patients (22%). Restricting HCV screening to only those with risk factors, 52% and 75% of all anti-HCV and HCV-RNA-positive undiagnosed patients were identified (number needed to screen: 111). We confirm prospectively the efficiency of a risk-based HCV screening. The risk-based algorithm should be evaluated in other countries with similarly low HCV prevalence as in Germany to achieve WHO HCV elimination goals.

Facilitators and barriers to professional nurses implementing integrated services in urban primary health care clinics in Kavango East region, Namibia.

The World Health Organization (WHO) has advocated for the implementation of people-centred and integrated health services. Although there is growing evidence of integration's benefits for sexual and reproductive health, human immunodeficiency virus (HIV) and rights, health services face tremendous resource constraints when it comes to integrating these services. The aim of study was to explore and describe the facilitators and barriers to professional nurses implementing the person-centred model of integrated services in urban primary health care clinics in the Kavango East region, Namibia. We interviewed professional nurses from urban primary health care clinics in low-resourced settings in Rundu health district, Kavango East region, Namibia. This study employed a qualitative approach utilising an explorative, descriptive and contextual strategy. Semistructured interviews were used to collect the data. Fifteen participants were selected using a purposive sampling technique. The interviews were audio recorded, transcribed verbatim and coded, before the data were analysed using thematic analysis. The data analysis led to the emergence of the following four themes: understanding integrated services; facilitators for implementing integrated services; barriers to the implementation of integrated services; and improvement measures for implementing integrated services. Findings showed that the implementation of integrated services faces many barriers, which are related to lack of human resources skills, a lack of essential supplies and space constraints. These findings will hopefully create an awareness and understanding of the facilitators and barriers that professional nurses face in the implementation of integrated services for urban primary health care in the Namibian urban context.Contribution:The study's findings can be used to develop strategies and ongoing interventions that focus on addressing the barriers professional nurses face in the implementation of integrated services in both urban and rural primary health care settings.

Implementing a multisector public-private partnership to improve urban hypertension management in low-and middle- income countries

BackgroundCardiovascular disease presents an increasing health burden to low- and middle-income countries. Although ample therapeutic options and care improvement frameworks exist to address its prime risk factor, hypertension, blood pressure control rates remain poor. We describe the results of an effectiveness study of a multisector urban population health initiative that targets hypertension in a real-world implementation setting in cities across three continents. The initiative followed the “CARDIO4Cities” approach (quality of Care, early Access, policy Reform, Data and digital technology, Intersectoral collaboration, and local Ownership).MethodThe approach was applied in Ulaanbaatar in Mongolia, Dakar in Senegal, and São Paulo in Brazil. In each city, a portfolio of evidence-based practices was implemented, tailored to local priorities and available data. Outcomes were measured by extracting hypertension diagnosis, treatment and control rates from primary health records. Data from 18,997 patients with hypertension in primary health facilities were analyzed.ResultsOver one to two years of implementation, blood pressure control rates among enrolled patients receiving medication tripled in São Paulo (from 12·3% to 31·2%) and Dakar (from 6·7% to 19·4%) and increased six-fold in Ulaanbaatar (from 3·1% to 19·7%).ConclusionsThis study provides first evidence that a multisectoral population health approach to implement known best-practices, supported by data and digital technologies, and relying on local buy-in and ownership, can improve hypertension control in high-burden urban primary care settings in low-and middle-income countries.

How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography

There is growing emphasis for primary care clinicians to initiate and engage in end-of-life (EOL) conversations with medically frail older adults. However, EOL conversations happen most often when death is imminent or are avoided altogether. The objective of this study was to understand the socio-political forces shaping EOL conversations between clinicians, medically frail older adults and/or their care partners within an urban primary care setting, a Family Health Team in Ontario, Canada. We conducted an eight-month critical ethnography in 2019 involving observations and interviews of clinicians, patients, and care partners (n ​= ​35). Analyzing this data for discourses and power-knowledge systems we found that two discourses, frailty and more life shape EOL conversations in this setting. More life discourse disrupts EOL conversations by making it more difficult to talk about decline and dying as well as personal goals. Biomedicine and clinical practice guidelines comprised the two major power-knowledge systems that increase the influence of more life in this setting as well as the norm of seeking longevity. Improving EOL conversations is complex and requires addressing the power-knowledge systems that perpetuate more life as well as a discursive shift towards prioritizing relationships and people's life worlds. Primary care as a specialty can critically reflect on the ways it is entrenched in a culture of care that valorizes more life and (re)create clinical practice guidelines and evaluations to align with person-centredness more meaningfully. Future research should involve patients, care-partners, and interprofessional clinicians to co-create approaches to care that can better accommodate frailty talk.

Perceptions of a Teleophthalmology Screening Program for Diabetic Retinopathy in Adults With Type 1 and Type 2 Diabetes in Urban Primary Care Settings

ObjectivesTeleophthalmology has improved diabetic retinopathy screening, and should be expanded in urban areas, where most unscreened individuals reside. In this study, we explored facilitators of and barriers to teleophthalmology in primary care settings in Toronto, Canada. MethodsSemistructured interviews were conducted with 7 health-care providers and 7 individuals with diabetes to explore their perspectives of teleophthalmology in urban primary care settings. Interview data were analyzed using interpretive thematic analysis to generate themes. ResultsSix themes were identified. Facilitators included patient-centred implementation, access to teleophthalmology at primary care sites and patients’ trust in their providers’ recommendations. Barriers included patients’ lack of understanding of diabetic retinopathy and the health-care system, providers’ lack of interest and the need to streamline administrative processes. ConclusionsAlthough teleophthalmology was well-received by patients, there was limited interest from primary care providers. Strategies for increasing uptake include increasing primary care providers’ awareness of teleophthalmology’s value in urban centres, improving administrative processes and centralizing patient recruitment.

Emotional Discomfort Scale: Instrument Development and Association With General Self-Efficacy and Data From an Urban Primary Care Setting.

Introduction: Sense of discomfort, which is experienced in daily encounters, can develop into stress, coexist with stress, or interplay with self-efficacy. This study presents two objectives, namely, to develop and test a new instrument called the Emotional Discomfort (EmoD) Scale and to compare the EmoD with the General Self-Efficacy (GSE) Scale.Methods: The study was conducted in an urban primary healthcare center in Greece over a three-week period in 2020. Out of 314 individuals invited to participate, 263 accepted and completed the questionnaire. The EmoD is a five-point Likert-type eight-item scale for assessing individual reaction and sense of discomfort in daily life situations.Results: Cronbach’s α for the new scale reached 0.730 (acceptable reliability). Participants who used psychotropic drugs scored higher in the EmoD scale compared with nonusers. GSE scores showed reverse associations with EmoD scores. Multiple linear regression analysis indicated that an increase in self-efficacy, as measured using the GSE scale, was associated with a reduction in sense of discomfort, as measured by the EmoD scale.Conclusions: The use of the EmoD scale can aid health or social care providers in detecting levels of emotional discomfort, a finding that is demonstrated to interplay with self-efficacy. Future studies employing the use of this new instrument could examine emotional discomfort in relation to stress coping and social isolation.