Is COVID-19 as Lethal as the Spanish Flu? The Australian Experience in 1919 and 2020 and the Role of Nonpharmaceutical Interventions (NPIs).

We conducted a comparative historical study to interrogate Professor Peter Doherty's warning to Australians in April 2020 that 'COVID-19 is just as lethal as the Spanish flu'. We identified the epicentres of both pandemics, namely, metropolitan Sydney in 1919 and metropolitan Melbourne in 2020 and compared the lethality of the Spanish Flu and COVID-19 in these two cities. Lethality was measured by the number and rate of hospital admissions, death rates, age-specific death rates and age-standardised mortality rates (ASMRs). Using these measures, we demonstrated the strikingly different waves of infection, their severity at various points in time and the cumulative impact of the viruses by the end of our study period, i.e., 30 September in 1919 and 2020. Hospital admissions and deaths from the Spanish Flu in 1919 were more than 30 times higher than those for COVID-19 in 2020. The ASMR per 100,000 population for the Spanish Flu was 383 compared to 7 for COVID-19: The former was about 55 times higher than the latter. These results suggest that the Spanish Flu was more lethal than COVID-19. Professor Doherty's warning was perhaps taken seriously and that partly explains the findings of this study. Containing infection in 1919 and 2020 threw the burden on nonpharmaceutical interventions (NPIs) such as 'protective sequestration' (quarantine), contact tracing, lockdowns and masks. It is likely that the persistent and detailed contact tracing scheme provides the best possible explanation for why NPIs in 2020 were more effective than in 1919 and therefore contributed to the lower lethality of the COVID-19 pandemic in its first year.

Uptake and effectiveness of online diabetes continuing education: The perspectives of Thai general practitioner trainees.

Background: Despite continuing medical education (CME) programmes on evidence-based diabetes care, evidence-based best practice and actual GP practice remain scant. Online CME offers numerous benefits to general practitioners (GPs), particularly during the coronavirus disease 2019 (COVID-19) pandemic. In Thailand, CME is a voluntary process and is yet to be established as a mandatory requirement. This study examined GP uptake of online diabetes CME and the changes in GPs' attitudes to and knowledge of Type 2 diabetes management. Methods: A cross-sectional study and a before-and-after study were employed with 279 GP trainees who voluntarily undertook a newly-developed online diabetes programme. A follow-up survey was conducted six months after the GP trainees completed their training. Results: One hundred and twelve out of 279 GP trainees (40.1%) participated in the study, of whom 37 (13.3%) enrolled in the online diabetes programme, and 20 (7.2%) completed the programme. Before enrolling in the programme, the participants' mean diabetes knowledge score was 61.5%. The participants' confidence in effective insulin treatment increased significantly after the programme (95% Confidence interval [CI], -0.51-0.00; P = 0.05), but their knowledge scores before and after the programme were not statistically different (95% CI, -3.93-0.59; P = 0.14). Conclusion: Uptake of the online diabetes CME was poor, although appropriate recruitment strategies were employed, and the online educational option was attractive and accessible during the COVID-19 pandemic. This study emphasises the gap between evidence-based practice and actual GP practice and the need for mandatory CME.

Prioritising national dementia guidelines for general practice: A Delphi approach.

OBJECTIVES: Australian guidelines for dementia cover 109 recommendations for dementia care. Knowing which recommendations to implement poses a challenge for general practitioners (GPs). This study aimed to gather general practice perspectives of priority recommendations for GPs in their practice. METHODS: To explore which recommendations are most important and those requiring the greatest support in GP implementation, a Delphi study was conducted. Thirty-six GPs, 4 practice nurses and 1 medical services director completed two rounds of email questionnaires. RESULTS: Recommendations requiring support for GP implementation relate to early assessment of behavioural and psychological symptoms; mental health interventions tailored to the person's preferences and abilities; language and cultural barriers in access to information and services; and cognitive and learning needs in treatment delivery. CONCLUSIONS: It is critical to understand where support may be needed for GPs to successfully implement recommendations to improve care provided to people with dementia and their carers.

How can dementia diagnosis and care for Aboriginal and Torres Strait Islander people be improved? Perspectives of healthcare providers providing care in Aboriginal community controlled health services.

BACKGROUND: Aboriginal and/or Torres Strait Islander people experience dementia at a rate three to five times higher than the general Australian population. Aboriginal Community Controlled Health Services (ACCHSs) have a critical role to play in recognising symptoms of cognitive impairment, facilitating timely diagnosis of dementia, and managing the impacts of dementia. Little is known about the barriers and enablers to Aboriginal people receiving a timely dementia diagnosis and appropriate care once diagnosed. This study aims to explore, from the perspective of healthcare providers in the ACCHS sector across urban, regional and remote communities, the barriers and enablers to the provision of dementia diagnosis and care. METHODS: A qualitative study involving semi-structured interviews with staff members working in the ACCHS sector. Aboriginal Health Workers, General Practitioners, nurses, practice or program managers, and Chief Executive Officers were eligible to participate. Consenting ACCHS staff completed a telephone interview administered by a trained interviewer. Interviews were audio-recorded, transcribed, and analysed using qualitative content analysis. RESULTS: Sixteen staff from 10 ACCHSs participated. Most participants perceived their communities had a limited understanding of dementia. Symptoms of dementia were usually noticed by the GP or another healthcare worker at the ACCHS who had an ongoing relationship with the person. Most participants reported that their service had established referral pathways with either hospital-based geriatricians, geriatricians located with aged care assessment teams, or specialists who visited communities periodically. Key enablers to high quality dementia care included the use of routine health assessments as a mechanism for diagnosis; relationships within communities to support diagnosis and care; community and family relationships; comprehensive and holistic care models; and the use of tailored visual resources to support care. Key barriers to high quality care included: denial and stigma; dementia being perceived as a low priority health condition; limited community awareness and understanding of dementia; lack of staff education and training about dementia; and numerous gaps in service delivery. CONCLUSIONS: Substantially increased investments in supporting best-practice diagnosis and management of dementia in Aboriginal communities are required. ACCHSs have key strengths that should be drawn upon in developing solutions to identified barriers to care.

Management of Domestic Violence by Primary Care Physicians in Hong Kong: Association With Barriers, Attitudes, Training, and Practice Background.

While primary care physicians (PCPs) have opportunities to recognize patients who encounter domestic violence (DV) by intimate partners, warning symptoms such as unexplained physical injury, bruising, anxiety, and depression are often missed during clinic visits. This study investigated the barriers of Hong Kong PCPs toward managing DV, including recognition, management, and referrals of these patients. Four focus group interviews were conducted to explore the in-depth opinions of PCPs on managing DV in Hong Kong. The themes identified were investigated in a questionnaire survey with data from 504 PCPs working in public and private sectors. Factor analysis of the survey data suggested four major barrier factors: (a) worries about the potential harms of intervening in patients' domestic affairs and DV issues, (b) lack of guidelines and support services, (c) limited skills and time in managing DV, and (d) patients' reluctance in disclosing DV issues. PCPs with more years of practice had more worries about intervening in domestic issues (Factor 1), while the younger PCPs tended to perceive limited skills and time in managing DV cases as barriers (Factor 3). PCPs working in the public setting were more likely to ask patients about DV (M = 5.4 vs. 2.9), suspected DV (M = 3.8 vs. 2.3), and managed DV (M = 1.7 vs. 1.0) in the past 5 years compared with the private PCPs. Some PCPs in the focus groups expressed the view that DV cases should be handled by social workers instead of doctors. Survey respondents who held such views about doctors' limited role in DV management also scored higher in all of the barrier factors. The findings suggest that there are boundaries between domestic and medical realms, especially in a Chinese context. Resolving PCPs' worries by training, provision of DV management guidelines, and referral pathway to social workers may be good starting points to bridge the gaps.

Factors that facilitate recognition and management of domestic violence by primary care physicians in a Chinese context - a mixed methods study in Hong Kong.

BACKGROUND: Domestic violence is common in the community. Many of its victims present to primary care physicians (PCPs) but are not being recognized and managed. The barriers, with specific reference to a Chinese cultural context, were investigated earlier. This paper explored the factors which facilitated the process of recognizing and managing suspected cases of domestic violence by PCPs in Hong Kong. METHODS: Four focus group interviews were conducted to explore in-depth the experiences of PCPs in recognition, management and referral of domestic violence cases from which facilitators were identified. The relevant themes were then investigated in a questionnaire survey with 504 PCPs working in public and private sectors. RESULTS: The focus group participants emphasized mood symptoms as useful indicators for probable abuse and continuity of care was important to unmask issues of domestic violence. The top facilitators perceived by the respondents of the survey included: a trusting doctor-patient relationship (99.8%), good communication skills (99.0%), patients' unexplained bruises (96.3%), medical history (94.6%), and mood symptoms (94.4%). Further, the survey found that PCPs with longer years of practice, a medical degree obtained from Western countries, and postgraduate training in family counselling or psychological medicine perceived more facilitators in managing domestic violence. CONCLUSIONS: Without a local screening policy and training protocol to manage domestic violence, PCPs regarded their skills in mental healthcare and good relationships with patients as the key facilitators. While training in mental health care helps PCPs manage domestic violence, a specific protocol emphasizing medical-social collaboration is anticipated to facilitate them to take a more proactive and effective stance from screening to management.

Improving depression outcomes among Australian primary care patients: protocol for a cluster randomised controlled trial.

INTRODUCTION: Depression is a common and debilitating condition. In Australia, general practitioners (GPs) are the key providers of depression care. However, available evidence suggests that case finding for depression in primary care is poor. This study will examine whether a systematic approach to screening for depression and assessing patient preferences for depression care improves depression outcomes among primary care patients. METHODS AND ANALYSIS: A cluster randomised controlled design will be used with general practice clinics randomly assigned to either the intervention (n=12) or usual care group (n=12). Patients who are aged 18 and older, presenting for general practice care, will be eligible to participate. Eighty-three participants will be recruited at each clinic. Participants will be asked to complete a baseline survey administered on a touch screen computer at their GP clinic, and then a follow-up survey at 3, 6 and 12 months. Those attending usual care practices will receive standard care. GPs at intervention practices will complete an online Clinical e-Audit, and will be provided with provider and patient-directed resources for depression care. Patients recruited at intervention practices who score 10 or above on the Patient Health Questionnaire-9 will have feedback regarding their depression screening results and preferences for care provided to their GP. The primary analysis will compare the number of cases of depression between the intervention and control groups. ETHICS AND DISSEMINATION: The study has been approved by the University of Newcastle Human Research Ethics Committee, and registered with Human Research Ethics Committees of the University of Wollongong, Monash University and University of New South Wales. Results will be disseminated through peer-reviewed journal publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12618001139268; Pre-results.

Impact of training for general practitioners on their mental health services: The Hong Kong experience.

METHOD: A questionnaire survey was conducted among GPs. Of the 516 respondents, 76 (14.7%) had attended a one­year postgraduate mental health training course. RESULTS: The GPs with mental health training saw significantly more patients with mental health problems per week (median class 11-15 versus 6-10) and treated a higher percentage of patients with mental health problems (median class 41-60% versus 21-40%). The differences remained significant, with odds ratios of 2.6 for both indicators after controlling for gender, healthcare setting and years of practice. DISCUSSION: Policies should promote training of GPs as part of the increasing workforce for mental healthcare. Estimated from the results, GPs with mental health training have nearly triple the number of consultations related to mental health, compared with other GPs (340 versus 120 per year).

Help-seeking behaviours for psychological distress amongst Chinese patients.

BACKGROUND: The stepped care model for psychological distress has been promoted in recent years, leading to the enhancing roles of primary care professionals and alternative sources of help. However, most of the research findings come from Western countries. This study investigates help-seeking behaviours of Chinese patients among different types of professional and alternative sources for psychological distress in Hong Kong. METHODS: A questionnaire survey was conducted with 1626 adult primary care attenders from 13 private and 6 public clinics, 650 (40.0%) reported that they had ever experienced psychological distress. Their help-seeking behaviours, demographic background and current distress level (measured by GHQ-12) were analysed. RESULTS: Among the respondents with experience of psychological distress, 48.2% had sought help from professional and/or alternative sources for their distress [10.2% from professionals only, 12.6% from alternative sources only, and 25.4% from both]. Those who had sought help from professionals only were more likely to be less educated and with lower income. In contrast, those using alternative sources only were more likely to be younger, better educated, and have higher income. Allowing multiple responses, psychiatrists (22.3%) was reported to be the most popular professional source, followed by primary care physicians (17.5%), clinical psychologists (12.8%) and social workers/counsellors (12.0%). Family members/friends (28.6%) was the top alternative source, followed by exercise/sports (21.8%), religious/spiritual support (16.9%) and self-help websites/books/pamphlets (8.9%). CONCLUSION: While psychiatrists remain the most popular professional source of help to the Chinese patients in Hong Kong, primary care professionals and alternative sources also play significant roles. Distressed patients who are younger, better educated and have higher income are more likely to use alternative sources only. The outcomes need further research.

Poor uptake of an online intervention in a cluster randomised controlled trial of online diabetes education for rural general practitioners.

BACKGROUND: In Australia, rural and remote communities have high rates of diabetes-related death and hospitalisation. General practitioners (GPs) play a major role in diabetes detection and management. Education of GPs could optimise diabetes management and improve patient outcomes at a population level. The study aimed to describe the uptake of a continuing medical education intervention for rural GPs and its impact on the viability of a cluster randomised controlled trial of the effects of continuing medical education on whole-town diabetes monitoring and control. METHOD: Trial design: the cluster randomised controlled trial involved towns as the unit of allocation and analysis with outcomes assessed by de-identified pathology data (not reported here). The intervention programme consisted of an online active learning module, direct electronic access to specialist advice and performance feedback. Multiple rounds of invitation were used to engage GPs with the online intervention content. Evidence-based strategies (e.g. pre-notification, rewards, incentives) were incorporated into the invitations to enrol in the programme. Recruitment to the programme was electronically monitored through the hosting software package during the study intervention period. RESULTS: Eleven matched pairs of towns were included in the study. There were 146 GPs in the 11 intervention towns, of whom 34 (23.3%) enrolled in the programme, and 8 (5.5%) completed the online learning module. No town had more than 10% of the resident GPs complete the learning module. There were no contacts made by GPs regarding requests for specialist advice. Consequently, the trial was discontinued. CONCLUSION: There is an ongoing need to engage primary care physicians in improving diabetes monitoring and management in rural areas. Online training options, while notionally attractive and accessible, are not likely to have high levels of uptake, even when evidence-based recruitment strategies are implemented. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, identifier: ACTRN12611000553976 . Retrospectively registered on 31 May 2011.

Patterns of type 2 diabetes monitoring in rural towns: How does frequency of HbA1c and lipid testing compare with existing guidelines?

OBJECTIVE: To indicate levels of monitoring of type 2 diabetes in rural and regional Australia by examining patterns of glycated haemoglobin (HbA1c) and blood lipid testing. DESIGN AND SETTING: Retrospective analysis of pathology services data from twenty regional and rural towns in eastern Australia over 24 months. PARTICIPANTS: Of 13 105 individuals who had either a single HbA1c result ≥7.0% (53 mmol mol-1 ); or two or more HbA1c tests within the study period. MAIN OUTCOME MEASURES: Frequency of testing of HbA1c and blood lipids (cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglycerides) were compared with guideline recommendations. RESULTS: About 58.3% of patients did not have the recommended 6-monthly HbA1c tests and 30.6% did not have annual lipid testing. For those who did not receive tests at the recommended interval, the mean between-test interval was 10.5 months (95% CI = 7.5-13.5) rather than 6 months for HbA1c testing; and 15.7 (95% CI = 13.3-18.1) months rather than annually for blood lipids. For those with at least one out-of-range test result, 77% of patients failed to receive a follow-up HbA1c test and 86.5% failed to receive a follow-up blood lipid test within the recommended 3 months. Patients less than 50 years of age, living in a more remote area and with poor diabetes control were less likely to have testing at the recommended intervals (P < 0.0001). CONCLUSIONS: Although poor diabetes testing is not limited to rural areas, more intensive diabetes monitoring is likely to be needed for patients living in non-metropolitan areas, particularly for some subgroups.

Infant gastro-oesophageal reflux disease (GORD): Australian GP attitudes and practices.

AIM: The aim of this study was to evaluate the attitudes and practices of Australian general practitioners (GPs) regarding infant gastro-oesophageal reflux disease (GORD) diagnosis and management. METHODS: A national cross-sectional survey, involving a random sample of currently practising Australian GPs (n = 2319) was undertaken between July and September 2011. GPs attitudes and management of infant GORD were surveyed via an online and paper-based 41-item questionnaire. RESULTS: In total, 400 responses were analysed (17.24% response rate). The majority of GPs employed empirical trials of acid-suppression medication and/or lifestyle modifications to diagnose infant GORD. GPs frequently recommended dietary modification despite the belief that they were only moderately effective at best. In addition, GPs frequently prescribed acid-suppression medication, despite concerns regarding their safety in the infant population. Other GP concerns included the lack of clinical guidelines and education for GPs about infant GORD, as well as the level of evidence available for the safety and efficacy of diagnostic tests and treatments. CONCLUSION: Despite the important role Australian GPs play in the diagnosis and management of infant GORD, high-level evidence-based guidelines for GPs are lacking. Consequently, GPs engage in diagnostic and management practices despite their concerns regarding the safety and effectiveness.

Challenges of the Pandemic Response in Primary Care during Pre-Vaccination Period: A Qualitative Study.

BACKGROUND: During the 2009/A/H1N1 pandemic, the main burden of the patient management fell on primary care physicians (PCPs), and they were the principal implementers of pandemic policies. Broad involvement of PCPs in the pandemic response offered an excellent opportunity to investigate the challenges that they encountered. OBJECTIVE: To examine challenges faced by PCPs as they implemented pandemic policies in Australia, Israel and England before the 2009/A/H1N1 pandemic vaccine became available. METHODS: This is a qualitative descriptive study that employed in-depth semi-structured interviews with 65 PCPs from Australia, Israel and England. The data were analysed thematically to provide a detailed account of the themes. RESULTS: Challenges in three fields of the pandemic response were identified. (i) Consultation of patients was challenged by the high flow of patients, sick and worried-well, the necessity to provide personalised information about the disease during consultations, and unfamiliar antiviral treatment. (ii) Performance of public health responsibilities was complicated in regards to patient segregation and introduction of personal protection measures. (iii) Communication with the health authorities was inefficient, with no established route to provide feedback about the pandemic policies. CONCLUSIONS: The experience of the 2009/A/H1N1 pandemic highlighted the centrality of primary care in the pandemic response. Despite intensive pre-pandemic planning, numerous barriers for implementation of the pandemic policies in primary care were identified. Investigation of three different approaches for involvement of PCPs in the pandemic management showed that none of these approaches worked smoothly.

The MOVE study: a study protocol for a randomised controlled trial assessing interventions to maximise attendance at physical activity facilities.

BACKGROUND: Physical activity is associated with a host of health benefits, yet many individuals do not perform sufficient physical activity to realise these benefits. One approach to rectifying this situation is through modifying the built environment to make it more conducive to physical activity, such as by building walking tracks or recreational physical activity facilities. Often, however, modifications to the built environment are not connected to efforts aimed at encouraging their use. The purpose of the Monitoring and Observing the Value of Exercise (MOVE) study is to evaluate the effectiveness of two interventions designed to encourage the ongoing use of a new, multi-purpose, community-based physical activity facility. METHODS/DESIGN: A two-year, randomised controlled trial with yearly survey points (baseline, 12 months follow-up, 24 months follow-up) will be conducted among 1,300 physically inactive adult participants aged 18-70 years. Participants will be randomly assigned to one of three groups: control, intervention 1 (attendance incentives), or intervention 2 (attendance incentives and tailored support following a model based on customer relationship management). Primary outcome measures will include facility usage, physical activity participation, mental and physical wellbeing, community connectedness, social capital, friendship, and social support. Secondary outcome measures will include stages of change for facility usage and social cognitive decision-making variables. DISCUSSION: This study will assess whether customer relationship management systems, a tool commonly used in commercial marketing settings, can encourage the ongoing use of a physical activity facility. Findings may also indicate the population segments among which the use of such systems are most effective, as well as their cost-effectiveness. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12615000012572 (registered 9 January 2015).

Online continuing medical education (CME) for GPs: does it work? A systematic review.

BACKGROUND: Numerous studies have assessed the effectiveness of online continuing medical education (CME) designed to improve healthcare professionals' care of patients. The effects of online educational interventions targeted at general practitioners (GP), however, have not been systematically reviewed. METHODS: A computer search was conducted through seven databases for studies assessing changes in GPs' knowledge and practice, or patient outcomes following an online educational intervention. RESULTS: Eleven studies met the eligibility criteria. Most studies (8/11, 72.7%) found a significant improvement in at least one of the following outcomes: satisfaction, knowledge or practice change. There was little evidence for the impact of online CME on patient outcomes. Variability in study design, characteristics of online and outcome measures limited conclusions on the effects of online CME. DISCUSSION: Online CME could improve GP satisfaction, knowledge and practices but there are very few well-designed studies that focus on this delivery method of GP education.

Mindfulness-based cognitive therapy for recurrent depression: A translational research study with 2-year follow-up.

OBJECTIVE: While mindfulness-based cognitive therapy (MBCT) has demonstrated efficacy in reducing depressive relapse/recurrence over 12-18 months, questions remain around effectiveness, longer-term outcomes, and suitability in combination with medication. The aim of this study was to investigate within a pragmatic study design the effectiveness of MBCT on depressive relapse/recurrence over 2 years of follow-up. METHOD: This was a prospective, multi-site, single-blind trial based in Melbourne and the regional city of Geelong, Australia. Non-depressed adults with a history of three or more episodes of depression were randomised to MBCT + depression relapse active monitoring (DRAM) (n=101) or control (DRAM alone) (n=102). Randomisation was stratified by medication (prescribed antidepressants and/or mood stabilisers: yes/no), site of usual care (primary or specialist), diagnosis (bipolar disorder: yes/no) and sex. Relapse/recurrence of major depression was assessed over 2 years using the Composite International Diagnostic Interview 2.1. RESULTS: The average number of days with major depression was 65 for MBCT participants and 112 for controls, significant with repeated-measures ANOVA (F(1, 164)=4.56, p=0.03). Proportionally fewer MBCT participants relapsed in both year 1 and year 2 compared to controls (odds ratio 0.45, p<0.05). Kaplan-Meier survival analysis for time to first depressive episode was non-significant, although trends favouring the MBCT group were suggested. Subgroup analyses supported the effectiveness of MBCT for people receiving usual care in a specialist setting and for people taking antidepressant/mood stabiliser medication. CONCLUSIONS: This work in a pragmatic design with an active control condition supports the effectiveness of MBCT in something closer to implementation in routine practice than has been studied hitherto. As expected in this translational research design, observed effects were less strong than in some previous efficacy studies but appreciable and significant differences in outcome were detected. MBCT is most clearly demonstrated as effective for people receiving specialist care and seems to work well combined with antidepressants.

Victims' barriers to discussing domestic violence in clinical consultations: a qualitative enquiry.

Victims of domestic violence frequently attend health care facilities. In many cases, their abusive experience is neither disclosed nor discussed during clinical consultations. This study examined the barriers faced by women when discussing abuse with health care providers, specifically in cases involving Malaysian women with a history of domestic violence. A qualitative study using in-depth interviews was conducted with 10 women with a history of domestic violence residing at a shelter. Purposive sampling was conducted until data saturation. Using the grounded theory approach of analysis, themes that emerged from these interviews were then further analyzed to examine the barriers faced by these women. Women who experienced domestic violence faced multiple barriers while discussing their accounts of abuse with others. Values placed on the privacy of domestic violence; upholding the traditional gender roles; preserving the family unity; minimizing the abuse, the feeling of shame, self-blame; and fearing their abuser generally create internal barriers when discussing their encounters of abuse with health care providers. The perceived unknown role of health care professionals when dealing with patients experiencing domestic violence as well as the previous negative experiences in clinical consultations acted as external barriers for discussing abuse with health care providers. Women with domestic violence experiences faced internal and external barriers to discussing their abuse during clinical consultations. Physicians and health care providers must consider domestic violence in consultations with female patients. A good doctor-patient relationship that encompasses empathy, confidence, trust, support, assurance, confidentiality, and guidance can help patients with abusive backgrounds overcome these barriers, leading to the disclosure and discussion of their abusive encounters. Proper education, guidelines, and support for health care providers are required to help them assist women with histories of domestic violence.

Response of general practitioners to infectious disease public health crises: an integrative systematic review of the literature.

OBJECTIVE: Previous research has identified gaps in pandemic response planning for primary care. Identifying the challenges that general practitioners (GPs) face during public health crises of infectious diseases will help to improve prepandemic planning. In this integrative systematic review, we identified research-based evidence to (1) challenges that GPs have when participating in pandemics or epidemics and (2) whether GPs from different countries encountered different challenges. METHODS: A systematic search was conducted in MEDLINE, PubMed, Scopus, EMBASE, PsycINFO, Cochrane Library, and ProQuest Dissertations and Theses databases during October to November 2012 to identify studies relevant to experience by GPs during epidemics or pandemics. RESULTS: Six quantitative, 2 mixed method, and 2 qualitative studies met the inclusion criteria. The challenges identified were not exclusive to specific countries and encompassed different responses to outbreaks. These challenges included difficulties with information access; supply and use of personal protective equipment; performing public health responsibilities; obtaining support from the authorities; appropriate training; and the emotional effects of participating in the response to an infectious disease with unknown characteristics and lethality. CONCLUSION: GPs' response to public health crises in different countries presents potential for improving pandemic preparedness.