Impact of training on primary care physicians' management of depression and anxiety disorders in rural China.

BACKGROUND: Primary care physicians (PCPs) in rural township health centers are the most easily accessible doctors to the residents in rural China, which covers 35% of the population. High prevalence of depression was reported among rural left-behind elderly and children as many workers had migrated to urban cities. AIM: This study explored mental health care provision by PCPs in rural China and the association with their training background. METHODS: Rural township health centers in both developed and less developed counties of Zhejiang Province, China were chosen as the study sites. A total of 697 PCPs completed questionnaires between December 2019 and January 2020, and the number of valid questionnaires was 673, with a valid response rate of 79.3%. RESULTS: The rural PCPs reported a median range of seeing 1 to 5 mental health patients per week. Over two-thirds (68.2%) of the respondents had never received any training on treating common mental health disorders (depression and anxiety) while 20.3% received at most 2 days of training; 6.4% received 3 to 20 days of training; and 5.1% received over 20 days of training. PCPs with mental health training were significantly associated with better mental health care in terms of confidence and practice characteristics (e.g. having patients who brought up mental health issues, providing follow-up), while years of practice made a difference in practice but not confidence. CONCLUSIONS: Training is the key determinant of the practice of mental health care by the PCPs in rural China. Our findings have implications for national policy to target two-thirds of rural PCPs who received no mental health training.

Medical interns' views on the strategies for reducing antibiotic misuse in the hospitals-what guidelines do they follow?

Objectives: Although the topic of antibiotic misuse is taught in medical schools, interns (fresh medical graduates) still encounter barriers to appropriate antibiotic prescription when they practice in hospitals under supervision. The impact of teaching in medical school, antibiotics stewardship program (ASP), and prescription guidelines was uncertain. This study explored the medical interns' views on antibiotic use and resistance, and their perceived enablers to appropriate antibiotic prescription. Methods: Two focus groups were conducted among medical interns with rotation experiences in different public hospitals of Hong Kong. The identified themes about attitudes to antibiotic resistance and enablers to appropriate antibiotic prescription were further examined by a questionnaire survey with 77 respondents. Results: The interns had lower preferences for tackling antibiotic resistance as they feared of delayed prescriptions. Guidelines provided by international evidence-based clinical resources and the interns' working hospitals were stronger enablers to appropriate antibiotic use than education materials from schools and the government. Qualitative findings revealed that the interns were aware of the existing ASP but doubted its effectiveness as it failed to get the prescribers' attention. They followed guidelines in their wards but perceived guidelines from local health authorities user-unfriendly. Knowledge from medical school was not very applicable. Varying prescribing practices between hospitals and the densely placed hospital beds made it difficult to prevent the spread of antimicrobial resistance. Conclusions: Minimizing delayed prescription is of a higher priority than tackling antibiotic resistance in medical interns' perspective. Interventions should target guidelines in hospitals and simplify the interface of local guidelines.

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.

Antibiotic prescriptions by medical interns in Hong Kong: influence of the hospital settings and prescription culture.

BACKGROUND: Inappropriate antibiotic prescribing practices predispose to resistance emergence. Despite the inclusion of the topic in medical school curricula worldwide, it is uncertain whether newly graduated medical interns have confidence in proper antibiotic prescription. OBJECTIVES: This study aimed to explore the antibiotic prescribing behaviours of the medical interns in Hong Kong and their barriers to appropriate antibiotic prescription. METHODS: Two focus groups were conducted among medical interns with training experiences in different public hospitals. Their prescribing behaviours and barriers were further examined with a questionnaire survey just before completion of internship. RESULTS: Focus group interviews identified a variety of hospital workplace cultures, including inappropriate empirical prescriptions and dosages, interns' passive roles in prescribing antibiotics and varied guidelines between different departments. Defensive medicine and lack of clinical experience were other barriers encountered. The interns believed that the incorrect practice learnt would perpetuate in their minds and affect their future practice. The top barriers reported by the survey respondents were adaptation to prescription culture of different hospitals (93.5%), lack of experience in antibiotic prescription (88.3%), inadequate knowledge in the choice of antibiotics (85.7%) and compliance with the seniors' instructions (80.6%). However, some focus group participants perceived weaker barriers in paediatric departments which provided close monitoring of antibiotic use. CONCLUSIONS: Inadequate knowledge and low confidence in antibiotic prescription led to the passive role of medical interns in antibiotic prescription, predisposing to future inappropriate practice. Inconsistent guidelines and prescription cultures between different hospitals and departments might further exacerbate their barriers.

Seasonal influenza vaccine uptake among Chinese in Hong Kong: barriers, enablers and vaccination rates.

BACKGROUND: Low influenza vaccination rates were observed in Asian countries including China. This study investigated the updated seasonal influenza vaccination rates among Chinese in Hong Kong, and the barriers and enablers to vaccination. METHODS: Eight focus groups were conducted among the Chinese general public, followed by a telephone survey between March and April 2018 with 2,452 respondents (response rate 41.4%). RESULTS: Of the survey respondents, 29.1% had received influenza vaccine in the past 12 months. A majority of them agreed with 'enhancing immunity' (94.4%) and 'feeling safer' (92.3%) as their reasons for vaccination, followed by the belief on 'quicker recovery' if they had influenza (69.5%), and free/subsidized vaccine (53.8%). Among respondents who had not received influenza vaccine, 71.2% 'believed in the strength of their own immunity' and 65.6% perceived 'low-risk of getting influenza'. Less than half were 'worried about side-effects' and 'effectiveness'. The groups aged 65-74 and 75 or above had vaccination rates of 49.1% and 69.9%, respectively, in contrast to 13.9% for the group aged 18-64. A rate of 37.9% for children was reported by the 442 respondents having children. CONCLUSIONS: The high uptake of vaccines among the children and elderly suggests the positive impact of the subsidy and outreach programs. However, young and middle-aged adults tend to believe in the strength of their own immunity and underestimate the infection risk. Public education should emphasize that inactivated vaccines such as influenza vaccines work by means of the viral antigens stimulating the host's immune system toward the major types of seasonal influenza.

Treatment of Chinese adolescents with anorexia nervosa in Hong Kong: The gap between treatment expectations and outcomes.

BACKGROUND AND OBJECTIVE: Anorexia nervosa (AN) is one of the most difficult-to-treat psychiatric disorders. AN is associated with individual vulnerability, societal and family factors. There has been limited research in Asia regarding the patients or their families' perceptions on its treatment. This study explored the perceived treatment outcomes among Chinese families having adolescents with AN. METHODS: Qualitative interviews were conducted on parents of adolescents with AN recruited through an eating disorder association in Hong Kong to understand their views and experiences regarding the help-seeking and treatment process. RESULTS: The parents expressed dissatisfaction towards help-seeking and treatment outcomes, including relationships with health professionals, hospitalization, health professionals' knowledge of AN, understanding of the treatment model and parents' role, amount of psychological support, and coordination among health professionals. The parents were unclear about the treatment plan as they received little explanation from the health professionals. The parents perceived that the AN treatment only focused on weight restoration with limited psychological support. Home diet monitoring was seen as a harsh task which worsened the relationship with their children. The parents often needed to take up the coordinator role and search around for different health professionals and integrate their advices by themselves. CONCLUSIONS: The study shows that limited psychoeducation, communication and coordination in the treatment for AN are major problems in a Chinese context. Open communication between the health professionals and the parents about the expected treatment outcomes and limitations is needed to enhance their mutual trust. Besides, treatment should emphasize not only family involvement but also empower them to fight against AN.