Senses and meanings of primary health care academic visions in nursing / Sentidos y significados de las visiones académicas de la atención/cuidado primaria de salud en enfermería / Sentidos e significados das visões acadêmicas da atenção básica/cuidado em enfermagem

Introduction: Primary Health Care (PHC) has acquired different meanings for different people, at specific times and places, which poses important challenges for its understanding. Objective: To analyze the meaning(s) and sense(s) of Primary/Basic Health Care in the academic views on Nursing/Health in the context of undergraduate Nursing courses offered at two public Higher Education Institutions. Materials and methods: Qualitative study with an exploratory approach. Semi-structured interviews and documentary analysis were used as data collection techniques. Results: The senses/meanings of Primary Health Care converge with the population's gateway to the health system at the first care level and with the first contact of a person with the health service. However, it is still considered as a less important service within the care network. Conclusion: Primary Health Care means a relevant possibility for Nursing/Health care through health promotion and disease prevention actions, with a commitment to respond to most of the population's health needs.

Introducción: La Atención Primaria de Salud ha adquirido diferentes significados para diversas personas, en momentos y lugares específicos, lo cual plantea importantes retos para su entendimiento. Objetivo: Analizar los significados y sentidos de la Atención Primaria de Salud desde una visión académica en Enfermería y en el contexto de cursos de pregrado en Enfermería ofrecidos en dos Instituciones Públicas de Educación Superior. Materiales y métodos: Estudio cualitativo con un enfoque exploratorio, para la recolección de datos se emplearon entrevistas semiestructuradas y análisis documental de contenidos. Resultados: Los sentidos/significados de la Atención Primaria de la Salud convergen con el ingreso de la población al sistema de salud en el primer nivel de atención y la primera experiencia de la persona con el servicio de salud. Sin embargo, dicha Atención Primaria todavía se considera un servicio de baja importancia dentro de la red asistencial. Conclusión: La Atención Primaria de Salud representa una posibilidad relevante para el cuidado de Enfermería a través de acciones de promoción de la salud y prevención de enfermedades, que debe fortalecerse para responder la mayoría de las necesidades de salud de la población.

Introdução: A Atenção Primária à Saúde tem adquirido diferentes significados para diferentes pessoas, em momentos e locais específicos, o que coloca desafios importantes para a sua compreensão. Objetivo: Analisar os sentidos e significados da Atenção Primária à Saúde na perspectiva acadêmica em Enfermagem e no contexto dos cursos de graduação em Enfermagem oferecidos em duas Instituições de Ensino Superior Públicas. Materiais e métodos: Estudo qualitativo com abordagem exploratória, utilizou-se entrevistas semiestruturadas para coleta de dados e análise de conteúdo documental. Resultados: Os sentidos/significados da Atenção Primária à Saúde convergem com a entrada da população no sistema de saúde no primeiro nível de atenção e a primeira experiência da pessoa com o serviço de saúde. Contudo, a referida Atenção Básica ainda é considerada um serviço de baixa importância dentro da rede de saúde. Conclusão: A Atenção Primária à Saúde representa uma possibilidade relevante para o cuidado de Enfermagem por meio de ações de promoção da saúde e prevenção de doenças, que devem ser fortalecidas para responder à maioria das necessidades de saúde da população.

Relação enfermeiro-pessoa afetada pela Tuberculose fundamentada na teoria do alcance de metas de imogene king / La relación enfermería-Persona afectada por la Tuberculosis, según la Teoría del logro de objetivos de imogene king / The nurse-tuberculosis patient relationship according to Imogene King's theory of goal achievement

Resumo Introdução: As ações desenvolvidas na Atenção Primária à Saúde são um dos pontos fortes de combate à tuberculose. Nesse nível de atenção, o contato contínuo do enfermeiro por meio da consulta de enfermagem permite manter relação com a população adoecida. Diante da relação enfermeiro-pessoa cuidada para o estabelecimento do vínculo e adesão ao tratamento contra tuberculose, compreende-se a importância do referencial teórico de Imogene King para estruturar a interação enfermeiro-pessoa cuidada e oferecer uma dinâmica para esse processo. Objetivo: Analisar a relação enfermeiro-pessoa afetada pela tuberculose fundamentada na Teoria do Alcance de Metas de Imogene King. Método: Estudo descritivo com abordagem qualitativa, com 14 enfermeiros da APS, selecionadas por conveniência. A coleta de dados ocorreu de agosto a novembro de 2018, por meio de entrevista semiestruturada, elaborada com base no Registro Meta-Orientado de Enfermagem de Imogene King. Os dados foram analisados de forme qualitativa pelo Software IRAMUTEQ. A pesquisa foi aprovada pelo Comitê de Ética. Resultados: Após a análise, emergiram quatro classes: 1) relação estabelecida com base no acolhimento; 2) relação enfermeiro-pessoa com tuberculose e o apoio de outros profissionais e familiares; 3) relação estabelecida com vistas ao cumprimento do tratamento; e 4) relação estabelecida para enfrentamento do preconceito diante da tuberculose. Conclusão: O acolhimento, a família e o vínculo entre profissional, paciente e equipe da Atenção Primária à Saúde fortalecem o enfrentamento da doença e reforçam a adesão ao tratamento medicamentoso.

Resumen Introducción: Uno de los puntos fuertes de la lucha contra la tuberculosis son las acciones desarrolladas en la atención primaria de salud. En este nivel asistencial, el contacto continuo de las enfermerías a través de la consulta de enfermería permite mantener una relación con la población enferma. Frente a la relación enfermería-persona para el establecimiento del vínculo y la adherencia al tratamiento contra la tuberculosis, se entiende la importancia del referente teórico de Imogene King para estructurar la interacción enfermería-persona y ofrecer una dinámica para este proceso. Objetivo: Análisis de la relación entre el personal de enfermería y las personas afectadas por la tuberculosis, a partir de la teoría del logro de objetivos de Imogene King. Método: Estudio descriptivo con abordaje cualitativo, con 14 enfermeras de atención primaria de salud, seleccionadas por conveniencia. La recolección de datos ocurrió de agosto a noviembre de 2018, a través de una entrevista semiestructurada, elaborada con base en el registro meta-orientado de enfermería de Imogene King. Los datos fueron analizados cualitativamente utilizando el software IRAMUTEQ. La investigación fue aprobada por el Comité de Ética. Resultados: Después del análisis, surgieron cuatro clases: 1) relación establecida con base en la recepción, 2) relación enfermería-persona con tuberculosis y apoyo de otras personas profesionales y familiares, 3) relación establecida con miras al cumplimiento del tratamiento y 4) relación establecida para combatir los prejuicios contra la tuberculosis. Conclusión: La acogida, la familia y el vínculo entre profesional, paciente y equipo de atención primaria de salud fortalecen el afrontamiento de la enfermedad y refuerzan la adherencia al tratamiento farmacológico.

Abstract Introduction: One of the main aspects in the fight against tuberculosis are the actions developed in Primary Health Care (PHC). At this level of care, the nurse's continuous contact through the nursing consultation allows them to maintain a relationship with the sick population. Regarding the nurse-patient relationship for establishing a bond and the compliance with tuberculosis treatment, we understand the importance of Imogene King's theoretical framework for structuring the nurse-patient interaction and offering a dynamic for this process. Objective: To analyze the nurse-tuberculosis patient relationship based on Imogene King's Theory of Goal Achievement. Method: A descriptive study with a qualitative approach, with 14 PHC nurses, selected by convenience. Data were collected from August to November 2018 through semi-structured interviews based on Imogene King's Meta-Oriented Nursing Record. The data were analyzed qualitatively using the IRAMUTEQ software. The research was approved by the Ethics Committee. Results: After the analysis, four classes emerged: 1) relationship established on the basis of welcoming; 2) nurse-tuberculosis patient relationship and the support of other professionals and family members; 3) relationship established towards treatment compliance; and 4) relationship established to confront prejudice associated with tuberculosis. Conclusion: The welcoming, the family, and the bond between the professional, the patient and Primary Health Care team strengthen the coping with the disease and reinforce the compliance with the pharmacological treatment.

"Being ill was the easy part": exploring cancer survivors' reactions to perceived challenges in engaging with primary healthcare.

PURPOSE: Cancer survivors experience barriers to primary healthcare (PHC) services. The aim was to explore reactions to and opinions about perceived challenges associated with PHC access and quality among cancer survivors in Sweden, including how they have acted to adapt to challenges. METHODS: Five semi-structured focus group interviews were conducted with cancer survivors (n = 20) from Skåne, Sweden, diagnosed with breast, prostate, lung, or colorectal cancer or malignant melanoma. Focus groups were mixed in regard to diagnosis. Data were analysed using a descriptive template analysis approach. RESULTS: In light of perceived challenges associated with access to adequate PHC, participants experienced that they had been forced to work hard to achieve functioning PHC contacts. The demands for self-sufficiency were associated with negative feelings such as loneliness and worry. Participants believed that cancer survivors who lack the ability to express themselves, or sufficient drive, risk missing out on necessary care due to the necessity of being an active patient. CONCLUSIONS: The findings highlight negative patient experiences. They have implications for the organization of care for cancer survivors as they indicate a need for more efficient post-treatment coordination between cancer specialist care and PHC providers, as well as increased support for patients leaving primary cancer treatment.

Improving person-centred care for older persons with serious multimorbidity in LMICs.

BACKGROUND:  Few interventions are documented to meet person-centred needs of older people with serious multimorbidity in low- and middle-income countries where access to palliative care is limited. Most of the care in these settings is delivered by primary care health workers. AIM:  This study reports the development and acceptability testing of a communication skills training and mentorship intervention for primary health care workers in Malawi. SETTING:  This study was conducted at Mangochi District Hospital in the south-eastern region of Malawi. METHODS:  Twelve primary health care workers (four clinical officers and eight nurses) working in the primary care clinics received the intervention. The intervention was designed using modified nominal group technique, informed by stakeholder interviews and a theory of change workshop. Acceptability is reported from thematic analysis of a focus group discussion with primary health care workers who received the intervention using NVivo version 14. RESULTS:  Older persons with serious multi-morbidity and their caregivers identified a need for enhanced communication with their healthcare providers. This helped to inform the development of a communication training skills and mentorship intervention package based on the local best practice six-step Ask-Ask-Tell-Ask-Ask-Plan framework. Primary health care workers reported that the intervention supported person-centred communication and improved the quality of holistic assessments, although space, workload and availability of medication limited the implementation of person-centred communication. CONCLUSION:  The Ask-Ask-Tell-Ask-Ask-Plan framework, supported person-centered communication and improved the quality of holistic assessment.Contribution: This intervention offers an affordable, local model for integrating person-centered palliative care in resource-limited primary healthcare settings.

Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours.

INTRODUCTION: Patients in the community with suspected Chronic limb-threatening ischaemia (CLTI) should be urgently referred to vascular services for investigation and management. The Theoretical Domains Framework (TDF) allows identification of influences on health professional behaviour in order to inform future interventions. Here, the TDF is used to explore primary care clinicians' behaviours with regards to recognition and referral of CLTI. METHODS: Semi-structured interviews were conducted with 20 podiatrists, nurses and general practitioners in primary care. Directed content analysis was performed according to the framework method. Utterances were coded to TDF domains, and belief statements were defined by grouping similar utterances. Relevance of domains was confirmed according to belief frequency, presence of conflicting beliefs and the content of the beliefs indicating relevance. RESULTS: Nine TDF domains were identified as relevant to primary care clinicians: Knowledge, Environmental context and resources, Memory, Decision and attention processes, Beliefs about capabilities, Skills, Emotions, Reinforcement and Behavioural regulation. Relationships across domains were identified, including how primary care clinician confidence and working in a highly pressurized environment can affect behaviour. CONCLUSION: We have identified key barriers and enablers to timely recognition and referral behaviour. These beliefs identify targets for theory-driven behaviour change interventions to reduce delays in CLTI pathways.

Implementation of a primary-tertiary shared care model to improve the detection of familial hypercholesterolaemia (FH): a mixed methods pre-post implementation study protocol.

INTRODUCTION: Familial hypercholesterolaemia (FH) is an autosomal dominant inherited disorder of lipid metabolism and a preventable cause of premature cardiovascular disease. Current detection rates for this highly treatable condition are low. Early detection and management of FH can significantly reduce cardiac morbidity and mortality. This study aims to implement a primary-tertiary shared care model to improve detection rates for FH. The primary objective is to evaluate the implementation of a shared care model and support package for genetic testing of FH. This protocol describes the design and methods used to evaluate the implementation of the shared care model and support package to improve the detection of FH. METHODS AND ANALYSIS: This mixed methods pre-post implementation study design will be used to evaluate increased detection rates for FH in the tertiary and primary care setting. The primary-tertiary shared care model will be implemented at NSW Health Pathology and Sydney Local Health District in NSW, Australia, over a 12-month period. Implementation of the shared care model will be evaluated using a modification of the implementation outcome taxonomy and will focus on the acceptability, evidence of delivery, appropriateness, feasibility, fidelity, implementation cost and timely initiation of the intervention. Quantitative pre-post and qualitative semistructured interview data will be collected. It is anticipated that data relating to at least 62 index patients will be collected over this period and a similar number obtained for the historical group for the quantitative data. We anticipate conducting approximately 20 interviews for the qualitative data. ETHICS AND DISSEMINATION: Ethical approval has been granted by the ethics review committee (Royal Prince Alfred Hospital Zone) of the Sydney Local Health District (Protocol ID: X23-0239). Findings will be disseminated through peer-reviewed publications, conference presentations and an end-of-study research report to stakeholders.

Risk factors for asthma-related hospital and intensive care admissions in children, adolescents and adults: a cohort study using primary and secondary care data.

BACKGROUND: Asthma remains a common cause of hospital admissions across the life course. We estimated the contribution of key risk factors to asthma-related hospital and intensive care unit (ICU) admissions in children, adolescents and adults. METHODS: This was a UK-based cohort study using linked primary care (Clinical Practice Research Datalink Aurum) and secondary care (Hospital Episode Statistics Admitted Patient Care) data. Patients were eligible if they were aged 5 years and older and had been diagnosed with asthma. This included 90 989 children aged 5-11 years, 114 927 adolescents aged 12-17 years and 1 179 410 adults aged 18 years or older. The primary outcome was asthma-related hospital admissions from 1 January 2017 to 31 December 2019. The secondary outcome was asthma-related ICU admissions. Incidence rate ratios adjusted for demographic and clinical risk factors were estimated using negative binomial models. Population attributable fraction (PAF) was estimated for modifiable risk factors. RESULTS: Younger age groups, females and those from ethnic minority and lower socioeconomic backgrounds had an increased risk of asthma-related hospital admissions. Increasing medication burden, including excessive use of short-acting bronchodilators, was also strongly associated with the primary outcome. Similar risk factors were observed for asthma-related ICU admissions. The key potentially modifiable or treatable risk factors were smoking in adolescents and adults (PAF 6.8%, 95% CI 0.9% to 12.3% and 4.3%, 95% CI 3.0% to 5.7%, respectively), and obesity (PAF 23.3%, 95% CI 20.5% to 26.1%), depression (11.1%, 95% CI 9.1% to 13.1%), gastro-oesophageal reflux disease (2.3%, 95% CI 1.2% to 3.4%), anxiety (2.0%, 95% CI 0.5% to 3.6%) and chronic rhinosinusitis (0.8%, 95% CI 0.3% to 1.3%) in adults. CONCLUSIONS: There are significant sociodemographic inequalities in the rates of asthma-related hospital and ICU admissions. Treating age-specific modifiable risk factors should be considered an integral part of asthma management, which could potentially reduce the rate of avoidable hospital admissions.

Benefits, challenges, and strategies related to using presumptive recommendations for HPV vaccination: A qualitative study with rural and non-rural-serving primary care professionals.

HPV vaccination coverage remains far below the national target of 80% among US adolescents, particularly in rural areas, which have vaccine uptake rates that are 10% points lower than non-rural areas on average. Primary care professionals (PCPs) can increase coverage by using presumptive recommendations to introduce HPV vaccination in a way that assumes parents want to vaccinate. Through semi-structured interviews, we explored PCPs' experiences and perceptions of using presumptive recommendations in rural- and non-rural-serving primary care clinics in North Carolina. Thematic analysis revealed that most PCPs in rural and non-rural contexts used presumptive recommendations and felt the strategy was an effective and concise way to introduce the topic of HPV vaccination to parents. At the same time, some PCPs raised concerns about presumptive recommendations potentially straining relationships with certain parents, including those who had previously declined HPV vaccine or who distrust medical authority due to their past experiences with the healthcare system. PCPs dealt with these challenges by using a more open-ended approach when introducing HPV vaccination to parents. In conclusion, our findings suggest that PCPs in both rural and non-rural settings see value in using presumptive recommendations to introduce HPV vaccination, but to adequately address concerns and ensure increased HPV vaccine uptake, PCPs can use simple and culturally sensitive language to ensure fully informed consent and to maintain parental trust. And to further strengthen HPV vaccine discussions, PCPs can utilize other effective HPV communication techniques, like the Announcement Approach, in discussing HPV vaccinations with hesitant parents.

Asynchronous Versus Synchronous Screening for Depression and Suicidality in a Primary Health Care System: Quality Improvement Study.

Background: Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety. Objective: We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9. Methods: This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion. Results: Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002). Conclusions: Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

Amanhã será um novo dia: SUS presente nos territórios e na vida de Manicoré, AM / Tomorrow will be a new day: SUS present in the territories and lives of Manicoré, AM

O livro que temos em mãos nasce de um momento de participação social que foi a Primeira Mostra de experiências dos trabalhadores e trabalhadoras de saúde do município de Manicoré. O título do livro foi inspirado na 17ª Conferência Nacional de Saúde, realizada em 2023, que teve como tema "Garantir direitos, defender o SUS, a vida e a democracia ­ Amanhã vai ser outro dia!". Portanto, o livro inicia na perspectiva de uma escrita coletiva e participativa, que também podemos denominar de Educação Permanente em Saúde porque houve uma reflexão e uma sistematização sobre o fazer e o saber no contexto do trabalho, percorrendo diferentes caminhos da gestão até as comunidades mais distantes. A caminhada foi coletiva, com muitas mãos, vozes, corpos, rostos, imagens e relatos, ou seja, foi um grande mutirão de produção do conhecimento a partir do lugar do trabalho e da gestão nos mais distintos territórios de Manicoré.

Using Guidelines of Care to Lower Cardiovascular Risk in Patients with Psoriasis.

National guidelines define psoriasis as a risk enhancer for cardiovascular disease and recommend increased monitoring and more intense management of cardiovascular risk factors in these patients, who face an increased burden of cardiovascular disease morbidity and mortality. Screening for modifiable cardiovascular risk factors, including blood pressure, weight, cholesterol, glucose, and smoking, can be efficiently incorporated into routine dermatology clinical practice. Partnerships with primary care providers and preventive cardiologists are essential to improving management of cardiovascular risk in patients with psoriasis.

Acceptability and feasibility of screening with a pediatric care provider-led social determinants of health identification tool.

BACKGROUND: Complex social determinants of health may not be easily recognized by health care providers and pose a unique challenge in the vulnerable pediatric population where patients may not be able to advocate for themselves. The goal of this study was to examine the acceptability and feasibility of health care providers using an integrated brief pediatric screening tool in primary care and hospital settings. METHODS: The framework of the Child and Adolescent Needs and Strengths (CANS) and Pediatric Intermed tools was used to inform the selection of items for the 9-item Child and Adolescent Needs and Strengths-Pediatric Complexity Indicator (CANS-PCI). The tool consisted of three domains: biological, psychological, and social. Semi-structured interviews were conducted with health care providers in pediatric medical facilities in Ottawa, Canada. A low inference and iterative thematic synthesis approach was used to analyze the qualitative interview data specific to acceptability and feasibility. RESULTS: Thirteen health care providers participated in interviews. Six overarching themes were identified: acceptability, logistics, feasibility, pros/cons, risk, and privacy. Overall, participants agreed that a routine, trained provider-led pediatric tool for the screening of social determinants of health is important (n = 10, 76.9%), acceptable (n = 11; 84.6%), and feasible (n = 7, 53.8%). INTERPRETATION: Though the importance of social determinants of health are widely recognized, there are limited systematic methods of assessing, describing, and communicating amongst health care providers about the biomedical and psychosocial complexities of pediatric patients. Based on this study's findings, implementation of a brief provider-led screening tool into pediatric care practices may contribute to this gap.

Developmental surveillance and screening practices in a pediatric oncology clinic: Initial progress of a quality improvement study.

BACKGROUND: Pediatric cancer patients' oncology teams regularly take on a primary care role, but due to the urgent nature of cancer treatment, developmental screenings may be deprioritized. This leaves patients at risk of developmental diagnoses and referrals being delayed. AIMS: Clarify the current developmental surveillance and screening practices of one pediatric oncology team. MATERIALS AND METHODS: Researchers reviewed charts for patients (n = 66) seen at a pediatric oncology clinic in a suburban academic medical center to determine engagement in developmental screening (including functioning around related areas such as speech, neurocognition, etc.) and referrals for care in these areas. RESULTS: Developmental histories were collected from all patients through admission history and physical examination (H&P), but there was no routinized follow-up. Physicians did not conduct regular developmental screening per American Academy of Pediatrics guidelines for any patients but identified n = 3 patients with needs while the psychology team routinely surveilled all patients seen during this time (n = 41) and identified n = 18 patients as having delays. DISCUSSION: Physicians did not routinely screen for development needs beyond H&P and were inconsistent in developmental follow-up/referrals. Integrated psychologists were key in generating referrals for developmental-based care. However, many oncology patients were not seen by psychologists quickly or at all, creating a significant gap in care during a crucial developmental period. CONCLUSION: The case is made for further routinization of ongoing developmental screening in pediatric oncology care.

Tobacco control policies and respiratory conditions among children presenting in primary care.

Tobacco control policies can protect child health. We hypothesised that the parallel introduction in 2008 of smoke-free restaurants and bars in the Netherlands, a tobacco tax increase and mass media campaign, would be associated with decreases in childhood wheezing/asthma, respiratory tract infections (RTIs), and otitis media with effusion (OME) presenting in primary care. We conducted an interrupted time series study using electronic medical records from the Dutch Integrated Primary Care Information database (2000-2016). We estimated step and slope changes in the incidence of each outcome with negative binomial regression analyses, adjusting for underlying time-trends, seasonality, age, sex, electronic medical record system, urbanisation, and social deprivation. Analysing 1,295,124 person-years among children aged 0-12 years, we found positive step changes immediately after the policies (incidence rate ratio (IRR): 1.07, 95% CI: 1.01-1.14 for wheezing/asthma; IRR: 1.16, 95% CI: 1.13-1.19 for RTIs; and IRR: 1.24, 95% CI: 1.14-1.36 for OME). These were followed by slope decreases for wheezing/asthma (IRR: 0.95/year, 95% CI: 0.93-0.97) and RTIs (IRR: 0.97/year, 95% CI: 0.96-0.98), but a slope increase in OME (IRR: 1.05/year, 95% CI: 1.01-1.09). We found no clear evidence of benefit of changes in tobacco control policies in the Netherlands for the outcomes of interest. Our findings need to be interpreted with caution due to substantial uncertainty in the pre-legislation outcome trends.

Disparities in Patient Portal Engagement Among Patients With Hypertension Treated in Primary Care.

Importance: Patient portals are increasingly used for patient-clinician communication and to introduce interventions aimed at improving blood pressure control. Objective: To characterize patient portal use among patients with hypertension managed in primary care. Design, Settings, and Participants: This retrospective cohort study used electronic health records linked with patient portal log file data from a large, diverse Midwestern health care system. Patients with hypertension who had a primary care visit from January 1, 2021, to December 31, 2021, were included. The first visit in 2021 was considered the baseline visit; patient portal engagement was evaluated during the following year. Multivariate logistic regressions, presented as odds ratios (ORs) and 95% CIs, were used to evaluate associations between patient characteristics and patient portal engagement, adjusting for potential confounders. Exposures: Primary exposures included 4 sociodemographic factors routinely collected in the electronic health record: race and ethnicity, insurance, preferred language, and smoking status. Main Outcomes and Measures: Indicators of patient engagement with the patient portal included accessing the patient portal at least once, accessing the portal within 7 days of at least 50.0% of primary care physician (PCP) visits, frequent logins (<28 vs ≥28), messaging (<2 vs ≥2), and sharing home blood pressure readings. Results: Among 366 871 patients (mean [SD], 63.5 [12.6] years), 52.8% were female, 3.4% were Asian, 7.8% were Hispanic, 19.7% were non-Hispanic Black, 66.9% were non-Hispanic White, and 2.3% were of other race or ethnicity. During the 1-year study period starting in 2021, 70.5% accessed the patient portal at least once, 60.2% accessed around the time of their PCP visits, 35.7% accessed the portal frequently, 28.9% engaged in messaging, and 8.7% shared home blood pressure readings. Compared with White patients, non-Hispanic Black and Hispanic patients had lower odds of any access (Black: OR, 0.53; 95% CI, 0.52-0.54; Hispanic: OR, 0.66; 95% CI, 0.64-0.68), access around PCP visit time (Black: OR, 0.49; 95% CI, 0.48-0.50; Hispanic: OR, 0.62; 95% CI, 0.60-0.64), frequent access (Black: OR, 0.56; 95% CI, 0.55-0.57; Hispanic: OR, 0.71; 95% CI, 0.69-0.73), and messaging (Black: OR, 0.63; 95% CI, 0.61-0.64); Hispanic: OR, 0.71; 95% CI, 0.69-0.73). Conclusions and Relevance: This cohort study of patients with hypertension found clear sociodemographic disparities in patient portal engagement among those treated in primary care. Without special efforts to engage patients with portals, interventions that use patient portals to target hypertension may exacerbate disparities.

Barriers and facilitators to community acceptability of integrating point-of-care testing to screen for sickle cell disease in children in primary healthcare settings in rural Upper East Region of Northern Ghana.

INTRODUCTION: Sickle cell disease (SCD) remains a public health problem especially in sub-Saharan Africa including Ghana. While pilot initiatives in Africa have demonstrated that neonatal screening coupled with early intervention reduces SCD-related morbidity and mortality, only 50-70% of screen-positive babies have been successfully retrieved to benefit from these interventions. Point-of-care testing (POCT) with high specificity and sensitivity for SCD screening can be integrated into existing immunization programs in Africa to improve retrieval rates. This study explored community acceptability of integrating POCT to screen for SCD in children under 5 years of age in primary healthcare facilities in Northern Ghana. METHOD: This was an exploratory study using qualitative research approach where 10 focus group discussions and 20 in-depth interviews were conducted with community members and health workers between April and June 2022. The recorded interviews were transcribed verbatim after repeatedly listening to the recordings. Data was coded into themes using QSR Nvivo 12 software before thematic analysis. RESULTS: Most participants (70.9%) described SCD as serious and potentially life-threatening condition affecting children in the area. Of 148 community members and health workers, 141 (95.2%) said the screening exercise could facilitate diagnosis of SCD in children for early management. However, discrimination, fear of being tested positive, stigmatization, negative health worker attitude linked with issues of maintaining confidentiality were reported by participants as key factors that could affect uptake of the SCD screening exercise. Most participants suggested that intensive health education (78.3%), positive attitude of health workers (69.5%), and screening health workers not being biased (58.8%) could promote community acceptability. CONCLUSION: A large majority of participants viewed screening of SCD in children as very important. However, opinions expressed by most participants suggest that health education and professionalism of health workers in keeping patients' information confidential could improve the uptake of the exercise.

Unpacking patient perspectives on social needs screening: A mixed methods study in western Colorado primary care practices.

OBJECTIVE: Explore factors influencing patient comfort with and perceived helpfulness of screening for health-related social needs. METHODS: In a parallel secondary mixed-methods analysis of data from three primary care clinics, we used logistic regression to examine effects of practice- and patient-level factors on comfort with and perceived helpfulness of social needs screening. We applied narrative analysis to 20 patient interviews to further understand how patients' lived experiences influenced their perceptions of screening. RESULTS: Among 511 patients, receiving an explanation about screening was associated with increased odds of comfort (OR 2.1, 95% CI [1.1-4.30]) and perceived helpfulness (OR 4.7 [2.8-7.8]). Those experiencing more needs were less likely to report comfort (3 + needs vs. 0: OR 0.2 [0.1-0.5]). Narratives elucidated how a history of stigmatizing experiences increased discomfort disclosing needs and captured how relationship quality with healthcare teams influenced perceptions of screening for patients with extensive needs. CONCLUSION: Practice-level (screening explanation and therapeutic rapport) and patient-level factors (history and extent of needs) are key influences on comfort with and perceived helpfulness of screening. PRACTICE IMPLICATIONS: Good communication about screening benefits all patients. Patients with extensive social needs may require additional sensitivity to their past experiences.

Effectiveness of a School- and Primary Care-Based HPV Vaccination Intervention: The PrevHPV Cluster Randomized Trial.

Importance: The human papillomavirus (HPV) vaccine is safe and effective, yet vaccination coverage remains below public health objectives in many countries. Objective: To examine the effectiveness of a 3-component intervention on HPV vaccination coverage among adolescents aged 11 to 14 years 2 months after the intervention ended, each component being applied alone or in combination. Design, Setting, and Participants: A cluster randomized trial with incomplete factorial design (PrevHPV) was conducted between July 1, 2021, and April 30, 2022, in French municipalities receiving 0, 1, 2, or 3 components of the intervention. Randomization was stratified by school district and municipalities' socioeconomic level. Analyses were carried out on 11- to 14-year-old adolescents living in all participating municipalities, regardless of what had been implemented. Intervention: The PrevHPV intervention had 3 components: (1) educating and motivating 11- to 14-year-old adolescents in middle schools, along with their parents; (2) training general practitioners (GPs) on up-to-date HPV information and motivational interviewing techniques; and (3) free HPV vaccination at school. Main Outcomes and Measures: The primary outcome was HPV vaccination coverage (≥1 dose) 2 months after the intervention ended among 11- to 14-year-old adolescents living in participating municipalities, based on the French national reimbursement database and data collected during the trial in groups randomized to implement at-school vaccination. Results: A total of 91 municipalities comprising 30 739 adolescents aged 11 to 14 years (15 876 boys and 14 863 girls) were included and analyzed. Half the municipalities were in the 2 lowest socioeconomic quintiles and access to GPs was poor in more than two-thirds of the municipalities. Thirty-eight of 61 schools (62.3%) implemented actions and 26 of 45 municipalities (57.8%) had at least 1 trained GP. The median vaccination coverage increased by 4.0 percentage points (IQR, 2.0-7.3 percentage points) to 14.2 percentage points (IQR, 9.1-17.3 percentage points) at 2 months. At-school vaccination significantly increased vaccination coverage (5.50 percentage points [95% CI, 3.13-7.88 percentage points]) while no effect was observed for adolescents' education and motivation (-0.08 percentage points [95% CI, -2.54 to 2.39 percentage points]) and GPs' training (-1.46 percentage points [95% CI, -3.44 to 0.53 percentage points]). Subgroup analyses found a significant interaction between at-school vaccination and access to GPs, with a higher effect when access was poor (8.62 percentage points [95% CI, 5.37-11.86 percentage points] vs 2.13 percentage points [95% CI, -1.25 to 5.50 percentage points]; P = .007 for interaction). Conclusions and Relevance: In this cluster randomized trial, within the context of the late COVID-19 pandemic period and limited school and GP participation, at-school HPV vaccination significantly increased vaccination coverage. The trial did not show a significant effect for training GPs and education and motivation, although it may be observed after more time has elapsed after the intervention. Trial Registration: ClinicalTrials.gov Identifier: NCT04945655.

Evaluating palliative care case conferences in primary care for patients with advanced non-malignant chronic conditions: a cluster-randomised controlled trial (KOPAL).

BACKGROUND: Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs. OBJECTIVE: To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC. METHODS: A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale. RESULTS: A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51). CONCLUSIONS: The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.