Crise global da atenção primária à saúde / Global crisis in primary health care / Crisis global de la atención primaria

Enquanto no Norte Global se discute uma crise na Atenção Primária à Saúde, a maioria dos países nunca chegou a constituir sistemas de saúde baseados propriamente numa atenção primária robusta. Nesse cenário, o Brasil apresenta uma tendência mais favorável, com conquistas importantes para a atenção primária e a medicina de família e comunidade nos últimos dez anos. Restam desafios a serem superados para que o Sistema Único de Saúde alcance níveis satisfatórios de acesso a seus serviços, com profissionais adequadamente formados e valorizados pela população.

While the Global North is discussing a crisis in primary health care, the majority of countries have never managed to establish health systems based on robust primary care. Brazil presents a more favorable trend, with important achievements for primary care and family practice over the last ten years. There are still challenges to be overcome so that the Unified Health System achieves satisfactory levels of access to its services, with professionals who are properly trained and valued by the public.

Mientras que en el Norte Global se habla de una crisis de la atención primaria, la mayoría de los países nunca han creado realmente sistemas sanitarios basados en una atención primaria robusta. Brasil, muestra una tendencia más favorable, con importantes logros para la atención primaria y la medicina familiar y comunitaria en los últimos diez años. Aún quedan retos por superar para que el Sistema Único de Salud alcance niveles satisfactorios de acceso a sus servicios, con profesionales debidamente formados y valorados por la población.

Relationship between research activity and general practice performance: cross sectional and longitudinal analyses.

BACKGROUND: Research activity usually improves outcomes by being translated into practice. However, there is developing evidence that research activity itself may improve the overall performance of health care organisations. However, evidence that these relationships represent a causal impact of research activity is less clear. Additionally, the bulk of the existing evidence relates to hospital settings, and it is not known if those relationships would also be found in general practice, where most patient contacts occur. AIM: We sought to (a) test whether there were significant relationships between research activity in general practice and organisational performance (b) test whether those relationships were plausibly causal. DESIGN AND SETTING: We analysed national data between 2008 and 2019 using cross sectional and longitudinal analyses, on general practices in England. METHODS: We used cross-sectional, panel and instrumental variable analyses to explore relationships between research activity (including measures from the NIHR Clinical Research Network and the Royal College of General Practitioners) and practice performance (including clinical quality of care, patient reported experience of care, prescribing quality and hospital admissions) Results: In cross-sectional analyses, research activity was positively associated with several measures of practice performance, including clinical quality of care, patient reported experience of care, and reduced hospital admissions. The associations were generally modest in magnitude. However, longitudinal analyses did not support a reliable causal relationship. CONCLUSION: Similar to findings from hospital settings, research activity in general practice is associated with practice performance. There is less evidence that research is causing those improvements, although this may reflect the limited level of research activity in most practices. We identified no negative impacts, suggesting that research activity is a potential marker of quality and something that high quality practices can deliver alongside their core responsibilities.

Family Medicine Implementation to Maternal and Child Health in Rural Japan: A Narrative Review.

This research provides a critical narrative review of maternal and child health (MCH) in rural Japan, reflecting broader challenges faced by aging societies globally. The study explores the intertwined roles of professional and lay care in sustaining rural communities, emphasizing the unique position of family medicine and primary care in enhancing MCH services. The scarcity of healthcare resources, particularly the shortage of obstetricians and the weakening of traditional community support systems, underscores the challenges in these areas. Our review method involved a comprehensive search of PubMed for articles published from April 2000 to August 2024, focusing on MCH issues in rural Japan. This study highlights several critical gaps in rural MCH provision: the migration of medical professionals to urban centers, the transformation of social structures affecting traditional caregiving, and the lack of specialized MCH training among primary care physicians. We discuss potential solutions such as incentivizing obstetric care in rural areas, integrating MCH education within family medicine curricula, and revitalizing community-based support systems. By addressing these issues, the research aims to formulate actionable strategies to bolster MCH services, thus ensuring better health outcomes and sustainability of rural communities in Japan and similar settings worldwide.

Establishing a standing patient advisory board in family practice research: A qualitative evaluation from patients' and researchers' perspectives.

INTRODUCTION: Patient and public involvement is vital for high-quality research. Integrating patients' and providers' perspectives early in research enhances the feasibility and relevance of study results. Within our family practice-based research network ForN, we established a standing patient advisory board (PAB) to include patients with diverse conditions and experiences. In this paper, we aim to describe the establishment and functioning of a standing PAB in family medicine research from patients' and researchers' perspectives. METHODS: After each PAB meeting, patients and researchers were asked to name anonymously positive and challenging moments in a feedback form with open questions. Researchers were also asked to reflect on how they implemented the discussion content in their research projects. The responses from both groups were transferred to MAXQDA 2018 and analyzed separately using thematic analysis. RESULTS: We analyzed 40 feedback forms from patients and 14 feedback forms from researchers. The dominant theme in the patients' feedback was 'exchange': They positively emphasized the 'exciting and open discussions' and the exchange of perspectives with one another and researchers. The clarity of the researchers' presentations and the research topics were appreciated. Researchers also positively highlighted the open atmosphere of the discussions. Presenting their research to the PAB helped most researchers reflect on their research topics from patients' perspectives and implement changes. However, researchers also mentioned several barriers to the implementation of PAB members' feedback. CONCLUSION: The establishment of a standing PAB in family practice research is feasible and productive both from patients' and researchers' perspectives. PATIENT OR PUBLIC CONTRIBUTION: This study reports the evaluation of the establishment of a standing PAB in family practice research. Board members are involved in the design of studies, the co-production of interventions and information material, and the interpretation of data.

Identifying research gaps and priorities for African family medicine and primary health care.

No abstract available.

Tailoring communication practices to support effective delivery of telehealth in general practice.

BACKGROUND: The unprecedented increase in telehealth use due to COVID-19 has changed general practitioners' (GP) and patients' engagement in healthcare. There is limited specific advice for effective communication when using telehealth. Examining telehealth use in practice in conjunction with perspectives on telehealth as they relate to communication allows opportunities to produce evidence-based guidance for optimal use of telehealth, while also offering practitioners the opportunity to reflect on elements of their communicative practice common to both styles of consultation. The objective of this research was to develop evidence-based resources to support effective, person-centred communication when GPs and patients use telehealth. This included examination of interactional practices of recorded telehealth consultations, exploration of GP and patient perspectives relating to telehealth, and identifying priorities for guidance informed by these analyses as well as participant co-design. METHODS: This study involved recording telehealth consultations (n = 42), conducting patient surveys (n = 153), and interviewing patients (n = 9) and GPs (n = 15). These were examined using interaction analytic methods, quantitative analysis, and thematic analyses, to create a robust, integrated picture of telehealth practice and perspectives. The process of research translation involved a co-design approach, engaging with providers, patients, and policy makers to facilitate development of evidence-based principles that focus on supporting effective communication when using telehealth. RESULTS: Three key themes relating to communication in telehealth were identified across the different analyses. These were relationship building, conversational flow, and safety netting. The draft best practice principles drawn from these themes were modified based on co-design feedback into five Best Practice Principles for Communication between GPs and Patients using Telehealth. CONCLUSIONS: Effective communication is supported through relationship building and attention to conversational flow in telehealth consultations, which in turn allows for safety netting to occur. In telehealth, GPs and patients recognise that not being co-present changes the consultation and use both intuitive and strategic interactional adjustments to support their exchange. The mixed-method examination of experiences through both a detailed analysis of telehealth consultations in practice and comparative exploration of GP and patient perspectives enabled the identification of principles that can support effective communication when using telehealth. Co-design helped ensure these principles are ready for implementation into practice.

A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study.

PURPOSE: To determine the effects of stratified primary care for low back pain (SPLIT program) in decreasing back-related disability for patients with low back pain (LBP) in primary care. METHODS: We conducted a before-and-after study. We compared health-related outcomes for 2 sequential, independent cohorts of patients with LBP recruited at 7 primary care units in Portugal. The first prospective cohort study characterized usual care (UC) and collected data from February to September 2018. The second was performed when the SPLIT program was implemented and collected data from November 2018 to October 2021. Between cohorts, physical therapists were trained in the implementation of the SPLIT program, which used the STarT Back Screening Tool to categorize patients for matched treatment. We compared back-related disability (Roland-Morris Disability Questionnaire, 0-24 points), pain (Numeric Pain Rating Scale, 0-10 points), perceived effect of treatment (Global Perceived Effect Scale, -5 to +5 points), and health-related quality of life (EuroQoL 5 dimensions 3 levels index, 0-1 points). RESULTS: We enrolled a total of 447 patients: 115 in the UC cohort (mostly treated with pharmacologic treatment) and 332 in the SPLIT cohort (all referred for a physical therapy intervention program). Over the study period of 6 months, patients in the SPLIT program showed significantly greater improvements in back-related disability (ß, -2.94; 95% CI, -3.63 to -2.24; P ≤ .001), pain (ß, -0.88; 95% CI, -1.18 to -0.57; P ≤ .001), perceived effect of treatment (ß, 1.40; 95% CI, 0.97 to 1.82; P ≤ .001), and health-related quality of life (ß, 0.11; 95% CI, 0.08 to 0.14; P ≤ .001) compared with UC. CONCLUSIONS: Patients in the SPLIT program for LBP showed greater benefits regarding health-related outcomes than those receiving UC.

ACTION Teens Saudi Arabia: Perceptions, attitudes, motivators, and barriers among adolescents living with obesity, caregivers, and healthcare professionals in Saudi Arabia.

Obesity is predicted to affect approximately one-quarter of children/adolescents in Saudi Arabia by 2030, but there is limited evidence regarding the perceptions, attitudes, behaviours, and barriers to effective obesity care for adolescents living with obesity (ALwO), caregivers of ALwO, and healthcare professionals (HCPs). We report data from 500 ALwO (aged 12-<18 years), 500 caregivers, and 200 HCPs surveyed in Saudi Arabia as part of the global, cross-sectional ACTION Teens study (NCT05013359). Nearly all respondents recognized that obesity has a strong impact on overall health (ALwO 88%; caregivers 85%; HCPs 90%). Most ALwO and caregivers were aware of the ALwO's obesity status (95% and 99%, respectively) and worried about weight impacting the ALwO's future health (both ≥99%), and social media was their most commonly used source of weight-management information (60% and 53%, respectively). Among ALwO and caregivers who had discussed weight with an HCP in the past year, most experienced ≥1 negative feeling following their most recent discussion (61% and 59%, respectively). Although 81% of HCPs felt motivated to help their ALwO patients lose weight, 57% believed weight loss was completely the ALwO's responsibility (compared with only 37% of ALwO and 35% of caregivers). This may reflect the finding that only 24% of HCPs had received advanced training in obesity/weight management after medical school. Overall, while respondents had similar perceptions of the impact of obesity, we found HCPs' attitudes towards weight loss were not aligned with those of ALwO and caregivers, suggesting a need for improved communication and obesity education.

They are my worries, so it's me the doctor should listen to-adolescent males' experiences of consultations with general practitioners.

BACKGROUND: Many adolescent males visit a general practitioner regularly, yet many report unmet health needs and negative experiences. This indicates a gap between provided healthcare and the needs of adolescent males. In order to improve adolescent males' possibilities to discuss their health concerns with general practitioners, the study's aim was to explore and describe how adolescent males understand and assign meaning to their experiences of consultations with general practitioners. METHODS: This qualitative study was conducted at two healthcare centres in mid-Sweden in 2022. Nine males 15 to 19 years old described their experiences in semi-structured interviews immediately after consulting a general practitioner, regardless of reason for the consultation and whether or not accompanied by a parent. The analysis was guided by thematic analysis according to Braun & Clarke and reflective lifeworld theory's concepts of openness and sensitivity. RESULTS: One overarching theme, To be listened to, and three themes were developed: To handle insecurity and uneasiness, To be understood and cared for, and To get parental support on his terms. In a good appointment, the general practitioner cares about him, listens attentively, and takes him seriously. More importantly, the general practitioner's understanding permeates the consultation, so that all aspects of it is adapted to him. The adolescent males doubted their ability to express themselves and to understand what would happen in the consultation, and therefore feared being dismissed without receiving any help. Such difficulties may be due to unfinished neurocognitive development and inexperience. They struggled with embarrassment, partly due to notions of masculinity, and strived to balance their needs of parental support, privacy, and being the one that the doctor listens to. CONCLUSIONS: We argue that adolescent males are particularly vulnerable due to on-going neurocognitive and emotional development, inexperience, and notions of masculinity. However, good experiences can be generated through rather simple means. Adolescent males need individual adaptations demonstrating that they are cared for, understood and taken seriously. Furthermore, they need an unhurried pace to facilitate understanding, verbal affirmations to mitigate embarrassment, and help in navigating parental involvement.

Don't wait for the perfect moment: The national training program in family medicine in Angola.

Like many Sub-Saharan countries, Angola struggles with a shortage of trained health professionals, especially for primary care. In 2021, the Angolan Ministry of Health in collaboration with the Angolan Medical Council launched the National Program for the Expansion of Family Medicine as a long-term strategy for the provision, fixation and training of family physicians in community health centres. Of the 425 residents 411 (96.7%) who entered the programme in 2021 will get their diplomas in the following months and will be certified as family physicians. Three main aspects make this National Programme unique in the Angolan context: (1) the common effort and engagement of the Ministry of Health with the Angolan Medical Council and local health authorities in designing and implementing this programme; (2) decentralisation of the training sites, with residents in all 18 provinces, including in rural areas and (3) using community health centres as the main site of practice and training. Despite this undeniable success, many educational improvements must be made, such as expanding the use of new educational resources, methodologies and assessment tools, so that aspects related to knowledge, practical skills and professional attitudes can be better assessed. Moreover, the programme must invest in faculty development courses aiming to create the next generation of preceptors, so that all residents can have in every rotation one preceptor or tutor responsible for the supervision of their clinical activities, case discussions and sharing their clinical duties, both at community health centres and municipal hospitals.

Cultivating leaders for primary health care: A revised approach for transformative development.

Family physicians require leadership skills to strengthen team-based primary care services. Interviews with South African district managers confirmed the need to develop leadership skills in family physicians. The updated national programmatic learning outcomes for South African family physician training were published in 2021. They sparked the need for curriculum renewal at the University of Cape Town's Division of Family Medicine. A review of the leadership and governance module during registrar training showed that the sessions were perceived to be content heavy with insufficient opportunities for reflection. Following a series of stakeholder engagements, the module convenors co-designed a revised module that was blueprinted on the updated learning outcomes. The module incorporates a group coaching style, facilitating learning through reflection on one's experiences. The revised module was implemented in 2022. It aims to provide a transformative learning experience centred on students' perceptions of themselves as leaders, as well as professional identity formation and resilience building. This short report describes preliminary insights from the revised module's developmental phase and forms part of an ongoing iterative evaluation process.Contribution: Family physicians should lead across all their defined roles. Formal and informal learning opportunities are needed to facilitate their growth as leaders and help them to meet the health needs of communities served by an evolving health care system. This short report describes an example of a revised postgraduate module on leadership and governance, which may be of value to clinician educators and academic departments exploring innovative methods for the African region.

Identifying strategies to support implementation of interprofessional primary care teams in Nova Scotia: Results of a survey and knowledge sharing event.

BACKGROUND: Interprofessional primary care teams (IPCTs) work together to enhance care. Despite evidence on the benefits of IPCTs, implementation remains challenging. This research aims to 1) identify and prioritize barriers and enablers, and 2) co-develop team-level strategies to support IPCT implementation in Nova Scotia, Canada. METHODS: Healthcare providers and staff of IPCTs were invited to complete an online survey to identify barriers and enablers, and the degree to which each item impacted the functioning of their team. Top ranked items were identified using the sum of frequency x impact for each response. A virtual knowledge sharing event was held to identify strategies to address local barriers and enablers that impact team functioning. RESULTS: IPCT members (n = 117), with a mix of clinic roles and experience, completed the survey. The top three enablers identified were access to technological tools to support their role, standardized processes for using the technological tools, and having a team manager to coordinate collaboration. The top three barriers were limited opportunity for daily team communication, lack of conflict resolution strategies, and lack of capacity building opportunities. IPCT members, administrators, and patients attended the knowledge sharing event (n = 33). Five strategies were identified including: 1) balancing patient needs and provider scope of practice, 2) holding regular and accessible meetings, 3) supporting team development opportunities, 4) supporting professional development, and 5) supporting involvement in non-clinical activities. INTERPRETATION: This research contextualized evidence to further understand local perspectives and experiences of barriers and enablers to the implementation of IPCTs. The knowledge exchange event identified actionable strategies that IPCTs and healthcare administrators can tailor to support teams and care for patients.

Results of the study of the attitude of women of reproductive age to the integrated gynecological care provision by family physicians.

OBJECTIVE: Aim: To study and analyze the attitude of women of reproductive age to the integrated gynecological care provision by family physicians, their readiness to receive some gynecological services from family physicians, as well as to analyze the level of women's support and readiness for the integrated provision of gynecological care depending on age and level of education. PATIENTS AND METHODS: Materials and Methods: For the survey, anonymous questionnaires containing questions on the attitude of women of reproductive age to the integrated provision of certain types of gynecological care by family physicians were developed. 181 women from the Kyiv region took part in the survey. RESULTS: Results: Support of more than 80% of respondents regarding the integrated gynecological care provision by family physicians received the following questions: counseling on the prevention of sexually transmitted infections and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (92,3%); counseling on family planning and prevention of unwanted pregnancy (83,4%); counseling on the use of various methods of contraception (82,3%); examination and palpation of mammary glands (80,1%); referral of women to a higher level of obstetric and gynecological care (if necessary (86,2%). CONCLUSION: Conclusions: The majority of respondents (67,4%) are ready or better ready than not ready to receive certain types of gynecological care services from family physicians. Almost the same percentage ratio (more than 60%) of women of each age group and all levels of education are ready or better ready than not ready to receive gynecological care services, which they supported, from family physicians.

Medicina familiar y comunitaria: la especialidad más elegida en el MIR / Family and community medicine: The most chosen specialty in the MIR

Medicina Familiar y Comunitaria es la especialidad más ofertada y elegida en el MIR, sin embargo, cada año se cuestiona su atractivo debido que no se ocupan todas las plazas ofertadas y un determinado número de médicos residentes desisten de continuar en dicha especialidad una vez iniciada. En este contexto algunas de las propuestas que se plantean para abordar el problema se centran en incrementar la oferta cuando los hechos muestran que el reto está en actuar sobre la demanda haciendo más atractiva la especialidad y su ámbito de ejercicio profesional. Se procede a analizar este problema y sus condicionantes abriendo el foco del análisis a 4 elementos que pueden estar influyendo en el mismo: los aspectos vocacionales de los graduados en medicina que acuden a la especialización, las características del programa de la especialidad y de las unidades docentes en las que se lleva a cabo la formación, la presencia de la medicina de familia en la universidad como elemento clave para el conocimiento y la afección a dicha especialidad desde el grado y finalmente la situación de la atención primaria, como espacio en el que se materializa la formación y lugar prioritario de desempeño profesional de los futuros especialistas. (AU)

Family and Community Medicine is the most offered and chosen specialty in the MIR (Spanish medical residency examination), however, every year its attractiveness is questioned due to not all offered positions being filled and a certain number of resident doctors deciding not to continue in this specialty once started. In this context, some of the proposals to address the problem focus on increasing the supply when the facts show that the challenge lies in addressing the demand by making the specialty and its professional scope more attractive. The problem and its determinants are analyzed in this context by focusing on four elements that may be influencing it: the vocational aspects of medical graduates who pursue specialization, the characteristics of the specialty program and the teaching units where training is carried out, the presence of family medicine in the university as a key element for knowledge and affinity to this specialty from undergraduate studies, and finally, the situation of primary care as the space where training is materialized and the priority setting for the professional practice of future specialists. (AU)

Using ChatGPT in family medicine and primary health care.

No abstarct available.

Storylines of family medicine I: framing family medicine - history, values and perspectives.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'I: framing family medicine-history, values, and perspectives', the authors address the following themes: 'Notes on Storylines of Family Medicine', 'Family medicine-the generalist specialty', 'Family medicine's achievements-a glass half full assessment', 'Family medicine's next 50 years-toward filling our glasses', 'Four enduring truths of family medicine', 'Names matter', 'Family medicine at its core' and 'The ecology of medical care.' May readers find much food for thought in these essays.

[Family and community medicine: The most chosen specialty in the MIR]. / Medicina familiar y comunitaria: la especialidad más elegida en el MIR.

Family and Community Medicine is the most offered and chosen specialty in the MIR (Spanish medical residency examination), however, every year its attractiveness is questioned due to not all offered positions being filled and a certain number of resident doctors deciding not to continue in this specialty once started. In this context, some of the proposals to address the problem focus on increasing the supply when the facts show that the challenge lies in addressing the demand by making the specialty and its professional scope more attractive. The problem and its determinants are analyzed in this context by focusing on four elements that may be influencing it: the vocational aspects of medical graduates who pursue specialization, the characteristics of the specialty program and the teaching units where training is carried out, the presence of family medicine in the university as a key element for knowledge and affinity to this specialty from undergraduate studies, and finally, the situation of primary care as the space where training is materialized and the priority setting for the professional practice of future specialists.

Prevalence and associations of provision of nursing home visits and home visits by early-career specialist general practitioners.

OBJECTIVE: To establish prevalence and associations of provision of nursing home visits (NHV) and home visits (HV) by early-career specialist GPs. Of particular interest were associations of rurality with performing NHVs and HVs. METHODS: A cross-sectional study. DESIGN: A questionnaire-based study. SETTING: Australian general practice. PARTICIPANTS: Early-career specialist GPs, practising in Australia, who attained Fellowship between January 2016 and July 2018, inclusive, having completed GP training in NSW, the ACT, Eastern Victoria or Tasmania. MAIN OUTCOME MEASURES: Current provision of NHV and HV. RESULTS: NHV were provided by 34% of participants (59% in rural areas) and HV by 41% of participants (60% in rural areas). Remote, rural or regional practice location, as compared to major-city practice, was strongly associated with performing NHV as an early-career specialist GP; multivariable OR 5.87 (95% CI: 2.73, 12.6), p < 0.001, and with the provision of HV; multivariable OR 3.64 (95% CI: 1.63, 8.11), p = 0.002. Rurality of GP training (prior to attaining Fellowship) was significantly univariably associated with providing NHV and with providing HV as an early-career specialist GP. On multivariable analyses, these were no longer statistically significant. CONCLUSION: Early-career specialist GPs located in regional/remote areas are more likely than their urban colleagues to provide NHV and HV.

[Choice of Family and Community Medicine in the MIR 2002-2023: An objective approach shows that it is as highly valued as hospital specialties]. / Elección de Medicina Familiar y Comunitaria en el MIR 2002-2023: un enfoque objetivo muestra que es una especialidad tan valorada como las hospitalarias.

INTRODUCTION: Currently there is a shortage of general practitioners (GP), and this is expected to increase in the coming years. Despite this need, it is a specialty that is supposedly little demanded, leaving specialized training places unfilled in recent years. The purpose of this study is to present new parameters to more objectively measure the demand and the relationship between supply and demand. METHODS: A database was used with the results of the places assigned in the MIR calls from 2002 to 2023. The calculated parameters were quoting index (CI), quote order, the order of top demand and the order of total demand of the GP specialty. The software R version 4.3.02 was used for statistical analysis. RESULTS: The specialty quotation and top demand have remained constant during the study period, while there has been a slight and progressive worsening of the total demand. Nevertheless, the total demand for Family Medicine in the last call for MIR exam was higher than that for specialties such as urology, neurology, ENT, endocrinology, oncology, intensive care medicine or neurosurgery, among others. CONCLUSIONS: In contrast to the subjective perception of the worsening attractiveness Family Medicine in the last MIR calls, using objective parameters, we found that the attractiveness of the specialty, measured as quotation (supply/demand ratio) and demand, has remained stable (with a slight worsening of total demand).