Evaluating structure and content of parent-implemented early logopaedic intervention models following the three stages of communicative development in children with cleft lip and/or palate: Systematic literature review with narrative synthesis.

BACKGROUND: The development of communication, speech and language follows three stages (development of the parent-child relationship, interactions and actual speech and language acquisition). Children born with cleft lip and/or palate are at increased risk of communicative problems while parents may be going through an emotionally difficult time. Early parent-implemented logopaedic intervention that supports both parents and child is important. Three systematic reviews have examined the effects of early speech and language interventions, but not their structure and content. AIMS: To investigate which early parent-implemented logopaedic interventions already exist for children with cleft lip and/or palate, and to evaluate their structure, content and time of onset against the three stages of communicative development. METHODS: Six databases (PubMed, Embase, Web of Science, APA PsycInfo, Cinahl and Scopus) were searched between inception and 31 March 2023 to identify published articles that reported early parent-implemented logopaedic interventions in children with cleft lip and/or palate, aged 0 to 3 years, clearly describing the strategies used to train parents. Two authors independently assessed the eligibility of the studies. Quality assessment was conducted using the Physiotherapy Evidence Database quality assessment tool, Single-Case Experimental Design tool and the National Institutes of Health pre-post-study tools. The structure and content of the interventions were analysed taking into account the needs and difficulties of both the parents and the child according to the three stages of communicative development. MAIN CONTRIBUTION: The systematic literature search identified four studies that met the inclusion criteria. Three of them had a Level of Evidence III and one study had a Level of Evidence IV. Strategies appropriate for Stage 1 of communicative development (parent-child relationship) are well represented in only one study, but the psychosocial needs of parents are currently not included in these programmes. However, research shows that parental emotional difficulties can adversely impact a child's communicative development. Strategies appropriate for Stage 2 (promoting social interactions) are better represented. However, strategies appropriate for Stage 3 (acquiring correct speech and language patterns) are most represented in all intervention programmes. CONCLUSIONS: Three out of four intervention programmes focus on Stage 3 (actual speech and language stimulation). Stage 1 is underrepresented and the psychosocial needs of parents are currently not included in existing intervention programmes. Further research is needed in close collaboration with psychologists to construct a comprehensive, longitudinal, developmentally appropriate intervention programme that equally represents the three stages of communicative development and considers the psychosocial needs of parents. WHAT THIS PAPER ADDS: What is already known on the subject Children with cleft lip and/or palate are at increased risk of speech and language problems from birth. Parents of these children often have emotional problems following their child's diagnosis. The effectiveness of early intervention to facilitate the child's speech and language development has already been proven. Early intervention is recommended for both parents and child, but little is known about early parent-implemented logopaedic interventions that also provide psychosocial support for parents. What this paper adds to existing knowledge This review has shown that existing early parent-implemented logopaedic interventions for children with cleft lip and/or palate focus mainly on facilitating responsive interactions and actual speech and language development (Stages 2 and 3 of communicative development). However, Stage 1, where the parent-child relationship develops, is currently not included, even though this stage is a prerequisite of subsequent stages. If parents are struggling with emotional problems (following their child's diagnosis) this can negatively impact their mental health, the parent-child relationship, attachment and their child's development. What are the potential or actual clinical implications of this work? A clinical implication of the findings in this review is that more attention should be paid to Stage 1 of communicative development in early parent-implemented logopaedic interventions. By working closely with the psychologist of the cleft (and craniofacial) team, any psychosocial needs of the parents can be included in the counselling. As a result, the parents and their child are seen and supported as a unit and the parent-child relationship can develop optimally.

Continuity of primary care for type 2 diabetes and hypertension and its association with health outcomes and disease control: insights from Central Vietnam.

BACKGROUND: Vietnam is undergoing a rapid epidemiological transition with a considerable burden of non-communicable diseases (NCDs), especially hypertension and diabetes (T2DM). Continuity of care (COC) is widely acknowledged as a benchmark for an efficient health system. This study aimed to determine the COC level for hypertension and T2DM within and across care levels and to investigate its associations with health outcomes and disease control. METHODS: A cross-sectional study was conducted on 602 people with T2DM and/or hypertension managed in primary care settings. We utilized both the Nijmegen continuity of care questionnaire (NCQ) and the Bice - Boxerman continuity of care index (COCI) to comprehensively measure three domains of COC: interpersonal, informational, and management continuity. ANOVA, paired-sample t-test, and bivariate and multivariable logistic regression analysis were performed to examine the predictors of COC. RESULTS: Mean values of COC indices were: NCQ: 3.59 and COCI: 0.77. The proportion of people with low NCQ levels was 68.8%, and that with low COCI levels was 47.3%. Primary care offered higher informational continuity than specialists (p < 0.01); management continuity was higher within the primary care team than between primary and specialist care (p < 0.001). Gender, living areas, hospital admission and emergency department encounters, frequency of health visits, disease duration, blood pressure and blood glucose levels, and disease control were demonstrated to be statistically associated with higher levels of COC. CONCLUSIONS: Continuity of primary care is not sufficiently achieved for hypertension and diabetes mellitus in Vietnam. Strengthening robust primary care services, improving the collaboration between healthcare providers through multidisciplinary team-based care and integrated care approach, and promoting patient education programs and shared decision-making interventions are priorities to improve COC for chronic care.

Understanding medical students' interests in family medicine in Vietnam: A qualitative study.

BACKGROUND AND OBJECTIVES: Family medicine has recently been introduced into undergraduate training programs after more than 10 years of only being available for postgraduate doctors in Vietnam. The aim of this study was to explore the perceptions of sixth-year medical students towards family medicine and the factors that influence their career choice for - or against - family medicine. METHOD: The authors used a qualitative approach with a criterion sampling technique, including 36 participants in eight interviews and four focus group discussions, with thematical analysis. RESULTS: Most students could explain well what they had learned about family medicine but showed little interest in it. Only a few of the interviewees indicated they would choose a career in family medicine. The following factors influenced their career choice: valuing continuing care, the doctor-patient relationship and work-life balance; family medicine clinical rotation and teachers' roles; and related health policies offering a clear practice pathway and patient allocation to capable family doctors. DISCUSSION: The students' perceptions of family medicine were positive, but their interests in and intention to pursue a career in family medicine were still low after a clinical rotation. The authors concluded that the family medicine rotation should be maintained, family medicine should become more prominent in more components of the medical curriculum, and health policies to support and encourage becoming a family doctor are necessary.

Correction: Estimation of the cardiovascular risk using world health organization/international society of hypertension risk prediction charts in Central Vietnam.

[This corrects the article DOI: 10.1371/journal.pone.0242666.].

Hepatitis C in two general practices in Flanders, Belgium: is there a need to reconsider current screening recommendations?

Objectives: Hepatitis C virus (HCV) is a major cause of acute and chronic liver disease (e.g. cirrhosis and hepatocellular carcinoma). In Belgium, screening recommendations focus on risk groups. However, it is estimated that 50% of the infected patients are undiagnosed. This study assessed the prevalence of HCV in patients visiting two general practices in Flanders, Belgium. We revealed the associated risk factors and explored whether the current recommendations for HCV screening need to be reconsidered.Methods: A cross-sectional study in a non-urban practice in Lendelede and an urban community health center in Ghent, Belgium was performed. Patients for whom a blood test was required, were recruited for HCV screening. A patient survey assessed the associated risk factors.Results: There were 1112 patients included in the study. Nineteen patients were HCV Ab positive (1.71%) and eight were HCV RNA positive (0.72%). Five patients were unaware of their status. Using IV drugs, being born in the baby boom cohort and originating from a non-Belgian low-endemic country are significantly associated with HCV Ab positivity. Four of the 19 HCV Ab positive patients didn't meet any of the registered risk factors.Conclusions: This study confirms the problem of underdiagnosis of HCV, which is both related to the fact that not all risk groups are being screened and to the fact that patients are identified beyond the risk groups. These results, as well as the current changes in treatment options and their reimbursement, justify a reconsideration of the current recommendations for screening of HCV. To develop the most effective screening strategy in Flanders, further research is necessary.

Estimation of the cardiovascular risk using world health organization/international society of hypertension risk prediction charts in Central Vietnam.

INTRODUCTION: Cardiovascular disease (CVD) being the leading cause of the morbidity and mortality in Vietnam, the objective of this study was to estimate the total 10-year CVD risk among adults aged 40-69 years by utilizing World Health Organization/International Society of Hypertension (WHO/ISH) risk prediction charts in Central Vietnam. MATERIALS AND METHODS: In this cross-sectional study, multi-staged sampling was used to select 938 participants from a general population aged from 40 to 69. The CVD risk factors were then collected throughout the interviews with a standardized questionnaire, anthropometric measurements and a blood test. The cardiovascular risk was calculated using the WHO/ISH risk prediction charts. RESULTS: According to the WHO/ISH charts, the proportion of moderate risk (10-20%) and high risk (>20%) among the surveyed participants were equal (5.1%). When "blood pressure of more than 160/100 mmHg" was applied, the proportion of moderate risk reduced to 2.3% while the high risk increased markedly to 12.8%. Those proportions were higher in men than in women (at 18.3% and 8.5% respectively, p-value <0.001, among the high-risk group), increasing with age. Male gender, smoking, ethnic minorities, hypertension and diabetes were associated with increased CVD risk. CONCLUSIONS: There was a high burden of CVD risk in Central Vietnam as assessed with the WHO/ISH risk prediction charts, especially in men and among the ethnic minorities. The use of WHO/ISH charts provided a feasible and affordable screening tool in estimating the cardiovascular risk in primary care settings.

Primary care quality in Vietnam: Perceptions and opinions of primary care physicians in commune health centers - a mixed-methods study.

INTRODUCTION: Measuring the performance of a primary care system is one of the very first steps to find out whether there is room for improvement. To obtain an objective and comprehensive view, this measurement should come from both the supply and demand sides of the system. Patients' experiences of primary care have been studied around the world, but much less energy has been invested in researching providers' perspectives. This research aims to explore how primary care physicians working at commune health centers in Vietnam evaluate their performance and their opinions on how to improve the quality of primary care services. MATERIALS AND METHODS: First, a quantitative study was conducted using the validated Vietnamese PCAT questionnaire-provider expanded version (VN PCAT PE) targeting all primary care physicians (PCPs) working at commune health centers in a province of Central Vietnam. Next, a qualitative study was carried out, consisting of in-depth interviews with PCPs, to better understand the results of the quantitative survey and gain insight on barriers of primary care services and how to overcome them. RESULTS: In the quantitative portion of our study, 150 PCPs rated the quality of ongoing care and first contact in CHCs as the best (3.09 and 3.11 out of 4, respectively), and coordination as the worst performing core domain (2.53). Twenty-two PCPs also participated in our qualitative research. In regards to challenges that primary care physicians face during their daily practice, three central themes emerged: 1) patient factors such as client attitude and knowledge, 2) provider factors such as the burden of administrative work and lack of training opportunities, and 3) contextual factors such as low income and lack of resources including medicines and diagnostics. Participants recommended more health promotion campaigns in the media, increasing the number of services available at CHCs (such as being able to take blood samples), reducing the workload related to administration for CHC leaders, greater government subsidies, and providing more training courses for PCPs. CONCLUSIONS: Findings from this study offer a valuable view from the supply-side of the primary care system, specifically those who directly deliver primary care services. Along with the earlier study on consumers' evaluation of the Vietnamese primary care system, and literature from other low and middle-income countries, these findings offer emerging evidence for policymakers to improve the quality of primary care in Vietnam.

Can combined online and face-to-face continuing medical education improve the clinical knowledge and skills of family doctors in Vietnam? A cluster randomised controlled trial.

OBJECTIVES: To assess the effectiveness of a combined online and face-to-face continuing medical education (CME) programme, for improvement in clinical knowledge and skills of family doctors, in comparison with a control group; and to explore the self-reported satisfaction, competencies and confidence of those in the intervention group. METHODS: We used a cluster randomised controlled trial, with pre- and post-testing, and a feedback survey at the end of the 18-month CME programme. The measurements consisted of a multiple-choice test, an objective structured clinical examination test and an anonymously self-administered questionnaire. RESULTS: There were 58 family doctors from four provinces in the intervention group and 32 doctors from three provinces in control group, both in the Mekong Delta region in Vietnam. The mean age of participants was 47.8 years, and the female/male ratio was 1/2.9. After training, the intervention group had significantly higher scores on overall knowledge (mean difference = 1.4, 95% CI 1.0-1.86, P < 0.001; Cohen's d 1.36, Pearson's r 0.53), in four of the five education modules: peptic disorders, diabetes, hypertension and bone-muscle-joint diseases (Pearson's r 0.56, 0.56, 0.34 and 0.4, respectively), and in problem-solving skills (Pearson's r 0.27). Self-reports showed a positive learning attitude, strong interest and improved confidence and competency among doctors in the intervention group. CONCLUSIONS: A combined online and face-to-face CME programme proved applicable and effective for improving the clinical knowledge and problem-solving skills of family doctors in Vietnam.

OBJECTIFS: Evaluer l'efficacité d'une combinaison d'un programme de formation médicale continue (FMC), en ligne et en face-à-face pour l' amélioration des connaissances cliniques et les compétences des médecins de famille, par rapport à un groupe témoin et explorer la satisfaction, les compétences et la confiance autodéclarées des participants dans le groupe d'intervention. Méthodes Nous avons utilisé un essai contrôlé randomisé en grappes , avec pré et post-test, et une enquête de rétroaction à la fin du programme de FMC de 18 mois. Les mesures consistaient en un test à choix multiple, un test d'examen clinique objectif structuré et un questionnaire anonyme administré. Résultats Il y avait 58 médecins de famille de 4 provinces dans le groupe d'intervention et 32 médecins de 3 provinces dans le groupe témoin, tous deux dans la région du delta du Mékong au Vietnam. L'âge moyen des participants était de 47,8 ans, et le ratio femmes/hommes était de 1/2,9. Après la formation, le groupe d'intervention avaient des scores significativement plus élevés sur l' ensemble des connaissances (moyenne de différence = 1,4 ; IC95%: 1,0 à 1,86 ; p < 0,001 ; d de Cohen: 1,36 ; r de Pearson 0,53), dans 4 des 5 modules d'éducation: troubles gastro-duodénaux, diabète, hypertension et maladies des os-muscles- articulaires (r de Pearson 0,56 ; 0,56 ; 0,34 et 0,4, respectivement), et dans les compétences à résoudre des problèmes (r de Pearson: 0,2 7). Les auto-évaluations ont montré une attitude d'apprentissage positive, un vif intérêt et une amélioration de la confiance et des compétences chez les médecins du groupe d'intervention. CONCLUSIONS: Une FMC combiné basé sur Internet et en direct est applicable et efficace pour l'amélioration des connaissances cliniques et les compétences à résoudre les problèmes chez les médecins de famille au Vietnam.

Can a family medicine rotation improve medical students' knowledge, skills and attitude towards primary care in Vietnam? A pre-test-post-test comparison and qualitative survey.

OBJECTIVES: Well-designed studies on the impact of a family medicine rotation on medical students are rare, and very few studies include a qualitative component. This study aimed to determine the improvement of medical students' knowledge, communication skills and attitude towards primary care and explore their perceptions after rotations, in comparison with a control group. METHODS: We used a mixed-methods design, comprising a pre-test-post-test comparison between a sample of trained students who took family medicine rotations and a control group and a qualitative survey. The measurement of improvement included (i) multiple choice question testing, (ii) objective structured checklist examinations, (iii) self-reporting and (iv) interviews and focus group discussions. Data were collected from August 2017 to June 2018. RESULTS: There were 696 students in the trained group and 617 controls. The two groups' baseline scores in knowledge, communication skills and attitude were not significantly different. Knowledge covering five domains of family medicine (Pearson's r from 0.6 to 0.9) improved significantly, as did attitudes towards primary care in the trained group. There were no differences in communication and counselling skills between the two groups for four situations, but for two-health check-ups and mental health care-skills were significantly improved (Pearson's r from 0.28 to 0.43). The qualitative survey showed highly positive feedback from trained students. CONCLUSIONS: The family medicine rotation significantly improved students' knowledge and attitude towards primary care and some communication skills. Further studies should investigate students' interest in and career choice for this discipline.

OBJECTIFS: Des études bien conçues sur l'impact d'une rotation de la médecine familiale sur les étudiants en médecine sont rares et très peu d'études comprennent une composante qualitative. Cette étude visait à mesurer l'amélioration des connaissances, des compétences en communication et de l'attitude des étudiants en médecine à l'égard des soins primaires, et à explorer leurs perceptions après les rotations, en comparaison avec un groupe témoin. MÉTHODES: Nous avons utilisé un concept de méthodes mixtes, comprenant une comparaison pre-test et post-test entre un échantillon d'étudiants formés qui ont effectué des rotations de la médecine familiale et un groupe témoins, et une enquête qualitative. La mesure de l'amélioration comprenait (1) des tests de questions à choix multiples, (2) des examens objectifs structurés de listes, (3) des rapports personnels et (4) des entretiens et des discussions focalisées de groupes. Les données ont été collectées d'août 2017 à juin 2018. RÉSULTATS: Il y avait 696 élèves dans le groupe formé et 617 témoins. Les scores de référence des deux groupes en termes de connaissances, de communication et d'attitude n'étaient pas significativement différents. Les connaissances couvrant cinq domaines de la médecine familiale se sont considérablement améliorées (r de Pearson de 0,6 à 0,9), tout comme l'attitude à l'égard des soins primaires dans le groupe formé. Il n'y avait pas de différence dans les compétences de communication et de conseil entre les deux groupes pour quatre situations, mais pour deux (bilan de santé et soins de santé mentale) les compétences ont été significativement améliorées (r de Pearson de 0. 28 à 0. 43). L'enquête qualitative a montré une rétroaction très positive des étudiants formés. CONCLUSIONS: La rotation de la médecine familiale a amélioré de manière significative la connaissance et l'attitude des étudiants à l'égard des soins primaires et certaines compétences de communications. Des études ultérieures devraient examiner l'intérêt des étudiants et le choix de carrière pour cette discipline.

Patient experiences of primary care quality amongst different types of health care facilities in central Vietnam.

BACKGROUND: Patient experience with primary health care services can vary markedly between different types of health care facilities, even within the same country setting. Given known benefits of high quality primary health care, the performance of these facilities may significantly impact population health. The aim of this study was to compare the quality of primary care in different types of health facilities as experienced by Vietnamese consumers. METHODS: 1662 people who utilized primary health care services at least once over the past two years in various types of facilities in central Vietnam were surveyed in a cross-sectional study using the Vietnamese version of the Primary Care Assessment Tool (VN PCAT-AE) to assess overall primary care quality as well as several different domains of high quality primary care services. RESULTS: Commune health centers were associated with the highest overall primary care quality (PCAT expanded score 21.07, p < 0.001) as well as high scores in nearly all individual domains of primary care quality experienced by consumers compared with other types of facilities. Conversely, private facilities such as private clinics and pharmacies were rated lowest overall (PCAT expanded score 18.45, p < 0.05 and 16.90, p < 0.001 respectively). District hospitals and other government hospitals (PCAT expanded score 20.10 and 19.72 respectively) were reported as the best quality in comprehensiveness of available services (p < 0.001). Polyclinics performed quite well in comprehensiveness of services available (3.11) and first contact-access (2.79) but less so in other domains, especially in cultural competency (1.87). CONCLUSIONS: The high quality of primary care services experienced by consumers in commune health centers compared with other facilities gives Vietnam ample reason to promote greater use of these community-based primary care facilities. Populations may benefit most from building and strengthening grassroots networks of such community-based health centers as an effective solution for overcrowding at hospitals while simultaneously providing better overall health outcomes.

Development and validation of the Vietnamese Primary Care Assessment Tool - provider version.

AIM: To adapt the provider version of the Primary Care Assessment Tool (PCAT) for Vietnam and determine its internal consistency and validity. BACKGROUND: There is a growing need to measure and explore the impact of various characteristics of health care systems on the quality of primary care. It would provide the best evidence for policy makers if these evaluations come from both the demand and supply sides of the health care sector. Comparatively more researchers have studied primary care quality from the consumer perspective than from the provider's perspective. This study aims at the latter. METHOD: Our study translated and adapted the PCAT provider version (PCAT PE) into a Vietnamese version, after which a cross-sectional survey was conducted to examine the feasibility, internal consistency and validity of the Vietnamese PCAT provider version (VN PCAT PE). All general doctors working at 152 commune health centres in Thua Thien Hue province had been selected to participate in the survey. FINDINGS: The VN PCAT PE is an instrument for evaluation of primary care in Vietnam with 116 items comprising six scales representing four core primary care domains, and three additional scales representing three derivative domains. From the translation and cultural adaptation stage, two items were combined, two items were removed and one item was added. Six other items were excluded due to problems in item-total correlations. All items have a low non-response or 'don't know/don't remember' response rate, and there were no floor or ceiling effects. All scales had a Cronbach's alpha above 0.80, except for the Coordination scale, which still was above the minimum level of 0.70. CONCLUSION: The VN PCAT PE demonstrates adequate internal consistency and validity to be used as an effective tool for measuring the quality of primary care in Vietnam from the provider perspective.

Prevalence, Awareness, Treatment, and Control of Hypertension and Its Risk Factors in (Central) Vietnam.

INTRODUCTION: The objective of this study is to describe the prevalence, awareness, treatment, and control of hypertension and its associated risk factors in (Central) Vietnam. METHODS: In this cross-sectional study, a multistage sampling was used to select 969 participants from the general population aged from 40 to 69 years. The cardiovascular risk factors were collected throughout the interviews with a standardized questionnaire. Multivariate logistic regression analysis was conducted to test the relationship between the prevalence, awareness, treatment, and control of hypertension and the prevalence of risk factors. RESULTS: The prevalence of hypertension was 44.8%. It was higher in men than in women (51.3% versus 39.7%, p < 0.001). In total 67.3% (74.5% in women, 60.1% in men; p = 0.001) of the participants were aware of their hypertension, 33.2% (37.5% in women, 28.9% in men; p = 0.01) of the participants were treated, and 12.2% (16.7% in women, 7.8% in men; p < 0.001) of the hypertensive participants' hypertension was controlled. Age, gender, place of residence, body mass index, and diabetes were found to be independent risk factors for hypertension. CONCLUSION: The prevalence of hypertension in Vietnam is high, and the proportion of treated and controlled patients is rather low.

Development and validation of the Vietnamese primary care assessment tool.

OBJECTIVE: To adapt the consumer version of the Primary Care Assessment Tool (PCAT) for Vietnam and determine its internal consistency and validity. DESIGN: A quantitative cross sectional study. SETTING: 56 communes in 3 representative provinces of central Vietnam. PARTICIPANTS: Total of 3289 people who used health care services at health facility at least once over the past two years. RESULTS: The Vietnamese adult expanded consumer version of the PCAT (VN PCAT-AE) is an instrument for evaluation of primary care in Vietnam with 70 items comprising six scales representing four core primary care domains, and three additional scales representing three derivative domains. Sixteen other items from the original tool were not included in the final instrument, due to problems with missing values, floor or ceiling effects, and item-total correlations. All the retained scales have a Cronbach's alpha above 0.70 except for the subscale of Family Centeredness. CONCLUSIONS: The VN PCAT-AE demonstrates adequate internal consistency and validity to be used as an effective tool for measuring the quality of primary care in Vietnam from the consumer perspective. Additional work in the future to optimize valid measurement in all domains consistent with the original version of the tool may be helpful as the primary care system in Vietnam further develops.

Excellence in PhD dissertations in health professions education: Toward standards and expectations.

The authors of this perspective contribution have served two terms (2014 and 2016) in the Jury of the biennial Best PhD Dissertation Award committee of the Netherlands Association for Medical Education. During this period, the committee reviewed 32 dissertations. Based on discussions among the jury regarding elements of an award winning dissertation and existing literature, we propose seven criteria to evaluate PhD dissertations: size, breadth of research skills exhibited, coherence of studies, relevance to field, validity, style, communicative power and ethics, and impact of the work. We anticipate these may not only assist similar committees but also provide criteria of excellence for future doctoral work in health professions education.

Insights of health district managers on the implementation of primary health care outreach teams in Johannesburg, South Africa: a descriptive study with focus group discussions.

BACKGROUND: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal. METHODS: This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method. RESULTS: There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team. CONCLUSIONS: Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues.

Insights of private general practitioners in group practice on the introduction of National Health Insurance in South Africa.

BACKGROUND: The South African government intends to contract with 'accredited provider groups' for capitated primary care under National Health Insurance (NHI). South African solo general practitioners (GPs) are unhappy with group practice. There is no clarity on the views of GPs in group practice on contracting to the NHI. OBJECTIVES: To describe the demographic and practice profile of GPs in group practice in South Africa, and evaluate their views on NHI, compared to solo GPs. METHODS: This was a descriptive survey. The population of 8721 private GPs in South Africa with emails available were emailed an online questionnaire. Descriptive statistical analyses and thematic content analysis were conducted. RESULTS: In all, 819 GPs responded (568 solo GPs and 251 GPs in groups). The results are focused on group GPs. GPs in groups have a different demographic practice profile compared to solo GPs. GPs in groups expected R4.86 million ($0.41 million) for a hypothetical NHI proposal of comprehensive primary healthcare (excluding medicines and investigations) to a practice population of 10 000 people. GPs planned a clinical team of 8 to 12 (including nurses) and 4 to 6 administrative staff. GPs in group practices saw three major risks: patient, organisational and government, with three related risk management strategies. CONCLUSIONS: GPs can competitively contract with NHI, although there are concerns. NHI contracting should not be limited to groups. All GPs embraced strong teamwork, including using nurses more effectively. This aligns well with the emergence of family medicine in Africa.

"It is not the fading candle that one expects": general practitioners' perspectives on life-preserving versus "letting go" decision-making in end-of-life home care.

BACKGROUND: Many general practitioners (GPs) are willing to provide end-of-life (EoL) home care for their patients. International research on GPs' approach to care in patients' final weeks of life showed a combination of palliative measures with life-preserving actions. AIM: To explore the GP's perspective on life-preserving versus "letting go" decision-making in EoL home care. DESIGN: Qualitative analysis of semi-structured interviews with 52 Belgian GPs involved in EoL home care. RESULTS: Nearly all GPs adopted a palliative approach and an accepting attitude towards death. The erratic course of terminal illness can challenge this approach. Disruptive medical events threaten the prospect of a peaceful end-phase and death at home and force the GP either to maintain the patient's (quality of) life for the time being or to recognize the event as a step to life closure and "letting the patient go". Making the "right" decision was very difficult. Influencing factors included: the nature and time of the crisis, a patient's clinical condition at the event itself, a GP's level of determination in deciding and negotiating "letting go" and the patient's/family's wishes and preparedness regarding this death. Hospitalization was often a way out. CONCLUSIONS: GPs regard alternation between palliation and life-preservation as part of palliative care. They feel uncertain about their mandate in deciding and negotiating the final step to life closure. A shortage of knowledge of (acute) palliative medicine as one cause of difficulties in letting-go decisions may be underestimated. Sharing all these professional responsibilities with the specialist palliative home care teams would lighten a GP's burden considerably. Key Points A late transition from a life-preserving mindset to one of "letting go" has been reported as a reason why physicians resort to life-preserving actions in an end-of-life (EoL) context. We investigated GPs' perspectives on this matter. Not all GPs involved in EoL home care adopt a "letting go" mindset. For those who do, this mindset is challenged by the erratic course of terminal illness. GPs prioritize the quality of the remaining life and the serenity of the dying process, which is threatened by disruptive medical events. Making the "right" decision is difficult. GPs feel uncertain about their own role and responsibility in deciding and negotiating the final step to life closure.

What are the most important tasks of tutors during the tutorials in hybrid problem-based learning curricula?

BACKGROUND: In problem-based learning, a tutor, the quality of the problems and group functioning play a central role in stimulating student learning. This study is conducted in a hybrid medical curriculum where problem-based learning is one of the pedagogical approaches. The aim of this study was to examine which tutor tasks are the most important during the tutorial sessions and thus should be promoted in hybrid (and in maybe all) problem-based learning curricula in higher education. METHODS: A student (N = 333) questionnaire was used to obtain data about the problem-based learning process, combined with the achievement score of the students on a multiple-choice exam. Structural equation modeling was used to test the fit of different models (two existing models and a new simplified model) representing the factors of interest and their relationships, in order to determine which tutor characteristics are the most important in the present study. RESULTS: A new simplified model is presented, which demonstrates that stimulation of active and self-directed learning by tutors enhances the perceived case quality and the perceived group functioning. There was no significant effect between the stimulation of collaborative learning and perceived group functioning. In addition, group functioning was not a significant predictor for achievement. CONCLUSIONS: We found that stimulating active and self-directed learning are perceived as tutors' most important tasks with regard to perceived case quality and group functioning. It is necessary to train and teach tutors how they can stimulate active and self-directed learning by students.