Práticas integrativas e complementares de saúde em Sergipe / Integrative and complementary health practices in Sergipe

A atenção primária em saúde (APS) é o primeiro nível de atenção em saúde, sendo um elo entre a população e o setor de saúde. Tem-se buscado a humanização dos atendimentos, e essa mudança, refletida pelas mudanças da sociedade, trouxe a implementação da Política Nacional de Práticas Integrativas e Complementares (PNPIC) no SUS. O objetivo deste trabalho foi realizar uma análise da tendência da quantidade das práticas integrativas e complementares realizadas nas regionais de saúde de Sergipe de 2017 a 2023, associando com a cobertura da atenção primária. Foi realizada análise de dados secundários através do Departamento de Informática do Sistema Único de Saúde (DATASUS), como forma de organização no período de junho/2015 a junho/2023 por regional de saúde de Sergipe. As análises dos dados foram descritivas e de correlação e por meio de análise de série temporal. A regional de saúde de Lagarto foi a que mais executou as práticas integrativas e complementares no período analisado e algumas regionais não tiveram continuidade na realização destas práticas. A regional de saúde com maior cobertura de APS foi Itabaiana. Não foi possível observar associação entre o número de práticas e a cobertura de atenção primária. Com o intuito de que o atendimento aos indivíduos seja cada vez mais humanizado, e em virtude da realização das práticas integrativas ter baixo índice ou descontinuidade em algumas regiões de Saúde de Sergipe, é relevante que os profissionais de saúde busquem conhecimentos sobre essas práticas, como também, os gestores em saúde incentivem esta ação.

Primary health care (PHC) is the first level of health care, being a link between the population and the health sector. The aim has been to humanize care, and this change, reflected by changes in society, has led to the implementation of the National Policy on Integrative and Complementary Practices (PNPIC) in the SUS. The objective of this work was to carry out an analysis of the trend in the number of integrative and complementary practices carried out in the health regions of Sergipe from 2017 to 2023, associating it with primary care coverage. Secondary data analysis was carried out through the Department of Informatics of the Unified Health System (DATASUS), as a form of organization from June/2015 to June/2023 by health region in Sergipe. Data analyzes were descriptive and correlational and through time series analysis. The Lagarto health region was the one that carried out the most integrative and complementary practices in the period analyzed and some regions did not continue to carry out these practices. The health region with the highest PHC coverage was Itabaiana. Observing an association between the number of practices and primary care coverage was impossible. With the aim that care for individuals is increasingly humanized, and because the implementation of integrative practices has a low rate or discontinuity in some Health regions of Sergipe, health professionals must seek knowledge about these practices as well as health managers encourage this action.

Invisibilização e preconceitos velados: barreiras para o acesso aos serviços de atenção básica pela população trans / Invisibilization and veiled prejudices: barriers to access to primary care services for the transgender population / Invisibilización y prejuicios velados: barreras para el acceso de la población trans a los servicios de atención primaria

Introdução: No processo de edificação da Política Nacional de Saúde Integral LGBT+, a Atenção Básica ganha importante destaque, pois deveria funcionar como o contato preferencial dos usuários transgênero (trans). Objetivo: Investigar quais as percepções dos profissionais da Atenção Básica quanto às situações de vulnerabilidade enfrentadas pelas pessoas trans, bem como pesquisar os impedimentos que eles consideram existir na busca dessa população por acesso a esses serviços. Métodos: Utilizou-se uma abordagem qualitativa por meio de entrevistas semiestruturadas com 38 profissionais de saúde atuantes das Estratégias Saúde da Família de dois municípios do interior do estado de São Paulo. O material obtido foi submetido à análise de conteúdo de Bardin. Resultados: Os resultados apontaram para o desconhecimento quanto aos reais empecilhos que dificultam o acesso e seguimento de pessoas trans nos serviços de saúde. Observou-se ainda a manutenção de preconceitos e ideias que reforçam estereótipos ligados ao tema e que se estendem ao exercício da profissão. Isso se relaciona diretamente com a falta da abordagem de assuntos relacionados à sexualidade humana na graduação desses profissionais, além da falta de atualização quanto ao tema, o que impacta a qualidade do serviço que é ofertado à população em estudo. Conclusões: As normativas e portarias já existentes precisam ser efetivamente postas em prática, fazendo-se imperativas a ampliação e difusão do conhecimento a respeito da temática trans no contexto dos serviços públicos de saúde, o que pode servir como base para subsidiar a formação dos profissionais que atuam nesse setor, bem como políticas públicas efetivas.

Introduction: In the process of creating the National LGBT+ Comprehensive Health Policy, primary care has important prominence as it must work as the preferential contact of transgender (trans) users. Objective: To investigate the perceptions of primary care professionals about the vulnerability situations faced by trans persons and also hindrances they consider existing in this population's search for access to these services. Methods: A qualitative approach was used through semi-structured interviews with 38 health care professionals working in the Family Health Strategy of two cities in the countryside of the state of São Paulo. The material obtained was submitted to analysis of Bardin content. Results: The results pointed to a lack of knowledge about real hindrances that obstruct the access to and follow-up by health services for trans persons. It was also observed the maintenance of prejudices and ideas that reinforce stereotypes connected to the matter and extend to the practice of professionals. It is directly related to the lack of approach of issues related to human sexuality in the education of those professionals, in addition to lack of update about it, which impacts the quality of service offered to the population under study. Conclusions: The standards and ordinances already existing need to be effectively practiced, being crucial the extension and spread of knowledge about trans matters in the context of public health services. It can be the basis for subsidizing the education of professionals who work in this field, as well as effective public policies.

Introducción: En el proceso de edificación de la Política Nacional de Salud Integral LGBT+, la Atención Básica tiene importante destaque, pues debería funcionar como contacto preferente de los usuarios transgénero (trans). Objetivo: Investigar las percepciones de los profesionales de Atención Básica sobre las situaciones de vulnerabilidad que enfrentan las personas trans, así como investigar los impedimentos que consideran que existe en la búsqueda de esta población por el acceso a estos servicios. Métodos: Se utilizó un abordaje cualitativo por medio de entrevistas semiestructuradas con 38 profesionales de salud actuantes de las Estrategias de Salud de la Familia de dos municipios del interior del estado de São Paulo. El material obtenido fue sometido a análisis de contenido de Bardin. Resultados: Los resultados apuntaron al desconocimiento sobre los reales obstáculos que dificultan el acceso de personas trans a los servicios, además del segmento de los cuidados en las unidades. Se observó además que se mantienen los prejuicios e ideas que refuerzan estereotipos vinculados al tema y que se extienden al ejercicio de la profesión. Esto se relaciona directamente a la falta da abordaje de asuntos relacionados a la sexualidad humana en la graduación de estos profesionales, además de la falta de actualización sobre el tema, lo que impacta en la calidad del servicio que se ofrece a la población en estudio. Conclusiones: Las normas y ordenanzas ya existentes deben ser efectivamente puestas en práctica, por lo que es imperativo ampliar y difundir el conocimiento sobre la temática trans en el contexto de los servicios públicos de salud, que pueda servir de base para apoyar la formación de profesionales que actúan en este sector, así como políticas públicas efectivas.

Implementation of decarbonisation actions in general practice: a systematic review and narrative synthesis protocol.

INTRODUCTION: There is growing recognition of the importance of primary care in addressing climate change. The World Organisation of Family Doctors has urged general practitioners worldwide to commit to tackling climate change and to serve as agents of systemic and individual change. Though an increasing number of resources have become available to support the decarbonisation of primary care, there remains a lack of evidence about how primary care teams are using them, their reach across practices, their level of adoption and maintenance, their cost impact and their effect on carbon emissions. This systematic review aims to understand how primary care, with a focus on general practice or equivalent settings within the context of primary care, is implementing decarbonisation actions to reduce carbon emissions arising from its operations, assess efficacy of the actions and generate recommendations on how to assist and accelerate their implementation and effectiveness. METHODS AND ANALYSIS: The literature search will be conducted on Medline, Embase, Web of Science, CINAHL and ProQuest, from 2007 to 29 March 2024. Article screening will be based on specified inclusion and exclusion criteria. Narrative synthesis will be used to analyse and integrate findings to offer new insights into key mechanisms that support decarbonisation in general practice and help refine an initial programme theory. The reporting of the systematic review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis framework. ETHICS AND DISSEMINATION: This review did not involve the collection or analysis of any data that was not included in previously published research in the public domain. The results will be disseminated through peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42023470889.

Impact of COVID-19 on MOUD retention in a sample of rural primary care patients: A secondary analysis of electronic health records.

Introduction: There is limited research examining factors impacting MOUD retention in rural settings, especially within the context of the COVID-19 pandemic. Using electronic health records data collected as part of a NIDA Clinical Trials Network study (CTN-0102), this study explored how the onset of the COVID-19 pandemic may have impacted MOUD retention in a sample of 563 rural primary care patients. Methods: Cox regression model was applied to examine if COVID-19 was related to treatment retention, controlling for demographics, clinic, insurance type, and other diagnoses. The independent variable was the number of days between the patient's first MOUD prescription date during the pre-COVID observation period (10/1/2019-3/13/2020) and the start of the COVID-19 pandemic. The dependent variable was retention on MOUD, defined as the time from the first MOUD prescription documented during the pre-COVID observation period to the first break in consecutive MOUD prescriptions (right censored at 180 days). Results: The findings demonstrated that there was a reduced risk of a prescription break for every 10-day increase in the time from the first documented MOUD prescription to the onset of the COVID-19 pandemic (HR = 0.96, 95 % CI = 0.92-0.99; p = 0.011). Conclusions: While the data did not include complete treatment histories to determine who was new to MOUD treatment, the findings suggest that patients whose first documented MOUD prescription in the dataset was closer to the onset of the pandemic had a greater likelihood of experiencing retention challenges. This underscores the importance for clinics to establish comprehensive contingency plans for future emergencies to ensure uninterrupted MOUD treatment and support, particularly for individuals in the early stabilization phase of their recovery.

Scalable and successful patient portal lifestyle coaching training for primary care clinical staff.

Maintaining a healthy weight postintentional weight loss is crucial for preventing chronic health conditions, yet many regain weight postintervention. Electronic health record (EHR) portals offer a promising avenue for weight management interventions, leveraging patient-primary care relationships. Our previous research demonstrated that coaching alongside self-monitoring improves weight maintenance compared to monitoring alone. Integrating weight management into routine clinical practice by training existing staff could enhance scalability and sustainability. However, challenges such as inconsistent staff qualifications and high coach turnover rates could affect intervention effectiveness. Standardizing services, training, and coaching continuity seem crucial for success. To report on developing, testing, and evaluating an EHR-based coaching training program for clinical staff, guided by an implementation tool for the MAINTAIN PRIME study. Conducted across 14 University of Utah primary care sites, we developed, tested, and evaluated a coaching training for clinical staff. Guided by a planning model and the Predisposing, Enabling, and Reinforcing (PER) tool, stakeholders actively participated in planning, ensuring alignment with clinic priorities. All clinical staff were invited to participate voluntarily. Evaluation measures included staff interest, training effectiveness, confidence, and readiness. Data collection utilized REDCap, with survey results analyzed using descriptive statistics. Despite increased clinical workload and reassignments posed by coronavirus disease 2019, we were able to train 39 clinical staff, with 34 successfully coaching patients. Feedback indicated high readiness and positive perceptions of coaching feasibility. Coaches reported satisfaction with training, support, and enjoyed establishing connections with patients. The PER strategies allowed us to implement a well-received training program found effective by primary care coaches.

This report describes a training program for medical staff like nurses and medical assistants. The goal is to teach them how to coach patients through an online portal to help them keep their weight off after making healthy lifestyle changes. We worked with different clinic groups and used a planning tool called PER worksheet (predisposing, enabling, and reinforcing) to set up the training program. From September 2021 to March 2023, we offered the training in 14 clinics, and most interested staff completed it. The results showed that the training worked well. People who took part felt they learned enough to coach patients and felt ready to coach. They liked the training and found it helpful. This study suggests that we can teach coaching skills in just four hours of training and that ongoing support and mentorship are important to the trained coaches. Furthermore, this training set-up allows new staff to be trained as they join, which is especially important in places where staff changes frequently. Overall, using the PER tool enabled us to create a training program that staff can use in outpatient clinics to help patients improve their weight management.

Regional socioeconomic characteristics and density of general practitioners in Germany: A nationwide cross-sectional and longitudinal spatial analysis.

OBJECTIVES: Limited healthcare availability impacts population health. Regional disparities in GP density across Germany raise questions about their association with regional socioeconomic characteristics. STUDY DESIGN: This longitudinal nationwide ecological German study used regional data at the county level (n = 401) from 2015 to 2019 provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). The outcome was general practitioners (GPs) density, defined as the number of GPs per 10,000 inhabitants. METHODS: Univariate Moran's I, cluster analysis (LISA), and spatial lag of X (SLX) models were employed to analyse the spatial distribution of GP density and its correlation with various regional socioeconomic characteristics from a cross-sectional and longitudinal perspective. RESULTS: In contrast to the univariate analysis, rural counties showed the highest GP density the multivariate model. Several counties were identified as embedded in low- or high-GP-density clusters. In 2015 and 2019, larger household size (2015: std. ß = -2.31, p = 0.021; 2019: std. ß = -4.14, p < 0.001) and higher unemployment rate (2015: std. ß = -2.84, p = 0.005; 2019: std. ß = -5.47, p < 0.001) were associated with lower GP density. In the longitudinal model, a greater increase in the unemployment rate was related to a greater decrease in GP density (std. ß = -2.17, p = 0.030). CONCLUSION: A higher regional unemployment rate is linked to lower GP availability in Germany, and a greater increase in the unemployment rate was related to a greater decrease in GP availability over time. This necessitates policy intervention to avoid socioeconomic disparities in GP care.

Incorporation of a specialist mental health clinical pharmacist within a primary care network: patient referrals, prescribing decisions, and clinical outcomes.

Background: The benefit of generalist pharmacists working within primary care networks (PCNs) and with general practitioners (GPs) is established. We wished to evaluate the contributions and potential benefits of a specialist mental health care prescribing pharmacist within PCNs. Method: We prospectively collected data, on clinical and demographic characteristics, referral sources, interventions, outcomes (objective and subjective), and patient feedback, from 466 completed patients, in one PCN by one specialist mental health pharmacist (working 0.5 whole time equivalent), over 15 months. Results: Referrals originated from multiple sources, including GPs, other members of the PCN mental health team, and community mental health teams (CMHTs). Two-thirds of treated patients were female; the most frequent age band was 18-30 years; the most common diagnosis was mixed depression and anxiety. Patients with diagnoses of mixed anxiety with depression or personality disorder needed more appointments than those with anxiety or depression. A range of evidence-based treatments were prescribed, including non-formulary medicines, and those medicines are more typically initiated or recommended in secondary care settings. The most frequently started medications were antidepressants (principally fluoxetine and duloxetine), followed by antipsychotics (principally quetiapine and aripiprazole): the most common dosage increases were for sertraline and quetiapine. Common non-medication recommendations were for cognitive behavioral therapy, cognitive behavioral therapy for insomnia, and other psychological therapies. Patient feedback was generally positive. Discussion: Developing and implementing a service incorporating a specialist mental health pharmacist within a PCN mental health team is potentially valuable in improving patient care quality, reducing workload for GPs and CMHTs, and enabling faster access to secondary care initiated and recommended medications. This innovative service addressed several national targets, including prevention, early intervention, and access to quality compassionate care.

Incorporation of a specialist mental health clinical pharmacist within a primary care network: patient referrals, prescribing decisions, and clinical outcomes Developing and implementing a service incorporating a specialist mental health pharmacist within a PCN mental health team is potentially valuable in improving patient care quality, reducing workload for general practitioners and community mental health teams, and enabling faster access to secondary care initiated and recommended medications. This innovative service addressed several national targets, including prevention, early intervention, and access to quality compassionate care.

End-of-Life Care Among Patients With Kidney Failure on Maintenance Dialysis: A Retrospective Population-Based Study.

Background: Nephrologists routinely provide end-of-life care for patients with kidney failure (KF) on maintenance dialysis. Involvement of primary care and palliative care physicians may enhance this experience. Objective: The objective was to describe outpatient care patterns in the last year of life and the end-of-life acute care utilization for patients with KF on maintenance dialysis. Design: Retrospective cohort study using population-level health administrative data. Setting & Participants: Outpatient and inpatient care during the last year of life among patients who died between 2017 and 2019, receiving maintenance dialysis in Ontario, Canada. Measurements: The primary exposure is patterns of physician specialties providing outpatient care in the last year of life. Outcomes include outpatient encounters in the last year of life, acute care visitation in the last month of life, and place of death. Methods: We reported the count and percentage of categorical outcomes and the median (interquartile range) for numeric outcomes. We produced time series plots of the mean monthly percentage of encounters to different specialties stratified by physician specialty patterns. We evaluated differences in outcomes by physician specialty patterns using analysis of variance (ANOVA) and Pearson's chi-square tests (P < .05, two-tailed). Results: Among 6866 patients, the median age at death was 73, 36.1% were female, and 87.8% resided in urban regions. Three patterns emerged: a primary care, nephrology, and palliative care triad (25.5%); a primary care and nephrology dyad (59.3%); and a non-primary care pattern (15.2%). Palliative care involvement is concentrated near death. Of all, 81.4% spent at least 1 day in hospital or emergency department in the last month, but those with primary care, palliative care, and nephrology involvement had the fewest acute care deaths (65.8%). Limitations: Outpatient care patterns were defined using physician billing codes, potentially missing care from other providers. Conclusions: Nephrology and primary care predominantly manage outpatient care in the last year of life for patients with KF on maintenance dialysis, with consistent acute care use across care patterns except for the place of death. Future research should explore associations between patterns of care and end-of-life outcomes to identify the most optimal model of care for patients with KF on maintenance dialysis.

Contexte: Il est courant pour les néphrologues de prodiguer des soins de fin de vie aux patients souffrant d'insuffisance rénale (IR) sous dialyse d'entretien. Cette expérience pourrait être enrichie par la participation des médecins des unités de soins primaires et de soins palliatifs. Objectif: Cette étude visait à décrire les modèles de soins ambulatoires prodigués au cours de la dernière année de vie et l'utilisation des soins aigus en fin de vie chez les patients atteints d'IR sous dialyse d'entretien. Conception: Étude de cohorte populationnelle rétrospective réalisée à partir des données administratives du système de santé. Cadre et sujets de l'étude: Les soins ambulatoires et hospitaliers au cours de la dernière année de vie chez les patients décédés sous dialyse d'entretien entre 2017 et 2019 en Ontario (Canada). Mesures: La principale mesure est le profil des spécialités médicales qui fournissent des soins ambulatoires dans la dernière année de vie. Les données recueillies comprennent les consultations externes au cours de la dernière année de vie, les visites en soins aigus au cours du dernier mois de vie et le lieu du décès. Méthodologie: Nous avons rapporté le nombre et le pourcentage de résultats catégoriels, ainsi que la médiane (écart interquartile) des résultats numériques. Nous avons produit des graphiques chronologiques du pourcentage mensuel moyen de consultations avec différentes spécialités, stratifiées selon les spécialités médicales. Nous avons évalué les différences dans les résultats selon les profils de spécialités médicales en utilisant les tests ANOVA et Chi-Square de Pearson (P <,05; bilatéral). Résultats: Des 6 866 patients inclus (âge médian au décès: 73 ans), 36,1% étaient des femmes et 87,8% vivaient en région urbaine. Trois modèles sont apparus: une triade soins primaires, néphrologie et soins palliatifs (25,5%); une dyade soins primaires et néphrologie (59,3%); et un modèle de soins non primaires (15,2%). La participation des soins palliatifs est concentrée autour du moment du décès. Une grande majorité des patients (81,4%) avait passé au moins une journée à l'hôpital ou aux urgences au cours du dernier mois, mais les personnes qui avaient bénéficié d'une triade de soins (primaires, néphrologie et soins palliatifs) présentaient une moins grande proportion de décès en soins aigus (65,8%). Limites: Les modèles de soins ambulatoires ont été définis à l'aide des codes de facturation des médecins, ce qui pourrait avoir exclu les soins dispensés par d'autres prestataires. Conclusion: Les soins ambulatoires au cours de la dernière année de vie des patients atteints d'IR sous dialyse d'entretien sont principalement prodigués par la néphrologie et les soins primaires, avec une utilisation constante des soins aigus dans tous les modèles de soins, sauf pour le lieu du décès. Les futures recherches devraient explorer les liens entre les modèles de soins et les résultats en fin de vie afin d'identifier le modèle de soins le plus optimal pour les patients atteints d'IR sous dialyse d'entretien.

Reasons for Neonatal Presentations to Pediatric Emergency Departments in Catania: Multicentric Cross-Sectional Analysis and Exhaustive Review of the Literature.

INTRODUCTION: This study aimed to characterize neonatal admissions to pediatric emergency departments (PEDs) in Catania, to analyze the primary pediatric conditions leading to these admissions, and to explore the association between the demographic characteristics of the population and the severity of their presentations. MATERIALS AND METHODS: A retrospective analysis was conducted on neonates (aged <28 days) admitted to three PEDs in Catania between January 2015 and December 2019. Additionally, a comprehensive review of the literature on this topic was performed. RESULTS: A total of 5183 neonates presented during the study period, with a median age of 14 days at admission. The top three diagnoses were neonatal jaundice (15%), abdominal discomfort (12%), and upper airway inflammation (11%). The majority of cases were classified as non-urgent (green) at triage (59%). Overall, 1296 patients (25%) required hospitalization; 95% of those assigned a yellow triage color at admission required hospitalization. Only 33% of hospitalized patients were referred by parents, while the majority were referred by primary care pediatricians. The highest number of admissions occurred in August, while the peak in hospitalizations was in February. CONCLUSIONS: The majority of neonatal PED admissions are for non-acute conditions that do not require immediate medical attention. This concerning trend leads to increased workloads for PED staff, higher healthcare costs, and potential risks to neonates. Possible causes include insufficient caregiver knowledge, inadequate parental education, and suboptimal transition from hospital to primary care pediatric services.

Role of mixed healthcare providers networks in strengthening primary care systems: a case study of a rural primary care site.

INTRODUCTION: Service delivery networks, also called healthcare providers networks (HCPNs) have been used to address health inequities and promote universal healthcare (UHC). This study described the effect of instituting a mixed HCPN (partnership of public health facilities with a private pharmacy) on the provision of medications in the rural primary care pilot site of the Philippine Primary Care Studies (PPCS). METHODS: This is a case study of the mixed HCPN in the PPCS rural site. A mixed HCPN involving one private pharmacy was instituted to increase the supply of drugs. The total number of medications prescribed per month from April 2019 to October 2021, and the number of medications dispensed from the public sector (rural health unit or RHU) and from the partner private pharmacy in the same time period were obtained. RESULTS: Of the 101 031 medications prescribed in the first year (April 2019 to March 2020), 21.7% were dispensed at the RHU and 66.7% were dispensed in the partner private pharmacy. The remaining 11.5% were unrendered or dispensed in other private pharmacies. Of the 35 408 medications prescribed in the second year (April 2020 to March 2021), 5.6% were dispensed at the RHU and 32.2% were dispensed at the partner private pharmacy. Majority (62.1%) were unrendered or dispensed in other private pharmacies. From April to October 2021, of the 6448 medications prescribed, 2.3% were dispensed at the RHU, and 47.3% were dispensed at the partner private pharmacy. Majority (50.3%) were unrendered or dispensed in other private pharmacies. CONCLUSION: Creation of a mixed HCPN in a rural primary care site augmented access to essential medications. The mixed HCPN model in the study showed potential in strengthening access to consultations and medications in a rural community. Improving essential primary care services can facilitate implementation of UHC in the Philippines.

Investigations and referral for suspected gastric cancer by primary care physicians: a cross-sectional study in Southeastern China.

BACKGROUND: Early recognition and accurate diagnosis are particularly important in the context of gastric cancer. This study mainly aimed to investigate primary care physicians' (PCPs') clinical behaviour and their readiness to consider investigation or referral for symptoms possibly indicative of gastric cancer. DESIGN: Cross-sectional study. SETTING: A self-administered online survey was carried out in five selected cities in the Fujian province of China between February 2022 and May 2022. PARTICIPANT: PCPs working in the departments, such as Internal Gastroenterology and Hepatology, General Internal Medicine, Internal Medical Oncology Gastrointestinal Surgery or other clinical departments, have the chance to diagnose or treat patients with suspected gastric cancer. MAIN OUTCOME MEASURES: Percentage of PCPs identifying gastric cancer patients either by undertaking an endoscopy at the primary hospital or by referring patients to an upper-level hospital. RESULTS: A total of 1210 complete responses were received. Nearly half of responding PCPs (46.4%) only had less than 5 years of clinical experience, and the majority worked in suburban or rural regions (64.4%). Direct access to blood tests for cancer diagnosis (77.9%), X-ray (77.2%), CT (55.7%), ultrasound (85.3%), upper gastrointestinal endoscopy (54.4%) and colonoscopy (51.9%) was common. Of the respondents, 85.5% reported that they could get specialist advice for a suspected cancer patient within 48 hours in terms of investigations and 84.0% in terms of referral. Patients' waiting time to either conduct a test or have a result was mostly less than 1 week. In patients indicative of gastric cancer, a total of 1148 (94.8%) physicians were ready to investigate cancer either by sending patients to an endoscopy test (49.7%) or referring them to an upper-level hospital (45.1%). CONCLUSIONS: Findings indicate that PCPs in five selected cities of Southeastern China have wide and rapid access to diagnostic tests and specialist advice. Furthermore, PCPs in this region seem to have a high level of readiness to consider investigation or referral for symptoms possibly indicative of gastric cancer.

A pilot program to improve TB care with primary and specialty care coordination in TB public health clinic.

BACKGROUND: The Wetmore Tuberculosis (TB) Clinic in New Orleans serves patients who often lack primary care (PC) or specialty care (SC), which is complicated by comorbidities. An initiative to provide on-site PC and coordinate care aims to enhance TB patient management. METHODS: Data collection involved categorizing patients based on their PC status: Group I (regular PC), Group II (intermittent PC), and Group III (no PC), with on-site Nurse Practitioner-based Bridge Care (NPBC) provided as needed. RESULTS: Over 12 months, 209 out of 354 patients required NPBC and PC/SC coordination, with a 20% shift from Group III to Group I, reducing the need for NPBC. CONCLUSION: The program improved TB care at Wetmore TB Clinic, offering a potential model for other TB clinics to enhance patient adherence and TB and post-TB treatment follow-up.

CONTEXTE: La clinique de TB de Wetmore à la Nouvelle-Orléans, États Unis, dessert des patients qui manquent souvent de soins primaires (PC, pour l'anglais « primary care ¼) ou de soins spécialisés (SC, pour l'anglais « specialty care ¼), ce qui est compliqué par des comorbidités. Une initiative visant à fournir des ordinateurs sur place et à coordonner les soins vise à améliorer la prise en charge des patients atteints de TB. MÉTHODES: La collecte des données a consisté à catégoriser les patients en fonction de leur statut de PC : Groupe I (PC régulier), Groupe II (PC intermittent) et GROUPE III (pas de PC), avec des soins de transition basés sur l'infirmière praticienne (NPBC, pour l'anglais « Nurse Practitioner-based Bridge Care ¼) sur place fournis au besoin. RÉSULTATS: Sur une période de 12 mois, 209 patients sur 354 ont nécessité une coordination NPBC et PC/SC, avec un passage de 20% du groupe III au groupe I, réduisant ainsi le besoin de NPBC. CONCLUSION: Le programme a amélioré les soins contre la TB à la clinique de TB de Wetmore, proposant ainsi un modèle potentiel pour d'autres cliniques afin d'améliorer l'observance des patients et le suivi du traitement de la TB et de la période post-traitement.

Community Health Dialogue Implementation for the Solution of Loneliness in Rural Communities: Autoethnography.

INTRODUCTION: Isolation and loneliness among older adults in rural communities pose significant risks to physical and mental health, leading to higher rates of morbidity and mortality. This study investigates the impact of continual rural health dialogues facilitated by family physicians on reducing loneliness and enhancing community health in Unnan City, Shimane Prefecture, Japan. METHOD: Using a constructivist grounded theory approach, we conducted a qualitative study involving 165 participants over 65 from five rural communities between April 2022 and March 2024. Monthly health dialogues covered chronic diseases, exercise, and polypharmacy. Data were collected through ethnographic observations, focus group interviews, and field notes, with iterative coding and analysis to identify themes and concepts. RESULTS: Three primary themes emerged: the existence of loneliness and its impact on health, motivation to address loneliness through a sense of security, and recognition of the importance of community engagement in reducing loneliness. Participants reported increased health awareness, enhanced community interaction, and recognition of loneliness's prevalence and health impacts. Regular dialogues fostered trust with healthcare professionals, encouraged proactive health management, and facilitated supportive community connections. These interactions significantly reduced feelings of loneliness and improved health outcomes. CONCLUSION: Continual rural health dialogues effectively mitigate loneliness and enhance health outcomes in rural communities by fostering regular interactions and building supportive networks. These findings underscore the importance of community engagement and continuous relationships with healthcare professionals in addressing loneliness. Policymakers and healthcare providers should consider integrating such dialogues into rural health strategies to promote healthier, more connected communities. Future research should explore these interventions' long-term sustainability and broader applicability across diverse rural settings.

The Adoption and Impact of Telemedicine on Health Equity: A Narrative Review From the Jamaican Context.

Telemedicine rose to popularity during the coronavirus disease 2019 (COVID-19) pandemic but is yet to be fully developed. Hence, this study explores the current status of telehealth in Jamaica, looking at its benefits, challenges with its implementation, the regulatory landscape, and solutions to using this technology. Due to the limited research on this topic, a majority of the sources utilized were gray literature with qualitative and quantitative studies. This review seeks to transform policy and practice, promoting telemedicine as a feasible solution for improving Jamaica's healthcare quality and access. By comparing telemedicine in Jamaica to a more developed nation like the United States, the review highlights not only benefits but also major challenges, including healthcare disparities due to the digital divide, less advanced technology, privacy breaches, and significant financing required for telemedicine infrastructure, among other barriers to its integration. The analysis advocates for improvement in various areas, such as cybersecurity measures, advanced training for healthcare professionals, further investments in technological infrastructure, refinement of regulatory frameworks and policies, and incorporation of community-based initiatives. This investigation further highlights the need for additional research to gain insights and a broader perspective.

The need for a broad perspective when assessing value-for-money for out-of-hours primary care.

BACKGROUND: Out-of-hours primary care (OOH-PC) has emerged as a promising solution to improve efficiency, accessibility, and quality of care and to reduce the strain on emergency departments. As this modality gains traction in diverse healthcare settings, it is increasingly important to fully assess its societal value-for-money and conduct thorough process evaluations. However, current economic evaluations mostly emphasise direct- and short-term effect measures, thus lacking a broader societal perspective. AIM: This study offers a comprehensive overview of current effect measures in OOH-PC evaluations and proposes additional measures from the evaluation of integrated care programmes. APPROACH AND DEVELOPMENT: First, we systematically identified the effect measures from published cost-effectiveness studies and classified them as process, outcome, and resource use measures. Second, we elaborate on the incorporation of 'productivity gains', 'health promotion and early intervention', and 'continuity of care' as additional effects into economic evaluations of OOH-PC. Seeking care affects personal and employee time, potentially resulting in decreased productivity. Challenges in taking time off work and limited access to convenient care are often cited as barriers to accessing primary care. As such, OOH-PC can potentially reduce opportunity costs for patients. Furthermore, improving access to healthcare is important in determining whether people receive promotional and preventive services. Health promotion involves empowering people to take control of their health and its determinants. Given the unscheduled nature and the fragmented or rotational care in OOH-PC, the degree to which interventions and modalities provide continuity should be monitored, assessed, and included in economic evaluations. Continuity of care in primary care improves patient satisfaction, promotes adherence to medical advice, reduces reliance on hospitals, and reduces mortality. CONCLUSION: Although it is essential to also address local settings and needs, the integration of broader scope measures into OOH-PC economic evaluations improves the comprehensive evaluation that aligns with welfare gains.

Trajectories of work disability among individuals with anxiety-, mood/affective-, or stress-related disorders in a primary healthcare setting.

BACKGROUND: Anxiety-, mood/affective-, or stress-related disorders affect up to one-third of individuals during their lives and often impact their ability to work. This study aimed to delineate trajectories of work disability (WD) among individuals diagnosed with anxiety-, mood/affective-, or stress-related disorder in primary healthcare and to examine associations between trajectory group membership and sociodemographic, clinical, and clinical-related factors. METHODS: The study population included working-age individuals, aged 22-62 years, living in Stockholm County, Sweden, who experienced a new episode of any anxiety-, mood/affective, or stress-related disorder in primary healthcare in 2017 (N = 11,304). Data were obtained from Swedish national and regional registers and were linked using pseudonymised unique personal identification numbers. The primary outcome was days with WD (sum of sickness absence and disability pension days) during the three years before and three years after a diagnosis of anxiety-, mood/affective-, or stress-related disorders in primary healthcare. A zero-inflated Poisson group-based trajectory model was used to identify groups of individuals with similar patterns of WD over the study period, with a multinomial logistic regression used to examine associations of sociodemographic, clinical, and clinical-related factors with trajectory group membership. RESULTS: Four distinct trajectory groups were found, high increasing (5.1%), with high levels, from 16 to 80 days of WD in six-monthly intervals during follow-up, peak (11.1%), with a peak in WD, up to 32 days of WD, around the time of the diagnosis, low increasing (12.8%), with an increase in days of WD from 4 to 22 during the study period, and constant low (71.1%), with almost no WD over the study period. In multinomial regression models, diagnostic category, psychotropic medication use, a diagnosis of a psychiatric disorder within secondary healthcare, age at diagnosis, and occupation were associated with WD trajectory groups. CONCLUSIONS: Around two-thirds of individuals treated for a new episode of any anxiety-, mood/affective-, or stress-related disorder in primary healthcare have an excellent prognosis regarding WD. Several sociodemographic and clinical characteristics were associated with group membership; these factors could identify individuals at risk of long-term welfare dependency and who might benefit from interventions to promote a return to work.

A multisector community-engaged collaborative for mental health integration in primary care and housing developments: Protocol for a stepped-wedge randomized controlled trial (the Harlem Strong Program).

BACKGROUND: Addressing mental health disparities following COVID-19 requires adaptive, multi-sectoral, equity-focused, and community-based approaches. Mental health task-sharing in gateway settings has been found to address mental health care gaps in low- and middle-income countries, but is not a common practice in the U.S., especially in non-medical settings, such as low-income housing developments (LIH). This research study will evaluate the effectiveness of a multisectoral community-engaged collaborative for task-sharing mental health care on consumer, provider, and implementation outcomes, as well as identify barriers and facilitators for implementation. METHODS: In this stepped-wedge randomized controlled trial with technology supplementation, LIH and primary care sites will be randomly assigned to one of five sequences of three implementation strategies: (1) Education and Resources (E&R), which involves online training and resources on basic mental health task-sharing skills, (2) Multisectoral Community Collaborative Care (MCC), which consists of all E&R resources plus additional community responsive implementation supports and participation in a multisectoral coalition and (3) MCC + Technology, which combines the MCC condition resources with a community crowdsourced technology solution to support implementation. The primary outcome is the effectiveness in meeting consumers' needs through direct service (e.g., adequately addressing depression and anxiety symptoms), and through implementation to increase access to mental health care (reach). The secondary outcome examines additional consumer outcomes including health functioning and social risks, as well as implementation outcomes including provider skills, program adoption, and factors related to barriers and facilitators of quality implementation. A total of 700 consumers receiving mental health care at 20 sites will be surveyed at baseline, 6-, and 12-month follow-ups. Additionally, 100 providers will be evaluated at baseline, 6-, 12-, and 24-month follow-ups before training and after randomization. DISCUSSION: We hypothesize that MCC and MCC + Technology conditions will demonstrate significantly higher efficacy in changing primary outcomes compared to E&R, and the MCC + Technology supplement will show significantly higher levels of reach of mental health tasks compared to the MCC condition alone. These findings will demonstrate the feasibility of mental health integration into accessible, non-medical community settings such as LIH. Moreover, it will help establish a multilevel system solution based on community engagement and planning with a multisectoral collaboration that can be sustained community-wide. TRIAL REGISTRATION: NCT05833555 on Clinicaltrials.gov. Registered April 26, 2023.

Integrating a Parenting Assessment into Practice: Pediatric Providers' Time and Perspectives.

PURPOSE: To integrate a parenting assessment into primary care and assess pediatric providers' time needed to review it and their perceptions of the process. DESCRIPTION: The Quick Parenting Assessment (QPA) is a validated, 13 item parent support tool that assesses for healthy and unhealthy parenting practices. Higher QPAs indicate more unhealthy parenting being used. In a clinic serving low-income parents, the QPA was integrated into the 15 month, 30 month, 5 year, and 8 year well child visits. After each well child visit in which the QPA was administered, providers were invited to complete a one-page survey-315 surveys were included in the analysis. ASSESSMENT: Most QPAs (78.7%) were low risk (QPA < = 2), 14.6% were medium risk (QPA = 3-4), and 6.7% were high risk (QPA > 4). The median time was 15-30 s to review low risk QPAs and 30 s to 1 min to review high risk QPAs. For most QPA reviews, health care providers reported that the QPA increased their objectivity in determining the level of support needed (68%), facilitated communication about parenting (77%), and increased the value of the visit (68%). CONCLUSION: A validated parenting assessment tool, integrated into pediatric primary care, appears to work for pediatric health care providers. These findings have implications for supporting parents in pediatrics, value-based care, and disease prevention.

Assessment of parenteral estradiol and dihydroxyprogesterone use among other feminizing regimens for transgender women: insights on satisfaction with breast development from community-based healthcare services.

The practice of hormone therapy is crucial in aligning secondary sex characteristics with the gender identity of transgender adults. This study examines the effects of a commonly used injectable hormone combination, specifically estradiol enanthate with dihydroxyprogesterone acetophenide (EEn/DHPA), on serum hormonal levels and self-reported satisfaction with breast development in transwomen. Our research focused on a retrospective longitudinal study involving a large cohort of transwomen evaluated between 2020 and 2022, comprising 101 participants. We assessed serum levels of estradiol (E2), testosterone (T), luteinizing hormone (LH), and follicle-stimulating hormone (FSH), comparing the EEn/DHPA hormonal regimen with other combined estrogen-progestogen (CEP) therapies. Additionally, a subset of 43 transwomen completed a 5-question survey to evaluate self-reported satisfaction with breast development using Tanner scales. Our findings indicated that participants using the EEn/DHPA regimen exhibited significantly higher serum E2 levels (mean: 186 pg/mL ± 32 pg/mL) than those using other therapies (62 ± 7 pg/mL), along with lower FSH levels, but no significant differences in T and LH levels. Concerning satisfaction with breast development, 76% reported increased fulfillment with breast augmentation while using EEn/DHPA. These results suggest that an injectable, low-cost EEn/DHPA administered every three weeks could serve as an alternative feminizing regimen, particularly considering the extensive long-term experience of the local transgender community. Further longitudinal studies on the efficacy of feminizing-body effects and endovascular risks of various parenteral CEP types are warranted to improve primary healthcare provision for transgender persons.