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Background: Adaptation to climate change (CC) is a priority for Small Island Developing States (SIDS) in the Caribbean, as these countries and territories are particularly vulnerable to climate-related events. Primary health care (PHC) is an important contributor to CC adaptation. However, knowledge on how PHC is prepared for CC in Caribbean SIDS is very limited. The aim of this paper is to discuss health system adaptation to climate change, with a focus on PHC. Methods: We explored the perspectives of PHC professionals in Dominica on PHC adaptation to climate change. Focus group discussions (FGDs) were conducted in each of the seven health districts in Dominica, a Caribbean SIDS, between November 2021 and January 2022. The semi-structured interview guide was based on the Essential Public Health Functions: assessment, access to health care services, policy development and resource allocation. Data coding was organized accordingly. Results: Findings suggest that health care providers perceive climate change as contributing to an increase in NCDs and mental health problems. Climate-related events create barriers to care and exacerbate the chronic deficiencies within the health system, especially in the absence of high-level policy support. Healthcare providers need to take a holistic view of health and act accordingly in terms of disease prevention and health promotion, epidemiological surveillance, and ensuring the widest possible access to healthcare, with a particular focus on the environmental and social determinants of vulnerability. Conclusion: The primary health care system is a key stakeholder in the design and operationalization of adaptation and transformative resilience. The Essential Public Health Functions should integrate social and climate and other environmental determinants of health to guide primary care activities to protect the health of communities. This study highlights the need for improved research on the linkages between climate events and health outcomes, surveillance, and development of plans informed by contextual knowledge in the SIDS. [ABSTRACT FROM AUTHOR]

Background: The integration of Primary Care (PC) into broader health systems has been a goal in jurisdictions around the world. Efforts to achieve integration at the meso-level have drawn particular attention, but there are few actionable recommendations for how to enact a 'pro-integration culture' amongst government and PC governance bodies. This paper describes pragmatic integration activity undertaken by meso-level participants in Alberta, Canada, and suggests ways this activity may be generalizable to other health systems. Methods: 11 semi-structured interviews with nine key informants from meso-level organizations were selected from a larger qualitative study examining healthcare policy development and implementation during the COVID-19 pandemic. Selected interviews focused on participants' experiences and efforts to 'do' integration as they responded to Alberta's first wave of the Omicron variant in September 2021. An interpretive descriptive approach was used to identify repeating cycles in the integration context, and pragmatic integration activities. Results: As Omicron arrived in Alberta, integration and relations between meso-level PC and central health system participants were tense, but efforts to improve the situation were successfully made. In this context of cycling relationships, staffing changes made in reaction to exogenous shocks and political pressures were clear influences on integration. However, participants also engaged in specific behaviours that advanced a pro-integration culture. They did so by: signaling value through staffing and resource choices; speaking and enacting personal and group commitments to collaboration; persevering; and practicing bi-directional communication through formal and informal channels. Conclusions: Achieving PC integration involves not just the reactive work of responding to exogenous factors, but also the proactive work of enacting cultural, relationship, and communication behaviors. These behaviors may support integration regardless of the shocks, staff turnover, and relational freeze-thaw cycles experienced by any health system. [ABSTRACT FROM AUTHOR]

Background: The STarT MSK cluster randomised controlled trial (RCT) investigated the clinical- and cost-effectiveness of risk-based stratified primary care versus usual care for patients with back, neck, shoulder, knee or multi-site pain. Trial quantitative results showed risk-based stratified care was not superior to usual care for patients' clinical outcomes, but the intervention led to some changes in GP clinical decision-making. This paper reports a linked qualitative study exploring how risk-based stratified care was perceived and used in the trial, from the perspectives of clinicians and patients. Methods: Semi-structured interviews were conducted with 27 patients, and focus groups and interviews with 20 clinicians (GPs and physiotherapists) in the intervention arm of the trial. Data were analysed thematically and findings explored using Normalisation Process Theory (NPT) and the COM-B model. Main findings: Risk-based stratified care (subgrouping and matching treatments) was found to have 'coherence' (i.e. made sense) to several clinicians and patients, in that it was well-integrated in practice, and supported clinical decision-making. However, for some GPs stratified care was less 'meaningful', as the risk-stratification tool did not fit with usual ways of consulting and added to already time-pressured consultations. GPs reported giving more patients written information/advice due to easier access to electronic information leaflets through the trial template and were motivated to refer patients to physiotherapy as they believed the trial resulted in faster physiotherapy access (although this was not the case). Patients and clinicians reported that risk-based stratified care influenced conversations in the consultation, prompting greater attention to psychosocial factors, and facilitating negotiation of treatment options. Physiotherapists saw benefits in receiving information about patients' risk subgroup on referral forms. Conclusion: These findings provide context for interpreting some of the trial outcomes, particularly in relation to changes in clinical decision-making when risk-based stratified care was used. Findings also indicate potential reasons for lack of GP engagement with risk-based stratified care. Positive outcomes were identified that were not captured in the quantitative data, specifically that risk-based stratified care positively influenced some GP-patient conversations and facilitated negotiation of treatment options. Trial registration: ISRCTN15366334 (26/04/2016). [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic period (2020 to 2022) challenged and overstretched the capacity of primary health care services to deliver health care globally. The sector faced a highly uncertain and dynamic period that encompassed anticipation of a new, unknown, lethal and highly transmissible infection, the introduction of various travel restrictions, health workforce shortages, new government funding announcements and various policies to restrict the spread of the COVID-19 virus, then vaccination and treatments. This qualitative study aims to document and explore how the pandemic affected primary health care utilisation and delivery in remote and regional Aboriginal and Torres Strait Islander communities. Methods: Semi-structured interviews were conducted with staff working in 11 Aboriginal Community-Controlled Health Services (ACCHSs) in outer regional, remote and very remote Australia. Interviews were transcribed, inductively coded and thematically analysed. Results: 248 staff working in outer regional, remote and very remote primary health care clinics were interviewed between February 2020 and June 2021. Participants reported a decline in numbers of primary health care presentations in most communities during the initial COVID-19 lock down period. The reasons for the decline were attributed to community members apprehension to go to the clinics, change in work priorities of primary health care staff (e.g. more emphasis on preventing the virus entering the communities and stopping the spread) and limited outreach programs. Staff forecasted a future spike in acute presentations of various chronic diseases leading to increased medical retrieval requirements from remote communities to hospital. Information dissemination during the pre-vaccine roll-out stage was perceived to be well received by community members, while vaccine roll-out stage information was challenged by misinformation circulated through social media. Conclusions: The ability of ACCHSs to be able to adapt service delivery in response to the changing COVID-19 strategies and policies are highlighted in this study. The study signifies the need to adequately fund ACCHSs with staff, resources, space and appropriate information to enable them to connect with their communities and continue their work especially in an era where the additional challenges created by pandemics are likely to become more frequent. While the PHC seeking behaviour of community members during the COVID-19 period were aligned to the trends observed across the world, some of the reasons underlying the trends were unique to outer regional, remote and very remote populations. Policy makers will need to give due consideration to the potential effects of newly developed policies on ACCHSs operating in remote and regional contexts that already battle under resourcing issues and high numbers of chronically ill populations. [ABSTRACT FROM AUTHOR]

Background: Transgender, non-binary, and/or gender expansive (TNG) individuals experience disproportionately high rates of mental illness and unique barriers to accessing psychiatric care. Integrating TNG-specific psychiatric care with other physical health services may improve engagement, but little published literature describes patient and clinician perspectives on such models of care. Here we present a formative evaluation aiming to inform future projects integrating psychiatric care with physical health care for TNG individuals. Methods: In this qualitative pre-implementation study, semi-structured interview guides were developed informed by the Consolidated Framework for Implementation Research to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. We elicited TNG patient (n = 11) and gender-affirming care clinician (n = 10) needs and preferences regarding integrating psychiatric care with other gender-affirming clinical services. We conducted a rapid analysis procedure, yielding a descriptive analysis for each participant group, identifying challenges of and opportunities in offering integrated gender-affirming psychiatric care. Results: Participants unanimously preferred integrating psychiatry within primary care instead of siloed service models. All participants preferred that patients have access to direct psychiatry appointments (rather than psychiatrist consultation with care team only) and all gender-affirming care clinicians wanted increased access to psychiatric consultations. The need for flexible, tailored care was emphasized. Facilitators identified included taking insurance, telehealth, clinician TNG-competence, and protecting time for clinicians to collaborate and obtain consultation. Conclusions: This health equity pre-implementation project engaged TNG patients and gender-affirming care clinicians to inform future research exploring integration of mental health care with primary care for the TNG community and suggests utility of such a model of care. [ABSTRACT FROM AUTHOR]

Background: More and more people suffer from concomitant chronic physical diseases and common mental disorders, calling for integrated self-management support in primary care. However, self-management support of chronic physical diseases and common mental disorders is not clearly operationalized by guidelines and is still conducted in silos by primary care nurses, especially in favour of chronic diseases. This study aims to better understand primary care nurses' experience of integrated self-management support for people with physical chronic diseases and common mental disorders. Methods: An interpretive descriptive qualitative approach was conducted with 23 primary care nurses from family medicine groups in Quebec (Canada). They were selected through purposive and snowball sampling methods to participate in an individual interview. Data were analysed using an iterative inductive and deductive analysis (Rainbow Model of Integrated Care and the Practical Reviews in Self-Management Support (PRISMS) taxonomy). Results: Nurses' experience of integrated self-management support for people with CD and CMD was structured around: (1) elements of the approach; (2) clinical integration through prevention and health promotion; and (3) operationalization of integrated self-management support. Several elements deemed essential to integrated self-management support were identified. Nurses offered integrated self-management support through prevention of risk factors and promotion of a healthy lifestyle for physical chronic diseases and common mental disorders. Nurses' self-management support activities included education, action plans, monitoring, and many practical, psychological, and social support strategies. A model of integrated self-management support for primary care nursing is proposed to better understand its clinical integration. Conclusion: This study presents clinical integration of self-management support and activities for people with physical chronic diseases and common mental disorders in primary care settings. Understanding integrated self-management support will help implement future interventions. [ABSTRACT FROM AUTHOR]

Background: Community health workers (CHW) are an integral part of primary health care re-engineering in South Africa. Cape Town is developing community-orientated primary care, with a central role for CHWs. Their role in human immunodeficiency virus, tuberculosis, maternal and child health has been articulated, but is less clear for non-communicable diseases (NCDs). Non-communicable diseases are now a major contributor to the burden of disease. The aim was to explore the current role of CHWs regarding NCDs in the Eastern sub-district of Cape Town, South Africa. Methods: An exploratory descriptive qualitative study made use of non-participant observation and qualitative interviews with CHWs, their managers, and nurse coordinators. Data from nine semi-structured interviews and ten observations were analysed with the framework method and Atlas-ti. Results: The CHWs were embedded in their communities and provided services via support groups, household visits and delivery of medication. They linked people to care with assistance of nurse coordinators. They could also provide physical care in the home. They lacked the ability to counsel people on the risk factors for NCDs and their role in rehabilitation and palliative care was unclear. More nurse coordinators were needed to provide supportive supervision. Inter-sectoral collaboration was weak and hindered CHWs from addressing social issues. More standardised and comprehensive training should equip CHWs for health promotion and disease prevention during household visits. Data collected in the community needed to be analysed, reported on and integrated with data from the primary care facility. This should also contribute to a community diagnosis. Their relationship with facility-based members of the primary health care team needed to be improved. Attention needed to be given to the requirements for and conditions of employment, as well as working hours and remuneration. Some equipment was absent and hindered their services for NCDs. Conclusions: CHWs have the potential to provide a comprehensive approach to NCDs, but community-orientated primary care needs to be strengthened in many of the key areas to support their activities. In relation to NCDs, they need training in basic and brief behaviour change counselling and risk factors as well as in the areas of rehabilitation and palliative care. [ABSTRACT FROM AUTHOR]

Background: Food insecurity (FI) is associated with negative health outcomes and increased healthcare utilization. Rural populations face increased rates of FI and encounter additional barriers to achieving food security. We sought to identify barriers and facilitators to screening and interventions for FI in rural primary care practices. Methods: We conducted a mixed-methods study using surveys and semi-structured interviews of providers and staff members from rural primary care practices in northern New England. Survey data were analyzed descriptively, and thematic analysis was used to identify salient interview themes. Results: Participants from 24 rural practices completed the survey, and 13 subsequently completed an interview. Most survey respondents (54%) reported their practices systematically screen for FI and 71% reported food needs were "very important" for their patients and communities. Time and resource constraints were the most frequently cited barriers to screening for and addressing FI in practices based on survey results. Interview themes were categorized by screening and intervention procedures, community factors, patient factors, external factors, practice factors, process and implementation factors, and impact of FI screening and interventions. Time and resource constraints were a major theme in interviews, and factors attributed to rural practice settings included geographically large service areas, stigma from loss of privacy in small communities, and availability of food resources through farming. Conclusions: Rural primary care practices placed a high value on addressing food needs but faced a variety of barriers to implementing and sustaining FI screening and interventions. Strategies that utilize practice strengths and address time and resource constraints, stigma, and large service areas could promote the adoption of novel interventions to address FI. [ABSTRACT FROM AUTHOR]

Background: NHS Health Check (NHSHC) is a national cardiovascular disease (CVD) risk identification and management programme. However, evidence suggests a limited understanding of the most used metric to communicate CVD risk with patients (10-year percentage risk). This study used novel application of video-stimulated recall interviews to understand patient perceptions and understanding of CVD risk following an NHSHC that used one of two different CVD risk calculators. Methods: Qualitative, semi-structured video-stimulated recall interviews were conducted with patients (n = 40) who had attended an NHSHC using either the QRISK2 10-year risk calculator (n = 19) or JBS3 lifetime CVD risk calculator (n = 21). Interviews were transcribed and analysed using reflexive thematic analysis. Results: Analysis resulted in the development of four themes: variability in understanding, relief about personal risk, perceived changeability of CVD risk, and positive impact of visual displays. The first three themes were evident across the two patient groups, regardless of risk calculator; the latter related to JBS3 only. Patients felt relieved about their CVD risk, yet there were differences in understanding between calculators. Heart age within JBS3 prompted more accessible risk appraisal, yet mixed understanding was evident for both calculators. Event-free survival age also resulted in misunderstanding. QRISK2 patients tended to question the ability for CVD risk to change, while risk manipulation through JBS3 facilitated this understanding. Displaying information visually also appeared to enhance understanding. Conclusions: Effective communication of CVD risk within NHSHC remains challenging, and lifetime risk metrics still lead to mixed levels of understanding in patients. However, visual presentation of information, alongside risk manipulation during NHSHCs can help to increase understanding and prompt risk-reducing lifestyle changes. Trial registration: ISRCTN10443908. Registered 7th February 2017. [ABSTRACT FROM AUTHOR]

Background: While remote patient management (RPM) has the potential to assist in achieving treatment targets for cardiovascular risk factors in primary care, its effectiveness may vary among different patient subgroups. Panel management, which involves proactive care for specific patient risk groups, could offer a promising approach to tailor RPM to these groups. This study aims to (i) assess the perception of healthcare professionals and other stakeholders regarding the adoption and (ii) identify the barriers and facilitators for successfully implementing such a panel management approach. Methods: In total, nineteen semi-structured interviews and two focus groups were conducted in the Netherlands. Three authors reviewed the audited transcripts. The Consolidated Framework for Implementation Strategies (CFIR) domains were used for the thematic analysis. Results: A total of 24 participants (GPs, nurses, health insurers, project managers, and IT consultants) participated. Overall, a panel management approach to RPM in primary care was considered valuable by various stakeholders. Implementation barriers encompassed concerns about missing necessary risk factors for patient stratification, additional clinical and technical tasks for nurses, and reimbursement agreements. Facilitators included tailoring consultation frequency and early detection of at-risk patients, an implementation manager accountable for supervising project procedures and establishing agreements on assessing implementation metrics, and ambassador roles. Conclusion: Panel management could enhance proactive care and accurately identify which patients could benefit most from RPM to mitigate CVD risk. For successful implementation, we recommend having clear agreements on technical support, financial infrastructure and the criteria for measuring evaluation outcomes. [ABSTRACT FROM AUTHOR]

Background: Despite the potential advantages of Internet-based diabetes self-management education, its adoption was not widespread among Singapore's public primary care clinics (polyclinics). An interactive online tool was thus developed to help educate patients with Type 2 diabetes mellitus (T2DM), and was now ready for user testing before implementation. Aim: To explore the perceived utility and usability of the educational tool in patients with suboptimally-controlled T2DM in a Singapore primary care setting. Methods: In-depth interviews were used to gather qualitative data from multi-ethnic Asian adults who had suboptimally-controlled T2DM. A total of 17 IDIs were conducted between April 2022 to March 2023, audio-recorded, transcribed, and analyzed to identify emergent themes via thematic analysis. Results: Regarding utility, users found the educational tool useful because it provided them with information that was comprehensive, accessible, reliable, and manageable. Regarding usability, the majority of users reported that the educational tool was easy to use, and suggested ways to improve navigational cues, visual clarity, readability and user engagement. Conclusion: Participants generally found the educational tool useful and easy to use. A revised educational tool will be developed based on their feedback and implemented in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Over the past two decades, Canadian provinces and territories have introduced a series of primary care reforms in an attempt to improve access to and quality of primary care services, resulting in diverse organizational structures and practice models. We examine the impact of these reforms on family physicians' (FPs) ability to adapt their roles during the COVID-19 pandemic, including the provision of routine primary care. Methods: As part of a larger case study, we conducted semi-structured qualitative interviews with FPs in four Canadian regions: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario. During the interviews, participants were asked about their personal and practice characteristics, the pandemic-related roles they performed over different stages of the pandemic, the facilitators and barriers they experienced in performing these roles, and potential roles FPs could have filled. Interviews were transcribed and a thematic analysis approach was applied to identify recurring themes in the data. Results: Sixty-eight FPs completed an interview across the four regions. Participants described five areas of primary care reform that impacted their ability to operate and provide care during the pandemic: funding models, electronic medical records (EMRs), integration with regional entities, interdisciplinary teams, and practice size. FPs in alternate funding models experienced fewer financial constraints than those in fee-for-service practices. EMR access enhanced FPs' ability to deliver virtual care, integration with regional entities improved access to personal protective equipment and technological support, and team-based models facilitated the implementation of infection prevention and control protocols. Lastly, larger group practices had capacity to ensure adequate staffing and cover additional costs, allowing FPs more time to devote to patient care. Conclusions: Recent primary care system reforms implemented in Canada enhanced FPs' ability to adapt to the uncertain and evolving environment of providing primary care during the pandemic. Our study highlights the importance of ongoing primary care reforms to enhance pandemic preparedness and advocates for further expansion of these reforms. [ABSTRACT FROM AUTHOR]

Background: Patients dealing with severe mental illnesses (SMI) often face suboptimal clinical outcomes and higher mortality rates due to a range of factors, including undetected physical health conditions. The provision of care for individuals with SMI is frequently disjointed, as they engage with diverse healthcare providers. Despite this fragmentation, primary care, particularly general practitioners (GPs), assumes a pivotal role in the care of SMI patients. Our study aimed to delve into the first-hand experiences of GPs in delivering somatic care to SMI patients, concentrating on the challenges they encounter and the strategies they employ to navigate these difficulties. Methods: We conducted in-depth interviews with fifteen GPs, utilizing a semi-structured interview guide, supplemented by ethnographic observations during clinical consultations in general practice. Through inductive coding, interview transcripts and observational field notes were systematically analysed using interpretative phenomenological analysis (IPA). The findings were then deliberated upon within the author group. Results: GPs revealed that managing the chronic somatic care of SMI patients posed significant challenges. These challenges encompassed the multifaceted needs of patients, their behavior tied to symptoms, a lack of care continuity, and overarching time constraints. To tackle these challenges, the GPs had devised various strategies. However, all participants underscored the critical importance of having adequate time to properly prepare for, conduct, and follow up on consultations. Conclusion: The GPs' interactions with SMI patients brought numerous challenges, although treating these patients were concurrently acknowledged as vital and fulfilling. The findings suggest that increased allocated time in general practice consultations for patients with SMI is important to support the somatic treatment requirements of this patient group. [ABSTRACT FROM AUTHOR]

Background: Primary health care (PHC) has historically led and implemented successful immunization programs, driven by strong relationships with patients and communities. During the COVID-19 pandemic, Canada began its vaccination strategy with mass immunizations that later included local efforts with PHC providers. This study seeks to understand how PHC contributed to the different phases of the COVID-19 vaccination rollouts in Ontario, Canada's most populous province. Methods: We conducted a descriptive qualitative study with focus groups consisting of PHC providers, administrators, and staff in Ontario. Eight focus groups were held with 39 participants representing geographic diversity across the six Ontario Health regions. Participants reflected a diverse range of clinical, administrative, and leadership roles. Each focus group was audio-recorded and transcribed with transcriptions analyzed using thematic analysis. Results: With respect to understanding PHC teams' participation in the different phases of the COVID-19 vaccination rollouts, we identified five themes: (i) supporting long-term care, (ii) providing leadership in mass vaccinations, (iii) integrating vaccinations in PHC practice sites, (iv) reaching those in need through outreach activities; and (v) PHC's contributions being under-recognized. Conclusions: PHC was instrumental in supporting COVID-19 vaccinations in Ontario, Canada across all phases of the rollout. The flexibility and adaptability of PHC allowed teams to participate in both large-scale and small-scale vaccination efforts. [ABSTRACT FROM AUTHOR]

Background: Families face a range of barriers in supporting their children's active play in nature including family circumstances, environmental constraints, and behavioral factors. Evidence-based strategies to address these barriers are needed. We aimed to develop and pilot test a primary care-based family-centered behavioral intervention to promote active outdoor play in 4–10 year-old children. Methods: Project Nature, a provider-delivered intervention that provides informational resources and an age-appropriate toy for nature play, was initially developed for children ages 0–3. With stakeholder input, we adapted existing materials for 4–10 year-olds and conducted usability testing at an urban clinic serving families from diverse backgrounds. Subsequently, we conducted a mix-methods pilot study to evaluate intervention feasibility and acceptability. Parents of 4–10 year-olds completed pre- and post-surveys (n = 22), and a purposive subset (n = 10) completed qualitative interviews. Post-intervention, pediatric providers (n = 4) were interviewed about their implementation experiences. Results: The majority (82%) of parents liked the information provided and the remaining (18%) were neutral. Qualitatively, parents reported that: the toy provided a tangible element to help children and parents be active, they did not use the website, and they wished the intervention emphasized strategies for physical activity during cold and wet seasons. Providers felt the materials facilitated discussion about behavior change with families. There were no statistically significant changes in PA and outdoor time pre- and post-intervention. Conclusions: Project Nature was welcomed by providers and families and may be a practical intervention to promote outdoor active play during well-child visits. Providing an age-appropriate nature toy seemed to be a critical component of the intervention, and may be worth the additional cost, time and storage space required by clinics. Building from these results, Project Nature should be revised to better support active outdoor play during suboptimal weather and evaluated to test its efficacy in a fully-powered trial. [ABSTRACT FROM AUTHOR]

Background: Primary health care is the setting for most patients with stress-related mental health problems. Good care processes are important for patients with stress-related mental health problems and the complex needs of these patients has become a challenge for primary care settings which is traditionally designed to manage acute episodes of one illness. The care process of these patients is thus interesting to investigate. The aim of this study was to explore psychologists´ involvement and experiences regarding the organisation of the care process and treatment of patients seeking care for stress-related exhaustion. Method: Fifteen psychologists (14 women and 1 man, age range 27–72 years)c from fifteen different primary health care centres in the western part of Sweden, located in both rural and urban areas were included. Qualitative content analysis of individual semi-structured interviews was conducted. Results: The analysis resulted in eight subcategories within the two main categories studied illuminating psychologists' involvement and experiences regarding the organisation of the care process and challenges regarding treatment of patients seeking care for stress-related exhaustion. Conclusion: The care process of patients with stress-related exhaustion is perceived to be ineffective and not congruent with the needs of the patients. A lack of holistic overview of the care process, a lack of collaboration and poor utilization of the health care professionals' competence leads to an unstructured process forcing the patients to be the carriers and coordinators of their own care. [ABSTRACT FROM AUTHOR]

Background: Primary care is integral to the health system and population health. Primary care research is still in development and most academic departments lack effective research investments. High impact primary care research programs are needed to advance the field to ensure a robust primary care system for the future. The project objective was to understand key informants' views of structures, functions, and processes required to create a high impact research program in an academic primary care department. Methods: A descriptive qualitative project with key informants from research programs in primary care. Participants included international research leaders in primary care (n = 10), department of family and community researchers (n = 37) and staff (n = 9) in an academic primary care department, other university leaders (n = 3) and members of the departmental executive leadership team (1 department; 25 members). Semi-structured interviews (n = 27), and focus groups (n = 6) were audio recorded, transcribed, and analyzed using thematic analysis. We used a socioecological framework which described micro, meso, macro levels of influence. Results: At the micro level despite barriers with respect to funding, protected time and lack of formal mentorship, personal motivation was a key factor. At the meso level, the organizational structure that promoted collaboration and a sense of connection emerged as a key factor. Specifically research leaders identified a research faculty development pipeline based on equity, diversity, inclusion, indigeneity, and accessibility principles with thematic areas of focus as key enablers. Lastly, at the macro level, an overarching culture and policies that promoted funding and primary care research was associated with high impact programs. Conclusion: The alignment/complementarity of micro, meso, and macro level factors influenced the creation of a high impact research department in primary care. High impact research in primary care is facilitated by the development of researchers through formalized and structured mentorship/sponsorship and a department culture that promote primary care research. [ABSTRACT FROM AUTHOR]

Background: In the United States, Latinos face a wide array of cultural and structural barriers to accessing and utilizing mental health care. Latino men specifically are at high risk of receiving inadequate mental health care, possibly due to additional obstacles they experience that are related to masculinity. Among men more generally, greater adherence to emotional control and self-reliance is associated with higher depression severity and less depression help-seeking. Men experience more stigma toward depression and help-seeking and are less likely to be diagnosed with depression than women. However, Latino men's barriers and facilitators to depression care remain largely unexplored. The objective of this study was to examine barriers and facilitators to depression care that are related to masculinity among English- and Spanish-speaking Latino men in a primary care setting. Methods: We used convenience and purposive sampling to recruit primary care patients who self-identified as Latino men, spoke English or Spanish, and screened positive for depressive symptoms on the Patient Health Questionnaire-2 or had a history of depression. Semi-structured interviews were conducted between December 2020 and August 2021. The interview guide examined views and experiences of depression, masculinity, and barriers and facilitators to engaging in depression care. Utilizing consensual qualitative research and thematic analysis informed by modified grounded theory, barriers and facilitators to depression care were identified. Results: We interviewed thirteen participants who varied in English proficiency, education, income, and country of origin. Barriers and facilitators were placed into three domains—Self-Recognition of Depression, Seeking Help for Depression, and Depression Diagnosis and Treatment. Participants described aspects of masculinity as barriers (emotional control and pressure to provide), facilitators (honesty, courage, collaboration, practicality, and responsibility), or both (self-reliance and autonomy). Conclusions: Masculinity influences barriers and facilitators for depression care among Latino men at the levels of self-recognition, seeking help, and diagnosis and treatment. Clinicians may promote Latino men's engagement in depression care by understanding patients' values and framing depression care as affirming masculinity. Providing education to primary care physicians and other healthcare professionals on gender and depression and addressing structural barriers are essential to providing access to all who need depression care. [ABSTRACT FROM AUTHOR]

Background: "Core values" help to guide practice of health care delivery. The core values of general practice are described in the European definition of general practice by WONCA, e.g. a holistic, comprehensive and continuous care. They may be associated with the idea that the general practitioner is the owner of the practice rather than an employee. Objectives: The objective was to examine the core values of employed GPs in their professional setting and their practical manifestation. Methods: From April to May 2021, we conducted 17 semi-structured telephone-interviews with employed GPs in two districts in Baden-Wuerttemberg, Germany. The data were analysed using qualitative content analysis. Results: We identified twelve core values, including values relevant to patient care and values relevant to the lives of employed GPs. Values with high relevance were job satisfaction, the professional distance from patients, collaboration and collegial exchange, comprehensive care, adequate consultation time and availability to patients. Values with heterogeneous relevance were continuity of care, waiting times and medical autonomy. The value "availability" of employed GPs to patients was associated with both patient care and personal life. The limited availability of employed GPs was accompanied by tensions between these two trends and other values. Conclusion: The values of employed GPs are partly consistent with the current WONCA definition of general practice. There were also indications of new values. The increase in the proportion of employed GPs implies a need to reflect on the core values of general practice, taking into account factors on the part of employed GPs, patients, and practice organisation. [ABSTRACT FROM AUTHOR]

Background: Post-smoking-cessation weight gain can be a major barrier to quitting smoking; however, adding behavior change interventions for physical activity (PA) and diet may adversely affect smoking cessation outcomes. The "Picking up the PACE (Promoting and Accelerating Change through Empowerment)" study assessed change in PA, fruit/vegetable consumption, and smoking cessation by providing a clinical decision support system for healthcare providers to utilize at the intake appointment, and found no significant change in PA, fruits/vegetable consumption, or smoking cessation. The objective of this qualitative study was to explore the factors affecting the implementation of the intervention and contextualize the quantitative results. Methods: Twenty-five semi-structured interviews were conducted with healthcare providers, using questions based on the National Implementation Research Network's Hexagon Tool. The data were analyzed using the framework's standard analysis approach. Results: Most healthcare providers reported a need to address PA and fruit/vegetable consumption in patients trying to quit smoking, and several acknowledged that the intervention was a good fit since exercise and diet could improve smoking cessation outcomes. However, many healthcare providers mentioned the need to explain the fit to the patients. Social determinants of health (e.g., low income, food insecurity) were brought up as barriers to the implementation of the intervention by a majority of healthcare providers. Most healthcare providers recognized training as a facilitator to the implementation, but time was mentioned as a barrier by many of healthcare providers. Majority of healthcare providers mentioned allied health professionals (e.g., dieticians, physiotherapists) supported the implementation of the PACE intervention. However, most healthcare providers reported a need for individualized approach and adaptation of the intervention based on the patients' needs when implementing the intervention. The COVID-19 pandemic was found to impact the implementation of the PACE intervention based on the Hexagon Tool indicators. Conclusion: There appears to be a need to utilize a flexible approach when addressing PA and fruit/vegetable consumption within a smoking cessation program, based on the context of clinic, the patients' it is serving, and their life circumstances. Healthcare providers need support and external resources to implement this particular intervention. Name of the registry: Clinicaltrials.gov. Trial registration number: NCT04223336. Date of registration: 7 January 2020 Retrospectively registered. URL of trial registry record: https://classic.clinicaltrials.gov/ct2/show/NCT04223336. [ABSTRACT FROM AUTHOR]

Introduction: Inspired by examples in low- and middle-income countries, 50 community health workers (CHWs) were introduced in Belgium to improve access to primary care for people living in socio-economically vulnerable circumstances. This article aims to explore the ways in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care. Methods: The qualitative research focuses on the first year of implementation of this pioneer nationwide CHW programme in Belgium. To respond to the research aim, thirteen semi-structured in-depth interviews were held with people living in socio-economically vulnerable circumstances. In addition, a photovoice study was conducted with fifteen CHWs comprising four phases: (1) photovoice training; (2) participatory observation with each CHW individually; (3) an individual semi-structured in-depth interview; and (4) three focus group discussions. The transcripts and the observation notes were analysed in accordance with the abductive analysis procedures described by Timmermans and Tavory. Results: The qualitative results show that the CHWs' outreaching way of working allows them to reach people living at the crossroads of different vulnerabilities that are intertwined and reinforce each other. They experience complex care needs, while at the same time they face several barriers that interrupt the continuum of access to primary care – as conceptualised in the theoretical access-to-care framework of (Levesque et al. Int J Equity Health. 12:18, 2013). Building on the theoretical access-to-care framework described by (Levesque et al. Int J Equity Health. 12:18, 2013), the conceptual model outlines first the underlying mechanisms of CHW-facilitated access to primary care: (I) outreaching and pro-active way of working; (II) building trust; (III) providing unbiased support and guidance in a culturally sensitive manner; and (IV) tailoring the CHWs' approach to the unique interplay of barriers at the individual and health system level along the access-to-care continuum as experienced by the individual. Further disentangling how CHWs provide support to the barriers in access to care across the continuum and at each step is outlined further in the process characteristics of this conceptual model. Furthermore, the qualitative results show that the way in which CHWs support people is also impacted by the broader health system, such as long waiting times and unwelcoming healthcare professionals after referral from a CHW. Discussion: The conceptual model of CHW-facilitated access to primary care developed in this article explores the way in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care in Belgium. Through their outreaching method, they play a valuable bridging role between the Belgian healthcare system and people living in socio-economically vulnerable circumstances. Highlights: - Community health workers (CHWs) reach people who live at the crossroads of different vulnerabilities. - CHWs adjust their support to the unique interplay of barriers at the individual and health system level across the access-to-care continuum. - Through their outreaching method, they play a valuable bridging role between the Belgian healthcare system and people living in socio-economically vulnerable circumstances. - The conceptual model of CHW-facilitated access to primary care explores the ways in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care in Belgium. [ABSTRACT FROM AUTHOR]

Background: Relationship-based, whole person care is foundational to quality general practice. Previous research has identified several characteristics of deep General Practitioner (GP)-patient relationships and their association with improved patient concordance, satisfaction and perceived health outcomes. Psychological attachment theory has been used to understand therapeutic relationships, but has only been explored to a limited extent in the general practice context. Additionally, evolving changes in sociocultural and commercial practice contexts may threaten relationship-based care. In view of this, we aimed to explore the nature and experience of deep GP-patient relationships, as identified by patients, from GP and patient perspectives. Methods: Semi-structured interview design. An initial survey assessed patients' perceived depth of their relationship with their GP, using the Health Care Provider Attachment Figure Survey and Patient-Doctor Depth of Relationship Scale. Patients who reported a deep relationship, and their GPs, were purposively selected for individual interviews exploring their experience of these relationships. A post-interview survey assessed interviewees' attachment styles, using the Modified and Brief Experiences in Close Relationships Scale. Patient interviewees also rated the patient-centredness of their GP's clinic using the Person-Centred Primary Care Measure. Transcripts were analysed using thematic analysis. Results: Thirteen patients and five GPs were interviewed. Four themes characterised deep relationships: the 'professional'; human connection; trust; and 'above and beyond'. Patient, GP and practice team all contributed to their cultivation. Conclusions: We present a revised conceptual framework of deep GP-patient relationships. Deep relationships come to the fore in times of patient trouble. Like attachment relationships, they provide a sense of safety, caring and support for patients experiencing vulnerability. They can stretch GP boundaries and capacity for self-care, but also provide joy and vocational satisfaction. Patients may not always desire or need deep relationships with their GP. However, findings highlight the importance of enabling and cultivating these for times of patient hardship, and challenges of doing so within current healthcare climates. [ABSTRACT FROM AUTHOR]

Background: In Canada, primary care is usually the front door to health care for people with health issues. Among these primary care services are primary care clinics (PCC), where the competencies of registered nurses (RNs) are needed. However, nursing practice in PCCs is variable and sometimes suboptimal from one PCC to another. In 2019, the Quebec Ministry of Health and Social Services deployed a practical guide for RNs practicing in PCCs. This guide was intended to support best professional and interprofessional practices and enhance the quality of services offered according to a physical-social vision of care, interprofessional collaboration and partnership with the patient. The Formation de formateurs en première ligne (F2PL) project team developed a train-the-trainer educational intervention to support RNs in assimilating the content of this guide. This educational intervention is uncommon because it includes patients as trainers (PTs). PTs developed and provided andragogic content about patient's experience to enhance patient engagement. Objective: To describe the impacts of the educational intervention provided by the PTs in nurses' patient engagement practices in PCCs. Methods: A descriptive qualitative approach was used to describe in-depth changes in RNs' practices. Individual interviews were conducted with 10 RNs and 3 PTs to explore the changes in RNs' practice and the barriers and facilitators to adopting this new practice. An inductive and deductive thematic analysis was carried out according to a conceptual model of patient engagement (the Montreal Model), and emerging themes were condensed into propositions. To ensure credibility, a peer review was conducted with the F2PL team, which includes a patient co-leader. Results: The educational intervention provided by PTs has impacted RNs' practice in 3 ways: awareness or reminding of general principles, updating commitment to already known principles and enhancing the development of new professional skills. Conclusions: PTs could effectively support the RNs' motivation to use patient engagement practices in primary care. [ABSTRACT FROM AUTHOR]

Background: Healthcare organizations are increasingly exploring ways to address the social determinants of health. Accurate data on social determinants is essential to identify opportunities for action to improve health outcomes, to identify patterns of inequity, and to help evaluate the impact of interventions. The objective of this study was to refine a standardized tool for the collection of social determinants data through cognitive testing. Methods: An initial set of questions on social determinants for use in healthcare settings was developed by a collaboration of hospitals and a local public health organization in Toronto, Canada during 2011–2012. Subsequent research on how patients interpreted the questions, and how they performed in primary care and other settings led to revisions. We administered these questions and conducted in-depth cognitive interviews with all the participants, who were from Saskatchewan, Manitoba, Ontario, and Newfoundland and Labrador. Cognitive interviewing was used, with participants invited to verbalize thoughts and feelings as they read the questions. Interview notes were grouped thematically, and high frequency themes were addressed. Results: Three hundred and seventy-five individuals responded to the study advertisements and 195 ultimately participated in the study. Although all interviews were conducted in English, participants were diverse. For many, the value of this information being collected in typical healthcare settings was unclear, and hence, we included descriptors for each question. In general, the questions were understood, but participants highlighted a number of ways the questions could be changed to be even clearer and more inclusive. For example, more response options were added to the question of sexual orientation and the "making ends meet" question was completely reworded in light of challenges to understand the informal phrasing cited by English as a Second Language (ESL) users of the tool. Conclusion: In this work we have refined an initial set of 16 sociodemographic and social needs questions into a simple yet comprehensive 18-question tool. The changes were largely related to wording, rather than content. These questions require validation against accepted, standardized tools. Further work is required to enable community data governance, and to ensure implementation of the tool as well as the use of its data is successful in a range of organizations. [ABSTRACT FROM AUTHOR]

Purpose: As the older adult population in Taiwan continues to increase, primary health centers (PHCs) play a crucial role in geriatric care. This study explored the differences in the PHC experiences and usage needs of older adults in urban versus rural areas. Methods: A qualitative study was conducted. Twenty-one older adults were recruited from PHCs in northern, central, southern, and eastern Taiwan. Semistructured interviews were used to collect data, and the interview guidelines included their reasons for visiting PHCs, the health-care services they received, their evaluation of the services, and the advantages and disadvantages of these centers. The data were analyzed using thematic content analysis. Results: The PHC usage needs of older adults in urban areas differ from those of older adults in rural areas in the following 3 aspects: (1) Medical services: older adults in rural areas demand clinics specializing in various medical domains, mobile and home medical care, and case management, whereas those in urban areas demand mobile health examinations. (2) Environment and transportation: older adults in rural areas demand diverse medical equipment, shuttle services, and accessible facilities, whereas those in urban areas demand recreational facilities. (3) Active aging: older adults in rural areas demand health education courses, and those in urban areas demand diverse senior citizen courses as well as opportunities to volunteer and build interpersonal relationships. Conclusion: The older adults in urban and rural areas had different PHC usage needs. The older adults in rural areas generally focused on medical care and transportation services in PHCs, whereas those in urban areas generally focused on health promotion as a means of social participation and active aging. [ABSTRACT FROM AUTHOR]

Background: The effects of the COVID-19 pandemic on older adults were felt throughout the health care system, from intensive care units through to long-term care homes. Although much attention has been paid to hospitals and long-term care homes throughout the pandemic, less attention has been paid to the impact on primary care clinics, which had to rapidly change their approach to deliver timely and effective care to older adult patients. This study examines how primary care clinics, in three Canadian provinces, cared for their older adult patients during the pandemic, while also navigating the rapidly changing health policy landscape. Methods: A qualitative case study approach was used to gather information from nine primary care clinics, across three Canadian provinces. Interviews were conducted with primary care providers (n = 17) and older adult patients (n = 47) from October 2020 to September 2021. Analyses of the interviews were completed in the language of data collection (English or French), and then summarized in English using a coding framework. All responses that related to COVID-19 policies at any level were also examined. Results: Two main themes emerged from the data: (1) navigating the noise: understanding and responding to public health orders and policies affecting health and health care, and (2) receiving and delivering care to older persons during the pandemic: policy-driven challenges & responses. Providers discussed their experiences wading through the health policy directives, while trying to provide good quality care. Older adults found the public health information overwhelming, but appreciated the approaches adapted by primary care clinics to continue providing care, even if it looked different. Conclusions: COVID-19 policy and guideline complexities obliged primary care providers to take an important role in understanding, implementing and adapting to them, and in explaining them, especially to older adults and their care partners. [ABSTRACT FROM AUTHOR]

Background: There have been significant achievements in controlling COVID-19 in Saudi Arabia (SA), but as in most healthcare settings worldwide, health services have been seriously disrupted. Also, with pandemic control measures such as lockdowns and curfews, and innovations such as digital health services, the delivery of primary healthcare (PHC) services has dramatically changed. However, little is known about patients' experiences of PHCs during the pandemic, their views on the pandemic-related interventions in SA, and patient views on impact on their medical care. Methods: Qualitative semi-structured online interviews were conducted for twenty-four Saudi patients across SA aged 18 and above who were diverse in terms of age, gender, education and health status. Data were analysed using thematic analysis yielding four major themes as an impact of COVID-19 on patient engagement with PHCs. Results: The COVID-19 pandemic has had profound mixed impacts on patient engagement with PHC in SA. Fear of infection or of breaking lockdown rules has negatively impacted the utilisation of PHCs but positively changed patients' attitudes towards seeking medical help for self-limiting conditions. The pandemic has also negatively impacted routine preventive care at PHCs, especially for patients with long-term health conditions. The mandatory use of some digital health services in SA that existed pre-pandemic has provided patients with a perception of better care during the pandemic. Yet, a lack of awareness of optional digital health services, such as virtual clinics, hindered optimal use. Despite pandemic-related disruption of patient engagement with PHCs, the reduced waiting time in PHC centres and healthcare providers' communication and empathy during the pandemic contributed to patients' perceptions of better care compared to pre-pandemic. However, patients living outside the main cities in SA perceived care quality as less good during the pandemic compared to PHCs in the main cities in SA. Conclusion: The lessons learned from patients' experiences and views of PHCs during the pandemic were beneficial in promoting patient engagement with PHCs. The digital health services mandated in response to the pandemic have accelerated digital health innovation in SA and allowed patients to recognise the benefits of digital health. This has huge potential for increasing continuous patient engagement with PHCs. Yet, patients' experiences of digital health services during the pandemic are essential for informing appropriate implementation and utilisation of e-health services. Patients' positive experiences of PHCs during the pandemic, such as the reduction in waiting times and the perception of improved healthcare providers' professionalism, communication and empathy, can be built on to sustain engagement with PHC services. These findings might have significance for clinicians and policymakers to support patient engagement with PHCs, particularly in healthcare systems like SA that struggle with the overuse of emergency departments (EDs) for PHC-treatable conditions. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease and type 2 diabetes are among the largest public health challenges in Sweden. Research indicates that a healthy lifestyle can prevent most cases. The health dialogue is an evidence-based public health programme for primary care with positive results in several regions of Sweden. This study aimed to describe health care professionals' experiences and perceptions of health promotion through the health dialogue intervention during the pilot phase in the Scania region of Sweden. Methods: The study consists of 12 individual interviews with health care professionals educated in the health dialogue method, implementing the intervention in Scania. Qualitative content analysis with an inductive approach was used. Results: The analysis resulted in 10 sub-categories and the four main categories: A more health-promoting mindset would benefit primary care; Empower individuals; Facilitate sustainable lifestyle changes; Challenges, tools and support for the implementation of the health dialogue. One overarching theme emerged: "Health dialogue, a potential start of a paradigm shift in Swedish primary care". Conclusions: Conclusions imply that the health dialogue is a well-structured method with tools to make health promotion and primary prevention an integrated part of primary care. A respectful and motivating approach during the health dialogue is recommended. It is important to have an ongoing discussion about the approach among the health care professionals. Incorporating the Health Belief Model in the health care professionals' education in the method could increase the focus on self-efficacy during counselling, which could favour the participants' change process. [ABSTRACT FROM AUTHOR]

Background: Significant challenges remain in the early identification of child developmental disabilities in the community. Implementing supports and services early in the life course has been shown to promote positive developmental outcomes for children at high likelihood of developmental disabilities, including autism. As part of a cluster randomised controlled trial, this study seeks to examine and compare the perspectives and experiences of Australian general practitioners (GPs) in relation to a digital developmental surveillance program for autism and usual care pathway, in general practice clinics. Methods: A qualitative research methodology with semi-structured interviews and thematic inductive analysis underpinned by grounded theory was utilised. All GPs from South Western Sydney (NSW) and Melbourne (Victoria) who participated in the main program ("GP Surveillance for Autism") were invited to the interview. GPs who provided consent were interviewed either over online or in-person meeting. Interviews were audio-recorded, transcribed, and coded using NVivo12 software. Inductive interpretive approach was adopted and data were analysed thematically. Results: Twenty-three GPs across the two sites (NSW: n = 11; Victoria: n = 12) agreed to be interviewed; data saturation had reached following this number of participants. Inductive thematic coding and analysis yielded eight major themes and highlighted common enablers such as the role of GPs in early identification and subsequent supports, enhanced communication between clinicians/professionals, relationship-building with patients, and having standardised screening tools. Specific facilitators to the feasibility and acceptability of a digital screening program for the early identification of developmental disabilities, including the early signs of autism, and encouraging research and education for GPs. However, several practical and socioeconomic barriers were identified, in addition to limited knowledge and uptake of child developmental screening tools as well as COVID-19 lockdown impacts. Common and specific recommendations involve supporting GPs in developmental/paediatrics training, streamlined screening process, and funding and resources in the primary healthcare services. Conclusions: The study highlighted the need for practice and policy changes, including further training of GPs alongside sufficient time to complete developmental checks and appropriate financial remuneration through a Medicare billing item. Further research is needed on implementation and scale up of a national surveillance program for early identification of developmental disabilities, including autism. [ABSTRACT FROM AUTHOR]

Background: There is moderate to strong evidence of the effectiveness of health-promotion interventions, but implementation in routine primary health care (PHC) has been slow. In the Act in Time project implementation support is provided for a health promotion practice using individually targeted lifestyle interventions in a PHC setting. Identifying health care professionals' (HCPs') perceptions of barriers and facilitators helps adapt implementation activities and achieve a more successful implementation. This study aimed, at a pre-implementation stage, to describe the expectations of managers, appointed internal facilitators (IFs) and HCPs on implementing a healthy lifestyle-promoting practice in PHC. Methods: In this qualitative study five focus group discussions with 27 HCPs and 16 individual interviews with managers and appointed IFs were conducted at five PHC centres in central Sweden. The PHC centres are participating in the Act in Time project, evaluating the process and outcomes of a multifaceted implementation strategy for a healthy lifestyle-promoting practice. A deductive qualitative content analysis based on the Consolidated Framework for Implementation Research (CFIR) was followed using inductive analysis. Results: Twelve constructs from four of five CFIR domains were derived: Innovation characteristics, Outer setting, Inner setting, and Characteristics of individuals. These domains are related to the expectations of HCPs to implement a healthy lifestyle-promoting practice, which includes facilitating factors and barriers. The inductive analysis showed that the HCPs perceived a need for a health-promotion approach to PHC. It serves the needs of the patients and the expectations of the HCPs, but lifestyle interventions must be co-produced with the patient. The HCPs expected that changing routine practice into a healthy lifestyle-promoting practice would be challenging, requiring sustainability, improved structures, cooperation in inter-professional teams, and a common purpose. A collective understanding of the purpose of changing practice was vital to successful implementation. Conclusions: The HCPs valued implementing a healthy lifestyle-promoting practice in a PHC setting. However, changing routine methods was challenging, implying that the implementation strategy should address obstacles and facilitating factors identified by the HCPs. Trial registration: This study is part of the Act in Time project, registered in ClinicalTrials.gov with the number NCT04799860. Registered 03 March 2021. [ABSTRACT FROM AUTHOR]

Introduction: Community participation is one of the principles of primary health care (PHC). However, it has not been adequately institutionalized due to numerous barriers. Therefore, the present study is conducted to identify barriers to community participation in primary health care in the district health network from the perspectives of stakeholders. Methods: This qualitative case study was conducted in 2021 in Divandareh city, Iran. A total of 23 specialists and experts experienced in community participation, including nine health experts, six community health workers, four community members, and four health directors in primary health care programs, were selected using the purposive sampling method until complete saturation. Data was collected using semi-structured interviews and analyzed simultaneously using qualitative content analysis. Results: After data analysis, 44 codes, 14 sub-themes, and five themes were identified as barriers to community participation in primary health care in the district health network. The themes included community trust in the healthcare system, the status of community participation programs, the community and system's perception of participation programs, health system management approaches, and cultural barriers and institutional obstacles. Conclusion: Based on the results of this study most important barriers to community participation relate to community trust, the organizational structure, community and the health profession's perception regarding the participatory programs. It seems necessary to take measures to remove barriers in order to realize community participation in primary healthcare system. [ABSTRACT FROM AUTHOR]

Background: There is a need to accelerate digital transformation in healthcare to meet increasing needs and demands. The accuracy of medical digital diagnosis tools is improving. The introduction of new technology in healthcare can however be challenging and it is unclear how it should be done to reach desired results. The aim of this study was to explore perceptions and experiences of introducing new Information Technology (IT) in a primary healthcare organisation, exemplified with a Clinical Decision Support System (CDSS) for malignant melanoma. Methods: A qualitative interview-based study was performed in Region Stockholm, Sweden, with fifteen medical doctors representing three different organisational levels – primary care physician, primary healthcare centre manager, and regional manager/chief medical officer. In addition, one software provider was included. Interview data were analysed according to content analysis. Results: One central theme "Introduction of digital CDSS in primary healthcare requires a multidimensional perspective and handling" along with seven main categories and thirty-three subcategories emerged from the analysis. Digital transformation showed to be key for current healthcare providers to stay relevant and competitive. However, healthcare represents a closed community, very capable but with lack of time, fostered to be sceptical to new why change needs to bring true value and be inspired by people with medical background to motivate the powerful frontline. Conclusions: This qualitative study revealed structured information of what goes wrong and right and what needs to be considered when driving digital change in primary care organisations. The task shows to be complex and the importance of listening to the voice of healthcare is valuable for understanding the conditions that need to be fulfilled when adopting new technology into a healthcare organization. By considering the findings of this study upcoming digital transformations can improve their success-rate. The information may also be used in developing a holistic approach or framework model, adapted to primary health care, that can support and accelerate the needed digitalization in healthcare as such. [ABSTRACT FROM AUTHOR]

Background: Despite lung cancer being a leading cause of death in the United States and lung cancer screening (LCS) being a recommended service, many patients eligible for screening do not receive it. Research is needed to understand the challenges with implementing LCS in different settings. This study investigated multiple practice members and patient perspectives impacting rural primary care practices related to LCS uptake by eligible patients. Methods: This qualitative study involved primary care practice members in multiple roles (clinicians n = 9, clinical staff n = 12 and administrators n = 5) and their patients (n = 19) from 9 practices including federally qualified and rural health centers (n = 3), health system owned (n = 4) and private practices (n = 2). Interviews were conducted regarding the importance of and ability to complete the steps that may result in a patient receiving LCS. Data were analyzed using a thematic analysis with immersion crystallization then organized using the RE-AIM implementation science framework to illuminate and organize implementation issues. Results: Although all groups endorsed the importance of LCS, all also struggled with implementation challenges. Since assessing smoking history is part of the process to identify eligibility for LCS, we asked about these processes. We found that smoking assessment and assistance (including referral to services) were routine in the practices, but other steps in the LCS portion of determining eligibility and offering LCS were not. Lack of knowledge about screening and coverage, patient stigma, and resistance and practical considerations such as distance to LCS testing facilities complicated completion of LCS compared to screening for other types of cancer. Conclusions: Limited uptake of LCS results from a range of multiple interacting factors that cumulatively affect consistency and quality of implementation at the practice level. Future research should consider team-based approaches to conduct of LCS eligibility and shared decision making. [ABSTRACT FROM AUTHOR]

Background: Australia has one of the highest rates of overweight and obesity in the developed world, and this increasing prevalence and associated chronic disease morbidity reinforces the importance of understanding the attitudes, views, and experiences of patients and health providers towards weight management interventions and programs. The purpose of this study was to investigate patients, family practitioners and family practice nurses' perceptions and views regarding the receipt or delivery of weight management within the context of the HeLP-GP intervention. Methods: A nested qualitative study design including semi-structured interviews with family practitioners (n = 8), family practice nurses (n = 4), and patients (n = 25) attending family practices in New South Wales (n = 2) and South Australia (n = 2). The patient interviews sought specific feedback about each aspect of the intervention and the provider interviews sought to elicit their understanding and opinions of the strategies underpinning the intervention as well as general perceptions about providing weight management to their patients. Interviews were recorded and transcribed verbatim, and coding and management conducted using NVivo 12 Pro. We analysed the interview data using thematic analysis. Results: Our study identified three key themes: long-term trusting and supportive relationships (being 'in it for the long haul'); initiating conversations and understanding motivations; and ensuring access to multi-modal weight management options that acknowledge differing levels of health literacy. The three themes infer that weight management in family practice with patients who are overweight or obese is challenged by the complexity of the task and the perceived motivation of patients. It needs to be facilitated by positive open communication and programs tailored to patient needs, preferences, and health literacy to be successful. Conclusions: Providing positive weight management in family practice requires ongoing commitment and an open and trusting therapeutic relationship between providers and patients. Behaviour change can be achieved through timely and considered interactions that target individual preferences, are tailored to health literacy, and are consistent and positive in their messaging. Ongoing support of family practices is required through funding and policy changes and additional avenues for referral and adjunctive interventions are required to provide comprehensive weight management within this setting. [ABSTRACT FROM AUTHOR]

Background: Despite well-documented increased demands and shortages of personal protective equipment (PPE) during previous disease outbreaks, health systems in Canada were poorly prepared to meet the need for PPE during the COVID-19 pandemic. In the primary care sector, PPE shortages impacted the delivery of health services and contributed to increased workload, fear, and anxiety among primary care providers. This study examines family physicians' (FPs) response to PPE shortages during the first year of the COVID-19 pandemic to inform future pandemic planning. Methods: As part of a multiple case study, we conducted semi-structured qualitative interviews with FPs across four regions in Canada. During the interviews, FPs were asked to describe the pandemic-related roles they performed over different stages of the pandemic, facilitators and barriers they experienced in performing these roles, and potential roles they could have filled. Interviews were transcribed and a thematic analysis approach was employed to identify recurring themes. For the current study, we examined themes related to PPE. Results: A total of 68 FPs were interviewed across the four regions. Four overarching themes were identified: 1) factors associated with good PPE access, 2) managing PPE shortages, 3) impact of PPE shortages on practice and providers, and 4) symbolism of PPE in primary care. There was a wide discrepancy in access to PPE both within and across regions, and integration with hospital or regional health authorities often resulted in better access than community-based practices. When PPE was limited, FPs described rationing and reusing these resources in an effort to conserve, which often resulted in anxiety and personal safety concerns. Many FPs expressed that PPE shortages had come to symbolize neglect and a lack of concern for the primary care sector in the pandemic response. Conclusions: During the COVID-19 pandemic response, hospital-centric plans and a lack of prioritization for primary care led to shortages of PPE for family physicians. This study highlights the need to consider primary care in PPE conservation and allocation strategies and to examine the influence of the underlying organization of primary care on PPE distribution during the pandemic. [ABSTRACT FROM AUTHOR]

Background: Self-management is essential for good outcomes in type 2 diabetes and patients often benefit from self-management education. Shared medical appointments (SMAs) can increase self-efficacy for self management but are difficult for some primary care practices to implement. Understanding how practices adapt processes and delivery of SMAs for patients with type 2 diabetes may provide helpful strategies for other practices interested in implementing SMAs. Methods: The Invested in Diabetes study was a pragmatic cluster-randomized, comparative effectiveness trial designed to compare two different models of diabetes SMAs delivered in primary care. We used a multi-method approach guided by the FRAME to assess practices' experience with implementation, including any planned and unplanned adaptations. Data sources included interviews, practice observations and field notes from practice facilitator check-ins. Results: Several findings were identified from the data: 1) Modifications and adaptations are common in implementation of SMAs, 2) while most adaptations were fidelity-consistent supporting the core components of the intervention conditions as designed, some were not, 3) Adaptations were perceived to be necessary to help SMAs meet patient and practice needs and overcome implementation challenges, and 4) Content changes in the sessions were often planned and enacted to better address the contextual circumstances such as patient needs and culture. Discussion: Implementing SMAs in primary care can be challenging and adaptations of both implementation processes and content and delivery of SMAS for patients with type 2 diabetes were common in the Invested in Diabetes study. Recognizing the need for adaptations based on practice context prior to implementation may help improve fit and success with SMAs, but care needs to be given to ensure that adaptations do not weaken the impact of the intervention. Practices may be able to assess what might need to adapted for them to be successful prior to implementation but likely will continue to adapt after implementation. Conclusion: Adaptations were common in the Invested in Diabetes study. Practices may benefit from understanding common challenges in implementing SMAs and adapting processes and delivery based on their own context. Trial registration: This trial is registered on clinicaltrials.gov under Trial number NCT03590041, posted 18/07/2018. [ABSTRACT FROM AUTHOR]

Background: Identifying patients at high risk of cardiovascular disease in primary prevention is a challenging task. This study aimed at detecting subclinical atherosclerosis burden in non-diabetic hypertensive patients in a primary care centre. Methods: Clinical, anthropometric and analytical data were collected from patients with hypertension who were free from clinical vascular disease and diabetes. The cardiovascular risk was assessed using the SCORE system. Subclinical atherosclerosis burden was assessed by carotid ultrasonography (intima-medial thickness [IMT] and plaque) and measurement of the ankle-brachial index (ABI). Results: Out of 140 patients, 59 (42%) have carotid plaque, 32 (23%) have IMT higher than 75% and 12 (9%) have an ABI < 0.9. Total atherosclerosis burden was present in 91 (65%) of the subjects. Consequently, 59 (42%) patients were re-classified into the very high-risk category. In multivariate analyses, smoking, creatinine levels and duration of hypertension were associated with atherosclerosis burden. In contrast, only smoking and age were associated with the presence of carotid plaque. Almost 90% of patients were treated with hypotensive drugs, half of them combined several drugs and 60% were well-controlled. Only 30% received statins in monotherapy and only less than 20% had an LDL cholesterol < 100 mg/dL. Conclusions: In non-diabetic hypertensive patients managed at a primary care centre, 4 out of 10 had subclinical atherosclerosis burden and were re-classified into the very high- risk category. There was clear undertreatment with lipid-lowering drugs of most LDL cholesterol inappropriate levels, according to current clinical guidelines. [ABSTRACT FROM AUTHOR]

Background: Primary healthcare (PHC) services are crucial in supporting people who use substances. The aims of this study were to explore the experiences of Aboriginal males in NSW in treatment for substance use about speaking about their substance use with PHC staff, and their preferences for accessing PHC about their substance use. Methods: Semi-structured interviews with residential drug and alcohol rehabilitation treatment service clients. Thematic analysis was used to develop themes inductively and deductively. Two interviews were independently double coded by an Aboriginal researcher and the project was supported by an Aboriginal Advisory Group. Results: Twenty male adults who self-identified as Aboriginal participated (mean age 27 years). Half reported visiting PHC and talking about their substance use before their residential service stay. Two major themes developed: (1) speaking up about substance use or mental health problems linked with substance use, (2) ways to improve access to PHC about substance use. Although some males were offered treatment, some were not, and others had concerns about the treatments offered. Conclusion: This research highlights opportunities to improve access and to better support Aboriginal males who use substances in PHC. Focus on culturally appropriate PHC and providing staff with training around substance use and treatment options may improve access. It is important to foster culturally appropriate services, develop PHC staff knowledge around substance use, focus on therapeutic relationships and have a range of treatment options available that can be tailored to individual circumstances. [ABSTRACT FROM AUTHOR]

Background: Healthcare systems may be resilient and adaptive, but they are not fit for purpose in their current state. Increasing threats to health system sustainability have underscored the need to move towards a learning health system in which research and data are used routinely in clinical practice to facilitate system improvement. This study aimed to establish which elements of the learning health system were being realised within a university-based general practice and determine acceptability from staff to embrace further the transition towards a learning health system. Methods: Semi-structured interviews were conducted with practice staff, including clinical and administrative staff, to determine the current state of the learning health system in the practice. An embedded researcher was placed within the general practice on a part-time basis to investigate the learning health system model. Interviews were transcribed and thematically analysed based on the National Academy of Medicine's framework of learning health systems. Results: In total, 32 (91%) practice staff were interviewed, comprising general practitioners (n = 15), nurses (n = 3), administrative staff (n = 13), and a psychologist (n = 1). Participants indicated that the practice was operating with several characteristics of a learning health system (e.g., emphasising science and informatics; focusing on patient-clinician partnerships; applying incentives; supporting a continuous learning culture; and establishing structures and governance for learning). These measures were supported by the university-based setting, and resultant culture of learning. Nevertheless, there were areas of the practice where the learning health system could be strengthened, specifically relating to the use of patient data and informatics. Staff generally expressed willingness to engage with the process of strengthening the learning health system within their practice. Conclusion: Although the idea of a learning health system has been gaining traction in recent years, there are comparatively few empirical studies presented in the literature. This research presents a case study of a general practice that is operating as a learning health system and highlights the utility of using the learning health system framework. [ABSTRACT FROM AUTHOR]

Background: Sodium-glucose co-transporter 2 inhibitors (SGLT2 I) has cardiorenal protective properties and are recommended for patients with diabetes and established atherosclerotic cardiovascular disease (ASCVD) and/or chronic kidney disease (CKD). Although cardiorenal complications are high in diabetes and pose a significant financial burden on the Hong Kong health care system, the use of SGLT2 I in these populations remains low. And yet this issue has not been explored in Hong Kong primary care. This study aimed to explore factors affecting primary care doctors' prescribing of SGLT2 I in patients with diabetes and established ASCVD/CKD in Hong Kong. Methods: A phenomenological qualitative research using semi-structured interviews was conducted between January and May 2021 in one Hospital Authority cluster in Hong Kong. Purposive sampling was employed to recruit primary care doctors in the cluster. The Theoretical Domains Framework (TDF) underpinned the study and guided the development of the interview questions. Data was analysed using both inductive and deductive approaches. The Consolidated criteria for reporting qualitative research (COREQ) checklist was used to guide the reporting. Results: Interviews were conducted with 17 primary care doctors. Four overarching themes were inductively identified: knowledge and previous practice patterns influence prescription, balancing risks and benefits, doctors' professional responsibilities, and system barriers. The four themes were then deductively mapped to the nine specific domains of the TDF: knowledge; intention; memory; beliefs about capabilities; beliefs about consequences; goals; role and identity; emotion; and environmental constraints. Most interviewees, to varying extent, were aware of the cardio-renal advantages and safety profile of SGLT2 I but are reluctant to prescribe or change their patients to SGLT2 I because of their knowledge gap that the cardio-renal benefits of SGLT2 I was independent of glyacemic efficacy. Other barriers included their considerations of patients' age and renal impairment, and patients' perceptions and preferences. Conclusions: Despite evidence-based recommendations of the utilisation of SGLT2 I in patients with established ASCVD/CKD, the prescription behaviour among primary care doctors was affected by various factors, most of which were amendable. Our findings will inform the development of structured interventions to address these factors to improve patients' cardio-renal outcomes. [ABSTRACT FROM AUTHOR]

Background: Primary healthcare (PHC) providers are widely acknowledged for putting the most efficient and long-lasting efforts for addressing community health issues and promoting health equity. This study aimed to explore PHC providers' experiences with coronavirus pandemic preparedness and response in Armenia. Methods: We applied a qualitative study design using semi-structured in-depth interviews and structured observation checklists. Study participants were recruited using theoretical and convenience sampling techniques throughout Armenia. Inductive conventional content analysis was utilized to analyze the in-depth interviews. Nineteen in-depth interviews were conducted with 21 participants. Observations took place in 35 PHC facilities. The data collected during the observations was analyzed using the "SPSS22.0.0.0" software. Results: Five main themes of primary healthcare providers' experiences were drawn out based on the study findings: 1) the gap in providers' risk communication skills; 2) uneven supply distributions; 3) difficulties in specimen collection and testing processes; 4) providers challenged by home visits; 5) poor patient-provider relationships. The results revealed that primary care providers were affected by uneven supply distribution throughout the country. The lack of proper laboratory settings and issues with specimen collection were challenges shaping the providers' experiences during the pandemic. The study highlighted the health systems' unpreparedness to engage providers in home visits for COVID-19 patients. The findings suggested that it was more challenging for healthcare providers to gain the trust of their patients during the pandemic. The study results also underlined the need for trainings to help primary care providers enhance their risk communication expertise or assign other responsible bodies to carry out risk communication on PHC providers' behalf. Conclusion: The study discovered that PHC providers have a very important role in healthcare system's preparedness and response to handle public health emergencies such as the COVID-19 pandemic. Based on the findings the study team recommends prioritizing rural PHC development, ensuring appropriate supply distributions, developing comprehensive protocols on safe home visits and specimen collection and testing processes, and trainings PHC providers on risk communication, patient-centeredness, as well as proper use of personal protective equipment. [ABSTRACT FROM AUTHOR]

Background: Singapore faces an ageing population with increasingly complex healthcare needs, a problem which could be addressed by high quality primary care. Many patients with complex needs are not managed by private general practitioners (GPs) who form the majority of the primary care workforce. Currently, there is paucity of literature describing the needs of these private GPs in providing such care. Aim: Understand the challenges, enablers and possible solutions from the perspective of private GPs in providing primary care of patients with complex needs. Method: We conducted a qualitative study using an inductive approach. Private GPs were interviewed using a semi-structured question guide with convenience sampling until thematic saturation was reached. These 12 interviewees were part of a network of clinics that provide primary care for complex patients who were recently discharged from a community hospital providing post-acute care. Data was transcribed prior to a process of familiarisation, coded and analysed using thematic analysis by three independent investigators. Results: Three themes emerged in the analysis. From a micro-organizational standpoint, private GPs and patients with complex needs must be willing to accept each other to have a therapeutic encounter (e.g., patients' multidimensional needs, GP clinic set-up is simple yet busy). Next, from a meso-organizational view, trust and good communication channels between the referring doctors and private GPs must exist for effective collaboration in managing complex care. Lastly, macro-organizationally, external stakeholders (e.g., policy-makers) should fund care models, which are financially viable to both patients, and private GPs (e.g., via adequate subsidies and renumeration respectively) as such complex care require many resources. Conclusion: Multiple factors exist which influence the ability of private GPs in Singapore to care for patients with complex needs. Addressing these factors may reduce the over dependence on high-cost hospitals for care delivery in similar healthcare systems. [ABSTRACT FROM AUTHOR]