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Background In recent decades, many self‐report instruments have been developed to assess the extent to which patients want to be informed and involved in decisions about their health as part of the concept of person‐centred care (PCC). The main objective of this research was to translate, adapt and validate the Patient‐Practitioner Orientation Scale (PPOS) using a sample of primary care health‐care professionals in Spain. Methods Baseline analysis of PPOS scores for 321 primary care professionals (general practitioners and nurses) from 63 centres and 3 Spanish regions participating in a randomized controlled trial. We analysed missing values, distributions and descriptive statistics, item‐to‐scale correlations and internal consistency. Performed were confirmatory factor analysis (CFA) of the 2‐factor model (sharing and caring dimensions), scale depuration and principal component analysis (PCA). Results Low inter‐item correlations were observed, and the CFA 2‐factor model only obtained a good fit to the data after excluding 8 items. Internal consistency of the 10‐item PPOS was acceptable (0.77), but low for individual subscales (0.70 and 0.55). PCA results suggest a possible 3‐factor structure. Participants showed a patient‐oriented style (mean = 4.46, SD = 0.73), with higher scores for caring than sharing. Conclusion Although the 2‐factor model obtained empirical support, measurement indicators of the PPOS (caring dimension) could be improved. Spanish primary care health‐care professionals overall show a patient‐oriented attitude, although less marked in issues such as patients’ need for and management of medical information.

Background Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient-centred care. Objectives To explore how individuals with HF conceptualize their care team, and perceive team members' roles. Setting and Participants Individuals with advanced HF were recruited from five cities in three Canadian provinces. Design Individuals were asked to identify their HF care team during semi-structured interviews. Team members' titles and roles, quotes pertaining to team composition and function, and frailty criteria were extracted and analysed using descriptive statistics and content analysis. Results A total of 62 individuals with HF identified 2–19 team members. Caregivers, nurses, family physicians and cardiologists were frequently identified; teams also included dentists, foot care specialists, drivers, housekeepers and spiritual advisors. Most individuals met frailty criteria and described participating in self-management. Discussion Individuals with HF perceived being active participants, not passive recipients, of care. They identified teams that were larger and more diverse than traditional biomedical conceptualizations. However, the nature and importance of team members' roles varied according to needs, relationships and context. Patients' degree of agency was negotiated within this context, causing multiple, sometimes conflicting, responses. Conclusion Ignoring the patient's role on the care team may contribute to fragmented care. However, understanding the team through the patient's lens – and collaborating meaningfully among identified team members – may improve health-care delivery.

Objective The aim of this study was to evaluate the knowledge and attitudes of dentists working in Primary Health Care Units from a Brazilian city, regarding oral cancer. Materials and methods A prospective, cross-sectional, epidemiologic survey was performed. Seventy-one dentists from Primary Health Care Units were contacted at their workplace, and participated of the study. Data were collected through a self-administered questionnaire of 31 multiple-choice questions addressing the main clinical features and risk factors for oral cancer. The questionnaire was divided into two sections: questions related to general data and self-perception of the participants regarding personal knowledge of oral cancer, and objective questions related to general information on oral cancer (clinical features, characteristics, traits, and risk factors). The data were tabulated and analyzed by descriptive statistics. Results Participants were mostly females (81.5%), less than 40 years of age (57.7%), who underwent training 10-20 years ago (47.9%). Most respondents (66.2%) considered their level of knowledge about oral cancer to be satisfactory. However, only 26.8% of tem felt that they were able to carry out diagnostic procedures for oral cancer. Most of them (95.8%) were interested in participating in training courses on Oral Diagnostics; 56.3% of them reported not having received any training or guidance on how to conduct an examination to detect oral cancer during undergraduate training. Conclusions These findings are consistent with previous reports and point to the need for new public policies to enable early diagnosis of oral cancer and a review of training in Oral Diagnostics in dental schools.

Background: The Information Assessment Method (IAM) allows clinicians to report the cognitive impact, clinical relevance, intention to use, and expected patient health benefits associated with clinical information received by email. More than 15,000 Canadian physicians and pharmacists use the IAM in continuing education programs. In addition, information providers can use IAM ratings and feedback comments from clinicians to improve their products. Objective: Our general objective was to validate the IAM questionnaire for the delivery of educational material (ecological and logical content validity). Our specific objectives were to measure the relevance and evaluate the representativeness of IAM items for assessing information received by email. Methods: A 3-part mixed methods study was conducted (convergent design). In part 1 (quantitative longitudinal study), the relevance of IAM items was measured. Participants were 5596 physician members of the Canadian Medical Association who used the IAM. A total of 234,196 ratings were collected in 2012. The relevance of IAM items with respect to their main construct was calculated using descriptive statistics (relevance ratio R). In part 2 (qualitative descriptive study), the representativeness of IAM items was evaluated. A total of 15 family physicians completed semistructured face-to-face interviews. For each construct, we evaluated the representativeness of IAM items using a deductive-inductive thematic qualitative data analysis. In part 3 (mixing quantitative and qualitative parts), results from quantitative and qualitative analyses were reviewed, juxtaposed in a table, discussed with experts, and integrated. Thus, our final results are derived from the views of users (ecological content validation) and experts (logical content validation). Results: Of the 23 IAM items, 21 were validated for content, while 2 were removed. In part 1 (quantitative results), 21 items were deemed relevant, while 2 items were deemed not relevant (R=4.86% [N=234,196] and R=3.04% [n=45,394], respectively). In part 2 (qualitative results), 22 items were deemed representative, while 1 item was not representative. In part 3 (mixing quantitative and qualitative results), the content validity of 21 items was confirmed, and the 2 nonrelevant items were excluded. A fully validated version was generated (IAM-v2014). Conclusions: This study produced a content validated IAM questionnaire that is used by clinicians and information providers to assess the clinical information delivered in continuing education programs. [JMIR Med Educ 2017;3(1):e4]

Objective To implement a prescribing-error reporting system in primary care offices and analyze the reports. Design Descriptive analysis of a voluntary prescribing-error-reporting system Setting Seven primary care offices in Vermont, USA. Participants One hundred and three prescribers, managers, nurses and office staff. Intervention Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems. Main Outcome Measures All reports were classified by severity category, setting, error mode, prescription domain and error-producing conditions. Results All practices submitted reports, although reporting decreased by 3.6 reports per month (95% CI, −2.7 to −4.4, P < 0.001, by linear regression analysis). Two hundred and sixteen reports were submitted. Nearly 90% (142/165) of errors were severity Category B (errors that did not reach the patient) according to the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Nineteen errors reached the patient without causing harm (Category C); and 4 errors caused temporary harm requiring intervention (Category E). Errors involving strength were found in 30% of reports, including 23 prescriptions written for strengths not commercially available. Antidepressants, narcotics and antihypertensives were the most frequent drug classes reported. Participants completed an exit survey with a response rate of 84.5% (87/103). Nearly 90% (77/87) of respondents were willing to continue reporting after the study ended, however none of the participants currently submit reports. Conclusions Nurses and office staff are a valuable resource for reporting prescribing errors. However, without ongoing reminders, the reporting system is not sustainable.

There is little literature related to access to inflammatory bowel disease (IBD) care that incorporates the perspective of key system stakeholders, such as primary healthcare providers (PHCP), despite their clear and integral role in facilitating access.This study aimed to identify barriers to referring patients to speciality IBD care as perceived by referring PHCP. In particular, we sought to understand PHCP satisfaction with the current IBD specialist referral system, as well as indicators of geographic variance to access.A population-based survey was mailed out to currently practising PHCPs who have referred or who are currently referring patients to IBD speciality care in Nova Scotia (Canada). Descriptive statistics and multivariate analyses were performed. Qualitative comments were themed using framework analysis to identify key barriers.The majority of PHCP (57%) were dissatisfied with the current referral process due to long patient wait times and perceived system inefficiency. Key areas of geographic variance in access included access to speciality care in the community and patient wait times. PHCPs suggested ideas to improve access including increased gastroenterologist supply, particularly in rural areas, and the creation of a provincial centralized referral and triage process.PHCPs play an important role in identifying and managing patients with IBD in partnership with gastroenterologists. This study identifies key PHCP perceived barriers that may prevent patients from accessing speciality IBD care. Understanding and addressing barriers to access from multiple stakeholder perspectives, including PHCPs, has the potential to support informed system redesign and overcome access inequities.Primary healthcare providers (e.g. family doctors and nurse practitioners) play an important role in connecting patients with speciality health care. Patients with digestive diseases, such as inflammatory bowel diseases (e.g. Crohn’s and colitis), may rely on primary healthcare providers to connect them with inflammatory bowel disease specialists (e.g. gastroenterologists). Past research on access to inflammatory bowel disease care has focused on the patient perspective; however, almost no research has focused on how primary healthcare providers perceive access to inflammatory bowel disease speciality care, despite their important role in facilitating access. This paper focuses on what 155 primary healthcare providers in Nova Scotia (Canada) perceive as key barriers for their patients when accessing speciality Inflammatory bowel disease care. This paper also presents potential improvements to the referral process and healthcare system, as suggested by primary healthcare providers, which may improve global access to inflammatory bowel disease care.

Background Primary healthcare (PHC) is an essential component of an effective healthcare system. The Kingdom of Saudi Arabia’s (KSA) health reforms prioritize tackling the increasing noncommunicable disease burden by prioritizing PHC, centering it as the core of the newly proposed Model of Care. To identify challenges and opportunities to scale up PHC capacity, understanding the current capacity of primary health care centers (PHCC) is critical. A limited number of publications review PHC capacity in KSA, focusing on specific regions/sectors; this paper is a first to examine PHC capacity on a national level. Methods The study uses a countrywide Facility Survey that collected data in 2018 from 2319 PHCCs, generating information on their characteristics, number of health workers, services provided, and capacity elements captured through the Service Availability and Drug Availability constructed indices. Descriptive analysis was performed by rural-urban classification. Ordinary Least Squares (OLS) regressions were used to understand correlates to health workers and equipment availability. Finally, a logistic regression was fitted for selected services. Regressions controlled for various measures to determine correlates with facilities’ capacity. Results On a national level, there are 0.74 PHCCs per 10,000 population in KSA. There are variations in the distribution of PHCCs across regions and within regions across rural and urban areas. PHCCs in urban areas have more examination rooms but lower examination room densities. Offering 24 × 7 services in PHCCs is infrequent and dependency on paper-based medical recording remains common. More urban regions are more likely to offer general services but less likely to offer burn management and emergency services. PHCCs are mostly staffed with general medicine, family medicine, and obstetrics & gynecology physicians, whose numbers are more concentrated in urban areas; however, their densities are higher in rural areas. Finally, psychiatrists and nutritionists are rare to find in PHCCs. Conclusions Decision-makers need to consider several factors when designing PHC policies. For instance, PHC accreditation needs to be prioritized given its positive correlation with service provision and health workers availability. PHC 24 × 7 operation also needs considerations in rural areas due to the high dependency on PHCCs. Finally, there is a substantial need for improvements in e-health.

Background While there is an extensive literature on Health System (HS) strengthening and on the performance of specific HSs, there are few exhaustive syntheses of the challenges HSs are facing worldwide. This paper reports the findings of a scoping review aiming to classify the challenges of HSs investigated in the scientific literature. Specifically, it determines the kind of research conducted on HS challenges, where it was performed, in which health sectors and on which populations. It also identifies the types of challenge described the most and how they varied across countries. Methods We searched 8 databases to identify scientific papers published in English, French and Italian between January 2000 and April 2016 that addressed HS needs and challenges. The challenges reported in the articles were classified using van Olmen et al.’s dynamic HS framework. Countries were classified using the Human Development Index (HDI). Our analyses relied on descriptive statistics and qualitative content analysis. Results 292 articles were included in our scoping review. 33.6% of these articles were empirical studies and 60.1% were specific to countries falling within the very high HDI category, in particular the United States. The most frequently researched sectors were mental health (41%), infectious diseases (12%) and primary care (11%). The most frequently studied target populations included elderly people (23%), people living in remote or poor areas (21%), visible or ethnic minorities (15%), and children and adolescents (15%). The most frequently reported challenges related to human resources (22%), leadership and governance (21%) and health service delivery (24%). While health service delivery challenges were more often examined in countries within the very high HDI category, human resources challenges attracted more attention within the low HDI category. Conclusions This scoping review provides a quantitative description of the available evidence on HS challenges and a qualitative exploration of the dynamic relationships that HS components entertain. While health services research is increasingly concerned about the way HSs can adopt innovations, little is known about the system-level challenges that innovations should address in the first place. Within this perspective, four key lessons are drawn as well as three knowledge gaps. Electronic supplementary material The online version of this article (10.1186/s12913-017-2585-5) contains supplementary material, which is available to authorized users.

Objective Since the introduction of legislative changes in 2010, services provided by privately practising nurse practitioners (PPNPs) in Australia have been eligible for subsidisation through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). To provide eligible services, PPNPs must collaborate formally with a medical practitioner or an entity that employs medical practitioners. This paper provides data from a national survey on these collaborative arrangements in Australia. The aim of the study was to evaluate the impact of PPNP services on patient access to care in Australia. Methods PPNPs in Australia were invited to complete an electronic survey. Quantitative data were analysed using descriptive statistics, whereas qualitative data were analysed using thematic analysis. Seventy-three surveys were completed. Results Ninety-three per cent of participants reported having a collaborative arrangement in place. Frequency of communication ranged from daily (27%) to never (1%). Participants reported that collaborative arrangements facilitate learning, patient care and offer support to PPNPs. However, for some PPNPs, organising a formal collaborative arrangement is demanding because it is dependent on the availability and willingness of medical practitioners and the open interpretation of the arrangement. Only 19% of participants believed that collaborative arrangements should be a prerequisite for PPNPs to access the MBS and PBS. Conclusion Although there are benefits to collaborative arrangements, there is also concern from PPNPs that mandating such arrangements through legislation presents a barrier to establishing PPNP services and potentially reduces patient access to care. Collaboration with medical practitioners is intrinsic to nursing practice. Thus, legislating for collaborative arrangements is unnecessary, because it makes the normal abnormal. What is known about the topic? To access the MBS and PBS, PPNPs are required by law to have a collaborative arrangement with a medical practitioner or entity that employs medical practitioners. To date, the effects of these collaborative arrangements on PPNP services in Australia have not been known. What does the paper add? This paper provides unique data from a national survey on collaborative arrangements between PPNPs and medical practitioners in Australia. What are the implications for practitioners? Although there are benefits to collaborative arrangements, there is also concern that mandating such arrangements presents a barrier to establishing PPNP services and potentially reduces patient access to care.

This paper starts from the reflection that although the National Policy for Primary Health Care does not define the nurse as the coordinator of Family Health Units, USF, very often this professional ends up by taking over this position due to several factors that compose nursing practices. It aimed at analyzing the nursescoordination of Family Health Units beginning from a descriptive analysis with qualitative approach. The study was carried out with eight nurses from the Primary Health Care network of Porto Alegre-RS through semi-structured interview while the observations were registered in a field diary. The findings were organized from the following categories: coordination activities; potentials before the coordination process; difficulties before the coordination process. In addition, they evidenced a double setting of challenges and qualities that compose the job of coordination nurses. This paper took over old challenges and discussed new perspectives of looking into the primary care work. Descriptors: Health management. Family health. Nursing. RESUMO

Objective:To identify publication and citation trends, most productive institutions and countries, top journals, most cited articles and authorship networks from articles that used and analysed data from primary care databases (CPRD, THIN, QResearch) of pseudonymised electronic health records in UK.\ud Methods: Descriptive statistics and scientometric tools were used to analyse a SCOPUS dataset of 1891 articles. Open access software was used to extract networks from the dataset (Table2Net), visualise and analyse co-authorship networks of scholars and countries (Gephi) and, density maps (VOSviewer) of research topics co-occurrence and journal co-citation.\ud Results: Research output increased overall at a yearly rate of 18.65%. While medicine is the main field of research, studies in more specialised areas include biochemistry and pharmacology. Researchers from UK, USA and Spanish institutions have published the most papers. Most of the journals that publish this type of research and most cited papers come from UK and USA. Authorship varied between 3-6 authors. Keyword analyses show that smoking, diabetes, cardiovascular diseases and mental illnesses, as well as medication that can treat such medical conditions, such as non-steroid anti-inflammatory agents, insulin and antidepressants constitute the main topics of research. Co-authorship network analyses show that lead scientists, directors or founders of these databases are, to various degrees, at the centre of clusters in this scientific community.\ud Conclusions: There is a considerable increase of publications in primary care research from electronic health records. The UK has been well placed at the centre of an expanding global scientific community, facilitating international collaborations and bringing together international expertise in medicine, biochemical and pharmaceutical research.

Background Perioperative optimisation can improve outcomes for older people having surgery. Integration with primary care could improve quality and reduce variability in access to preoperative optimisation. Aim Our aim was to explore attitudes, beliefs and behaviours of general practitioners (GPs) regarding the perioperative pathway, and evaluate enablers and barriers to GP-led preoperative optimisation. Methods Stakeholder interviews (n=38) informed survey development. A purposive sampling frame was used to target delivery of online and paper surveys. Results were analysed using descriptive statistics. Results We had 231 responses (response rate 32.7%). Enablers included belief among GPs that optimisation improves postoperative outcomes (86%) and that they have a role discussing modifiable risk factors with patients (85%). Barriers included low frequency exposure to older surgical patients, minimal training in perioperative medicine and rare interaction with perioperative services. Conclusion This survey illustrates the importance of interprofessional education, cross-sector training opportunities and collaboration to deliver integrated preoperative optimisation for older people undergoing surgery.

Background Progress in health service quality is vital to reach the target of Universal Health Coverage. However, in order to improve quality, it must be measured, and the assessment results must be actionable. We analyzed an electronic tool, which was developed to assess and monitor the quality of primary healthcare in Tanzania in the context of routine supportive supervision. The electronic assessment tool focused on areas in which improvements are most effective in order to suit its purpose of routinely steering improvement measures at local level. Methods Due to the lack of standards regarding how to best measure quality of care, we used a range of different quantitative and qualitative methods to investigate the appropriateness of the quality assessment tool. The quantitative methods included descriptive statistics, linear regression models, and factor analysis; the qualitative methods in-depth interviews and observations. Results Quantitative and qualitative results were overlapping and consistent. Robustness checks confirmed the tool’s ability to assign scores to health facilities and revealed the usefulness of grouping indicators into different quality dimensions. Focusing the quality assessment on processes and structural adequacy of healthcare was an appropriate approach for the assessment’s intended purpose, and a unique key feature of the electronic assessment tool. The findings underpinned the accuracy of the assessment tool to measure and monitor quality of primary healthcare for the purpose of routinely steering improvement measures at local level. This was true for different level and owner categories of primary healthcare facilities in Tanzania. Conclusion The electronic assessment tool demonstrated a feasible option for routine quality measures of primary healthcare in Tanzania. The findings, combined with the more operational results of companion papers, created a solid foundation for an approach that could lastingly improve services for patients attending primary healthcare. However, the results also revealed that the use of the electronic assessment tool outside its intended purpose, for example for performance-based payment schemes, accreditation and other systematic evaluations of healthcare quality, should be considered carefully because of the risk of bias, adverse effects and corruption.

Background Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study “Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)” aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components. Methods A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data. Results Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use. Conclusions The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population. Trial registration ISRCTN, ISRCTN15061174. Registered 13 July 2018 – Retrospectively registered

Background The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India. Methods Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015–16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis. Results Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015–16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was − 0.161 [95% CI, − 0.158, − 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres. Conclusion Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India.

BackgroundObesity within the USA is a public health crisis. Nutrition counselling in primary care is an effective yet underutilized intervention because of both health care professional (HCP) barriers and patient barriers.ObjectiveThe purpose of this study was to: (i) identify HCP and patient perceptions, needs and barriers surrounding nutrition counselling, (ii) develop nutrition resources for HCPs and patients and (iii) assess utility of the approach.MethodsPaper surveys were completed by 48 HCPs (response rate: 63.2%) and 185 patients in five family medicine clinics. Based on results, nutrition resources were developed and integrated into the electronic medical record. To assess utility, paper surveys were completed by 25 HCPs (response rate: 32.9%) after 4 weeks. Results were presented as descriptive statistics.ResultsBoth HCPs and patients indicated that nutrition counselling is necessary to improve dietary behaviours, but barriers prevented HCPs from providing counselling and patients from improving dietary behaviours. HCPs indicated that improved patient handouts (74.5%), community nutrition classes (72.3%) and community cooking classes (63.8%) could enhance nutrition counselling. Patients identified that coupons and discounts (45.5%), sample meal plans and recipes (44.3%) and websites for recipes, grocery guides, and cooking videos (35.9%) would help them to consume a healthy diet. Patient education handouts, patient resource guides and HCP education were created. Following receipt, most HCPs (85%) indicated that the resources enhanced their nutrition counselling.ConclusionsHCP and patient barriers to nutrition counselling are multiple and varied. Design and implementation of an approach tailored to stakeholders’ needs have potential to improve nutrition counselling in primary care.

Introduction The federal Opioid State Targeted Response (Opioid STR) grants provided funding to each state to ramp up the range of responses to reverse the ongoing opioid crisis in the U.S. Washington State used these funds to develop and implement an integrated care model to expand access to medication treatment and reduce unmet need for people with opioid use disorders (OUD), regardless of how they enter the treatment system. This paper examines the design, early implementation and results of the Washington State Hub and Spoke Model. Methods Descriptive data were gathered from key informants, document review, and aggregate data reported by hubs and spokes to Washington State's Opioid STR team. Results The Washington State Hub and Spoke Model reflects a flexible approach that incorporates primary care and substance use treatment programs, as well as outreach, referral and social service organizations, and a nurse care manager. Hubs could be any type of program that had the required expertise and capacity to lead their network in medication treatment for OUD, including all three FDA-approved medications. Six hub-spoke networks were funded, with 8 unique agencies on average, and multiple sites. About 150 prescribers are in these networks (25 on average). In the first 18 months, nearly 5000 people were inducted onto OUD medication treatment: 73% on buprenorphine, 19% on methadone, and 9% on naltrexone. Conclusions The Washington State Hub and Spoke Model built on prior approaches to improve the delivery system for OUD medication treatment and support services, by increasing integration of care, ensuring “no wrong door,” engaging with community agencies, and supporting providers who are offering medication treatment. It used essential elements from existing integrated care OUD treatment models, but allowed for organic restructuring to meet the population needs within a community. To date, there have been challenges and successes, but with this approach, Washington State has provided medication treatment for OUD to nearly 5000 people. Sustainability efforts are underway. In the face of the ongoing opioid crisis, it remains essential to develop, implement and evaluate novel models, such as Washington's Hub and Spoke approach, to improve treatment access and increase capacity.

Background The continued escalation of opioid use disorder (OUD) calls for heightened vigilance to implement evidence-based care across the US. Rural care providers and patients have limited resources, and a number of barriers exist that can impede necessary OUD treatment services. This paper reports the design and protocol of an implementation study seeking to advance availability of medication assisted treatment (MAT) for OUD in rural Pennsylvania counties for patients insured by Medicaid in primary care settings. Methods This project was a hybrid implementation study. Within a chronic care model paradigm, we employed the Framework for Systems Transformation to implement the American Society for Addiction Medicine care model for the use of medications in the treatment of OUD. In partnership with state leadership, Medicaid managed care organizations, local care management professionals, the Universities of Pittsburgh and Utah, primary care providers (PCP), and patients; the project team worked within 23 rural Pennsylvania counties to engage, recruit, train, and collaborate to implement the OUD service model in PCP practices from 2016 to 2019. Formative measures included practice-level metrics to monitor project implementation, and outcome measures involved employing Medicaid claims and encounter data to assess changes in provider/patient-level OUD-related metrics, such as MAT provider supply, prevalence of OUD, and MAT utilization. Descriptive statistics and repeated measures regression analyses were used to assess changes across the study period. Discussion There is an urgent need in the US to expand access to high quality, evidence-based OUD treatment—particularly in rural areas where capacity is limited for service delivery in order to improve patient health and protect lives. Importantly, this project leverages multiple partners to implement a theory- and practice-driven model of care for OUD. Results of this study will provide needed evidence in the field for appropriate methods for implementing MAT among a large number of rural primary care providers.

Background: The Missed Opportunities for Maternal and Infant Health (MOMI) project, which aimed at upgrading maternal and infant postpartum care (PPC), implemented a package of interventions including the integration of maternal PPC in infant immunization services in 12 health facilities in Kaya Health district in Burkina Faso from 2013 to 2015. This paper assesses the coverage and the quality of combined mother-infant PPC in reproductive, maternal, newborn and child health services (RMNCH). Methods: We conducted a mixed methods study with cross-sectional surveys before and after the intervention in the Kaya health and demographic surveillance system. On the quantitative side, two household surveys were performed in 2012 ( N = 757) and in 2014 ( N = 754) among mothers within one year postpartum. The analysis examines the result of the intervention by the date of delivery at three key time points in the PPC schedule: the first 48 h, days 6 - 10 and during weeks 6 - 8 and beyond. On the qualitative side, in depth interviews, focus group discussions and observations were conducted in four health facilities in 2012 and 2015. They involved mothers in the postpartum period, facility and community health workers, and other stakeholders. We performed a descriptive analysis and a two-sample test of proportions of the quantitative data. The qualitative data were recorded, transcribed and analysed along the themes relevant for the intervention. Results: The findings show that the WHO guidelines, in terms of content and improvement of maternal PPC, were followed for physical examinations and consultations. They also show a significant increase in the coverage of maternal PPC services from 50% (372/752) before the intervention to 81% (544/672) one year after the start of the intervention. However, more women were assessed at days 6 - 10 than at later visits. Integration of maternal PPC was low, with little improvements in history taking and physical examination of mothers in immunization services. While health workers are polyvalent, difficulties in restructuring and organizing services hindered the integration. Conclusion: Unless a comprehensive strategy of integration within RMNCH services is implemented to address the primary health care challenges within the health system, integration will not yield the desired results.

Aims: The paper assessed the influence of clinic - based health education (C - BHE) on pregnant women’s attitude in relation to birth preparedness, complication and readiness (BP/CR) and utilization of Primary Health Care (PHC) services in Ogun State. Study Design : Quasi - experimental design was used. Primary data was collected from surveyed participants. Place and Duration of Study: Study was conducted between February and May 2013 in Ikenne, Ogun state, Nigeria. Methodology: Stratified sampling method was used to allocate 48 pregnant women, attending ante - natal care, each to experimental and control groups, making a total of 96 respondents. Structured questionnaire was used to collect data from the respondents. The women in the experimental group were exposed to two hours of health education discussion addressing pertinent maternal health issues weekly for five weeks. Data were analyzed using descriptive statistics and independent t - test. All tests were measured at p ≤0.05 level of significance. Results: Results showed that the women were between 19 and 24 years, had up to secondary education, recorded parity of 1 - 2 while timing of first visit was between 20 and 24 weeks of gestation and number of Ante - natal visits were ≥ 4. At baseline, there were no significant difference in the attitudes and desires for utilization of PHC facility for delivery for the experimental and Original Research Article

Background Ghana introduced capitation payment for primary care in 2012 with the view to containing escalating claims expenditure. This shift in provider payment method raised issues about its potential impact on patient-provider trust relationship and insured-patients’ trust in the Ghana National Health Insurance Scheme. This paper presents findings of a study that explored insured-patients’ perception about, and attitude towards capitation payment in Ghana; and determined whether capitation payment affect insured-patients’ trust in their preferred primary care provider and the National Health Insurance Scheme in general. Methods We adopted a survey design for the study. We administered closed-ended questionnaires to collect data from insurance card-bearing members aged 18 years and above. We performed both descriptive statistics to determine proportions of observations relating to the variables of interest and chi-square test statistics to determine differences within gender and setting. Results Sixty-nine per cent (69 %) out of 344 of respondents selected hospital level of care as their primary care provider. The two most important motivations for the choice of a provider were proximity in terms of geographical access (40 %) and perceived quality of care (38 %). Eighty-eight per cent (88 %) rated their trust in their provider as (very) high. Eighty-two per cent (82 %) actively selected their providers. Eighty-eight per cent (88 %) had no intention to switch provider. A majority (91 %) would renew their membership when it expires. Female respondents (91 %; n = 281) were more likely to renew their membership than males (87 %; n = 63). Notwithstanding capitation payment experience, 81 % of respondents would recommend to their peers to enrol with the NHIS with rural dwellers (87 %; n = 156) being more likely to do so than urban dwellers (76 %; n = 188). Almost all respondents (92 %) rated the NHIS as (very) good. Conclusion Health Insurance subscribers in Ghana have high trust in their primary care provider giving them quality care under capitation payment despite their negative attitude towards capitation payment. They are guided by proximity and quality of care considerations in their choice of provider. The NHIA would, however, have to address itself to the negative perceptions about the capitation payment policy. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1622-0) contains supplementary material, which is available to authorized users.

Objective: Turkey has implemented family practice on a pilot basis as part of the reform in health care, since 2005. This paper aims to understand and describe the prevalent practice patterns and clinic characteristics during the transition period. Design: A cross-sectional descriptive study design was used. Subjects: An online survey was conducted among Turkish GPs working as primary care doctors (without vocational training) during the reform period. Clinic and GP characteristics are analysed with descriptive statistics. Results: List size is an important factor; larger lists lead to shorter consultation time and a longer wait for patients. GPs are generally satisfied with the reform. Conclusion: During the transition to family practice access of patients to health care has improved and GPs are satisfied with their job., Scientific and Technological Research Council of Turkey (TÜBİTAK); Akdeniz University Research Management Unit

Background No literature exists which examines referral preferences to, or the consultation process with, Otolaryngology. In a recent Canadian Medical Association nation-wide survey of General Practitioners and Family Physicians, Otolaryngology was listed as the second-most problematic specialty for referrals. The purpose of this study was to learn about and improve upon the referral process between primary care physicians (PCPs) and Otolaryngology at an academic centre in Southwestern Ontario. Methods PCPs who actively refer patients to Otolaryngology within the catchment area of Western University were asked to complete a short paper-based questionnaire. Data was analyzed using descriptive statistics. Results A total of 50 PCPs were surveyed. Subspecialty influenced 90.0 % of the referrals made. Specialist wait times altered 58.0 % of referrals. All PCPs preferred to communicate via fax. Half of those surveyed wanted clinical notes from every encounter. Seventy-four percent of respondents wanted inappropriate referrals forwarded to the proper specialist automatically. Twenty-two percent of those surveyed were satisfied with current wait times. A central referral system was favored by 74 % of PCPs. Conclusion Improvements could help streamline the referral and consultation practices with Otolaryngology in Southwestern Ontario. A central referral system and reduction in the frequency of consultative reports can be considered. Electronic supplementary material The online version of this article (doi:10.1186/s40463-015-0114-2) contains supplementary material, which is available to authorized users.

Introduction. Consumer satisfaction is the core element of the quality health care service. If the patient is unsatisfied with health care service, the main aim of the health care system is not achieved. The Aim. The aim of this paper is to show the level of patient satisfaction in primary health care settings in the district Pomoravlje from 2004 to 2009. Method. For the measurement of patient satisfaction the questionnaire of the World Health Organization and Institute of Public Health Serbia was used. The representative sample of 3567 patient in primary health care was used. Descriptive statistic was applied. Results. The average figures of consumer satisfaction with general practitioners (GP) and nurses in the primary health care from 2004 to 2009 were balanced and with continual rise. Patients satisfaction is the highest with general practitioners (86,8%) but the level of the consumer satisfaction is the lowest in the gynecology (9,5%). In the dental health care the consumer satisfaction was 84%. Conclusion. This research shows that over 80% of the patients were satisfied in primary health care settings and indicate the importance of improvement of consumer satisfaction for amelioration of the health care.

The purpose of this study was to explore and describe the use of the Nursing Process by registered nurses in local level primary health care practice in Namibia. The findings were used to serve as a basis to develop strategies to support registered nurses in their daily local PHC practice. A quantitative research approach using a survey design with self-report questionnaire was used. The population consisted of two groups. The first group consisted of 239 registered nurses working in Clinics, health Centers and in Outreach Programs. The second group consisted of 39 registered nurses supervisors of the registered nurses in these facilities. Quantitative, descriptive analysis was used to summarize and organize data using tables and figures as well as t-test and analysis of variance (ANOVA), where applicable.Five main problem areas were identified. It was concluded that strategies needed to be developed to support registered nurses in their daily local Primary health care practice. The development of strategies will be dealt with in a different paper.

Background While some research has been conducted examining recruitment methods to engage physicians and practices in primary care research, further research is needed on recruitment methodology as it remains a recurrent challenge and plays a crucial role in primary care research. This paper reviews recruitment strategies, common challenges, and innovative practices from five recent primary care health services research studies in Ontario, Canada. Methods We used mixed qualitative and quantitative methods to gather data from investigators and/or project staff from five research teams. Team members were interviewed and asked to fill out a brief survey on recruitment methods, results, and challenges encountered during a recent or ongoing project involving primary care practices or physicians. Data analysis included qualitative analysis of interview notes and descriptive statistics generated for each study. Results Recruitment rates varied markedly across the projects despite similar initial strategies. Common challenges and creative solutions were reported by many of the research teams, including building a sampling frame, developing front-office rapport, adapting recruitment strategies, promoting buy-in and interest in the research question, and training a staff recruiter. Conclusions Investigators must continue to find effective ways of reaching and involving diverse and representative samples of primary care providers and practices by building personal connections with, and buy-in from, potential participants. Flexible recruitment strategies and an understanding of the needs and interests of potential participants may also facilitate recruitment.

In today's highly competitive health care environment, many private health care settings are now looking into customer service indicators to learn customers' perceptions and determine whether they are meeting customers' expectations in order to ensure that their customers are satisfied with the services. This research paper aims to investigate whether the human elements were more important than the nonhuman elements in private health care settings. We used the internationally renowned SERVQUAL five-dimension model plus three additional dimensions-courtesy, communication, and understanding of customers of the human element-when evaluating health care services. A total of 191 respondents from three private health care settings in the Klang Valley region of Malaysia were investigated. Descriptive statistics were calculated by the Statistical Package for Social Sciences (SPSS) computer program, version 15. Interestingly, the results suggested that customers nowadays have very high expectations especially when it comes to the treatment they are receiving. Overall, the research indicated that the human elements were more important than the nonhuman element in private health care settings. Hospital management should look further to improve on areas that have been highlighted. Implications for management practice and directions for future research are discussed.