Family Practice - Advance Access

'If I feel something wrong, then I will get a mammogram': understanding barriers and facilitators for mammography screening among Chilean women

Puschel, K., Thompson, B., Coronado, G., Gonzalez, K., Rain, C., Rivera, S. — Fri, 06 Nov 2009 01:26:57 PST

Background. Breast cancer is the leading cause of cancer among women in Chile and in many Latin American countries. Breast cancer screening is an effective strategy to reduce mortality, but it has a very low compliance among Chilean women.

Objective. To understand barriers and facilitators for breast cancer screening in a group of Chilean women aged 50–70.

Methods. Following the Predisposing, Enabling and Reinforcing (PRECEDE) framework, seven focus groups (N = 48 women) were conducted with women that have had diverse experiences with breast cancer and screening practices. Information was collected using field notes and audio and video recording. Following the grounded theory model, a sequential process of open, axial and selective coding was used for the information analysis. Atlas ti 5.5 software was used for coding and segmenting the data obtained from the interviews.

Results. The presence of symptoms and/or the finding of lumps through breast self-examination (BSE) were the main predisposing factors for getting a mammogram. Secrecy, embarrassment and fatalism about breast cancer were significant cultural factors that influenced the decision to seek mammogram screening. Confidence in medical staff and dignity in the treatment at the clinic were important enabling factors. The main reinforcing factors for getting the test were a sense of fulfilment by doing something good for themselves and getting timely information about the results.

Conclusions. Primary health care providers should use culturally appropriate strategies to better inform women about the importance of mammography screening and the limitations of BSE for preventing advanced breast cancer.

Factors influencing general practice follow-up attendances of patients with complex medical problems after hospitalization

Yang, S. C., Zwar, N., Vagholkar, S., Dennis, S., Redmond, H. — Wed, 04 Nov 2009 01:07:01 PST

Background. Supported discharge care of patients with complex medical problems is associated with improved health outcomes. GPs are ideally placed to provide post-discharge care in the community. Knowledge of factors that influence patients’ decisions to attend such follow-up is thus important to improve health care outcomes of these patients.

Objectives. To explore factors that influence complex medical patients’ decision to attend GP follow-up after discharge and factors affecting their level of satisfaction with such follow-up.

Methods. Qualitative investigation using semi-structured telephone interviews of 26 patients with complex medical issues conducted 2 weeks after hospital discharge.

Results. Complex medical patients experienced varying degrees of concern and information needs after discharge from hospital. Patients’ understanding of the role of the GP and experiences of continuity of care also influence patients’ decisions to attend follow-up with their GP. In addition, practical factors such as GP availability, presence of discharge instructions, access to transport and level of social support also affect patients’ ability to attend early GP follow-up after hospital discharge. Patients’ satisfaction with GP follow-up was influenced by perceived competence and personal continuity with the GP.

Conclusions. Patients’ decisions to attend GP follow-up after hospitalization are influenced by a number of factors. Interventions to support post-hospital care that address these issues need to be developed and tested. Key issues are patients’ understanding of their condition, understanding of the role of the GP in follow-up and continuity of care.

Effectiveness of a protocol-based strategy for achieving better blood pressure control in general practice

Tue, 03 Nov 2009 02:02:44 PST

Background. There continues be a problem with the proportion of treated hypertension patients who are actually at recommended blood pressure targets.

Objective. Is an intensive protocol-based strategy for achieving blood pressure control effective in family practice and will family physicians and their hypertensive patients adhere to such a protocol.

Methods. Design of the study is a cluster randomized controlled trial at the Centre for Studies in Primary Care, Queen's University, Kingston, Ontario. Participants were 19 family physicians and 156 (98 intervention group and 58 control group) of their patients in and around the Kingston area. Patients were eligible if they had a diagnosis of hypertension and had not yet achieved their target blood pressure. Patients in the intervention group were managed according to a protocol that involved seeing their family doctor every 2 weeks over a 16-week period and having their antihypertensive medication regimen adjusted at each visit if target was not achieved. This was compared to usual care. Main outcomes were primary effectiveness outcome measured at 12 months was the differences in blood pressure between baseline and 12 months in the two groups. Secondary effectiveness outcomes included rates of achieving BP target and compliance with protocol by physicians and patients. Adherence outcomes were assessed by determining the number of visits made during the 16-week intervention period and the increase in the number of drugs being used.

Results. Of the patients enrolled, 72 (74%) from the intervention group and 41 (71%) in the control group were available for analysis. Improvement between baseline and 12-month follow-up was significantly better for the intervention group than the control for diastolic mean daytime BP on 24 hours ambulatory blood pressure monitoring (4.5 mmHg reduction versus 0.5 mmHg reduction) and for both systolic (14.7 mmHg reduction versus 2.7 mmHg reduction) and diastolic (7.4 mmHg reduction versus 0.6 mmHg increase) blood pressure on BpTRU. Of the 98 patients in the intervention, 80% attended four or more of the eight visits and 25% attended all eight visits; physicians increased the number or dosage of drugs the patient was taking in 52% of the visits.

Conclusions. An intensive, protocol-based, management approach to achieving blood pressure control in hypertensive patients in family practice is effective and works even when there is flexibility built into the algorithm to allow family physicians to use their judgement in individual patients.

Implementing family practice research in countries with limited resources: a stepwise model experienced in Crete, Greece

Lionis, C., Symvoulakis, E. K, Vardavas, C. I — Sun, 01 Nov 2009 23:08:05 PST

The need for a cost-effective decision-making process is increasingly seen as a challenge within modern family practice. The role of family practice research is well recognized in countries with readily available resources and capacity. However, the situation is different in a number of countries with limited financial resources and current low research capacity. This article reports on an empirical model of 10 steps developed and applied in Crete, Greece. It aims to exchange views on how to better design and undertake actions in order to develop future family practice research in countries with limited resources.

Prevalence, incidence, morbidity and treatment patterns in a cohort of patients diagnosed with anxiety in UK primary care

Sun, 01 Nov 2009 23:08:05 PST

Background. Anxiety disorders are common and can cause substantial quality of life impairment.

Objective. The aim of this study was to investigate the frequency of anxiety in UK primary care. Treatment patterns and factors associated with an anxiety diagnosis were also assessed.

Methods. The Health Improvement Network was used to identify all patients aged 10–79 years with a new diagnosis of anxiety in 2002–04 (n = 40 873) and age-, sex- and calendar-year-matched controls (n = 50 000). A nested case–control analysis was used to quantify potential risk factors for anxiety by multivariate logistic regression.

Results. The prevalence of anxiety was 7.2% and the incidence was 9.7 per 1000 person-years. Incidence and prevalence were highest in women and young adults (20–29 years). Anxiety was associated with heavy alcohol use, smoking and addiction problems as well as stress, sleep and depression disorders. Anxiety patients used health care services more frequently than controls. Among patients diagnosed with anxiety, 63% were treated pharmacologically. Antidepressants accounted for almost 80% of prescriptions.

Conclusions. The prevalence and incidence of anxiety are high in UK primary care and are almost twice as high in women than in men. Anxiety is associated with other psychiatric morbidity as well as frequent health care use. Antidepressants are the most commonly used pharmacological treatment.

The role of theory in qualitative health research

Kelly, M. — Thu, 29 Oct 2009 13:32:10 PDT

The role of theory in qualitative research is often underplayed but it is relevant to the quality of such research in three main ways. Theory influences research design, including decisions about what to research and the development of research questions. Theory underpins methodology and has implications for how data are analyzed and interpreted. Finally, theory about a particular health issue may be developed, contributing to what is already known about the topic that is the focus of the study. This paper will critically consider the role of theory in qualitative primary care research in relation to these three areas. Different approaches to qualitative research will be drawn upon in order to illustrate the ways in which theory might variably inform qualitative research, namely generic qualitative research, grounded theory and discourse analysis. The aim is to describe and discuss key issues and provide practical guidance so that researchers are more aware of the role theory has to play and the importance of being explicit about how theory affects design, analysis and the quality of qualitative research.

The role and impact of facilitators in primary care: findings from the implementation of the Gold Standards Framework for palliative care

Petrova, M., Dale, J., Munday, D., Koistinen, J., Agarwal, S., Lall, R. — Thu, 29 Oct 2009 13:32:09 PDT

Background. Facilitation is the process of providing support to individuals or groups to achieve beneficial change. It is intrinsic to the Gold Standards Framework (GSF) for palliative care, a programme introduced widely in UK general practices.

Objectives. To explore how GSF facilitators fulfil their role and the impact of the facilitators’ backgrounds and approach on practices’ uptake of the programme.

Setting. Primary care organizations and general practices in England and Northern Ireland.

Methods. Self-completed questionnaire and semi-structured interviews with facilitators. Practice audit questionnaire. Descriptive statistics. Thematic analysis. Linear and random effects models.

Results. A total of 102 (59.6%) facilitators completed a questionnaire; interviews were performed with nine facilitators. A large variability was found in the facilitators’ professional backgrounds, role setup and activities. The impact of several facilitation characteristics on practice change was modelled for 63 (36.8%) facilitators and 266 practices (20.4%). No evidence was found of an association between practice change and facilitators’ specialist knowledge of palliative care, mean facilitation time per practice, mean number of visits, facilitator budget and incentives offered to practices. Facilitators with a GP background were associated with higher levels of GSF change than those with a clinical nurse specialist background (P = 0.0078 with Bonferroni correction, significance threshold for corrected P = 0.008). The interviews indicated that the differential implementation of the framework might have been strongly affected by internal and external practice-related factors that were not readily amenable to facilitation.

Conclusion. This study goes some way towards untangling aspects of facilitation associated with successful implementation of the GSF. Further prospective research and evaluation is needed to identify ways of improving its sustainability, effect on patient outcomes and cost-effectiveness.

Work problems due to low back pain: what do GPs do? A questionnaire survey

Coole, C., Watson, P. J, Drummond, A. — Mon, 26 Oct 2009 00:04:11 PDT

Background. Low back pain can affect work ability and remains a main cause of sickness absence. In the UK the GP is usually the first contact for patients seeking health care. The UK government intends that the GP will continue to be responsible for sickness certification and work advice. This role requires a considerable level of understanding of work rehabilitation, and effective communication between GPs, patients, employers and therapists.

Objectives. The aim of this study was to identify GPs’ current practice in managing patients whose ability to work is affected by low back pain, and their perception of the support services required.

Method. A postal questionnaire of 441 GPs in the South Nottinghamshire area of the UK was carried out. Areas covered included referral patterns, sickness certification, and communication with therapists and employers.

Results. There was a 54.6% response rate. The majority of GPs (76.8%) reported that they did not take overall responsibility for managing the work problems of patients arising from low back pain. Few ‘mainly agreed’ that they initiated communication with employers (2.5%) and/or therapists (10.4%) regarding their patients’ work.

Conclusion. The results of this study demonstrate that most GPs do not readily engage in vocational rehabilitation and do not initiate contact with employers or other health care practitioners regarding patients’ work problems. Thus the current government expectation that GPs are able to successfully manage this role may be unrealistic; considerable training and a change in the GPs’ perception of their role will be required.

Young people and their GP: a register-based study of 1717 Norwegian GPs

Hetlevik, O., Haug, K., Gjesdal, S. — Mon, 26 Oct 2009 00:04:10 PDT

Background. Internationally, there has been a call to improve the youth-friendliness of health services. In surveys, 60–90% of young people report having contact with a GP at least once a year. Regular contact with the GP can be assumed to be an indicator of a youth-friendly health service. The aim of the current study was to identify associations between a high consultation rate with young people (15–24 years) on the one hand and GP characteristics, patient list characteristics and practice profiling factors on the other.

Methods. A cross-sectional national register-based study from 2002–04 in Norwegian general practice. Data on 1717 GPs, their practice populations and a sample of 316 773 consultations with young people were used to estimate differences between GPs, using one-way analysis of variance and logistic regression.

Results. The mean annual consultation rate with young people was 1.4 (95% confidence interval 1.4–1.5) and 2.2 (2.1–2.2) for the age groups 15–19 and 20–24, respectively. List characteristics indicating free capacity—a shorter patient list, a growing patient list and a high access for persons not on the patient list—were associated with a high youth consultation rate. Young age of the GP, low educational level among the list population and a high rate of interdisciplinary activity by the GP were also associated with a high youth consultation rate.

Conclusions. GPs seem to assign especially low priority to young people when workload is high or free capacity low. Increased awareness of these mechanisms and greater interdisciplinary cooperation could increase the youth-friendliness of general practice.

Pharmacists and nurses as independent prescribers: exploring the patient's perspective

Hobson, R. J, Scott, J., Sutton, J. — Mon, 26 Oct 2009 00:04:09 PDT

Background. Little is known about patients’ opinions upon the development of non-medical prescribing (NMP).

Objective. To explore the opinions of patients on the development of NMP.

Methods. In-depth interviews using qualitative methodology (Interpretative Phenomological Analysis). Eighteen interviews were undertaken in Bristol (Sites 1 and 3), Swindon (Site 2) and Brighton (Site 4). [Site 1 = primary care, GP prescriber (n = 5), Site 2 = secondary care, consultant prescriber (n = 5), Site 3 = primary care (n = 5) and Site 4 = secondary care (n = 3) (both pharmacist supplementary prescribers.] Participants (n = 18) were randomly sampled from patients under the care of the participating prescriber. Participants were aged between 42 and 81 years of age (n = 11 male and n = 7 female). Interviews took place between January and August 2006.

Results. Participants expressed concerns about clinical governance, privacy and whether sufficient space were available to provide the service in community pharmacies. Participants acknowledged the expert drug knowledge of pharmacists and their accessibility. These factors enhanced acceptability of this role for pharmacists. Nurses were highly regarded, accepted and preferred as prescribers with few concerns.

Conclusions. The results indicate support for pharmacists and nurses as prescribers, which aid successful implementation. Further research may be needed to evaluate the level of understanding that the public has of NMP and their views of the service once NMP is more widely established. Stakeholders should be mindful that the public may be hesitant regarding the professionalism, quality and clinical governance standards of clinics in community pharmacies in particular.

Conducting oral examinations for cancer in general practice: what are the barriers?

Wade, J, Smith, H, Hankins, M, Llewellyn, C. — Thu, 15 Oct 2009 08:12:29 PDT

Background. The incidence of oral (mouth) cancer in the UK is continuing to rise. Individuals who are at greatest risk rarely visit a dentist but do consult general medical practitioners (GMPs). Therefore, GMPs could have an important role in the early detection of oral cancer. Research has shown that GMPs do not opportunistically screen high-risk individuals; however, the barriers to screening are poorly understood.

Objectives. To understand the reasons why GMPs may not screen for oral cancer.

Methods. A questionnaire was developed, using the Theory of Planned Behaviour (TPB), to measure GMPs attitudes to and screening for oral cancer. The questionnaire was designed using all the key theoretical constructs of the TPB and incorporating the themes identified in a qualitative elicitation study. The questionnaire was posted to 499 GPs in Surrey Primary Care trust.

Results. Two hundred and twenty-eight completed questionnaires were returned (46%). Two TPB constructs [subjective norm (e.g. peer pressure) and perceived external control factors (e.g. adequate equipment, time constraints)] were identified as significant predictors of ‘intention’ to perform oral screening. Intention and perceived internal control factors (e.g. self-efficacy) were predictive of actually performing oral screening with patients.

Conclusions. The results of the study suggest that there is considerable potential for improving intention to perform oral cancer screening in general practice. Theory-based interventions could include further training to enhance confidence, expertise, knowledge and ease of examination, the provision of adequate equipment in the surgery and increasing the motivation to comply with significant others by introducing guidelines on opportunistic screening.

Using your electronic medical record for research: a primer for avoiding pitfalls

Terry, A. L, Chevendra, V., Thind, A., Stewart, M., Marshall, J N., Cejic, S. — Wed, 14 Oct 2009 02:33:34 PDT

In Canada, use of electronic medical records (EMRs) among primary health care (PHC) providers is relatively low. However, it appears that EMRs will eventually become more ubiquitous in PHC. This represents an important development in the use of health care information technology as well as a potential new source of PHC data for research. However, care in the use of EMR data is required. Four years ago, researchers at the Centre for Studies in Family Medicine, The University of Western Ontario created an EMR-based research project, called Deliver Primary Health Care Information. Implementing this project led us to two conclusions about using PHC EMR data for research: first, additional time is required for providers to undertake EMR training and to standardize the way data are entered into the EMR and second, EMRs are designed for clinical care, not research. Based on these experiences, we offer our thoughts about how EMRs may, nonetheless, be used for research. Family physician researchers who intend to use EMR data to answer timely questions relevant to practice should evaluate the possible impact of the four questions raised by this paper: (i) why are EMR data different?; (ii) how do you extract data from an EMR?; (iii) where are the data stored? and (iv) what is the data quality? In addition, consideration needs to be given to the complexity of the research question since this can have an impact on how easily issues of using EMR data for research can be overcome.

Peer-based behavioural strategies to improve chronic disease self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research

Funnell, M. M. — Tue, 09 Jun 2009 13:52:44 PDT

The diagnosis of a chronic disease such as diabetes generally evokes strong emotions and often brings with it the need to make changes in lifestyle behaviours, such as diet, exercise, medication management and monitoring clinical and metabolic parameters. The diagnosis thus affects not only the person diagnosed but also the family members. Chronic illnesses are largely self-managed with ~99% of the care becoming the responsibility of patients and their families or others involved in the daily management of their illnesses. While the responsibility for outcomes, such as metabolic control and chronic complications, are shared with the health care team, the daily decisions and behaviours adopted by patients clearly have a strong influence on their future health and well-being. While diabetes self-management education is essential, it is generally not sufficient for patients to sustain behaviours and cope with a lifetime of diabetes. Peers have been proposed as one method for assisting patients to deal with the behavioural and affective components of diabetes and to provide ongoing self-management support.

This paper first describes effective behavioural strategies in diabetes, based on multiple studies and/or meta-analyses, and then provides examples of their use by peers or in peer-based programmes in diabetes. A comprehensive search using the MEDLINE® and Cinahl databases was conducted. Key search terms included peer mentors, peer leaders, peer educators, lay health workers and community health workers. Studies that clearly identified behavioural strategies used by peers were included.

Different models to mobilize peer support to improve diabetes self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research

Heisler, M. — Tue, 17 Mar 2009 12:49:21 PDT

Much of diabetes care needs to be carried out by patients between office visits with their health care providers. Yet, many patients face difficulties carrying out these tasks. In addition, many adults with diabetes cannot count on effective support from their families and friends to help them with their self-management. Peer support programmes are a promising approach to enhance social and emotional support, assist patients in daily management and living with diabetes and promote linkages to clinical care. This background paper provides a brief overview of different approaches to mobilize peer support for diabetes self-management support, discusses evidence to date on the effectiveness of each of these models, highlights logistical and evaluation issues for each model and concludes with a discussion of directions for future research in this area.

Cross-cultural and international adaptation of peer support for diabetes management

Fisher, E. B, Earp, J. A., Maman, S., Zolotor, A. — Tue, 10 Mar 2009 06:09:04 PDT

Peer support may improve self-management among the millions of people with diabetes around the world. A major challenge to international promotion of peer support is allowing for tailoring to population, cultural, health system and other features of specific settings, while also ensuring congruence with standards for what peer support entails. One strategy to address this challenge was used in the Robert Wood Johnson Foundation Diabetes Initiative. Key functions of self-management—Resources and Supports for Self-Management—were identified. Individual programmes were then encouraged to implement these resources and support in ways that were feasible in their settings and responsive to the needs and perspectives of those they serve. Extending this to peer support, three Key functions are (i) assistance in managing and living with diabetes in daily life; (ii) social and emotional support and (iii) linkage to clinical care. International promotion may be advanced by emphasizing these key functions and then encouraging local variation in the specific ways they are addressed. Similarly, evaluation of the general benefits of peer support across several individual programmes may rest on measurement of implementation of the key functions, participants' reports of receipt of them and common end points. Challenges to promoting peer support include integrating peers amidst others in the health care system, harmonizing peers with family and other social networks, maintaining the engagement of peer supporters and those they assist and preventing training, quality improvement and professionalism from distorting the fundamental benefits of support from a peer.

Experiences in peer-to-peer training in diabetes mellitus: challenges and implications

Baksi, A. K — Tue, 03 Mar 2009 07:51:36 PST

This paper briefly describes the functions of peer advisers in diabetes (PADs) and their training. The formal process used in the assessment of the peer advisers at the completion of the training courses is also stated. The findings of a recent randomized controlled trial to study the effectiveness of peer advisers in delivering a programme of education on self-management are also described. The experience gained after the completion of four courses for the training of peer advisers, in addition to a review of the literature, forms the basis for discussion of the subject of peer-to-peer support activities in diabetes. PADs are effective in the provision of one-to-one psychosocial support and advice on self-management. They are also effective as committee members and advocates for diabetes. More recently, they have been shown to be effective as teachers on self-management to their peers with diabetes. With the imminent explosion in the number of people with diabetes, there will be increased need for psychosocial support and in the requirement for the provision of education on self-management. It is unlikely that health services would be given sufficient resources to cope with this. Society should identify alternative resources. People with diabetes and their close carers are the obvious choice, and we need to commence their training now. The implications for primary care are discussed.

The New Zealand experience in peer support interventions among people with diabetes

Simmons, D, Voyle, J., Rush, E., Dear, M. — Mon, 02 Mar 2009 04:16:39 PST

Background. Peer-to-peer support has the potential to assist people with diabetes, or at risk of diabetes.

Objective. To review the development of diabetes peer support initiatives in New Zealand.

Methods. A systematic review of diabetes peer support publications from New Zealand, supplemented by unpublished records from Diabetes New Zealand (DNZ, the national diabetes patient organization) and the two major regional initiatives in South Auckland and Waikato.

Results. DNZ, which has 40 societies and 71 diabetes support groups, delivers a range of services to members and non-members. The membership is mainly older European New Zealanders with diabetes, with some Maori and associated societies for Pacific and Youth. While demand exists, no quantitative evaluation of health impact by these organizations has been undertaken. Other peer support groups have developed in South Auckland and Northland. Common themes that emerge relate to leadership, organization and balancing the different needs of people with diabetes at different stages (e.g. newly diagnosed versus others) and with different personal needs. In South Auckland and the Waikato, lay educators have been trained to provide 1:1 and group sessions for people with, or at high risk of, diabetes. A range of training, management, funding and organizational barriers existed in the implementation of these lay educator programmes.

Conclusions. Peer-to-peer support and education programmes in diabetes have been considered useful in New Zealand. Knowledge regarding training, management and organization is nearing a level, which would allow formal evaluation of a strategy for both the prevention of diabetes and in supporting people with diabetes.

An overview of training curricula for diabetes peer educators

Nettles, A., Belton, A. — Thu, 08 Jan 2009 10:24:34 PST

Global community members who experience similar health problems gravitate to each other for information and support. Peers may be more approachable and can relate to the particular living circumstances one experiences. In well-resourced countries, people have opportunities for learning diabetes self-management; however, empathy may be more helpful when practical barriers arise. Little is published in medical literature about how to foster diabetes peer support and what is published is often limited to English language. Among those programs available, commonalities are readily seen. There is significant evidence that well-informed people cope better with adapting their lifestyle to medical regimens. Professionally delivered diabetes education has been well defined, but there may be additional benefit from learning from those who are living the experience everyday regarding how to navigate health care systems, handle finances, deal with natural emotions or family relations. Diabetes is epidemic and worldwide. There will never be sufficient traditional health care services to meet all future patients needs. While we persist in training health care professionals to deliver better diabetes care, we can explore how to mobilize willing volunteers to provide additional ongoing support to people with diabetes, where they live and work. While the characteristics of a peer educator have been defined slightly differently by several programs, there is agreement across programs that they need to be able to communicate clearly, they need to be willing to learn, they need to have confidence and they need to be flexible and dependable.