Impact of Beef and Beef Product Intake on Cognition in Children and Young Adults: A Systematic Review

(1) Background: Undernutrition and micronutrient deficiency have been consistently linked to cognitive impairment among children and young adults. As a primary source of dietary animal protein, beef consumption holds the potential to improve diet quality and positively influence cognitive function. This study systematically reviewed evidence linking beef intake to cognition among children and young adults. (2) Methods: A literature search was conducted in seven electronic bibliographic databases for studies assessing the impact of beef consumption on cognition. (3) Results: We identified eight studies reporting results from five unique interventions. Two interventions were conducted in Kenya, two in the U.S. and one in four countries including Guatemala, Pakistan, Democratic Republic of the Congo and Zambia. Only one intervention employed a non-feeding control arm and found beef consumption to improve cognitive abilities compared to the control. However, the other interventions comparing beef consumption to other food types found no consistent result. (4) Conclusions: Evidence pertaining to the impact of beef consumption on cognition remains limited due to the small and heterogeneous set of studies. Future research should adopt a population representative sample and longer follow-up period, employ a non-feeding control arm and comprehensively measure nutrient intakes among study participants.

Disparities in mental health care utilization among inpatients in various types of health institutions: a cross-sectional study based on EHR data in Shanghai, China

BACKGROUND

Reform of the health care system in China has prompted concerns about the utilization of mental health services. This study aims to compare the utilization of mental health services among inpatients in various types of health institutions in Shanghai (community health care centres, secondary general hospitals, tertiary general hospitals, and specialty hospitals).

METHODS

Based on electronic health record (EHR) data, we extracted all of the mental hospitalization data from various types of public health institutions in Pudong New Area, Shanghai, China, from 2013 to 2016. The distribution of mentally ill inpatients and the possible factors contributing to the observed differences in these institutions were analysed.

RESULTS

Specialty psychiatric hospitals in Pudong New Area, Shanghai, admitted more inpatients and treated in patients with more severe disorders (49.73%). However, those who were male (OR = 0.545), were elderly (OR = 20.133), had inferior insurance (urban social insurance for citizens: OR = 4.013; paying themselves, OR = 29.489), had a longer length of stay (OR = 1.001) and had lower costs (OR = 0.910) were more likely to choose community health centres than specialty hospitals. Those who preferred the secondary and tertiary hospitals to the specialty ones were more likely to be in the male, elderly, married, shorter length of stay and higher-cost groups. Notably, compared to those with urban social insurance for workers, those who had urban social insurance for citizens (OR = 3.136) or paid out-of-pocket (OR = 9.822) were significantly clustered in the tertiary hospitals rather than the specialty hospitals.

CONCLUSIONS

Inpatients who were male, were older, had inferior insurance, had a longer length of stay and had lower costs preferred the elementary health services. However, the utilization of mental health care in high-tier institutions reflected defects, especially the fact that the current health insurance system does not adequately restrict patients' choices, and those who paid more tended to choose tertiary hospitals instead of professional specialty ones. We suggest that psychiatric services should be enhanced by instituting reforms, including public education, improved health insurance, a forceful referral system, and competency reinforcement for primary care physicians, to provide a more integrated mental health system.

Changing attitudes to psychiatry and interest in the specialty as a career choice during clinical undergraduate years at a medical school in Penang, Malaysia

BACKGROUND

Studies have suggested that the undergraduate clinical clerkship improves medical students' attitudes to psychiatry and career interest in the specialty, but few studies have explored the sustainability of these changes.

AIMS

To explore changes in students' attitudes to psychiatry and career preference for psychiatry during the course of their senior clinical years at RCSI & UCD Malaysia Campus (RUMC).

METHODS

All year 3 students (n = 111) at RUMC were invited to complete the Attitudes towards Psychiatry questionnaire (ATP-30) and a separate questionnaire seeking opinions on career preferences. The questionnaires were administered at 3 points in time: in year 3 before the 8-week psychiatry posting, following completion of the posting in year 4, and at the end of year 5. Quantitative data analysis was performed using SPSS version 18, and free-text responses were thematically analysed.

RESULTS

One hundred completed questionnaires (90.1%) were returned. There was a significant improvement in students' ATP scores after their psychiatry rotation and this was sustained into year 5. Psychiatry as a career choice had highest preference levels following completion of the clerkship but declined in year 5 to below pre-clerkship preference levels. Qualitative analysis of factors influencing a career in psychiatry revealed themes of job satisfaction, lifestyle factors, perceived image of psychiatry, and self-appraisal.

CONCLUSIONS

Our findings suggest that an enriched undergraduate clinical clerkship experience can help to sustain improved attitudes to psychiatry into the final medical year. However, declining interest in the specialty a career choice prior to graduation presents an enduring challenge.

Childhood otitis media: Relationship with daycare attendance, harsh parenting, and maternal mental health

Psychological stress has been linked to developmental problems and poor health in children, but it is unclear whether it is also related to otitis media (OM). As part of a long-term study surveying the characteristics of childcare and development in Taiwan, we analyzed the relationship between OM and sources of psychological stress in children, such as poor maternal mental health and harsh parental discipline. We analyzed the data of 1998 children from the "Kids in Taiwan: National Longitudinal Study of Child Development & Care (KIT) Project" at the age of 3 years. Using bivariate and multivariate logistic regression models, we tested several risk factors as potential independent predictors of two outcomes: parent-reported incidence of OM and child health. The proportion of children who had developed OM in the first 3 years of their life was 12.5%. Daycare attendance (odds ratio [OR]: 1.475; 95% confidence interval [CI]: 1.063-2.046), poor maternal mental health (OR: 1.913; 95% CI: 1.315-2.784), and harsh parental discipline (OR: 1.091; 95% CI: 1.025-1.161) correlated with parent-reported occurrence of OM. These findings suggest that providing psychosocial support to both parents and children might be a novel strategy for preventing OM.

Current needs for the improved management of depressive disorder in community healthcare centres, Shenzhen, China: a view from primary care medical leaders

Background

The prevalence of depressive disorder in Shenzhen is higher than for any other city in China. Despite national health system reform to integrate mental health into primary care, the majority of depression cases continue to go unrecognized and untreated. Qualitative research was conducted with primary care medical leaders to describe the current clinical practice of depressive disorder in community healthcare centres (CHC) in Shenzhen and to explore the participants' perceptions of psychological, organizational and societal barriers and enablers to current practice with a view to identifying current needs for the improved care of depressive disorder in the community.

Methods

Seventeen semi-structured, audio-recorded interviews (approx. 1 h long) were conducted in Melbourne (n = 7) and Shenzhen (n = 10) with a convenience sample of primary care medical leaders who currently work in community healthcare centres (CHC) in Shenzhen and completed any one of the 3-month long, Melbourne-based, "Monash-Shenzhen Primary Healthcare Leaders Programs" conducted between 2015 and 2017. The interview guide was developed using the Theoretical Domain's Framework (TDF) and a directed content analysis (using Nvivo 11 software) was performed using English translations.

Results

Despite primary care medical leaders being aware of a mental health treatment gap and the benefits of early depression care for community wellbeing, depressive disorder was not perceived as a treatment priority in CHCs. Instead, hospital specialists were identified as holding primary responsibility for formal diagnosis and treatment initiation with primary care doctors providing early assessment and basic health education. Current needs for improved depression care included: (i) Improved professional development for primary care doctors with better access to diagnostic guidelines and tools, case-sharing and improved connection with mentors to overcome current low levels of treatment confidence. (ii) An improved consulting environment (e.g. allocated mental health resource; longer and private consultations; developed medical referral system; better access to antidepressants) which embraces mental health initiatives (e.g. development of mental health departments in local hospitals; future use of e-mental health; reimbursement for patients; doctors' incentives). (iii) Improved health literacy to overcome substantive mental health stigma in society and specific stigma directed towards the only public psychiatric hospital.

Conclusions

Whilst a multi-faceted approach is needed to improve depression care in community health centres in Shenzhen, this study highlights how appropriate mental health training is central to developing a robust work-force which can act as key agents in national healthcare reform. The cultural adaption of the depression component of the World Health Organisation's mental health gap intervention guide (mhGAP-IG.v2) could provide primary care doctors with a future training tool to develop their assessment skills and treatment confidence.

Physically active individuals have a 23% lower risk of any colorectal neoplasia and a 27% lower risk of advanced colorectal neoplasia than their non-active counterparts: systematic review and meta-analysis of observational studies

BACKGROUND

Few studies have examined the associations between physical activity (PA), sedentary behaviour (SB) and risk of colorectal neoplasia (CN).

METHODS

We systematically searched Medline, Embase, PsyInfo, Cochrane and other sources from their inception to 30 September 2018 for cohort, case-control and cross-sectional studies that evaluated these associations in asymptomatic, average-risk subjects. Random-effect models were used to estimate relative risks (RRs) of any-type CN, advanced CN, and non-advanced CN, respectively, in individuals with the highest versus the lowest level of PA and SB. Dose-response analyses and subgroup analyses were conducted. The I² statistic was used to examine heterogeneity among studies.

RESULTS

We identified 32 observational studies, including 17 cross-sectional studies, 10 case-control studies and five longitudinal studies. PA (highest vs lowest) was inversely associated with risk for any-type CN (n=23 studies) and advanced CN (n=15 studies), with a RR of 0.77 (95% CI=0.71 to 0.83, I²=57.5%) and 0.73 (95% CI=0.63 to 0.82, I²=45.5%), respectively. There was no association between PA and non-advanced CN (n=5 studies). There was an as association between PA and any-type CN in both sexes, and also for the distal colon. We found no dose-response relationship between PA and any-type or advanced CN. Based on three studies identified, SB time (longest vs shortest) was associated with an increased risk of advanced CN (RR=1.24, 95% CI 1.04 to 1.49, I²=14.4%). No publication bias was detected by Begg's test.

CONCLUSION

We report a 23% lower relative risk of any type of CN and a 27% lower risk of advanced CN in people with the highest level of PA compared with those in the lowest.

Impact of smoking on health system costs among cancer patients in a retrospective cohort study in Ontario, Canada

OBJECTIVE

Smoking is the main modifiable cancer risk factor. The objective of this study was to examine the impact of smoking on health system costs among newly diagnosed adult patients with cancer. Specifically, costs of patients with cancer who were current smokers were compared with those of non-smokers from a publicly funded health system perspective.

METHODS

This population-based cohort study of patients with cancer used administrative databases to identify smokers and non-smokers (1 April 2014-31 March 2016) and their healthcare costs in the 12-24 months following a cancer diagnosis. The health services included were hospitalisations, emergency room visits, drugs, home care services and physician services (from the time of diagnosis onwards). The difference in cost (ie, incremental cost) between patients with cancer who were smokers and those who were non-smokers was estimated using a generalised linear model (with log link and gamma distribution), and adjusted for age, sex, neighbourhood income, rurality, cancer site, cancer stage, geographical region and comorbidities.

RESULTS

This study identified 3606 smokers and 14 911 non-smokers. Smokers were significantly younger (61 vs 65 years), more likely to be male (53%), lived in poorer neighbourhoods, had more advanced cancer stage,and were more likely to die within 1 year of diagnosis, compared with non-smokers. The regression model revealed that, on average, smokers had significantly higher monthly healthcare costs ($5091) than non-smokers ($4847), p<0.05.

CONCLUSIONS

Smoking status has a significant impact on healthcare costs among patients with cancer. On average, smokers incurred higher healthcare costs than non-smokers. These findings provide a further rationale for efforts to introduce evidence-based smoking cessation programmes as a standard of care for patients with cancer as they have the potential not only to improve patients' outcomes but also to reduce the economic burden of smoking on the healthcare system.

The willingness of patients to make the first visit to primary care institutions and its influencing factors in Beijing medical alliances: a comparative study of Beijing's medical resource-rich and scarce regions

BACKGROUND

To improve the efficiency of the use of medical resources, China has implemented medical alliances (MAs) to implement a hierarchical diagnosis and treatment system. The willingness to undertake a first visit to primary care institutions (PCIs) is an important indicator of the effect of this system. Beijing has also built MAs since 2013, but to date, there have been few studies on the first visit to PCIs in Beijing. The purpose of this study is to analyze patients' willingness to make their first visit to PCIs and its influencing factors to provide references for the realization of a hierarchical diagnosis and treatment system.

METHODS

Two relatively different districts with large differences in resources in Beijing, D and F, were selected, and a self-reported questionnaire and convenience sampling method were applied. A cross-sectional survey was administered to 1221 patients of MAs. The chi-square test and binary logistic regression were used to analyze the influencing factors of patients' willingness to undertake a first visit to a PCI.

RESULTS

Fewer patients in District D received medical alliance services (44.42%) than those in District F (59.25%), but patients in District D had a higher degree of satisfaction with the services they received (72.04%) than those in District F (28.96%). Patients in District D had a higher willingness to undertake a first visit (64.00%) than those in District F (58.18%). Patients of an older age, low medical expenses, participation in urban employees' basic medical insurance, a high understanding of MAs and high satisfaction with medical services were indicators of being more willing to choose primary care institutions for their first visit.

CONCLUSIONS

The different medical resources and MA constructions in the two districts have resulted in a difference between the two districts in terms of the willingness of individuals to make their first visit to PCIs. Strengthening the service capabilities of PCIs remains a priority. The government should propose solutions to solve the problems encountered in practice and actively promote the realization of MAs and hierarchical diagnosis and treatment.

Measuring Variation Across Dimensions of Integrated Care: The Maryland Medicaid Health Home Model

Despite the proliferation of initiatives to integrate services for people with serious mental illness (SMI), measures of distinct dimensions of integration, such as spatial arrangement and care team expertise, are lacking. Such measures are needed to support organizations' assessment of progress toward integrated service delivery. We developed measures characterizing integration of behavioral, somatic, and social services to operationalize the integrated care dimensions conceived by the Agency for Healthcare Research and Quality. In a survey fielded to 46 Maryland Medicaid health homes (response rate: 96%) serving adults with SMI during 2015-2016, we found that these measures provided a useful description of variation across dimensions of integration.

Complex Multimorbidity and Breast Cancer Screening Among Midlife and Older Women: The Role of Perceived Need

BACKGROUND AND OBJECTIVES

There is minimal survival benefit to cancer screening for those with poor clinical presentation (complex multimorbidity) or at advanced ages. The current screening mammography guidelines consider these objective indicators. There has been less attention, however, to women's subjective assessment of screening need. This study examines the interplay between complex multimorbidity, age, and subjective assessments of health and longevity for screening mammography receipt.

RESEARCH DESIGN AND METHOD

This cross-sectional study uses self-reported data from 8,938 women over the age of 52 in the 2012 Health and Retirement Study. Logistic regression models estimated the association between women's complex multimorbidity (co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes), subjective health and longevity assessments, age, and screening mammography in the 2 years before the interview. These associations were evaluated adjusting for sociodemographic and behavioral factors.

RESULTS

Both age and complex multimorbidity were negatively associated with screening mammography. However, women's perceived need for screening moderated these effects. Most significantly, women optimistic about their chances of living another 10-15 years were more likely to have had screening mammography regardless of their health conditions or advanced age.

DISCUSSION AND IMPLICATIONS

Women with more favorable self-assessed health and perceived life expectancy were more likely to receive screening mammography even if they have poor clinical presentation or advanced age. This is contrary to current cancer screening guidelines and suggests an opportunity to engage women's subjective health and longevity assessments for cancer screening decision making in both for screening policy and in individual clinician recommendations.

Consensus among healthcare stakeholders on a collaborative medication therapy management model for chronic diseases in Malaysia; A Delphi study

Background

The general problem is lack of inter-professional collaboration and the way private primary care responds to manage chronic diseases in Malaysia. Absence of prescription review, inadequate patient education, the highest percentage of prescribing errors and half of the chronic disease patients are nonadherent. Medicines are the most common and life long used interventions in chronic diseases. Hence, the need to manage medicine in chronic diseases becomes obligatory. As both general practitioner and community pharmacist can dispense medications, this has resulted in a business rivalry. There is a need to build consensus among various healthcare stakeholders for a collaborative medication therapy management model (CMTM) where community pharmacist has an active role in chronic care.

Method

This study utilized modified e-Delphi method to build consensus. A validated e-Delphi survey was administered to a purposive sample of 29 experts. Consensus was pre-defined to be the point where >85% of the experts fall in either agree or strongly agree category for each statement. The inter-expert agreement was computed in both rounds using Intra-class correlation coefficient and Kendall's W. Delphi operates in an iterative fashion till there comes stability in responses. At the end of each round, experts were provided aggregate response, their own response and choice to change their response in the light of aggregate response.

Results

Response rate was 70.73% and 100% in 1^st and 2^nd round, respectively. Consensus was achieved on 119/132 statements which mainly referred to the need, structural and regulatory aspects of CMTM model in Malaysia. However, there were some flashpoints on dispensing separation and means to finance this model. Stability in response of experts was achieved after 2^nd round; hence, no next round was executed.

Conclusion

Overall, the study findings witnessed the expert panel’s support for the CMTM model. Study helped to sketch CMTM model and facilitated development of some recommendations to the authorities which may help to formulate a policy to bring CPs under a working relationship with GPs. Hence, this study should be taken as a call for redefining of the roles of CPs and GPs in Malaysia.

Foeniculum vulgare as Valuable Plant in Management of Women's Health

This review paper evaluates use of Foeniculum vulgare extracts as a popular female plant in management of different ailments of women. Information in this paper was gathered from accessible sources (PubMed, Science Direct, Springer, Wiley, and Google), and traditional books (Persian or English modern traditional books), unpublished data (R&D reports, thesis and dissertation) by keywords based on the words F. vulgare or fennel and women. Efficacy of oral fennel oil in management of dysmenorrhea, premenstrual syndrome, amenorrhea, menopause, lactation, and polycystic ovary syndrome were confirmed according to results of clinical studies. Results of clinical efficacy of fennel oil on menstrual bleeding is complicated, but results of one meta-analysis study revealed that fennel oil significantly increased means of bleeding in the first menstrual periodic cycle (P = 0.001), while fennel oil had no significant effect on bleeding in the second menstrual cycle (P = 0.67). Topical and vaginal fennel extract (5%) exhibited good efficacy in treatment of sexual function, vaginal atrophy, and hirsutism. Fennel had no effect on bone density, or body mass index of menopause women. Results of clinical studies introduce fennel as a valuable medicinal plant in management of women's ailments, but understanding the mechanism of action could be the subject of future studies.

The Provision of Health Care by Family Physicians in Taiwan as Illustrated With Population Pyramids

Family physicians serve as personal doctors for individuals and their families and also act as gatekeepers of the health care system. If no special status is accorded to family physicians, however, then the rates at which health care recipients utilize their service might be affected. In the present cross-sectional study, representative claims data sets for 2010 from Taiwan’s National Health Insurance program, a health care system in which beneficiaries are not required to register with a family physician, were used to investigate the provision of health care to the population by family physicians. Among 919 206 beneficiaries with a total of 13 713 199 ambulatory visits, 49.1% had visited family physicians, 34.1% had visited internists, 24.3% had visited pediatricians, and 38.9% had visited otolaryngologists. Women (χ²(1) = 538, P < .001) and patients aged 65 and above (χ²(1) = 16 000, P < .001) had a higher proportion of visiting family physicians rather than visiting other specialties. The onion-shaped population pyramid with family medicine visits was compatible with the general population, and the proportion of visiting family physicians increased with increasing age. Among 112 289 patients with essential hypertension, 63 379 patients with diabetes mellitus, and 80 090 patients with hyperlipidemia, only 35.3%, 32.0%, and 31.1%, respectively, had visited family physicians. The age and sex distributions of these patients were illustrated with population pyramids for data visualization and direct comparisons. Taken together, the results of this study indicate that the utilization of family physicians in Taiwan and the effectiveness of their associated role in chronic disease management still have room for improvement.

Medical Student Perceptions of the Value of Learning Psychiatry in Primary Care Settings in Penang, Malaysia

OBJECTIVE

The study's objective was to determine the educational value of participation in a consultation/liaison psychiatry service to primary care clinics, from the perspective of Malaysian medical undergraduates.

METHODS

A mixed method design was used. Fourth-year medical students participated in a consultation/liaison psychiatry service to two government-operated primary care clinics. Each student attended two half-day consultations to the clinics during the psychiatry clinical clerkship. Students joined in discussions with primary care clinicians, performed supervised clinical assessments, and administered a depression screening instrument. The learning experience was evaluated through four focus groups, each with 9-10 participants, held throughout the academic year. An end-of-year, anonymous, online questionnaire survey was administered to the entire class. Thematic analysis of focus group transcripts was performed and quantitative statistics were calculated (Stata version 13).

RESULTS

Focus group themes included the following: (a) active learning opportunities in primary care psychiatry consultation had perceived added educational value, (b) students benefited from contact with patients with previously undiagnosed common mental disorders, and (c) students' primary care experience raised their awareness of societal and professional responsibilities. Of the class of 113 students, 93 (82%) responded to the questionnaire. The survey responses reflected the qualitative themes, with 79 respondents (85%) stating that the learning experience met or exceeded their expectations.

CONCLUSIONS

Academic psychiatry has been criticized for its overreliance on secondary care settings in undergraduate clinical teaching. Our findings suggest that supervised clinical placements in primary care are feasible and provide added educational value as a routine component of the undergraduate psychiatry clinical clerkship.

Fundamentals of qualitative analysis in family medicine

The primary purpose of this article is to provide family physician researchers interested in conducting a qualitative research study a concise guide to the analysis. Drawing from approaches outlined in popular research methodology textbooks and employing an exemplar from a minority health disparities research study, this article outlines specific steps useful for researchers and practitioners in the field of family medicine. This process of qualitative data analysis is situated within the larger framework of qualitative research to better position those new to qualitative designs to more effectively conduct their studies. A 10-step process useful for guiding qualitative data analysis is provided. The 10 steps include (1) assembling data for analysis, (2) refamiliarising oneself with the data, (3) open or initial coding procedures, (4) generating categories and assigning codes to them, (5) generating themes from categories, (6) strategies of validation, (7) interpreting and reporting findings from the participants, (8) interpreting and reporting findings from the literature, (9) visual representations of data and findings, and (10) strengths, limitations, delimitations and suggestions for future research. This work provides clear and accessible guidelines for conducting qualitative data analysis for emerging researchers that is applicable across a wide array of topics, disciplines and settings.

Capability of four sigmoidoscopy-based screening strategies to predict proximal neoplasia in an asymptomatic Chinese population

BACKGROUND AND AIM

A proper colonoscopy referral criterion is essential for flexible sigmoidoscopy-based colorectal cancer screening. We aimed to compare the predictive capability of four existing criteria to detect proximal neoplasia (PN) and advanced proximal neoplasia (APN) in a Chinese population.

METHODS

Asymptomatic Chinese participants aged 50-75 years, who received screening colonoscopy, were consecutively recruited. The four criteria included (i) UK flexible sigmoidoscopy; (ii) Italian Screening for COlon REctum; (iii) NORwegian Colorectal Cancer Prevention trial; and (iv) US clinical index. The sensitivity, specificity, positive/negative predictive value, and the number of subjects needed to screen (NNS)/refer (NNR) to detect one APN/PN were examined. The area under receiver operating characteristic curve was evaluated.

RESULTS

Among 5833 subjects, 749 (12.8%) and 151 (2.6%) cases were found to have PN and APN, respectively. US criteria achieved the highest sensitivity for PN (49%) and APN (66%), while UK criteria attained the highest specificity (93%) for PN/APN. The lowest NNS was required by US criteria for PN (16 vs 19-38) and APN (58 vs 69-86), while the lowest NNR was required by UK criteria for PN (3.2 vs 4.0-4.8) and APN (7 vs 10-16). The receiver operating characteristic of all four criteria was 0.57-0.61 for PN and 0.68-0.70 for APN.

CONCLUSIONS

Among all the four criteria, US criteria had the highest sensitivity and lowest NNS, while UK criteria achieved the highest specificity and lowest NNR. Their limited discriminatory capability highlighted the need for a new score to predict PN/APN in Chinese populations.

Getting started in primary care research: choosing among six practical research approaches

While many primary care practitioners want to conduct research, many also struggle with getting started. This article’s purpose is to assist emerging researchers in identifying a topic of interest, to try the ‘fit’ of feasible research approaches and commit to a research approach. The article addresses six objectives: (1) identify how important primary care research comes from clinical stories; (2) recognise how clinical stories become the source of research topics; (3) discern how the research process resembles the care of patients; (4) distinguish the essential features of six research approaches feasible for primary care researchers; (5) evaluate the fit of the six research approaches featured in this special issue; and (6) develop a list of steps that need to be taken to implement primary care research projects. Using ‘HPV (human papilloma) vaccination’ as a hypothetical topic, the article illustrates how an emerging researcher can complete the worksheets. Using the HPV topic, a worksheet illustration shows how to complete the worksheets, and examples from the literature illustrate how actual studies have used six feasible research approaches for primary care: (1) survey research, (2) semistructured qualitative interviews, (3) curriculum development, (4) continuous quality improvement, (5) clinical policy analysis and (6) case study research. The worksheet exercises support choosing a feasible research approach for emerging researchers. Emerging researchers using these exercises can identify a topic, choose a research strategy aligned with the researcher’s interest, create a study title, develop a list of the next steps, and be well positioned to implement an original research project

Mixed methods and survey research in family medicine and community health

Many family medicine and community health researchers use surveys as an original research methodology. Our purpose is to illustrate how survey research provides an important form of quantitative research that can be effectively combined with qualitative data to form a mixed methods study. We first provide an overview of the key principles in survey research and in mixed methods research. We review the various ways that survey can be used in mixed methods studies, citing options such as beginning a study with a survey, using a survey as the second form of data collection, or combining a survey and a form of qualitative data in a single data collection procedure. Finally, we illustrate in a specific example six steps in conducting a mixed methods study using survey research. In a mixed methods study using a survey, primary care researchers should consider six steps. Step 1. Articulate the rationale for mixed methods study. Step 2. Detail quantitative and qualitative databases. Step 3. Identify a mixed methods design. Step 4. Analyse and report the results of the quantitative and qualitative databases. Step 5. Present and show integration. Step 6. Explicate the value of using mixed methods. The ability to combine and integrate survey research into a mixed methods study provides a more rigorous approach to research than conducting only a survey or conducting just a qualitative interview. While requiring skills beyond traditional survey approaches, surveys in primary care offers an opportunity for a high level of sophistication in research methodology.

Continuous quality improvement methodology: a case study on multidisciplinary collaboration to improve chlamydia screening

This article illustrates quality improvement (QI) methodology using an example intended to improve chlamydia screening in women. QI projects in healthcare provide great opportunities to improve patient quality and safety in a real-world healthcare setting, yet many academic centres lack training programmes on how to conduct QI projects. The choice of chlamydia screening was based on the significant health burden chlamydia poses despite simple ways to screen and treat. At the University of Michigan, we implemented a multidepartment process to improve the chlamydia screening rates using the plan-do-check-act model. Steps to guide QI projects include the following: (1) assemble a motivated team of stakeholders and leaders; (2) identify the problem that is considered a high priority; (3) prepare for the project including support and resources; (4) set a goal and ways to evaluate outcomes; (5) identify the root cause(s) of the problem and prioritise based on impact and effort to address; (6) develop a countermeasure that addresses the selected root cause effectively; (7) pilot a small-scale project to assess for possible modifications; (8) large-scale roll-out including education on how to implement the project; and (9) assess and modify the process with a feedback mechanism. Using this nine-step process, chlamydia screening rates increased from 29% to 60%. QI projects differ from most clinical research projects by allowing clinicians to directly improve patients' health while contributing to the medical science body. This may interest clinicians wishing to conduct relevant research that can be disseminated through academic channels.

Fundamentals of case study research in family medicine and community health

The aim of this article is to introduce family medicine researchers to case study research, a rigorous research methodology commonly used in the social and health sciences and only distantly related to clinical case reports. The article begins with an overview of case study in the social and health sciences, including its definition, potential applications, historical background and core features. This is followed by a 10-step description of the process of conducting a case study project illustrated using a case study conducted about a teaching programme executed to teach international family medicine resident learners sensitive examination skills. Steps for conducting a case study include (1) conducting a literature review; (2) formulating the research questions; (3) ensuring that a case study is appropriate; (4) determining the type of case study design; (5) defining boundaries of the case(s) and selecting the case(s); (6) preparing for data collection; (7) collecting and organising the data; (8) analysing the data; (9) writing the case study report; and (10) appraising the quality. Case study research is a highly flexible and powerful research tool available to family medicine researchers for a variety of applications.

Perinatal outcomes of severe preeclampsia/eclampsia and associated factors among mothers admitted in Amhara Region referral hospitals, North West Ethiopia, 2018

Objective

This study was aimed to assess perinatal outcomes of severe preeclampsia/eclampsia and associated factors among mothers admitted in Amhara Region referral hospitals, North West Ethiopia, 2018.

Results

This study revealed that the overall prevalence of unfavorable perinatal outcome from the severe preeclamptic/eclamptic mothers was 46.5%. It shows that the finding of unfavorable perinatal outcome was high which needs an obligation to put our recommendation as improvement of health care set ups for preventions as well as interventions of such problems. Variables which were positively associated with unfavorable perinatal outcomes were: maternal educational status (AOR = 6.6, 95% CI 1.32, 10.03), parity (AOR = 8.3, 95% CI 6.27, 27.02), gestational age in weeks (AOR = 9.6, 95% CI 2, 18.65) and time of drug given for the mother (AOR = 3.8, 95% CI 1.81, 8.07).

Increasing access to smoking cessation treatment among Latino smokers using case management

Introduction

Disparities exist among Latino smokers with respect to knowledge and access to smoking cessation resources. This study tested the feasibility of using case management (CM) to increase access to pharmacotherapy and quitlines among Latino smokers.

Methods

Latino smokers were randomized to CM (n = 40) or standard care (SC, n = 40). All participants received educational materials describing how to utilize pharmacy assistance for cessation pharmacotherapy and connect with quitlines. CM participants received four phone calls from staff to encourage pharmacotherapy and quitline use. At 6-months follow-up, we assessed the utilization of pharmacotherapy and quitline. Additional outcomes included self-reported smoking status and approval for pharmacotherapy assistance.

Results

Using intention-to-treat analysis, CM produced higher utilization than SC of both pharmacotherapy (15.0% versus 2.5%; P = 0.108) and quitlines (12.5% versus 5.0%; P = 0.432), although differences were not statistically significant. Approval for pharmacotherapy assistance programs (20.0% versus 0.0%; P = 0.0005) was significantly higher for CM than SC participants. Self-reported point-prevalence smoking abstinence at 6-months were 20.0% and 17.5% for CM and SC, respectively (P = 0.775).

Conclusions

CM holds promise as an effective intervention to connect Latino smokers to evidence-based cessation treatment.

Semistructured interviewing in primary care research: a balance of relationship and rigour

Semistructured in-depth interviews are commonly used in qualitative research and are the most frequent qualitative data source in health services research. This method typically consists of a dialogue between researcher and participant, guided by a flexible interview protocol and supplemented by follow-up questions, probes and comments. The method allows the researcher to collect open-ended data, to explore participant thoughts, feelings and beliefs about a particular topic and to delve deeply into personal and sometimes sensitive issues. The purpose of this article was to identify and describe the essential skills to designing and conducting semistructured interviews in family medicine and primary care research settings. We reviewed the literature on semistructured interviewing to identify key skills and components for using this method in family medicine and primary care research settings. Overall, semistructured interviewing requires both a relational focus and practice in the skills of facilitation. Skills include: (1) determining the purpose and scope of the study; (2) identifying participants; (3) considering ethical issues; (4) planning logistical aspects; (5) developing the interview guide; (6) establishing trust and rapport; (7) conducting the interview; (8) memoing and reflection; (9) analysing the data; (10) demonstrating the trustworthiness of the research; and (11) presenting findings in a paper or report. Semistructured interviews provide an effective and feasible research method for family physicians to conduct in primary care research settings. Researchers using semistructured interviews for data collection should take on a relational focus and consider the skills of interviewing to ensure quality. Semistructured interviewing can be a powerful tool for family physicians, primary care providers and other health services researchers to use to understand the thoughts, beliefs and experiences of individuals. Despite the utility, semistructured interviews can be intimidating and challenging for researchers not familiar with qualitative approaches. In order to elucidate this method, we provide practical guidance for researchers, including novice researchers and those with few resources, to use semistructured interviewing as a data collection strategy. We provide recommendations for the essential steps to follow in order to best implement semistructured interviews in family medicine and primary care research settings.

Curriculum development: a how to primer

Curriculum development is a topic everyone in the field of medical education will encounter. Due to the breadth of ages and types of care provided in Family Medicine, family medicine faculty in particular need to be facile in developing effective curricula for medical students, residents, fellows and for faculty development. In the area of medical education, changing and evolving learning environments, as well as changing requirements necessitate new and innovative curricula to address these evolving needs. The process of developing a medical education curriculum can seem daunting but when broken down into smaller components can become very straightforward and easy to accomplish. This paper focuses on the curriculum development process using a six-step approach: performing a needs assessment, determining content, writing goals and objectives, selecting the educational strategies, implementing the curriculum and, finally, evaluating the curriculum. This process may serve as a template for Family Medicine educators, and all medical educators looking to design (or redesign) their own medical education curriculum.

Readmission risk and costs of firearm injuries in the United States, 2010-2015

BACKGROUND

In 2015 there were 36,252 firearm-related deaths and 84,997 nonfatal injuries in the United States. The longitudinal burden of these injuries through readmissions is currently underestimated. We aimed to determine the 6-month readmission risk and hospital costs for patients injured by firearms.

METHODS

We used the Nationwide Readmission Database 2010-2015 to assess the frequency of readmissions at 6 months, and hospital costs associated with readmissions for patients with firearm-related injuries. We produced nationally representative estimates of readmission risks and costs.

RESULTS

Of patients discharged following a firearm injury, 15.6% were readmitted within 6 months. The average annual cost of inpatient hospitalizations for firearm injury was over $911 million, 9.5% of which was due to readmissions. Medicare and Medicaid covered 45.2% of total costs for the 5 years, and uninsured patients were responsible for 20.1%.

CONCLUSIONS

From 2010-2015, the average total cost of hospitalization for firearm injuries per patient was $32,700, almost 10% of which was due to readmissions within 6 months. Government insurance programs and the uninsured shouldered most of this.

Cultura de segurança e comunicação sobre erros cirúrgicos na perspectiva da equipe de saúde

Resumo OBJETIVO Analisar a cultura de segurança do paciente em relação às dimensões relativas à comunicação e notificação de eventos na percepção da equipe de saúde. MÉTODO Survey realizado em hospital de ensino do Paraná mediante aplicação do questionário Hospital Survey on Patient Safety Culture a 158 profissionais atuantes em unidades cirúrgicas no período de maio a setembro de 2017. A análise dos dados se deu por estatística descritiva e analítica; dimensões com respostas positivas ≥75% representam áreas fortes para a segurança do paciente. RESULTADOS Nenhuma dimensão ou item/questão foram considerados fortes para a segurança do paciente cirúrgico. Houve diferença, com percepção menos negativa da enfermagem em relação à medicina, nas dimensões “Retorno da informação e comunicação sobre o erro” e “Frequência de relatos de eventos” (p<0,001). CONCLUSÃO A equipe de saúde percebe fragilidade na segurança de pacientes em relação à dimensão comunicação, demandando ações promotoras da segurança do paciente.

Cultural Perspectives on Tobacco Use and Cessation Among Chinese American Immigrants: A Community-Engaged Qualitative Study

INTRODUCTION

Tobacco use is a preventable cause of death among ethnic minorities. Chinese Americans have high smoking rates and underutilize evidence-based cessation therapies. Community members' perspectives on tobacco use and cessation may help bridge treatment gaps and ensure that cessation approaches are aligned with cultural values.

METHODS

Focus group methods were used to explore cultural factors influencing tobacco use and cessation among 50 Chinese immigrants. Emerging themes were identified using thematic analysis.

RESULTS

The three emerging themes are (a) tobacco use is influenced by Chinese American immigrants' socioecological environment, (b) self-discipline determines the ability to quit, and (c) complex family dynamics influence quitting.

DISCUSSION

Cessation approaches framed within cultural perspectives may help bridge treatment gaps. Innovations such as leveraging soft technologies that are widely used in the community may extend the reach of health promotion campaigns and treatments.

Mixed methods in public health research in Taiwan - Using visual diagrams to communicate complex design procedures

Scholars introduce modern mixed methods research (MMR) and its application in public health research in Taiwan. Specifically, they showcase a multi-phased Taiwan cervical cancer screening mixed methods study using visual diagrams to communicate complex design procedures. While some previous researchers have incorporated quantitative and qualitative data in research, here we hope to provide significant clarity to guide those new to the MMR field. We have structured the article in the following way. First, we provide a brief overview of MMR. Second, we illustrate the compelling need for MMR from a public health perspective using cancer screenings as an example. Third, we introduce the Taiwan cervical cancer screening program as an exemplar of MMR application and the utility of visual diagrams. Study methodology can be applied to international researchers and scholars from interdisciplinary fields beyond public health.

The Indonesian general practitioners' perspectives on formal postgraduate training in primary care

BACKGROUND

To be recognized as a primary care physician (PCP), an Indonesian general practitioner (GP) has to follow a formal postgraduate training in primary care. However, 4 years since the regulation was published, the progress of the training is slow. There is a need to deeply investigate the doctors' perspectives, particularly to explore factors associated with their willingness to follow this training.

AIM

This study aims to explore the GPs' views and perspectives related to the formal postgraduate training in primary care that may influence their enrolment in PCP program.

METHODS

We conducted semi-structured interviews with a topic guide. The study took place in Yogyakarta from January to December 2016. The participants were GPs practicing in Yogyakarta primary care clinics who were recruited using purposive-maximum variation sample design. The interviews were audio-recorded and transcribed. The data were analysed using interpretative phenomenological analysis approach.

RESULTS

Nineteen GPs participants were involved in this study. Three major themes were identified, namely unfamiliarity, resistance, and positivism. Almost all the GP participants were unfamiliar with the primary care training program. They were also pessimistic if the training could change the health service in the country while it lacked resources and infrastructures. However, exposure to the training brought positive insights that it could improve the doctors' knowledge and skills in primary care practice.

DISCUSSION

The government intention to establish PCP training is currently on the right tract. However, information dissemination and more supports in primary care are also essential.

Negative Effects of "Predatory" Journals on Global Health Research

Predatory journals (PJ) exploit the open-access model promising high acceptance rate and fast track publishing without proper peer review. At minimum, PJ are eroding the credibility of the scientific literature in the health sciences as they actually boost the propagation of errors. In this article, we identify issues with PJ and provide several responses, from international and interdisciplinary perspectives in health sciences. Authors, particularly researchers with limited previous experience with international publications, need to be careful when considering potential journals for submission, due to the current existence of large numbers of PJ. Universities around the world, particularly in developing countries, might develop strategies to discourage their researchers from submitting manuscripts to PJ or serving as members of their editorial committees.

Preeclampsia: Disease biology and burden, its management strategies with reference to India

Preeclampsia is the cause of significant maternal and fetal mortality and morbidity. It is characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. Preeclamptic women and children born from preeclamptic pregnancies are at greater risk to develop severe cardiovascular complications and metabolic syndromes later in life. The incidence of preeclampsia is estimated to be seven times higher in developing countries as compared to the developed countries. This review summarizes the pathophysiology of preeclampsia, emerging new hypothesis of its origin, risk factors that make women susceptible to developing preeclampsia and the potential of various biomarkers being studied to predict preeclampsia. The health care of developing countries is continuously challenged by substantial burden of maternal and fetal mortality. India despite being a fast developing country, is still far behind in achieving the required maternal mortality rates as per Millennium Development Goals set by the World Health Organization. Further, this review discusses the prevalence of preeclampsia in India, health facilities to manage preeclampsia, current guidelines and protocols followed and government policies to combat this complication in Indian condition.

Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?

The Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of primary health care, reflecting the disappointing implementation of the Alma-Ata declaration of 1978 over the past four decades. The draft Astana declaration (Alma-Ata 2·0), released in June, 2018, restates the key principles of primary health care and renews these as driving forces for achieving the SDGs, emphasising universal health coverage. We use accumulating evidence to show that countries that reoriente their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or low investment in health. We then argue that an even bolder approach, which fully embraces the Alma-Ata vision of primary health care, could deliver substantially greater SDG progress, by addressing the wider determinants of health, promoting equity and social justice throughout society, empowering communities, and being a catalyst for advancing and amplifying universal health coverage and synergies among SDGs.

Health utility scores of family caregivers for leukemia patients measured by EQ-5D-3L: a cross-sectional survey in China

BACKGROUND

This study assessed the health related quality of life of family caregivers (FCs) of leukemia patients by using the health utility scores derived from the EuroQol five-dimensional (EQ-5D) questionnaire.

METHODS

A cross-sectional survey was undertaken on 306 family caregivers of leukemia patients to assess their health utility using the EQ-5D-3L. Participants were recruited from three hospitals in China's Heilongjiang province. The health utility scores of the participants were estimated based on the Chinese EQ-5D-3L value set and compared with those of the local general population. Factors predicting the health utility scores were identified through the Kruskal-Wallis analysis of variance and median regression analyses.

RESULTS

FCs had lower health utility scores than the general population (p < 0.001). The participants with a lower socioeconomic status had lower utility scores and reported more problems than those with a higher socio-economic status. Better family function and higher social support were associated with higher health utility scores. The type of leukemia, household income, and social support are significant predictors of health utility scores of the FCs. Chronic lymphocytic leukemia, low socio-economic status, and low social support are associated with lower health utility scores of the FCs.

CONCLUSIONS

FCs for leukemia patients have lower health utility scores than the local general population, as measured by the EQ-5D-3L. There is an immediate need to address the health concerns of FCs, who play an important role in the Chinese health care system.

Community Health Worker Programs to Improve Healthcare Access and Equity: Are They Only Relevant to Low- and Middle-Income Countries?

Background: Community Health Workers (CHWs) are proven to be highly effective in low- and middle-income countries with many examples of successful large-scale programs. There is growing interest in deploying CHW programs in high-income countries to address inequity in healthcare access and outcomes amongst population groups facing disadvantage. This study is the first that examines the scope and potential value of CHW programs in Australia and the challenges involved in integrating CHWs into the health system. The potential for CHWs to improve health equity is explored.

Methods: Academic and grey literature was searched to examine existing CHW roles in the Australian primary healthcare system. Semi-structured telephone interviews were conducted with a purposive sample of 11 people including policymakers, program managers and practitioners, to develop an understanding of policy and practice.

Results: Literature on CHWs in Australia is sparse, yet combined with interview data indicates CHWs conduct a broad range of roles, including education, advocacy and basic clinical services, and work with a variety of communities experiencing disadvantage. Many, and to some extent inconsistent, terms are used for CHWs, reflecting the various strategies employed by CHWs, the characteristics of the communities they serve, and the health issues they address. The role of aboriginal health workers (AHWs) is comparatively well recognised, understood and documented in Australia with evidence on their contribution to overcoming cultural barriers and improving access to health services. Ethnic health workers assist with language barriers and increase the cultural appropriateness of services. CHWs are widely seen to be well accepted and valuable, facilitating access to health services as a trusted ‘bridge’ to communities. They work best where ‘health’ is conceived to include action on social determinants and service models are less hierarchical. Short term funding models and the lack of professional qualifications and recognition are challenges CHWs encounter.

Conclusion: CHWs serve a range of functions in various contexts in Australian primary healthcare (PHC) with a common, valued purpose of facilitating access to services and information for marginalised communities. CHWs offer a promising opportunity to enhance equity of access to PHC for communities facing disadvantage, especially in the face of rising chronic disease.

Diagnostic Performance of Intestinal Fusobacterium nucleatum in Colorectal Cancer: A Meta-Analysis

Background:

Increasing evidence has supported the link of intestinal Fusobacterium nucleatum infection to colorectal cancer (CRC). However, the value of F. nucleatum as a biomarker in CRC detection has not been fully defined. In order to reduce the random error and bias of individual research, this meta-analysis aimed to evaluate the diagnostic performance of intestinal F. nucleatum in CRC patients and provide evidence-based data to clinical practice.

Methods:

An article search was performed from PubMed, Embase, Cochrane Library, and Web of Science databases up to December 2017, using the following key words: “Fusobacterium nucleatum”, ”Fusobacterium spp.”, ”Fn”, “colorectal cancer(s)”, “colorectal carcinoma(s)”, “colorectal neoplasm(s)”, and “colorectal tumor(s)”. Articles on relationships between F. nucleatum and CRC were selected according to the preestablished inclusion and exclusion criteria. This meta-analysis was performed using STATA 12.0 software, which included mapping of forest plots, heterogeneity tests, meta-regression, subgroup analysis, sensitivity analysis, and publication bias. The sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and their corresponding 95% confidence interval (CI) of each eligible study were summarized.

Results:

Finally, data for 1198 participants (629 CRC and 569 healthy controls) in 10 controlled studies from seven articles were included. The summary receiver operator characteristic curve was mapped. The diagnostic performance of intestinal F. nucleatum infection on CRC was as follows: the area under the curve: 0.86 (95% CI: 0.83–0.89), the pooled sensitivity: 0.81 (95% CI: 0.64–0.91), specificity: 0.77 (95% CI: 0.59–0.89), and DOR: 14.00 (95% CI: 9.00–22.00).

Conclusion:

Intestinal F. nucleatum is a valuable marker for CRC diagnosis.

Detecting Land Use Changes in a Rapidly Developing City during 1990–2017 Using Satellite Imagery: A Case Study in Hangzhou Urban Area, China

As one of the rapidly-developing mega cities in China, Hangzhou has experienced great land use change during the past three decades. By analyzing land use change in designated period, it is beneficial to understand urbanization process in Hangzhou, and undertake further urban management and urban planning. In this study, the land use change from 1990 to 2017 in Hangzhou urban area was detected by a method of supervised classification with Landsat TM images from 1990, 1997, 2004, 2010 and 2017, and analyzed by a Markov matrix. The results show that from 1990 to 2017, a great deal of rural areas transformed into built up areas in the Hangzhou urban area. Consequently, the urban area of Hangzhou increased eight times over the period from 1990 to 2017. This may imply that such a change should be directly related to the Chinese government policy, of which the main factor is rapidly-developing urbanization in China, such as in Hangzhou. Thus, it is believed that China’s land use change is going to be small in the following decades. This may indicate that China’s urban construction is slowing down, while its urban planning is being shifted from construction to management.

Performance of multitarget stool DNA testing in African American patients

BACKGROUND

Multitarget stool DNA (mt-sDNA) is an approved method for colon cancer screening that is especially relevant for patients who cannot undergo colonoscopy. Although the test performance has been evaluated in a large clinical trial, it was limited to a predominantly white population. Given differences in the epidemiology and biology of colon cancer in African American individuals, the authors sought to compare the performance of mt-sDNA between racial groups.

METHODS

The authors prospectively identified patients aged ≥40 years who were referred for colonoscopy at an academic medical center and 2 satellite facilities. Prior to the colonoscopy, the authors collected stool for mt-sDNA and fecal immunochemical testing (FIT). They compared the sensitivity, specificity, and receiver operating characteristic curve between African American and white patients for the detection of advanced lesions or any adenoma.

RESULTS

A total of 760 patients were included, 34.9% of whom were African American. The prevalence of any adenoma (38.9% for African American patients and 33.9% for white patients) and that for advanced lesions (6.8% and 6.7%, respectively) were similar between groups. The overall sensitivities of mt-sDNA for the detection of advanced lesions and any adenoma were 43% and 19%, respectively, and the specificities were 91% and 93%, respectively. In general, mt-sDNA was more sensitive and less specific than FIT. When stratified by race, the sensitivity, specificity, and receiver operating characteristic curve area were similar between African American and white patients for both mt-sDNA and FIT.

CONCLUSIONS

Test performance characteristics of mt-sDNA were comparable in African American and white patients. Given the lower uptake of colonoscopy in African American individuals, mt-sDNA may offer a promising screening alternative in this patient population.

An epidemiological study of dental caries and associated factors among children residing in orphanages in Kerala, India: Health in Orphanages Project (HOPe)

BACKGROUND

It is estimated that, as of 2010, there were 32 million orphaned children in India. There is little published information on the oral health of children in orphanages in India.

AIM

To determine caries status and associated risk factors among children in orphanages in Kerala, India.

METHODS

This cross-sectional study assessed caries using World Health Organization (WHO) criteria, and caries experience was reported as decayed, missing and filled primary or secondary teeth (dmft or DMFT, respectively). A brief questionnaire captured information on child oral health behaviours. Mean [standard deviation (SD)] and median [interquartile range (IQR)] scores were used to describe caries rates. Multivariable logistic regression analysis was conducted to identify independent disease predictors. Study design complexities, such as clustering by orphanage and stratification by district, were accounted for in the multivariable regression analysis. This was carried out using the survey commands in STATA 13. A value of P<0.05 was considered as statistically significant.

RESULTS

Overall, 1,137 children residing in 31 orphanages across the State of Kerala were recruited to the study. Female children made up 82% of the sample. In 6-year-old children the prevalence of caries was 77% and the mean dmft score was 3.60 (SD= 3.50); in 12-year-old children the prevalence of caries was 44% and the mean DMFT score was 1.35 (SD = 1.96). Among 12-year-old children, those who reported being shown how to clean their teeth were less likely to have caries (odds ratio = 0.62; 95% confidence interval: 0.38-0.95).

CONCLUSION

Caries rates among children in orphanages were much higher than among children in the general population in Kerala. There is an urgent need for evidence-based and sustainable primary prevention strategies to reduce the burden of caries in this highly vulnerable population.

A 10-year review of health care reform on Family Practice Integrated Care Project-Taiwan experience

OBJECTIVE

Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness of this nationwide demonstration programme over a 10-year period.

METHODS

Papers and reports related to the FPICP published both in English and in Chinese from 2003 to 2015 were collected systematically based on keywords including 'family doctor', 'primary care', 'integrated care' and 'Taiwan'. Also collected and reviewed were national health insurance administration annual reports and related publications from Taiwan Association of Family Medicine. Quality care indicators including structure, process and outcome for programme monitoring were reported.

RESULTS

Up to June 2015, the project had enrolled a total of 10.5% of Taiwan's population. Approximately 24.9% of primary care physicians and 29.7% of community clinics joined the project to serve the members of 426 community health care groups (CHCGs). Compared to non-members, CHCG members received more preventive care services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (43% versus 31%) (P < 0.01). Members showed a markedly high level of satisfaction (>95%), especially in overall satisfaction, provision of health consultation and information, and improvement in understanding personal health condition.

CONCLUSIONS

In the future, through the support of family physicians and CHCGs, a person-centred integrated health care delivery system can be an effective solution to the current barriers in the medical care system.

What Can Be Learned from Health-Related Tensions and Disparities in Ultra-Orthodox Jewish Families?

Promoting healthy lifestyle from early childhood is a key objective in public health, yet health behaviors are often culturally driven, especially in closed-religious communities. This study aims to reveal key cultural-religious aspects of attitudes and behaviors regarding lifestyle in one such closed community-the ultra-orthodox Jewish community. In-depth interviews were conducted with 20 participants: religious leaders, educational figures, psycho-medical professionals from two major ultra-orthodox communities in Israel. A thematic analysis was used to reveal key themes in the interviews. We found tensions between conflicting themes in the parenting, nutrition and physical activity domains, while the sleep domain illustrated cultural solution for a tension. By illuminating the perceptional components of lifestyle, the study contributes to better foundations of health promotion in closed-religious communities.

Measuring inequalities in the demographical and geographical distribution of physicians in China: Generalist versus specialist

OBJECTIVE

The equitable distribution of both generalist and specialist physicians is vital in establishing a fair and efficient health care system. The presents study aims at comparatively measuring the demographical and geographical distribution of generalist and specialist physicians in China from 2012 to 2016.

METHODS

The data were obtained from China Health and Family Planning Statistics and China Statistical Yearbooks 2013 to 2017. Descriptive statistical methods were used to address the quantity and density of physicians, and Gini coefficient was adopted as inequality indicator to trace their distribution inequalities.

RESULTS

The quantity and density of total physicians, generalist, and specialist physicians increased during the last 5 years. The demographic distribution inequalities of total physicians, generalist, and specialist physicians are decent with Gini coefficients of approximately 0.3, whereas the corresponding geographical distribution inequalities are severe with Gini coefficients higher than 0.6. Compared with generalist physicians, specialist physicians not only had a higher geographical and geographical density but also maintained a more equitable distribution.

CONCLUSION

The present study compares the distribution inequalities between generalist and specialist physicians in China for the first time. Despite the rapid increase in quantity and density of these physicians, the whole nation faces a severe shortage and maldistribution of generalist physicians. The increase in the number of physicians has not necessarily eliminated the geographical distribution inequalities. The government should consider all influencing factors when allocating health workers and continue promoting the development of primary health care to alleviate these inequalities in physician distribution.