Doctors' experience providing primary care for refugee women living with chronic pain: a qualitative study

BACKGROUND

The experiences of GPs in Australia highlight key considerations regarding workload demands, remuneration incentives and the practical implications of working in regions with high ethnic density. This exploration helps to understand the elements that influence GPs delivery of care, particular for refugee women who exhibit disproportionately higher rates of chronic pain. This qualitative study explored the experiences of GPs providing care for refugee women living with chronic pain.

METHODS

Semi-structured interviews were undertaken with 10 GPs (9 female and 1 male) practicing across metropolitan Melbourne, Australia. GPs were recruited via purposive sampling and a snowballing strategy. Participants work experience ranged from one to 32 years. Audio recordings of the interviews were transcribed verbatim and stored in qualitative data Nvivo 12 software for coding. Transcripts of interviews were analysed thematically using a phenomenological approach.

RESULTS

Three overarching themes were identified: (1) meeting the needs of refugee women living with chronic pain; (2) the role of the GP; and (3) the challenges of the health care system. These themes reflected the complexity of consultations which arose, in part, from factors such as trust, the competencies of clinician's and the limitations posed by time, funding and interpreter use.

CONCLUSION

GPs acknowledged the uniqueness of refugee women's chronic pain needs and whilst doctors welcomed care, many were often challenged by the complex nature of consultations. Those that worked in settings that aligned with refugee women's needs highlighted the importance of cultivating culturally safe clinical environments and listening to their patients' stories. However, system level challenges such as time, funding and resource constraints created significant challenges for GPs. Exploring GPs experiences allows for a better understanding of how vectors of disadvantage intersect in health care and highlights the need to better support doctors to improve health care provision for refugee women living with chronic pain.

Multifaceted intervention to increase the delivery of alcohol brief interventions in primary care: a mixed-methods process analysis

BACKGROUND

Brief interventions (BIs) are effective for reducing harmful alcohol consumption, but their use in primary care is less frequent than clinically indicated. The REducing AlCohol- related Harm (REACH) project aimed to increase the delivery of BIs in primary care.

AIM

To assess the effectiveness of the REACH programme in increasing alcohol BIs in general practice and explore the implementation factors that improve or reduce uptake by clinicians.

DESIGN AND SETTING

This article reports on a sequential, explanatory mixed-methods study of the implementation of the REACH project in six general practice clinics serving low-income communities in Melbourne, Australia.

METHOD

Time-series analyses were conducted using routinely collected patient records and semi-structured interviews, guided by the consolidated framework for implementation research.

RESULTS

The six intervention sites significantly increased their rate of recorded alcohol status (56.7% to 60.4%), whereas there was no significant change in the non-intervention practices (344 sites, 55.2% to 56.4%).

CONCLUSION

REACH resources were seen as useful and acceptable by clinicians and staff. National policies that support the involvement of primary care in alcohol harm reduction helped promote ongoing intervention sustainability.

Effectiveness of weight management interventions for adults delivered in primary care: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To examine the effectiveness of behavioural weight management interventions for adults with obesity delivered in primary care.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

ELIGIBILITY CRITERIA FOR SELECTION OF STUDIES

Randomised controlled trials of behavioural weight management interventions for adults with a body mass index ≥25 delivered in primary care compared with no treatment, attention control, or minimal intervention and weight change at ≥12 months follow-up.

DATA SOURCES

Trials from a previous systematic review were extracted and the search completed using the Cochrane Central Register of Controlled Trials, Medline, PubMed, and PsychINFO from 1 January 2018 to 19 August 2021.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Meta-analyses were conducted with random effects models, and a pooled mean difference for both weight (kg) and waist circumference (cm) were calculated.

MAIN OUTCOME MEASURES

Primary outcome was weight change from baseline to 12 months. Secondary outcome was weight change from baseline to ≥24 months. Change in waist circumference was assessed at 12 months.

RESULTS

34 trials were included: 14 were additional, from a previous review. 27 trials (n=8000) were included in the primary outcome of weight change at 12 month follow-up. The mean difference between the intervention and comparator groups at 12 months was -2.3 kg (95% confidence interval -3.0 to -1.6 kg, I²=88%, P<0.001), favouring the intervention group. At ≥24 months (13 trials, n=5011) the mean difference in weight change was -1.8 kg (-2.8 to -0.8 kg, I²=88%, P<0.001) favouring the intervention. The mean difference in waist circumference (18 trials, n=5288) was -2.5 cm (-3.2 to -1.8 cm, I²=69%, P<0.001) in favour of the intervention at 12 months.

CONCLUSIONS

Behavioural weight management interventions for adults with obesity delivered in primary care are effective for weight loss and could be offered to members of the public.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021275529.

Obesity management in primary care: systematic review exploring the influence of therapeutic alliance

PURPOSE

To identify the influence of the therapeutic alliance on the effectiveness of obesity interventions delivered in primary care.

METHOD

Systematic review of randomized controlled trials of primary care interventions for adult patients living with obesity. Comprehensive search strategy using the terms 'obesity', 'primary care' and 'intervention' of seven databases from 1 January 1998 to March 2018. Primary outcome was difference in weight loss in interventions where a therapeutic alliance was present.

RESULTS

From 10 636 studies, 11 (3955 patients) were eligible. Only one study had interventions that reported all aspects of therapeutic alliance, including bond, goals and tasks. Meta-analysis was not included due to high statistical heterogeneity and low numbers of trials; as per our protocol, we proceeded to narrative synthesis. Some interventions included the regular primary care practitioner in management; very few included collaborative goal setting and most used prescriptive protocols to direct care.

CONCLUSIONS

We were surprised that so few trials reported the inclusion of elements of the therapeutic alliance when relational aspects of primary care are critical for effectiveness. Interventions could be developed to maximize therapeutic relationships and research reports should describe interventions comprehensively.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42018091338 in PROSPERO (International prospective register of systematic reviews).

Feasibility of identifying and describing the burden of early-onset metabolic syndrome in primary care electronic medical record data: a cross-sectional analysis

BACKGROUND

The prevalence of metabolic syndrome is growing worldwide, yet remains underinvestigated in Canadian young adults. We sought to explore the use of a harmonized case definition specific to early-onset metabolic syndrome and determine its feasibility in assessing the prevalence of metabolic syndrome among electronic medical record (EMR) data of young adults in Northern Alberta.

METHODS

We conducted a cross-sectional study using a sample of EMR data from young adult patients aged 18-40 years and residing in Northern Alberta, who had an encounter with a participating primary care clinic between June 29, 2015, and June 29, 2018. Physical examination, laboratory investigation and disease diagnosis data were collected. A case definition and algorithm were developed to assess the feasibility of identifying metabolic syndrome, including measures for body mass index (BMI), blood pressure (BP), dysglycemia, hypertriglyceridemia, high-density lipoprotein cholesterol, diabetes and hypertension.

RESULTS

Among 15 766 young adults, the case definition suggested the prevalence of metabolic syndrome was 4.4%, 95% confidence interval (CI) 4.1%-4.7%. The most frequent 3-factor combination (41.6%, 95% CI 37.9%-45.3%) of metabolic syndrome criteria consisted of being overweight or obese, having elevated BP and hypertriglyceridemia. Half of metabolic syndrome cases (51.3%, 95% CI 47.6%-55.0%) were missing measures for fasting blood glucose, and one-fifth were missing a hemoglobin A_1c (HbA_1c) level. Notably, most young adults with a BMI of 25 or greater were missing HbA_1c (68.7%, 95% CI 67.6%-69.8%), fasting blood glucose (84.0%, 95% CI 83.2%-84.8%) and triglyceride testing (79.0%, 95% CI 78.1%-79.9%).

INTERPRETATION

We have shown that our case definition is feasible in identifying early-onset metabolic syndrome using EMR data; however, the degree of missing data limits the feasibility in assessing prevalence. Further investigation is required to validate this case definition for metabolic syndrome in the EMR data, which may involve comparing this definition to other validated metabolic syndrome case definitions.