Sex difference in the association between excessive daytime sleepiness and health-related quality of life in community-dwelling older adults: The Yilan study, Taiwan

OBJECTIVES

The association between excessive daytime sleepiness and health-related quality of life among older adults and at-risk individuals remains unclear. This study examined relationships between excessive daytime sleepiness and unfavorable health-related quality of life and explored the moderating effect of sex.

STUDY DESIGN

This was a community-based study of adults aged 65 years or more. Excessive daytime sleepiness was defined as a score exceeding 10 on the Epworth Sleepiness Scale. Multiple logistic regression analyses were used to examine the relationships between excessive daytime sleepiness and health-related quality of life. The moderating effect of sex was examined by testing interaction terms.

MAIN OUTCOME MEASURES

Health-related quality of life was measured using the Short Form 12 Health Survey, which includes a physical component summary and a mental component summary. Unfavorable health-related quality of life was defined as the lowest tertile of the scores for both components.

RESULTS

In total, 3788 individuals participated. After controlling for covariates, older adults with excessive daytime sleepiness did not have an unfavorable physical component summary but were more likely to have an unfavorable mental component summary (odds ratio 1.96; 95 % confidence interval 1.47-2.61). When stratified by sex, excessive daytime sleepiness was associated with a poor physical component summary in men (odds ratio 1.77, 95 % confidence interval 1.00-3.13) but not in women.

CONCLUSIONS

Excessive daytime sleepiness was associated with a poor mental component summary in both sexes; however, the association with a poor physical component summary was specific to men.

The Role of Chief Medical officers in making Public Health Overview Documents in Norwegian Municipalities. A qualitative Study

AIMS

To investigate how Chief Medical Officers experience their role in the municipalities´ work with making the public health overview documents, demanded by the Norwegian Public Health Act from 2012.

METHODS

A qualitative study with semi-structured focus group interviews with 21 Chief Medical Officers from 20 different municipalities in Norway. The interviews were conducted in 2017. The data were analyzed thematically.

RESULTS

The Chief Medical Officers were mainly positive to participating in making public health overview documents. They took on roles as leaders of the work, medical advisors, data collectors towards local GPs and listening post to other sectors. Organizational factors like too small positions and a lack of tradition to involve the CMO in public health work were experienced as barriers to their involvement. The collaboration with the public health coordinators was said to be rewarding, and the intersectoral process involved employees from other sectors in a new way in public health. Although there were some positive experiences, several CMOs considered the use and impact of the public health overview document as limited.

CONCLUSION

There was a large variation in the amount and the type of involvement the Chief Medical Officers had in making the public health overview documents in Norwegian municipalities. More research is needed to understand if this has any consequences for the quality of public health work in the municipalities and whether it is a sign of a changing role of the Chief Medical Officers.

Healthcare utilization is increased in children living in urban areas, with ethnicity-related disparities: A big data analysis study

This study aimed to investigate differences in pediatric healthcare utilization in Israel over 10 years by examining differences across populations defined by living environment and ethnicity. Data was obtained from the Clalit Health Care data warehouse, covering over 250,000 children residing in Haifa and Western Galilee districts. The population groups were categorized based on ethnicity (Jewish vs Arab) and residential settings (urban vs rural). Healthcare utilization was consistently higher among Jewish than Arab children, irrespective of the specific dimension analyzed. Additionally, urban-dwelling children exhibited higher usage rates than those residing in rural areas in all investigated dimensions. However, Jewish children showed significantly about 18% lower hospitalization rates than Arab children across all years (P < 0.001). No significant differences in hospitalizations were observed between urban and rural children (RR 0.999, CI (0.987-1.011)). Notably, the study revealed reduced antibiotic consumption and hospitalizations over the years for all populations. Additionally, we found that Arab children and those living in rural areas had reduced access to healthcare, as evidenced by 10-40% fewer physician visits, laboratory tests, and imaging (P < 0.001).    Conclusion: This study highlights the substantial population-based disparities in healthcare utilization among children in Israel despite the equalizing effect of the national health insurance law. Rural and low socioeconomic populations seem to have reduced healthcare access, showing decreased healthcare utilization. Consequently, it is imperative to address these disparities and implement targeted interventions to enhance healthcare access for Arab children and rural communities. The decline in antibiotic usage and hospitalizations suggests positive trends in pediatric health care, necessitating ongoing efforts to ensure equitable access and quality of care for all populations. What is Known: • Healthcare systems worldwide vary in coverage and accessibility, including Israel, which stands out for its diverse population. • Existing research primarily focuses on healthcare utilization among adults, leaving a need for comprehensive data on children's healthcare patterns globally. What is New: • Investigating over 250,000 children, this study reveals higher healthcare utilization among Jewish and urban children across all dimensions. • Despite Israel's national health insurance law, the study underscores the significant population-based disparities in healthcare utilization.

[Choice of Family and Community Medicine in the MIR 2002-2023: An objective approach shows that it is as highly valued as hospital specialties]

INTRODUCTION

Currently there is a shortage of general practitioners (GP), and this is expected to increase in the coming years. Despite this need, it is a specialty that is supposedly little demanded, leaving specialized training places unfilled in recent years. The purpose of this study is to present new parameters to more objectively measure the demand and the relationship between supply and demand.

METHODS

A database was used with the results of the places assigned in the MIR calls from 2002 to 2023. The calculated parameters were quoting index (CI), quote order, the order of top demand and the order of total demand of the GP specialty. The software R version 4.3.02 was used for statistical analysis.

RESULTS

The specialty quotation and top demand have remained constant during the study period, while there has been a slight and progressive worsening of the total demand. Nevertheless, the total demand for Family Medicine in the last call for MIR exam was higher than that for specialties such as urology, neurology, ENT, endocrinology, oncology, intensive care medicine or neurosurgery, among others.

CONCLUSIONS

In contrast to the subjective perception of the worsening attractiveness Family Medicine in the last MIR calls, using objective parameters, we found that the attractiveness of the specialty, measured as quotation (supply/demand ratio) and demand, has remained stable (with a slight worsening of total demand).

[Approach to Childhood Obesity in Spain. A comparison among autonomies]

OBJECTIVE

Childhood obesity represents a serious public health problem and given its multifactorial nature and its consequences; it is necessary to carry out an effective approach. The Spanish system of autonomies, with delegated powers, could accentuate inequality in its approach. The objective of the study was to know the existence or not of these inequalities.

METHODS

A descriptive cross-sectional study was carried out between the months of February-April 2022, in which the approach to childhood obesity was compared among the seventeen communities and two autonomous cities, through the analysis of the following indicators: pediatric staff, pediatric nursing, nutrition personnel and their legal recognition, the existence of comprehensive plans and health expenditure on childhood obesity. The search for information has been carried out through a bibliographic review and a request for access to public information to the corresponding regional councils. It were performed ratios of paediatricians and nurses per 1,000 inhabitants and health expenditure per inhabitant were calculated.

RESULTS

It was observed that in Spain paediatricians have a ratio according to international recommendations (1.21), but not general and paediatric nursing (with a ratio of 0.65, which is equivalent to approximately 1,544 inhabitants for each nurse), and nutrition professionals. Among autonomies there were large variations for the three categories. Comprehensive plans were outdated or absent altogether, as well as the periodic analysis of obesity expenditure.

CONCLUSIONS

The approach to childhood obesity seems to vary considerably among autonomies according to the analysed indicators. Thus, it would be advisable to lead all efforts to homogenize it, to improve care quality and prevention and treatment choices in all national regions.

The enhanced paper grip test can substantially improve community screening for the risk of falling

BACKGROUND

Lower-limb strength measures can enhance falls risk assessment but due to the lack of clinically applicable methods, such measures are not included in current screening. The enhanced paper grip test (EPGT) is a simple-to-use and cost-effective test that could fill this gap. However, its outcome measure (EPGT force) has not yet been directly linked to the risk of falling.

RESEARCH QUESTION

Is the EPGT a good candidate for falls risk screening in older people in the community?

METHODS

Seventy-one older people living independently in the community were recruited for this prospective observational study (median age 69 y, range 65y-79y). Lower-limb and whole-body strength were assessed at baseline using the EPGT and a standardised hand-grip method respectively. Incident falls were recorded monthly for a year through follow-up telephone conversations. The capacity of individual strength measures to predict falls and to enhance an established falls risk assessment tool (FRAT) commonly used by UK's national health service (NHS) was assessed using binomial logistic regression. The analysis was repeated for the subset of participants without history of falling at baseline (prediction of first-ever falls).

RESULTS

Increased EPGT force and increased symmetry in strength between limbs were significantly associated with reduced risk of falling. Compared to the NHS-FRAT, the EPGT correctly classified more people (73% vs 69%), it achieved higher sensitivity (56% vs 26%) and higher negative predictive value (76% vs 68%). Complementing the NHS-FRAT with the EPGT produced a more comprehensive model that correctly classified 91% of participants and achieved 98% specificity, 81% sensitivity, 89% negative and 96% positive predictive value. Replacing the EPGT with hand-grip strength consistently undermined prediction accuracy. The EPGT remained highly accurate when focused on the prediction of first-ever falls.

SIGNIFICANCE

The EPGT can substantially enhance falls screening in the community. These results can also inform effective personalised strength exercise interventions.

Family Adoption Program for Undergraduate Medical Students at a New Medical School of Jharkhand: An Experience and SWOC Analysis

Introduction

Family adoption program (FAP) incorporated into the undergraduate medical education curriculum is beneficial to all stakeholders involved. Many medical colleges have started FAP at different times and various levels based on resources availability, feasibility, and accessibility. This article is intended to cover the process of FAP implementation, the strength, weakness, opportunities, and challenges at various levels, and its scope in future.

Methodology

FAP was launched by adopting a hamlet 17 km away from the college. During the foundation course, orientation lessons and logbook discussions were conducted online before the actual field visit. During the initial visit, families were assigned, which was followed by collecting sociodemographic information, a plantation drive, and organizing medical camp/ door to door screening in the last visits for phase one students.

Observations

The strengths perceived were early community exposure of students and leadership skills, and the weaknesses were allocating adequate number of slots in the curriculum, adopting families far away, etc., Similarly, FAP has an opportunity to achieve the larger goal of Heath for All in terms of identifying, following up, and managing various socio clinical cases in the adopted families. However, few challenges can pose as it progresses across other phases, such as language problem, allotment of problem families, existing social pathology in family, cultural taboos, etc.

Conclusion

The article suggests that once a student leaves, another student should continue the cycle of adoption and provide continuum care of services to prevent the family from being orphaned.

Development and Validation of a Questionnaire to Measure a Medical Student's Interest in the Subject of Community Medicine

Background

Lack of interest has been cited by many studies as the predominant cause for students undervaluing the subject of Community Medicine. However, there are few valid and reliable tools that could measure this interest. To develop and validate a questionnaire to measure a medical student's interest in the subject of Community Medicine.

Material and Methods

Cross-sectional study conducted at MTMC Jamshedpur. The Community Medicine Interest Questionnaire (CMIQ) was developed in two phases: item generation and item reduction. Items were generated through a review of the literature, focused group discussions, and in-depth interviews. In the item reduction phase, the content and construct validity of the questionnaire were ascertained. Content validity was carried out by a group of experts based on three parameters: the interrater agreement on the representativeness of the item, the interrater agreement on the clarity of the items, and the content validity index. The construct validity was ascertained through pilot testing of 480 responses from undergraduate medical students. Exploratory factor analysis through principal axis factoring and Promax rotation.

Results

Twenty-five items were generated. Three of these items were removed following expert validation. Furthermore, three items were removed after pilot testing. The resulting CMIQ consisted of 19 items distributed over three dimensions: feeling, value, and predisposition to reengage toward the subject. The internal consistency of each of the subscales was ascertained.

Conclusions

CMIQ is a valid and reliable tool that can be used to measure such interest for providing educational interventions.

Training items for trainee residents in community medicine in rural areas

OBJECTIVE

To examine the significant events experienced by initial trainees during community medicine training, evaluate their impact on community medicine practice, and support improvements in rural community medicine training.

RESULTS

Three faculty teachers independently evaluated the reports of 25 residents who had completed a four-week community medicine training in a rural area to analyze major events. The reports were analyzed using topics from the Model Core Curriculum for Medical Education that relate to rural medicine. The most frequently reported items were identified as follows: Primary care: 9 (36.0%); integrated community care systems: 8 (32.0%); medical care in the local community: 7 (28.0%); home health care and systems, patient-physician relationship, and end-of-life medical treatment and care: 6 each (24.0%). Reports from residents describing events related to home health care and systems and end-of-life medical treatment and care were related to more than one item.

Contribution of Medical Education through Role Playing in Community Health Promotion: A Review

Background

Didactic lecture is most commonly used method to teach medical students in Family and Community Medicine. However, considering its demerits and the need to integrate theoretical knowledge into practice, the objective of this paper is to review the contribution of role play in medical education and to propose it's applications to deliver healthcare services in community more effectively.

Methods

Research studies on role play were searched in PubMed, Google scholar, Google using terms role play, medical education, community medicine, family medicine, health promotion, awareness during the period between January 2000 up to December 2021 to evaluate the potential and contribution of role play in medical education and health promotion.

Results

Review of role play and related researches were included to analyze the outcome. The outcomes of different studies analyzed were showing several teaching methodologies used in medical field. Several studies have tested role play in other medical specialities and have found it to be a powerful educational tool. However, not many studies have tested its effectiveness to educate students in Family and Community Medicine although it could have immense practical applications like demonstrating and creating awareness in the community about the importance of cancer screening, breast feeding, immunisation, food fortification, genetic screening, premarital counselling, ante natal checkups, danger signs in pregnancy.

Conclusion

Role play simulates real scenarios enabling students to apply their skills and knowledge into practice in real time. It can integrate theory concepts into practice. Hence, it must be introduced in medical curriculum to achieve the objectives of teaching and learning more effectively.

[Health impact of the community intervention programme "Health education in adolescence"]

OBJECTIVE

To measure the impact of the community health programme "Education for health in adolescence" carried out in the Parquesol neighborhood, Valladolid (Spain), during the years 2015-2019.

METHOD

Community-based quasi-experimental pre- and post-test analytical intervention trial with control group. A total of 407 adolescent surveys were collected. The CHIP-AE test validated for Spain was used. Pre- and post-test results were analyzed and compared with the control group.

RESULTS

Improvements were found in the female intervention group compared to the control group in the variables resilience (3.68 vs. 3.41; p <0.01), health and safety at home (4.30 vs. 4.00; p <0.01), physical activities (3.16 vs. 2.60; p <0.01) and self-esteem (3.17 vs. 2.79; p <0.05).

CONCLUSIONS

The community intervention carried out improves the health profile of adolescents. The baseline perception of health presents differences by gender, with higher scores in males. Post-intervention improvement is substantial in females in resilience, physical activities and health and safety at home. In addition, the worsening due to the passage of time described in previous studies is corrected in the variables self-esteem, satisfaction and well-being.

Effect of Self-Directed Learning Module and Assessment on Learning of National Health Programme by Medical Undergraduates - A Mixed Methods Evaluation

Background

Competency-based medical education (CBME) curriculum in India has introduced many new concepts like a foundation course, early clinical exposure, and self-directed learning (SDL). Sometimes SDL simply means self-study. Self-directed learning as defined by Knowles is a process in which individuals take the initiative with or without the help of others in diagnosing their learning needs, setting their own learning goals, identifying appropriate learning resources, and selecting appropriate learning strategies. SDL is seen as a prerequisite for life-long learners, especially medical graduates. We found poor uptake of SDL sessions in terms of learning and attendance by students. To develop and assess the effect of the SDL module in Community Medicine for Phase -3 MBBS students.

Materials and Methods

The study design was a program development and evaluation design. The program development consists of free listing and Nominal Group Technique (NGT). The evaluation design consists of a formative assessment, an end-of-module assessment, and feedback from undergraduate students, postgraduates, and faculties. Data collection procedure: SDL module was developed, agreed and implemented among undergraduates of Phase - 3 MBBS students.

Results

Free listing was conducted among undergraduate students who had completed the phase 3 MBBS examination and Nominal Group Technique was conducted among the faculties (n = 7) and Postgraduates of the Department of Community Medicine (n = 2) to explore the appropriate topics for SDL in Community Medicine. The topic with the highest ranking and which was finalized for preparation of the SDL module was "National Health Programme". Three fourth 118 (75%) of the students scored ≥50% at the end of the module assessment. Manual content analysis for the feedback was categorized into three themes such as facilitating factors, challenges, and solutions.

Conclusions

Effective implementation and assessment of SDL sessions are one of the new concepts in the CBME curriculum.

Germline BRCA-Mutated HER2-Negative Advanced Breast Cancer: Overcoming Challenges in Genetic Testing and Clinical Considerations When Using Talazoparib

Genetic testing is essential to the diagnosis and management of patients with breast cancer. For example, women who carry mutations in BRCA1/2 genes have an increased lifetime risk of breast cancer and the presence of these mutations may sensitize the patient to treatment with poly(ADP-ribose) polymerase (PARP) inhibitors. Two PARP inhibitors are approved by the US Food and Drug Administration for patients with germline BRCA-mutated advanced breast cancer (olaparib and talazoparib). The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer (Version 2.2023) recommend that all patients with recurrent or metastatic breast cancer (mBC) be assessed for the presence of germline BRCA1/2 mutations. However, many women eligible for genetic testing do not receive it. Here, we provide our perspectives on both the importance of genetic testing and the challenges patients and community clinicians may face when trying to access genetic testing. We also present a hypothetical case study involving a female patient with germline BRCA-mutated human epidermal growth factor receptor 2 (HER2)-negative mBC to highlight potential clinical considerations on the use of talazoparib, including the decision to initiate therapy, dosing considerations, potential drug-drug interactions, and managing side effects. This case illustrates the benefits of a multidisciplinary approach to managing patients with mBC and involving the patient in the decision-making process. This patient case is fictional and does not represent events or a response from an actual patient; this fictional case is for educational purposes only.

Family Adoption Programme for Medical Undergraduates in India - The Way Ahead: A Qualitative Exploration of Stakeholders' Perceptions

Introduction

Community engagement in medical education gives the students an insight into the living conditions of the public and how they influence their health. Community Medicine departments accomplish this through field practice and family health studies. The Family Adoption Programme, newly mandated for all medical undergraduate students, brings its own set of challenges and opportunities. The study aims to understand the perceptions of various stakeholders regarding this program.

Material and Methods

A qualitative exploratory study was conducted. The faculty, undergraduate and postgraduate students, and field workers were purposively invited to participate. Thematic analysis was done on qualitative inputs obtained by Key Informant Interviews and Focussed Group Discussions.

Results

The participants felt that FAP will provide a good insight into the patient's living conditions and also motivate the students for the kind of career they have to prepare for. The major challenges were the lack of transport and logistics in government colleges and the faculty shortage in private colleges. There was a difference of opinion regarding the right time to initiate the student into FAP. Gaining the trust and cooperation of the family and reducing the expectations were also felt important. While more field involvement by faculty was advocated, increased workload and reduced faculty requirement specifications were a matter of concern.

Conclusion

While there was mixed response regarding the utility and long-term sustainability of FAP, it was hoped that with proper motivation and supervision, this program can create a significant difference in medical education and also the lives of adopted families.

Learning innovation in community medicine teaching: A-Z of job responsibilities of anganwadi worker, accredited social health activist, and auxiliary nurse midwife

The interaction between medical students and frontline healthcare workers is one of the crucial components of community medicine. The interaction of medical students with frontline healthcare workers provides multiple opportunities. Medical students like to understand their job responsibilities and their involvement in implementing the various national health programs at the community level. Innovation is required to train our medical students better and enhance their learning. A learning and teaching innovation was developed by us to provide insight into the various roles and involvement of frontline healthcare workers in the community. One innovation is the A-Z activity calendar of frontline healthcare workers in teaching and learning in medical education.

Entrustable professional activities for Junior Brazilian Medical Students in community medicine

BACKGROUND

Entrustable professional activities (EPAs) have been defined to promote the workplace participation of undergraduate medical students, generally in the context of high-income countries with a focus on the secondary and tertiary health care sectors. These EPAs have limited applicability to training and health care contexts in low- to middle-income countries that have a focus on primary health care, for instance, the context of community medicine. The purpose of this article is to report the process and results of defining EPAs for undergraduate medical training in a community health care setting.

METHODS

A modified Delphi study was performed to develop EPAs for the training of medical students in community medicine during their first and second years of education at the Marília Medical School (FAMEMA), Brazil. The supervision level was operationalized in terms of a student's ability to perform the EPA autonomously in an effective and safe manner with supervision readily available on request. Panellists (9 physicians and 6 nurses) rated the completeness of the proposed list of EPAs and EPA categories on four-point Likert scales. The threshold for consensus among panellists was a mean content validity index of at least 80%.

RESULTS

Consensus was reached after two Delphi rounds, resulting in 11 EPAs for undergraduate medical education and training in community medicine. These EPAs were organized into three overarching EPA domains: integrality of care for individual health needs in all phases of the life cycle (5 EPAs), integrality of care for family health needs (3 EPAs), and integrality of care for community health needs (3 EPAs). For each EPA, descriptions of the following categories were created: title; specifications and limitations; conditions and implications of the entrustment decision; knowledge, skills, and attitudes; links to competencies; and assessment sources.

CONCLUSION

The resulting 11 EPAs for training medical students in community medicine expand the application of the EPA framework to both early undergraduate medical education and the context of primary health care. This report can support and guide other medical schools in their attempts to train students in primary health care contexts and to incorporate EPAs into their curricula.

Training in public health and community medicine without training of precautionary principles is incomplete

What has been the learning is from the current pandemic. Besides the fact that it taught us the immense potential of pandemics to lead to ruin, it also taught us about our limitations in dealing with it.

The effect of a patient informative leaflet on chronic use of proton pump inhibitors in a primary care center: a randomized control trial

BACKGROUND

Chronic non-medically indicated PPIs are highly prescribed worldwide. The long-term side effects of PPI must be wisely considered during an extended prescription duration. Our study purpose is to assess the impact of providing patients and physicians with educational guides on the rates of reducing or eliminating PPIs.

DESIGN AND METHODS

A controlled study targeting adult patients with chronic PPI use was conducted in a family medicine center in Beirut. Block randomization was employed. Patients (n = 140) were equally divided into an intervention group consisting of a patient-oriented informative and motivational leaflet and a control group having the same follow-up without having the leaflet. All participants filled a questionnaire. All participants received a short phone call in 2 and 6 months. An e-mail clarifying the objective of this study was sent to all physicians and supplemented with a PPI deprescribing algorithm.

RESULTS

At the 6-month follow-up, the rate of participants who talked to treating physicians about their PPI therapy was higher in the intervention group (p-value<0.0001), and the rate of participants who stepped down or off PPI was higher in the intervention group (p-value<0.0001). In participants who stepped down or off PPI, the reported breakthrough symptoms decreased over time (moderate: 24.2%, mild: 35.5%, and nil: 40.3% at 2-month follow-up; and moderate: 0%, mild: 55.4% and nil: 44.6% at 6-month follow-up; p-value<0.0001).

CONCLUSION

A low-intensity, low-cost, and easily replicable intervention encouraged a significant number of long-term users of PPIs to reduce or stop these medications without causing significant breakthrough symptoms.

Evaluation of e-learning in a department of Community Medicine as a response to COVID-19 pandemic

BACKGROUND

COVID-19 pandemic pushed all educational institutions to rely exclusively on technology-based learning. As this was done for the first time, it is ideal to evaluate the e-learning program to refine and consolidate the learned experience. Hence, the current study was undertaken to evaluate the online learning and teaching experiences of students and teachers.

MATERIALS AND METHODS

This program evaluation on e-learning was carried out in the department of Community Medicine (DCM) in a private medical college using context/input/process/product framework among IV, VI, and VII semester undergraduate students and faculties in DCM who were exposed to e-learning for the period of 2 months since April 2020. Google Forms was used to design a survey questionnaire that was conceptualized as per the needs of the evaluation framework. Ethics Committee approval was obtained. Descriptive analysis was done for quantitative variables and manual content analysis using Lewin's force field framework was performed for the qualitative data.

RESULTS

Out of 301 undergraduates contacted, 196 (65.1%) responded to online survey. Their mean age was 19.9 years and 128 (65.3%) were females. Mobile phone was used by 93.4% to access e-learning. Combined modality of learning was preferred by 58.2% of them in future. Six "for" and "against" factors on e-learning emerged out of content analysis pertaining to three main stakeholders, namely administrator, faculty, and student.

CONCLUSION

Our evaluation conveys that for effective e-learning in any subject, the students, educators, and institutional factors that were identified need to be considered throughout all phases of program development with careful assumptions about its acceptance by the millennial.

How do elderly people with malnutrition and their families perceive collaborative practice in primary care? A phenomenological study

As a frequent and serious problem in elderly people, malnutrition is a complex health issue. It requires comprehensive care through interprofessional collaborative practice (IPCP) engaging five health professionals in primary care consisting of a physician, dentist, nurse, dietitian and pharmacist. In Indonesia, the usual care involves monthly health screening in community programmes named Posyandu. The current study aimed to explore perceptions of elderly people with malnutrition and their families' experiences with interprofessional teams compared with usual care in primary care. This qualitative study used the phenomenological approach based on Creswell. Interviews were conducted with fourteen elderly people and their families in the intervention group and fourteen elderly people with their families in the control group. Data were analysed using the four steps of descriptive qualitative analysis described by Giorgi, including comparing the experiences of both groups. Elderly people with malnutrition in the intervention group had more valued experiences regarding two-way communication with the IPCP team and felt it involved more comprehensive care for malnutrition management. Participants in the control group experienced communication between the health care providers and elderly people; however, it was not clear enough. There were overlapping roles among health care providers in the usual care. However, both groups shared the experience that family members are partners in nutritional management. Elderly people and their families in the intervention group have more valuable experiences related to two-way communication and comprehensive care. Family as partners was experienced in both the intervention and control groups.

Effectiveness of a collaborative model in improving maternal and child health outcomes among urban poor in Chandigarh, a North Indian city

BACKGROUND

To ascertain the effectiveness of a collaborative model between the Department of Community Medicine and state health department to improve MCH outcomes among the urban poor in Chandigarh.

MATERIALS AND METHODS

A quasi-experimental study was conducted from 2011-12 to 2015-16 in the intervention and control areas. A collaboration was established between the state health department and the Department of Community Medicine of an autonomous institute. The intervention and control areas were mainly inhabited by the poor migrant population. Critical elements of an efficient collaboration such as the early engagement of partners, clearly stated purpose with common goals, effective communication, and no financial conflict were implemented in the intervention area. MCH program's implementation was strengthened through supportive supervision, enhanced community engagement, male partner involvement, tracking of high-risk pregnant women, and identification of problem families. Trend analysis of MCH indicators was done. The difference-in-difference (DID) analysis was done to measure the net effect of the intervention.

RESULTS

All the MCH indicators improved significantly in the intervention area compared to the control area (P < 0.05). DID analysis depicted a net increase in the early registration of pregnancies by 18%, tetanus toxoid immunization by 9.2%, and fully immunized children by 8.6%. There was also an improvement in the maternal mortality ratio by 121.1 points, infant mortality rate by 2.2 points, and neonatal mortality rate by 2.6 points in the intervention area.

CONCLUSION

An innovative, collaborative model between the state health department and the Department of Community Medicine effectively improved the MCH outcomes in Chandigarh.

Bringing Sickle Cell Disease Care Closer to Home: Feasibility and Efficacy of a Quality Improvement Initiative at a Community Hospital

Comprehensive care for patients with sickle cell disease has been shown to improve morbidity. However, few studies have focused on community hospitals where the burden of disease is highest. From 2017 to 2019, a series of quality improvement interventions was implemented in Brampton, Toronto, ON, Canada, directed toward pediatric and adult sickle cell disease populations. This included a new adult clinic and education directed at patients and healthcare providers. There were 206 visits from 88 unique patients at the clinic and hydroxyurea (HU) uptake increased from 41.0 to 60.0% over that time (p < 0.001). The annual admission rate by adult patients before and after intervention was 90.0 and 75.0% respectively (p = 0.010). The length of stay of pediatric patients decreased from 3.5 to 2.9 days (p = 0.039). These interventions resulted in significant improvements in acute care utilization and HU use by sickle cell disease patients locally, but larger studies are required to confirm these findings.

"Written Formative Assessments with Peer-Assisted Learning" an Innovative Teaching Program for Postgraduate Students in Community Medicine

Introduction:

There is a paucity of research on conducting written formative assessment with constructive feedback for theory paper writing for postgraduates of Community Medicine in India. The concept of “Written Formative assessments with Peer-Assisted Learning Program” was implemented to improve the first 2 levels of Miller's Pyramid and assess its impact on the summative assessment.

Materials and Methods:

The program was conducted for 2 batches of postgraduate students in the Community Medicine enrolled for the academic session of 2016–2019 and 2017–2020. The written formative assessment was conducted every Saturday for 1 h from August to March month in 2018 and 2019. After each test, answer papers were evaluated by the peer and faculty from the department. Written and oral feedback was given by the peer. After IEC approval, we planned to assess the program's effect on level 1 and level 2 Kirkpatrick's framework. The data were analyzed using SPSS statistical package version 24 (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant.

Results:

Total 23 formative written assessments were conducted per year. The proportions of knowledge, comprehension, and analytical type of questions asked were 47%, 32%, and 21%, respectively. The mean attendance rate was 76.28% ±16.4%. There was no statistically significant difference in the average percentage of marks in formative (weekly test) and summative assessment (university final examination). There was a statistically significant positive co-relation of projected mean marks and summative assessment marks with the co-efficient of the determination being 22.6%. There was overall positive feedback of the formative and peer-assisted learning (PAL) from post graduate students.

Conclusions:

Written Formative Assessment with PAL program is one of the effective programs for postgraduate students to gain confidence in writing and presentation skills and to score higher in theory examination.

The confusion is killing Public Health, Community Medicine and Family Medicine; all critical to India's healthcare delivery system

The clarity on the structure and functioning of academic Public health, Community Medicine and Family Medicine appears to missing to a large extent. The confusion appears more visible now than ever before. The dichotomy in regulating medical training by India's regulators, the National Medical Commission (NMC) and National Board of Examination (NBE) does not seem to be helping the situation either. Added to it is the confusion created by academic institution not directly regulated by the NMC.

What role conceptions do multi-healthcare professionals have of physicians and what role expectation do they have of physicians in a community?

Background

To create an effective community-based integrated care system, interprofessional collaboration based on healthcare professionals’ mutual understanding of their respective roles must be promoted. This study aimed to identify the role conception and role expectation that other healthcare professionals have towards physicians in the context of a community-based integrated care system.

Methods

We organized focus groups and adopted ‘Role Theory’ as a theoretical framework. We collected data from healthcare professionals attending a conference on community-based integrated care systems in Japan. Fifty-four non-physician healthcare professionals consented to participate in 7 focus groups. Theme analysis based on the verbatim recorded transcripts was conducted in accordance with the framework of “Role Theory”.

Results

The role conception of physicians is as a figure of intellectual authority positioned at the top of a traditional hierarchy, with a personal character of criticism/autonomy/closedness, not accommodative of interference from others, and upholding the Biomedical Model as an absolute standard. In response to this, the role expectation of physicians in the community is that they undertake actions that only physicians can undertake to ensure that a flat organization functions properly in providing medical explanations during patient transitions, and to offer healthcare support for patients who are difficult to access. This role expectation also includes the perception of patients as human beings, with physicians adapting to the Bio-Psycho-Social Model, explaining to patients about their disease as an authoritative voice based on an understanding of psychosocial circumstances, and sharing the prognosis of disease or disability. The expected personal character is a person with an open mind who allows others to seek advice, as well as a sense of approachableness which facilitates such seeking of advice.

Conclusion

In the context of a community-based integrated care system, physicians should consider the understanding of their role conception and role expectation that other professionals have of them, and endeavor to create an open relationship with all healthcare professionals while giving careful consideration to their own role.

Demographic profile of COVID-19 positive mothers & their outcome in government Rajaji hospital, Madurai, Tamilnadu - A cross sectional Study

Background

COVID-19 is a new pandemic disease. This disease course and its effect on pregnancy is little known due to limited available data. The objective of this study was to describe the demographic profile of COVID-19 positive mothers admitted in Government Rajaji hospital, Madurai in terms of time, place and person and to assess the general and pregnancy outcome of study population.

Methods

This cross-sectional study was done among 381 COVID-19 positive mothers* admitted during March 22 – August 31, 2020 in dedicated COVID-19 hospital, Madurai. Data was collected using Case Investigation Form (CIF) as a part of Rapid Response Team*(RRT) by Community Medicine* Department and analysed using SPSS version 21. Descriptive statistics done; Chi-square test & Fischer exact test was done to find out association between patient profile and outcomes.

Results

Out of 381, 154 (40.4%) belonged to 21–25 years, 192 (50.4%) to rural area, 318 (83.5%) to 3rd trimester,189 (49.6%) Primi gravida. 125 (32.8%) were symptomatic and 153 (80.8%) had at least one comorbidity. Death as general outcome was 3 (0.8%), all of them were referred cases and had comorbidity like GDM/PIH. 10 (2.62%) had abortion or perinatal death, 14 (3.77%) had preterm delivery, 99 (25.98%) babies were born small for gestational age. Increased maternal age had more death but was not statistically significant; All symptomatic mothers (p = 0.000),1st & 2nd trimester (p = 0.000) mothers had statistically significant poor pregnancy outcome*.

Conclusion

COVID positive mothers with increased age, symptomatic, 1st & 2nd trimester were significantly associated with poor outcome, requires special attention. Early referral must be emphasized to mitigate maternal death.

NEWS2 to assess suspected COVID-19 in the community: a service evaluation of a primary care assessment centre

BACKGROUND

Primary care has played a central role in the community response to the coronavirus disease-19 (COVID-19) pandemic. The use of the National Early Warning Score 2 (NEWS2) has been advocated as a tool to guide escalation decisions in the community. The performance of this tool applied in this context is unclear.

AIM

To evaluate the process of escalation of care to the hospital within a primary care assessment centre (PCAC) designed to assess patients with suspected COVID-19 in the community.

DESIGN AND SETTING

A retrospective service evaluation of all adult patients assessed between 30 March and 22 April 2020 within a COVID-19 primary care assessment centre within Sandwell West Birmingham CCG.

METHOD

A database of patient demographics, healthcare interactions and physiological observations was constructed. NEWS2 and CRB65 scores were calculated retrospectively. The proportion of patients escalated was within risk groups defined by NHSE guidelines in place during the evaluation period was determined.

RESULTS

A total of 150 patients were identified. Following assessment 13.3% (n = 20) patients were deemed to require escalation. The proportion of patients escalated with a NEWS2 greater than or equal to 3 was 46.9% (95% CI 30.8-63.6%). The proportion of patients escalated to secondary care using NHSE defined risk thresholds was 0% in the green group, 22% (n = 4) in the amber group, and 81.3% (n = 13) in the red group.

CONCLUSION

Clinical decisions to escalate care to the hospital did not follow initial guidance written for the COVID-19 outbreak but were demonstrated to be safe.

Training Family Medicine Residents to Prevent and Respond to In-flight Emergencies

In-flight emergencies (IFE) reportedly occur globally in about 1 in 604 flights¹. During training, family medicine (FM) residents acquire the skills necessary to counsel patients who are at risk, provide comprehensive management, and respond in emergent situations. The purpose of this study was to assess FM resident's knowledge about IFE, counseling, and attitudes towards responding to IFEs. A 15-question survey was sent to FM residents in the Dallas-Fort Worth area. IFE training options were also reviewed. Survey results revealed gaps in knowledge, yet a willingness to assist if necessary. A didactic IFE training format was found to be more achievable.

Characteristics and outcomes of family-practice patients with coronavirus disease 2019: a case series

BACKGROUND

The clinical history and outcomes of coronavirus disease 2019 among people not hospitalized is not yet well characterized. To better inform clinical evaluation, we set out to characterize the natural history of coronavirus disease 2019 in primary health care.

METHODS

Case series of all patients rostered to physicians at a university-affiliated Family Medicine clinic. Cases met the Centers for Disease Control and Prevention definition of coronavirus disease 2019 from March 1 to May 21 2020.

RESULTS

In total, 89 patients meeting Centers for Disease Control and Prevention criteria for coronavirus disease 2019 were documented. Their average age was 55.6 years (range 6-95 years), and all but one was symptomatic. Fifty-seven cases (64%) had a polymerase chain reaction test for coronavirus disease 2019, of whom 77.2% tested positive. Thirty cases (33.7%) reported contact with a confirmed or probable case of coronavirus disease 2019. Based on the Charlson Comorbidity Index, 28 cases (31.5%) had no comorbid conditions. The median number of days from symptom onset to first polymerase chain reaction test was 6 days (interquartile range 2.3-11 days). The median duration of fever was 3.5 days (interquartile range 1-7 days). Twenty-four cases (27%) visited the Emergency Department, and 10 were admitted to hospital. The median number of days between symptom onset and first Emergency Department visit was 8 days (interquartile range 3.5-27 days).

CONCLUSIONS

At the start of this pandemic, the implementation of basic measures such as diagnostic testing was delayed. If we are to improve our control over the spread of coronavirus disease 2019, we will need to substantially reduce the time from symptom onset to diagnostic testing, and subsequent contact tracing. To minimize unnecessary Emergency Department visits, we propose a testable strategy for Family Medicine to engage with coronavirus disease 2019 patients in the acute phase of their illness.

Self-Referral to the University Hospital Resulting in Unnecessary Patient Expenses: A Prospective Descriptive Study in a Super-Tertiary Hospital

Context:

Thailand subsidizes health-care costs, allowing citizens access to health care without out-of-pocket expenses. However, some citizens still spend large amounts of money on treatment provided at tertiary care hospitals.

Aim:

To identify the proportion of patients whose visits are not covered by national health insurance at the tertiary hospital and their reasons for visiting.

Settings and Design:

Prospective, descriptive study in patients visiting Srinagarind hospital outpatient department from July to September 2019.

Subjects and Methods:

We gathered and analyzed the data regarding demographics, hospital visits, and illness severity using a questionnaire.

Statistical Analysis Used:

Descriptive analyses and logistic regression were performed as appropriate.

Results:

Of the 700 participants, 40% (95% confidence interval 36.3–43.7) was not covered for their visits. The three common reasons visiting this hospital were desire of treatment from a specialist (42.9%), the reputation of the hospital (31.4%), and service satisfaction (26.6%).

Conclusions:

Although the national health-care system provides a gratis service pathway, some people still pay out-of-pocket unnecessarily. Officials should work to better raise the level of public confidence in the primary and secondary care units.

A remotely-delivered community action project to promote a diabetes lifestyle intervention programme in northwest London: basis, process and outcomes

Background : The prevalence of type 2 diabetes mellitus (T2DM) in London is rising, obesity being a major driver. As part of a primary care placement, the authors (two medical students and a lead general practitioner) directly promoted the Reducing Weight with Intensive Dietary Support (REWIND) programme to patients in Northwest London and collected feedback on the promotion. Methods : The team developed and delivered three remote interventions: a redesigned patient-facing information leaflet, phone calls and text messages, and a live, interactive webinar, to directly engage patients and raise awareness about REWIND. Feedback was collected pre and post-webinar using an anonymised, online survey (essentially functioning as a 'teaching' evaluation). Results : Mean interest in REWIND had increased from 2.7 (pre-promotion) to 4.7 (post-promotion), knowledge about REWIND had increased from 2.1 to 4, and self-reported likelihood of enrolling had increased from 2.6 to 4.2 (P<0.01 in all cases). The reported usefulness of the leaflet and webinar was scored 3.7 and 4.4 respectively. Within two weeks of the webinar, two of these patients had joined REWIND. Conclusion : Feedback from the patients and GP revealed that the project successfully raised awareness, improved knowledge, and increased the likelihood of enrolment in REWIND. Diabetes programmes and organisations are encouraged to adapt the methods of this project to their own contexts, especially in light of COVID-19 where remote interventions will remain essential.

Descriptive Analysis of a Telephone Based Community Monitoring Service for COVID-19

The coronavirus disease (COVID-19) pandemic has required health services to rapidly respond to the needs of people diagnosed with the virus. Over 80% of people diagnosed with COVID-19 experience a mild illness and there is a need for community management to support these people in their home. In this paper we present, a telephone based COVID-19 community monitoring service developed in an Australian public health network, and we describe the rapid implementation of the service and the demographic and clinical characteristics of those enrolled. A retrospective mixed methods evaluation of the COVID-19 community monitoring service using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Eight hundred and fifty COVID-19 positive patients were enrolled, 54% female, 45% male, mean age 34 years SD 17. Four hundred and nine (48%) patients were born outside Australia. Among the 850 patients, 305 (36%) were classified as having a high risk of serious illness from COVID-19. The most prevalent risk factors were cardiovascular disease (37%), lung disease (30%) and age over 60 years (26%). The most common reported ongoing symptoms were fatigue (55%), breathing issues (26%) and mental health issues such as low mood (19%). There were no deaths in patients that participated in the service. The process of risk stratification undertaken with telephone triage was effective in determining risk of prolonged illness from COVID-19. Telephone monitoring by trained health professionals has a strong potential in the effective management of patients with a mild COVID-19 illness.

General practitioner perceptions of assessment and reporting of absolute cardiovascular disease risk via pathology services: a qualitative study

BACKGROUND

Guidelines for cardiovascular disease (CVD) prevention recommend assessment of absolute CVD risk to guide clinical management. Despite this, use among general practitioners (GPs) remains limited.

OBJECTIVE

Pathology services may provide an appropriate setting to assess and report absolute CVD risk in patients attending for cholesterol measurement. This study aimed to explore GPs perceptions of such a service.

METHODS

A focus group and semi-structured interviews were conducted with GPs (n = 18) in Tasmania, Australia, to identify perceptions of assessment and reporting of absolute CVD risk via pathology services. An example pathology report including absolute CVD risk was provided and discussed. Audio-recordings were transcribed and thematically coded by two researchers.

RESULTS

Almost all GPs identified that absolute CVD risk assessed and reported via pathology services could address deficits in practice. First, by reducing the number of appointments required to collect risk factors. Second, by providing a systematic (rather than opportunistic) approach for assessment of absolute CVD risk. Third, by reducing misclassification of patient CVD risk caused by overreliance on clinical intuition. All GPs reported they would order absolute CVD risk when issuing a cholesterol referral if such a service was offered. GPs recommended improving the service by providing information on methods used to measure risk factors on the pathology report.

CONCLUSIONS

Absolute CVD risk assessed and reported via pathology services may address challenges of screening CVD risk experienced by GPs in practice and encourage dedicated follow-up care for CVD prevention.

"AI's gonna have an impact on everything in society, so it has to have an impact on public health": a fundamental qualitative descriptive study of the implications of artificial intelligence for public health

Background

Our objective was to determine the impacts of artificial intelligence (AI) on public health practice.

Methods

We used a fundamental qualitative descriptive study design, enrolling 15 experts in public health and AI from June 2018 until July 2019 who worked in North America and Asia. We conducted in-depth semi-structured interviews, iteratively coded the resulting transcripts, and analyzed the results thematically.

Results

We developed 137 codes, from which nine themes emerged. The themes included opportunities such as leveraging big data and improving interventions; barriers to adoption such as confusion regarding AI’s applicability, limited capacity, and poor data quality; and risks such as propagation of bias, exacerbation of inequity, hype, and poor regulation.

Conclusions

Experts are cautiously optimistic about AI’s impacts on public health practice, particularly for improving disease surveillance. However, they perceived substantial barriers, such as a lack of available expertise, and risks, including inadequate regulation. Therefore, investment and research into AI for public health practice would likely be beneficial. However, increased access to high-quality data, research and education regarding the limitations of AI, and development of rigorous regulation are necessary to realize these benefits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10030-x.

Integration of absolute cardiovascular disease risk assessment into routine blood cholesterol testing at pathology services

BACKGROUND

Absolute cardiovascular disease (CVD) risk assessment is recommended for primary prevention of CVD, yet uptake in general practice is limited. Cholesterol requests at pathology services provide an opportunity to improve uptake by integrating absolute CVD risk assessment with this service.

OBJECTIVE

This study aimed to assess the feasibility of such an additional service.

METHODS

Two-hundred and ninety-nine patients (45-74 years) referred to pathology services for blood cholesterol had measurement of all variables required to determine absolute CVD risk according to Framingham calculator (blood pressure, age, sex, smoking and diabetes status via self-report). Data were recorded via computer-based application. The absolute risk score was communicated via the report sent to the referring medical practitioner as per usual practice. Evaluation questionnaires were completed immediately post visit and at 1-, 3- and 6-month follow-up via telephone (n = 262).

RESULTS

Absolute CVD risk reports were issued for 90% of patients. Most patients (95%) reported that the length of time for the pathology service assessment was acceptable, and 91% that the self-directed computer-based application was easy to use. Seventy-eight per cent reported a preference for pathology services to conduct absolute CVD risk assessment. Only 2% preferred a medical practitioner. Of follow-up patients, 202 (75%) had a consultation with a medical practitioner, during which, aspects of CVD risk prevention were discussed (cholesterol and blood pressure 74% and 69% of the time, respectively).

CONCLUSIONS

Measurement of absolute CVD risk in pathology services is feasible, highly acceptable among middle-to-older adults and may increase uptake of guideline-directed care in general practice.

A path to early diagnosis of mild cognitive impairment and dementia: validity and reliability of the myMemCheck® self-administered screening tool

BACKGROUND

Barriers to the early detection of mild cognitive impairment (MCI) and dementia can delay diagnosis and treatment. myMemCheck® was developed as a rapid free cognitive self-assessment tool that can be completed at home to identify older adults that would benefit from a more comprehensive cognitive evaluation.

OBJECTIVE

Two prospective cross-sectional studies were conducted to examine the psychometric properties and clinical utility of myMemCheck®.

METHODS

In Study 1, participants were independent living residents referred to an outpatient memory clinic (N = 59); older adults in the community and post-acute nursing home residents (N = 357) comprised Study 2.

RESULTS

Psychometric analyses were performed on cognitive and psychological testing data, including myMemCheck®. myMemCheck® evidenced adequate reliability and strong construct validity. Receiver operating characteristic analysis evidenced an optional myMemCheck® cut score for identifying older adults at risk for MCI or dementia. myMemCheck® explained 25% of cognitive status beyond basic patient information.

CONCLUSIONS

myMemCheck® may help fast-track the diagnostic process, facilitate appropriate referrals for cognitive and neuropsychological evaluation, reduce assessment burden in health care and prevent negative outcomes associated with undetected cognitive impairment.

Relevance of Community-Based Participatory Research in Community Medicine Training

Community-based participatory research (CBPR) is an approach in which researchers undertake research in partnership with those affected by the issue being studied, for the purpose of taking action or effecting social change. It can also incorporate those who will use the results to change practice and inform policy. The practice of CBPR is primarily focused on “Knowledge for Change.” Most research projects in such CBPR partnerships are funded through the academic partners. In many situations, academic and professional researcher institutions and researchers find it difficult to share the information and resources or to directly engage with local community and other local stakeholders. In practice, finding an intermediary partner who has good rapport with local community and local government can be very effective. While there are good initiatives in selected medical colleges for community orientation of medical undergraduates and postgraduates in community medicine, these are not immersive enough to cause an attitudinal change. It is time that we exposed our graduates and postgraduates to CBPR concepts and practice.

Flipped classroom - An innovative teaching model to train undergraduate medical students in community medicine

Background

Second-year MBBS students need to be trained in applying theoretical knowledge into practice so that they can give appropriate advice during family visits in the community. For this, it is necessary to utilize the classroom timing for discussion and facilitation. In "flipped classrooms," what is normally done in class and what is normally done as homework is switched or flipped. Thus, a study was planned to train the students to apply theory into practice by using flipped classroom methodology.

Methods

After ethical committee approval and informed consent, 48 second year MBBS students were enrolled in the study. Selected topics (i.e., "nutrition in under-five children") was taught through the "flipped classroom"model after a pretest assessment. Students were allotted a family case in the urban slums having at least one under-five child so that they can apply theory into practice. The formal assessment was done through structured case viva and spot examination. After 3 months, a posttest was conducted in the classroom to assess retention in knowledge. Feedback of the students was taken on the flipped classroom model.

Results

The average marks scored in structured case viva with spot examination was 8.28 ± 2.4 marks. There was a statistically significant association of scores in the structured case viva with spot examination with participation in all pre- and in-class activities (P < 0.05). There was a statistically significant difference in pre- and posttest marks (10.03 ± 2.17 vs. 18.84 ± 3.8). The class average normalized gain was 44%. Overall, there was positive feedback for "flipped classroom teaching." Most of the students felt that this was a practical approach to the topic.

Discussion

Students can apply theory into practice and knowledge gained is also retained through the use of the flipped classroom teaching method.

Bridging the intergenerational gap: the outcomes of a student-initiated, longitudinal, inter-professional, inter-generational home visit program

BACKGROUND

Older persons consume disproportionately more healthcare resources than younger persons. Tri-Generational HomeCare (TriGen), a service-learning program, aims to reduce hospital admission rates amongst older patients with frequent admissions. The authors evaluated the educational and patient outcomes of TriGen.

METHODS

Teams consisting of healthcare undergraduates and secondary school (SS) students - performed fortnightly home visits to patients over 6 months. Self-administered scales were used to evaluate the educational outcomes in knowledge and attitudes towards the older people and nine domains of soft skills pre- and post-intervention. Patients' reported satisfaction and clinical outcomes were also assessed.

RESULTS

Two hundred twenty-six healthcare undergraduates and 359 SS students participated in the program from 2015 to 2018. Response rates were 80.1 and 62.4% respectively. One hundred six patients participated in TriGen. There was a significant increase in Kogan's Attitudes towards Old People Scale (KOP) scores for healthcare undergraduates and SS students with a mean increase of 12.8 (95%CI: 9.5-16.2, p <  0.001) and 8.3 (95%CI: 6.2-10.3, p <  0.001) respectively. There was a significant increase in Palmore Facts on Aging Quiz (PFAQ) score for SS students but not for healthcare undergraduates. Most volunteers reported that TriGen was beneficial across all nine domains assessed. There was also a significant decrease in hospital admission rates (p = 0.006) and emergency department visits (p = 0.004) during the 6-month period before and after the program. Fifty-one patients answered the patient feedback survey. Of this, more than 80% reported feeling less lonely and happier.

CONCLUSION

TriGen, a student-initiated, longitudinal, inter-generational service-learning program consisting of SS students and healthcare undergraduates can reduce ageism, develop soft skills, inculcate values amongst SS students and healthcare undergraduates. In addition, TriGen potentially reduces hospital admissions and emergency department visits, and loneliness amongst frequently admitted older patients.

A critical review of new competency-based curriculum for community medicine using various curricular review frameworks

The purpose of the present review is to examine the new competency-based undergraduate curriculum in community medicine against the established frameworks and criteria and suggest the way forward for achieving competencies expected of the Indian Medical Graduate (IMG). The new Graduate Medical Education Regulations, 2018, is based on Harden's concept of the curriculum. Hence, we reviewed the components of new curriculum against Harden's conceptualization of various components of the curriculum, and since it claims it is competency-based, we used Tyler's Goal/Objective-Based Evaluation. The new undergraduate curriculum has shown a move toward integration of course content and defined the competencies in more measurable terms. However, it appears that the earlier information-based curriculum corresponding to book chapters ("topics") has been modified to specify higher cognitive domains with no explicit link between the IMG level curriculum outcomes to subject level intended learning outcomes (ILOs). The mechanism to link ILOs to assessment is also not clear and so needs more clarity. The assessment system hinted at in the current document is mostly based on the existing conventional system of 50% as pass cutoff, etc., against criterion-referenced assessment applicable to competencies that need to be performed. Furthermore, there is no guidance on the creation of educational opportunities and environment for students and faculty - perhaps it is left to "Curriculum Implementation Support Programme (CISP) Workshops." Hence, the need for preparing a roadmap/blueprint to learning experiences and assessment methods and levels and milestones to be reached at various phases of MBBS and during internship is required.

[Effectiveness evaluation of health belief model-based health education intervention for patients with hypertension in community settings]

Objective: To evaluate the effectiveness of health belief model-based health education intervention in improving blood pressure control of patients with hypertension in community settings. Methods: From September 2016 to September 2017, 400 newly diagnosed patients with hypertension were recruited from 6 community healthcare centers with comparable population size and health services in the Shunyi District of Beijing. All community healthcare centers were randomly assigned to the intervention group (206 patients) and the control group (194 patients). Patients in the intervention group received 3 lectures (20-30 min for each) of health belief model-based health education. Patients in the control group received usual care. The basic characteristics, health beliefs, and health literacy were collected, and blood pressure was measured before and after the intervention, respectively. The difference-in-difference model was used to analyze the change of blood pressure and the influencing factors between two groups before and after the intervention. Results: A total of 134 patients in the intervention group and 129 patients in the control group completed the study. After adjusting for the age, gender, family income, medical insurance, chronic diseases and family history, the score of perceived barriers was increased by 1.65 (P=0.016), and perceived seriousness was decreased by 0.73 (P=0.018). The systolic blood pressure of patients was decreased by 7.37 mmHg (1 mmHg=0.133 kPa, P=0.001) and diastolic blood pressure was decreased by 4.07 mmHg (P=0.014), respectively. The β (95%CI) values were -7.37 (-11.88,-2.86) and -4.07 (-7.30, -0.84). The perceived susceptibility and self-efficacy had a significant influence on the blood pressure of patients (P<0.05). Conclusion: Health belief model-based health education intervention could significantly improve the blood pressure control of patients with hypertension in the community settings.

General outpatient department in tertiary care institute: A model to be adopted by medical colleges

Context:

Teaching medical institutes and tertiary care hospitals in various cities are overcrowded and overburdened. The general outpatient department (GOPD) plays a vital role as screening OPD to triage patients who require secondary or tertiary care and refer them to appropriate OPD. Primary health care is initiated at the GOPD itself and the mechanism of referral is established.

Aim:

To study GOPD model and its services in the institute. To assess perception of patients towards it.

Settings and Design:

It was an observational study conducted in a medical college of Mumbai, Maharashtra for 1 month on persons attending the GOPD.

Materials and Methods:

Data and monthly reports were used for baseline comparisons and exit interviews of patients were taken using questionnaire.

Statistical Analysis Used:

Quantitative analysis was done using the proportions and means for the number of patients served daily by the GOPD and medicine OPD.

Results:

Around 44% of services were therapeutic in nature and it had contributed to a significant reduction in patient load into another specialist department. Nearly 30% cases needed referrals during the study period. Statistically, the significant value was obtained for patient satisfaction for consultation services from GOPD.

Conclusions:

A statistically significant value for patient satisfaction for consultation services from GOPD indicates that patients were in favor of such type of services.

General paediatric practice in autism spectrum disorder screening in Ontario, Canada: Opportunities for improvement

Background

Screening is important for early identification of children with autism spectrum disorder (ASD), potentially leading to earlier intervention. Research has identified some barriers to early identification of ASD, however, information about ASD screening in Canadian general paediatric practice is lacking.

Objectives

The aim of the study is to better understand ASD screening practice patterns by examining the use of ASD and general developmental screening tools by general paediatricians.

Methods

The research team conducted a cross-sectional survey of general paediatricians.

Results

Two-hundred and sixty-seven paediatricians responded and 132 were eligible for the study. Ninety-three per cent of the responders used a developmental screening tool. Eighty-five per cent of the responders used an ASD screening tool when there were concerns for ASD, and 15% never used one. The most commonly used ASD screening tool was the M-CHAT. Children suspected of having ASD were referred to specialists not only to confirm the diagnosis but also to facilitate access to resources. General paediatricians were keen to incorporate formal ASD screening tools in their practice but identified the need for clearer guidelines.

Conclusion

Previous studies have shown that children at risk of ASD continue to be missed through developmental surveillance and targeted screening. Paediatricians are interested in implementing an ASD screening tool and cite brevity and forms that can be completed by parents as factors that would support the use of a screening tool. Clearer guidelines and tools to support ASD screening and access to resources are needed.

Safe Injection Sites: A Moral Reflection

This article addresses the issue of safe injection sites (SIS) that municipalities in the United States and elsewhere in the world propose to save lives by curbing the instances of fatal overdoses and provide addicts with healthcare services and opportunities for detoxification and social rehabilitation. Drawing on current clinical science and the medical facts regarding substance abuse and addiction, widely accepted bioethical principles, Catholic social teaching, and the common good, it shows the administration and consumption of illicit recreational drugs in an SIS is not a suitable medical intervention and a violation of the core principles of Catholic social teaching and Catholic healthcare ethics. More importantly, municipal governing bodies and the clinicians who staff these facilities cooperate in the evil of illegal drug abuse.

Summary

Safe injection sites are morally illicit.

Role of community health service programs in navigating the medical ethical slippery slope-a 10-year retrospective study among medical students from southern China

BACKGROUND

For promoting autonomous learning motivation, the learning effect of community-oriented service is beneficial, because through community participation and service, students can transfer their implicit cognition of ethics into explicit cognition, leading to the cultivation of a sympathetic partnership between the community and medical students. Despite the proven benefits of medical students' community health service (CHS) in Western countries, CHS programs designed for medical students are not well established in mainland China, and their effects on medical students' ethical cognition are largely unknown. This study evaluated the effects of CHS programs on the ethical cognition of medical students.

METHODS

A cross-sectional study was conducted on third- and fourth-year medical students and graduates working at Shantou University Medical College by using a self-administered anonymous questionnaire. Through interviews, we applied a thematic approach to analyze the responses of the participating students. The questionnaire adopted in this study was revised based on a review of the literature on medical ethics in medical students and on the CHS environment in China. The reviewed questionnaires included an evaluation questionnaire on cultivating medical ethics in a CHS context, and questionnaires used to explore the cultivation and transformation of medical ethics in medical students during the preclinical period.

RESULTS

A total of 361 (54.4%) undergraduate medical students and 302 (45.6%) graduates participated in this survey. Significant differences were observed in self-evaluation of the cognitive development of ethics between those who had participated in CHS programs 1-5 times and those who had participated > 6 times. The successful identification of accepting money from the patients under the table as unethical behavior significantly differed (p = .031) among the graduates but not (p = .567) among the undergraduate students. The participants expressed the positive impact of CHS programs on their self-development.

CONCLUSION

CHS programs can be widely applied in medical education in China. This educational strategy, which supports medical professionalism and incorporates humanitarian behavior as a complement to learning, should be encouraged and promoted nationally.

Evaluating practice variance among family physicians to identify targets for laboratory utilization management

BACKGROUND

There is widespread variation in testing practice among practitioners, however there has been no objective way to pinpoint target tests for utilization management. We propose to take advantage of inter-physician variance in clinical practice as a quantitative measure to generate lists of potentially misutilized tests.

METHODS

Testing frequencies from a database of clinical testing volumes for outpatients in Calgary, Canada, were obtained for the study period of 2016. For each chemistry, microbiology or hematology test, an arithmetic coefficient of variation (CV) was calculated from family physicians' ordering frequencies.

RESULTS

The mean CV for all 358 tests considered was 219% (95% CI 206-231%) with a range of 52-729%. The highest variance was observed for human T-lymphotropic virus antibody testing and several tests for heavy metal levels (mercury, copper, zinc and chromium). Among the 100 most commonly run tests, high variance was found for several endocrinology tests including cortisol.

CONCLUSIONS

The utility of ranking clinical tests by ordering variance presents a practical approach to evaluate relative variation in physician practice strategy and to identify potential areas of misutilization.

Multi-level prevention of human trafficking: The role of health care professionals

As a major public health issue, human trafficking (HT) affects individuals, families, communities, and societies around the world. A public health approach to combating HT has been advocated. Such an approach seeks to prevent HT by engaging diverse stakeholder groups in addressing risk factors at multiple levels. As a key stakeholder group, health care professionals (HCPs) play a critical role in HT prevention. Herein, we use the Centers for Disease Control (CDC) Social-Ecological Model as a framework to present potential HT prevention strategies for health care professionals. As clinicians, HCPs may deliver tailored interventions to patients and families to address individual- and relationship-level risk factors for HT in the health care setting. As educators, advocates, and researchers, HCPs may collaborate across sectors to implement community- and society-level prevention strategies. Such strategies may include enhancing awareness of HT through education; advocating for local and national policies that promote community health and wellness; combating social or cultural norms that contribute to HT; and building a strong evidence-base to guide future HT prevention programs. Guided by the CDC Social-Ecological Model, we recommend that HCPs use their diverse skills to target risk factors for HT at multiple levels and thereby expand their impact in preventing this form of exploitation.

Impact of post-transplantation maintenance therapy on health-related quality of life in patients with multiple myeloma: data from the Connect® MM Registry

Maintenance therapy after autologous stem cell transplantation (ASCT) is recommended for use in multiple myeloma (MM); however, more data are needed on its impact on health-related quality of life (HRQoL). Presented here is an analysis of HRQoL in a Connect MM registry cohort of patients who received ASCT ± maintenance therapy. The Connect MM Registry is one of the earliest and largest, active, observational, prospective US registry of patients with symptomatic newly diagnosed MM. Patients completed the Functional Assessment of Cancer Therapy-MM (FACT-MM) version 4, EuroQol-5D (EQ-5D) questionnaire, and Brief Pain Inventory (BPI) at study entry and quarterly thereafter until death or study discontinuation. Patients in three groups were analyzed: any maintenance therapy (n = 244), lenalidomide-only maintenance therapy (n = 169), and no maintenance therapy (n = 137); any maintenance and lenalidomide-only maintenance groups were not mutually exclusive. There were no significant differences in change from pre-ASCT baseline between any maintenance (P = 0.60) and lenalidomide-only maintenance (P = 0.72) versus no maintenance for the FACT-MM total score. There were also no significant differences in change from pre-ASCT baseline between any maintenance and lenalidomide-only maintenance versus no maintenance for EQ-5D overall index, BPI, FACT-MM Trial Outcomes Index, and myeloma subscale scores. In all three groups, FACT-MM, EQ-5D Index, and BPI scores improved after ASCT; FACT-MM and BPI scores deteriorated at disease progression. These data suggest that post-ASCT any maintenance or lenalidomide-only maintenance does not negatively impact patients' HRQoL. Additional research is needed to verify these findings.

Platelet-rich plasma (PRP) therapy for knee arthritis: a feasibility study in primary care

BACKGROUND

Platelet-rich plasma (PRP) is a concentrate of autologous blood growth factors which has been shown to provide some symptomatic relief in early osteoarthritis (OA) of the knee. The objective of this study was to test the feasibility and efficacy potential of platelet rich plasma (PRP) in primary care.

METHODS

Feasibility study to assess safety of the intervention procedures and assess primary and secondary outcome measures. Consecutive patients presenting with symptomatic knee OA were recruited in a primary care setting in Ireland. All participants received three injections of PRP 4 weeks apart. The following self-reported clinical outcomes were evaluated before and after therapy (4 months): Pain and disability (ICOAP questionnaire); health utility (EUROQol); adverse events; patient satisfaction and goal-orientated outcomes.

RESULTS

Seventeen potential patients were identified of whom 14 were eligible to participate. Twelve consented and completed the intervention and all outcome measures. There were no losses to follow-up. One patient reported pain and stiffness for 2 days after the first injection but did complete the study. No growth was detected from nine consecutive samples sent for microbiology analysis. Changes in constant, intermittent and total pain scores were reported; pain fully resolved in two patients. In addition, health utility, patient satisfaction and goal-orientated outcomes also demonstrated improvement.

CONCLUSIONS

Platelet-rich plasma therapy is a simple and minimally invasive intervention which is feasible to deliver in primary care to treat osteoarthritis of the knee joint. Well-designed randomised controlled trials are needed to measure outcomes, durability of effect and cost effectiveness.

Motivations of South African physicians specialising in public health

Background: South African physicians can specialise in public health through a four-year ‘registrar’ programme. Despite national health policies that seemingly value public health (PH) approaches, the Public Health Medicine (PHM) speciality is largely invisible in the health services. Nevertheless, many physicians enrol for specialist training.

Objectives: This study investigated physicians’ motivations for specialising in PHM, their intended career paths, perceptions of training, and perspectives about the future of the speciality.

Methods: Focus groups and in-depth interviews were conducted with specialists-in-training and newly qualified specialists, and thematic analysis of transcripts was performed.

Results: Motivations, often driven by difficult experiences as young physicians in poorly resourced clinical settings, stemmed from a commitment to improving communities’ health and desire to impact on perceived failing health systems. Rather than ‘exiting’ the South African health service, selecting PHM specialist training enacted participants’ ‘loyalty’ to population health. Participants anticipated carving out their own careers due to an absence of public sector career paths. They believed specialists’ contribution centred on providing ‘public health intelligence’ – finding and interpreting information; supporting services through management and leadership; and inputting into policymaking and planning.

Conclusions: Competencies of PHM specialists should be refined to inform and improve management of this scarce human resource for health. This is particularly important given the proposed major health reforms towards universal health coverage in South Africa presently. In addition, findings highlight the importance of physicians’ early work experiences where avenues for expressing ‘voice’, mediated by ‘loyalty’, could be utilised to improve public sector health systems.