Developing an appropriate context-based school-age obesity prevention programme, understanding the root causes of obesity in real-life situations is vital. The objectives of this study were to explore the risk factors of school-age obesity based on Ecological System Theory (EST) and develop mutual problem-solving guidelines for school-age obesity prevention.

Participation Action Research (PAR) was used as the study design. The data collection employed focus group discussions, in-depth interviews, participant’s observations, together with the procedures of Appreciation, Influence, and Control (AIC) with 55 school key informants.

Risk factors supported by EST at all level included high-calorie intake; sedentary lifestyles; perceptions of ‘Chubby are cute’; indulgent parenting, including limited exercise area in school. PAR process guarantees the sustained context-based prevention guidelines.

The results could be used as a policy-driven for school-based participation and environmental support in order to promote health-promoting school.

This study aimed to explore the current challenges of Iran’s Iranian Primary Health Care (PHC) network and possible ways forward.

PHC network was established in 1985. It remains a core instrument of health care delivery. However, it faces several challenges that can threaten its effective functioning.

We conducted face-to-face semi-structured interviews with 26 key stakeholders. We used the deductive content analysis approach. World Health Organization’s health system framework guided our analyses. Data were analysed using MAXQDA software. To enhance data triangulation, we reviewed PHC national related plans, bylaws, and national and international published reports.

PHC network experiences financial challenges and fails to respond fully to the emerging population’s needs due to unfair distribution of resources and a lack of community health workers for PHC and a sustainable financing model for PHC. Furthermore, the insurance package is not well integrated into the PHC network system. Policy interests and resource commitments for innovative, preventive, and health promotion initiatives are lacking. Innovative, preventive, and health promotion initiatives should become the highest priority for policymakers. Well-trained community health professionals, active community participation, private sector engagements and active involvement of non-government organisations are fundamental for a well-functioning PHC network in Iran, especially to foster the delivery of evidence-based initiatives.

Multimorbidity is common among general practice patients and increases a general practitioner’s (GP’s) workload. But the extent of multimorbidity may depend on its definition and whether a time delimiter is included in the definition or not.

The aims of the study were (1) to compare practice prevalence rates yielded by different models of multimorbidity, (2) to determine how a time delimiter influences the prevalence rates and (3) to assess the effects of multimorbidity on the number of direct and indirect patient contacts as an indicator of doctors’ workload.

This retrospective observational study used electronic medical records from 142 German general practices, covering 13 years from 1994 to 2007. The four models of multimorbidity ranged from a simple definition, requiring only two diseases, to an advanced definition requiring at least three chronic conditions. We also included a time delimiter for the definition of multimorbidity. Descriptive statistics, such as means and correlation coefficients, were applied.

The annual percentage of multimorbid primary care patients ranged between 84% (simple model) and 16% (advanced model) and between 74% and 13% if a time delimiter was included. Multimorbid patients had about twice as many contacts annually than the remainder. The number of contacts were different for each model, but the ratio remained similar. The number of contacts correlated moderately with patient age (r = 0.35). The correlation between age and multimorbidity increased from model to model up to 0.28 while the correlations between contacts and multimorbidity varied around 0.2 in all four models.

Multimorbidity seems to be less prevalent in primary care practices than usually estimated if advanced definitions of multimorbidity and a temporal delimiter are applied. Although multimorbidity increases in any model a doctor’s workload, it is especially the older person with multiple chronic diseases who is a challenge for the GP.

To explore how a palliative approach to care is operationalized in primary care, through the description of clinical practices used by primary care clinicians to identify and care for patients with progressive life-limiting illness (PLLI).

Increasing numbers of people are living with PLLI but are often not recognized as needing a palliative approach to care. To meet growing needs, generalists such as family physicians will need to adopt a palliative approach to care in their own setting. Practical descriptions of a palliative approach in non-specialist settings have been lacking.

We conducted a qualitative descriptive study design using in-depth semi-structured interviews with 11 key informant participants (6 physicians, 3 nurse practitioners, 1 registered nurse, and 1 registered practical nurse) known to be providing comprehensive care to patients with PLLI in family practices in Ontario, Canada. We asked about their approach to identifying patients with PLLI and the strategies used in their care. We employed content analysis to develop themes.

Participants identified patients by functional decline, change in needs, increased acuity, and the specifics of a condition/diagnosis. Care strategies included concretizing commitment to care, eliciting goals of care, shifting care to the home, broadening team members including leveraging the support of family and community resources, and shifting to a ‘proactive’ approach involving increased follow-up, flexibility, and intensity.

Primary care providers articulated strategies for identifying and providing care to patients with PLLI that illuminate an upstream approach tailored to their setting.

Aim of the present study was to assess the knowledge of the potential role of nurses in the primary care setting and to analyse the attitudes towards their utilization by nurses and General Practitioners (GPs) in a region of Italy.

Nowadays, in Italy, the role of the nurse in primary care is still under-recognized and most primary care medical offices are managed individually by a physician.

The study consists of a questionnaire-based cross-sectional survey carried out in Piedmont, Italy, between February and September 2015.

We included 105 participants, 57 nurses and 48 physicians. The presence of a nurse working together with the GP was defined as ‘useful’ by 54.4% of nurses (versus 60.4% of physicians), as ‘essential’ by 45.6% of nurses (versus 25.0% of physicians), as ‘marginal’ by no nurses (versus 14.6% of physicians) and as ‘unimportant’ by none (P=0.002). Thus, physicians seemed to be less favorable towards a full collaboration and power-sharing with nurses. Furthermore, GPs and nurses showed a different attitude towards the role of nurses in primary care: while nurses highlighted their clinical value, physicians tended rather to recognize them a ‘supportive’ role. Moreover, only 20.8% of the physicians interviewed stated that they worked with a nurse. At the multivariate analysis, the age class resulted to be a significant predictor of the perception that the presence of a nurse working with the GP is essential: participants >50 years had an OR of 0.03 (P=0.028). Although the primary care organization appears still largely based on a traditional physician-centric care model, the positive attitude of nurses and young GPs towards a more collaborative model of primary care might represent a promising starting point.

To examine general practitioners’ (GPs) clinical expertise in assessing, communicating with, and managing suicidal young people aged 14–25 to inform the development of an educational intervention for GPs on youth suicide prevention.

Suicide is the second leading cause of death for young people worldwide. GPs are ideally suited to facilitate early identification and assessment of suicide risk. However, GPs’ levels of competence, knowledge, and attitudes towards suicidal young people have not yet been explored.

A cross-sectional survey on GPs’ levels of confidence in assessing and managing young people at risk of suicide; knowledge of risk factors and warning signs of suicide in young people; attitudes towards young suicidal people; and training preferences on managing suicide risk.

Seventy GPs completed the survey (30 males). The majority of GPs reported high levels of confidence in assessing and managing suicidality in young people. Experienced GPs demonstrated high levels of knowledge of suicide risk factors in young people but low levels of knowledge of warning signs that might indicate heightened risk. Although 48% of GPs disagreed that maintaining compassionate care is difficult with those who deliberately self-harm, GPs perceived communication with young people to be difficult, with one-third reporting frustration in managing those at risk of suicide. A total of 75% of GPs said they would be interested in receiving further training on assessing and managing young people at risk of suicide.

The study has important implications for providing specialist training to support GPs in assessing and managing youth suicide risk and facilitating attitudinal change. GP education on youth suicide risk assessment and management should promote a holistic understanding and assessment of risk and its individual, social and contextual influences in line with clinical recommendations to facilitate therapeutic engagement and communication with young people.

To examine the choices Canadian family medicine residents make for oral anticoagulation (OAC) for patients with nonvalvular atrial fibrillation (AF).

AF increases the risk of strokes. An important consideration in AF management is risk stratification for stroke and prescription of appropriate OAC. Family physicians provide the vast majority of OAC prescriptions.

We administered a survey to residents in multiple Canadian family medicine training programmes. Questions explored the experiences and attitudes towards risk stratification and choices of OAC when presented with standardized clinical scenarios. In each scenario, a novel oral anticoagulant (NOAC) would be the preferred treatment according to the contemporary Canadian and European guidelines.

A total of 247 residents participated in the survey. Most used the congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, stroke or TIA (2 points) (81%) and congestive heart failure, hypertension, age ≥ 75 (2 points) or age 65-74 (1 point), diabetes mellitus, stroke or TIA, vascular disease including peripheral arterial disease, myocardial infarction, or aortic plaque, sex (female) (67%) risk stratification schemes while the preferred bleeding risk stratification scheme was hypertension, abnormal liver or renal function, stroke, bleeding, labile international normalized ratio, elderly (age ≥ 65), drugs or alcohol (84%). In the clinical scenarios, residents generally preferred warfarin in favour of NOACs, independent of training level. Residents ranked the risk of adverse events and the cost to the patient as their most and least important consideration when prescribing OAC, respectively. Therefore in patients with nonvalvular AF, Canadian family medicine residents prefer warfarin in comparison with NOACs despite the latest Canadian and European guideline recommendations. This knowledge gap may be enhanced by multiple factors, including a sometimes magnified fear of adverse events and a rapidly changing landscape in stroke prophylaxis.

To conduct an environmental scan of a rural primary care clinic to assess the feasibility of implementing an e-communications system between patients and clinic staff.

Increasing demands on healthcare require greater efficiencies in communications and services, particularly in rural areas. E-communications may improve clinic efficiency and delivery of healthcare but raises concerns about patient privacy and data security.

We conducted an environmental scan at one family health team clinic, a high-volume interdisciplinary primary care practice in rural southwestern Ontario, Canada, to determine the feasibility of implementing an e-communications system between its patients and staff. A total of 28 qualitative interviews were conducted (with six physicians, four phone nurses, four physicians’ nurses, five receptionists, one business office attendant, five patients, and three pharmacists who provide care to the clinic’s patients) along with quantitative surveys of 131 clinic patients.

Patients reported using the internet regularly for multiple purposes. Patients indicated they would use email to communicate with their family doctor for prescription refills (65% of respondents), appointment booking (63%), obtaining lab results (60%), and education (50%). Clinic staff expressed concerns about patient confidentiality and data security, the timeliness, complexity and responsibility of responses, and increased workload.

Clinic staff members are willing to use an e-communications system but clear guidelines are needed for successful adoption and to maintain privacy of patient health data. E-communications might improve access to and quality of care in rural primary care practices.

Practice-based performance measurement is fundamental for improvement and accountability in primary care. Traditional performance measurement of the patient’s experience is often too costly and cumbersome for most practices.

This scoping review explores the literature on the use of interactive voice response (IVR) telephone surveys to identify lessons for its use for collecting data on patient-reported outcome measures at the primary care practice level.

The literature suggests IVR could potentially increase the capacity to reach more representative patient samples and those traditionally most difficult to engage. There is potential for long-term cost effectiveness and significant decrease of the burden on practices involved in collecting patient survey data. Challenges such as low response rates, mode effects, high initial set-up costs and maintenance fees, are also reported and require careful attention.

This review suggests IVR may be a feasible alternative to traditional patient data collection methods, which should be further explored.

The investigators aimed to assess the willingness of patients to utilize and pay for a proposed short message service- (SMS) based appointment scheduling service.

Telecommunication applications have been introduced to improve the delivery of healthcare services in developed countries; however, public-funded healthcare systems in developing countries like Nigeria are mostly unfamiliar with the use of such technologies for improving healthcare access.

We proposed a SMS-based (text message) appointment scheduling system to consenting subjects at an outpatients’ clinic and explored their willingness to utilize and pay for the service. Using semi-structured interview schedules, we collected information on: estimated arrival time, most important worry when seeking for healthcare services at public hospitals in the study setting, ownership of a mobile phone, willingness to utilize a SMS-based appointment for clinic visits and willingness to pay for the service. In addition, respondents were asked to suggest a tariff for the proposed system.

A total of 500 consecutively recruited patients aged 16–86 (42.1±15.4) years participated; 54% (n=270) were females. Waiting time ranged from 1–7.5 h (3.9±1.1). Two overlapping themes emerged as most important worries: crowded waiting rooms and long waiting time. Ownership of mobile phones was reported by 96.4% (n=482) of subjects. Nearly all favoured the proposed appointment scheduling system (n=486, 97.2%). Majority of patients who favoured the system were willing to pay for the service (n=484, 99.6%). Suggested tariff ranged from 0.03 to 20.83 (1.53±2.11) US dollars; 89.8% (n=349) of the subjects suggested tariffs that were greater than the prevailing retail cost of the proposed service. In sum, our findings indicate that patients in this study were willing to utilize and pay for a proposed SMS-based appointment scheduling system. The findings have implications for policies aimed at improving healthcare access and delivery of healthcare services at the primary care level in developing countries like Nigeria.

The Mental Health Act 2001 introduced important reforms of Irish mental health law and services. This paper aims to provide an evidence-based exploration of general practitioners’ views on the implementation of the Mental Health Act 2001.

We posted questionnaires to 1200 general practitioners in Ireland seeking their views on their experiences with the Mental Health Act 2001.

Eight hundred and twenty general practitioners (68.3%) responded. Among those who provided comments, a majority (75.2%) provided negative comments. The most commonly occurring themes related to difficulties with transport of patients to inpatient facilities, form filling, time requirements and administrative matters. Other negative comments related to general practitioner recommendations for involuntary admission, training, mental health tribunals, applications for involuntary admission and the position of children. Minorities provided neutral (18.0%) or positive comments (6.8%), chiefly related to user-friendliness, transparency and improved communication.

General practitioners highlight a need for greater training and clear guidelines in relation to the Mental Health Act 2001. Their forthright responses demonstrate deep engagement with the new legislation and eagerness to see the Mental Health Act 2001 realise its full potential to improve the involuntary admission process and protect human rights, in the best interests of patients.

Dementia is a complex and variable condition which makes recognition of it particularly difficult in a low prevalence primary care setting. This study examined the factors associated with agreement between an objective measure of cognitive function (the revised Cambridge Cognitive Assessment, CAMCOG-R) and general practitioner (GP) clinical judgment of dementia.

This was a cross-sectional study involving 165 GPs and 2,024 community-dwelling patients aged 75 years or older. GPs provided their clinical judgment in relation to each of their patient's dementia status. Each patient's cognitive function and depression status was measured by a research nurse using the CAMCOG-R and the 15-item Geriatric Depression Scale (GDS), respectively.

GPs correctly identified 44.5% of patients with CAMCOG-R dementia and 90% of patients without CAMCOG-R dementia. In those patients with CAMCOG-R dementia, two patient-dependent factors were most important for predicting agreement between the CAMCOG-R and GP judgment: the CAMCOG-R score (p = 0.006) and patient's mention of subjective memory complaints (SMC) to the GP (p = 0.040). A higher CAMCOG-R (p < 0.001) score, female gender (p = 0.005), and larger practice size (p < 0.001) were positively associated with GP agreement that the patient did not have dementia. Subjective memory complaints (p < 0.001) were more likely to result in a false-positive diagnosis of dementia.

Timely recognition of dementia is advocated for optimal dementia management, but early recognition of a possible dementia syndrome needs to be balanced with awareness of the likelihood of false positives in detection. Although GPs correctly agree with dimensions measured by the CAMCOG-R, improvements in sensitivity are required for earlier detection of dementia.

PredictD is a risk algorithm that was developed to predict risk of onset of major depression over 12 months in general practice attendees in Europe and validated in a similar population in Chile. It was the first risk algorithm to be developed in the field of mental disorders. Our objective was to extend predictD as an algorithm to detect people at risk of major depression over 24 months.

Participants were 4190 adult attendees to general practices in the UK, Spain, Slovenia and Portugal, who were not depressed at baseline and were followed up for 24 months. The original predictD risk algorithm for onset of DSM-IV major depression had already been developed in data arising from the first 12 months of follow-up. In this analysis we fitted predictD to the longer period of follow-up, first by examining only the second year (12–24 months) and then the whole period of follow-up (0–24 months).

The instrument performed well for prediction of major depression from 12 to 24 months [c-index 0.728, 95% confidence interval (CI) 0.675–0.781], or over the whole 24 months (c-index 0.783, 95% CI 0.757–0.809).

The predictD risk algorithm for major depression is accurate over 24 months, extending it current use of prediction over 12 months. This strengthens its use in prevention efforts in general medical settings.

This study assessed the prescription of potentially nephrotoxic non-steroidal anti-inflammatory drugs (NSAIDs) to patients with chronic kidney disease (CKD) in general practice.

CKD poses a considerable disease burden in the UK. Guidelines state that caution should be exercised when prescribing NSAIDs to CKD patients, due to increased risk of rapid kidney disease progression.

We reviewed the medical records of 1427 patients with CKD Stages 3–5 in seven general practices in West Yorkshire.

A total of 792 (55.5%) were prescribed NSAIDs; 128 (9%) of these were prescribed NSAIDs excluding low-dose aspirin. Twenty-three (20.2%) patients who were prescribed NSAIDs had no record of CKD monitoring in the preceding year.

Prescription of NSAIDs is likely to be contributing to unnecessary renal impairment.

Guidelines may improve clinical outcomes for depression, but whether they are followed in primary care is uncertain.

To assess general practioners (GPs’) adherence to the National Institute for Health and Clinical Excellence (NICE) guidelines for managing depression in adults (2004).

Anonymized Questionnaire Survey.

Thirty-eight partnerships within one primary care trust in England.

Focused questionnaire incorporating measurable criteria, posted to GPs in May 2007.

The response rate was 67% (143/215 GPs). GPs followed NICE guidelines when screening for depression in patients with physical illness, using selective serotonin reuptake inhibitor antidepressants appropriately and referring to counselling and secondary care. However, 48% GPs did not screen patients with a history of depression, 44% discontinued medication too soon and 38% avoided prescribing for ‘understandable’ moderate depression. GPs identified poor access to cognitive behaviour therapy (CBT) as the greatest barrier to implementing guidelines. Only 41% personally used CBT. Adherence to NICE guidelines was significantly higher for GPs trained in psychiatry and in younger GPs, but was not associated with gender, practice size, possessing the Membership of the Royal College of General Practitioners or reading guidelines. Less than half (38%) of the GPs rated NICE as having a moderate or substantial impact upon their clinical management. The Quality and Outcomes Framework (QOF) had more influence than NICE guidelines upon detection and recording of care, especially in larger practices.

Training more cognitive behaviour therapists, making psychiatry experience mandatory for future GPs and focusing QOF incentives upon treatment outcomes as well as screening may improve adherence to NICE depression guidelines.

To map the results of four empirical quantitative and qualitative studies to the Normalization Process Model (NPM) to explain why open access hysterosalpingography (HSG) for the initial management of infertile couples has or has not normalized in primary care.

The NPM is an applied theoretical model to help understand the factors that lead to the routine embedding of a complex intervention in everyday practice. Open access HSG has recently become available for the initial assessment of infertility in primary care.

The results of two qualitative studies (a focus group study and an in-depth interview study with patients and professionals) and two quantitative studies (a pilot survey and a pragmatic cluster-randomized controlled trial) evaluating open access HSG are interpreted by mapping the results to the NPM.

Application of the model shows that open access HSG would confer an advantage to all agencies if they could be sure that the expertise was present and supported within primary care.

Open access HSG was adopted but not normalized into everyday practice. Despite demonstration of modest workability, it has been counteracted by limited integration. Further evaluation of integration within contexts is required.