Primary Care

US Latino adults are disproportionately affected by the HIV epidemic and experience disparities in access to HIV care. However, relatively little is known about how acculturation affects perceived barriers to engagement in care among Latinos. This article examines factors that may be associated with engaging HIV-infected persons in primary care by using interview data from 651 Latino and non-Latino adults presenting for services at five agencies that participated in a multisite demonstration project Latinos (n=219) were more likely than non-Latino Whites (n=117) to be male, recently diagnosed with HIV, less educated, without health insurance, not on Medicaid, taking HIV medications, and in better physical health. In addition, Latinos were more likely to report facing numerous structural barriers, stigma-related worries/concerns, and belief barriers than were non-Latino Whites. Upon closer examination of the Latino subsample, acculturation (based on language) was associated with repo...

In almost all cultures, intriguingly, care has both positive and negative
connotations as in taking care of something or somebody and, at
the same time, carrying the burden of something or somebody. This
article claims that this contradictory use of care is a result of the
historical development of the meaning of care and that this is
a hindrance to understand the meaning of care in our lives. In the
course of its historical development, care has been understood as
a means to an end; either as care for the self or for others, or as
a transition to a higher end. Only in the phenomenological-existential
rehabilitation of care in the twentieth century, it has been examined
beyond this instrumental conception and placed at the center of who
we are. To explain these claims, the article has two sections: the first
section offers a historical outline of some of the main theories of care
that have been developed; the second section explains the novelty of
Heidegger’s and Arendt’s theories of care. The latter section aims to
demonstrate the necessity of understanding care as the source of our
existence, and why care cannot be postponed.

Care; Heidegger; Arendt;
existentialism;
instrumentality; historical
development of care

BACKGROUND Recommendations suggest that all patients with diabetes who use insulin should home test their blood glucose. Recommendations for those not using insulin remain contradictory. These recommendations are in part based upon the assumption that people with diabetes cannot make an accurate estimate. AIM To explore whether people with diabetes can accurately estimate their blood glucose levels and to assess which factors explain variability in these estimates. DESIGN A cross-sectional design. SETTING One general practice in Oxfordshire, UK. PARTICIPANTS One hundred and fifteen consecutive patients with diabetes attending a diabetic clinic were invited to estimate their blood glucose level prior to having it routinely measured. RESULTS One hundred and four patients made estimates. Of these, 45 (43.3%) underestimated their blood glucose, 18 (17.3%) overestimated, and 41 (39.4%) made guesses that fell into the range defined as accurate. Of those not using insulin (n = 85), 37 (43....

Lifestyle factors (eg, smoking, diet) and compliance with screening recommendations play a role in cancer risk, and emerging technologies (eg, new vaccines, genetic testing) hold promise for improved risk management. However, optimal outcomes from cancer control efforts require better preparation of health professionals in risk assessment, risk communication, and implementing health behavioral change strategies that are vitally important to cancer control. Although physician assistants (PAs) are substantively engaged in cancer-related service delivery in primary care settings, few models exist to facilitate integration of cancer control learning experiences into the curricula used in intense, fast-paced, 24- to 30-month PA training programs.

Medical students have had a declining interest in family medicine as a career. Some studies have shown a small inverse relationship between debt levels and primary care, but it is unclear how students perceive remuneration in different specialties and how these perceptions might influence career choice. Medical students at one school were surveyed to understand their perceptions of physician remuneration and to gain insight into how these perceptions might affect career selection. Response rate was 72% (560/781 students). Students' estimates of physician income were accurate throughout training, with the overall estimate for family medicine being lower than the actual income by only $10,656. The vast majority of students agreed with the statement that family physicians get paid too little (85%-89% of each class). The importance of payment as a factor in career decision making increased with higher debt and with advancing training. Students are able to accurately predict income b...

To describe empirically the risky sexual behavior of an at-risk sample of adolescent girls, to assess psychosocial correlates of risky behavior, and to examine the utility of applying a risk and protective model to predicting teens' risky sexual behavior. Participants included 158 African American girls, ages 12 to 19, who were receiving medical care in an adolescent primary care clinic. Teens completed measures of depression, conduct problems, substance use, peer norms, social support, HIV knowledge, sexual self-efficacy, and sexual behavior. Teens in this sample reported high rates of risky sexual behaviors, including early sexual debuts and frequent unprotected sexual encounters with multiple partners. African American girls who reported high rates of substance use and who reported that their peers engaged in risky behaviors also reported engaging in high rates of risky sexual behaviors. Little support was obtained for protective factors (HIV knowledge, social support, sexual...

Pulmonary rehabilitation programmes are often costly and dependent on the infrastructure of specialised centres. We developed a modular, outpatient-based rehabilitation programme, which is inexpensive and can be implemented in a variety of settings. The aim of this study was to determine the effects and feasibility of this programme. Thirteen patients with COPD and 7 patients with asthma were enrolled by their primary care physician because of dyspnoea. Initial assessment included cardiopulmonary exercise testing, six-minute walking distance, lung function testing and multiple questionnaires addressing dyspnoea, depression and quality of life issues. The training consisted of 36 sessions of high intensity training of 2 hours duration to improve exercise tolerance, including 30 minutes of stationary cycling at the anaerobic threshold. Another complete assessment was done on completion of the study at 3 months. The six-minute walking distance improved significantly from 401 to 551 m (...

To design and test the performance of a new knee pain screening tool (KNEST), both separately and together with a combination of existing questionnaires, which will be used to assess the general health status of knee pain sufferers in primary care. A postal survey of knee pain and disability was sent to a random sample of 240 individuals aged over 55 yr registered with two general practices in North STAFFORDSHIRE: The survey questionnaire consisted of the KNEST; a pain manikin; the Short Form 36 (SF-36); the Hospital Anxiety and Depression Scale (HADS); demographic questions; and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for those who reported knee pain. A second, identical questionnaire was sent 2 weeks later to a random subsample of responders (n=80) to test repeatability. An 85% baseline response rate was achieved for the first questionnaire. The 12-month prevalence of knee pain identified from baseline responders to the survey was 45%. A response rate of 74% was achieved for the repeatability questionnaire. Each section of the questionnaire was well completed and repeatability was good for nearly all measures (most reliability scores exceeded 0.6). A new core question about knee pain showed good internal reliability, with an agreement score of 91% between baseline and retest assessment, and good construct validity in relation to knee pain identified on the pain manikin (agreement 95%). Good agreement was found between recalled consultation for knee pain in the questionnaire and evidence of consultation for knee pain in general practice records. The KNEST appears to be a reliable and valid composite tool for the study of population needs and outcomes of care for people aged over 55 yr with knee pain.

Aim This audit was designed to compare current referral practice with the Ministry of Health elective services National Access Criteria for first Specialist Assessment (ACA) guidelines, to identify specific problems, and (if possible) to improve the use of acute dermatology services. Method Information regarding referral source, information provided, urgency and diagnostic accuracy, time interval between referral and consultation date, and

BACKGROUND:Practice nurses have a key role within UK general practice, especially since the 2004 GMS contract. This study aimed to describe that role, identify how professionally supported they felt and their career intentions. An additional aim was to explore whether they felt isolated and identify contributory factors.METHODS:A cross-sectional questionnaire survey in one large urban Scottish Health Board, targeted all practice nurses (n = 329). Domains included demographics, workload, training and professional support. Following univariate descriptive statistics, associations between categorical variables were tested using the chi-square test or chi-square test for trend; associations between dichotomous variables were tested using Fisher's Exact test. Variables significantly associated with isolation were entered into a binary logistic regression model using backwards elimination.RESULTS:There were 200 responses (61.0% response rate). Most respondents were aged 40 or over and were practice nurses for a median of 10 years. Commonest clinical activities were coronary heart disease management, cervical cytology, diabetes and the management of chronic obstructive pulmonary disease. Although most had a Personal Development Plan and a recent appraisal, 103 (52.3%) felt isolated at least sometimes; 30 (15.5%) intended leaving practice nursing within 5 years.Isolated nurses worked in practices with smaller list sizes (p = 0.024) and nursing teams (p = 0.003); were less likely to have someone they could discuss a clinical/professional (p = 0.002) or personal (p < 0.001) problem with; used their training and qualifications less (p < 0.001); had less productive appraisals (p < 0.001); and were less likely to intend staying in practice nursing (p = 0.009). Logistic regression analysis showed that nurses working alone or in teams of two were 6-fold and 3.5-fold more likely to feel isolated. Using qualifications and training to the full, having productive appraisals and planning to remain in practice nursing all mitigated against feeling isolated.CONCLUSIONS:A significant proportion of practice nurses reported feeling isolated, at least some of the time. They were more likely to be in small practices and more likely to be considering leaving practice nursing. Factors contributing to their isolation were generally located within the practice environment. Providing support to these nurses within their practice setting may help alleviate the feelings of isolation, and could reduce the number considering leaving practice nursing

To understand the current use of electronic health records (EHRs) in small primary care practices and to explore experiences and perceptions of physicians and staff toward the benefits, challenges, and successful strategies for implementation and meaningful use of advanced EHR functions. Qualitative case study of 6 primary care practices in Virginia. We performed surveys and in-depth interviews with clinicians and administrative staff (N = 38) and observed interpersonal relations and use of EHR functions over a 16-month period. Practices with an established EHR were selected based on a maximum variation of quality activities, location, and ownership. Physicians and staff report increased efficiency in retrieving medical records, storing patient information, coordination of care, and office operations. Costs, lack of knowledge of EHR functions, and problems transforming office operations were barriers reported for meaningful use of EHRs. Major disruption to patient care during upgrad...

The presentation of depression in primary care is in many ways different from that seen in psychiatric settings. The process of detection and treatment is also different. This is particularly so in developing countries like Pakistan, which has high prevalence rates of depression but poorly organized primary health care services and primary care physicians (PCPs) who have little psychiatric training, either at undergraduate or postgraduate levels. There is a need to review difficulties faced by primary care physicians in detection and management of depression. It is hoped this would lead to better and more effective management of depression at primary health care level.

Mental disorders affect a great number of people worldwide. Four out of the 10 leading causes of disability in the world are mental disorders. Because of the scarcity of specialists around the world and especially in developing countries, it is important for primary care physicians to provide services to patients with mental disorders. The most widely researched and used psychological approach in primary care is cognitive behavioral therapy. Due to its brief nature and the practical skills it teaches, it is convenient for use in primary care settings. The following paper reviews the literature on psychotherapy in primary care and provides some practical tips for primary care physicians to use when they are faced with patients having mental disorders.

The goals of this study were to develop a computer-based electronic screening tool (eScreening) and determine the feasibility of implementing eScreening for rural users of primary care. This descriptive pilot adapted existing screening measures for depression and alcohol abuse to a portable computer-based format and examined the feasibility of its adoption and use. This was a three-step design using convenience samples for (1) a focus group with providers,(2) usability testing with selected rural patients using the ...

Rising concern over the poor level of blood-pressure (BP) control among hypertensive patients has prompted searches for novel ways of managing hypertension. The objectives of this study were to develop and pilot-test a home BP tele-management system that actively engages patients in the process of care.Phase 1 involved a series of focus-group meetings with patients and primary care providers to guide the system’s development. In Phase 2, 33 diabetic patients with uncontrolled ambulatory hypertension were enrolled in a 4-month pilot study, using a before-and-after design to assess its effectiveness in lowering BP, its acceptability to users, and the reliability of home BP measurements.The system, developed using commodity hardware, comprised a Bluetooth-enabled home BP monitor, a mobile phone to receive and transmit data, a central server for data processing, a fax-back system to send physicians’ reports, and a BP alerting system. In the pilot study, 24-h ambulatory BP fell by 11/5 (±13/7 SD) mm Hg (both P < .001), and BP control improved significantly. Substantially more home readings were received by the server than expected, based on the preset monitoring schedule. Of 42 BP alerts sent to patients, almost half (n = 20) were due to low BP. Physicians received no critical BP alerts. Patients perceived the system as acceptable and effective.The encouraging results of this study provide a strong rationale for a long-term, randomized, clinical trial to determine whether this home BP tele-management system improves BP control in the community among patients with uncontrolled hypertension.

To examine patient preferences for age-,gender-, and racial/ethnic-concordant primary care physicians. Focus group interviews. Forty-nine adults (African Americans, Caucasians, and Latinos) receiving their outpatient medical care in university-based primary care clinics in Northern California. Guiding questions were designed to elicit information about what patients look for in establishing and maintaining a therapeutic relationship with a primary care physician. Patients were prompted to provide examples and to discuss demographic-concordance factors. Many participants felt that their continuity of care was poor and that they could not choose their own primary care physicians in the academic system. Most reported tolerating these inconveniences for what they perceived to be a higher quality of care linked to medical innovations at academic medical centers. Patients&#39; views regarding age concordance were varied and unrelated to gender or racial/ethnic group. Women in all English-...

Pediatricians are in an ideal position to advise families about the prevention and management of oral diseases in children. The objective of the study was to determine knowledge, attitude, and practices regarding the prevention of oral diseases among pediatricians in Italy. A systematic random sample of 1000 pediatricians received a questionnaire on socio-demographic and practice characteristics; knowledge on risk factors; attitude and practices towards the prevention of oral diseases. A total of 507 pediatricians participated. More than half knew the main risk factors for oral diseases and this knowledge was higher in primary care pediatricians (p = 0.007), in those with a higher number of hours worked per week (p = 0.012), and who believed that oral diseases may be prevented (p = 0.017). Pediatricians with higher knowledge about the main risk factors (p = 0.006) believe that they have an important role in preventing oral diseases and that they can perform an oral examination. Almo...