We conducted an integrative review of the global-free maternity (FM) policies and evaluated the quality of care (QoC) and cost and cost implications to provide lessons for universal health coverage (UHC).

Using integrative review methods proposed by Whittemore and Knafl (2005), we searched through EBSCO Host, ArticleFirst, Cochrane Central Registry of Controlled Trials, Emerald Insight, JSTOR, PubMed, Springer Link, Electronic collections online, and Google Scholar databases guided by the preferred reporting item for systematic review and meta-analysis protocol (PRISMA) guideline. Only empirical studies that described FM policies with components of quality and cost were included. There were 43 papers included, and the data were analysed thematically.

Forty-three studies that met the criteria were all from developing countries and had implemented different approaches of FM policy. Review findings demonstrated that some of the quality issues hindering the policies were poor management of complications, worsened referral systems, overburdening of staff because of increased utilisation, lack of transport, and low supply of stock. There were some quality improvements on monitoring vital signs by nurses and some procedures met the recommended standards. Equally, mothers still bear the burden of some costs such as the purchase of drugs, transport, informal payments despite policies being ‘free’.

FM policies can reduce the financial burden on the households if well implemented and sustainably funded. Besides, they may also contribute to a decline in inequity between the rich and poor though not independently. In order to achieve the SDG goal of UHC by 2030, there is a need to promote awareness of the policy to the poor and disadvantaged women in rural areas to help narrow the inequality gap on utilisation and provide a sustainable form of transport through collaboration with partners to help reduce impoverishment of households. Also, there is a need to address elements such as cultural barriers and the role of traditional birth attendants which hinder women from seeking skilled care even when they are freely available.

The depth and breadth of problems related to depressive symptomatology and optimal treatment outcomes, including medication treatment adherence, have long been documented in the literature. Missing are clear explanations as to what factors and patient characteristics may account for lack of medication treatment adherence.

The two objectives of the current study were to examine the predictive strength of depression, patient characteristics, and patient attachment style regarding medication treatment adherence and to consider the extent to which attachment styles mediate the relation between depression and medication treatment adherence.

Participants in the present study were 237 racially diverse American primary care patients with a diagnosis of hypertension who were participants in a clinical trial. Depression, patient characteristics, attachment style, and medication treatment adherence were assessed.

Partly consistent with our four hypotheses, the following results were found: (a) Black American, younger, never married, and poorer patients had lower medication treatment adherence (b) depression was significantly associated with lower self-reported medication adherence; (c) insecure–dismissing attachment style was related to lower medication adherence; and (d) insecure–dismissing attachment style mediates the relation between depression and medication treatment adherence by exacerbating the negative association.

Physicians and other primary care providers should consider how depressive symptomatology, patient characteristics, and attachment style may inform the treatment plans they put forward and the extent to which patients may adhere to those treatment plans.

Historically, epilepsy care has been documented as poor. The New Contract introduced epilepsy as a quality indicator from April 2004.

To measure the unmet clinical needs in patients with epilepsy, following an audit, with educational intervention and the introduction of the New Contract.

Prospective audit.

Thirteen general practices (population 68 240).

The case notes of 388 patients receiving treatment for epilepsy were reviewed in the two years before, and four years after, the introduction of the New Contract in April 2004. An intervention took place, which consisted of (a) a letter to each practice summarising the main findings; (b) the provision of a comprehensive template; (c) an individualised categorisation for each patient; (d) a single educational session led by a Neurologist with an interest in epilepsy in March 2004; and (e) the introduction of the New Contract in April 2004.

The audit was completed in 267 cases. There was a significant increase in the annual review rate and documentation of seizure frequency. This happened after the New Contract was introduced, and has been sustained. The number of patients under shared care fell significantly from 22% to 16%. Thirty of the 62 (48%) patients with poor control were not receiving shared care. There were 13 referrals and 32 practice interventions related to the audit, with 39 positive outcomes. There was one death in a poorly controlled patient who was not under shared care, nor had been seen regularly by their general practitioner.

The unmet needs of some patients were highlighted by the audit resulting in appropriate management of these patients. However, despite the significantly improved review rates in primary care, and the availability of specialist services locally, we remain concerned about the proportion of patients with refractory epilepsy who do not seem to be receiving coordinated shared care.

The aims of this study were to (1) assess the initial experiences of parenthood amongst mainly disadvantaged mothers; (2) explore their views on the extent to which they felt they had benefitted (or not) from participating in a newly developed, intensive mother and baby support programme in the community; and (3) explore the perspectives of those who delivered the programme (i.e., facilitators), most of whom were Public Health Nurses (PHNs).

Positive parent–child interactions and appropriate levels of infant stimulation are essential to promoting a child’s well-being and laying a foundation in the early years for positive developmental outcomes. It is important, therefore, to examine participants’ experiences of community-based, family-focused, early prevention and intervention programmes.

This study was undertaken as part of a larger evaluation of a newly developed parent and infant (PIN) programme which was delivered in two disadvantaged areas in Ireland. One-to-one interviews were conducted with both mothers (n = 22) and facilitators (n = 8) (including three PHNs) plus six focus groups with an additional sub-group of facilitators (n = 17).

The collective findings suggest that mothers found the programme helpful in promoting a greater understanding of their infants’ behaviour and needs, and in alleviating stress and concerns associated with motherhood. Mothers described feeling more knowledgeable about the importance of regular and appropriate infant interaction to encourage learning and development. Facilitators, specifically PHNs, also reported a greater awareness of the value of infant socioemotional development for their clinical practice and observed greater positive communication between mothers and infants.

These findings suggest that a community-based, intensive mother and baby programme can help to promote parental competence and enhance infant learning and development. Additional benefits in terms of early intervention and positive changes to public health nursing practice are also discussed.

To explore the beliefs, attitudes, and behaviours of fathers towards breastfeeding and how they impact either positively or negatively on their partners’ decisions to initiate or continue breastfeeding.

Despite policy initiatives at a national and international level and the increased number of baby-friendly hospitals within the UK, breastfeeding rates are slow to rise. Support from both parents has been proven to increase uptake and continuation rates, but there is little research into the emotional experience of fathers when it comes to breastfeeding.

We conducted qualitative interviews with 18 fathers in Wiltshire, England. Principles of grounded theory were used throughout this study to guide the sampling, data collection, and data analysis.

Fathers knew the health benefits of breastfeeding and wanted their child to breastfeed but were unsure of their place in the feeding process because they felt it was not their body. While they were aware of the benefits of breast milk for infants, fathers felt less informed of the practicalities of breastfeeding and the potential challenges they and their partner might have to overcome to breastfeed successfully for the recommended six-month period. Based on these findings, three segments were identified: the problem bonders, the dual bonders, and the pragmatists. All segments were concerned with the well-being of their partner and child and wanted their child to be breastfed. Health professionals can use the results of this study to create prenatal educational resources that take more of a preventive and problem-solving approach as opposed to promoting breastfeeding in efforts to comply with National Health Service guidelines, without offering solutions to common breastfeeding problems.

This study examines GP perceptions, attitudes and knowledge of complementary medicine (CM), and to understand contextual factors that influence these perceptions, attitudes and knowledge.

CM use is increasing, and its influence on primary care becoming increasingly significant. Although general practitioners (GPs) often have central primary care gate-keeper roles within health systems, few studies have looked specifically at GPs’ perceptions, attitudes and knowledge of CM.

A questionnaire was mailed to all 1486 GPs registered as practicing in non-metropolitan areas of New South Wales. The survey included one free-text qualitative question, where respondents were invited to highlight issues associated with CM in their own words. Free-text responses were analyzed qualitatively using thematic analysis.

In total, 585 GPs responded to the survey (adjusted response rate 40.1%), with 152 (26.0%) filling in the free-text question. Central themes which emerged were risk as a primary concern; opposition to, resistance to and the inappropriateness of complementary therapies; struggles with complexity and ambivalent tolerance.

GPs in Australia have a wide variety of perceptions toward CM. A minority of GPs have absolute views on CM, with most GPs having numerous caveats and qualifications of individual CM. Efficacy is only one aspect of CM critically evaluated by GPs when gauging support for individual therapies – risk, alignment with medical principles and an openness to exploring new avenues of treatment where others have failed, all appear to be equally important considerations when GPs form their views around CM.

This study had two aims: to describe the dialogue between district nurses (DNs) and older people in preventive home visits (PHVs) from the perspective of the DNs, and to identify barriers to and facilitators of this dialogue as perceived by the DNs.

The number of older people is rapidly increasing in all western countries, and as people’s age increases, the probability that they will have multiple diseases also increases. Planned actions are therefore needed to promote health and prevent diseases among older people so they can remain in good health and live in their homes for as long as possible. In Sweden, PHVs to 75-year-olds by DNs are one such action.

This qualitative study included five group interviews with 20 DNs. Data were analysed with qualitative content analysis.

DNs’ experiences of barriers to and facilitators of a successful health dialogue were sorted into five domains. Together, these domains provided a systematic description of the interaction between the DN and the older person in the PHV. The domains included: establishing trustful contact, conducting a structured interview, making an overall assessment, proposing health-promoting activities and offering follow-up. The barriers and facilitators could be related to the older person, the DN or the home environment. The latent content of the interviews was evident in three themes that were related to the DNs’ experiences of barriers and facilitators. These themes illustrated professional dilemmas that the DNs had to resolve to achieve the purpose of the PHV. The study demonstrates that the interaction between a DN and an older person in a PHV can be described as a complex social process in which the DN balances a personal and professional approach, combines a person-oriented and a task-oriented approach and employs both a salutogenic and pathogenic perspective.

The aim of this study was to explore the factors affecting role development in practice nursing in the United Kingdom.

General practice is currently central to National Health Service reform, producing favourable conditions for the practice nurse role to be further strengthened and developed. However, the literature has continued to describe evidence that practice nurses are a disempowered, isolated group with many constraints reducing their ability to respond to opportunities to develop their role. The rationale for conducting the study was therefore to provide a greater understanding about the constraining factors and their influence on practice nurses wishing to develop their role.

The method used to conduct the research followed a case approach, as the subject being investigated was complex with multiple inter-related factors and the approach was exploratory. The cases comprised six UK general practices and the participants within each case were a practice nurse, a GP and a practice manager.

A combination of factors was found to contribute to the way the practice nurse role evolves. These are education, practice culture, practice nurse personal characteristics and empowerment. Empowerment holds the key to maximising the conditions favourable to practice nurse role evolution. This is not, however, a ‘single’ factor; it represents the combined synergistic effects of practice culture and practice nurse personal characteristics on creating an empowering environment. The inter-relationship between these was captured in a framework and given the title ‘empowering employment principles’.

The ‘empowering employment principles’ illustrate the features most conducive to role evolution, thus providing a tool for practice nurses and their employers to enhance opportunities for nurses to develop their role.

This paper describes the study protocol, which aims to evaluate the effectiveness of a multifaceted intervention package called ‘Enhanced Primary Healthcare’ (EnPHC) on the process of care and intermediate clinical outcomes among patients with Type 2 diabetes mellitus (T2DM) and hypertension. Other outcome measures include patients’ experience and healthcare providers’ job satisfaction.

In 2014, almost two-thirds of Malaysia’s adult population aged 18 years or older had T2DM, hypertension or hypercholesterolaemia. An analysis of health system performance from 2016 to 2018 revealed that the control and management of diabetes and hypertension in Malaysia was suboptimal with almost half of the patients not diagnosed and just one-quarter of patients with diabetes appropriately treated. EnPHC framework aims to improve diagnosis and effective management of T2DM, hypertension or hypercholesterolaemia and their risk factors by increasing prevention, optimising management and improving surveillance of diagnosed patients.

This is a quasi-experimental controlled study which involves 20 intervention and 20 control clinics in two different states in Malaysia, namely Johor and Selangor. The clinics in the two states were matched and randomly allocated to ‘intervention’ and ‘control’ arms. The EnPHC framework targets different levels from community to primary healthcare clinics and integrated referral networks.

Data are collected via a retrospective chart review (RCR), patient exit survey, healthcare provider survey and an intervention checklist. The data collected are entered into tablet computers which have installed in them an offline survey application. Interrupted time series and difference-in-differences (DiD) analyses will be conducted to report outcomes.

There is widespread, unexplained variation in activity and outcome between general practices.

To explore the relationship between practice size and participation in optional activities, including the Quality and Outcomes Framework (QOF).

Cross-sectional analyses of routinely available data on practice characteristics, QOF performance and optional activities including undergraduate teaching, postgraduate training, research, enhanced clinical data collection and service development.

All 1031 general practices were located in mainland Scotland.

The most popular optional activity was undergraduate medical teaching, which involved 41% of all general practices. About a third of practices took part in postgraduate general practitioner training (29%), research (33%), enhanced clinical data collection through the Scottish Programme for Improving Clinical Effectiveness (31%) and the activities of the Scottish Primary Care Collaborative (33%). The most important driver of the number of activities undertaken by a practice is size with single handed, small and medium sized practices all undertaking a significantly lower number of activities than larger practices (P < 0.001). Deprivation had no overall effect, but was associated with lower rates of participation in postgraduate training. The average number of points achieved in the QOF ranged from 961 by the 18% of practices taking part in no optional activities, to 973 by 29% of practices taking part in one activity, 984 by 25% of practices taking part in two activities and 985 in 28% of practices taking part in three or more activities. Single handed practices in urban areas taking part in three or more additional activities had similar QOF point totals to larger practices taking part in three or more activities, and achieved 44 more QOF points than urban single-handed practices taking part in less than two additional activities.

Practice size is strongly related to participation in optional activities. There is a small but significant relationship between the practice size and number of QOF points achieved by practices taking part in less than two additional activities. Participation in optional activities is a possible indicator of cultural and organisational factors within practices, which constrain the volume and quality of services, which they are able to provide.

The aim of this study was to determine if the problem-solving therapy (PST) helps control metabolic variables in patients with type 2 diabetes mellitus (T2DM) who show depressive and anxiety symptoms.

T2DM is a chronic-degenerative multifactorial disease. It is considered one of the main public health problems in the world, and it represents an important social and economic burden. It is frequently associated with major depression and anxiety disorders, which are related with high glycated hemoglobin (HbA1c) concentrations and poor metabolic control.

We initially included 123 patients diagnosed with T2DM from five primary care centers (PCC) in Mexico City. HbA1c, central glucose, and lipid profile were measured in each patient. In addition, the Kessler psychological distress scale (K-10), the Beck Depression Inventory, and the Beck Anxiety Inventory were applied at the beginning and, to those who continued, at the end of the PST, as well as four months later.

In total, 36 patients completed the PST and the follow-up. There was a significant decrease in depressive and anxiety symptoms (P<0.001), as well as in total cholesterol (P=0.002), HbA1c (P=0.05), and low-density lipoprotein (LDL) (P=0.022). The PST helps reduce depressive and anxiety symptoms and may help stabilize glucose and cholesterol up to four months. Further studies on this area are recommended. If our findings are confirmed, the PST could help improve the quality of life of thousands of individuals with psychiatric-metabolic co-morbidity who only visit PCC.

Our aim was to compare the return-to-work rates between individuals supported by their GP plus workplace health advisers (intervention group) and those supported by their GP alone.

Workplace sickness absence places a significant cost burden on individuals and the wider economy. Previous research shows better outcomes for individuals if they are supported while still in employment, or have been on sick leave for four weeks or less. Those helped back to work at an early stage are more likely to remain at work. A non-medicalised case-managed approach appears to have the best outcomes and can prevent or reduce the slide onto out-of-work benefits, but UK literature on its effectiveness is sparse.

The design was a feasibility-controlled trial in which participants were sickness absentees, or presentees in employment with work-related health problems. Individuals completed health status measures (SF-36; EQ-5D) and a Job Content Questionnaire at baseline and again at four-month follow-up.

In the intervention group, 29/60 participants completed both phases of the trial. GP practices referred two control patients, and, despite various attempts by the research team, GPs failed to engage with the trial. This finding is of concern, although not unique in primary care research. In earlier studies, GPs reported a lack of knowledge and confidence in dealing with workplace health issues. Despite this, we report interesting findings from the case-managed group, the majority of whom returned to work within a month. Age and length of sickness absence at recruitment were better predictors of return-to-work rates than the number of case-managed contacts. The traditional randomised controlled trial approach was unsuitable for this study. GPs showed low interest in workplace sickness absence, despite their pivotal role in the process. This study informed a larger Department for Work and Pensions study of case-managed support.

The use of complementary and alternative medicine (CAM) is increasing. Access to CAM through primary care referral is common with some of these referrals occurring through existing NHS contracts. Yet currently little is understood about General Practitioners (GPs) referrals to CAM via an NHS contract.

This exploratory qualitative study was designed to explore UK GPs experiences of referring patients to CAM under an NHS contract.

Semistructured interviews were conducted with 10 GPs in the UK, purposively sampled, who referred patients under an NHS contract to a private CAM clinic, staffed by medically qualified CAM practitioners. Qualitative methodology making use of the framework approach was used to undertake the interviews and analysis.

The decision of GPs to refer a patient to CAM through an NHS contract is complex and based on negotiation between patient and GP but is ultimately determined by the patients’ openness and motivation towards CAM. Most GPs would consider referral when there are no other therapeutic options for their patients. Various factors, including clinical evidence, increase the likelihood of referral but two overarching influences are crucial: (a) the individual GPs positive attitude to, and experience of CAM, including a trusting relationship with the CAM practitioner; and (b) the patient’s attitude towards CAM. In-depth knowledge of CAM was not a vital factor for most GPs in the decision to refer.

A CAM referral only took place if the patient readily agreed with this therapeutic approach, and in this respect it may differ from referrals by GPs to conventional medicinal practitioners. Such an approach, then, relies on patients having a positive view of CAM and as such could result in inequity in treatment access. Increasing knowledge about and evidence for CAM will assist GPs in making appropriate referrals in a timely manner. We propose a preliminary model that explains our findings about referrals considering patients need as well as the medical process. As data saturation may not have been achieved, further investigation is warranted to confirm or refute these suggestions.