This study investigates the knowledge, attitudes, and practices (KAP) of family physicians in Iran, regarding osteoporosis and their experience with national osteoporosis guideline.

Osteoporosis is a relatively preventable, chronic and progressive disease. Family physicians play a crucial role in relieving the burden of care.

This cross-sectional study was addressed at all qualified family physicians who registered at urban family physicians and referral system program. Data collection included demographics, professional experience, and knowledge of guidelines based on a standardized KAP questionnaire. Student’s t-test was used to measure the associations between KAP scores and demographic, professional experience variables.

The response rate was 72% (540/750). Based on Bloom’s cut off scale, family physicians knowledge and practice scores were in moderate level, and only 14 and 38.5% of them had good knowledge and practice, respectively. Attitude score was in good level, and 64.1% of participants had positive attitude. Mean score of knowledge and practice were higher significantly among family physicians that practice in public settings. Family physicians, who completed osteoporosis training courses, had higher attitude score (P=0.03). Only 23.5% of family physicians were aware of the existence of national osteoporosis guideline.

Although most family physicians believed in the importance of preventive measures, however, limited number of them had good knowledge and practice regarding osteoporosis and less than a quarter were aware of national guideline. This is a clear need to disseminate the guideline more effectively, make greater use of efficient training methods.

This non-randomized pre–post-intervention study investigated the effect of a systemic public health intervention on the length of time between anorexia nervosa symptom onset and contact with the health care system as well as the initiation of treatment.

Although systemic public health interventions have successfully been implemented in physical and mental health fields, their effect on the early treatment of patients with anorexia nervosa remains unclear.

In total, 59 anorexia nervosa patients (mean age=21.5 years, SD=7.2) were recruited before a systemic public health intervention, and 18 patients (mean age=22.2 years, SD=8.9) were recruited afterwards. Using validated self-report measures and a semi-structured interview, the duration of untreated anorexia nervosa and the duration until first contact with the health care system were investigated.

At the beginning of the individual treatment initiation process, participants in both samples most frequently consulted their general practitioner or paediatrician about their eating disorder-related symptoms. Neither the mean duration of untreated anorexia nervosa, that is, the time between illness onset and the initiation of a recommended treatment, nor the duration until first contact with the health care system significantly decreased after the implementation of the systemic public health intervention. The mean duration of untreated anorexia nervosa was 36.5 months (SD=68.2) before the systemic public health intervention and 40.1 months (SD=89.4) after the implementation of the systemic public health intervention. The mean duration until first contact with the health care system was 25.0 months (SD=53.0) before the intervention and 32.8 months (SD=86.5) after the intervention.

Primary care providers are crucial to the treatment initiation process and should be involved in future interventions to improve early detection and treatment commencement amongst patients with anorexia nervosa.

The aim of this position paper is to assist primary health care (PHC) providers, policymakers, and researchers by discussing the current context in which palliative health care functions within PHC in Europe. The position paper gives examples for improvements to palliative care models from studies and international discussions at European Forum for Primary Care (EFPC) workshops and conferences.

Palliative care is a holistic approach that improves the quality of life of patients and their families facing problems associated with terminal illness, through the prevention and relief of suffering by means of early identification and diligent assessment and treatment of pain and other problems, whether physical, psychosocial, or spiritual. Unfortunately, some Europeans, unless they have cancer, still do not have access to generalist or specialist palliative care.

A draft of this position paper was distributed electronically through the EFPC network in 2015, 2016, and 2017. Active collaboration with the representatives of the International Primary Palliative Care Network was established from the very beginning and more recently with the EAPC Primary Care Reference Group. Barriers, opportunities, and examples of good and bad practices were discussed at workshops focusing on palliative care at the international conferences of Southeastern European countries in Ljubljana (2015) and Budva (2017), at regular conferences in Amsterdam (2015) and Riga (2016), at the WONCA Europe conferences in Istanbul (2015), Copenhagen (2016), and Prague (2017), and at the EAPC conference in Madrid (2017).

There is great diversity in the extent and type of palliative care provided in primary care by European countries. Primary care teams (PCTs) are well placed to encourage timely palliative care. We collected examples from different countries. We found numerous barriers influencing PCTs in preparing care plans with patients. We identified many facilitators to improve the organization of palliative care.

Are there differences in diabetes care between rural and non-rural US adults with diabetes?

Rural Healthy People 2010 includes diabetes as a major health priority, suggesting a possible disparity between diabetes care in rural settings as compared to non-rural locales.

This cross-sectional study using population-based survey data sought to determine if there was a difference in the quality of diabetes care between rural and non-rural US adults (⩾18 years). A diabetes care index was computed from five separate dichotomous care-related variables (HbA1c checked, lipids checked, dilated eye exam, feet checked by health care provider, and diabetes education), with adequate care defined as receiving at least four of these interventions. Multivariate methods were used to detect differences in diabetes care received by individuals living in rural compared to non-rural settings.

Multivariate regression analysis revealed that US adults with diabetes living in rural communities were more likely to receive inadequate care than non-rural residents (OR = 1.205; 95% CI 1.201, 1.209). Rural residents were more likely to receive inadequate diabetes care if they were: <40 years of age, male, Caucasian, not a high school graduate, not partnered, without health insurance, inactive or without an identified health care provider. Those deferring medical care because of cost, or who did not have an annual routine physical or had fewer than two diabetes related office visits annually were also at greater risk for suboptimal care. Routine physical checkups and deferring medical care because of cost had a greater impact on diabetes care for rural adults compared to non-rural adults.

The results of this study indicated that rural residents were less likely to receive adequate diabetes care compared to their non-rural counterparts. The findings suggest that efforts to identify and to address this disparity would likely improve the outcomes for diabetic individuals living in rural communities.

To explore the experiences and challenges for residential care home staff when managing the healthcare needs of their residents, in particular those living with dementia.

Increasing number of older people, with complex health and social care needs are living in residential care homes. Yet there is limited appreciation of why staff sometimes struggle to manage residents’ healthcare needs, or understanding of their working relationship with district nurses (DNs), whose responsibility it is to provide nursing support.

This PhD study, in a metropolitan area in the United Kingdom, was conducted by an experienced DN and involved three phases. This paper focuses on the first two phases. Phase 1 data included: semi-structured interviews (n=8), reflective field notes based on non-participant observation, documentary analysis of policies, procedures and assessment tools and other contextual data from one care home (case study site). The practitioner researcher reflected on the findings from the case study, in relation to her own knowledge and experience as a DN, focusing in particular on findings that were familiar, or which surprised. In Phase 2 she fed these findings back to other care homes (n=11) to check whether the findings from the single case study were unique or resonated with others. She gathered their feedback through semi-structured interviews with senior care staff (n=14). Data were analysed using thematic data analysis.

Findings highlight the complexity facing residential care homes: high levels of healthcare needs amongst residents, the demands of caring for residents living with dementia, variations in the knowledge and skill set of care staff, inequity in the level of healthcare support, the challenges of building a good relationship with DNs, and funding pressures facing care homes.

Any, or all of these factors can prevent care home staff from managing the healthcare needs of their residents.

The chronic care model (CCM) has been widely used in a variety of health care settings to guide system improvement for chronic illness care, including diabetes care. However, the evidence base for the specific components of the model has not been systematically reviewed. This review aimed at examining the extent to which interventions featuring the CCM components improve diabetes care and determining the relative effectiveness of different CCM components.

We systematically searched MEDLINE (1966 to December 2004), the Cochrane Effective Practice and Organisation of Care and the Cochrane Controlled Trials Register to identify interventions featuring one or more system components of the CCM for diabetes care. Outcome measures included HbA1c, blood pressure and blood lipid control. We used random-effects meta-analysis and meta-regression for quantitative synthesis of data.

In all, 69 studies (43 randomized controlled trials and 26 controlled before–after studies) met inclusion criteria and were included in this review. Overall, included studies reported a mean reduction of 0.46% (95% CI 0.38, 0.54) in HbA1c, mean reduction of 2.2 (95% CI 0.9, 3.5) mmHg in systolic blood pressure, mean reduction of 1.3 (95% CI 0.6, 2.1) mmHg in diastolic blood pressure and mean reduction of 0.24 (95% CI 0.06, 0.41) mmol/L in total cholesterol. For specific CCM components, interventions that addressed delivery system design reported the largest improvements in patient outcomes, followed by those employing a self-management support component. Interventions involving decision support or clinical information systems reported relatively smaller effect sizes.

Interventions featuring CCM components for diabetes care produced small-to-moderate improvements in a range of patient intermediate outcomes. The findings support the concept of the CCM in which the state of development of various aspects of primary care service systems defined in this model appear to be important factors in the quality of care provided to people with diabetes.

To describe the natural history of acute upper respiratory tract infections (AURIs) in primary-school children, by recording their daily symptoms.

AURIs in children are one of the most common reasons for people seeking advice from general practitioners (GPs); however, little is known about the natural history of AURIs in terms of the length and severity of symptoms, because the majority of illnesses are contracted at home.

After an initial pilot study to test the feasibility of parents recording symptoms in a diary based on the Canadian Acute Respiratory Illness and Flu Scale (CARIFS), a random selection of primary schools operating in the region was carried out in order to minimise selection bias. Meetings were arranged at the 20 schools to obtain written consent from parents and to give out diaries with a stamped addressed envelope. The diaries recorded daily symptom severity for one episode of AURI, and the data were analysed using SPSS programmes.

Diaries were returned from 223 children, of whom 146 had had an AURI. The average age was eight years, and there were almost equal numbers of boys and girls. The most frequent symptoms were runny nose, cough, feeling unwell and sore throat. There was a biphasic distribution with systemic symptoms in the first three days characterised by fever, poor sleep, irritability, not playing and headache. By day four, symptoms localising the infection to the upper respiratory tract appeared with runny nose, cough, sore throat and poor appetite; these continued into the second and occasionally third week. Most symptoms lasted for 5–11 days, with a median length for all symptoms of seven days. Symptoms defined by parents tended to be scored less for severity than symptoms defined by children.

To improve engagement of Health Visitors and Community Practitioners delivering the Healthy Child Programme with fathers. To evaluate a one-day, father-focused workshop with a supporting handbook for Practitioners. To identify institutional and organisational barriers to engagement with fathers.

The UK government policy encourages health professionals to engage with fathers. This derives from robust evidence that fathers’ early involvement with their children impacts positively on emotional, behavioural and educational development. Yet, there is little evidence that the importance of engaging fathers is reflected in Health Visitor training or that primary-care services are wholly embracing father-inclusive practice. The Fatherhood Institute (FI), a UK charity, has developed a workshop for Practitioners delivering the Healthy Child Programme.

A ‘before and after’ evaluation study, comprising a survey followed by telephone interviews, evaluated the impact of the FI workshop on Health Visitors’ and Community Practitioners’ knowledge, attitudes and behaviour in practice. A total of 134 Health Visitors and Community Practitioners from eight NHS Trusts in England attended the workshop from November 2011 to January 2014 at 12 sites. A specially constructed survey, incorporating a validated questionnaire, was administered before the workshop, immediately afterwards and three months later. Telephone interviews further explored participants’ responses.

Analysis of the questionnaire data showed that the workshop and handbook improved participants’ knowledge, attitudes and behaviour in practice. This was sustained over a three-month period. In telephone interviews, most participants said that the workshop had raised their awareness of engaging fathers and offered them helpful strategies. However, they also spoke of barriers to engagement with fathers. NHS Trusts need to review the training and education of Health Visitors and Community Practitioners and take a more strategic approach towards father-inclusive practice and extend services to meet the needs of fathers.

To assess the effectiveness of supported employment interventions for improving competitive employment in populations of people with conditions other than only severe mental illness.

Supported employment interventions have been extensively tested in severe mental illness populations. These approaches may be beneficial outside of these populations.

We searched PubMed, Embase, CINAHL, PsycInfo, Web of Science, Scopus, JSTOR, PEDro, OTSeeker, and NIOSHTIC for trials including unemployed people with any condition and including severe mental illness if combined with other co-morbidities or other specific circumstances (e.g., homelessness). We excluded trials where inclusion was based on severe mental illness alone. Two reviewers independently assessed risk of bias (RoB v2.0) and four reviewers extracted data. We assessed rates of competitive employment as compared to traditional vocational rehabilitation or waiting list/services as usual.

Ten randomised controlled trials (913 participants) were included. Supported employment was more effective than control interventions for improving competitive employment in seven trials: in people with affective disorders [risk ratio (RR) 10.61 (1.49, 75.38)]; mental disorders and justice involvement [RR 4.44 (1.36,14.46)]; veterans with posttraumatic stress disorder (PTSD) [RR 2.73 (1.64, 4.54)]; formerly incarcerated veterans [RR 2.17 (1.09, 4.33)]; people receiving methadone treatment [RR 11.5 (1.62, 81.8)]; veterans with spinal cord injury at 12 months [RR 2.46 (1.16, 5.22)] and at 24 months [RR 2.81 (1.98, 7.37)]; and young people not in employment, education, or training [RR 5.90 (1.91–18.19)]. Three trials did not show significant benefits from supported employment: populations of workers with musculoskeletal injuries [RR 1.38 (1.00, 1.89)]; substance abuse [RR 1.85 (0.65, 5.41)]; and formerly homeless people with mental illness [RR 1.55 (0.76, 3.15)]. Supported employment interventions may be beneficial to people from more diverse populations than those with severe mental illness alone. Defining competitive employment and increasing (and standardising) measurement of non-vocational outcomes may help to improve research in this area.

To determine whether a process of care planning for people with diabetes, combining a patient-centred approach by practitioners with measures to promote self-management by patients, improve health outcomes.

Health policy, in many countries, seeks to engage people with long-term conditions in protecting their health. This review was conducted by members of a working group established by the Department of Health and Diabetes, UK to consider the potential for personalized care planning in UK diabetes services.

Review of systematic reviews. The Cochrane Library and Database of Reviews of Effectiveness were searched to identify reviews concerned with components of care planning. Reviews conducted before 1990, and those involving education outside the consultation were excluded. Abstracts were reviewed and data extraction undertaken by reviewers working independently in pairs.

In all, 86 reviews were identified as potentially relevant and 22 included. Patient-focused interventions, such as pre-consultation prompts, enhanced the role patients played in consultations. Personalized approaches using tailored information influenced health behaviour more than uniform approaches. Decision aids and computerized knowledge management improved the process of decision-making. Although effective communication was important, focusing solely on changing practitioner behaviour appeared inadequate. Taken together, there was good evidence that the processes involved in personalized care planning would engage patients more effectively in managing their care, but little robust research on the impact on health outcomes of doing so.

The present review identifies effective interventions that are available for clinicians to use in diabetes consultations, but engaging patients requires more than this. Mechanisms to share information and decision-making need further development and evaluation to assess their impact on health outcomes. Narrowly targeted interventions focused on practitioner behaviour appear less effective than whole-system approaches. Personalized care planning offers a mechanism to integrate patient-centred medicine and support for self-management to improve diabetes care.

Pulmonary rehabilitation (PR), a programme of exercise, education and psycho-social support, is recommended for patients with chronic obstructive pulmonary disease but referral rates are relatively low compared with need.

Working with primary care clinicians (GPs and practice nurses) from eight practices, this project developed strategies for influencing clinician and patient behaviours as a means of increasing referral rates for PR.

A participatory action research design was employed. Semi-structured questionnaires captured clinicians’ baseline knowledge of PR and their ideas for increasing referrals. Actionable changes were then recommended. Audits (at baseline, mid-point and end of project) were used to assess and initiate improvements in the quality of practice data about PR referrals. The impacts of these changes were explored via further clinician surveys (free text questionnaire). Semi-structured questionnaires, posted to patients eligible for PR, assessed their characteristics, and, where applicable, their views on PR referral processes and reasons for not wanting PR.

The baseline survey of clinicians (n=22) revealed inadequate knowledge about PR, particularly among GPs. Actionable changes recommended included in-house education sessions, changes to practice protocols, and ‘pop-ups’ and memory aids (mugs and coasters) to prompt clinician/patient discussions about PR. Audit findings resulted in changes to improve the quality and availability of coded information about patients eligible for PR. These changes, supported by clinicians (n=9) in the follow-up survey, aimed to facilitate and increase the quality of patient/clinician discussions about PR. Findings from the patient survey (n=126, response rate 25.7%) indicate that such changes will increase the uptake of PR as patients who accepted a referral for PR provided more positive feedback about their discussions with clinicians.

The strategies introduced were relatively easy to implement and the anticipated advantage is more patients accessing the health and quality of life benefits that PR offers.

The aim of this paper is to identify and descriptively map the key characteristics of the model of service delivery in operation, and to explore the user, carer and professional experience of service provision. This included an exploration of congruity and mismatch between the different stakeholder groups.

In the United Kingdom (UK), 15% of the children under five years of age and 20% of the 5 to 15-year age group are reported to have a complex long-term condition, with the likelihood of having a condition increasing according to socio-economic circumstances. An increasing number of young people with complex needs are now surviving into late adolescence and early adulthood. However, service provision for children with complex needs is an area that, nationally, has been underdeveloped.

An exploratory single-site case study was undertaken across one Primary Care Trust in the UK. Documentary and policy review were undertaken along with in-depth qualitative exploration. Eighteen in-depth interviews were undertaken with relevant stakeholders and professionals across the multidisciplinary teams. Families with children between 12 months and 16 years of age who have continuing complex care needs were invited to take part in an interview to give their views about the care they receive. Interviews focused on the family experience and understanding of the child's condition, transition between secondary and primary care, effectiveness of admission and discharge planning and the overall contribution of different professionals. Professionals were also asked about their experiences of delivering care.

This study highlighted issues of communication between professionals and with parents and children as a major factor in determining the quality of service provision. Key aspects relating to the model of service provision, namely, paucity of communication, interagency collaboration and the parent as health worker, are highlighted.

Parents experienced both health and social service communication challenges when seeking care for their child. These challenges can be located within a general systems theory and hierarchy approaches to understand the complexity of service provision.

Obesity is a major public health issue and primary care practitioners are well placed to opportunistically raise the issue of overweight or obesity with their patients.

This study investigated the prevalence of weight discussion in primary care consultations with overweight and obese patients, in a practice in Fife, Scotland, and described weight-related communication using video analysis.

Weight was raised in 25% of consultations with overweight and obese patients. GPs initiated weight discussion more often than patients; however, these attempts were often blocked by patients. Weight-related outcomes were more common when patients initiated the weight discussion. This study confirms the potential of video analysis for understanding primary care weight discussion. It also suggests that GPs may benefit from a communication-based intervention to tackle patient blocking behaviours and contributes to the evidence suggesting that interventions targeted to increase the prevalence of weight-related discussions with their patients are needed.

The aim was to assess the oral health needs of homeless people in dedicated homeless dental units in London, Cardiff and Glasgow and a homeless shelter in Birmingham in order to allow recommendations for service delivery to be made for this socially excluded group.

Two questionnaires were designed, one to be completed by homeless people and the other by members of the dental team. A total of seventeen staff working in homeless dentistry completed questionnaires. Of these, nine were dentists, seven were nurses and one was a therapist. Twenty-seven homeless adults took part in interview. Of these, 22 were under active treatment at a homeless dental clinic and the remaining five were from the Birmingham homeless shelter who were not receiving dental care.

This study found evidence that the oral health of homeless adults was poor, with a high level of dental need. The service use of homeless people is low, with low levels of registration and utilisation of accident and emergency services. In terms of the most suitable method of dental treatment, staff felt a dedicated homeless service was most appropriate, whereas there was almost an equal split of patients advocating the General Dental Service or the dedicated dental clinics.