Continuity of maternal healthcare services utilisation in Indonesia: analysis of determinants from the Indonesia Demographic and Health Survey

ObjectiveWHO recommends that every pregnant woman and newborn receive quality care throughout the pregnancy, delivery and postnatal periods. However, Maternal Mortality Ratio in Indonesia for 2015 reached 305 per 100 000 live births, which exceeds the target of Sustainable Development Goals (<70 per 100 000 live births). Receiving at least four times antenatal care (ANC4+) and skilled birth attendant (SBA) during childbirth is crucial for preventing maternal and neonatal deaths. The study aims to assess the determinants of ANC4 +and SBA independently, evaluate the distribution of utilisation of ANC4 + and SBA services, and further investigate the associations of two levels of continuity of services utilisation in IndonesiaDesignData from the Indonesia Demographic and Health Survey, a cross-sectional and large-scale national survey conducted in 2017 were used.SettingThis study was set in Indonesia.ParticipantsThe study involved ever-married women of reproductive age (15–49 years) and had given birth in the last 5 years prior to the survey (n=15 288). The dependent variables are the use of ANC4 + and SBA. Individual, family and community factors, such as age, age at first birth, level of education, employment status, parity, autonomy in healthcare decision-making, level of education, employment status of spouses, household income, mass media consumption residence and distance from health facilities were also measured.ResultsResults showed that 11 632 (76.1%) women received ANC4 + and SBA during childbirth. Multivariate analysis revealed that age, age at first birth, and parity have a statistically significant association with continuity of services utilisation. The odds of using continuity of services were higher among women older than 34 years (adjusted OR (aOR) 1.54; 95% CI 1.31 to 1.80) compared with women aged 15–24 years. Women with a favourable distance from health facilities were more likely to receive continuity of services utilisation (aOR 1.39; 95% CI 1.24 to 1.57).ConclusionsThe continuity of services utilisation is associated with age, reproductive status, family influence and accessibility-related factors. Findings demonstrated the importance of enhancing early reproductive health education for men and women. The health system reinforcement, community empowerment and multisectoral engagement enhance accessibility to health facilities, reduce financial and geographical barriers, and produce strong quality care.

Implementation of cancer screening in rural primary care practices after joining an accountable care organisation: a multiple case study

ObjectiveTo describe common strategies and practice-specific barriers, adaptations and determinants of cancer screening implementation in eight rural primary care practices in the Midwestern United States after joining an accountable care organisation (ACO).DesignThis study used a multiple case study design. Purposive sampling was used to identify a diverse group of practices within the ACO. Data were collected from focus group interviews and workflow mapping. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. Data were cross-analysed by clinic and CFIR domains to identify common themes and practice-specific determinants of cancer screening implementation.SettingThe study included eight rural primary care practices, defined as Rural-Urban Continuum Codes 5–9, in one ACO in the Midwestern United States.ParticipantsProviders, staff and administrators who worked in the primary care practices participated in focus groups. 28 individuals participated including 10 physicians; one doctor of osteopathic medicine; three advanced practice registered nurses; eight registered nurses, quality assurance and licensed practical nurses; one medical assistant; one care coordination manager; and four administrators.ResultsWith integration into the ACO, practices adopted four new strategies to support cancer screening: care gap lists, huddle sheets, screening via annual wellness visits and information spread. Cross-case analysis revealed that all practices used both visit-based and population-based cancer screening strategies, although workflows varied widely across practices. Each of the four strategies was adapted for fit to the local context of the practice. Participants shared that joining the ACO provided a strong external incentive for increasing cancer screening rates. Two predominant determinants of cancer screening success at the clinic level were use of the electronic health record (EHR) and fully engaging nurses in the screening process.ConclusionsJoining an ACO can be a positive driver for increasing cancer screening practices in rural primary care practices. Characteristics of the practice can impact the success of ACO-related cancer screening efforts; engaging nurses to the fullest extent of their education and training and integrating cancer screening into the EHR can optimise the cancer screening workflow.

Cash transfer during the COVID-19 pandemic: a multicentre, randomised controlled trial

ObjectiveTo evaluate the effect of a one-time cash transfer of $C1000 in people who are unable to physically distance due to insufficient income.DesignOpen-label, multi-centre, randomised superiority trial.SettingSeven primary care sites in Ontario, Canada; six urban sites associated with St. Michael’s Hospital in Toronto and one in Manitoulin Island.Participants392 individuals who reported trouble affording basic necessities due to disruptions related to COVID-19.InterventionAfter random allocation, participants either received the cash transfer of $C1000 (n=196) or physical distancing guidelines alone (n=196).Main outcome measuresThe primary outcome was the maximum number of symptoms consistent with COVID-19 over 14 days. Secondary outcomes were meeting clinical criteria for COVID-19, SARS-CoV-2 presence, number of close contacts, general health and ability to afford basic necessities.ResultsThe primary outcome of number of symptoms reported by participants did not differ between groups after 2 weeks (cash transfer, mean 1.6 vs 1.9, ratio of means 0.83; 95% CI 0.56 to 1.24). There were no statistically significant effects on secondary outcomes of the meeting COVID-19 clinical criteria (7.9% vs 12.8%; risk difference −0.05; 95% CI −0.11 to 0.01), SARS-CoV-2 presence (0.5% vs 0.6%; risk difference 0.00 95% CI −0.02 to 0.02), mean number of close contacts (3.5 vs 3.7; rate ratio 1.10; 95% CI 0.83 to 1.46), general health very good or excellent (60% vs 63%; risk difference −0.03 95% CI −0.14 to 0.08) and ability to make ends meet (52% vs 51%; risk difference 0.01 95% CI −0.10 to 0.12).ConclusionsA single cash transfer did not reduce the COVID-19 symptoms or improve the ability to afford necessities. Further studies are needed to determine whether some groups may benefit from financial supports and to determine if a higher level of support is beneficial.Trial registration numberNCT04359264.

Specificity of early-career general practitioners’ problem formulations in patients presenting with dizziness: a cross-sectional analysis

ObjectivesDizziness is a common and challenging clinical presentation in general practice. Failure to determine specific aetiologies can lead to significant morbidity and mortality. We aimed to establish frequency and associations of general practitioner (GP) trainees’ (registrars’) specific vertigo provisional diagnoses and their non-specific symptomatic problem formulations.DesignA cross-sectional analysis of Registrar Clinical Encounters in Training (ReCEnT) cohort study data between 2010 and 2018. ReCEnT is an ongoing, prospective cohort study of registrars in general practice training in Australia. Data collection occurs once every 6 months midtraining term (for three terms) and entails recording details of 60 consecutive clinical consultations on hardcopy case report forms. The outcome factor was whether dizziness-related or vertigo-related presentations resulted in a specific vertigo provisional diagnosis versus a non-specific symptomatic problem formulation. Associations with patient, practice, registrar and consultation independent variables were assessed by univariate and multivariable logistic regression.SettingAustralian general practice training programme. The training is regionalised and delivered by regional training providers (RTPs) (2010–2015) and regional training organisations (RTOs) (2016–2018) across Australia (from five states and one territory).ParticipantsAll general practice registrars enrolled with participating RTPs or RTOs undertaking GP training terms.Results2333 registrars (96% response rate) recorded 1734 new problems related to dizziness or vertigo. Of these, 546 (31.5%) involved a specific vertigo diagnosis and 1188 (68.5%) a non-specific symptom diagnosis. Variables associated with a non-specific symptom diagnosis on multivariable analysis were lower socioeconomic status of the practice location (OR 0.94 for each decile of disadvantage, 95% CIs 0.90 to 0.98) and longer consultation duration (OR 1.02, 95% CIs 1.00 to 1.04). A specific vertigo diagnosis was associated with performing a procedure (OR 0.52, 95% CIs 0.27 to 1.00), with some evidence for seeking information from a supervisor being associated with a non-specific symptom diagnosis (OR 1.39, 95% CIs 0.92 to 2.09; p=0.12).ConclusionsAustralian GP registrars see dizzy patients as frequently as established GPs. The frequency and associations of a non-specific diagnosis are consistent with the acknowledged difficulty of making diagnoses in vertigo/dizziness presentations. Continuing emphasis on this area in GP training and encouragement of supervisor involvement in registrars’ diagnostic processes is indicated.

Trends in maternal body mass index in Northern Ireland: a cross-sectional and longitudinal study

ObjectivesExplore (1) associations between maternal body mass index (BMI), demographic and clinical characteristics, (2) longitudinal trends in BMI, (3) geographical distributions in prevalence of maternal overweight and obesity.DesignRetrospective population-based study.SettingLinked, anonymised, routinely collected healthcare data and official statistics from Northern Ireland.ParticipantsAll pregnancies in Northern Ireland (2011–2017) with BMI measured at ≤16 weeks gestation.MethodsAnalysis of variance and χ2 tests were used to explore associations. Multiple linear regression was used to explore longitudinal trends and spatial visualisation illustrated geographical distribution. Main outcomes are prevalence of overweight (BMI ≥25 kg/m2) and obesity (BMI ≥30 kg/m2).Results152 961 singleton and 2362 multiple pregnancies were included. A high prevalence of maternal overweight and obesity in Northern Ireland is apparent (singleton: 52.4%; multiple: 48.3%) and is increasing. Obesity was positively associated with older age, larger numbers of previous pregnancies and unplanned pregnancy (p<0.001). BMI category was also positively associated with unemployment (35% in obese class III vs 22% in normal BMI category) (p<0.001). Higher BMI categories were associated with increased rate of comorbidities, including hypertension (normal BMI: 1.8% vs obese III: 12.4%), diabetes mellitus (normal BMI: 0.04% vs obese III: 1.29%) and mental ill-health (normal BMI: 5.0% vs obese III: 11.8%) (p<0.001). Prevalence of maternal obesity varied with deprivation (most deprived: 22.8% vs least deprived: 15.7%) (p<0.001). Low BMI was associated with age <20 years, nulliparity, unemployment and mental ill-health (p<0.001).ConclusionsThe prevalence of maternal BMI >25 kg/m2 is increasing over time in Northern Ireland. Women are entering pregnancy with additional comorbidities likely to impact their life course beyond pregnancy. This highlights the need for prioritisation of preconception and inter-pregnancy support for management of weight and chronic conditions.

Primary care providers should prescribe aspirin to prevent cardiovascular disease based on benefit−risk ratio, not age

Recent guidelines restricted aspirin (ASA) in primary prevention of cardiovascular disease (CVD) to patients <70 years old and more recent guidance to <60.In the most comprehensive prior meta-analysis, the Antithrombotic Trialists Collaboration reported a significant 12% reduction in CVD with similar benefit−risk ratios at older ages. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four trials were added to an updated meta-analysis.ASA produced a statistically significant 13% reduction in CVD with 95% confidence limits (0.83 to 0.92) with similar benefits at older ages in each of the trials.Primary care providers should make individual decisions whether to prescribe ASA based on benefit−risk ratio, not simply age. When the absolute risk of CVD is >10%, benefits of ASA will generally outweigh risks of significant bleeding. ASA should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit such as statins, which are, at the very least, additive to ASA. Our perspective is that individual clinical judgements by primary care providers about prescription of ASA in primary prevention of CVD should be based on our evidence-based solution of weighing all the absolute benefits and risks rather than age. This strategy would do far more good for far more patients as well as far more good than harm in both developed and developing countries. This new and novel strategy for primary care providers to consider in prescribing ASA in primary prevention of CVD is the same as the general approach suggested by Professor Geoffrey Rose decades ago.

Primer on binary logistic regression

Family medicine has traditionally prioritised patient care over research. However, recent recommendations to strengthen family medicine include calls to focus more on research including improving research methods used in the field. Binary logistic regression is one method frequently used in family medicine research to classify, explain or predict the values of some characteristic, behaviour or outcome. The binary logistic regression model relies on assumptions including independent observations, no perfect multicollinearity and linearity. The model produces ORs, which suggest increased, decreased or no change in odds of being in one category of the outcome with an increase in the value of the predictor. Model significance quantifies whether the model is better than the baseline value (ie, the percentage of people with the outcome) at explaining or predicting whether the observed cases in the data set have the outcome. One model fit measure is the count- R2, which is the percentage of observations where the model correctly predicted the outcome variable value. Related to the count- R2 are model sensitivity—the percentage of those with the outcome who were correctly predicted to have the outcome—and specificity—the percentage of those without the outcome who were correctly predicted to not have the outcome. Complete model reporting for binary logistic regression includes descriptive statistics, a statement on whether assumptions were checked and met, ORs and CIs for each predictor, overall model significance and overall model fit.

Perspectives of primary care physicians on acceptance and barriers to COVID-19 vaccination

ObjectivesThe purpose of this study was to examine the perspectives of primary care physicians in Texas around vaccine acceptance and potential patient barriers to vaccination. National surveys have shown fluctuating levels of acceptance for COVID-19 vaccination, and primary care physicians could play a crucial role in increasing vaccine uptake.DesignThis study employed a cross-sectional anonymous survey design to collect data using an online questionnaire. Participants were asked about vaccination practices and policies at their practice site, perceptions of patient and community acceptance and confidence in responding to patient vaccine concerns.SettingFrom November 2020 to January 2021, family medicine physicians and paediatricians completed an online questionnaire on COVID-19 vaccination that was distributed by professional associations.ParticipantsThe survey was completed by 573 practising physicians, the majority of whom identified as family medicine physicians (71.0%) or paediatricians (25.7%), who are currently active in professional associations in Texas.ResultsAbout three-fourths (74.0%) of participants reported that they would get the vaccine as soon as it became available. They estimated that slightly more than half (59.2%) of their patients would accept the vaccine, and 67.0% expected that the COVID-19 vaccine would be accepted in their local community. The majority of participants (87.8%) reported always, almost always or usually endorsing vaccines, including high levels of intention to recommend COVID-19 vaccination (81.5%). Participants felt most confident responding to patient concerns related to education about vaccine types, safety and necessity and reported least confidence in responding to personal or religious objections to COVID-19 vaccination.ConclusionsThe majority of the physicians surveyed stated that they would receive the COVID-19 vaccination when it was available to them and were confident in their ability to respond to patient concerns. With additional education, support and shifting COVID-19 vaccinations into primary care settings, primary care physicians can use the trust they have built with their patients to address vaccine hesitancy and potentially increase acceptance and uptake.