Journal of Primary Care & Community Health

The family history is used as a screening tool to identify persons who may be at risk for a heritable disorder. Primary care providers sometimes do not thoroughly gather and document the family history. This pilot study was undertaken to determine whether having a genetic counselor on site at our family medicine clinic 2 days a week for 3 months would improve the quality of the family history field in patient records. We compared 7 elements in the family history field for patients seen before and after the genetic counselor was on site. Documentation of 1 of the 7 elements (major disease) improved significantly after the intervention period (P = .02). Changing provider behavior with regard to gathering and documenting family history of major disease may be facilitated by tools to help collect the family history and by using the increasing number of available genetic tests.

Background: Increases in hospital emergency department use have been driven by insured patients with problems accessing primary care services. Access problems are especially pronounced in rural communities with health professional shortages. This qualitative study explored reasons for nonurgent pediatric emergency department use in the Mississippi Delta. Method: Using a community-based participatory research framework, a semistructured survey was administered face-to-face in a hospital emergency department waiting room with parents/caregivers who brought their children. Interviews were done over 144 hours in 2-hour blocks covering regular “business hours” and “after hours” (evenings/weekends). Open-ended items allowed qualitative data to be gathered describing reasons for emergency department use and perceptions of urgency of the visit in the parents’/caregivers’ own words. Results: There were 112 children, with a response rate of 87%. The mean child age was 5.7 years; 52% were male; 95% were African American and 5% white; 80.6% had Medicaid/SCHIP, 7.8% commercial, and 3.9% other insurance; 7.8% were uninsured. Most (88%) had a usual source of pediatric care. Only 24.3% tried to obtain care before emergency department visit; 23.2% said their children required “urgent” care. Mean distance from home to usual source of care was 10 miles. Ten percent cited transportation as a barrier to keeping health care appointments; 5.5% cited insurance or cost. Families who used the emergency department during evening/weekends were significantly more likely to have cited clinic hours of operation as a reason care was not sought previously than were “business hours” users, who emphasized convenience. Conclusion: Nonurgent pediatric emergency department use could be reduced by extending clinic hours, adding a walk-in service, and making transportation more available.

Postpartum depression (PPD) has emerged as an important issue for pediatricians and family practitioners because of detrimental effects on children. PPD occurs in 10% to 22% of women who have recently given birth, but fewer than half of cases are recognized. Despite the impact of PPD, many primary care clinicians do not have systemic screening approaches implemented. This paper will review the development of a screening protocol for PPD in a multispecialty clinic, with the implementation utilizing depression care managers and the preliminary results of our process. Of the 333 screened examinations during the 4-month study, 38.1% (n = 127) were performed for the 2-month well child examination; 33.6% (n = 112) were for the 4-month examination, with 28.2% (n = 94) being performed for the 6-month well child examination. Only 15 (4.5%) were positive for possible depression with a screening compliance rate of 47.9%. No significant difference was noted in the timing of the well child visit with a positive screening test result, nor was there any difference in family medicine versus pediatric colleagues in the utilization of the screening or diagnosis of PPD. Implementation of PPD screening in a multispecialty clinic can be effective, given utilization of depression care managers.

Objective: The objective of this study was to investigate the importance of immigration as a risk factor for self-reported frequent mental distress (FMD) among black respondents to an Internet survey. Method: Snowball sampling was used to obtain Internet survey responses from immigrant and non-immigrant black adults in the United States. Multiple logistic regression analysis was used to control for the effects of personal characteristics (N = 301). Results: In this sample of black adults, 13.3% had FMD. Being an immigrant was not associated with FMD in this sample (adjusted odds ratio [OR] = 0.75, P = .53). However, more drinking days was an independent risk factor (OR = 1.07, P < .01). Conclusions: Being an immigrant was not an independent risk factor for FMD in this sample of black adults. However, drinking more days per month was a significant risk factor. Primary care providers should be alert for FMD and alcohol consumption in this population. Directing health education about hazardous drinking toward high-risk individuals should be considered.

Health care providers face many challenges when providing prenatal care. This article reports on a program called Prenatal Care: the Beginning of a Lifetime (PCBL), to implement standardized prenatal care in central North Carolina. The purpose of this pilot study was to determine if there were differences in patient outcomes between a control group and 3 groups (A, B, and C) of increasing levels of intervention in standardized prenatal care. A total of 150 patients were enrolled and followed through delivery. There were no significant differences between the groups in cigarette smoking status, weight gain, genetic screening, sexually transmitted infection screening, diabetes screening, domestic violence assessment, 17P candidacy assessment, gestational age at delivery, or infant birth weight. However, a significant difference was found in depression screening. An association between intervention group membership and likelihood of being screened for depression was found in each trimester. As the level of intervention increased, the number of participants screened for depression increased significantly.

While physician counseling has been suggested as a strategy to promote physical activity, there is insufficient evidence to support its effectiveness at present. The purpose of this study was to examine the effect of brief physician counseling (modified PACE protocol) and telephone follow-ups on changes in the energy expenditure levels of patients over a 20-month period. Forty-five participants completed physical activity questionnaires at both baseline and 20 months. Following brief physician counseling (modified PACE protocol), patients were randomized into a counseling-only group or an enhanced counseling group that included 3 telephone follow-ups. Energy expenditure significantly increased from baseline (1.5 kcal/kg/d [KKD]) to 20 months (2.2 KKD, P < .05) in both groups. Neither the group nor group-by-time interaction was significant (P > .05). In line with the counseling provided by physicians, participants showed an increase in moderate intensity activities and a decrease in light intensity activities (Ps < .001). These findings provide support for the effectiveness of brief physician counseling. However, the additional telephone support did not appear to enhance the physician counseling.

Background/Purpose: Being overweight is defined as having a body mass index greater than 25. Reduced postural control has been implicated in the presence of increased body mass index. The purpose of this study was to assess the effects of body mass index on postural stability in healthy sedentary middle-aged adults. Based on body mass index, subjects were divided into 2 groups (25.00-27.49 and 27.50-29.99) to assess for differences in postural control. Methods: Twenty healthy sedentary subjects between 40 and 64 years (13 women and 7 men) with a mean age of 52.45 years were recruited by convenience. After determination of body mass index, postural control was assessed on all subjects using the Activities Specific Balance Confidence Scale, Berg Balance Scale, Timed Up and Go Test, gait speed measurement, and Biodex Stability Index testing. Results: The Timed Up and Go Test duration was increased in these subjects when compared with normative data. Gait speed was also reduced in those subjects in the fifth and sixth decades when compared with established norms. Biodex SD balance system scores demonstrated reduced postural stability. A 2-tailed t test revealed no significant difference between body mass index ranges of 25.0 to 27.5 and 27.6 to 29.99. Conclusion: There may be increased risk for falls with increases in body mass short of obesity thresholds of body mass index 30% for this sedentary middle-aged adult population. Future studies, with larger groups of subjects, that address postural stability and body mass index are necessary. Although these subjects are younger, falls screening measures may prove beneficial as a prevention strategy for sedentary overweight middle-aged adults.

Objectives: To determine the nutritional status of under-5 tribal children. Design: Community-based cross-sectional observational study. Setting: Three tribal villages of the Chanchal II block of the Maldah district in West Bengal. Subjects and Methods: In 3 tribal villages, 188 children under 5 years of age were examined to detect nutritional deficiency disorders. By anthropometric measurement, nutritional grading of them was determined. Interviews of mothers provided breast-feeding and weaning practices. Results: 63.83% of study subjects were suffering from different grades of malnutrition. Prevalence of anaemia and angular stomatitis was 45.74% and 19.12%, respectively, among them.

Introduction: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) requently causes skin and soft tissue infections (SSTIs). Referring primary care physicians often prescribe inactive antibiotics when referring SSTIs caused by MRSA for incision and debridement. Methods: Demographics and culture results (organism and sensitivity) were collected for patients treated for SSTI between 2007-2009. Antibiotic regimens started by referring PCPs were noted. Prevalence of MRSA and antibiotic resistance profiles were tabulated. Isolates resistant to the drug initially prescribed were also noted. Results: Of 187 patients, 40.1% grew MRSA. All MRSA was sensitive to doxycycline and trimethoprim-sulfamethoxazole, whereas 88% were sensitive to clindamycin and 79% to levofloxacin. 48% of patients received an antibiotic inadequate for their isolate before referral. Conclusions: CA-MRSA is extremely common. Patients are often prescribed antibiotics inadequate for MRSA. Doxycycline or trimethoprim-sulfamethoxazole with incision/drainage should be used as initial therapy for SSTI when MRSA is suspected.

Background: India’s current health transition stage poses a critical challenge of dealing with the unfinished agenda of communicable diseases and the steadily rising burden of noncommunicable diseases. A significant burden of chronic diseases in India is attributable to household and individual level health risk factors coupled with socioeconomic conditions. From this perspective, this article made a first time effort to assess disease burden attributable to health risk factors using cross-sectional population health survey data. Methods: Population attributable fractions (PAF) were estimated for a cluster of health risk factors that include unsafe water, lack of sanitation, exposure to cooking smoke, tobacco and alcohol use, physical inactivity, and socioeconomic conditions on a set of widely prevalent chronic diseases such as tuberculosis, malaria, diarrhea, diabetes, angina, and asthma. Data from the 2003 World Health Survey was used. Results: The analysis revealed evidence of a significant contribution of health risk factors to India’s escalating chronic disease burden. The contribution of health risk factors toward chronic disease burden varied by residence. Conclusion: Results suggest that promotional health care based policies to deal with health risks should be a major priority in policy agenda to combat with the challenge of emerging noncommunicable disease coupled with the persistent burden of communicable diseases. Disease burden in India could be halved by effectively modifying exposure to the risk factors through promotional health care.

Objective: Hypertension prevalence in the African American community is greater than in all other ethnic groups. Cultural perceptions of health and disease introduce barriers to providing effective care. The purpose of this study was to identify racial differences in the perceived causes of hypertension, current behaviors performed to control blood pressure, and perceived barriers to preventing or treating hypertension. Methods: A self-administered survey of patients seen for medical care in a primary care network was conducted. The survey was developed to measure perceptions of hypertension etiology and treatments. Data from African American (n = 69) and Caucasian (n = 218) respondents were used to assess racial differences in perceptions of blood pressure control. Results: About half of respondents knew their current blood pressures. African American patients were significantly less likely to believe that hypertension was caused by a lack of exercise and obesity. Significantly more Caucasians were less likely to report cutting down on table salt and taking prescription medications for blood pressure control. Both African Americans and Caucasians believed that sodium reduction was the most easily changed behavior to control their blood pressure, while both groups identified weight loss as being the most difficult. Conclusion: Racial differences exist in the perceived causes and treatments of high blood pressure, indicating a need for further patient education. When treating and counseling patients, physicians and support staff members must be sensitive to racial diversity and strive to offer culturally relevant solutions, especially for behaviors perceived as most difficult to change.

Objective: Obesity and type 2 diabetes have emerged as critical health issues among Latino youth. Although both conditions manifest early in life, very few diabetes prevention programs have been developed to specifically meet the needs of this population. The authors describe the development, implementation, and metabolic impact of a culturally informed, community-based diabetes prevention program for obese Latino youth. Methods: A lifestyle education program was developed to address the health needs of Latino youth served by a community-based medical clinic. The program consisted of group education sessions delivered to children and their families to address nutrition, physical activity, family roles and responsibilities, and self-esteem. The metabolic impact of the program was evaluated by assessing body mass index (BMI), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, total cholesterol, triglycerides, glucose, and insulin. Results: On entry, the prevalence of risk factors among the 102 youth (mean BMI, 30.4 ± 4.9 kg/m²) was substantial (68.6% with low HDL cholesterol, 32.1% with elevated triglycerides, 9.4% with impaired fasting glucose, 39.4% with elevated total cholesterol, 43.0% with elevated LDL cholesterol, and 60.6% with hyperinsulinemia). The 50 youth who returned after the program for follow-up measurements exhibited significant health improvements, including a 3.8% reduction in BMI; 5.4% and 8.6% decreases in total and LDL cholesterol, respectively; a 9.3% increase in HDL cholesterol; and a 24.0% decrease in fasting insulin (all P values < .05). Conclusions: These promising findings suggest that a community-based diabetes prevention program for obese Latino youth is a feasible strategy for improving health in this high-risk population. Further studies are warranted to examine whether similar programs can be implemented in diverse communities and settings.

Objective: To reduce direct parental referral of low acuity ill pediatric patients to the outpatient facilities of a nation’s only pediatric referral hospital. Patients and Methods: Longitudinal monitoring of outpatient visits at Orotta Children’s Hospital (OCH) and primary health facilities (PHFs) following implementation of an intervention designed in response to information provided by parents and health-care providers. Parental surveys were undertaken before and after exposure to the intervention to assess effects on knowledge, attitudes, and behavioral intentions. Results: We analyzed 5,639 visits between baseline and follow-up, documenting a decline in parental referral among OCH outpatients from 95% to approximately 80%. Educational intervention increased the proportion of parents intending to use PHF for future outpatient care from 28% to 82%. Staff of the PHFs responded enthusiastically to this intervention program and requested further activities. Conclusions: Self-referral to tertiary care hospital was reduced following a modest program of parental education designed and implemented by residents in training.