Enriqueta Pujol-Ribera

Effectiveness of a Mindfulness Education Program in Primary Health Care Professionals: A Pragmatic Controlled Trial

Introduction: Burnout is a very prevalent type of stress among health professionals. It affects their well‐being, performance, and attitude toward patients. This study assessed the effectiveness of a training program for primary health care professionals designed to reduce burnout and mood disturbance, increase empathy, and develop mindfulness. Methods: Pragmatic randomized controlled trial with pre‐ and postintervention measurements of 68 primary health care professionals (43 in the intervention and 25 in the control group) in Spain. The intervention consisted of presentations of clinically relevant topics, mindfulness‐based coping strategies, mindfulness practice, yoga, and group discussions (8 sessions of 2.5 hours per week plus a 1‐day session of 8 hours). Outcome measures included the Maslach Burnout Inventory, Profile of Mood States, Jefferson Scale of Physician Empathy, Baers Five Facets Mindfulness Questionnaire, and a questionnaire on changes in personal habits and mindfulness practice. Measurements were performed at baseline and after 8 weeks. Results: The intervention group improved in the 4 scales measured. The magnitude of the change was large in total mood disturbance (difference between groups ‐7.1; standardized effect‐size [SES] 1.15) and mindfulness (difference between groups 11; SES 0.9) and moderate in the burnout (difference between groups ‐7; SES 0.74) and empathy scales (difference between groups 5.2; SES 0.71). No significant differences were found in the control group. Discussion: Our study supports the use of mindfulness‐based programs as part of continuing professional education to reduce and prevent burnout, promote positive attitudes among health professionals, strengthen patient‐provider relationships, and enhance well‐being.

Impact of multimorbidity: acute morbidity, area of residency and use of health services across the life span in a region of south Europe

BackgroundConcurrent diseases, multiple pathologies and multimorbidity patterns are topics of increased interest as the world’s population ages. To explore the impact of multimorbidity on affected patients and the consequences for health services, we designed a study to describe multimorbidity by sex and life-stage in a large population sample and to assess the association with acute morbidity, area of residency and use of health services.MethodsA cross-sectional study was conducted in Catalonia (Spain). Participants were 1,749,710 patients aged 19+ years (251 primary care teams). Primary outcome: Multimorbidity (≥2 chronic diseases). Secondary outcome: Number of new events of each acute disease. Other variables: number of acute diseases per patient, sex, age group (19–24, 25–44, 45–64, 65–79, and 80+ years), urban/rural residence, and number of visits during 2010.ResultsMultimorbidity was present in 46.8% (95% CI, 46.7%-46.8%) of the sample, and increased as age increased, being higher in women and in rural areas. The most prevalent pair of chronic diseases was hypertension and lipid disorders in patients older than 45 years. Infections (mainly upper respiratory infection) were the most common acute diagnoses. In women, the highest significant RR of multimorbidity vs. non-multimorbidity was found for teeth/gum disease (aged 19–24) and acute upper respiratory infection. In men, this RR was only positive and significant for teeth/gum disease (aged 65–79). The adjusted analysis showed a strongly positive association with multimorbidity for the oldest women (80+ years) with acute diseases and women aged 65–79 with 3 or more acute diseases, compared to patients with no acute diseases (OR ranged from 1.16 to 1.99, p < 0.001). Living in a rural area was significantly associated with lower probability of having multimorbidity. The odds of multimorbidity increased sharply as the number of visits increased, reaching the highest probability in those aged 65–79 years.ConclusionsMultimorbidity is related to greater use of health care services and higher incidence of acute diseases, increasing the burden on primary care services. The differences related to sex and life-stage observed for multimorbidity and acute diseases suggest that further research on multimorbidity should be stratified according to these factors.

Study protocol of effectiveness of a biopsychosocial multidisciplinary intervention in the evolution of non-speficic sub-acute low back pain in the working population: cluster randomised trial

BackgroundNon-specific low back pain is a common cause for consultation with the general practitioner, generating increased health and social costs. This study will analyse the effectiveness of a multidisciplinary intervention to reduce disability, severity of pain, anxiety and depression, to improve quality of life and to reduce the incidence of chronic low back pain in the working population with non-specific low back pain, compared to usual clinical care.Methods/DesignA Cluster randomised clinical trial will be conducted in 38 Primary Health Care Centres located in Barcelona, Spain and its surrounding areas. The centres are randomly allocated to the multidisciplinary intervention or to usual clinical care. Patients between 18 and 65 years old (n = 932; 466 per arm) and with a diagnostic of a non-specific sub-acute low back pain are included. Patients in the intervention group are receiving the recommendations of clinical practice guidelines, in addition to a biopsychosocial multidisciplinary intervention consisting of group educational sessions lasting a total of 10 hours. The main outcome is change in the score in the Roland Morris disability questionnaire at three months after onset of pain. Other outcomes are severity of pain, quality of life, duration of current non-specific low back pain episode, work sick leave and duration, Fear Avoidance Beliefs and Goldberg Questionnaires. Outcomes will be assessed at baseline, 3, 6 and 12 months. Analysis will be by intention to treat. The intervention effect will be assessed through the standard error of measurement and the effect-size. Responsiveness of each scale will be evaluated by standardised response mean and receiver-operating characteristic method. Recovery according to the patient will be used as an external criterion. A multilevel regression will be performed on repeated measures. The time until the current episode of low back pain takes to subside will be analysed by Cox regression.DiscussionWe hope to provide evidence of the effectiveness of the proposed biopsychosocial multidisciplinary intervention in avoiding the chronification of low back pain, and to reduce the duration of non-specific low back pain episodes. If the intervention is effective, it could be applied to Primary Health Care Centres.Trial RegistrationISRCTN21392091

Population and primary health-care team characteristics explain the quality of the service

OBJECTIVES To identify the characteristics of the primary health-care (PHC) teams structure and of the assigned population affecting service quality dimensions, and to check whether the PHC teams performance varies when assessing the service quality using crude values or those adjusted by the structural factors that affect it. RESEARCH DESIGN Cross-sectional descriptive study. SUBJECTS 213 Catalan PHC teams. MEASUREMENTS Service quality indicators measured in three dimensions: (1) access and physician-patient relationship; (2) team coordination and (3) evidence-based practice. The PHC team structural factors studied are: experience, setting (urban or rural), geographical dispersion, teaching activities and managerial structure. The catchment population characteristics analysed are: age, socio-economic level, mortality, and the proportion of the population that are immigrants. RESULTS Access and physician-patient relationship dimension were not affected by the studied structural factors. Team coordination improved in rural teams and in those providing care for older populations. Evidence-based practice was found to be higher in teaching teams, in more experienced teams and in those attending populations with a lower socio-economic level. Adjusted service quality indicator values substantially modify the PHC team quality ranking carried out on the basis of its crude values, especially in the team coordination and evidence-based practice dimensions. CONCLUSIONS A fair evaluation of PHC team performance must be based on its health-care service quality indicators adjusted for setting, age and socio-economic level of the catchment population and for the teams experience and teaching activities.

Multimorbidity Patterns in Elderly Primary Health Care Patients in a South Mediterranean European Region: A Cluster Analysis

Objective The purpose of this study was to identify clusters of diagnoses in elderly patients with multimorbidity, attended in primary care. Design Cross-sectional study. Setting 251 primary care centres in Catalonia, Spain. Participants Individuals older than 64 years registered with participating practices. Main outcome measures Multimorbidity, defined as the coexistence of 2 or more ICD-10 disease categories in the electronic health record. Using hierarchical cluster analysis, multimorbidity clusters were identified by sex and age group (65–79 and ≥80 years). Results 322,328 patients with multimorbidity were included in the analysis (mean age, 75.4 years [Standard deviation, SD: 7.4], 57.4% women; mean of 7.9 diagnoses [SD: 3.9]). For both men and women, the first cluster in both age groups included the same two diagnoses: Hypertensive diseases and Metabolic disorders. The second cluster contained three diagnoses of the musculoskeletal system in the 65- to 79-year-old group, and five diseases coincided in the ≥80 age group: varicose veins of the lower limbs, senile cataract, dorsalgia, functional intestinal disorders and shoulder lesions. The greatest overlap (54.5%) between the three most common diagnoses was observed in women aged 65–79 years. Conclusion This cluster analysis of elderly primary care patients with multimorbidity, revealed a single cluster of circulatory-metabolic diseases that were the most prevalent in both age groups and sex, and a cluster of second-most prevalent diagnoses that included musculoskeletal diseases. Clusters unknown to date have been identified. The clusters identified should be considered when developing clinical guidance for this population.

Motivational interviewing interactions and the primary health care challenges presented by smokers with low motivation to stop smoking: a conversation analysis

BackgroundResearch indicates that one third of smokers have low motivation to stop smoking. The purpose of the study was to use Conversational Analysis to enhance understanding of the process in Motivational Interviewing sessions carried out by primary care doctors and nurses to motivate their patients to quit smoking. The present study is a substudy of the Systematic Intervention on Smoking Habits in Primary Health Care Project (Spanish acronym: ISTAPS).MethodsMotivational interviewing sessions with a subset of nine participants (two interview sessions were conducted with two of the nine) in the ISTAPS study who were current smokers and scored fewer than 5 points on the Richmond test that measures motivation to quit smoking were videotaped and transcribed. A total of 11 interviews conducted by five primary health care professionals in Barcelona, Spain, were analysed. Qualitative Content Analysis was used to develop an analytical guide for coding transcriptions. Conversation Analysis allowed detailed study of the exchange of words during the interaction.ResultsMotivational Interviewing sessions had three phases: assessment, reflection on readiness to change, and summary. The interaction was constructed during an office visit, where interactional dilemmas arise and can be resolved in various ways. Some actions by professionals (use of reiterations, declarations, open-ended questions) helped to construct a framework of shared relationship; others inhibited this relationship (focusing on risks of smoking, clinging to the protocol, and prematurely emphasizing change). Some professionals tended to resolve interactional dilemmas (e.g., resistance) through a confrontational or directive style. Interactions that did not follow Motivational Interviewing principles predominated in seven of the interviews analysed.ConclusionsConversational analysis showed that the complexity of the intervention increases when a health professional encounters individuals with low motivation for change, and interactional dilemmas may occur that make it difficult to follow Motivational Interview principles. Incorporating different forms of expression during the Motivational Interviewing could help to build patient-centred health care relationships and, for patients with low motivation to stop smoking, offer an opportunity to reflect on tobacco use during the office visit. The study findings could be included in professional training to improve the quality of motivational interviewing.

Study protocol of psychometric properties of the Spanish translation of a competence test in evidence based practice: The Fresno test

BackgroundThere are few high-quality instruments for evaluating the effectiveness of Evidence-Based Practice (EBP) curricula with objective outcomes measures. The Fresno test is an instrument that evaluates most of EBP steps with a high reliability and validity in the English original version. The present study has the aims to translate the Fresno questionnaire into Spanish and its subsequent validation to ensure the equivalence of the Spanish version against the English original.Methods and designThe questionnaire will be translated with the back translation technique and tested in Primary Care Teaching Units in Catalonia (PCTU). Participants will be: (a) tutors of Family Medicine residents (expert group); (b) Family Medicine residents in their second year of the Family Medicine training program (novice group), and (c) Family Medicine physicians (intermediate group). The questionnaire will be administered before and after an educational intervention. The educational intervention will be an interactive four half-day sessions designed to develop the knowledge and skills required to EBP. Responsiveness statistics used in the analysis will be the effect size, the standardised response mean and Guyatts method. For internal consistency reliability, two measures will be used: corrected item-total correlations and Cronbachs alpha. Inter-rater reliability will be tested using Kappa coefficient for qualitative items and intra-class correlation coefficient for quantitative items and the overall score. Construct validity, item difficulty, item discrimination and feasibility will be determined.DiscussionThe validation of the Fresno questionnaire into different languages will enable the expansion of the questionnaire, as well as allowing comparison between countries and the evaluation of different teaching models.

Prolonged Sitting Time: Barriers, Facilitators and Views on Change among Primary Healthcare Patients Who Are Overweight or Moderately Obese

Background and Objectives Prolonged sitting time has negative consequences on health, although the population is not well aware of these harmful effects. We explored opinions expressed by primary care patients diagnosed as overweight or moderately obese concerning their time spent sitting, willingness to change, and barriers, facilitators, goals and expectations related to limiting this behaviour. Methods A descriptive-interpretive qualitative study was carried out at three healthcare centres in Barcelona, Spain, and included 23 patients with overweight or moderate obesity, aged 25 to 65 years, who reported sitting for at least 6 hours a day. Exclusion criteria were inability to sit down or stand up from a chair without help and language barriers that precluded interview participation. Ten in-depth, semi-structured interviews (5 group, 5 individual) were audio recorded from January to July 2012 and transcribed. The interview script included questions about time spent sitting, willingness to change, barriers and facilitators, and the prospect of assistance from primary healthcare professionals. An analysis of thematic content was made using ATLAS.Ti and triangulation of analysts. Results The most frequent sedentary activities were computer use, watching television, and motorized journeys. There was a lack of awareness of the amount of time spent sitting and its negative consequences on health. Barriers to reducing sedentary time included work and family routines, lack of time and willpower, age and sociocultural limitations. Facilitators identified were sociocultural change, free time and active work, and family surroundings. Participants recognized the abilities of health professionals to provide help and advice, and reported a preference for patient-centred or group interventions. Conclusions Findings from this study have implications for reducing sedentary behaviour. Patient insights were used to design an intervention to reduce sitting time within the frame of the SEDESTACTIV clinical trial.

Effectiveness and cost-effectiveness of a health coaching intervention to improve the lifestyle of patients with knee osteoarthritis: cluster randomized clinical trial

BackgroundThe prevalence of osteoarthritis and knee osteoarthritis in the Spanish population is estimated at 17% and 10.2%, respectively. The clinical guidelines concur that the first line treatment for knee osteoarthritis should be non-pharmacological and include weight loss, physical activity and self-management of pain. Health Coaching has been defined as an intervention that facilitates the achievement of health improvement goals, the reduction of unhealthy lifestyles, the improvement of self-management for chronic conditions and quality of life enhancement.The aim of this study is to analyze the effectiveness, cost-effectiveness and cost-utility of a health coaching intervention on quality of life, pain, overweight and physical activity in patients from 18 primary care centres of Barcelona with knee osteoarthritis.Methods/DesignMethodology from the Medical Research Council on developing complex interventions. Phase 1: Intervention modelling and operationalization through a qualitative, socioconstructivist study using theoretical sampling with 10 in-depth interviews to patients with knee osteoarthritis and 4 discussion groups of 8–12 primary care professionals, evaluated using a sociological discourse analysis. Phase 2: Effectiveness, cost-effectiveness and cost-utility study with a community-based randomized clinical trial. Participants: 360 patients with knee osteoarthritis (180 in each group). Randomization unit: Primary Care Centre. Intervention Group: will receive standard care plus 20-hour health coaching and follow-up sessions. Control Group: will receive standard care. Main Outcome Variable: quality of life as measured by the WOMAC index. Data Analyses: will include standardized response mean and multilevel analysis of repeated measures. Economic analysis: based on cost-effectiveness and cost-utility measures. Phase 3: Evaluation of the intervention programme with a qualitative study. Methodology as in Phase 1.DiscussionIf the analyses show the cost-effectiveness and cost-utility of the intervention the results can be incorporated into the clinical guidelines for the management of knee osteoarthritis in primary care.Trial registrationISRCTN57405925. Registred 20 June 2014.

Psychometric properties of a test in evidence based practice: the Spanish version of the Fresno test

BackgroundValidated instruments are needed to evaluate the programmatic impact of Evidence Based Practice (EBP) training and to document the competence of individual trainees. This study aimed to translate the Fresno test into Spanish and subsequently validate it, in order to ensure the equivalence of the Spanish version against the original English version.MethodsBefore and after study performed between October 2007 and June 2008. Three groups of participants: (a) Mentors of family medicine residents (expert group) (n = 56); (b) Family medicine physicians (intermediate experience group) (n = 17); (c) Family medicine residents (novice group) (n = 202); Medical residents attended an EBP course, and two sets of the test were administered before and after the course. The Fresno test is a performance based measure for use in medical education that assesses EBP skills. The outcome measures were: inter-rater and intra-rater reliability, internal consistency, item analyses, construct validity, feasibility of administration, and responsiveness.ResultsInter-rater correlations were 0.95 and 0.85 in the pre-test and the post-test respectively. The overall intra-rater reliability was 0.71 and 0.81 in the pre-test and post-test questionnaire, respectively. Cronbachs alpha was 0.88 and 0.77, respectively. 152 residents (75.2%) returned both sets of the questionnaire. The observed effect size for the residents was 1.77 (CI 95%: 1.57-1.95), the standardised response mean was 1.65 (CI 95%:1.47-1.82).ConclusionsThe Spanish version of the Fresno test is a useful tool in assessing the knowledge and skills of EBP in Spanish-speaking residents of Family Medicine.