Registered nurses in primary care: A value proposition

The aims of the present study were to understand enablers to participation in postgraduate education for primary care nurses (PCNs), and to explore how postgraduate education has advanced their nursing practice. Cross-sectional questionnaires were mailed out in April 2012 to current and past students undertaking postgraduate studies in primary care nursing at The University of Melbourne, Victoria, Australia. Questionnaires were returned by 100 out of 243 nurses (response rate 41%). Ninety-one per cent (91/100) of the respondents were first registered as nurses in Australia. Fifty-seven per cent were hospital trained and 43% were university educated to attain their initial nurse qualification. The respondents reported opportunities to expand scope of practice (99%; 97/98), improve clinical practice (98%; 97/99), increase work satisfaction (93%; 91/98) and increase practice autonomy (92%; 89/97) as factors that most influenced participation in postgraduate education in primary care nursing. Major enablers for postgraduate studies were scholarship access (75%; 71/95) and access to distance education (74%; 72/98). Many respondents reported an increased scope of practice (98%; 95/97) and increased job satisfaction (71%; 70/98) as an education outcome. Only 29% (28/97) cited an increase in pay-rate as an outcome. Of the 73 PCNs currently working in general practice, many anticipated an increase in time spent on the preparation of chronic disease management plans (63%; 45/72), multidisciplinary care plans (56%; 40/72) and adult health checks (56%; 40/72) in the preceding 12 months. Recommendations emerging from findings include: (1) increased access to scholarships for nurses undertaking postgraduate education in primary care nursing is imperative; (2) alternative modes of course delivery need to be embedded in primary care nursing education; (3) the development of Australian primary care policy, including policy on funding models, needs to more accurately reflect the educational level of PCNs, PCN role expansion and the extent of interprofessional collaboration that is evident from research undertaken to date. Nurses with postgraduate education have the potential to increase their scope of practice, take on a greater teaching role and provide more preventive and chronic disease services in primary care. Policies aimed at increasing access to education for nurses working in primary care would strengthen the primary care nursing profession, and enhance the delivery of primary health care services in Australia.

Adapting to Inspire: The ‘Future of Primary Care’ Seminar Series: Evaluating a Primary Care Seminar Series to inspire medical students toward academic and portfolio careers Purpose As healthcare systems face growing demands, general practice (GP) workforce shortages in both academic and clinical practice persist. An online ‘Grand Round’ seminar series was developed to inspire healthcare students to consider primary care careers by showcasing innovative GP careers and providing role models. This study evaluates impact on student career choices and learning. Materials and Methods: Expert-led seminars were co-developed with staff and students, and were made available synchronously and asynchronously, covering student suggested topics including health equity, digital innovation, and sustainability. A mixed-methods evaluation was conducted, using surveys and focus groups. The data was analysed using a reflexive thematic approach. Results Ten one-hour seminars were delivered over eighteen months, with over 650 registrations (506 live and 413 asynchronous viewers). Fifty-eight percent of viewers completed the evaluation survey, of whom 97% encountered new aspects of GP, and would recommend the series. Of respondents not already committed to primary (27%) or secondary care (4%), all reported increased interest in primary care careers. Focus groups highlighted features participants valued, including portfolio careers, personal stories, and interactivity. Conclusions The series successfully sparked interest in academic GP roles. Future efforts will target a broader audience, including early-career doctors yet to make specialty decisions.

Primary care is the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained relationship with patients, and practicing in the context of family and community. 1 A frontline, broad based and holistic approach makes primary care essential for the success and sustainability of any healthcare system. In most circumstances, Family Physicians, Internists, Pediatricians and Obstetricians form the core Primary Care Practitioners. Family Physicians form the main component of the primary care team. Scandinavian countries have better health indicators in Europe because of strong emphasis given to primary care. South India has better health indicators compared to rest of India, again because of the presence of primary care orientation to health care delivery. Similarly, Sri Lanka has better health indicators in the region because of their strong emphasis on primary care. There is enough evidence to suggest relationship, better health indicators and primary care orientation of health care delivery.2 Ten industrialized countries were compared on the basis of the extent of primary health service, twelve health indicators and population satisfaction with overall costs of the systems. A general concordance was found among these three characteristics, highlighting the importance of primary healthcare, health indicators and the costs of health care.3 In today’s, day and age with rising cost of health care, a primary care orientation of health care is the way forward. The role of primary care in ensuring success of health care delivery is critical for several reasons. The frontline position allows Primary Care Practitioners to offer preventive care and health maintenance initiatives to their patients and diagnose diseases in early stages where they can be successfully handled with minimum and cost effective interventions. The community based location of Primary Care Practitioners offer them a unique position to provide care to patients in their context and environment. Patients are known to their practitioners, allowing a better understanding of their symptoms. The trusting relationship exists between a Primary Care Practitioner and patients, allowing better sharing of information and with confidence. The Primary Care Practitioner knows their patient’s health seeking behaviour, allowing them to determine appropriate approach for their symptoms evaluation. They also know their patient’s family which allows better understanding of home dynamics and its impact on health. The role of family in the health care of individual patient can be exploited to get better health outcomes. The community based location of Primary Care Practitioners allow them to be the main focus for patient care and referrals. The ‘gate keeper’4 position of Primary Care Practitioner in selecting patients for hospital care referral curtails health care costs. Primary Care Practitioners are trained in effective communication skills, which allow them to better communicate and understand their patient’s problems. Practice of effective communication skills is known to improve patient’s satisfaction with the clinician.5 These skills allow Primary Care Practitioner to form the focus for effective communications between patient and the health care team, supporting other members of the team in delivery of this challenging task. Primary Care Practitioners practice holistic medicine, allowing them to effectively handle multiple patient problems at the same time. The bio-psycho-sociospiritual model of medical practice allow them to tackle patient complaints at multiple levels. This provides value to them in the health care delivery by providing cost effective care in a convenient manner and leads to enhanced patient’s satisfaction.

Introduction: During the COVID-19 pandemic, primary care practices felt poorly supported by existing infection prevention and control (IPAC) guidelines, which focused primarily on acute care facilities. This issue was further complicated by insufficient provision of personal protective equipment in primary care settings, which limited clinic capacity and the ability of primary care to provide in-person services. Nurses play an integral role in the implementation of IPAC procedures and the provision of ongoing primary care during a health crisis; however there is limited literature related to nurses' roles in the enactment of IPAC procedures in primary care settings. This paper aims to describe primary care nurses' experiences and roles in implementing IPAC during the COVID-19 pandemic. Design: Qualitative analysis of interviews as part of a larger mixed methods case study. Methods: We conducted semistructured qualitative interviews with primary care nurses across four Canadian regions in the provinces of British Columbia, Ontario, Nova Scotia, and Newfoundland and Labrador. During the interviews, we asked participants to describe the roles they enacted during the various stages of the pandemic, any facilitators and challenges they encountered, and the potential roles that nurses could have played. We employed a thematic analysis approach, and, for the purposes of this paper, we analyzed themes relevant to the implementation of IPAC. Results: We interviewed 76 nurses across the four regions and identified two overarching themes: (1) nurse-led transformation of clinic operations and (2) impact on workload. Primary care nurses developed and implemented IPAC policies, educated staff, and made critical decisions about patient care, often out of necessity and ahead of regional guidelines. In addition, nurses adapted workflows, managed supplies, and balanced in-person and virtual care to protect both patients and staff from COVID-19 exposure. Conclusion: Despite the additional responsibilities and challenges that nurses faced in response to evolving guidelines, their IPAC efforts were pivotal in maintaining primary care clinic operations during the pandemic. The findings from this study underscore primary care nurses' capacity to adapt and apply evidence-based practices and demonstrate the need for better pandemic planning to support primary care. IPAC guidance documents, suitable for primary care settings and informed by experiences from the COVID-19 pandemic, should be included in future pandemic plans. Implications for Nursing Management: Our findings highlight the need for stronger institutional support and preparedness for primary care nurses during a pandemic. Nursing management should ensure that IPAC responsibilities are explicitly recognized within primary care nursing roles and supported through ongoing training, resource allocation, and standardized protocols. Proactively integrating IPAC into primary care practice and strengthening these supports will enhance future health crisis preparedness while mitigating nurse burnout and promoting sustainable workforce capacity.

China has a shortage of physicians and nurses in primary care and rural health. This study explores factors that influence the choices of medical and nursing students in China to select a career in primary care, or in rural health. A total of 3826 medical students and 1771 nursing students were surveyed in China. Data were analysed using descriptive statistics, Chi-squared tests, and logistic regression models. The majority of medical and nursing students were willing to practice primary care (55% and 59%, respectively). Yet, only 16% and 5% of medical and nursing students, respectively, desired to work in a village or small city. The most common reasons cited to not practice primary care is the lack of opportunities for clinical skills improvement, academic and personal development, and networking. Medical students who were living in a rural residence between ages 1 and 15years were more likely to report a willingness to work in a rural location (OR: 2.18, 95% CI: 1.33-3.58) or in primary care (OR: 1.72, 95% CI: 1.31-2.25). More efforts are needed to understand how preferences among medical and nursing students influence their career choices and change in choices over time. Understanding the concerns of students can help to tailor interventions in healthcare education and training to increase student satisfaction with their career choice and enrolment counts in medical and nursing fields.

85 Background: While evidence-based guidelines for survivorship care exist, implementation in oncology and primary care practices has fallen short. There is little evidence of the barriers preventing successful implementation in rural primary care and oncology practices. We sought to assess knowledge gaps and barriers to successful implementation of evidence-based survivorship care guidelines in rural Kansas practices. Methods: Midwest Cancer Alliance, outreach arm of the University of Kansas Cancer Center, and Kansas Patients and Providers Engaged in Prevention Research, completed interviews in rural primary care and oncology practices. Results: Primary Care (n=7) and Oncology Practices (n=4): Interviews with primary care physicians, medical oncologists, advanced practice providers, nurses, tumor registrar, outreach coordinator, and office management & staff. Conclusions: Rural primary care and oncology practices experienced barriers to delivering survivorship care including: educational gaps, communication of history, treatment, and recommendations, EHR integration, and lack of resources. Next steps focus on a unified approach to state-wide survivorship education of patients, primary care and oncology practices. [Table: see text]

Purpose: Primary care (PC) career choice has been declining among U.S. medical graduates and residents since the 1990s. 1,2 By 2034, an estimated shortage of 17,800–48,000 PC physicians is expected. 2 Some medical schools have developed programs to increase students’ interest in PC specialties and practice in underserved areas. 3,4 To our knowledge, the durability of early PC-specialty preference for long-term PC practice has not been reported. Method: The Association of American Medical Colleges provided linked, deidentified data for a national cohort of 48,533 U.S. MD-granting medical school matriculants from 1998–1999 through 2000–2001. Data from the Student Records System (sex, race/ethnicity, and graduation year), Matriculating Student Questionnaire (MSQ; specialty board certification plans and attitudinal variables: importance of prestige and social responsibility in choosing a medical career), Graduation Questionnaire (GQ; total debt, plans to practice in underserved areas, and student ratings [excellent vs not excellent] of PC and non-PC clerkship experiences), and American Medical Association (AMA) Physician Masterfile practice data through May 2020 were used. The outcome was office-based practice in a specialty from the AMA Physician Masterfile, categorized as follows: (1) general-PC (i.e., internal medicine, pediatrics, family practice, general practice, internal medicine/pediatrics, or internal medicine/family practice as primary specialty, with another general-PC or unspecified secondary specialty), (2) PC-subspecialty (i.e., general-PC primary and PC-subspecialty secondary specialty, or PC-subspecialty as primary specialty), and (3) non-PC specialties (i.e., non-PC primary specialty). Multivariable logistic regression models identified variables independently associated with general-PC vs each of PC-subspecialty and non-PC-specialty practice. Results: Of 46,698 graduates in 2002–2013, 30,435 (65.2%) had complete data for analysis (7,700 [25.3%] general-PC physicians, 5,327 [17.5%] PC subspecialists, and 17,408 [57.2%] non-PC specialists). Female (vs male) students, and students with plans to practice in underserved areas (vs no plans) were more likely to report general-PC (vs PC-subspecialty) practice. Underrepresented racial/ethnic minorities in medicine (URiM), Asian/Pacific Islander (Asian/PI) students (each vs White), and students planning to pursue non-PC specialties or no board certification (each vs PC board certification plans) on the MSQ were each less likely to report general-PC (vs PC-subspecialty) practice. In the second model, female students and students reporting plans to practice in underserved areas (vs no plans), endorsing higher importance of social responsibility, or rating only PC clerkships excellent (vs rating both PC and non-PC clerkships excellent) were each more likely to report general-PC (vs non-PC-specialty) practice. URiM, Asian/PI students, students planning to pursue non-PC or no board certification, and students endorsing higher importance of prestige were each less likely to report general-PC (vs non-PC-specialty) practice. Discussion: Several factors were associated with future PC practice. The greater likelihood of women and lower likelihood of URiM graduating students to choose PC specialties on the GQ has been reported. 1 We extend this work, finding lower likelihood of URiM and A/PI physicians to be in general-PC practice. Importantly, early preference for PC specialties was positively associated with general-PC practice in both models. This may reassure medical schools considering early specialty preferences for admissions or entry into early, PC-pathway programs. Although clerkship experiences might influence students to change specialty interests, 5 to our knowledge, associations between clerkship experiences and PC practice have not been examined. We observed that students reporting excellent PC-clerkship experiences were more likely to report general-PC (vs non-PC) practice. Greater importance of social responsibility in choosing medicine also was positively associated with general-PC (vs non-PC) practice. Significance: Medical school experiences that are amenable to intervention were associated with greater odds of general-PC practice. Admitting students with early interest in PC specialties or who highly value social responsibility, fostering students’ plans to practice in underserved areas, 3,4 and improving PC-clerkship experiences may help mitigate the PC-physician shortage. Acknowledgments: The authors thank Hershel Alexander, PhD, Marie Caulfield, PhD (retired), David Matthew, PhD, and Lindsay Roskovensky, at the Association of American Medical Colleges (AAMC), for their efforts to obtain and prepare the deidentified datasets from various sources and their assistance with data coding; the National Board of Medical Examiners (NBME) Office for Research Strategy for permission to use Step 1 licensing examination data; Kristy Vanderplow at MMS, Inc., for provision of the American Medical Association (AMA) Physician Masterfile data; and Maria Pérez, MA, at Washington University School of Medicine, for data management and preparation of the data for analysis.

Expanded roles of registered nurses in primary care delivery of the future

The nursing role in primary care is increasing in importance, particularly in the Australian health care system (Royal College of Nursing Australia [RCNA] 2003). The expanding nursing role in primary care has implications for the health of Australian society, nursing education, continuing professional development, health service policy, inter-professional politics, regulatory affairs and the monitoring of standards and professional practice. Professional nursing organisations represent the voice of their membership in influencing development of public policy, setting professional standards and in promoting the profession and raising awareness of its vital role and contribution to the health care sector (Australian Practice Nurses Association 2007; RCNA 2007).A range of variables has contributed to shaping the nursing role in the general practice setting. Perhaps the most significant of these to date include legal and industrial factors and consumer expectations. However, the political challenges of introducing change and innovation in nursing in general practice must also be given careful consideration. Professional leadership that successfully manages the complex interplay of these and other factors will be important in advancing the role in the future.As this nursing role evolves it is important that the nursing profession, including professional, industrial and regulatory representatives work collaboratively to promote the health and well-being of Australians. The impact of this role on health service provision also needs to be carefully examined through research processes in order to build an evidence-base. Evaluative data will be useful in developing and expanding the role in the future in defensible ways through policy development.In this special issue of Contemporary Nurse, McMurray (2007) emphasises the importance of leadership in primary care and provides us with useful strategies for promoting the health of communities. Hall et al. (2007) and Porritt (2007) trace the recent developments of the practice nurse role in Australian general practice and underscore the importance of policy in driving health care reforms and developing nurses' roles that are responsive to needs of contemporary health care systems.Models of nursing roles in primary care should complement and support the role of other health practitioners, particularly the general practitioner. The role for the nurse practitioner in general practice will evolve as multidisciplinary models of care are advanced, in order to enhance existing service provision and improve access to primary care for all consumers. Nursing is in a good position to influence development of these models, the end point of which must be improved health outcomes for consumers of these services. Consequently education initiatives in the undergraduate, post graduate and professional development sphere need to prepare nurses to work collaboratively with multidisciplinary colleagues, particularly in the general practice setting. Nurses working in specialist domains of practice should also establish links with nurse colleagues in the primary care setting to support their professional growth, promote the quality and continuity of clinical care and in developing practice-based research and scholarship.Over the last five years, nursing in Australian general practice has developed substantially and will evolve as multidisciplinary models of care are advanced to improve existing service provision and improve access to primary care for all consumers (Council of Deans of Nursing and Midwifery of Australia and New Zealand 2004). …

When I was young, I wanted to become a physician because I was interested in human beings and curious to know more about the biology and psychology of these creatures. If you are interested in people, there is no better job than that of a GP. Many young medical students share my enthusiasm for their career, yet few of them would like to specialize in general practice. As a teacher of medical students, I have noticed that during the first years of study general practice seems to be a possible choice for them, yet the longer the studies continue, the more a good many of them prefer a career in a narrower, hospital-based specialty. A recent article in this journal surveyed fifth-year medical students’ opinions on general practice [1]. While students respected GPs’ versatile and challenging work, they were concerned that the work was too hasty and pressing. The majority of the students (82%) considered that the most important aim of the GP's work is to identify serious diseases in order to refer patients for specialized care, which means that they overlooked the GP's important role in public health, i.e. the aim of better health for all people. Another concern among medical students was that GPs have to deal too much with non-medical problems. Bureaucratic duties such as sickness certification take up a large part of a GP's day, and GPs often consider these tasks problematic [2]. We need a continuous discussion about which jobs GPs should and should not do. As generalists, we are needed for many different tasks; however, not all of them are considered efficient use of the GP's time nor do they contribute to achieving the main aims of the GP's work. In Helsinki, the general practice training has been updated to help young doctors cope with the current challenges of primary care. General practice courses now get more positive feedback than before, and the number of young doctors wanting to specialize in general practice has increased. Nevertheless, young doctors who choose a career in primary care still face several barriers. The shortage of primary care physicians seems to continue, and young doctors often tend to leave after their mandatory period in general practice. In Finland, a primary care reform has been planned for several years, and one initiative was launched in 2012. However, it is based on municipalities as organizers of primary health care, and the initiative is strongly linked to a parallel reform of the number of municipalities. Few believe that this reform is going to solve the problems of primary care in Finland. GPs play a decreasing role in the leadership of primary care. High demands and limited resources challenge their role as primary care leaders, a similar situation to what was lately described in rural primary care in Norway [3]. Recently, three enthusiastic young physicians described their vision of future primary care in an editorial in the New England Journal of Medicine [4]. They emphasized multi-professional teams, quality-improvement cycles, patient groups, and the use of new technologies in communication with patients. Some of these ideas, such as teamwork and focus on quality, seem familiar in Scandinavia. Many countries, including the United States, Norway, and Finland, are simultaneously carrying out primary health care reforms. Despite the challenges, the many good practices and innovations in primary health care in Scandinavia are important models for the current reforms. Times are interesting for the transforming of primary care systems. The number of young physicians who choose a career in primary care serves as a good measure for the success of transformation. A journal like this plays an important part in letting us read and write about the importance of primary care and the successful innovations that are made in the few well-functioning systems. All this knowledge is useful for the GPs who are taking the lead in re-imaging the future of primary care.

Nurse Practitioner Role, Independent Practice, and Teamwork in Primary Care

RECENT REPORTS HAVE WARNED OF A CRISIS RELATED to a shortage of primary care physicians. However, much of the current concern seems to have stemmed from articles in the medical literature specifically reporting that fewer internal medicine residents are choosing to pursue primary care and that fewer medical students are choosing family medicine residencies. Hauer et al found, among a national sample of fourth-year medical students, that only 22% planned careers in internal medicine and just 2% intended to practice general internal medicine. Ebell hypothesized that fewer medical students are choosing primary care specialties as a result of lower salaries relative to other specialties. It is important to note that the results of his trend-line analysis showed this was true only for family physicians. There has not been an appreciable change in the proportion of pediatric residents who choose primary care pediatrics. Thus, the concerns expressed regarding primary care should really only focus on the care of adults. While this is a large and important patient population, adults are not the only group served by primary care physicians. Historically, primary care has encompassed internal medicine, pediatrics, and family medicine; in some instances, obstetrics/gynecology is included. These groups are similar with respect to their primary care roles, but they are markedly different in many other ways, including workforce projections. For these reasons, it is disappointing that national discussions about the “crisis in primary care” have moved beyond the valid concerns regarding a shortage of physicians providing primary care to adults and have somehow come to imply a shortage of all primary care physicians. Multiple government reports also fail to distinguish among the primary care specialties when reporting on the crisis in primary care. For example, in its February 2008 report to Congress, the Government Accounting Office reported findings predicting a shortage of primary care physicians in 2018, without reference to specific specialties. Assessments by those tasked with determining sufficiency of training the physician workforce are no more specific. A 2005 report by the Council on Graduate Medical Education did not distinguish among the primary care specialties when assessing the future training needs of the country in this important area. The need to understand primary care workforce issues in a specialty-specific manner is critical, because any policy changes or economic incentives that affect the proportion of physicians pursuing primary care will likely have a differential effect across the primary care specialties. For example, it might be viewed as positive if the number of internal medicine residents who pursue primary care were to double. Indeed, a November 2008 American Medical Association news release reported a new policy aimed at “increasing the ranks of primary care physicians” without any reference to specific primary care specialties. However, the most recent published data regarding pediatric residents completing training in 2008 demonstrated that 40% were planning to pursue a career in primary care, with 10% still undecided. Similar findings were seen among senior residents scheduled to complete their training in 2009 (G.L.F. and J.A.S., unpublished data, 2008). Thus in pediatrics, a doubling or substantial increase of the proportion entering primary care could result in a possible oversupply of primary care pediatricians, likely at the expense of needed pediatric subspecialists. Markedly increasing the number of primary care pediatricians in the pipeline could create more such physicians than jobs available, resulting in the opposite effect of any intended legislation or other policy solution aimed at primary care. In contrast, the idea that there is a shortage of primary care pediatricians—or that, relative to the past, there are fewer primary care pediatricians to care for the current population of children—is contrary to published workforce and population data. While the absolute number of children in the United States has remained relatively stable, the number of pediatricians has increased substantially (FIGURE). This has resulted in an increase in the number of primary care pediatricians, from 32 to 78 per 100 000 children in the period 1975 to 2005. Similarly, there has been an increase in

The principal goals of health care reform are to improve quality, increase access, and contain costs. In this issue, Pham and colleagues calculated that a typical primary care clinician must coordi...

In the past 10 years, significant developments in general practice teaching and research have led to the considerable growth of academic general practice as a discipline. This paper reviews issues relating to these developments, particularly career pathways and training aspects. The need to extend these advances to the broadening arena of primary health care has given further impetus for the development of academic careers. General practice will need to work closely with secondary care, community health, and social services to develop primary health care in its broadest sense, and an evidence base, generated by relevant research and evaluation, must underpin all of this. Structural and funding changes to undergraduate education, postgraduate training and primary care research have created a range of opportunities for general practice clinicians to define career pathways, not formerly available, within multiprofessional and multidisciplinary departments and groups. Education for future general practice and primary care must underpin developments as much as a research base. Relevant masters' degrees and diplomas are now widely available, and extended vocational training and higher professional education will enable general practitioners in their formative years to consider academic opportunities.

Alcohol is a leading risk factor contributing to the global burden of disease. National and international agencies recommend evidence-based screening and brief interventions in primary care settings in order to reduce alcohol consumption. However, the majority of primary care professionals do not routinely deliver such interventions. To identify factors influencing general practitioners/family physicians' and primary care nurses' routine delivery of alcohol screening and brief intervention in adults. A systematic literature search will be carried out in the following electronic databases: Medline, CINAHL, CENTRAL, and PsycINFO. Two authors will independently abstract data and assess study quality using the NIH National Heart, Lung, and Blood Institute quality assessment tools for quantitative studies, and the CASP checklist for qualitative studies. A narrative synthesis of the findings will be provided, structured around the barriers and facilitators identified. Identified barriers and facilitators will be further analysed using the Behavioural Change Wheel/Theoretical Domains Framework. This review will describe the barriers to, and facilitators for, the implementation of alcohol screening and brief interventions by general practitioners/family physicians and nurses at primary care practices. By mapping the barriers and facilitators to the domains of the Behavioural Change Wheel/Theoretical Domains Framework, this review will also provide implementation researchers with a useful tool for selecting promising practitioner-oriented behavioural interventions for improving alcohol screening and brief intervention delivery in primary care. This review will provide important information for implementing alcohol screening and brief intervention in primary health care.Systematic Review Registration: PROSPERO CRD42016052681.