基层医疗卫生服务整合的国际经验及对我国的启示

目的:总结典型国家基层卫生服务提供中实现医防整合的经验,为我国基层医疗卫生服务整合提供借鉴。方法:本研究方法为文献研究。结果:在个人层面,英国、泰国、古巴培养全科医生作为"守门人"并将其作为提供医防整合服务的主体;在机构层面,各国基层机构组成服务网络,内部强调跨学科合作;在体系层面,通过横向合作和有序的首诊与转诊协调服务;国家立法保障和健康保险筹资等引导支持基层医疗卫生服务整合。结论:培养和配置高质量的医防一体的全科医生、促进机构跨学科融合、通过立法和筹资体系予以保障是各国提供基层整合型服务的核心,值得我国基层医防服务整合借鉴。     

The influence of environmental and health indicators on premature mortality: An empirical analysis of the City of Toronto's 140 neighborhoods

The objective of this paper was to assess the link between premature mortality and a combination of neighbourhood contextual (environmental and health) and compositional (socioeconomic and demographic) characteristics. We statistically and spatially examined six environmental variables (ultrafine particles, carcinogenic and non-carcinogenic pollutants, pollution released to air, tree cover, and walkability index), six health service indicators (number health providers, breast, colorectal and cervical cancer screening uptake rates, student nutrition program uptake rates, and healthy food index), and eight socioeconomic indicators (total income, Gini coefficient, two age categories – below and above 40 years, proportion of females to males, visible minorities, Indigenous peoples, education, less than grade 9) among 140 neighbourhoods of the City of Toronto in Ontario (Canada). We applied principal component analysis to identify patterns and to reduce the number of explanatory variables into combined component axes that represent unique variation in these confounded and overlapping factors. We then applied regression analysis to model the relationship between the indices of enviro-health and socioeconomics and their potential relationship with premature mortality. Residual spatial analysis was used to investigate any remaining spatial structure (such as neighbourhoods with higher residual premature mortality rates). Neighbourhood Equity Index was correlated with our enviro-health and socioeconomic indices. Premature mortality within neighbourhoods was predicted by poor cancer screenings, pollution, lack of tree canopy, increased uptake of student nutrition programs and high walkability index. A negative association between premature mortality and pollution was associated low walkability index and presence of visible minorities within neighbourhoods. There was some unexplained residual spatial variation in our model of premature mortality - especially along the shores of Lake Ontario and in neighbourhoods with major highways or road corridors: premature mortality in Toronto neighbourhoods was higher than expected along highway-corridor neighbourhoods and shorelines. Our analysis revealed a significant relationship between neighbourhood contextual features – both environmental and health – and premature mortality, suggesting that these contextual components of neighbourhoods can predict rates of urban premature mortality in Toronto.     

Insufficient knowledge and inapproriate physiotherapy management of Relative Energy Deficiency in Sport (RED-S) in lightweight rowers

ObjectiveTo investigate the knowledge and management of Relative Energy Deficiency in Sport (RED-S), from the perspective of lightweight rowers and physiotherapists.DesignSemi-structured individual qualitative interviews.MethodsPhysiotherapists who had worked with lightweight rowers, and current and former lightweight rowers (who had experienced at least one symptom of RED-S), undertook audio-recorded semi-structured telephone interviews. An inductive thematic analysis was performed, facilitated by NVivo software.ResultsTwelve physiotherapists (n = 6 females, 1–20 years of experience managing lightweight rowers) and twelve lightweight rowers (n = 8 females, 1–8 years lightweight rowing experience, intermediate to elite/international level) were interviewed. Five key themes were identified: insufficient knowledge of RED-S, inadequate RED-S education, inappropriate management of RED-S, referral to other health professionals, prioritising performance over health. Participants provided suggestions for improving knowledge and management of RED-S in lightweight rowers, including formal physiotherapy education and training, and targeted education for athletes and coaches.ConclusionsThere was a significant lack of awareness of RED-S amongst physiotherapists and lightweight rowers. Most physiotherapists were not confident discussing or managing RED-S in athletes, and lightweight rowers were dissatisfied with the management they received. Improving RED-S education for physiotherapists and athletes may have important health implications for lightweight rowers.     

Self-reported outcomes of a randomized trial comparing three community health worker interventions for diabetes prevention among Cambodian Americans with depression

ObjectiveCambodian Americans have complex, interrelated and persistent medical and mental health problems stemming from genocide and the social determinants of health. We examined changes in multiple domains of self-reported health outcomes from a diabetes prevention trial. Methods: Cambodian Americans with depression and high risk for diabetes (n = 188) were randomized to one of three community health worker interventions: lifestyle vs lifestyle plus medication therapy management vs social services. Assessments were at baseline, 12- and 15-months. Results: The typical participant was 55 years old, female, earned below $20,000 annually, and had 7 years of education. About one-third were taking antidepressant medication and over half had elevated depressive symptoms. Relative to social services, lifestyle and lifestyle plus medication therapy management were both similarly effective at increasing diabetes knowledge, nutrition habits, sleep quality and decreasing pain; 2) lifestyle alone was superior to social services for self-reported health; and, 3) all three groups showed improved anxiety and insomnia. There were no effects on physical activity or physical functioning. Conclusion: Community health worker interventions have multiple benefits beyond delaying diabetes. Practice Implications: Health promotion programs that are designed and delivered appropriately can impact even hard to reach and hard to treat groups.     

Factors associated with provision of depot medroxyprogesterone acetate to adolescents by US health care providers

ObjectiveIdentify factors associated with healthcare providers' frequency of depot medroxyprogesterone acetate (DMPA) provision to adolescents.Study designWe analyzed data from surveys mailed to a nationally representative sample of public-sector providers and office-based physicians (n=1984). We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with frequent DMPA provision to adolescents in the past year.ResultsAlthough most providers (>95%) considered DMPA safe for adolescents, fewer reported frequent provision (89% of public-sector providers; 64% of office-based physicians). Among public-sector providers, factors associated with lower odds of frequent provision included working in settings without Title X funding (aOR 0.44, 95% CI 0.30–0.64), reporting primary care as their primary clinical focus versus reproductive or adolescent health (aOR 0.42, 95% CI 0.28–0.61), and providing fewer patients with family planning services. Among office-based physicians, factors associated with lower odds of frequent provision included specializing in obstetrics/gynecology (aOR 0.50, 95% CI 0.27–0.91) and family medicine (aOR 0.21, 95% CI 0.09–0.47) versus adolescent medicine, completing training ≥15 versus <5 years ago (aOR 0.27, 95% CI 0.09–0.83), and reporting that 0–24% of patients pay with Medicaid or other government healthcare assistance versus ≥50% (aOR 0.23, 95% CI 0.09–0.61). The reason most commonly reported by providers for infrequent DMPA provision was patient preference for another method.ConclusionsWhile most providers reported frequently providing DMPA to adolescents, training on evidence-based recommendations for contraception, focused on subgroups of providers with lower odds of frequent DMPA provision, may increase adolescents' access to contraception.ImplicationsAlthough >95% of providers considered depot medroxyprogesterone (DMPA) a safe contraceptive for adolescents, only 89% of public-sector providers and 64% of office-based physicians reported frequently providing DMPA to adolescents. Provider training on evidence-based recommendations for contraception counseling and provision may increase adolescents' access to DMPA and all methods of contraception.