Ensuring quality preventive care: the Texas Department of Health's Put Prevention into Practice initiative.

In the current public health arena, assurance of quality clinical preventive services to all populations will be possible only if collaborations are nurtured between public health and the private sector health care delivery systems. This article explores key preventive health programs that serve as the historical context for the evolution of the Texas Department of Health-Put Prevention Into Practice (TDH-PPIP) initiative, outlines documented barriers to implementation of preventive services in primary care, and reviews national public health programs launched to reduce these barriers. Lastly, a discussion regarding the joint responsibilities of the public health and the private sector professionals in assuring quality preventive services to all populations is initiated. Collaborative efforts, such as the TDH-PPIP, initiative improve the availability and quality of clinical preventive services and, thus, result in significant advances in the public health goal of ensuring conditions in which people can be healthy.     

Acceptance of hospital-based respite care by families and elders

Health and social service professionals generally view respite services as a preventive health care measure for both caregiver and recipient. However, many families with dependent elders are reluctant to use formal respite care services. Factors associated with family member perceptions of hospital-based respite care as a viable personal option are examined. The findings suggest that families often fail to recognize the preventive health care functions that respite care may offer and that practitioners should propose respite care as part of overall treatment plans.     

Counselling in a hospital-based newborn screening service

The newborn screening and parent counselling service at Howard University Hospital is an integral component of services to newborn infants. The organization of this service presents a model that appears appropriately suited to the general organization of health-care delivery in the United States. Significant features of this service are: hospital-based planning and management of the service; integration of multiscreening components into a unified service; tight integration between screening, education, and counselling; a hospital-based team that provides coherent and in-depth counselling for all screening-related needs; a forum for orienting parents to the benefits of preventive health care; and a context in which to teach students the applied aspects of preventive health care based on early detection of disorders. If we are to have high quality newborn services in this area it may be incumbent on hospital-based health professionals to designate this as a required component of adequate hospital-based services for newborn infants rather than relinquishing the initiative to centralized health planners and legislators.     

深化城市卫生服务体系改革大力发展社区卫生服务

为适应城市居民卫生需求和城市卫生服务体系改革的需求,天津市卫生局在调研基础上明确了城市社区卫生服务的发展方向,通过实践,创建了符合当地实际的社区卫生服务新模式。     

Health risks, ability to pay, and the use of primary care: is the distribution of service effective and equitable?

BACKGROUND: This study clarifies the confusion about what factors are consistent predictors of primary care service use, of which preventive services are a major component. A variety of health risk, predisposing, and enabling characteristics were assessed for their association with the use of primary care. Variable selection was guided by the use of the Andersen-Newman Behavioral Model of health service utilization. METHODS: The responses of 1,512 residents of Oklahoma to the BRFS survey were used in this study. Both probit and logistic analyses were used to assess the use of nine preventive services and a summary index of service use. RESULTS: The results indicate that those at greater risk of illness and least able to use finance services have the lowest rates of use among the nine preventive services individually and when combined as an index of overall primary care use. CONCLUSIONS: Problems persist with the adequate distribution of primary care among the medically vulnerable. Furthermore, recent welfare and health reforms may present added obstacles to their access to quality primary care services. The paper concludes with a discussion of policy options that may improve the effectiveness of primary care and redress inequities in the use of these services.     

Which way for competition? None of the above

Despite growing documentation that the conditions needed to support competition in health care do not exist, consumer-directed health care has been offered as the new market-based solution to cost inflation. Yet typical consumer-based insurance products undermine the very logic of expecting consumers to make good health care decisions by making preventive services--the category of services about which consumers are best able to make informed decisions using their own money--exempt from cost sharing. Consumer-directed care threatens important societal values--in particular, the goal of establishing relationships between patients and clinical professionals based on trust.     

The preventive-curative conflict in primary health care

Approximately 80% of the rural population in developing countries do not have access to appropriate curative care. The primary health care (PHC) approach emphasizes promotive and preventive services. Yet most people in developing countries consider curative care to be more important. Thus, PHC should include curative and rehabilitative care along with preventive and promotive care. The conflict between preventive and curative care is apparent at the community level, among health workers from all levels of the health system, and among policy makers. Community members are sometimes willing to pay for curative services but not preventive services. Further, they believe that they already know enough to prevent illness. Community health workers (CHWs), the mainstays of most PHC projects are trained in preventive efforts, but this hinders their effectiveness, since the community expects curative care. Besides, 66% of villagers' health problems require curative care. Further, CHWs are isolated from health professionals, adding to their inability to effect positive change. Health professionals are often unable to set up a relationship of trust with the community, largely due to their urban-based medical education. They tend not to explain treatment to patients or to simplify explanations in a condescending manner. They also mystify diseases, preventing people from understanding their own bodies and managing their illnesses. National governments often misinterpret national health policies promoting PHC and implement them from a top-down approach rather than from the bottom-up PHC-advocated approach. Nongovernmental organizations (NGOs) and international agencies also interpret PHC in different ways. Still, strong partnerships between government, NGOs, private sector, and international agencies are needed for effective implementation of PHC. Yet, many countries continue to have complex hierarchical social structures, inequitable distribution, and inadequate resources, making it difficult to implement effective PHC.     

Managed care and women's health: access, preventive services, and satisfaction.

This paper examines insured women's access to health care, receipt of preventive services, and satisfaction with care by the types of health plans in which they are enrolled. Three types of plans are compared: managed care (HMOs and PPOs), fee-for-service with utilization controls, and traditional fee-for-service. For women who have been enrolled in their plans for at least one year, we find the same or better access to care in managed care plans as compared with other plans; receipt of more gender-specific clinical preventive services in managed care plans, but no differences among types of plans for non-gender-specific preventive services or counseling services; and lower satisfaction with care in managed care plans. The implications for practice and policy are discussed.     

The coronary risk factor problem: a behavioral perspective.

This paper examines the conditions under which one would expect to observe the development and perpetuation of preventive health behavior patterns in populations. It is hypothesized that preventive health behavior is a function of both macro-level societal constraints and micro-level organizational, group, and individual factors. The concept of the “at risk” or “high-risk” role is developed and contrasted with the traditional sick and illness roles.Based on the behavioral science literature, the following macro-level factors are presented as predictors of preventive health behavior: (a) legislation and economic incentives; (b) social norms and cultural patterns; (c) training and consequent practices of physicians and other health professionals; and (d) organization of health services. On the micro-level, the following predictors of preventive health behavior can be supported: (a) social supports from primary and reference groups; (b) socialization of children; (c) formal organizational sanctions; and (d) individual motivation and responsibility.In support of the theoretical framework, the paper draws upon the literature reviewed in the recent American Heart Association Monograph Applying Behavioral Science to Cardiovascular Risk. The authors describe some current risk factor intervention studies and conclude with a proposal for community intervention projects with simple, quasi-experimental designs in which outside facilitators would initiate programs and continuing education for local health professionals who would eventually assume responsibility for their perpetuation.     

Hazardous alcohol use: screening and brief intervention as routine practice in primary care

The variety of problems related to the so-called hazardous patterns of alcohol use make the latter a prominent public health concern. Screening instruments associated with brief interventions in primary care provide one of the frequently recommended secondary prevention strategies. The objective of this study was to assess the implementation of this strategy as a routine practice in primary health care services in the city of Juiz de Fora, Minas Gerais State, Brazil. A qualitative design was employed, including the application of semi-structured interviews for managers and health care professionals in the city's public health system, in addition to content analysis and participant observation. Results point to difficulties in the effective implementation of such routines both by managers and health care professionals. Health care professionals limit the approach to alcohol-dependent patients and demonstrate lack of motivation for preventive work. Health services managers experience difficulties in the organization and administration of such instruments, despite affirming their interest in the project.     

Presidential address: Preventive medical practice

Review of national programs in the past decade suggests that there is a developing consensus regarding the need for preventive services, but the proportion of them that physicians provide is decreasing. As teachers of preventive medicine, we should have a particular concern with the physician's performance in providing preventive services. Specialization, practice organizations, and comprehensiveness of payment for medical care appear to be related to the volume of preventive services provided. Organized primary care practice sites, where other health professionals are available, seem especially well-suited to providing preventive services. A review of several effective preventive activities involving physicians (child and adult immunizations, early detection and treatment of PKU infants, and stroke prevention) indicates that current prevention practice is less than desirable. Better performance can be attained through successful national and community programs of consumer and physician education. Implications of these observations for medical undergraduate and graduate education in prevention are discussed.     

试论医院分级管理对以病人为中心的促进

结合医院实际,从两个方面阐述了医院分级管理对以病人为中心的促进,即医院分级管理在理论与思路上对医院以病人为中心的促进;医院分级管理在实践操作上对医院以病人为中心的促进。     

Use of preventive services by managed care enrollees: an updated perspective

We examined whether enrollees in managed care plans received more preventive services than enrollees in non-managed care plans did, by conducting an updated literature synthesis of studies published between 1990 and 1998. We found that 37 percent of comparisons indicated that managed care enrollees were significantly more likely to obtain preventive services; 3 percent indicated that they were significantly less likely to do so; and 60 percent found no difference. Enrollees in group/staff-model health maintenance organizations (HMOs) were more likely to receive preventive services, but there was little evidence, outside of Medicaid managed care, that managed care plans are worse at providing preventive services. However, most of the evidence is equivocal: Provision of preventive services was neither better nor worse in managed versus non-managed care plans. Because of the blurred distinctions among types of health plans, more research is needed to identify which plan characteristics are most likely to encourage appropriate utilization.     

乡镇医疗卫生服务均等化及供给效率——基于湖北省982个乡镇数据的实证分析

良好的医疗卫生服务是居民健康的重要保障,而医疗卫生服务的均等化和高效供给是良好医疗卫生服务的基本内容。对湖北省982个乡镇医疗卫生服务现状的实证考察发现,各乡镇都有卫生站(所)和卫生人员,但乡镇间差距明显,均等度有待提高;医疗卫生服务供给效率整体比较低,还有巨大的提升空间;乡镇管辖村数增多、辖区人口的增加有助于医疗卫生服务效率的改善,而农业人口比重的提高则会降低医疗卫生服务供给效率,推进"撤乡并镇"和农民的非农化对促进医疗卫生服务供给效率的增进具有积极价值。     

Perceptions of Health Care and Access to Preventive Services Among Young Adults

The enactment of the Affordable Care Act increased the emphasis on health promotion and disease prevention by making preventive care accessible for many Americans, especially young adults, who could remain on their parents or legal guardians’ health insurance until the age of 26. Yet, many Americans receive only half of the recommended preventive care services, which highlight the need for the improvement of health promotion and prevention services. The aim of this study was to assess the relationship among access to health care insurance, perceptions about health insurance, and use of preventive care services among young adults. Nine hundred and forty-six participants ages 19–34 completed a 40 question web-based survey. Data analysis suggested that while the majority of participants had health insurance, there were significant differences in opinions about the ACA, health insurance, and use of preventive services by gender, education level, and health insurance status. Overall, participants with health insurance were more likely to have received at least three of the basic preventive care services; however, most of them were not getting the preventive care as recommended. Results reaffirm the need for further studies on the impact of health insurance among young adults and the need for the emphasis on health promotion to educate young adults about the importance of disease prevention and preventive services.     

Community organization to enhance the delivery of preventive health services

Preventive health services are most effective when provided to large groups, but health care professionals often are limited to provision to individuals or small groups. As recent studies show, the effects of preventive services can be enhanced through the use of community organization, which mobilizes a community's energies and resources to define and address a problem in a way that promotes local ownership and generates increasing effects over time. We pragmatically adapt community organization for health care practitioners. There are three guiding principles: (1) the community of interest must be clearly defined; (2) existing community structures should be used to reach and stimulate community members; and (3) the organizer's role is temporary. We discuss four tactics of community organization: (1) use of community analysis to understand the community; (2) stimulation of community activity; (3) provision of concrete assistance to accomplish community change; and (4) reinforcement of structures that will remain to carry on the programs. Use of these community organization tactics will allow delivery of preventive health services in a way that promotes widespread and lasting effects.     

Private Care and Public Health: Do Vaccination and Prenatal Care Rates Differ between Users of Private versus Public Sector Care in India?

Objective. To determine whether patients who use private sector providers for curative services have lower vaccination rates and are less likely to receive prenatal care.
Data Sources/Study Setting. This study uses data from the 52d round of the National Sample Survey, a nationally representative socioeconomic and health survey of 120,942 rural and urban Indian households conducted in 1995–1996.
Study Design. Using logistic regression, we estimate the relationship between receipt of preventive care at any time (vaccinations for children, prenatal care for pregnant women) and use of public or private care for outpatient curative services, controlling for demographics, household socioeconomic status, and state of residence.
Data Collection/Extraction Methods. We analyzed samples of children ages 0 to 4 and pregnant women who used medical care within a 15-day window prior to the survey.
Principal Findings. With the exception of measles vaccination, predicted probabilities of the receipt of vaccinations and prenatal care do not differ based on the type of provider at which children and women sought curative care. Children and pregnant women in households who use private care are almost twice as likely to receive preventive care from private sources, but the majority still obtains preventive care from public providers.
Conclusions. We do not find support for the hypothesis that children and pregnant women who use private care are less likely to receive public health services. Results are consistent with the notion that Indian households are able to successfully navigate the coexisting public and private systems, and obtain services selectively from each. However, because the study employed an observational, cross-sectional study design, findings should be interpreted cautiously.     

Feasibility of a tailored intervention to improve preventive care use in women

BACKGROUND: Women age 50 years and older are in need of multiple preventive health care services. Despite recent improvements in rates of delivery of preventive care services, especially within managed care organizations, substantial numbers of women are still being underscreened. Efforts to improve delivery of preventive care services have often focused on one outstanding service despite the fact that patients often are in need of many services. METHODS: A total of 893 women age 50 to 55 years were mailed a self-administered survey to identify outstanding preventive health care service needs. Patients in need of three or more outstanding preventive health care services were identified from survey respondents to participate in a feasibility study evaluating a tailored, customized intervention called Tic Tac Health. RESULTS: Five-hundred ninety-one women returned the survey (67%). Four-hundred forty-eight (76%) women were in need of one or more preventive health services; 92 (16%) were in need of three or more. Twenty-two patients (24%) completed the Tic Tac Health card. The women who completed the card were similar to those who did not. CONCLUSIONS: Despite documented physician visits, presence of managed care health insurance, and a designated primary care provider, a significant number of women are still in need of multiple preventive health services. An intervention targeting multiple preventive health services was demonstrated to be both feasible and effective. Further evaluation via a randomized controlled trial should be conducted to determine if an intervention like Tic Tac Health would be an effective modality for improving rates of receipt of multiple preventive health care services.     

Caring for children with specialized health care needs in the community: the challenges for primary care

People needing intensive and specialized health care are being cared for now in community settings; this has implications for both primary health care professionals and family carers. This paper draws on research investigating how services can be developed to support families caring for children with complex health care needs, to consider the challenges facing professionals working in the primary health care sector. Interviews conducted with parents, professionals and those who fund and commission specialized health services reveal particular problems in relation to the purchasing and provision of short-term care and specialist equipment/therapies in the community. These problems need to be addressed if people with specialized needs are to be cared for outside hospitals. The new Primary Care Groups (PCGs) will have the opportunity to enhance the provision of these services. Primary care professionals will also need to work in partnership with other sectors of the health service and with local authority services, at both strategic and operational levels, to develop integrated and coordinated services for this growing group of people.