Use of maternal health services in rural Mexico

Because of the spread of western health care into rural Mexican communities through primary health care programs and medical school graduates performing their year of community service, the proportion of rural Mexican women whose deliveries were attended by physicians increased from 17.7% in 1969 to 45.8% in 1981. The primary objective of this work is to identify factors involved in the utilization of the modern medical system for prenatal care and of hospital delivery in transitional rural areas. A secondary objective is to evaluate the impact of modern prenatal care and hospital delivery on perinatal and neonatal mortality. The data came from a 1981 survey by the Mexican Institute of Social Security of a nationally representative sample of 7953 fertile-aged women in 410 communities with fewer than 2500 inhabitants. The survey provided information on both utilization of health services and on medical and biological conditions that might have prompted women to seek modern medical care. This study was limited to 1579 pregnancies which arrived at term in the 13 months preceding the survey. Among dependent variables, the variable for prenatal care was a 1st prenatal visit in the 1st 5 months of pregnancy. 486 women, about 31% of the sample, had such a visit. 69% of the subsample of 1579 women had had some form of prenatal care, of whom 63% had their 1st consultation in the 1st 5 months. 36% of deliveries occurred in hospitals. There were 64 prenatal or neonatal deaths in the 1579 pregnancies, including 38 deaths in the 1st month and 26 stillbirths. The independent variables included 5 factors measuring health facilities available in the community, 3 assessing the commercial center used by the community, and 2 assessing the respondent's housing. The 2 individual factors were birth order and education. 7 factors concerned symptoms of pregnancy and 4 complications during delivery. The multivariate analysis of these factors was carried out by logistic regression. The availability of different types of health services in the community was not a significant predictor of utilization of prenatal services, but existence of a good road was associated with a 30% increase in probability of using medical services and presence in the community of persons speaking only an indigenous language was associated with a 57% decline in probability. Use of prenatal services and hospital delivery were also associated with maternal educational level and housing characteristics. The results appear to indicate the isolation, poverty, and lack of familiarity with western culture constitute important barriers to use of modern maternal health services. The analysis suggests that the policy of providing medical facilities at the community level has had little effect on the extremely disparate use of prenatal care and hospital delivery in rural Mexico.     

Urban/rural differences in prevalence and risk factors for intestinal helminth infection in southern Malawi

Urbanization may increase the risk of human infection with intestinal helminths. A cross-sectional survey was conducted to investigate the prevalence, intensity and potential risk factors of acquiring such infection, among children aged 3-14 years in similar urban and rural communities in southern Malawi. Stool samples were collected from 553 children (273 urban and 280 rural). The overall prevalence of helminth infection was significantly higher in the urban subjects than in the rural (16.5% v. 3.6%; P < 0.001), mostly because of differences in the prevalence of Ascaris lumbricoides infection. Living in an urban community was associated with a significantly higher risk of infection [odds ratio (OR) = 5.3; 95% confidence interval (CI) = 2.6-12.1], even after controlling for potential confounding factors. In the urban community, risk factors included having pools of water/sewage around houses (OR = 3.0; CI = 1.4-6.5), not wearing shoes (OR = 7.1; CI = 2.7-19.2), not attending school (OR = 2.8; CI = 1.2-6.5), having mothers with 4-8 years of education (OR = 5.2; CI = 2.0-14.0), and having mothers below 35 years of age (OR = 4.09; CI = 1.39-16.28). In this part of Africa, efforts to reduce helminth infections may best be focused on reducing geohelminth burden in urban areas.     

Mental health services and the mortality of nursing home residents

This article examines the impact of mental health services on the mortality rate for mentally ill nursing home residents. Previous research has documented the unmet need for mental health services among nursing home residents. Some research using small data sets has indicated patient benefits from treatment. This article examines the issue using data from the nationally representative National Nursing Home Survey. In a series of multivariate logistic regressions, treatment for mental illness provided by either general practice physicians or by mental health specialists appears to have few impacts on mortality. A statistically significant treatment effect is found only for residents with schizophrenia, other psychoses, or anxiety disorders when treated by mental health specialists. The results are discussed with reference to ongoing reforms for mental health care in nursing homes.     

Ethnic differences in the production of informal home health care

Informal health care providers (usually family members, friends, and other unpaid helpers) determine the quantity and quality of home health services received by the elderly. Yet our knowledge of informal health care production is limited, in sharp contrast to our detailed knowledge of market-produced home health services. This paper assesses family choices in the production of informal home care, with special attention given to the influence of ethnicity on family caregiving style.     

Mental health services of the rural elderly outreach program

This paper describes an elderly outreach program (EOP) designed to identify and provide mental health services to the rural elderly. The project integrates a variety of health, mental health, and human service agencies in the planning and delivery of services. Five referral sources are identified and described as well as the assessment, treatment, and referral process. Outcomes are discussed in terms of: characteristics of persons served, ability of the project to identify and deliver mental health services, treatment effectiveness, and cost effectiveness of the project. The EOP seems to have prevented an increase in need for mental health care among Iowans that might have occurred in the program's absence.     

Chronic and acute disease problems in rural nursing home patients.

The patients of a rural nursing home in Iowa were surveyed according to age and sex, plus chronic and acute disease problems. With the use of the International Classification of Health Problems in Primary Care, the diagnoses were organized by major disease category and by specific diagnosis. Of the 66 patients, 76 percent were age 75 or older. Women comprised 61 percent of the group, and men 39 percent. Overall, the mean age was 79.1 years. Senility was the most common diagnosis for chronic diseases, and genitourinary infections for acute diseases. Circulatory system disorders comprised the largest category of chronic diseases, whereas genitourinary comprised the largest category of acute diseases. Overall, there were 4.2 chronic disorders per patient. Although the data compare favorably with those in the National Health Survey of nursing homes, more research is needed to prepare medical personnel for the problems associated with a rapidly expanding population of elderly patients.     

Depression prevalence and treatment among older home health services users in the United States

ObjectiveThe purpose of this study is to provide a nationally representative estimate of the rates of depression and depression treatment, and to explore factors associated with receipt of depression treatment, among older home health services users.MethodsOlder home health services users (n = 1666) were selected from 2008 to 2013 Medical Expenditure Panel Survey. Depression was measured by the Patient Health Questionnaire-2. Depression treatment included antidepressants use and receipt of mental health counseling or psychotherapy. Logistic regression was used to examine the association of individual characteristics and receipt of depression treatment.ResultsCurrent depression affected 23% of older home health services users. Less than 40% of those who screened positive for depression reported receiving depression treatment. Among those who received treatment, virtually all (99.8%) reported receiving antidepressants and only 9.5% reported receiving psychotherapy. Among older home health services users with current depression, older age and non-Hispanic black race were associated with lower odds of receiving depression treatment whereas having cognitive impairment was positively associated with receiving depression treatment.ConclusionDepression affects a substantial proportion of older home health services users and is undertreated. Home health services settings may be important platforms to improve depression care among older adults. Future research is needed to develop optimal strategies for integrating depression assessment and treatment in home health services settings.     

Cognitive impairment, caregiver burden, and the utilization of home health services

This study addresses the relationship between caregiver burden and the use of home health services among older adults with cognitive impairment. Analyses draw on data from personal interviews conducted with 327 older adults with cognitive impairment and living in the community of their primary caregivers. Using the Andersen-Newman framework, the results of ordinary least squares and logistic regression analyses reveal that caregiver burden and formal home health service use are only weakly related. Possible explanations for the findings are discussed.     

Decomposing differences in utilization of health services between depressed and non-depressed elders in Europe

Utilization rates of non-psychiatric health services are often higher in depressed compared to non-depressed adults. We examine whether these differences can be explained by the increased prevalence or the increased impact of demographic, socioeconomic, geographic, and health-related factors. The sample was taken from The Survey of Health, Ageing and Retirement in Europe (Wave 1 Release 2), a prospective observational study of 31,115 randomly selected people ages 50+ living in Austria, Germany, Sweden, the Netherlands, Spain, Italy, France, Denmark, Greece, Switzerland, Belgium, and Israel. Blinder–Oaxaca decomposition methods for multivariate linear regression models were used to estimate the influence of prevalence and impact of covariates on utilization among depressed and non-depressed participants. We find robust evidence that the gap in utilization between depressed and non-depressed can be accounted for by both prevalence (explained) and impact (unexplained) differences. The prevalence effect accounted for 57.7% whereas differences in the impact of covariates between depressed and non-depressed persons explained 42.3% of differences in utilization rates. Despite cross-national differences in quality and coverage of health services, in all countries, the prevalence effect was explained entirely by health measures, including: chronic diseases, functional mobility, painful symptoms, and self-reported health. The impact effect varied cross-nationally, but was largely explained by socioeconomic status and urbanicity. Hospitalization among depressed adults was twice that of non-depressed adults. Policies aimed at improving adherence and improving disease management among depressed adults should be explored.     

Patterns and determinants of health services use and mortality after VA nursing home care

Risk factors for institutionalization and death for up to four years for a nationwide cohort (n = 6,488) of males discharged alive from Department of Veterans Affairs (DVA) nursing homes were identified through linked records of the DVA. Two-year cumulative probabilities of nursing home readmission, hospitalization, and death among nursing home dischargees were 0.30, 0.61, and 0.24, respectively. Using multivariate survival analyses, chronic functional impairments and past nursing home use were important predictors of nursing home readmission, whereas hospitalizations for exacerbations of chronic medical conditions were predictors of hospitalization and death. Past hospitalizations predicted all three outcomes. Differences in risk factors for nursing home readmission as compared with hospitalization or death among DVA nursing home dischargees suggest that high-risk patients can be identified at nursing home discharge and that different types of interventions will be necessary to decrease nursing home readmission as compared with hospitalization or death. Future development of linked record systems across multiple settings, both within and outside the DVA, will help to further characterize persons at high risk of institutionalization or death and to design and evaluate targeted interventions to decrease this risk.     

Mental health services for the rural elderly: the SAGE experience

The mental health services of the Senior Adult Growth and Enrichment (SAGE) Program, a demonstration project in North Carolina, are described. The SAGE staff used a differentiated model of day treatment that tracked clients according to disabilities and potentials. Staff provided outreach in a rural area to older people with mental illness and to their caregivers. The rationale and specialized methods of the project are described. Services were tailored to meet unique needs brought on by diverse mental disorders, functional disabilities, and varying life circumstances.     

Comparison of health services use by Chinese urban and rural older adults in Yunnan province

Background:   This article examines and compares the pattern of determinants of health services use between Chinese older adults residing in urban and rural areas of Yunnan province, China.
Methods:   Data from the Sample Survey on Aged Population in Urban/Rural China (SSAPUR) are used to compare the patterns of determinants for both physician visit and hospitalization between the urban and rural respondents. Andersen's health service utilization model was adopted as a conceptual framework.
Results:   Findings revealed that different patterns of determinants in physician visits and hospitalization existed among the two groups, implying that different barriers in health access are faced. The financial barrier was a prominent factor faced by urban elders in access to both physician visits and hospitalization, while rural elders encountered physical barriers in addition to financial difficulty when accessing health care.
Conclusion:   Study of the elderly population in Yunnan province helps to contrast the differences in health service use between urban and rural elders, which would shed light on possible focus in health policy-making and resource allocation to tackle the different health access barriers.     

Black/White differences in pressure ulcer incidence in nursing home residents

OBJECTIVES: To compare black and white nursing home residents with respect to the incidence of nursing home (NH)-acquired pressure ulcers (PUs) and to examine the role of resident characteristics and facility characteristics in explaining differences between the racial groups. DESIGN: Prospective cohort study conducted between 1992 and 1995. SETTING: Fifty-nine Maryland NHs. PARTICIPANTS: A total of 1,938 residents (301 black, 1,637 white) aged 65 and older newly admitted to participating NHs. MEASUREMENTS: The outcome variable was the first occurrence of a Stage 2, 3, or 4 PU as determined based on medical record review. The predictor variable was race (black, white). Eight resident characteristics (age, sex, number of activity of daily living dependencies, bedfast, PU on admission to facility, incontinence, dementia, and whether the resident was on Medicaid) and three facility characteristics (number of beds, for-profit ownership status, and urban/nonurban location) were considered as possible confounding variables. RESULTS: The incidence of PUs was 0.38 per person-year in the NH. The rate for blacks was significantly higher than for whites (0.56 vs 0.35 per person-year) (P<.001). In multivariate analysis, controlling for eight resident characteristics and three facility characteristics, race was significantly associated with PU incidence (hazard ratio comparing blacks with whites=1.31, 95% confidence interval=1.02-1.66). CONCLUSION: Blacks have a higher incidence of NH-acquired PUs than whites; resident characteristics appear to mediate the higher risk. Future research should aim to identify modifiable factors that explain differences between racial groups in PU risk and to develop solutions to prevent the suffering and cost associated with PUs.