Health care providers' attitudes toward nutrition

A survey questionnaire, assessing general attitudes toward the importance of nutrition in the prevention of disease and the maintenance of good health, was administered to physicians, nurses, dentists, and technicians at five U.S. Army medical centers. The various groups of health care specialists differed significantly on many items concerning the importance of good nutrition and eating habits for maintenance of good health and for recovery from illness, as well as on items concerning the importance of nutrition knowledge and training in their health care professions. More agreement was found among the groups on items concerned with the relationship between disease states and dietary factors and the effectiveness of health education programs in the prevention of various diseases. Self-reports of personal health habits did not correlate with scores on survey items concerned with the importance of good nutrition, suggesting that personal attitudes toward nutrition may be unrelated to other health practices.     

Antenatal care services in rural Uganda: missed opportunities for good-quality care

Experience from countries that have achieved low maternal mortality suggests that access to good-quality maternity services is critical to improve maternal health. In this article we appraise the quality of antenatal care (ANC) services in a rural district of Uganda. We used a mixed methods approach, relying on a combination of semistructured interviews with both clients and providers, structured observations of provider-patient interactions, and infrastructure assessment of selected health facilities. We found several bottlenecks in health service delivery, including ineffective organization of educational sessions; selective omission of certain services; lack of explanation of important clinical and laboratory procedures; failure to link the performed procedures with preventive information; and occasional lack of respect for clients. The policy implications of these findings are discussed in relation to the need to (a) ensure an adequate supply of medical equipment and drugs, (b) enhance health workers' compliance with ANC guidelines, and (c) combine medical procedures with educational messages.     

Health care providers' perceptions of spirituality while caring for veterans

To determine health care providers' views on spirituality, its role in the health of patients, and barriers to discussing spiritual issues with patients, the author convened five focus groups at two Veterans Administration Medical Centers. Participants were nurses, physicians, social workers, psychologists, and chaplains. Common themes included (a) the lack of education for professionals regarding how to address patients' spiritual needs; and (b) systems-related issues, including communication systems that do not function well, how spiritual needs are addressed on admission, support or lack thereof by hospital administrators, and lack of support for the spiritual needs of staff. The aging and illnesses of many current veterans plus the escalated potential of war highlight the importance of addressing veterans' spiritual needs.     

Preventing rubella: assessing missed opportunities for immunization.

Cases of rubella continue to occur among adults in the United States because 10-20 per cent of persons in this age group remain susceptible. To evaluate the potential preventability of these cases, we present a method for assessing missed opportunities for rubella immunization, based on immunization recommendations of the Immunization Practices Advisory Committee (ACIP) of the US Public Health Service (PHS). Immunization programs faced with limited resources can use analysis of missed opportunities to focus on those gaps in implementation contributing most to the remaining rubella cases.     

Health care providers' perspectives on the provision of prenatal care to immigrants

In addition to facing barriers to health care and experiencing poor health status, immigrants to Canada and Sweden tend to have more negative birth outcomes than the native-born population, including low birth weight and perinatal mortality rates. Explored through interviews with health care professionals, including midwives, nurse practitioners, social workers and obstetrician gynaecologists, this paper evaluates their experiences in providing prenatal care to immigrants in Hamilton, Ontario, Canada. Results reveal the complexity of delivering care to immigrants, particularly with respect to expectations surrounding language, culture and type and professionalism of care. The paper concludes by discussing future research options and implications for the delivery of prenatal care to this population.     

Sociomedical correlates of missed opportunities for immunisation

Missed opportunity for immunisation is one of the hurdles in the achievement of 85 percent or more immunisation coverage. It is essential to screen every child for immunisation status and advise necessary immunisation at every opportunity otherwise full immunisation coverage may not be possible. Present survey was carried out at Indira Gandhi Medical College and Hospital, Nagpur to study the sociomedical correlates of missed opportunities for immunisation in children below 2 years of age attending the hospital. Missed opportunities for immunisation in these children was found to be 39.9%. It is mostly for B. C. G. (21.8%) and measles (9.8%) and maximum for booster doses of DPT and polio (43%).     

Medicaid managed care and STDs: missed opportunities to control the epidemic

We examined the extent to which selected Medicaid managed care organizations (MCOs) promoted certain prevention and control services for sexually transmitted diseases (STDs) and the potential influence of health plans and medical groups on the delivery of STD care by primary care providers (PCPs) in seven large U.S. cities. Low-cost clinical services were routinely performed by PCPs, but higher-cost services were less often provided. Lack of organizational priority to promote STD prevention and control is a major barrier even for those MCOs that serve this high-risk, low-income population. Stronger incentives and legally binding provisions in Medicaid contracts are needed to promote adherence to standards of STD care.     

Health care providers' attention to food insecurity in households with children

Objective

To determine the extent to which physicians and nurse practitioners monitor household food insecurity (FI) of families with children, and to examine factors that influence FI monitoring.

Method

A 2007 mail survey of family practice and pediatric physicians and nurse practitioners in the Portland, Oregon, region yielded 186 responses. Factor analysis was used to identify barriers to asking about FI. Regression analysis was used to determine whether monitoring of household food status was predicted by those barriers, attentiveness to potential FI indicators, and other variables.

Results

Most respondents did not routinely inquire about household FI during clinic visits. However, 88.8% expressed willingness to use a standardized screening question, if available. Monitoring of household food nutritional quality was significantly predicted by one of three identified barriers (providers' time availability). Monitoring of household food sufficiency was predicted by years in practice, attentiveness to FI indicators, and the remaining two identified barriers (inadequate knowledge about FI, discomfort in discussing FI).

Conclusion

Routine monitoring of patients' household FI by health care providers is an underutilized strategy for reducing this condition, which poses serious risks to children's health and development. Addressing providers' concerns and introducing standardized screening procedures can increase their monitoring behaviors.     

Prevention of tuberculosis in children: missed opportunities.

We conducted an eight-year prospective investigation in Tennessee of all cases of tuberculosis (TB) reported statewide in children younger than 15 years of age. Of the 109 verified childhood cases reported from 1981 to 1988, at least 23 (21%) were preventable. Eleven children developed the disease while they were under surveillance but were not receiving preventive therapy, nine cases resulted from failure of health care providers to conduct timely contact interviews/investigations, and three were due to other reasons. Improved surveillance, increased use of preventive therapy, and ensured compliance will contribute significantly to the elimination of tuberculosis in children at high risk of developing the disease.     

Health service providers' perceptions of barriers to tuberculosis care in Russia

The Russian Federation has witnessed a marked rise in rates of tuberculosis (TB) over the past decade. Public health TB control institutions remain broadly modelled along pre-1990 lines despite substantial programmes of investment and advocacy in implementing the World Health Organization's 'Directly Observed Treatment--short course' (DOTS) strategy. In 2002, we undertook a qualitative study to explore health care providers' perceptions of existing barriers to access to TB services in Samara Oblast in Russia. Six focus group discussions were conducted with physicians and nurses from facilities in urban and rural areas. Data were analyzed using a framework approach for applied policy research. Barriers to access to care were identified in interconnected areas: barriers associated with the health care system, care process barriers, barriers related to wider contextual issues, and barriers associated with patients' personal characteristics and behaviour. In the health care system, insufficient funding was identified as an underlying problem resulting in a decrease in screening coverage, low salaries, staff shortages, irregularities in drug supplies and outdated infrastructure. Suboptimal collaboration with general health services and social services limits opportunities for care and social support to patients. Worsening socioeconomic conditions were seen both as a cause of TB and a major obstacle to access to care. Behavioural characteristics were identified as an important barrier to effective care and treatment, and health staff favoured compulsory treatment for 'noncompliant' patients and involvement of the police in defaulter tracing. TB was profoundly associated with stigma and this resulted in delays in accessing care and barriers to ensuring treatment success.     

Studies of missed opportunities for immunization in developing and industrialized countries.

Missed opportunities for immunization are an obstacle to raising immunization coverage among children and women of childbearing age. To determine their global magnitude and reasons, studies reported up to July 1991 were reviewed. A standard measure for the prevalence of missed opportunities was calculated for each study. Seventy-nine studies were identified from 45 countries; 18 were population-based, 52 were health-service-based, and 9 were intervention trials. A median of 32% (range, 0-99%) of the children and women of childbearing age who were surveyed had missed opportunities during visits to the health services for immunization or other reasons. Missed opportunities were mainly due to failure to administer simultaneously all vaccines for which a child was eligible; false contraindications; health workers'' practices, including not opening a multidose vaccine vial for a small number of persons to avoid vaccine wastage; and logistical problems. To eliminate missed opportunities for immunization, programmes should emphasize routine supervision and periodic in-service training of health workers which would ensure simultaneous immunizations, reinforce information about true contraindications, and improve health workers'' practices.     

Health care follow-up after stroke: opportunities for secondary prevention

BACKGROUND: Stroke patients have a 15-fold increased risk of a recurrence, but management of risk factors following stroke has been found to be unsatisfactory. Little is known about health service follow-up of patients after stroke or, consequently, the opportunities for providing secondary prevention to patients. OBJECTIVE: The aim of the present study was to investigate the relationship between health service follow-up and management of risk factors after stroke. METHODS: The study used data from the population-based South London Stroke Register, collected prospectively between 1995 and 1998. Main measures included risk factor change and follow-up by hospital physicians, GPs and district nurses. Logistic regression was used to determine relationships between these measures. RESULTS: Seven hundred and seventeen stroke survivors were registered with first stroke between 1995 and 1998. Most patients were followed-up on at least one occasion by at least one service within the first 3 months after stroke: 51% saw a hospital specialist; 72% saw a GP; and 14% saw a community nurse. However, 14% of patients did not see a doctor at all. Disabled patients were less likely to see a doctor, only 17% of severely disabled patients seeing a hospital specialist [odds ratio (OR) 0.17; 95% confidence interval (CI) 0.07-0.41]. Doctor-led follow-up was related to treatment of physiological risk factors (e.g. 73% of hypertensive patients who had seen a GP were treated compared with 59% who had seen only a hospital specialist and 47% who had seen neither). Contact with health services was not associated with behavioural risk factor change. CONCLUSIONS: Opportunities for delivering secondary prevention existed through a range of services, but problems of continuity and effectiveness of care are evident. Further investigation is needed to determine how best to intervene to address these issues. In other words, whether interventions should concentrate on improving access and availability of current services, or whether the focus should be on making current strategies more effective.     

A systematic review of strategies for reducing missed opportunities for vaccination

BackgroundMissed opportunities for vaccination (MOVs) occur when persons eligible for vaccination visit a health facility and do not get the vaccines they need. We conducted a systematic review to assess effects of interventions for reducing MOVs.MethodsWe searched PubMed, Scopus, and the Cochrane Central Register of Controlled Trials in April 2017. Three authors independently screened search outputs, reviewed potentially eligible papers, assessed risk of bias, and extracted data; resolving disagreements by consensus. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI) and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.ResultsSix studies (five trials and one cohort study) met our inclusion criteria, all conducted in the United States of America. All six studies had various limitations and were classified as having a high risk of bias. We found moderate certainty evidence that the following interventions probably improve vaccination coverage: patient education (RR 1.92, 95% CI 1.38–2.68), patient tracking using community health workers (RR 1.18, 95% CI 1.11–1.25), and patient tracking and provider prompts (RR 1.24, 95% CI 1.18–1.31). In addition, we found low certainty evidence that concurrent interventions targeting health-facility (education, prompts, and audit and feedback) and family settings (phone calls) may increase vaccination coverage (RR 1.25, 95% CI 1.08–1.46).ConclusionsThe currently available evidence suggests that patient education, patient tracking, outreach sessions, and provider prompts reduce missed opportunities for vaccination and improve vaccination coverage. Rigorous studies are required to confirm these findings and increase the certainty of the current evidence base. WHO is currently coordinating efforts to generate such evidence, especially from low-income and middle-income countries, and it is likely that the data will be available in the next few years.     

Effectiveness of pediatric practice consultation on missed opportunities for immunization

Objective To evaluate the effectiveness of pediatric practice consultation in reducing missed-opportunity rates at eight pediatric sites in Baltimore, Maryland. The overarching goal was to decrease the occurrence of missed opportunities from 33% to 15% for the first, second, and third diphtheria and tetanus toxoids and pertussis vaccines during visits at which children were eligible for the vaccines. Design The effect of an in-office educational program alone at four sites is compared with the educational program and a consultation on office vaccination practices at four matched sites. All eight sites received a small grant ($2,000) to fund practice changes. The medical records of children making visits before and after the interventions were audited to determine missed-opportunity rates. The policies and operations and the knowledge, attitudes, and practices of physicians and nurse practitioners at each site were also assessed. Results The four education-consultation sites experienced a statistically significant 14% net reduction in the missed-opportunity rate relative to the education-only sites. This positive effect, however, was largely due to an increase in missed opportunities at one education-only site. There was a 10% increase in the missed-opportunity rate among the education-only sites and a 4% decrease among the education-consultation sites; neither change was statistically significant. Two of the three sites that reduced missed opportunities were matched health maintenance organizations (HMOs). Shortly after the interventions, both HMOs implemented tracking and follow-up information systems, which were planned before the interventions. Conclusions There is no evidence that either the educational program alone or the educational program and consultation combination reduced missed opportunities. The findings suggest that improved tracking and follow-up data systems and vaccination of children at sick visits may reduce missed opportunities. This study was funded by the Centers for Disease Control and Prevention, contract number 200-90-0850.     

Adults with invasive pneumococcal disease: missed opportunities for vaccination

BACKGROUND: The pneumococcal polysaccharide vaccine (PPV) can prevent invasive pneumococcal disease (IPD) in the elderly and those with certain underlying illnesses. However, vaccine uptake remains suboptimal. Identification of missed opportunities for vaccination could guide new strategies for improving uptake. Missed opportunities for vaccination were defined as one or more visits to a hospital, emergency room (ER), or main provider in the 2 years before infection among unvaccinated, adult IPD case-patients with a vaccine indication. METHODS: Adults aged 18 years or older with IPD were identified in six Active Bacterial Core surveillance/Emerging Infections Program Network sites during a 1-year period in 2001 to 2003. Using chart review, patient/proxy interview, a main provider questionnaire, and vaccine questionnaires from additional providers, data were collected on demographics, vaccine indications, vaccine status, and recent healthcare encounters. RESULTS: A total of 1878 cases were enrolled, and 83% had a vaccine indication. Of the 1177 cases with a vaccine indication and sufficient information on recent healthcare encounters, 617 (52%) were unvaccinated. Of these, 566 (92%) had one or more opportunities for vaccination, 54% were hospitalized, 58% had ER visits, and 76% visited their main provider in the 2 years before illness. The number of visits to main providers (median = 6) was higher than hospitalizations (median = 1), and ER visits (median = 1). CONCLUSIONS: One or more missed opportunities for vaccination were documented in nearly all unvaccinated IPD case-patients with a vaccine indication. Most visited their main provider multiple times. Implementation of systematic PPV programs in outpatient settings will likely increase pneumococcal vaccine uptake among high-risk adults.     

Health care in America: lost opportunities amid plenty

Despite frequent breakthroughs in medicine, and in the face of an expenditure on health that is almost twice that of any other country in the world, there are significant problems with health care in the United States. Fundamental failings reflect the underuse, overuse, and misuse of resources, which result in inadequate care for important medical conditions. An apparent blind faith in the benefits of science and technology may help account for these startling inadequacies, as lavish funding of the biomedical research effort diverts attention from the fundamental matter of delivering care for common diseases. With a shift in research priorities, the United States could shape a health care system that is far more responsive to the needs of its people.