Literacy in primary care populations: is it a problem?

BACKGROUND: Almost half of Canadians experience difficulty using print media, according to the 1994 International Adult Literacy Survey. Our objectives were to estimate the prevalence of low-literacy patients in our practice, to determine whether reading grade level is associated with self-perceived health status in primary care, and to evaluate the reading difficulty of commonly used patient education pamphlets. METHODS: We surveyed a random sample of 229 patients aged 18 to 85 years presenting for scheduled and walk-in care. Main outcome measures were reading ability as estimated by word decoding skill with the validated Rapid Estimate of Adult Literacy in Medicine (REALM) and self-perceived health status using COOP/WONCA functional health measures. We assessed the reading difficulty of 120 commonly used patient education pamphlets using the Simple Measure of Gobbledygook (SMOG) formula. RESULTS: The prevalence of low-literate patients was 9%. Poor reading ability in English was most likely among patients under 45 years of age not having completed high school, and among those whose maternal language was neither English nor French (immigrants). REALM scores and self-perceived health were weakly correlated but not significant statistically. The mean reading grade level of pamphlets was grade 11.5 (SD: 1.5). Seventy-eight percent of pamphlets required at least a high school reading level. CONCLUSION: Literacy levels were higher than expected in our patient population; this finding may be due to the rapid assessment tool used, which may have underestimated the difficulty of using print media. Clearly, the vast majority of commonly used patient education materials would not meet the needs of low-literate patients, who may be more likely to experience poorer health. Providers need to be sensitive to the reading limitations of patients and patient education materials should be written at a lower reading level.     

Therapeutic vaccines: a solution to the prevention problem?

Therapeutic vaccines are likely to provide a significant and growing contribution to tackling some of the manifold health problems that face us in the future. However, despite these real benefits, I suggest the need for caution in relation to one possible ethical argument that could be used to support the introduction of therapeutic vaccination over preventive vaccination for contagious diseases where both types of vaccination exist. I argue that therapeutic vaccination will not solve what I call the 'prevention problem': that is, a perceived injustice in the distribution of benefits and harms arising from population-based preventive vaccination policies.     

Waning of vaccine-induced immunity: is it a problem in Africa?

Strebel et al. misinterpreted the authors' paper on the role of schools in measles transmission. As Strebel et al. noted, the main reason for the outbreak was low vaccine coverage among children aged 5-14 years, together with a marked reduction in the incidence of measles over the past 10 years. Because of the high measles vaccine coverage in younger age groups, many children in Niakhar have gone through their first 5 years of life without being infected with the measles virus. The waning of vaccine-induced immunity has played a role. Strebel et al. believe that there is no indication of waning immunity in the authors' paper and that there is a downward bias in vaccine efficacy due to faulty methodology. Their argument, however, misses the point. The children's ages at vaccination with standard vaccine were completely different in those age groups, with the median age being 295 days for those under age 5 years and 1017 days for those aged 10-14 years. Whether waning immunity will translate into declining vaccine efficacy with age depends upon whether misclassification of vaccination status and measles history is the same in all age groups. Other observations support the existence of waning immunity. The phenomenon of waning vaccine-induced immunity needs to be examined for measles and other vaccine-preventable diseases.     

Tetanus in the geriatric population: is it a collective health problem?

Tetanus is an infectious non-contagious disease caused by the bacillus Clostridium tetani, which penetrates in the organism through wounds. Psychomotor dysfunction facilitates accidents among elderly people and vaccinal coverage is low in this population, thus contributing to high lethality. This study aimed at reflecting on the situation faced by elderly people in relation to tetanus in the perspective of Collective Health. It is a Case Study conducted with two elderly males who had accidental tetanus and were hospitalized in a hospital in the municipality of Fortaleza. Data collection took place from March to April, 1998. The analysis showed the absence of vaccinal coverage as well as of the implementation of emergency prophylaxis. The two patients' conditions developed to death, which confirmed the high mortality due to tetanus in this age group. The critical reflection pointed out the urgency of a collective health approach.     

Hepatitis B and C infection: Is it a problem in Polish healthcare workers?

Objectives

Hepatitis B (HBV) and C viruses (HCV) are among the most frequent blood borne pathogens. According to WHO, 5% of healthcare workers (in central Europe), are exposed to at least one sharps injury contaminated with HBV per year, 1,7% — contaminated with HCV.

Aims

The aims of the study were to determine prevalence of HCV and HBV infections, vaccination efficacy against hepatitis B and usefulness of alanine aminotransferase (ALT) testing in prophylactic examinations in healthcare workers (HCWs).

Material and Methods

In a group of 520 healthcare workers, a survey, laboratory and serologic tests such as ALT, HBsAg, anti-HBs, anti-HBcT and anti-HCV were carried out.

Results

The study revealed a low rate of workers with presence of HBsAg and anti-HCV (1,2% and 0,8% respectively). Anti-HBcT was found in 99 subjects (19%) without a significant association with experiencing an occupational percutaneous injury. Being vaccinated against HBV was declared by 90% of the subjects. There was no relationship between ALT level rise and positive HBsAg, anti-HCV and anti-HBcT tests.

Conclusion

A seroprevalence of HBV and HCV markers in HCWs found in the study is low and similar to the one found in general population. Current or past hepatitis B infections were independent of needle stick injuries. Vaccination against HBV coverage, although found to be high, should improve to 100%. Occupational prophylactic medical examinations found performing ALT test (obligatory in Poland for HCWs) not helpful. It seems that determination of anti-HBcT and anti-HCV status would be essential in pre-employment medical examinations.     

Strategic market planning in hospitals: is it done? Does it work?

A nationwide survey of strategic market planning within hospitals was conducted. The level of strategic market planning activity performed by hospitals is reported. Level of planning maturity also is determined. Levels of activity and maturity are related to satisfaction with strategic market planning. Results and implications are presented.     

Iron overload in Sub-Saharan Africa: to what extent is it a public health problem?

Excessive deposition of Fe in the organs and tissues of Sub-Saharan Africans was first described in South Africa in 1929. Fe overload, or siderosis, was initially attributed to infections and to metallic poisoning (Cu, Sn, Zn), and then to malnutrition. In 1953 it was hypothesized that it was due primarily to excessive Fe intake derived from foods and drinks prepared in Fe vessels. Recently, in 1992 it was advanced that a gene distinct from any HLA-linked locus may also play a role. As to sequelae, in early research on series of hospital patients, the condition was linked to scurvy, osteoporosis, diabetes, cirrhosis, and latterly, to hepatocellular cancer and tuberculosis. Accordingly, many have concluded that Fe overload is responsible for considerable morbidity and mortality, that adventitious Fe intake should be reduced, and that phlebotomy be recommended for those severely affected. However, there are numerous limitations in the evidence. There are also problems in interpretation, since levels of Fe in the serum are affected additionally by a variety of factors: infection, inflammation, certain cancers and alcohol intake. These considerations complicate attempts to assess to what extent the associations described denote causation, and whether Fe overload has significant ramifications for ill in the general African population. While the adverse sequelae of overload may be less of significance than many believe, the precise pathogenicity of the phenomenon will remain uncertain until further investigations, including prospective studies, are undertaken.     

Teenage pregnancy: whose problem is it?

BACKGROUND: The UK has the highest rates of teenage conception in Europe. Teenage conception has been identified in medical literature as a problem for society and teenagers. However, little attempt has been made to see it from the perspective of the teenagers themselves. OBJECTIVE: To explore teenage women's attitudes to sexual health, contraception and pregnancy. METHODS: Ethnographic qualitative study based on in-depth interviews and participant observation. The study took place in young mothers' groups, young persons' clinics and general practices in Bristol. Subjects were 34 young women between the ages of 16 and 20, sampled purposefully in two groups to include young mothers and never-pregnant young women from advantaged and disadvantaged socioeconomic backgrounds. RESULTS: The two groups did not differ in their use of contraception at first intercourse. Young women from more socioeconomically advantaged backgrounds felt that motherhood would not be acceptable to them, but were more tolerant to others who became young mothers. The pregnant/ young mothers revealed more difficulties getting access to reliable contraceptive services, and dissatisfaction with sex education in schools. The pregnant/young mothers found abortion to be less acceptable than the more socially advantaged group. Both groups reported sexual behaviour that involved risks of becoming pregnant, but the more socially advantaged group were more likely to use emergency contraception. CONCLUSIONS: The study demonstrates the importance of taking the views of young people into account when planning both sex education and the provision of contraceptive services.     

Long-term contracts in the NHS: a solution in search of a problem?

Purchasers and providers in the National Health Service (NHS) are now required to move from annual contracting cycles to longer-term contracts. The benefits are expected to include more efficient investment and improved sharing of financial risk. This paper argues that the economic analysis of longer-term contracts has assumed implicitly that agents operate in the private sector. Once the constraints of the public sector are introduced, the apparent economic benefits of longer-term contracts become doubtful. The paper explores these issues using evidence collected from analysis of the contracts of a sample of Health Authorities and from semi-structured interviews with individuals involved in the contracting process. We conclude that with the property rights and financial structure of the public sector, the move from short- to long-term contracts is unlikely to produce the improvements in performance expected by the government.     

The first attempt to create a national strategy for reducing waiting times in Poland: Will it succeed?

The waiting lists package, proposed in March 2014, is the first attempt to create a national strategy to reduce waiting times for specialist care in Poland. The policy proposes a number of measures directed at primary, specialist ambulatory and hospital care with the goal of shifting patients to the lowest possible level of care. Initially, it has been welcomed by the patients and there has been, so far, no strong opposition against the reform from other stakeholders. However, this may be because there is some disbelief that the policy would actually be implemented (due to limited funding available for its implementation) and because some of the proposed changes are vague and have yet to be clarified. One stakeholder group that may obstruct the implementation of the reform, if they are not satisfied with the final shape of the proposed measures, is the primary care doctors. They are directly affected by the reform and enjoy a relatively strong bargaining position compared to other groups of medical professionals. Thus, the future of the reform remains uncertain.