Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor?

Background

Uganda implemented health sector reforms to make services more accessible to the population. An assessment of the likely impact of these reforms is important for informing policy. This paper describes the changes in utilization of health services that occurred among the poor and those in rural areas between 2002/3 and 2005/6 and associated factors.

Methods

Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset based index derived from Principal Components Analysis (PCA). The probability of choice of health care provider was assessed using multinomial logistic regression and multi-level statistical models.

Results

The odds of not seeking care in 2005/6 were 1.79 times higher than in 2002/3 (OR = 1.79; 95% CI 1.65 - 1.94). The rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access (OR = 0.57; 95% CI 0.48 - 0.67). The risk of not seeking care due to high costs did not change significantly. Private for profit providers (PFP) were the major providers of services in 2002/3 and 2005/6. Using PFP as base category, respondents were more likely to have used private not for profit (PNFP) in 2005/6 than in 2002/3 (OR = 2.15; 95% CI 1.58 - 2.92), and also more likely to use public facilities in 2005/6 than 2002/3 (OR = 1.31; 95% CI 1.15 - 1.48). The most poor, females, rural residents, and those from elderly headed households were more likely to use public facilities relative to PFP.

Conclusion

Although overall utilization of public and PNFP services by rural and poor populations had increased, PFP remained the major source of care. The odds of not seeking care due to distance decreased in rural areas but cost continued to be an important barrier to seeking health services for residents from poor, rural, and elderly headed households. Policy makers should consider targeting subsidies to the poor and rural populations. Public private partnerships should be broadened to increase access to health services among the vulnerable.     

Getting the ‘blues’: the existence,diffusion and influence of pornography on young peoples' sexual health in Sierra Leone

While substantial research has examined the effects of pornography on young people in developed societies, existing studies fall short in addressing how sexually-explicit material affects young people in developing countries. The importance of such knowledge increases as the globalising effects of technology expand young peoples' access and exposure to pornography. During the summer of 2012, a study was undertaken in Sierra Leone examining factors affecting young peoples' sexual and reproductive health. The research assessed the influence of HIV knowledge, communication about sex, civil war and contraception myths on sexual behaviours, while remaining open to unanticipated factors. During data collection, respondents identified pornography, also called blues, as an influential factor, detailing its newfound accessibility driven by improved access to information and communication technologies in the country. Respondents also addressed several presumed ways in which pornography impacts young peoples' decisions about sexual health. The following study examines perceived effects of young peoples' exposure to pornography based on existing literature. It then outlines the findings of research conducted in Sierra Leone, drawing on primary data from the respondents and relevant published literature and concludes with proposals for addressing its negative effects.     

Job stress and mental health among nonregular workers in Korea: What dimensions of job stress are associated with mental health?

Although nonregular workers experience higher job stress, poorer mental health, and different job stress dimensions relative to regular workers, little is known about which job stress dimensions are associated with poor mental health among nonregular workers. This study investigated the association between job stress dimensions and mental health among Korean nonregular workers. Data were collected from 333 nonregular workers in Seoul and Gyeonggi Province, and logistic regression analysis was conducted. Results of the study indicated that high job insecurity and lack of rewards had stronger associations with poor mental health than other dimensions of job stress when controlling for sociodemographic and psychosocial variables. It is important for the government and organizations to improve job security and reward systems to reduce job stress among nonregular workers and ultimately alleviate their mental health issues.     

‘If there were doctors who could understand our problems,I would already be better’: dissatisfactory health care and marginalisation in superdiverse neighbourhoods.

How people in community settings describe their experience of disappointing health care, and their responses to such dissatisfaction, sheds light on the role of marginalisation and underlines the need for radically responsive service provision. Making the case for studying unprompted accounts of dissatisfaction with healthcare provision, this is an original analysis of 71 semi-structured interviews with healthcare users in superdiverse neighbourhoods in four European cities. Healthcare users spontaneously express disappointment with services that dismiss their concerns and fail to attend to their priorities. Analysing characteristics of these healthcare users show that no single aspect of marginalisation shapes the expression of disappointment. In response to disappointing health care, users sought out alternative services and to persuade reluctant service providers, and they withdrew from services, in order to access more suitable health care and to achieve personal vindication. Promoting normative quality standards for diverse and diversifying populations that access care from a range of public and private service providers is in tension with prioritising services that are responsive to individual priorities. Without an effort towards radically responsive service provision, the ideal of universal access on the basis of need gives way to normative service provision.     

Emotional exhaustion and mental health problems among employees doing “people work”: the impact of job demands,job resources and family-to-work conflict

Objective  This study investigates the relationship between four job characteristics and family-to-work conflict on emotional exhaustion and mental health problems. Methods  Multiple regression analyses were performed using data from 1,008 mental health care employees. Separate regression analyses were computed for high and low patient interaction jobs. Results  Different job characteristics as well as family-to-work conflict were associated with emotional exhaustion and mental health problems in each job type. The relationship between family-to-work conflict and emotional exhaustion was mitigated by social support from colleagues for those who worked in low patient interaction jobs. Conclusion  In addition to general and specific stressors, it is worthwhile to include home-related stressors that interfere with the work domain in stress research.

Balancing roles and blurring boundaries: Community health workers’ experiences of navigating the crossroads between personal and professional life in rural South Africa

As demand for health services grows, task-shifting to lay health workers has become an attractive solution to address shortages in human resources. Community health workers (CHWs), particularly in low-resource settings, play critical roles in promoting equitable healthcare among underserved populations. However, CHWs often shoulder additional burdens as members of the same communities in which they work. We examined the experiences of a group of CHWs called Mentor Mothers (MMs) working in a maternal and child health programme, navigating the crossroads between personal and professional life in the rural Eastern Cape, South Africa. Semi-structured qualitative interviews (n = 10) were conducted by an experienced isiXhosa research assistant, asking MMs questions about their experiences working in their own communities, and documenting benefits and challenges. Interviews were transcribed and translated into English and thematically coded. Emergent themes include balancing roles (positive, affirming aspects of the role) and blurring boundaries (challenges navigating between professional and personal obligations). While many MMs described empowering clients to seek care and drawing strength from being seen as a respected health worker, others spoke about difficulties in adequately addressing clients’ needs, and additional burdens they adopted in their personal lives related to the role. We discuss the implications of these findings, on an immediate level (equipping CHWs with self-care and boundary-setting skills), and an intermediate level (introducing opportunities for structured debriefings and emphasising supportive supervision). We also argue that, at a conceptual level, CHW programmes should provide avenues for professionalisation and invest more up-front in their workforce selection, training and support.     

Globalisation,rural restructuring and health service delivery in Australia: policy failure and the role of social work?

The impacts of globalisation and rural restructuring on health service delivery in rural Australia have been significant. In the present paper, it is argued that declining health service access represents a failure of policy. Rural communities across the world are in a state of flux, and Australia is no different: rural communities are ageing at faster rates than urban communities and young people are out-migrating in large numbers. During the past 5 years, rural Australia has also experienced a severe and widespread drought that has exacerbated rural poverty, and impacted on the health and well-being of rural Australians. Australian governments have responded to globalising forces by introducing neoliberal policy initiatives favouring market solutions and championing the need for self-reliance among citizens. The result for rural Australia has been a withdrawal of services at a time of increased need. This paper addresses the social work response to these changes.     

“I can’t do this,it’s too much”: building social inclusion in cancer diagnosis and treatment experiences of Aboriginal people,their carers and health workers

Objectives

Social inclusion theory has been used to understand how people at the margins of society engage with service provision. The aim of this paper was to explore the cancer care experiences of Aboriginal people in NSW using a social inclusion lens.

Methods

Qualitative interviews were conducted with 22 Aboriginal people with cancer, 18 carers of Aboriginal people and 16 health care workers.

Results

Participants’ narratives described experiences that could be considered to be situational factors in social inclusion such as difficulties in managing the practical and logistic aspects of accessing cancer care. Three factors were identified as processes of social inclusion that tied these experiences together including socio-economic security, trust (or mistrust arising from historic and current experience of discrimination), and difficulties in knowing the system of cancer treatment.

Conclusions

These three factors may act as barriers to the social inclusion of Aboriginal people in cancer treatment. This challenges the cancer care system to work to acknowledge these forces and create practical and symbolic responses, in partnership with Aboriginal people, communities and health organisations.     

‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala

Background

In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s health issues required more than just hospital-based and physician-centered policies. The declaration called for a paradigm change that would allow governments to provide essential care to their population in a universally acceptable manner. The figure of the community health worker (CHW) remains a central feature of participation within the PHC approach, and being a CHW is still considered to be an important way of participation within the health system.

Methods

This study explores how the values and personal motivation of community health workers influences their experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, we used an ethnographic approach and collected data in January-March of 2009 and 2010 by using participant observation and in-depth interviews.

Results

We found that the CHWs in the municipality had a close working relationship with the mobile health team and with the community, and that their positions allowed them to develop leadership and teamwork skills that may prove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is a key value in Palencia, but there is a lack of infrastructure and growth opportunities.

Conclusion

Attention should be paid to keeping the high levels of commitment and integration within the health team as well as keeping up supervision and economic funds for the program.     

“Of and beyond medical consequences”: Exploring health information scanning and seeking behaviors of Filipino domestic service workers in Hong Kong

The increasing trend for women in developing countries to engage in international and temporary labor migration has exposed female migrant workers to health inequities. In this article, we problematize the impact of international and temporary labor migration on the health of Filipino domestic workers in Hong Kong by exploring their general patterns of health information acquisition. Through a series of focus group discussions with Filipino domestic workers in Hong Kong, we found that employers serve as stakeholders in migration health, social networking sites can be a platform for participatory health promotion, and religious beliefs and behaviors can promote favorable health behaviors.     

Empirically driven definitions of “good,” “moderate,” and “poor” levels of functioning in the treatment of schizophrenia

Purpose

This study used an empirical approach to identify and validate the classification of patients with schizophrenia in “good,” “moderate,” or “poor” functioning groups based on the assessment of functional measures.

Methods

Using data from a study of schizophrenia outpatients, patients were classified into functional groups using cluster analysis based on the Heinrich–Carpenter Quality of Life Scale (QLS), the 36-item Short-Form Health Survey (SF-36) Mental Component Summary Score, and a productivity measure. A three-cluster solution was chosen. Concurrent, convergent, and discriminant validity were assessed. Criteria for classifying patient functioning as “good,” “moderate,” or “poor” were established using classification and regression tree analysis.

Results

The three clusters consistently differentiated patients on the QLS, SF-36 Mental Component Summary Score, and productivity measure. The clusters also differed on other functional measures and were concordant with previous functional classifications. Concurrent, convergent, and discriminant validity were good. “Good” functioning was identified as a QLS total score ≥84.5; “moderate” and “poor” functioning were separated by a cutoff score of 15.5 on the QLS intrapsychic foundation domain. Sensitivity ranged from 86 to 93 % and specificity from 89 to 99 %.

Conclusions

The heterogeneity in functioning of schizophrenia patients can be classified reliably in an empirical manner using specific cutoff scores on commonly used functional measures.     

The health and social well-being of female sex workers’ children in Bangladesh: A qualitative study from Dhaka,Chittagong, and Sylhet

Numerous studies have documented the health problems of sex workers; however, there has been limited research documenting the well-being of children of sex workers. Threats to the health and welfare of these children span their lives. Problems among infants may be more difficult to observe, but field observations by staff at NGOs, who operate drop-in-centers for sex workers in Bangladesh, suggest that older children of sex workers experience significant risks to their health and safety.

This qualitative study explored the threats to the health and welfare of children of sex workers through focus group discussions with sex workers and brothel madams in Bangladesh, all of whom were mothers. Risks to their children were explored from the time of pregnancy through adolescence.

Findings indicate that stigmatization of and discrimination against these children and their mothers are underlying conditions that compromise their access to safe housing, childcare, health care, education, and the protection of law enforcement. The threats they face may exceed those of other children in Bangladesh and include sexual exploitation, exploitive labor, trafficking for adoption, and forced entry into crime. In addition, many children of sex workers have reportedly been traumatized after witnessing police brutality against their mothers. While both sons and daughters of sex workers face similar barriers in altering their life trajectories, gender-specific challenges were also identified.

Additional research documenting trends among children of sex workers and their mothers is needed; however, much can be done immediately to mitigate potential harm by targeting family-based support to these mothers and children to meet basic needs and ensure their basic rights. Our recommendations are to strengthen health, social welfare, and other services to address protection and prevention needs; ensure access to basic services; and provide interventions that address the marginalization resulting from stigma and discrimination.     

‘As prostitutes,we control our bodies’: perceptions of health and body in the lives of establishment-based female sex workers in Tijuana,Mexico

Many studies of female sex work focus on HIV and other sexually transmitted infections because sex workers are considered bridges between high-risk and low-risk populations. The voices of female sex workers as they pertain to health issues are often lacking in the literature. This paper offers a feminist constructivist grounded theory study with establishment-based female sex workers in Tijuana, Mexico. Analyses of interviews with 20 women reveal that they are aware of the impact of their work on their bodies, but conceptualise their health holistically and not just in terms of HIV. They emphasise that working in the sex industry has implications for sexual health, non-sexual physical health and mental health. The paper concludes that in order for public health interventions to have more sustainable impact on the lives of female sex workers, they should take into account the voices of the women, including how they define their health. The findings suggest that public health professionals need to be more aware that female sex workers have agency and a desire to control their health and their bodies.     

Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales,Australia: A step towards explaining high CAM use in rural health?

Objective: Complementary and alternative medicine (CAM) use is high in rural health and an agenda for research in the geography of CAM has been outlined. Unfortunately, no studies to date have mapped the geographic distribution of CAM practitioners in rural areas. For the first time we investigate CAM practitioner distributions across a large district/region in rural Australia. Setting and design: A CAM infrastructure audit of practitioners was performed in rural Divisions of General Practice in New South Wales, Australia. Results: CAM providers form a significant part of the health care system in rural New South Wales with substantial representation across all degrees of rurality and in both under‐serviced and well‐serviced areas. CAM practitioners outnumbered GPs in four NSW Divisions of General Practice and in no Division numbered less than half of the total number of GPs. Conclusions: Given the challenges of access to and recruitment and retention of conventional health care providers in rural settings and the significant presence of CAM practitioners, it is possible to consider such practitioners as an untapped resource in rural health care delivery. Assuming appropriate regulatory and quality standards are in place this resource should attract careful attention as part of future rural health policy and planning. The significant presence and high prevalence of use of CAM practitioners should also serve as an impetus to reform CAM service delivery in Australia.     

Women's experiences with HIV-related stigma from health care providers in Lima,Peru: “I would rather die than go back for care”

In Peru, HIV/AIDS is increasing among heterosexual women. In this qualitative study researchers examined HIV-related stigma among 14 women in Lima, Peru, who were HIV positive and at least 18 years of age. Data were analyzed using thematic analysis and indicated that women experienced stigma from health care providers. Two broad themes emerged from the data: forms of stigma and response to stigma. Within these themes, subthemes included maltreatment during care, neglect of patients' rights to confidentiality and privacy, and the process of women speaking out. Stigma from health care providers had a long-term, negative impact on women's willingness to seek treatment. Future stigma reduction initiatives, on a global level, should include health care workers.     

Relationships of organizational social capital with the presence of “gossip and slander,” “quarrels and conflicts,” sick leave,and poor work ability in nursing homes

Purpose

This study aimed to explore the associations of organizational social capital (OSC) with the presence of “gossip and slander,” the presence of “conflicts and quarrels,” sick leave prevalence, and prevalence of poor work ability in frontline working personnel of nursing homes.

Methods

A total of 239 subjects (81 % participation), working in 11 different nursing homes, took part in a cross-sectional questionnaire study. Following end points were considered, they are as follows: prevalence of “gossip and slander,” “conflicts and quarrels,” sick leave, and poor work ability. Associations with OSC were explored at individual level (binomial log-linear regression analysis) and on group level (Kendall’s tau correlation coefficients).

Results

Significant associations were found between OSC and “gossip and slander,” sick leave, and poor work ability, both in the individual- and group-level analyses. The associations showed a higher significance level in the group-level analyses, with the strongest association found between mean OSC of the workplace and the prevalence of poor work ability at the workplace (τ = ?0.722; p = 0.002).

Conclusions

This study demonstrated significant associations of OSC with three end points that are relevant within the framework of well-being at work in nursing homes. The results are suggestive that OSC should be treated as a characteristic of the entire workplace, rather than as an individually experienced characteristic. The strikingly strong association between OSC and prevalence of poor work ability is suggestive for an important role of OSC within the context of maintaining work ability.     

The effects of probiotics on mental health and hypothalamic–pituitary–adrenal axis: A randomized,double-blind,placebo-controlled trial in petrochemical workers

Objective: The aim of this study was to determine effects of probiotic yogurt and multispecies probiotic capsule supplementation on mental health and hypothalamic–pituitary–adrenal axis in petrochemical workers.

Methods: The present randomized double-blind, placebo-controlled trial was conducted on 70 petrochemical workers. Subjects were randomly divided into three groups to receive 100?g/day probiotic yogurt?+?one placebo capsule (n?=?25) or one probiotic capsule daily?+?100?g/day conventional yogurt (n?=?25) or 100?g/day conventional yogurt?+?one placebo capsule (n?=?20) for 6 weeks. Mental health parameters including general health questionnaire (GHQ) and depression anxiety and stress scale (DASS) scores were measured. Fasting blood samples were obtained at the beginning and 6 weeks after the intervention to quantify hypothalamic–pituitary–adrenal axis.

Results: After 6 weeks of intervention, a significant improvement of GHQ was observed in the probiotic yogurt (18.0?±?1.5 vs. 13.5?±?1.9, P?=?0.007) and in the probiotic capsule group (16.9?±?1.8 vs. 9.8?±?1.9, P?=?0.001), as well as a significant improvement in DASS scores in the probiotic yogurt (23.3?±?3.7 vs. 13.0?±?3.7, P?=?0.02) and the probiotic capsule group (18.9?±?3.2 vs. 9.4?±?4.0, P?=?0.006). However, there was no significant improvement in the conventional yogurt group (P?=?0.05 for GHQ and P?=?0.08 for DASS).

Discussion: The consumption of probiotic yogurt or a multispecies probiotic capsule had beneficial effects on mental health parameters in petrochemical workers.     

Perceptions of postnatal depression and health care needs in a South African sample: the “mental” in maternal health care

Background

Maternal mental health care is a neglected area in low and middle income countries (LAMIC) such as South Africa, where maternal and child health care priorities are focused on reducing maternal and infant mortality and promoting infant physical health. In the context of a paucity of mental health specialists, the aim of this study was to understand the explanatory models of illness held by women with maternal depression with the view to informing the development of an appropriate counselling intervention using a task sharing approach.

Methods

Twenty semi-structured qualitative interviews were conducted with mothers from a poor socio-economic area who were diagnosed with depression at the time of attending a primary health care facility. Follow-up interviews were conducted with 10 participants in their homes.

Results

Dimensions of poverty, particularly food and financial insecurity and insecure accommodation; unwanted pregnancy; and interpersonal conflict, particularly partner rejection, infidelity and general lack of support were reported as the causes of depression. Exacerbating factors included negative thoughts and social isolation. Respondents embraced the notion of task sharing, indicating that counselling provided by general health care providers either individually or in groups could be helpful.

Conclusion

Counselling interventions drawing on techniques from cognitive behavioural therapy and problem solving therapy within a task sharing approach are recommended to build self-efficacy to address their material conditions and relationship problems in poorly resourced primary health care facilities in South Africa.