Women and AIDS in Africa: demographic implications for health promotion

The population pyramid in most African countries is symmetricalwith a broad base. However, in urban areas, one finds a prominentone-sided bulge caused by the migration of young males (aged18–35) into the cities for employment. The prevalenceof HIV infection in urban populations in Africa is highest inthe 25–35 year old age-group in males and in the 15–25year old age-group in females. This difference is due to thefact that on average, sexual partnerships are formed betweenolder men and younger women. The distortion of the urban populationprofile caused by male migration results in an overall 1:1 female:maleprevalence ratio of infection. However, as the epidemic spreadsinto the larger rural population, the absolute size of the mostseverely affected younger female population is larger than thesize of the older male population, which eventually resultsin a higher number of infections in women. This excess of female morbidity from HIV infection has importantimplications for the social and the economic role of women insociety. It also adds fuel to an emerging epidemic of paediatricAIDS. Health promotion strategies to address this issue shouldinclude: (1) public policies designed to narrow the male:femaleage-gap of sexual partnership formation; (2) policies addressingthe economic migration patterns of the male work force and;(3) policies to narrow the base of the general population pyramid.     

Large-scale study of freedom from smoking clinics--factors in quitting.

The American Lung Association's Freedom From Smoking Clinics are widely available in the community and at the worksite for smokers who wish the help of a formal group program in quitting the habit. Little has been published on their outcomes. A study of 494 smokers attending 42 Freedom From Smoking Clinics in western New York State showed that 29 percent reported not smoking about 1 year after attending the clinic sessions. There was a wide range of quit rates over different clinics, but the rates were similar for men and women and for different age groups. Those initially smoking less than one pack per day were more likely to be successful in quitting than heavier smokers. Quit rates were similar in work site groups and in the community clinics. Perceptions of having received group support at the clinic were also related to higher success rates. Research on group composition and process might be a fruitful road to raising what seems to be a ceiling on the success of current techniques.     

Patterns of attendance at Jamaican sickle cell clinics 1952 to 1981

The development of sickle cell clinics in Jamaica over a 30-year period is reviewed. The clinics are expanding almost exponentially, new cases of SS disease being recruited at approximately 150 per year and new cases of SC disease at approximately 60 per year.In the first 20 years, the median age of clinic attenders increased markedly but has remained stable since 1970. This stable age structure in the presence of an almost exponential rate of clinic expansion implies that the influx of young cases is balanced by the increasing age of existing clinic attenders. The pattern of new referrals has also changed to that of predominantly young patients, suggesting that the bulk of symptomatic older patients in the community have already been recruited into the clinic population.     

Oral contraception and smoking: Time trends for a risk behaviour in Finland

The main health risks of modern oral contraceptives (OCs) areassociated with simultaneous smoking. According to current medicalguidelines in Finland, OCs should not be prescribed for smokersaged over 30 years. We report how smoking and OC use were relatedfrom 1975 to 1993. The data were collected from 3 national postalsurveys: a biannual survey of 16 and 18 year old girls since1981 (sample sizes of 462–1,667 and response rates of83–91%), an annual survey of 20–39 year old womensince 1978 (size of 5 year age groups of 205–375 and responserates of 68–91%) and a survey of 20–39 year oldtwins in 1975 and 1981 (size of 5 year age groups of 758–3,366and response rates of 85–90%). Early initiation of OCsbecame more frequent. Half of the 16 year old and one-thirdof 18 year old OC users were smokers in the most recent survey.Adult women aged under 30 years more than doubled their OC useduring the 1980s. Although smoking showed a declining trend,the proportion of women having combined use of OCs and tobaccoincreased (up to 9–13% in the most recent surveys). Womenaged over 30 years increased their OC use in the late 1980s(10–18% in the most recent surveys). The combined useof OCs and tobacco has become more frequent both among adolescentand adult women. The lifetime duration of combined use willprobably increase without more active intervention on smokingin the family planning clinics, even among young women.     

Cost and efficiency of public sector sexually transmitted infection clinics in Andhra Pradesh, India

Background

Control of sexually transmitted infections (STIs) is an important part of the effort to reduce the risk of HIV/AIDS. STI clinics in the government hospitals in India provide services predominantly to the poor. Data on the cost and efficiency of providing STI services in India are not available to help guide efficient use of public resources for these services.

Methods

Standardised methods were used to obtain detailed cost and output data for the 2003–2004 fiscal year from written records and interviews in 14 government STI clinics in the Indian state of Andhra Pradesh. The economic cost per patient receiving STI treatment was calculated, and the variations of total and unit costs across the STI clinics analysed. Multivariate regression technique was used to estimate incremental unit costs. The optimal number of STIs that could be handled by the clinics was estimated.

Results

18807 STIs were diagnosed and treated at the 14 STI clinics in fiscal year 2003–2004 (range 323–2784, median 1199). The economic cost of treating each STI varied 5-fold from Indian Rupees (INR) 225.5 (US$ 4.91) to INR 1201.5 (US$ 26.15) between 13 clinics, with one other clinic having a very high cost of INR 2478.5 (US$ 53.94). The average cost per STI treated for all 14 clinics combined was INR 729.5 (US$ 15.88). Personnel salaries made up 76.2% of the total cost. The number of STIs treated per doctor full-time equivalent and cost-efficiency for each STI treated had a significant direct non-linear relation (p < 0.001, R² = 0.81; power function). With a multiple regression model, apart from the fixed costs, the incremental cost for each STI detected and cost of treatment was INR 55.57 (US$ 1.21) and for each follow-up visit was INR 3.75 (US$ 0.08). Based on estimates of optimal STI cases that could be handled without compromising quality by each doctor full-time equivalent available, it was projected that at 8 of the 14 clinics substantially more STI cases could be handled, which could increase the total STI cases treated at the 14 clinics combined by 38% at an additional cost of only 3.5% for service provision.

Conclusion

There is un-utilised capacity in the public sector STI clinics in this Indian state. Efforts to facilitate utilisation of this capacity would be useful, as this would enable more poor patients with STIs to be served at minimal additional cost, and would also reduce the cost per STI treated leading to more efficient use of public resources.     

Knowledge,perceived stigma,and care-seeking experiences for sexually transmitted infections: a qualitative study from the perspective of public clinic attendees in Rio de Janeiro,Brazil

Background  

An estimated 12 million sexually transmitted infections (STIs) are documented in Brazil per year. Given the scope of this public health challenge and the importance of prompt treatment and follow-up counseling to reduce future STI/HIV-related risk behavior, we sought to qualitatively explore STI clinic experiences among individuals diagnosed with STIs via public clinics in Rio de Janeiro, Brazil. The study focused on eliciting the perspective of clinic users with regard to those factors influencing their STI care-seeking decisions and the health education and counseling which they received during their clinic visit.     

Comparative evaluation of American Cancer Society and American Lung Association smoking cessation clinics.

We compared the effectiveness of American Cancer Society, FreshStart, American Lung Association, Freedom from Smoking, and laboratory clinic methods in subjects (N = 1041) from three communities. Three-month follow-up results favored the laboratory method over the two public service approaches on both a prevalence and a sustained abstinence measure. At one-year follow-up, treatment effects for smoking prevalence were no longer significant. However, sustained abstinence results at one-year remained highly significant and favored the more intensive laboratory and Freedom from Smoking clinics over the FreshStart method. FreshStart fared less well than the other interventions both in producing initial quit attempts and in sustaining abstinence among initial quitters. It should be noted, however, that FreshStart requires considerably less facilitator contact than do the other approaches. Unexpected outcome effects occurred for treatment location. Future clinic programs should include a specific target date for quitting and should place more emphasis upon recycling participants who fail to sustain abstinence.     

Intimate Partner Violence and Health Care-Seeking Patterns Among Female Users of Urban Adolescent Clinics

To assess the prevalence of intimate partner violence (IPV) and associations with health care-seeking patterns among female patients of adolescent clinics, and to examine screening for IPV and IPV disclosure patterns within these clinics. A self-administered, anonymous, computerized survey was administered to female clients ages 14–20 years (N = 448) seeking care in five urban adolescent clinics, inquiring about IPV history, reasons for seeking care, and IPV screening by and IPV disclosure to providers. Two in five (40%) female urban adolescent clinic patients had experienced IPV, with 32% reporting physical and 21% reporting sexual victimization. Among IPV survivors, 45% reported abuse in their current or most recent relationship. IPV prevalence was equally high among those visiting clinics for reproductive health concerns as among those seeking care for other reasons. IPV victimization was associated with both poor current health status (AOR 1.57, 95% CI 1.03–2.40) and having foregone care in the past year (AOR 2.59, 95% CI 1.20–5.58). Recent IPV victimization was associated only with past 12 month foregone care (AOR 2.02, 95% CI 1.18–3.46). A minority (30%) reported ever being screened for IPV in a clinical setting. IPV victimization is pervasive among female adolescent clinic attendees regardless of visit type, yet IPV screening by providers appears low. Patients reporting poor health status and foregone care are more likely to have experienced IPV. IPV screening and interventions tailored for female patients of adolescent clinics are needed.     

The effectiveness of smoking cessation methods for smokers in public health maternity clinics: a randomized trial.

Little insight is available in the literature on how best to assist the pregnant smoker in public health maternity clinics to quit during pregnancy. A randomized pretest/posttest experiment was used to evaluate the effectiveness of two different self-help cessation methods. Three hundred and nine pregnant women from three public health maternity clinics were assigned randomly to one of three groups with one-third assigned to each: a control group; a group receiving the American Lung Association's Freedom From Smoking Manual; and those receiving A Pregnant Woman's Self-Help Guide to Quit Smoking. Using a saliva thiocyanate (SCN) and behavioral report at mid-pregnancy and end of pregnancy to confirm cessation or reduction, 2 per cent in the control group quit and 7 per cent reduced their SCN levels substantially. Of the women assigned to the ALA method, 6 per cent quit and 14 per cent reduced their SCN levels substantially. Of the women who used the Guide, 14 per cent quit and 17 per cent reduced their SCN levels substantially. Results of this trial indicate that health education methods tailored to the pregnant smoker are more effective in changing smoking behavior than the standard clinic information and advice to quit and/or the use of smoking cessation methods not tailored to the needs of the pregnant smoker.     

Information as intervention: how Georgia used vaccination coverage data to double public sector vaccination coverage in seven years.

All states are now required by federal law to measure immunization coverage in each public clinic in their jurisdiction once a year. This law is based on data suggesting a twofold increase of immunization coverage in public clinics in Georgia during a seven-year period when the state developed a system for measuring clinic coverage and using these data to stimulate immunization performance. Review of the history of the development of the Georgia system suggests that measurement alone is not sufficient to raise coverage, however. In Georgia, measurement was coupled with a vigorous program of feedback of coverage data, provision of incentives for good performance, and exchange of information among clinics. The Centers for Disease Control and Prevention (CDC) has summarized the Georgia system with the acronym AFIX--Assessment, Feedback, Incentives, eXchange of information--and recommends that all state immunization program managers test and adapt this methodology. The article comments on the development of the Georgia system and describes why CDC believes other states should adopt it.     

A cost-effectiveness analysis of self-help smoking cessation methods for pregnant women.

Estimates of the cost effectiveness and cost benefit of health promotion-health education methods for pregnant smokers designed to increase birth weight are not available. This paper presents the results of a cost-effectiveness analysis from a recently completed randomized trial to evaluate the effectiveness of self-help smoking cessation methods for pregnant women in public health maternity clinics. The study population--309 pregnant smokers from 3 prenatal clinics--were randomly assigned, during their first clinic visit, to 1 of 3 groups: (a) group 1 received the standard clinic information and advice to quit smoking, (b) group 2 received the standard clinic information and advice to quit plus the manual "Freedom From Smoking in 20 Days" by the American Lung Association, and (c) group 3 received the standard clinic information and advice to quit plus the pregnancy-specific manual "A Pregnant Woman''s Self-Help Guide to Quit Smoking." The quit rates by the end of pregnancy were 2 percent for group 1, 6 percent for group 2, and 14 percent for group 3. Analyses also indicated that the method used for group 3 was the most cost effective: group 3 achieved smoking cessation at less than half the cost experienced by the other two groups. Although additional studies are needed concerning the behavioral impact, cost effectiveness, and cost benefit of self-help health education methods for smoking cessation, the methods tested in this trial are promising as solutions to part of the problem of low birth weight among infants of smoking mothers in the United States.     

The Influence of Visiting Consultant Clinics on Measures of Access to Cancer Care: Evidence from the State of Iowa

Objective

To determine the effect of visiting consultant clinics on measures of access to cancer care for rural patients.

Data Sources

2010 Visiting Medical Consultant Database for the state of Iowa (Carver College of Medicine) and the Iowa Physicians Information System (Carver College of Medicine).

Study Design

We compared shortest driving times to the nearest medical oncologist for all Iowa census tracts under two scenarios: including only primary practice locations and adding monthly visiting consultant clinic locations.

Principal Findings

For rural Iowans, the median driving time to the closest site for medical oncology care falls from 51.6 to 19.2 minutes when monthly visiting consultant clinics are considered.

Conclusions

Including visiting consultant clinics has a significant impact on measures of geographic access to cancer care.     

美国联邦公立医院医生薪酬制度及其对我国启示

美国联邦退役军人医疗系统是美国最大的公立医疗系统,有145家医疗中心,1231个门诊部。2016年,该系统有三十一万雇员,为九百多万退役军人提供医疗服务,所有医务人员均为薪酬制雇员。在市场的竞争和社会舆论及国会监督下,该系统从几乎被解散的境地,经30年不断改革,目前医疗服务质量已经超过私立医院。VHA医生全部作为公务员聘用,薪酬由美国联邦立法规定。本文通过VHA医疗系统详细介绍了美国联邦公立医院医生薪酬制度的法律形式和各类专科医生的薪酬水平及晋升方式,讨论分析了我国公立医院薪酬制度改革的方向。     

Primary Health Care in the United Arab Emirates

The aim of this paper was to assess some of the important variablefactors concerning health care in United Arab Emirates (UAE),with special emphasis on primary health care (PHC). Other aspectsconsidered are the population per bed, population per physician,population per dentist, population per pharmacist and populationper nurse, all of which influence health care delivery in theUAE. There is a gradual improvement in health status, whichcan be seen by the increase of life expectancy in both malesand females, and decrease in leading cause of death from infectiousdiseases. The health strategy of 1986–1991 has achievedits goals and has been reviewed and the new 5 year strategyhas been formalized to adopt some major aspects in the developmentof health care delivery. Overall results showed that every 1235people will be served by one physician and other health serviceindicators are bed/doctor 3.9; bed/nurse 1.3; population/dentist15 763; population/pharmacist 13 174; and population/nurse 438.Also, a very good coverage of PHC has been achieved throughoutthe country so that no more than 200 people live in an area>30 km away from health service or without a PHC clinic.All PHC clinics provide curative, preventive and promotive serviceswith a small percentage of rehabilitation services. The governmenthas adopted the PHC approach as the long-term strategy for achievingthe goal of health for all by the year 2000. This was supportedby the ministerial decree no. 139/86 in 1986. Recommendationsare also made for improving health services and performanceas well as better meeting the specific medical care needs ofthe people through expansion of PHC services.     

How federalism shapes public health financing, policy, and program options

In the United States, fiscal and functional federalism strongly shape public health policy and programs. Federalism has implications for public health practice: it molds financing and disbursement options, including funding formulas, which affect allocations and program goals, and shapes how funding decisions are operationalized in a political context. This article explores how American federalism, both fiscal and functional, structures public health funding, policy, and program options, investigating the effects of intergovernmental transfers on public health finance and programs.     

Self-reported health problems among Swedish miners one year after unemployment

Unemployment is considered to be a public health concern sincedeterioration in the health of the unemployed is often anticipated.However, for some groups, such as miners, unemployment mightimprove health due to a cessation of potentially harmful occupationalexposures. This study evaluates the health of 79 miners in oneSwedish iron-ore mine, and 226 age-matched controls from thegeneral population, during one year after the closure of themine. The participants received a questionnaire regarding medicalhistory and subjective symptoms at the beginning of the studyperiod, and after one year. Statistically significant negativeeffects on self-reported health attributable to unemploymentwere not found, although neuropsychiatric symptoms were morecommon among the unemployed miners. The miners reported a statisticallysignificant improvement in grip force (p=0.031). They had asignificantly higher prevalence of symptoms associated withmining related exposures when compared with the population controls;pain in the upper extremities [relative risk (RR)=2.27, 95%confidence interval (Cl)=1.44–3.59), back pain (RR=1.84;Cl=1.237–2.75), vasospastic disease of the fingers (RR=2.05;Cl=1.18–3.57) and obstructive respiratory symptoms (attacksof dyspnea and wheezing: RR=3.67; Cl=1.167–11.6).     

Differences in parental vaccine confidence and attitudes by health system in Guatemala and their impact on immunization timeliness

ObjectiveThe objectives of this study were to evaluate parental confidence and attitudes towards immunization in urban Guatemala between private versus public health systems and their impact on vaccination timeliness in their children.MethodsA cross-sectional survey was conducted in parents 6–18-month-old children who attended well-child outpatient clinics from two health systems (public employee-based insurance and private health care) in Guatemala City from November 2017 through August 2018. Parental demographics, household characteristics, food insecurity, vaccine hesitancy using the WHO SAGE Vaccine Hesitancy Scale, and information on parental use of social media platforms and vaccine information sources were collected.ResultsFive hundred-three parents were surveyed, most of them mothers. Only 9 parents reported they had previously refused a vaccine for their child: 8 (3.2 %) from private clinics and 1 (0.4 %) from the public clinic (p = 0.02). Significantly more children attending private clinics (226, 90.4 %) were shown to have a delay in any of their vaccines scheduled for the first 2 years of life compared to those in the public clinic (169, 66.8 %; p < 0.01). Children of parents having a college degree (84.5 vs 70.1 %; p < 0.001), earning more than US$ 1,000 per month (81.5 vs 70.7 %; p < 0.001), and having a computer at home (81.4 vs 70.2; p = 0.007) were more likely to have any delays in the scheduled vaccines. Parents seeking care at private clinics were 1.14 times more at risk of delaying a vaccine compared to those at the public clinic, adjusted for other covariates (p = 0.03, 95 % CI: 1.01, 1.28).ConclusionsIn Guatemala, children receiving immunizations at private clinics were significantly more likely than those attending public clinics to be delayed in their immunization schedule and to remain more days without the recommended protection, especially for third doses of the primary vaccine series.     

Integrating partner professionals. The Early Explorers project: Peers Early Education Partnership and the health visiting service

Background A range of voluntary sector organizations are involved in the delivery of services to children, particularly within the Early Year's sector and children's centres. Peers Early Education Partnership (PEEP) Early Explorers project is one example of the way in which explicit partnerships are being forged across statutory and voluntary sectors with the aim of improving outcomes for children and families. This paper reports an exploration of stakeholder views and experiences of two Early Explorer clinics located in areas of high deprivation. Methods Semi‐structured interviews were conducted with a purposive sample of stakeholders (n= 25) from children's centres, PEEP, the health visiting service and service users. Data were fully transcribed and analysed using a thematic approach. Results The data suggest that the two key groups of stakeholders providing Early Explorer clinics (i.e. health visitors and PEEP practitioners) had quite different objectives in terms of their early goals for the clinic, but that despite these differences good progress was achieved in terms of working together effectively. All stakeholders including service users referred to the presence of PEEP as having improved the quality of the clinic environment, and participating mothers identified a wide range of benefits from the enhanced service. However, somewhat restricted views about the role of practitioners within the clinics were identified by users, and the findings suggest that although the early goals for the clinic had been exceeded, these may have been limited in terms of true ‘partnership’ working. Conclusions Early Explorer clinics appeared to have enhanced the service provided within traditional child health clinics and to have provided practitioners with access to hard‐to‐reach families and parents with access to services that are consistent with the broader policy aims of improving parent–infant interaction. However, questions remain as to whether the benefit of ‘partnership’ working was fully realized.     

Accessibility and organizational settings for public supported family planning services

This article reports on a survey of public supported family planning clinic users' travel time, appointment-delay time and waiting-room time. Comparisons of policy norms are made with three contraceptive organizational settings: hospitals, freestanding and community health clinics. The findings reveal freestanding and community health clinics were more accessible. This study suggests that despite the variety of public supported family planning clinics most were accessible to low-income women in western Pennsylvania.     

Changes in Service Delivery Patterns After Introduction of Telemedicine Provision of Medical Abortion in Iowa

Objectives. We assessed the effect of a telemedicine model providing medical abortion on service delivery in a clinic system in Iowa.Methods. We reviewed Iowa vital statistic data and billing data from the clinic system for all abortion encounters during the 2 years prior to and after the introduction of telemedicine in June 2008 (n = 17 956 encounters). We calculated the distance from the patient’s residential zip code to the clinic and to the closest clinic providing surgical abortion.Results. The abortion rate decreased in Iowa after telemedicine introduction, and the proportion of abortions in the clinics that were medical increased from 46% to 54%. After telemedicine was introduced, and with adjustment for other factors, clinic patients had increased odds of obtaining both medical abortion and abortion before 13 weeks’ gestation. Although distance traveled to the clinic decreased only slightly, women living farther than 50 miles from the nearest clinic offering surgical abortion were more likely to obtain an abortion after telemedicine introduction.Conclusions. Telemedicine could improve access to medical abortion, especially for women living in remote areas, and reduce second-trimester abortion.Medical abortion involves the use of medication to induce an abortion nonsurgically, and the regimen used most commonly in the United States involves oral mifepristone followed by misoprostol administered vaginally, orally, buccally, or sublingually.1 The mifepristone–misoprostol regimen is highly effective up to 9 weeks’ gestation and has been found to be very safe.2,3 Studies in the United States and elsewhere have found that women are very satisfied with this abortion method, and some women prefer it to vacuum aspiration.4,5 Medical abortion is not a surgical procedure and can be offered by nonphysician clinicians or by physicians who do not perform surgical abortion.6 However, US clinicians outside of abortion clinics do not appear to have adopted the technology in large numbers. An analysis of data from 2007 found that almost all medical abortion–only providers were located within 50 miles of a large-volume surgical abortion provider.7One factor limiting the uptake of medical abortion is the restriction that most states impose regarding who can provide the service. As of 2009, only 15 states allowed advanced practice clinicians to provide medical abortion; the remainder required that a physician provide the service.8 Iowa is one such state where a physician must provide medical abortion.Telemedicine is the delivery of health care services at a distance through information and communication technology. A recent systematic review of economic analyses of telemedicine services found that this care model was cost effective for a range of services.9 In June 2008, Planned Parenthood of the Heartland in Iowa launched a telemedicine program to allow physicians to provide medical abortion to patients at clinic sites not staffed by a physician to improve access to early abortion and reduce physician travel to outlying clinics. Prior to introducing telemedicine, the network had 17 clinic sites. Two clinics had an on-site physician and offered both medical and surgical abortion, 2 sites offered surgical and medical abortion when a physician traveled there, and 2 additional sites offered only medical abortion when the physician traveled there. The remaining 11 clinics did not provide abortions. A recently published cohort study found that the telemedicine model provided by this clinic system was as effective as a model involving an in-person visit with a physician; telemedicine was also found to be highly acceptable to women, with a low rate of adverse events.10We examined how the clinic system’s service delivery patterns changed after the introduction of telemedicine. In particular, we asked whether the proportion of abortions that were medical abortion and second-trimester abortion changed, as well as whether there were changes in the geographical patterns of service delivery.