Does distance affect utilization of substance abuse and mental health services in the presence of transportation services?

Long travel times have been identified as a significant barrier to accessing mental health and other critical services. This study examines whether distance to treatment was a barrier to receiving outpatient mental health and substance abuse care for HIV-positive persons when transportation was provided. Data from a cohort of HIV-positive persons who participated in a year-long substance abuse and mental health treatment programme were examined longitudinally. Transportation, which included buses, taxis, and mileage reimbursement for private transportation, was provided free of charge for participants who needed this assistance. Nearly three-quarters (74%) of participants utilized the transportation services. No statistically significant differences in retention in, or utilization of, the mental health and substance abuse treatment programme were identified by distance to the treatment site. This analysis demonstrated that increased distance to care did not decrease utilization of the treatment programme when transportation was provided to the client when necessary. These results provide preliminary evidence that distance to substance abuse and mental health services need not be a barrier to care for HIV-positive individuals when transportation is provided. Such options may need to be considered when trying to treat geographically dispersed individuals so that efficiencies in treatment can be attained.     

Can malaria be controlled where basic health services are not used?

OBJECTIVE: To assess the potential of integrating malaria control interventions in underused health services. METHODS: Using the Piot predictive model, we estimated malaria cure rates by deriving parameters influencing treatment at home and in health facilities from the best-performing African malaria programmes and applying them to Yanfolila district, Mali. RESULTS: Without any malaria control intervention, the population cure rate is 8.4% with home treatment, but would be 13% if access to timely treatment were improved (as in Kenya). A further 3.2% of malaria patients could be cured in institutional settings with more sensitive diagnosis, timely start of treatment, better compliance (as in Uganda, Tanzania, Ghana) and 80% chloroquine efficacy. Applied in a setting where 7.6% of malaria patients seek institutional care, these assumptions would result in a total population cure rate of 14.5%. Increasing the health service user rate from 0.17 in Yanfolila to 0.95 new cases/inhabitant/year (as in Namibia) would result in half of all malaria patients attending professional services, raising the cure rate to 26.1%. CONCLUSION: If malaria patients are to be treated and followed-up early and appropriately, basic health services need to deliver integrated care and be attended by an adequate pool of users. Improved service user rates and case management can increase malaria cure rates far more than isolated control interventions can. This has implications for international policies endorsing a narrow disease-based approach.     

Is routine vaginal examination necessary for asymptomatic women attending sexual health services?

The aim of this study was to determine whether our sexual health service could be streamlined by dispensing with routine vaginal examination of asymptomatic women, without missing important diagnoses. This was an audit of asymptomatic women presenting to the centre who had had a Papanicolaou (PAP) smear in the previous two years. Of the 421 women who were eligible, no abnormalities were found on genital inspection in 392 (93%) individuals. Abnormalities detected on clinical examination included one case (0.2%) with mucopurulent cervicitis that tested positive for Chlamydia trachomatis, four (1%) with warts or molluscum contagiosum, and one with an asymptomatic genital ulcer of unknown cause. Dispensing with the vaginal examination in asymptomatic women who have had a speculum examination as part of biennial cervical screening may be appropriate in settings where sensitive non-invasive testing for sexually transmitted infections (STI) is in use and STI prevalence is low.     

Does health insurance matter to the use of health services for the elderly in China? A multiyear,nationwide, cross-sectional study

Background

China has a population that is rapidly ageing. This rapid growth raises many challenges such as financing and delivery of health care. The Urban Residents Basic Medical Insurance (URBMI) has provided financial protection for the urban elderly not covered by other health insurance schemes since 2007. We therefore aimed to do a national level assessment on the changes in perceived health needs and use of health services of the elderly enrolled in URBMI.

Physician, heal Thyself? Regular source of care and use of preventive health services among physicians

BACKGROUND: Little is known about the regular source of care (RSOC) among physicians, a group whose self-care may reflect the attitudes and recommendations they convey to their patients. METHODS: We performed a cohort study of physicians who graduated from the Johns Hopkins School of Medicine from 1948 through 1964 to identify predictors of not having an RSOC, and to determine whether not having an RSOC was associated with subsequent receipt of preventive services. The RSOC was assessed in a 1991 survey; use of cancer screening tests and the influenza vaccine was assessed in 1997. RESULTS: The response rate in 1991 was 77% (915 respondents); 35% (312) had no RSOC. Internists (odds ratio [OR], 3.26; 95% confidence interval [CI], 1.58-6.74), surgeons (OR, 2.42; 95% CI, 1.17-5.02), and pathologists (OR, 5.46; 95% CI, 2.09-14.29) were significantly more likely to not have an RSOC than pediatricians. Not having an RSOC was inversely related to the belief that health is determined by health professionals (OR, 0.45; 95% CI, 0.29-0.68) and directly related to the belief that chance (OR, 1.90; 95% CI, 1.28-2.82) determines health. Not having an RSOC in 1991 predicted not being screened for breast, colon, and prostate cancer, as well as not receiving an influenza vaccine at 6 years of follow-up. CONCLUSIONS: A large percentage of physicians in our sample had no RSOC, and this was associated with both medical specialty and beliefs about control of health outcomes. Not having an RSOC was significantly associated with failure to use preventive services several years later. Arch Intern Med. 2000;160:3209-3214.     

Is neuropsychological development related to maternal hypothyroidism or to maternal hypothyroxinemia?

Several recent publications have drawn attention to the role of the thyroid hormone status of the mother on the future neuropsychological development of the child. The screening of pregnant women for clinical or subclinical hypothyroidism based on second trimester elevated maternal TSH values has been proposed. Here, we have summarized present epidemiological and experimental evidence strongly suggesting that conditions resulting in first trimester hypothyroxinemia (a low for gestational age circulating maternal free T4, whether or not TSH is increased) pose an increased risk for poor neuropsychological development of the fetus. This would be a consequence of decreased availability of maternal T4 to the developing brain, its only source of thyroid hormone during the first trimester; T4 is the required substrate for the ontogenically regulated generation of T3 in the amounts needed for optimal development in different brain structures, both temporally and spatially. Normal maternal T3 concentrations do not seem to prevent the potential damage of a low supply of T4, although they might prevent an increase in circulating TSH and detection of the hypothyroxinemia if only TSH is measured. Hypothyroxinemia seems to be much more frequent in pregnant women than either clinical or subclinical hypothyroidism and autoimmune thyroid disease, especially in regions where the iodine intake of the pregnant woman is inadequate to meet her increased needs for T4. It is proposed that the screening of pregnant women for thyroid disorders should include the determination of free T4 as soon as possible during the first trimester as a major test, because hypothyroxinemia has been related to poor developmental outcome, irrespective of the presence of high titers of thyroid autoantibodies or elevated serum TSH. The frequency with which this may occur is probably 150 times or more that of congenital hypothyroidism, for which successful screening programs have been instituted in many countries.     

Can mothers recognize neonatal illness correctly? comparison of maternal report and assessment by community health workers in rural Bangladesh

Objectives To validate maternal recognition of neonatal illnesses at home compared to assessment by community health workers (CHWs) during routine household surveillance for neonatal illness in rural Bangladesh. Methods Surveillance in the intervention arm of two cluster‐randomized, controlled trials of newborn interventions conducted in Sylhet and Mirzapur districts of Bangladesh. CHWs promoted birth and newborn care preparedness during two prenatal visits, including recognition of neonatal illnesses. CHWs assessed 8472 neonates on post‐natal days 0, 3, and 6 between 2004 and 2005 in Sylhet, and 7587 neonates on post‐natal days 0, 2, 5, and 8 between 2004 and 2006 in Mirzapur. In both sites, CHW identified neonates with very severe disease (VSD), using clinical algorithms that included ascertainment of illness history reported by mother and observation of clinical signs of illness. We calculated sensitivity, specificity, positive predictive value and negative predictive value of maternal report of any illness sign compared to CHWs’ assessments and classification of VSD. Analysis was restricted to mothers whose neonates were assessed by CHWs at home during the routine visit schedule. Results Maternal report of any signs had sensitivity of 24% and 20% and positive predictive value of 45% and 54% in Sylhet and Mirzapur, respectively. Conclusions Maternal recognition of neonatal illnesses at home was poor in two rural areas in Bangladesh. Interventions need to be designed to improve maternal recognition, and routine post‐natal assessment by CHWs at home may be an essential component of community‐based newborn care to improve care‐seeking for newborn illness.     

Racial and ethnic disparities in the use of health services: bias,preferences, or poor communication?

African Americans and Latinos use services that require a doctor's order at lower rates than do whites. Racial bias and patient preferences contribute to disparities, but their effects appear small. Communication during the medical interaction plays a central role in decision making about subsequent interventions and health behaviors. Research has shown that doctors have poorer communication with minority patients than with others, but problems in doctor-patient communication have received little attention as a potential cause, a remediable one, of health disparities. We evaluate the evidence that poor communication is a cause of disparities and propose some remedies drawn from the communication sciences.     

Patients accessing HIV treatment via sexual health services: what are the risks of the dual case-note system?

In many British hospitals, HIV-positive patients access care via genitourinary (GU) medicine services. As a result of National Health Service (NHS) legislation, such patients may have information concerning HIV treatment filed separately from their general clinical records. We sought to evaluate accuracy of medication records of patients with both GU medicine and general hospital case-notes, and to assess clinical risk arising from incorrect or incomplete recording. In this retrospective review, 156 episodes of care from 100 HIV-positive patients with separate HIV case-notes were evaluated for accuracy of medication recording, when paired with clinical notes from attendances in other hospital departments. Discrepancies were observed in 52.6% of care episodes; significant discrepancies were apparent in 7.8%. The dual case-note system represents significant risk to patient care. We recommend that hospitals that continue to operate this system urgently consider amalgamation of HIV care records into hospital case sheets, in line with current national standards.     

Do exemptions from user fees mean free access to health services? A case study from a rural Cambodian hospital

Objectives To assess the effects of a user fee scheme, and related fee exemption system, on the health care seeking behaviour, the out‐of‐pocket expenditure and the coping mechanisms of fee‐exempted patients (FEP) at Kirivong Referral Hospital in Cambodia. Methods A pre‐coded structured questionnaire administered to pre‐identified FEP and fee‐paying patients (PP) of the same age group and with the same medical condition, who were paired for comparison. Survey data were supplemented with unstructured in‐depth interviews. Results 199 pairs of patients were compared. The timing of the start of health care seeking was equal for FEP and PP, although significantly more FEP consulted first‐line public health providers than PP. Only a third of interviewees who visited public health facilities prior to hospitalization were referred. The direct costs of health care seeking were US$4.3 for FEP and US$15.3 for PP. FEP borrowed at a ratio of 3.4:1 to direct costs incurred, vs. 0.74:1 for PP. Hospitalization rates were 32.5/1000 population and 18.4/1000 population for FEP and PP, respectively. Conclusions User fee exemption schemes can be pro‐poor provided that the fee exemption system is based on effective pre‐identification of intended beneficiaries, that these beneficiaries are informed of their right to free health care and that health care providers are reimbursed for the revenue foregone due to exemptions. To be effective in the Cambodian context, exemption schemes need to be underpinned by a range of additional interventions.