Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications

Aim Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications. Methods The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities. Results The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols. Conclusions The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes.

A pilot RCT of a multi-component nutrition intervention for nursing home residents with dementia

Background Malnutrition and unintentional weight loss are major clinical issues in people with dementia living in residential aged care facilities (RACFs) and are associated with serious adverse outcomes. However, evidence regarding effective interventions is limited and strategies to improve the nutritional status of this population are required. This presentation describes the implementation and results of a pilot randomised controlled trial of a multi-component intervention for improving the nutritional status of RACF residents with dementia. Method Fifteen residents with moderate-severe dementia living in a secure long-term RACF participated in a five week pilot study. Participants were randomly allocated to either an Intervention (n=8) or Control group (n=7). The intervention comprised four elements delivered in a separate dining room at lunch and dinner: the systematic reinforcement of residents’ eating behaviors using a specific communication protocol; family-style dining; high ambiance table presentation; and routine Dietary-Nutrition Champion supervision. Control group participants ate their meals according to the facility’s standard practice. Baseline and follow-up assessments of nutritional status, food consumption, and body mass index were obtained by qualified nutritionists. Additional assessments included measures of cognitive functioning, mealtime agitation, depression, wandering status and multiple measures of intervention fidelity. Results No participant was malnourished at study commencement and participants in both groups gained weight from follow-up to baseline which was not significantly different between groups (t=0.43; p=0.67). A high degree of treatment fidelity was evident throughout the intervention. Qualitative data from staff indicate the intervention was perceived to be beneficial for residents. Conclusions This multi-component nutritional intervention was well received and was feasible in the RACF setting. Participants’ sound nutritional status at baseline likely accounts for the lack of an intervention effect. Further research using this protocol in malnourished residents is recommended. For success, a collaborative approach between researchers and facility staff, particularly dietary staff, is essential.

Water, water everywhere: Dehydration in the midst of plenty: An observational study of barriers and enablers to adequate hydration in older hospitalized patients

While dehydration is common in older patients and is associated with poor outcomes, it has been infrequently studied in the hospital setting. Thus, the aim of this study was to identify potential barriers and enablers to the maintenance of adequate hydration in older patients in an acute hospital environment. An observational study, involving patients aged 60 years and older admitted to an acute care hospital in Queensland, Australia, was undertaken. Forty-four patients were observed during mealtimes, and chart and room audits were performed to identify hydration management strategies, weight records and the presence or absence of fluid balance charts. Results revealed a number of system and practice-related barriers including patient difficulties with opening fluid containers and low levels of documentation of hydration management strategies. Addressing these issues is an important first step towards improving the management of hydration in medically ill older hospital patients.

Post-traumatic stress and dementia: Staff perspectives

Some evidence suggests that behavioural and psychological symptoms of dementia (BPSD) are more pronounced in veterans with a history of post-traumatic stress disorder (PTSD) than in others with dementia. Catherine Travers, Elizabeth Beattie and Elaine Fielding surveyed Australian healthcare professionals to better understand whether PTSD influences the expression of these symptoms in veterans with dementia.

Improved wound management at lower costs: A sensible goal for Australia

Chronic wounds cost the Australian health system at least US$2·85 billion per year. Wound care services in Australia involve a complex mix of treatment options, health care sectors and funding mechanisms. It is clear that implementation of evidence-based wound care coincides with large health improvements and cost savings, yet the majority of Australians with chronic wounds do not receive evidence-based treatment. High initial treatment costs, inadequate reimbursement, poor financial incentives to invest in optimal care and limitations in clinical skills are major barriers to the adoption of evidence-based wound care. Enhanced education and appropriate financial incentives in primary care will improve uptake of evidence-based practice. Secondary-level wound specialty clinics to fill referral gaps in the community, boosted by appropriate credentialing, will improve access to specialist care. In order to secure funding for better services in a competitive environment, evidence of cost-effectiveness is required. Future effort to generate evidence on the cost-effectiveness of wound management interventions should provide evidence that decision makers find easy to interpret. If this happens, and it will require a large effort of health services research, it could be used to inform future policy and decision-making activities, reduce health care costs and improve patient outcomes.

Measuring the expressed emotion in Chinese family caregivers of persons with dementia: Validation of a Chinese version of the Family Attitude Scale

- Background Expressed emotion (EE) captures the affective quality of the relationship between family caregivers and their care recipients and is known to increase the risk of poor health outcomes for caregiving dyads. Little is known about expressed emotion in the context of caregiving for persons with dementia, especially in non-Western cultures. The Family Attitude Scale (FAS) is a psychometrically sound self-reporting measure for EE. Its use in the examination of caregiving for patients with dementia has not yet been explored. - Objectives This study was performed to examine the psychometric properties of the Chinese version of the FAS (FAS-C) in Chinese caregivers of relatives with dementia, and its validity in predicting severe depressive symptoms among the caregivers. - Methods The FAS was translated into Chinese using Brislin's model. Two expert panels evaluated the semantic equivalence and content validity of this Chinese version (FAS-C), respectively. A total of 123 Chinese primary caregivers of relatives with dementia were recruited from three elderly community care centers in Hong Kong. The FAS-C was administered with the Chinese versions of the 5-item Mental Health Inventory (MHI-5), the Zarit Burden Interview (ZBI) and the Revised Memory and Behavioral Problem Checklist (RMBPC). - Results The FAS-C had excellent semantic equivalence with the original version and a content validity index of 0.92. Exploratory factor analysis identified a three-factor structure for the FAS-C (hostile acts, criticism and distancing). Cronbach's alpha of the FAS-C was 0.92. Pearson's correlation indicated that there were significant associations between a higher score on the FAS-C and greater caregiver burden (r = 0.66, p < 0.001), poorer mental health of the caregivers (r = −0.65, p < 0.001) and a higher level of dementia-related symptoms (frequency of symptoms: r = 0.45, p < 0.001; symptom disturbance: r = 0.51, p < 0.001), which serves to suggest its construct validity. For detecting severe depressive symptoms of the family caregivers, the receiving operating characteristics (ROC) curve had an area under curve of 0.78 (95% confidence interval (CI) = 0.69–0.87, p < 0.0001). The optimal cut-off score was >47 with a sensitivity of 0.720 (95% CI = 0.506–0.879) and specificity of 0.742 (95% CI = 0.643–0.826). - Conclusions The FAS-C is a reliable and valid measure to assess the affective quality of the relationship between Chinese caregivers and their relatives with dementia. It also has acceptable predictability in identifying family caregivers with severe depressive symptoms.

HIV outbreak among injecting drug users in Finland

An HIV outbreak among Finnish injecting drug users (IDUs) occurred in 1998. By the end of 2005, 282 IDUs were in-fected, most of them by recombinant virus CRF01_AE of HIV. After a rapid spread, the outbreak subsided, and the prevalence of HIV among IDUs remained low (<2%). The purpose of the study was to describe the outbreak in order to recognise factors that have influenced the spread and restriction of the outbreak, and thus to find tools for HIV preven-tion. Data on Finnish IDUs newly diagnosed HIV-positive between 1998 and 2005 was collected through interviews and patient documents. Study I compared markers of disease progression between 93 Finnish IDUs and 63 Dutch IDUs. In study II, geographical spread of the HIV outbreak was examined and compared with the spatial distribution of employed males. In study III, risk behaviour data from interviews of 89 HIV-positive and 207 HIV-negative IDUs was linked, and prevalence and risk factors for unprotected sex were evaluated. In study IV, data on 238 newly diagnosed IDUs was combined with data on 675 sexually transmitted HIV cases, and risk factors for late HIV diagnosis (CD4 cell count <200/µL, or AIDS at HIV diagnosis) were analysed. Finnish IDUs infected with CRF01_AE exhibited higher viral loads than did Amsterdam IDUs infected with subtype B, but there was no difference in CD4 development. The Finnish IDU outbreak spread and was restricted socially in a marginalised IDU population and geographically in areas characterised by low proportions of employed males. Up to 40% of the cases in the two clusters outside the city centre had no contact with the centre, where needle exchange services were available since 1997. Up to 63% of HIV-positive and 80% of HIV-negative sexually active IDUs reported inconsistent condom use, which was associated with steady relationships and recent inpatient addiction care. Com-pared to other transmission groups, HIV-positive IDUs were diagnosed earlier in their infection. The proportion of late diagnosed HIV cases in all transmission groups was 23%, but was only 6% among IDUs diagnosed during the first four years of the epidemic. The high viral load in early HIV infection may have contributed to the rapid spread of recombinant virus in the Finnish outbreak. The outbreak was restricted to a marginalised IDU population, and limited spatially to local pockets of pov-erty. To prevent HIV among IDUs, these pockets should be recognised and reached early through outreach work and the distribution of needle exchange and other prevention activities. To prevent the sexual transmission of HIV among IDUs, prevention programmes should be combined with addiction care services and targeted at every IDU. The early detection of the outbreak and early implementation of needle exchange programmes likely played a crucial role in re-versing the IDU outbreak.

Sinusta kiinni : Tutkimus puolisohoivan arjen toimijuuksista

Depending on you – A study of spousal care, everyday life and agency The present aim of the aging policy is to promote old peoples´ possibilities to live at their own home. It is also many elderly couples´ own wish. At home a persons spouse is the most natural care giver, if she or he is able to give care. Spousal care means living together, giving and receiving care and interdependency between the spouses. The aim of the policy is to support spousal care by paying financial support to a carer and arrang-ing formal home care services. The purpose of this research is to study the agency of care giving and receiving spouses as care givers and receivers and also as home care service users. The data of the study consist of the interviews of 21 elderly couples. Both spouses were interviewed seper-ately, with the exception of five couples who were interviewed together. In these inter-views a care receiver had difficulties in communicating by speaking and a spouse was her or his interpreter. The study is based on a social constructionistic and a discourse analytical view of con-struction of meanings in human communication. Talking is a social action: people achieve identities, realities, social order and social relationship through talking. In inter-pretating the spouses agency I have used of Harvey Sack´s method of Membership Categorization Device (MCD). The spouses construct social categories which made the meaning of their agency visible. Care changes the routines and actions of everyday life. The couples have to negotiate their duties and rights between each other. Care giving and receiving are both physical and emotional actions. In the end it becomes a part of the couples´ normal life. The pur-pose of couples´ action is to live together as long as possible. They want to strengthen both their own agency and their spouses´ agency. The living together depends on both of them. The spouses decided together what home care services they would like to use and on which conditions they have to use services. Spouses have different kind of agencies as service users which describe their relationship and confidency on formal home care support and services. Services must support the elderly couples´ shared life at home. They cannot be against the conditions on the spousal care. When you want to arrange services to elderly care giving and receiving couples, you have to consider their own wishes and the meanings of their own relationship and shared life.

Hospital social work in Australia: Emerging trends or more of the same?

Social work in health care has been established for more than 100 years and is one of the largest areas of practice for social workers. Over time, demographic changes and growth in the aging population, increased longevity rates, an explosion in rates of chronic illness together with rapidly increasing cost of health care have created serious challenges for acute hospitals and health social workers. This article reviews the Australian health care system and policies with particular emphasis on the public hospital system. It then examines current hospital social work roles, including the continued role in discharge planning and expanding responsibility for emerging client problems, such as patient complexity, legal, and carer issues. The article concludes with a discussion of evolving issues and challenges facing health social work to ensure that social work remain relevant within this practice context.

Sosiaalipalveluja kaikille ja kaiken ikää? : Tutkimus suomalaisten mielipiteistä ja kokemuksista sosiaalipalveluista sekä niiden suhteesta legitimiteettiin

This research analyses opinions on the system of social welfare services from the point of view of clients and the public in general in Finland. The approach is quantitative, drawing on theories of the welfare-state tradition. The data used comes from the comprehensive Welfare and Services in Finland survey compiled by STAKES. While previous research on the welfare state has predominantly focused on surveying public opinion on social protection, this research focuses on social welfare services. The main focus of this research is on publicly funded care provided by municipal social welfare services. In this research, social welfare services include child day care, services for people with disabilities, home-help services, counselling by social workers and social assistance. The research considered in particular whether the clients or the population has different opinions towards social welfare services or social benefits. In addition, the research partly covers areas of informal care provided by family and friends. The research material consisted of the STAKES Welfare and Services in Finland survey. The data was compiled in 2004 and 2006 by Statistics Finland. The research comprises five articles. Additional data have been extracted from social welfare statistics and registers. Multiple approaches were applied in the survey on welfare and services the methods in this research included interviews by phone and mail, and register data. The sample size was 5 810 people in 2004 and 5 798 in 2006. The response rates were 82.7% and 83.7%, respectively. The results indicate that a large majority (90%) of the Finnish population is of the opinion that the public sector should bear the main responsibility for organising social and health services. The system of social welfare services and its personnel have strong public support 73% and 80% respectively. However, new and even negative tones have emerged in the Finnish debate on social welfare services. Women are increasingly critical of the performance of social welfare services and the level of social protection. Furthermore, this study shows that women more often than men wish to see an increase in the amount of privately organised social welfare services. Another group critical of the performance of social welfare services are pensioners. People who had used social welfare services were more critical than those who had not used them. Thus, the severest criticism was received from the groups who use and gain most from public services and benefits. However, the education and income variables identified in earlier studies no longer formed a significant dividing line, although people with higher education tend to foster a more positive view of the performance of social welfare services as well as the level of social protection. Income differences did not bear any significance, that is, belonging to a high or low income group was not a determining factor in the attitude towards social welfare services or social benefits. According to the research, family and friends still form an informal yet significant support network in people's everyday lives, and its importance has not been diminished by services provided by the welfare state. The Finnish public considers child day care the most reliable form of social welfare services. Indeed, child day care has become the most universal sector of our system of social welfare services. Other services that instil confidence included counselling by social workers and services for people with disabilities. On the other hand, social assistance and home-help services received negative feedback. The negative views were based on a number of arguments. One argument contends that the home-help service system, which was originally intended for universal use, is crumbling. The preventive role of home-help services has been reduced. These results mirror the increasingly popular opinion that social welfare services are not produced for all those who need them, but to an increasing extent for a select few of them. Municipalities are struggling with their finances and this, combined with negative publicity, has damaged the public's trust in some municipal social welfare services. A welfare state never achieves a stable condition, but must develop over time, as the world around it changes. Following the 1990's recession, we are now in a position where we can start to develop a system that responds to the needs of the next generation. Study results indicating new areas of dissatisfaction reflect the need to develop and improve the services provided. It is also increasingly essential that social welfare services pay attention to the opinions of clients and the public. Should the gap between opinions and actual activities increase, the legitimacy of the whole system would be questioned. Currently, the vast majority of Finns consider the system of social welfare services adequate, which provides us with the continuity required to maintain and improve client-oriented and reasonably priced social welfare services. Paying attention to the signals given by clients and the general public, and reacting to them accordingly, will also secure the development and legitimacy of the system in the future.

Perinatal mortality and maternal health in rural China

Background and context Since the economic reforms of 1978, China has been acclaimed as a remarkable economy, achieving 9% annual growth per head for more than 25 years. However, China's health sector has not fared well. The population health gains slowed down and health disparities increased. In the field of health and health care, significant progress in maternal care has been achieved. However, there still remain important disparities between the urban and rural areas and among the rural areas in terms of economic development. The excess female infant deaths and the rapidly increasing sex ratio at birth in the last decade aroused serious concerns among policy makers and scholars. Decentralization of the government administration and health sector reform impacts maternal care. Many studies using census data have been conducted to explore the determinants of a high sex ratio at birth, but no agreement has been so far reached on the possible contributing factors. No study using family planning system data has been conducted to explore perinatal mortality and sex ratio at birth and only few studies have examined the impact of the decentralization of government and health sector reforms on the provision and organization of maternal care in rural China. Objectives The general objective of this study was to investigate the state of perinatal health and maternal care and their determinants in rural China under the historic context of major socioeconomic reforms and the one child family planning policy. The specific objectives of the study included: 1) to study pregnancy outcomes and perinatal health and their correlates in a rural Chinese county; 2) to examine the issue of sex ratio at birth and its determinants in a rural Chinese county; 3) to explore the patterns of provision, utilization, and content of maternal care in a rural Chinese county; 4) to investigate the changes in the use of maternal care in China from 1991 to 2003. Materials and Methods This study is based on a project for evaluating the prenatal care programme in Dingyuan county in 1999-2003, Anhui province, China and a nationwide household health survey to describe the changes in maternal care utilization. The approaches used included a retrospective cohort study, cross sectional interview surveys, informant interviews, observations and the use of statistical data. The data sources included the following: 1) A cohort of pregnant women followed from pregnancy up to 7 days after birth in 20 townships in the study county, collecting information on pregnancy outcomes using family planning records; 2) A questionnaire interview survey given to women who gave birth between 2001 and 2003; 3) Various statistical and informant surveys data collected from the study county; 4) Three national household health interview survey data sets (1993-2003) were utilized, and reanalyzed to described the changes in maternity care utilization. Relative risks (RR) and their confidence intervals (CI) were calculated for comparison between parity, approval status, infant sex and township groups. The chi-square test was used to analyse the disparity of use of maternal care between and within urban and rural areas and its trend across the years in China. Logistic regression was used to analyse the factors associated with hospital delivery in rural areas. Results There were 3697 pregnancies in the study cohort, resulting in 3092 live births in a total population of 299463 in the 20 study townships during 1999-2000. The average age at pregnancy in the cohort was 25.9 years. Of the women, 61% were childless, 38% already had one child and 0.3% had two children before the current pregnancy. About 90% of approved pregnancies ended in a live birth while 73% of the unapproved ones were aborted. The perinatal mortality rate was 69 per thousand births. If the 30 induced abortions in which the gestational age was more than 28 weeks had been counted as perinatal deaths, the perinatal mortality rate would have been as high as 78 per thousand. The perinatal mortality rate was negatively associated with the wealth of the township. Approximately two thirds of the perinatal deaths occurred in the early neonatal period. Both the still birth rate and the early neonatal death rate increased with parity. The risk of a stillbirth in a second pregnancy was almost four times that for a first pregnancy, while the risk of early neonatal deaths doubled. The early neonatal mortality rate was twice as high for female as for male infants. The sex difference in the early neonatal mortality rate was mainly attributable to mortality in second births. The male early neonatal mortality rate was not affected by parity, while the female early neonatal mortality rate increased dramatically with parity: it was about six times higher for second births than for first births. About 82% early neonatal deaths happened within 24 hours after birth, and during that time, girls were almost three times more likely to die than boys. The death rate of females on the day of birth increased much more sharply with parity than that of males. The total sex ratio at birth of 3697 registered pregnancies was 152 males to 100 females, with 118 and 287 in first and second pregnancies, respectively. Among unapproved pregnancies, there were almost 5 live-born boys for each girl. Most prenatal and delivery care was to be taken care of in township hospitals. At the village level, there were small private clinics. There was no limitation period for the provision of prenatal and postnatal care by private practitioners. They were not permitted to provide delivery care by the county health bureau, but as some 12% of all births occurred either at home or at private clinics; some village health workers might have been involved. The county level hospitals served as the referral centers for the township hospitals in the county. However, there was no formal regulation or guideline on how the referral system should work. Whether or not a woman was referred to a higher level hospital depended on the individual midwife's professional judgment and on the clients' compliance. The county health bureau had little power over township hospitals, because township hospitals had in the decentralization process become directly accountable to the township government. In the township and county hospitals only 10-20% of the recurrent costs were funded by local government (the township hospital was funded by the township government and the county hospital was funded by the county government) and the hospitals collected user fees to balance their budgets. Also the staff salaries depended on fee incomes by the hospital. The hospitals could define the user charges themselves. Prenatal care consultations were however free in most township hospitals. None of the midwives made postnatal home visits, because of low profit of these services. The three national household health survey data showed that the proportion of women receiving their first prenatal visit within 12 weeks increased greatly from the early to middle 1990s in all areas except for large cities. The increase was much larger in the rural areas, reducing the urban-rural difference from more than 4 times to about 1.4 times. The proportion of women that received antenatal care visits meeting the Ministry of Health s standard (at least 5 times) in the rural areas increased sharply from 12% in 1991-1993 to 36% in 2001-2003. In rural areas, the proportion increase was much faster in less developed areas than in developed areas. The hospital delivery rate increased slightly from 90% to 94% in urban areas while the proportion increased from 27% to 69% in rural areas. The fastest change was found to be in type 4 rural areas, where the utilization even quadrupled. The overall difference between rural and urban areas was substantially narrowed over the period. Multiple logistic regression analysis shows that time periods, residency in rural or urban areas, income levels, age group, education levels, delivery history, occupation, health insurance and distance from the nearest health care facilities were significantly associated with hospital delivery rates. Conclusions 1. Perinatal mortality in this study was much higher than that for urban areas as well as any reported rate from specific studies in rural areas of China. Previous studies in which calculations of infant mortality were not based on epidemiological surveys have been shown to underestimate the rates by more than 50%. 2. Routine statistics collected by the Chinese family planning system proved to be a reliable data source for studying perinatal health, including still births, neonatal deaths, sex ratio at birth and among newborns. National Household Health Survey data proved to be a useful and reliable data source for studying population health and health services. Prior to this research there were few studies in these areas available to international audiences. 3.Though perinatal mortality rate was negatively associated with the level of township economic development, the excess female early neonatal mortality rate contributed much more to high perinatal mortality rate than economic factors. This was likely a result of the role of the family planning policy and the traditional preferences for sons, which leads to lethal neglect of female newborns and high perinatal mortality. 4. The selective abortions of female foetuses were likely to contribute most to the high sex ratio at birth. The underreporting of female births seemed to have played a secondary role. The higher early neonatal mortality rate in second-born as compared to first-born children, particularly in females, may indicate that neglect or poorer care of female newborn infants also contributes to the high sex ratio at birth or among newborns. Existing family planning policy proved not to effectively control the steadily increased birth sex ratio. 5. The rural-urban gap in service utilization was on average significantly narrowed in terms of maternal healthcare in China from 1991 to 2003. This demonstrates that significant achievements in reducing inequities can be made through a combination of socio-economic development and targeted investments in improving health services, including infrastructure, staff capacities, and subsidies to reduce the costs of service utilization for the poorest. However, the huge gap which persisted among cities of different size and within different types of rural areas indicated the need for further efforts to support the poorest areas. 6. Hospital delivery care in the study county was better accepted by women because most of women think delivery care was very important while prenatal and postnatal care were not. Hospital delivery care was more systematically provided and promoted than prenatal and postnatal care by township hospital in the study area. The reliance of hospital staff income on user fees gave the hospitals an incentive to put more emphasis on revenue generating activities such as delivery care instead of prenatal and postnatal care, since delivery care generated much profits than prenatal and postnatal care . Recommendations 1. It is essential for the central government to re-assess and modify existing family planning policies. In order to keep national sex balance, the existing practice of one couple one child in urban areas and at-least-one-son a couple in rural areas should be gradually changed to a two-children-a-couple policy throughout the country. The government should establish a favourable social security policy for couples, especially for rural couples who have only daughters, with particular emphasis on their pension and medical care insurance, combined with an educational campaign for equal rights for boys and girls in society. 2. There is currently no routine vital-statistics registration system in rural China. Using the findings of this study, the central government could set up a routine vital-statistics registration system using family planning routine work records, which could be used by policy makers and researchers. 3. It is possible for the central and provincial government to invest more in the less developed and poor rural areas to increase the access of pregnant women in these areas to maternal care services. Central government together with local government should gradually provide free maternal care including prenatal and postnatal as well as delivery care to the women in poor and less developed rural areas. 4. Future research could be done to explore if county and the township level health care sector and the family planning system could be merged to increase the effectiveness and efficiency of maternal and child care. 5. Future research could be done to explore the relative contribution of maternal care, economic development and family planning policy on perinatal and child health using prospective cohort studies and community based randomized trials. Key words: perinatal health, perinatal mortality, stillbirth, neonatal death, sex selective abortion, sex ratio at birth, family planning, son preference, maternal care, prenatal care, postnatal care, equity, China

Information Technology Development Needs in Community Pharmacies : A Strategic Approach

In the context of health care, information technology (IT) has an important role in the operational infrastructure, ranging from business management to patient care. An essential part of the system is medication management in inpatient and outpatient care. Community pharmacists strategy has been to extend practice responsibilities beyond dispensing towards patient care services. Few studies have evaluated the strategic development of IT systems to support this vision. The objectives of this study were to assess and compare independent Finnish community pharmacy owners and staff pharmacists priorities concerning the content and structure of the next generation of community pharmacy IT systems, to explore international experts visions and strategic views on IT development needs in relation to services provided in community pharmacies, to identify IT innovations facilitating patient care services and to evaluate their development and implementation processes, and to assess community pharmacists readiness to adopt innovations. This study applied both qualitative and quantitative methods. A qualitative personal interview of 14 experts in community pharmacy services and related IT from eight countries and a national survey of Finnish community pharmacy owners (mail survey, response rate 53%, n=308), and of a representative sample of staff pharmacists (online survey, response rate 22%, n=373) were conducted. Finnish independent community pharmacy owners gave priority to logistical functions but also to those related to medication information and patient care. The managers and staff pharmacists have different views of the importance of IT features, reflecting their different professional duties in the community pharmacy. This indicates the need for involving different occupation groups in planning the new IT systems for community pharmacies. A majority of the international experts shared the vision of community pharmacy adopting a patient care orientation; supported by IT-based documentation, new technological solutions, access to information, and shared patient data. Community pharmacy IT innovations were rare, which is paradoxical because owners and staff pharmacists perception of their innovativeness was seen as being high. Community pharmacy IT systems development processes usually had not undergone systematic needs assessment research beforehand or evaluation after the implementation and were most often coordinated by national governments without subsequent commercialization. Specifically, community pharmacy IT developments lack research, organization, leadership and user involvement in the process. Those responsible for IT development in the community pharmacy sector should create long-term IT development strategies that are in line with community pharmacy service development strategies. This could provide systematic guidance for future projects to ensure that potential innovations are based on a sufficient understanding of pharmacy practice problems that they are intended to solve, and to encourage strong leadership in research, development of innovations so that community pharmacists potential innovativeness is used, and that professional needs and strategic priorities will be considered even if the development process is led by those outside the profession.

Sosiaaliturvan ulkopuolella - kokemuksia kansalaisuuden reunalta

Muuttaessaan maasta toiseen ihminen kohtaa useita rajoja. Ylittäessään kohdemaan valtion rajan hän kulkee läpi ensimmäisestä maahanmuuton portista. Toinen raja erottaa tilapäiset asukkaat pysyvistä: tämän maahanmuuton toisen portin läpikulkemisen myötä yksilö pääsee osalliseksi sosiaalisista oikeuksista. Maahanmuuton viimeisestä portista kuljettuaan yksilö saavuttaa kyseisen valtion kansalaisuuden. (Hammar 1990, 21.) Tässä pro gradu -tutkielmassa tarkastelen toisen maahanmuuton portin aukeamista ja sosiaaliturvan piiriin pääsyä odottavien maahan-muuttajien kokemuksia. Käytän tarkastelussa sosiaalisen kansalaisuuden ja marginaalisuuden käsitteitä. Tutkielmassa selvitän, miten sosiaali- ja terveyspalveluiden sekä toimeentuloturvan ulkopuolelle jääminen vaikuttaa maahanmuuttajien arkeen ja miten he kokevat osallisuutensa ja jäsenyytensä yhteiskunnassa. Tutkimus on lähtökohdiltaan fenomenologis-hermeneuttinen ja sovellan lähestymistapana ko-kemuksiin keskittyvän narratiivista tutkimusta. Tutkimusaineisto on koottu kevään 2011 aikana ja se koostuu 10 teemahaastattelusta. Haastateltavien maahanmuuton keinot ja syyt vaihtelivat: he olivat saapuneet Suomeen perhesyistä, työn vuoksi tai hakeakseen turvaa. Haastateltavat tavoitettiin Helsingin Diakoniaopiston, Pro-tukipisteen, Kansainvälisen seurakunnan ja tuttava-verkostojen kautta. Aineiston analyysi toteutettiin sisällönanalyysillä Atlas-ohjelman avulla syksyn 2011 aikana. Toisen maahanmuuton portin aukeamisen odottaminen oli raskaaksi: tuota aikaa leimasi epä-varmuus, tyhjyys ja yksinäisyys. Sosiaaliturvan ulkopuolella jääminen aiheutti osalle haastatel-tavista taloudellisia vaikeuksia sekä ongelmia terveydenhuollon palveluiden piiriin pääsemisessä. Toisaalta apua hakeneet haastateltavat olivat sitä lopulta saaneet. Auttamistyön ammattilaiset ja maistraatti saivat haastateltavien kertomuksissa portinvartijan aseman. Kaikille sosiaaliturvan ulkopuolelle jääminen ei ollut ongelma vaan he kokivat sosiaaliturvan puutetta suuremmaksi ongelmaksi työnteko-oikeuden puuttumisen. Kuulumisen ja ulkopuolisuuden kokemus voivat olla läsnä samanaikaisesti, ja kuulumisesta neuvotellaan jatkuvasti esimerkiksi sosiaalisessa kanssakäymisessä tai palveluita hakiessa. Insti-tutionaaliset käytännöt ja poiskäännyttämisen kokemukset tuottavat marginaalisia identiteettejä. Tasavertainen oikeus sosiaaliturvaan vahvistaa kokemusta kuulumisesta ja kodista. Sosiaaliturva ei kuitenkaan yksin määritä kuulumisen ja kodin kokemusta vaan siihen vaikuttavat myös muut tekijät. Näistä tärkeimmät ovat kehon fyysinen sijoittuminen Suomeen, perhe- ja ystä-vyyssuhteet, työ, asunto ja rasismin kokemukset.

Skill premium effects on fertility and female labor force supply

Published as an article in: Journal of Population Economics, 2004, vol. 17, issue 1, pages 1-16.

O acesso aos exames de alta complexidade nos planos de saúde privados na perspectiva dos usuários

A dissertação trata do acesso aos serviços de alta complexidade, particularmente os exames diagnósticos e complementares, estudado entre usuários de planos de saúde privados que buscam atendimento e diagnóstico especializado. Desde a década de 80 o usuário do sistema público de saúde vem procurando a saúde suplementar. Contudo, afirmar que o acesso é garantido no domínio privado, através da contratação dos planos de saúde, é uma incerteza que rodeia a inspiração para esta pesquisa, que se justifica pela relevância de ações que possibilitem a melhora da qualidade regulatória dos planos de saúde, a partir do controle social de seus usuários. O objetivo geral é analisar as percepções do acesso aos exames de alta complexidade nos serviços de saúde privados entre usuários de planos de saúde. Os objetivos específicos são descrever as percepções dos usuários de planos de saúde acerca do acesso aos exames de alta complexidade; analisar as motivações dos usuários de planos de saúde privados para a realização de exames de alta complexidade através da rede privada de assistência; e analisar o nível de satisfação dos usuários de planos de saúde quanto ao acesso aos exames de alta complexidade. A metodologia é qualitativa-descritiva, onde a amostra foi de trinta usuários de planos de saúde, acima de 18 anos, selecionados no campo de estudo no ano de 2010. O cenário de estudo foi um laboratório privado de medicina diagnóstica no Rio de Janeiro. As técnicas de coleta de dados utilizadas foram formulário e entrevista individual estruturada. A análise do formulário foi realizada através de estatística descritiva, e as entrevistas através da análise de conteúdo temática-categorial. Os usuários de plano de saúde declararam que o acesso é garantido com facilidade para os exames de alta complexidade. Suas principais motivações para a realização desses exames na rede privada de assistência foram caracterizadas pela rapidez de atendimento, flexibilidade e facilidade de marcação pela internet, telefone ou pessoalmente no laboratório estudado, pronta entrega dos resultados, dificuldade e morosidade do atendimento do SUS, localização do prestador credenciado próxima de bairros residenciais ou do trabalho, resolutividade diagnóstica de imagem de excelência, possibilidade de escolha pelo usuário entre as modalidades aberta e fechada de ressonância magnética e tomografia computadorizada, além da densitometria óssea que foram facilmente acessíveis a todos os sujeitos da pesquisa. O nível de satisfação foi correspondido com a rapidez na realização dos exames em caráter eletivo e de urgência quase equiparados na escala de tempo de acordo com os usuários. Contudo, embora as notas de avaliação dos usuários quanto aos seus planos de saúde tenham sido altas, foram abordadas algumas dificuldades, tais como: prazos de validade dos pedidos médicos com datação prévia; solicitações de senhas de autorização pela operadora; burocracia nos procedimentos de agendamento; dificuldades de acesso para tratamentos como implantes, fisioterapia, RPG, pilates, home care, consultas de check up; negação de reembolsos; restrição de materiais cirúrgicos, em especial as próteses e órteses; e restrições específicas de grau para cirurgias de miopia. Conclui-se que o atendimento rápido dos exames de imagem de alto custo na amostra foi descrito como satisfatório, embora a percepção de rapidez possa variar em função do tipo de produto do plano de saúde privado contratado, com necessidade de melhoria regulatória em alguns aspectos pontuais da saúde suplementar.