An evaluation of Primary health care system in Kerala

The thesis entitled An Evaluation of Primary Health Care System in Kerala. The present study is intended to examine the working of primary health care system and its impact on the health status of people. The hypothesis tested in the thesis includes, a. The changes in the health profile require reallocation of resources of primary health care system, b. Rate of utilization depends on the quality of services provided by primary health centers, and c. There is a significant decline in the operational efficiency of the primary health care system. The major elements of primary health care stated in the report of AlmaAta International Conference on Primary Health Care (WHO, 1994)” is studied on the basis of the classification of the elements in to three: Preventive, Promotive, and Curative measures. Preventive measures include Maternal and Child Health Care including family Planning. Provision of water and sanitation is reviewed under promotive measures. Curative measures are studied using the disease profile of the study area. Collection of primary data was done through a sample survey, using pre-tested interview schedule of households of the study area. Multi stage random sampling design was used for selecting the sample. The design of the present study is both descriptive and analytical in nature. As far as the analytical tools are concerned, growth index, percentages, ratios, rates, time series analysis, analysis of variance, chi square test, Z test were used for analyzing the data. Present study revealed that no one in these areas was covered under any type of health insurance. Conclusion states that considering the present changes in the health profile, traditional pattern of resource allocation should be altered to meet the urgent health care needs of the people. Preventive and promotive measures like health education for giving awareness among people to change health habits, diet pattern, life style etc. are to be developed. Proper diagnosis and treatment of the disease at the beginning of the stage itself may help to cure majority of disease. For that, Public health policy must ensure the primary health care as enunciated at Alma- Ata international Conference. At the same time Public health is not to be treated as the sole responsibility of the government. Active community participation is an essential means to attain the goals.

Content of prenatal care and spontaneous preterm birth: Findings from the 1988 National Maternal and Infant Health Survey

The purposes of this study were to examine (1) the relationship between selected components of the content of prenatal care and spontaneous preterm birth; and (2) the degree of comparability between maternal and caregivers' responses regarding the number of prenatal care visits, selected components of the content of prenatal care, and gestational age, based on analyses of the 1988 National Maternal and Infant Health Survey conducted by the National Centers for Health Statistics. Spontaneous preterm birth was subcategorized into very preterm and moderately preterm births, with term birth as the controls. The study population was limited to non-Hispanic Anglo- and African-American mothers. The racial differences in terms of birth outcomes were also compared.^ This study concluded that: (1) there was not a high degree of comparability (less than 80%) between maternal and prenatal care provider's responses regarding the number of prenatal care visits and the content of prenatal care; (2) there was a low degree of comparability (less than 50%) between maternal and infant's hospital of delivery responses regarding gestational age at birth; (3) there were differences in selected components of the content of prenatal care between the cases and controls, overall and stratified by ethnicity (i.e., hemoglobin/hematocrit test, weight measurement, and breast-feeding counseling), but they were confounded with missing values and associated preterm delivery bias; (4) there were differences in selected components of the content of prenatal care between Anglo- and African-American cases (i.e., vitamin/mineral supplement advice, weight measurement, smoking cessation and drug abuse counseling), but they, too, were difficult to interpret definitively due to item nonresponse and preterm delivery biases; (5) no significant predictive association between selected components of the content of prenatal care and spontaneous preterm birth was found; and (6) inadequate/intermediate prenatal care and birth out of wedlock were found to be associated with moderately preterm birth.^ Future research is needed to examine the validity of maternal and prenatal care providers' responses and identify the sources of disagreement between their responses. In addition, further studies are needed to examine the relationship between the quality of prenatal care and preterm birth. Finally, the completeness and quality of patient and provider data on the utilization and content of prenatal care needs to be strengthened in subsequent studies. ^

Barriers to adolescent and young men's access of reproductive health care

Purpose. The purpose of this study was to identify the health needs and barriers that young men face in accessing health care and family planning services and to identify what health centers can do to attract young men to the clinic. A focus group format was used to elicit ideas from participants. ^ Methods. Forty-eight young men participated in nine focus groups. The young men were asked about the health issues they have, the barriers they face in accessing reproductive health care, and what clinics can do to attract young men to the clinic. Thematic analysis principles were used to identify the main themes that emerged in the focus groups. ^ Results. Sexually transmitted infections (STIs), mental health problems, and drug use were the major health issues that were mentioned in the majority of the focus groups. The main barriers discussed in the focus groups were attitudinal factors such as young men thinking it is unmanly to seek help, emotional factors such as young men not seeking help because of their ego or pride, and institutional factors such as the location of the clinic. The main suggestions for improvements in the health clinic included decreasing waiting times, emphasizing the fact that the clinics are free for males, having more female nurses, and encouraging clinic staff to treat the young men with respect. Young men suggested advertising and promoting the clinic in schools, in the community, and through the media. Focus group participants also provided their input about the design and format of the clinic flyer. ^ Conclusions. Many studies focus on the reproductive health care needs of adolescent and young females. This study has helped to show that young men also have health care needs and face barriers to accessing reproductive health care services.^

Health care providers' opinions on abortion: a study for the implementation of the legal abortion public policy in the Province of Santa Fe, Argentina

Background: In Argentina, abortion has been decriminalized under certain circumstances since the enactment of the Penal Code in 1922. Nevertheless, access to abortion under this regulatory framework has been extremely limited in spite of some recent changes. This article reports the findings of the first phase of an operations research study conducted in the Province of Santa Fe, Argentina, regarding the implementation of the local legal and safe abortion access policy. Methods: The project combined research and training to generate a virtuous circle of knowledge production, decision-making, and the fostering of an informed healthcare policy. The project used a pre-post design of three phases: baseline, intervention, and evaluation. It was conducted in two public hospitals. An anonymous self-administered questionnaire (n = 157) and semi-structured interviews (n = 27) were applied to gather information about tacit knowledge about the regulatory framework; personal opinions regarding abortion and its decriminalization; opinions on the requirements needed to carry out legal abortions; and service’s responses to women in need of an abortion. Results: Firstly, a fairly high percentage of health care providers lack accurate information on current legal framework. This deficit goes side by side with a restrictive understanding of both health and rape indications. Secondly, while a great majority of health care providers support abortion under the circumstances consider in the Penal Code, most of them are reluctant towards unrestricted access to abortion. Thirdly, health care providers’ willingness to perform abortions is noticeably low given that only half of them are ready to perform an abortion when a woman’s life is at risk. Willingness is even lower for each of the other current legal indications. Conclusions: Findings suggest that there are important challenges for the implementation of a legal abortion policy. Results of the study call for specific strategies targeting health care providers in order to better inform about current legal abortion regulations and to sensitize them about abortion social determinants. The interpretation of the current legal framework needs to be broadened in order to reflect a comprehensive view of the health indication, and stereotypes regarding women’s sexuality and abortion decisions need to be dismantled.

Stressors, mediators, and health care outcomes of home enteral nutrition in family caregivers and their older adult care recipients

Family caregivers manage home enteral nutrition (HEN) for over 77% of an estimated 1 of every 400 Medicare recipients. Increasing usage of HEN in older adults combined with reliance on family caregivers raises concerns for the quality, outcomes, and costs of care. These concerns are relevant in light of Medicare limitations on nursing assistance and non-reimbursement for nutrition services, despite annual costs of over $600 million. This study applied stress process theories to assess stressor, mediator, and outcome variables salient to HEN and caregiving. In-home structured interviews occurred with a multi-ethnic sample of 30 caregiving dyads at 1–3 months after discharge on HEN. Care recipients were aged ≥60 (M = 68.4 years) and did not have dementia. Caregivers were aged ≥21, unpaid, and lived within 45 minutes of care recipients. Caregivers performed an average of 19.7 tasks daily for 61.9 hours weekly. Training needs were identified for 33 functional, care management, technical, and nutritional tasks. Preparedness scores were low (M = 1.73/4.0), and positively correlated with competence, self-rated quality of care and positive feelings, and negatively with overload, role captivity, and negative feelings (Ps < .05). Caregivers had multiple changes in lifestyle and dietary behaviors. Lifestyle changes positively correlated with overload, and negatively with preparedness and positive feelings. Dietary changes positively correlated with number of tasks, overload, role captivity and negative feelings, and negatively with preparedness (Ps < .01). Fifty-seven percent of caregivers aged >50 were at nutrition risk. Care recipients fared worse. Average weight change was −4.35 pounds (P < .001). Physical complications interrupted daily enteral infusions. Water intake was half of fluid need and associated with signs of dehydration (P < .001). Physical and social function was poor, with older subjects more impaired ( P < .04). Those with better prepared or less overloaded caregivers had higher functionality and QOL (P < .002). Complications, type of feeding tube, and caregiver preparedness correlated with frequency of health care utilization (Ps < .05). Efficacy of HEN in older adults requires specialized caregiver training, attention to caregivers' needs, and frequent monitoring from a highly skilled multidisciplinary team including dietitians. ^

The Affordable Care Act and the Transformation of US Health Care

The neoliberal period was accompanied by a momentous transformation within the US health care system.  As the result of a number of political and historical dynamics, the healthcare law signed by President Barack Obama in 2010 ‑the Affordable Care Act (ACA)‑ drew less on universal models from abroad than it did on earlier conservative healthcare reform proposals. This was in part the result of the influence of powerful corporate healthcare interests. While the ACA expands healthcare coverage, it does so incompletely and unevenly, with persistent uninsurance and disparities in access based on insurance status. Additionally, the law accommodates an overall shift towards a consumerist model of care characterized by high cost sharing at time of use. Finally, the law encourages the further consolidation of the healthcare sector, for instance into units named “Accountable Care Organizations” that closely resemble the health maintenance organizations favored by managed care advocates. The overall effect has been to maintain a fragmented system that is neither equitable nor efficient. A single payer universal system would, in contrast, help transform healthcare into a social right.

Lack of access and continuity of adult health care: a national population-based survey

OBJECTIVE To describe the lack of access and continuity of health care in adults.METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

The role of public policy in health care promotion: a comparative perspective

Comunicação apresentada na 17th International conference on Health Promotio Hospitals and Health Services em Hersonissis, Crete, Grécia de 6-8 de maio de 2009

Negotiation advantages of professional associations in health care

In several instances, third-party payers negotiate prices of health care services with providers. We show that a third-party payer may prefer to deal with a professional association than with the sub-set constituted by the more efficient providers, and then apply the same price to all providers. The reason for it is the increase in the bargaining position of providers. The more efficient providers are also the ones with higher profits in the event of negotiation failure. This allows them to ext act a higher surplus from the third-party payer.

Screening primary-care patients forgoing health care for economic reasons.

BACKGROUND: Growing social inequities have made it important for general practitioners to verify if patients can afford treatment and procedures. Incorporating social conditions into clinical decision-making allows general practitioners to address mismatches between patients' health-care needs and financial resources. OBJECTIVES: Identify a screening question to, indirectly, rule out patients' social risk of forgoing health care for economic reasons, and estimate prevalence of forgoing health care and the influence of physicians' attitudes toward deprivation. DESIGN: Multicenter cross-sectional survey. PARTICIPANTS: Forty-seven general practitioners working in the French-speaking part of Switzerland enrolled a random sample of patients attending their private practices. MAIN MEASURES: Patients who had forgone health care were defined as those reporting a household member (including themselves) having forgone treatment for economic reasons during the previous 12 months, through a self-administered questionnaire. Patients were also asked about education and income levels, self-perceived social position, and deprivation levels. KEY RESULTS: Overall, 2,026 patients were included in the analysis; 10.7% (CI95% 9.4-12.1) reported a member of their household to have forgone health care during the 12 previous months. The question "Did you have difficulties paying your household bills during the last 12 months" performed better in identifying patients at risk of forgoing health care than a combination of four objective measures of socio-economic status (gender, age, education level, and income) (R(2) = 0.184 vs. 0.083). This question effectively ruled out that patients had forgone health care, with a negative predictive value of 96%. Furthermore, for physicians who felt powerless in the face of deprivation, we observed an increase in the odds of patients forgoing health care of 1.5 times. CONCLUSION: General practitioners should systematically evaluate the socio-economic status of their patients. Asking patients whether they experience any difficulties in paying their bills is an effective means of identifying patients who might forgo health care.

New roles for community pharmacists in modern health care systems: a challenge for pharmacy education and research.

The academic activities led by the Unit of Community Pharmacy can be classified as translational. Our group is interested in person-centered pharmaceutical services aimed at a more responsible use of drugs (effectiveness, safety, efficiency) in collaboration with physicians and other health care professionals in a primary care setting. The following domains of education and research are high priorities for our group: medication therapy management, medication adherence, integrated care, individualization of therapies, care management for the elderly and e-health.

Data bases for the assessment of medical technologies: examples from Europe.

The assessment of medical technologies has to answer several questions ranging from safety and effectiveness to complex economical, social, and health policy issues. The type of data needed to carry out such evaluation depends on the specific questions to be answered, as well as on the stage of development of a technology. Basically two types of data may be distinguished: (a) general demographic, administrative, or financial data which has been collected not specifically for technology assessment; (b) the data collected with respect either to a specific technology or to a disease or medical problem. On the basis of a pilot inquiry in Europe and bibliographic research, the following categories of type (b) data bases have been identified: registries, clinical data bases, banks of factual and bibliographic knowledge, and expert systems. Examples of each category are discussed briefly. The following aims for further research and practical goals are proposed: criteria for the minimal data set required, improvement to the registries and clinical data banks, and development of an international clearinghouse to enhance information diffusion on both existing data bases and available reports on medical technology assessments.

Long-term assessment of didanosine, lamivudine, and efavirenz in antiretroviral-naive patients: 3-year follow-up.

The aim of this study was to evaluate the long-term efficacy and safety of didadosine (ddI), lamivudine (3TC), and efavirenz (EFV). This was a follow-up to the VESD study, a 12-month open-label, observational, multicenter study of adult patients with HIV infection who started antiretroviral treatment with the ddI-3TC-EFV once-daily regimen. Of the 167 patients originally included, 106 patients remained on the same triple therapy at the end of the study (1 year), and they were offered an extra 24 months of follow-up; 96 were enrolled in this study (VESD-2). Seventy patients out of the initial cohort were still on the same regimen at month 36, with 97% of them with plasma viral load <50 copies /ml. An intention-to-treat analysis showed that the percentage of patients with plasma viral load <50 copies/ml was 73% at 36 months. CD4 cell counts increased 344 cells/microl over the 36 months. Safety and tolerance were good with no unexpected long-term toxicity. After 3 years of treatment with ddI-3TC-EFV, more than 40% of the patients were still receiving the initial antiretroviral therapy with sustained, durable immunovirological benefit and good acceptance. Long-term toxicity and virological failure were low.

Compliance with guidelines-recommended processes in pneumonia: impact of health status and initial signs

Initial care has been associated with improved survival of community-acquired pneumonia (CAP). We aimed to investigate patient comorbidities and health status measured by the Charlson index and clinical signs at diagnosis associated with adherence to recommended processes of care in CAP. We studied 3844 patients hospitalized with CAP. The evaluated recommendations were antibiotic adherence to Spanish guidelines, first antibiotic dose <6 hours and oxygen assessment. Antibiotic adherence was 72.6%, first dose <6 h was 73.4% and oxygen assessment was 90.2%. Antibiotic adherence was negatively associated with a high Charlson score (Odds ratio [OR], 0.91), confusion (OR, 0.66) and tachycardia ≥100 bpm (OR, 0.77). Delayed first dose was significantly lower in those with tachycardia (OR, 0.75). Initial oxygen assessment was negatively associated with fever (OR, 0.61), whereas tachypnea ≥30 (OR, 1.58), tachycardia (OR, 1.39), age >65 (OR, 1.51) and COPD (OR, 1.80) were protective factors. The combination of antibiotic adherence and timing <6 hours was negatively associated with confusion (OR, 0.69) and a high Charlson score (OR, 0.92) adjusting for severity and hospital effect, whereas age was not an independent factor. Deficient health status and confusion, rather than age, are associated with lower compliance with antibiotic therapy recommendations and timing, thus identifying a subpopulation more prone to receiving lower quality care.

Ageing prisoners' health care: analysing the legal settings in Europe and the United States.

BACKGROUND: Relatively little is known about the current health care situation and the legal rights of ageing prisoners worldwide. To date, only a few studies have investigated their rights to health care. However, elderly prisoners need special attention. OBJECTIVE: The aim of this article is to critically review the health care situation of older prisoners by analysing the relevant national and international legal frameworks with a particular focus on Switzerland, England and Wales, and the United States (U.S.). METHODS: Publications on legal frameworks were searched using Web of Science, PubMed, MEDLINE, HeinOnline, and the National Criminal Justice Reference Service. Searches utilizing combinations of keywords relating to ageing prisoners were performed. Relevant reports and policy documents were obtained in order to understand the legal settings in Switzerland, England and Wales, and the U.S. All articles, reports, and policy documents published in English and German between 1774 to June 2012 were included for analysis. Using a comparative approach, an outline was completed to distinguish positive policies in this area. Regulatory approaches were investigated through evaluations of soft laws applicable in Europe and U.S. Supreme Court judgements. RESULTS: Even though several documents could be interpreted as guaranteeing adequate health care for ageing prisoners, there is no specific regulation that addresses this issue completely. The Vienna International Plan of Action on Ageing contributes the most by providing an in-depth analysis of the health care needs of older persons. Still, critical analysis of retrieved documents reveals the lack of specific legislation regarding the health care for ageing prisoners. CONCLUSION: No consistent regulation delineates the provision of health care for ageing prisoners. Neither national nor international institutions have enforceable laws that secure the precarious situation of older adults in prisons. To initiate a change, this work presents critical issues that must be addressed to protect the right to health care and well-being of ageing prisoners. Additionally, it is important to design legal structures and guidelines which acknowledge and accommodate the needs of ageing prisoners.