ResearchPad - health-care-policy https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: A web-based survey]]> https://www.researchpad.co/article/elastic_article_11233 Global surgery is a growing field studying the determinants of safe and affordable surgical care and advocating to gain the global health community's attention. In Cameroon, little is known about the level of knowledge and attitudes of students. Our survey aimed to describe the knowledge and attitudes of Cameroonian medical students towards global surgery.Materials and methodsWe performed an anonymous online survey of final-year Cameroonian medical students. Mann-Whitney U test and Spearman correlation analysis were used for bivariate analysis, and the alpha value was set at 0.05. Odds ratios and their 95% confidence intervals were calculated.Results204 respondents with a mean age of 24.7 years (±2.0) participated in this study. 58.3% were male, 41.6% had previously heard or read about global surgery, 36.3% had taken part in a global surgery study, and 10.8% had attended a global surgery event. Mercy Ships was well known (46.5%), and most students believed that surgical interventions were more costly than medical treatments (75.0%). The mean score of the global surgery evaluation was 47.4% (±29.6%), and being able to recognize more global surgery organizations was correlated with having assumed multiple roles during global surgery studies (p = 0.008) and identifying more global surgery indicators (p = 0.04). Workforce, infrastructure, and funding were highlighted as the top priorities for the development of global surgery in Cameroon.ConclusionMedical students are conscious of the importance of surgical care. They lack the opportunities to nurture their interest and should be taught global surgery concepts and skills. ]]> <![CDATA[Towards universal coverage for nutrition services in children under five years—A descriptive analysis of the capacity of level one hospitals to provide nutrition services in five provinces of Zambia]]> https://www.researchpad.co/article/elastic_article_7846 Malnutrition continues to be a major public health challenge in Zambia. To effectively address this, health systems must be well strengthened to deliver an effective continuum of care. This paper examines health systems issues and services in relation to nutritional support to children under five years, in order to identify gaps and propose interventions towards universal coverage of essential nutrition services.MethodsThis analysis utilized data from a cross sectional mixed-methods study on factors associated with Severe Acute Malnutrition (SAM) in under-five children to assess health facility nutrition services on offer at select level-one hospitals in five out of ten provinces in Zambia. Stata version 13 was used for analysis. We conducted univariate analysis to assess nutrition services offered, functionality of equipment and tools, availability of human resource and human resource development, and availability of drugs used for assessment and management of nutrition-related health outcomes.ResultsWe found large variations in the level of nutrition services on offer across districts and provinces. Eighty-eight percent of all the hospitals sampled provided group nutrition counseling and 92% of the hospitals in our sample offered individual nutrition counseling to their clients. Overall, the existence of referral and counter-referral systems between the Community Based Volunteers and hospitals were the lowest among all services assessed at 48% and 58% respectively. We also found inadequate numbers of human resource across all cadres with an exception of nutritionists as recommended by the Ministry of Health.ConclusionsThis study has revealed a number of gaps in the health system and health service delivery that requires to be addressed; most notably, a lack of tools, policies and guidelines, drugs and health specialists to help care for malnourished infants and children. Our findings also reveal inadequate referral systems between the community and health facilities in the management of severe acute malnutrition. Achieving universal coverage for nutrition services in Zambia will require a lot more attention to the health systems issues found in this study. ]]> <![CDATA[Distinguishing moral hazard from access for high-cost healthcare under insurance]]> https://www.researchpad.co/article/N9aa1c21e-eb0c-47d9-9336-743c9eef5b98

Context

Health policy has long been preoccupied with the problem that health insurance stimulates spending (“moral hazard”). However, much health spending is costly healthcare that uninsured individuals could not otherwise access. Field studies comparing those with more or less insurance cannot disaggregate moral hazard versus access. Moreover, studies of patients consuming routine low-dollar healthcare are not informative for the high-dollar healthcare that drives most of aggregate healthcare spending in the United States.

Methods

We test indemnities as an alternative theory-driven counterfactual. Such conditional cash transfers would maintain an opportunity cost for patients, unlike standard insurance, but also guarantee access to the care. Since indemnities do not exist in U.S. healthcare, we fielded two blinded vignette-based survey experiments with 3,000 respondents, randomized to eight clinical vignettes and three insurance types. Our replication uses a population that is weighted to national demographics on three dimensions.

Findings

Most or all of the spending due to insurance would occur even under an indemnity. The waste attributable to moral hazard is undetectable.

Conclusions

For high-cost care, policymakers should be more concerned about the foregone efficient spending for those lacking full insurance, rather than the wasteful spending that occurs with full insurance.

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<![CDATA["Clicks, likes, shares and comments" a systematic review of breast cancer screening discourse in social media]]> https://www.researchpad.co/article/N8d8d3073-6769-4a60-aed8-e2beb958c228

Background

Unsatisfactory participation rate at population based organised breast cancer screening is a long standing problem. Social media, with 3.2 billion users in 2019, is potentially an important site of breast cancer related discourse. Determining whether these platforms might be used as channels by screening providers to reach under-screened women may have considerable public health significance.

Objectives

By systematically reviewing original research studies on breast cancer related social media discourse, we had two aims: first, to assess the volume, participants and content of breast screening social media communication and second, to find out whether social media can be used by screening organisers as a channel of patient education.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After searching PubMed, ScienceDirect, Web of Science, Springer and Ebsco, 17 studies were found that met our criteria. A systematic narrative framework was used for data synthesis. Owing to the high degree of heterogeneity in social media channels, outcomes and measurement included in this study, a meta-analytic approach was not appropriate.

Results

The volume of breast cancer related social media discourse is considerable. The majority of participants are lay individuals as opposed to healthcare professionals or advocacy groups. The lay misunderstandings surrounding the harms and benefits of mammography is well mirrored in the content of social media discourse. Although there is criticism, breast cancer screening sentiment on the social media ranges from the neutral to the positive. Social media is suitable for offering peer emotional support for potential participants.

Conclusion

Dedicated breast screening websites operated by screening organisers would ensure much needed quality controlled information and also provide space for reliable question and answer forums, the sharing of personal experience and the provision of peer and professional support.

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<![CDATA[Assessment of availability, awareness and perception of stakeholders regarding preschool vision screening in Kumasi, Ghana: An exploratory study]]> https://www.researchpad.co/article/N637f6c02-dcec-48f9-ae4a-5e42bca666db

Background

Regardless of the importance of preschool vision screening (PSVS), there is limited data on the current state of these programs in Africa (particularly Ghana). This study sought to investigate the level of awareness and perception of stakeholders regarding PSVS, its availability and related policies/programmes in the Kumasi Metropolis, Ghana.

Methods

This descriptive cross-sectional study included 100 systematically sampled preschools in the metropolis (using probability proportional-to-size method); 72 private schools and 28 public schools. Convenience sampling was used to recruit stakeholders of preschools (teachers, head teachers, proprietors, administrators, directors, and educationists), and were interviewed using a well-structured questionnaire. Questionnaires were administered to all eligible respondents who were present at the time of data collection.

Results

A total of 344 respondents participated in the study; 123 (35.8%) males and 221 (64.2%) females. The overall mean age of respondents was 37.63 ±12.20 years (18–71 years). Of the respondents, 215 (62.5%), 94 (27.3%), and 35 (10.2%) were enrolled from private schools, public schools, and Metropolitan Education Directorate, respectively. 73.8% of respondents reported the absence of routine PSVS in schools whereas 90.1% reported no written policies for PSVS in schools. Only 63.6% of respondents were aware of PSVS whereas more than half (59.6%) of all respondents perceived PSVS to be very important for preschoolers. Private school ownership was significantly associated with availability of PSVS whereas age, teachers, private school ownership, and preschool experience > 10 years were significantly associated with awareness of PSVS (P < 0.05). However, there was no significant association between sociodemographic factors and perception of PSVS.

Conclusion

PSVS is largely unavailable in most Ghanaian schools. Majority of stakeholders were aware of PSVS and agreed to its implementation and incorporation into schools’ health programmes. There is the need to implement a national programme/policy on preschool vision screening in Ghana.

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<![CDATA[Health promotion with physiolytics: What is driving people to subscribe in a data-driven health plan]]> https://www.researchpad.co/article/N67264028-7608-43f5-811f-a7ed2c904b8b

Data-driven health promotion programs and health plans try to harness the new possibilities of ubiquitous and pervasive physiolytics devices. In this paper we seek to explore what drives people to subscribe to such a data-driven health plan. Our study reveals that the decision to subscribe to a data-driven health plan is strongly influenced by the beliefs of seeing physiolytics as enabler for positive health behavior change and of perceiving health insurances as trustworthy organizations that are capable of securely and righteously manage the data collected by physiolytics.

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<![CDATA[Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo]]> https://www.researchpad.co/article/Nf97c5072-5c0f-45dc-b83f-09c75045dd0d

Background

In their mission to achieve better access to quality healthcare services, mutual health organisations (MHOs) are not limited to providing health insurance. As democratically controlled member organisations, MHOs aim to make people’s voices heard. At national level, they seek involvement in the design of social protection policies; at local level, they seek to improve responsiveness of healthcare services to members’ needs and expectations.

Methods

In this qualitative study, we investigated whether MHOs in the Democratic Republic of Congo (DRC) succeed in defending members’ rights by improving healthcare quality while minimising expenses. The data originate from an earlier in-depth investigation conducted in the DRC in 2016 of the performance of 13 MHOs. We re-analysed this existing dataset and more specifically investigated actions that the MHOs undertook to improve quality and affordability of healthcare provision for their members, using a framework for analysis based on Hirschman’s exit-voice theory. This framework distinguishes four mechanisms for MHO members to use in influencing providers: (1) ‘exit’ or ‘voting with the feet’; (2) ‘co-producing a long voice route’ or imposing rules through strategic purchasing; (3) ‘guarding over the long voice route of accountability’ or pressuring authorities to regulate and enforce regulations; and (4) ‘strengthening the short voice route’ by transforming the power imbalance at the provider–patient interface.

Results

All studied MHOs used these four mechanisms to improve healthcare provision. Most healthcare providers, however, did not recognise their authority to do so. In the DRC, controlling quality and affordability of healthcare is firmly seen as a role for the health authorities, but the authorities only marginally take up this role. Under current circumstances, the power of MHOs in the DRC to enhance quality and affordability of healthcare is weak.

Conclusion

On their own, mutual health organisations in the DRC do not have sufficient power to influence the practices of healthcare providers. Greater responsiveness of the health services to MHO members requires cooperation of all actors involved in healthcare delivery to create an enabling environment where voices defending people’s rights are heard.

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<![CDATA[Improved calibration estimators for the total cost of health programs and application to immunization in Brazil]]> https://www.researchpad.co/article/5c8977b1d5eed0c4847d3333

Multi-stage/level sampling designs have been widely used by survey statisticians as a means of obtaining reliable and efficient estimates at a reasonable implementation cost. This method has been particularly useful in National country-wide surveys to assess the costs of delivering public health programs, which are generally originated in different levels of service management and delivery. Unbiased and efficient estimates of costs are essential to adequately allocate resources and inform policy and planning. In recent years, the global health community has become increasingly interested in estimating the costs of immunization programs. In such programs, part of the cost correspond to vaccines and it is in most countries procured at the central level, while the rest of the costs are incurred in states, municipalities and health facilities, respectively. As such, total program cost is a result of adding these costs, and its variance should account for the relation between the totals at the different levels. An additional challenge is the missing information at the various levels. A variety of methods have been developed to compensate for this missing data. Weighting adjustments are often used to make the estimates consistent with readily-available information. For estimation of total program costs this implies adjusting the estimates at each level to comply with the characteristics of the country. In 2014, A National study to estimate the costs of the Brazilian National Immunization Program was initiated, requested by the Ministry of Health and with the support of international partners. We formulate a quick and useful way to compute the variance and deal with missing values at the various levels. Our approach involves calibrating the weights at each level using additional readily-available information such as the total number of doses administered. Taking the Brazilian immunization costing study as an example, this approach results in substantial gains in both efficiency and precision of the cost estimate.

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<![CDATA[The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and the path to universal health coverage in India: Overcoming the challenges of stewardship and governance]]> https://www.researchpad.co/article/5c8acc3bd5eed0c48498f23f

In an Essay, Blake Angell and colleagues discuss ambitious reforms planned to expand coverage of the health system in India.

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<![CDATA[Exploring the use of machine learning for risk adjustment: A comparison of standard and penalized linear regression models in predicting health care costs in older adults]]> https://www.researchpad.co/article/5c89772fd5eed0c4847d264d

Background

Payers and providers still primarily use ordinary least squares (OLS) to estimate expected economic and clinical outcomes for risk adjustment purposes. Penalized linear regression represents a practical and incremental step forward that provides transparency and interpretability within the familiar regression framework. This study conducted an in-depth comparison of prediction performance of standard and penalized linear regression in predicting future health care costs in older adults.

Methods and findings

This retrospective cohort study included 81,106 Medicare Advantage patients with 5 years of continuous medical and pharmacy insurance from 2009 to 2013. Total health care costs in 2013 were predicted with comorbidity indicators from 2009 to 2012. Using 2012 predictors only, OLS performed poorly (e.g., R2 = 16.3%) compared to penalized linear regression models (R2 ranging from 16.8 to 16.9%); using 2009–2012 predictors, the gap in prediction performance increased (R2:15.0% versus 18.0–18.2%). OLS with a reduced set of predictors selected by lasso showed improved performance (R2 = 16.6% with 2012 predictors, 17.4% with 2009–2012 predictors) relative to OLS without variable selection but still lagged behind the prediction performance of penalized regression. Lasso regression consistently generated prediction ratios closer to 1 across different levels of predicted risk compared to other models.

Conclusions

This study demonstrated the advantages of using transparent and easy-to-interpret penalized linear regression for predicting future health care costs in older adults relative to standard linear regression. Penalized regression showed better performance than OLS in predicting health care costs. Applying penalized regression to longitudinal data increased prediction accuracy. Lasso regression in particular showed superior prediction ratios across low and high levels of predicted risk. Health care insurers, providers and policy makers may benefit from adopting penalized regression such as lasso regression for cost prediction to improve risk adjustment and population health management and thus better address the underlying needs and risk of the populations they serve.

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<![CDATA[Health system barriers to implementation of TB preventive strategies in South African primary care facilities]]> https://www.researchpad.co/article/5c6f14b4d5eed0c48467a684

Background

Isoniazid preventive therapy (IPT) is a key component of TB/HIV control, but few countries achieve high IPT coverage.

Methods

Using a behavioural COM-B design approach, the intervention consisted of a training on IPT guidelines and tuberculin skin testing (TST), identification of the optimal IPT implementation strategy by the health care workers (HCWs) of 3 primary care clinics, and a 2-month mentoring period. Using routine register data, TST and IPT uptake was determined 3 months before and 5 months after the intervention. Records were reviewed to identify factors associated with IPT initiation and HCW fidelity to the guidelines. A survey among HCWs was conducted to determine barriers to IPT.

Results

Two clinics implemented TST-guided IPT for all clients receiving HIV care, one clinic decided against use of TST. According to routine register data, the proportion of clients initiating IPT increased substantially at the clinic not opting for TST (6% vs 36%), but minimally (34% vs 37% and 0.7% vs 3%) in the two other clinics. TST uptake did not increase (0 vs 0% and 0.5%). In addition to poor IPT uptake, HCW fidelity to investigation for TB and timing of IPT initiation was poor, with only 68% of symptomatic patients investigated and IPT initiation delayed to a median of 374 days post-ART initiation. In multivariate analysis, pregnancy (aOR 18.62, 95% CI 6.99–53.46), recent HIV diagnosis (aOR 3.65, 95% CI 1.73–7.41), being on ART (aOR 9.44, 95% CI 3.05–36.17), and CD4 <500 cells/mm3 (aOR 2.19, 95% CI 1.22–4.18) were associated with IPT initiation. Time needed to perform a TST, motivating patients to return for TST reading, and low IPT patient awareness were the main barriers to IPT implementation.

Conclusion

Despite using a behavioural intervention framework including training and participatory development of the clinic IPT strategy, HCW fidelity to the guidelines was poor, resulting in low TST coverage and low IPT uptake under primary care conditions. To achieve the benefits of IPT, health system level approaches including TST-free guidelines and sensitization are needed.

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<![CDATA[Assessing mental health service user and carer involvement in physical health care planning: The development and validation of a new patient-reported experience measure]]> https://www.researchpad.co/article/5c6dc9a5d5eed0c484529f71

Background

People living with serious mental health conditions experience increased morbidity due to physical health issues driven by medication side-effects and lifestyle factors. Coordinated mental and physical healthcare delivered in accordance with a care plan could help to reduce morbidity and mortality in this population. Efforts to develop new models of care are hampered by a lack of validated instruments to accurately assess the extent to which mental health services users and carers are involved in care planning for physical health.

Objective

To develop a brief and accurate patient-reported experience measure (PREM) capable of assessing involvement in physical health care planning for mental health service users and their carers.

Methods

We employed psychometric and statistical techniques to refine a bank of candidate questionnaire items, derived from qualitative interviews, into a valid and reliable measure involvement in physical health care planning. We assessed the psychometric performance of the item bank using modern psychometric analyses. We assessed unidimensionality, scalability, fit to the partial credit Rasch model, category threshold ordering, local dependency, differential item functioning, and test-retest reliability. Once purified of poorly performing and erroneous items, we simulated computerized adaptive testing (CAT) with 15, 10 and 5 items using the calibrated item bank.

Results

Issues with category threshold ordering, local dependency and differential item functioning were evident for a number of items in the nascent item bank and were resolved by removing problematic items. The final 19 item PREM had excellent fit to the Rasch model fit (x2 = 192.94, df = 1515, P = .02, RMSEA = .03 (95% CI = .01-.04). The 19-item bank had excellent reliability (marginal r = 0.87). The correlation between questionnaire scores at baseline and 2-week follow-up was high (r = .70, P < .01) and 94.9% of assessment pairs were within the Bland Altman limits of agreement. Simulated CAT demonstrated that assessments could be made using as few as 10 items (mean SE = .43).

Discussion

We developed a flexible patient reported outcome measure to quantify service user and carer involvement in physical health care planning. We demonstrate the potential to substantially reduce assessment length whilst maintaining reliability by utilizing CAT.

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<![CDATA[Towards a universal concept of vulnerability: Broadening the evidence from the elderly to perinatal health using a Delphi approach]]> https://www.researchpad.co/article/5c76fe2ed5eed0c484e5b68a

Background

The concept 'vulnerability' is prevalent in the public domain, health care, social institutions and multidisciplinary research. Conceptual heterogeneity is present, hampering the creation of a common evidence-base of research achievements and successful policies. Recently an international expert group combined a specific literature review with a 2-stage Delphi procedure, arriving at a seemingly universal concept of vulnerability for the elderly with applications for research instruments. We replicated and extended this study, to generalize this result to health in general, and perinatal health in particular.

Methods

Two independent expert panels (general health, perinatal health) repeated the Delphi-procedure, using an extended and updated literature review to derive statements on the concept and defining pathways of vulnerability. Additional views were collected on research tools. Consensus-by-design was explicitly avoided. Data collection and processing was independent.

Results

Both panels showed surprising convergence on the pathways of vulnerability to health/ill-health, and their interaction. The agreed conceptual model describes a dynamic relation between health and ill-health and vulnerability. The 2 key pathways that link to vulnerability, are complementary, but not symmetrical as biological processes of maintaining health or obtaining better health are not reciprocal to recovery, so also not in terms of vulnerability impacts. An individual's degree of vulnerability is the net balance of risk effects and protective and healing factors (socially, biologically and in terms of health literacy and health care access). These factors can for measurement purposes (according to the panels: interview for exploration, checklists for population research) be grouped into ‘material resources’, ‘taking responsibility for one’s own health’, ‘risky activities and behaviors’, and ‘social support’.

Supportive and transforming action can thus be undertaken.

Conclusion

A universal concept of vulnerability in the context of health was successfully derived after careful replication and extension of an international Delphi study on vulnerability among the elderly.

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<![CDATA[Epigenome-wide analysis of sperm cells identifies IL22 as a possible germ line risk locus for psoriatic arthritis]]> https://www.researchpad.co/article/5c75ac57d5eed0c484d085ff

Psoriasis and its associated inflammatory arthritis, psoriatic arthritis (PsA), have a clear heritable component, but a large proportion of the heritable risk remains unexplained by gene sequence variation. This study aimed to determine if epigenetic factors contribute to the missing heritability in psoriatic disease. DNA methylation profiling was performed on sperm cells from 23 probands with psoriasis without PsA (PsC), 13 PsA probands, and 18 unaffected controls. Differentially methylated CpGs and regions (DMRs) were identified and validated by pyrosequencing. Underlying AluY and copy number variation (CNV) in the HCG26 and IL22 genes, respectively, were assessed by genotyping. Array, subject’s age, age of psoriasis onset, psoriasis severity, and medication usage were found to influence methylation at many genes and were included as covariates in the analysis. Between PsC probands vs. controls, 169 DMRs were found; 754 DMRs were found between PsA probands vs. controls, and 86 between PsA and PsC probands (adjusted p<0.05). Differences in methylation across DMRs were generally subtle (<10%) but correlated well with pyrosequencing. Biological inference prioritized notable DMRs associated with skin disease (SIGLEC14, JAM3, PCOLCE, RXRB), skin and/or joint disease (MBP, OSBPL5, SNORD115, HCG26), and joint disease (IL22, ELF5, PPP2R2D, PTPRN2, HCG26). Hypermethylation of the DMR within the first exon of arthritis-associated IL22 showed significant correlation (rho = 0.34, 95% CI 0.06–0.57, p = 0.01) between paired sperm and blood samples, independent of a CNV within the same region. Further studies are needed to rule out underlying genetic causes and determine if these represent heritable, constitutional epimutations, or are the result of exposure of germ cells to endogenous or exogenous environmental factors.

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<![CDATA[Austerity measures and the transforming role of A&E professionals in a weakening welfare system]]> https://www.researchpad.co/article/5c6dca19d5eed0c48452a785

In 2010, the UK embarked on a self-imposed programme of contractionary measures signalling the beginning of a so-called “age of austerity” for the country. It was argued that budgetary cuts were the most appropriate means of eliminating deficits and decreasing national debt as percentage of General Domestic Product (GDP). Although the budget for the National Health Service (NHS) was not reduced, a below-the-average increase in funding, and cuts in other areas of public spending, particularly in social care and welfare spending, impacted significantly on the NHS. One of the areas where the impact of austerity was most dramatically felt was in Accidents and Emergency Departments (A&E). A number of economic and statistical reports and quantitative studies have explored and documented the effects of austerity in healthcare in the UK, but there is a paucity of research looking at the effects of austerity from the standpoint of the healthcare professionals. In this paper, we report findings from a qualitative study with healthcare professionals working in A&E departments in England. The study findings are presented thematically in three sections. The main theme that runs through all three sections is the perceptions of austerity as shaping the functioning of A&E departments, of healthcare professions and of professionals themselves. The first section discusses the rising demand for services and resources, and the changed demographic of A&E patients—altering the meaning of A&E from ‘Accidents and Emergencies’ to the Department for ‘Anything and Everything’. The second section in this study’s findings, explores how austerity policies are perceived to affect the character of healthcare in A&E. It discusses how an increased focus on the procedures, time-keeping and the operationalisation of healthcare is considered to detract from values such as empathy in interactions with patients. In the third section, the effects of austerity on the morale and motivations of healthcare professionals themselves are presented. Here, the concepts of moral distress and burnout are used in the analysis of the experiences and feelings of being devalued. From these accounts and insights, we analyse austerity as a catalyst or mechanism for a significant shift in the practice and function of the NHS–in particular, a shift in what is counted, measured and valued at departmental, professional and personal levels in A&E.

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<![CDATA[Financial risk protection at the bedside: How Ethiopian physicians try to minimize out-of-pocket health expenditures]]> https://www.researchpad.co/article/5c6c7593d5eed0c4843cfec0

Background

Out-of-pocket health expenditures can pose major financial risks, create access-barriers and drive patients and families into poverty. Little is known about physicians’ role in financial protection of patients and families at the bedside in low-income settings and how they perceive their roles and duties when treating patients in a health care system requiring high out-of-pocket costs.

Objective

Assess physicians’ concerns regarding financial welfare of patients and their families and analyze physicians’ experiences in reducing catastrophic health expenditures for patients in Ethiopia.

Method

A national survey was conducted among physicians at 49 public hospitals in six regions in Ethiopia. Descriptive statistics were used.

Results

Totally 587 physicians responded (response rate 91%) and 565 filled the inclusion criteria. Health care costs driving people into financial crisis and poverty were witnessed by 82% of respondants, and 88% reported that costs for the patient are important when deciding to use or not use an intervention. Several strategies to save costs for patients were used: 37–79% of physicians were doing this daily or weekly through limiting prescription of drugs, limiting radiologic studies, ultrasound and lab tests, providing second best treatments, and avoiding admission or initiating early discharge. Overall, 75% of the physicians reported that ongoing and future costs to patients influenced their decisions to a greater extent than concerns for preserving hospital resources.

Conclusion

In Ethiopia, a low-income country aiming to move towards universal health coverage, physicians view themselves as both stewards of public resources, patient advocates and financial protectors of patients and their families. Their high concern for family welfare should be acknowledged and the economic and ethical implications of this practice must be further explored.

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<![CDATA[Individual and community level factors associated with health facility delivery: A cross sectional multilevel analysis in Bangladesh]]> https://www.researchpad.co/article/5c6dca09d5eed0c48452a6ef

Introduction

Improving maternal health remains one of the targets of sustainable development goals. A maternal death can occur at any time during pregnancy, but delivery is by far the most dangerous time for both the woman and her baby. Delivery at a health facility can avoid most maternal deaths occurring from preventable obstetric complications. The influence of both individual and community factors is critical to the use of health facility delivery services. In this study, we aim to examine the role of individual and community factors associated with health facility-based delivery in Bangladesh.

Methods

This cross-sectional study used data from the Bangladesh Maternal Mortality Survey. The sample size constitutes of 28,032 women who had delivered within five years preceding the survey. We fitted logistic random effects regression models with the community as a random effect to assess the influence of individual and community level factors on use of health facility delivery services.

Results

Our study observed substantial amount of variation at the community level. About 28.6% of the total variance in health facility delivery could be attributed to the differences across the community. At community level, place of residence (AOR 1.48; 95% CI 1.35–1.64), concentration of poverty (AOR 1.15; 95% CI 1.03–1.28), concentration of use of antenatal care services (AOR 1.11, 95% CI 1.00–1.23), concentration of media exposure (AOR 1.20, 95% CI 1.07–1.34) and concentration of educated women (AOR 1.12, 95% CI 1.02–1.23) were found to be significantly associated with health facility delivery. At individual level, maternal age, educational status of the mother, religion, parity, delivery complications, individual exposure to media, individual access to antenatal care and household socioeconomic status showed strong association with health facility-based delivery.

Conclusion

Our results strongly suggest factors at both Individual, and community level influenced the use of health facility delivery services in Bangladesh. Thus, any future strategy to improve maternal health in Bangladesh must consider community contexts and undertake multi-sectorial approach to address barriers at different levels. At the individual level the programs should also focus on the need of the young mother, the multiparous the less educated and women in the poorest households.

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<![CDATA[Chlamydia trachomatis infection among patients attending sexual and reproductive health clinics: A cross-sectional study in Bao'an District, Shenzhen, China]]> https://www.researchpad.co/article/5c75ac92d5eed0c484d08a5a

This study aimed to estimate the prevalence of chlamydial trachomatis (CT) infection and explore its risk factors among patients attending sexual and reproductive health clinics in Shenzhen, China. We collected demographic and clinical information from attendees (aged 18–49). CT and Neisseria gonorrhoeae (NG) infection was determined by nucleic acid amplification test (NAAT) on self-collected urine specimens. Of 1,938 participants recruited, 10.3% (95% confidence interval [CI]: 9.6%-11.0%) tested positive for CT. Prevalence was similar between men (10.6% [85/804]; 95% CI, 9.5%–11.7%) and women (10.1% [115/1134]; 95% CI: 9.2%–11.0%). Being 18–25 years old (adjusted odds ratio [aOR] = 2.52; 95%CI:1.35–4.71), never tested for CT before (aOR = 2.42; 95%CI: 1.05–5.61) and infected with NG(aOR = 3.87; 95%CI: 2.10–7.10) were independently associated with CT infection. We found that CT infection is prevalent among patients attending sexual and reproductive health clinics in Shenzhen, China. A comprehensive program including CT screening, surveillance and treatment is urgently needed.

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<![CDATA[District-level health management and health system performance]]> https://www.researchpad.co/article/5c5df34ad5eed0c4845810c0

Strengthening district-level management may be an important lever for improving key public health outcomes in low-income settings; however, previous studies have not established the statistical associations between better management and primary healthcare system performance in such settings. To explore this gap, we conducted a cross-sectional study of 36 rural districts and 226 health centers in Ethiopia, a country which has made ambitious investment in expanding access to primary care over the last decade. We employed quantitative measure of management capacity at both the district health office and health center levels and used multiple regression models, accounting for clustering of health centers within districts, to estimate the statistical association between management capacity and a key performance indicator (KPI) summary score based on antenatal care coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. In districts with above median district management capacity, health center management capacity was strongly associated (p < 0.05) with KPI performance. In districts with below median management capacity, health center management capacity was not associated with KPI performance. Having more staff at the district health office was also associated with better KPI performance (p < 0.05) but only in districts with above median management capacity. The results suggest that district-level management may provide an opportunity for improving health system performance in low-income country settings.

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<![CDATA[The impact of the Family Medicine Model on patient satisfaction in Turkey: Panel analysis with province fixed effects]]> https://www.researchpad.co/article/5c5b52d2d5eed0c4842bd0b7

Background

In this study, we aim to establish the impact of the introduction of the Family Medicine Model patient satisfaction in the Turkish health system.

Methods

We use data on data 69,028 primary health care (PHC) patients over the period 2010–2012. We estimate the impact of the Family Medicine Model in panel regressions with province fixed effects, exploiting the sequential introduction of this health systems transformation across Turkey's 81 provinces. We use principal component analysis to reduce the dimensionality of the data from the European Patients Evaluate General/Family Practice (EUROPEP) patient satisfaction survey, to focus on the fundamental dimensions of patient satisfaction and to decrease the need for multiple hypothesis testing. We identified two key principal components. The first captured primarily information on satisfaction with provider behavior and the second on satisfaction with the organization of care. We then use these two principal components as outcome variables in our panel analysis to estimate the causal impact of the introduction of the Family Medicine Model.

Results

The Family Medicine Model significantly improved patient satisfaction across a range of dimensions. The coefficient results showed a positive and statistically significant impact (p-values<0.05) of the Family Medicine Model on the outcome variables representing the satisfaction dimensions clinical behaviour and the organization of care even after controlling for calendar time fixed effects.

Conclusions

The introduction of the Family Medicine Model in Turkey, which was primarily aimed at achieving universal health coverage goals, substantially improved patient satisfaction. This study provides some of the first national-level evidence that the introduction of a Family Medicine Model can substantially improve patient satisfaction.

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