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PubMed1999

[An epidemiological study of health care seeking behavior by children under the age of 5 years at hospital emergency services in Togo].

The functioning and efficacy of pediatric emergency services are currently being questioned in many Northern countries, as well as in the South, for example in North Africa. Reference is often made to unjustified medical emergencies in the face of an influx of patients with benign problems who come from socially disadvantaged families. In the university and regional hospitals in three regions in Togo, we compared three categories of under-5 patients: children sent to "day-time" emergency services after triage done by health personnel; those sent to the "ordinary consultation"; and children brought after hours by their family (without referral by a health professional in 92% of cases) and seen in the "after-hours" emergency service. Serious tropical pathology (cerebral malaria, malaria, sickle cell disease) is mainly seen in emergency consultations, in which high hospitalization rates are noted (83% during the day, 67% at night) and a lethality of 3.4%. One cannot therefore use terms such as "false emergencies", "felt" and "medically unjustified" and the pediatric supervisor for the research considered that recourse to after-hours emergency services was justified in 75% of cases. Families using night services have higher educational levels than those sent to day emergency services, the mother's educational level being the main factor associated with certain characteristics of health seeking behavior (duration of symptoms prior to arrival at hospital, recourse to modern medical drugs). There is often a long delay before recourse to hospital: only 45% of children seen after hours and half of those who died came the 1st or 2nd day of the illness. Self-medication at home is usual but recourse to tradi-practitioners appears rare (4%). Several solutions can be envisaged and should be linked: strengthening of the first level of care, technical improvements in emergency services, training of tradi-practitioners in the recognition and referral of emergency cases, improvement of reception practices at the hospital level, prophylactic and preventive measures for tropical diseases.

Age Factors↗
PubMed2000

[Frequency of use of school cafeterias in middle and high schools in 3 French districts].

Reports from the French Ministry of Education warn of a decrease in the use of school food services, especially in sensitive urban areas. They also suggest that this decline has led to cases of malnutrition. This article describes the characteristics of the current supply of school meals and measures the evolution of demand observed between 1992 and 1996 in relation to the economic situation of students' families. The study was carried out in 3 departments in France: Doubs, Herault, and Val de Marne. The administrators of all public and private middle and high schools in the 3 departments received a questionnaire asking them to describe the services offered in their cafeterias and to provide the corresponding statistical and accounting data. External food services near the schools were also taken into account. Seventy-nine percent of schools responded to the survey. Concerning the services offered, 91% of schools have their own cafeterias, of which 81% are managed by the schools. Concerning the evolution of utilisation, a significant decrease in the number of meals served in seen in middle schools. On the other hand, high schools have observed stable utilisation. The positive changes in utilisation are linked, in middle schools, to characteristics of the schools' internal food services (self-service, choice of main courses, modulation of seats). In high schools, positive changes in the utilisation of school services are linked to the lack of external food services near the schools. As middle schools and high schools control the logistics and management of food services offered to students, they are potentially in a position to influence a policy on this issue. The evolution in utilisation is very different among departments and between middle and high schools. While economic precariousness has a negative structural effect on utilisation, it doesn't seem to be a major factor in the evolution of the decrease observed over the past few years.

Accounting↗
PubMedDate not supplied

Preventing pregnancy and improving health care access among teenagers: an evaluation of the children's aid society-carrera program.

CONTEXT: Despite the recent declines in rates of teenage pregnancy, relatively little is known about the few programs that have been successful in reducing adolescent pregnancy. METHODS: Six agencies in New York City each randomly assigned 100 disadvantaged 13-15-year-olds to their usual youth program or to the intervention being tested--the Children's Aid Society-Carrera program, a year-round afterschool program with a comprehensive youth development orientation. Both program and control youth were followed for three years. Multivariate regression analyses assessed the effects of program participation on the odds of current sexual activity, use of a condom along with a hormonal contraceptive, pregnancy and access to good health care. RESULTS: Seventy-nine percent of participants remained in the program for three full years. Female program participants had significantly lower odds than controls of being sexually active (odds ratio, 0.5) and of having experienced a pregnancy (0.3). They had significantly elevated odds of having used a condom and a hormonal method at last coitus (2.4). However, participation in the program created no significant impact on males' sexual and reproductive behavior outcomes. Nonetheless, program participants of both genders had elevated odds of having received good primary health care (2.0-2.1). CONCLUSIONS: This program is one of only four whose evaluation has successfully documented declines in teenage pregnancy using a random-assignment design. Better outcomes among males may be achieved if programs reach them even earlier than their teenage years.

Adolescent↗
PubMed1983

Defining and measuring patient satisfaction with medical care.

This paper describes the development of Form II of the Patient Satisfaction Questionnaire (PSQ), a self-administered survey instrument designed for use in general population studies. The PSQ contains 55 Likert-type items that measure attitudes toward the more salient characteristics of doctors and medical care services (technical and interpersonal skills of providers, waiting time for appointments, office waits, emergency care, costs of care, insurance coverage, availability of hospitals, and other resources) and satisfaction with care in general. Scales are balanced to control for acquiescent response set. Scoring rules for 18 multi-item subscales and eight global scales were standardized following replication of item analyses in four field tests. Internal-consistency and test-retest estimates indicate satisfactory reliability for studies involving group comparisons. The PSQ well represents the content of characteristics of providers and services described most often in the literature and in response to open-ended questions. Empirical tests of validity have also produced generally favorable results.

Consumer Behavior↗
PubMed2001

Service quality perceptions and patient satisfaction: a study of hospitals in a developing country.

Patients'perceptions about health services seem to have been largely ignored by health care providers in developing countries. That such perceptions, especially about service quality, might shape confidence and subsequent behaviors with regard to choice and usage of the available health care facilities is reflected in the fact that many patients avoid the system or avail it only as a measure of last resort. Those who can afford it seek help in other countries, while preventive care or early detection simply falls by the wayside. Patients'voice must begin to play a greater role in the design of health care service delivery processes in the developing countries. This study is, therefore, patient-centered and identifies the service quality factors that are important to patients; it also examines their links to patient satisfaction in the context of Bangladesh. A field survey was conducted. Evaluations were obtained from patients on several dimensions of perceived service quality including responsiveness, assurance, communication, discipline, and baksheesh. Using factor analysis and multiple regression, significant associations were found between the five dimensions and patient satisfaction. Implications and future research issues are discussed.

Bangladesh↗
PubMed2000

Measuring continuity of elders' posthospital care.

Continuity of care is a critical component of quality patient care, yet the paucity of reliable and valid measures of continuity of care make it difficult to ascertain the extent to which continuity has been achieved. The purpose of this article is to describe the development of an instrument to measure continuity of care that incorporates the perspectives of elders hospitalized for a chronic illness and their family caregivers. The instrument was used, and its reliability and validity examined, in a series of studies related to elders' posthospital transition. Elders in the studies ranged in age from 55 to 94 years. The findings supported content and construct validity, internal consistency reliability, and ability to detect changes in the same subjects at different points in time for the care management and services subscales. With further refinement, the continuity of provider and conflicting information subscales might also facilitate assessment of care continuity.

Aftercare↗
PubMed2005

Modelling the effectiveness of financing policies to address underutilization of children's health services in Nepal.

OBJECTIVE: To estimate the price responsiveness of utilization of formal children's health-care services in Nepal and to use this information to model the impact on utilization of subsidies or increases in user fees. METHODS: A total of 8112 individual observations (of children aged < 15 years) from 2847 households in 274 communities were obtained from the 1996 Nepal Living Standards Survey. A logit model was applied to determine the net impact of price on a parent or caregiver's decision to seek care for a given instance of illness. The model's coefficients were used to calculate the price responsiveness of utilization decisions. FINDINGS: Parents or caregivers reported that 9.7% of children (788/8112) had been ill or injured in the previous month. Parents reported that they had sought care in 566 (71.8%) of these cases; care was most frequently sought from public providers. The price elasticity of demand for children's health-care services in the formal sector was estimated at -0.16. As prices rise, the demand curve exhibits continuous and declining price elasticity. Overall, a 100% subsidy of user fees would increase current utilization rates by 56%, while a 100% increase in fees would lead to a drop in utilization of only 12%. The differential in utilization across income groups was substantial after changes in fees were implemented. CONCLUSION: While the effect of price on the utilization of children's health-care services in Nepal is statistically significant, the size of the impact is modest. Policies to subsidize fees could increase utilization substantially, while fee increases would lead to modest declines in utilization and generate increased revenue.

Adolescent↗
PubMed2005

Proxies and other external raters: methodological considerations.

OBJECTIVE: The purpose of this paper is to introduce researchers to the measurement and subsequent analysis considerations involved when using externally rated data. We will define and describe two categories of externally rated data, recommend methodological approaches for analyzing and interpreting data in these two categories, and explore factors affecting agreement between self-rated and externally rated reports. We conclude with a discussion of needs for future research. DATA SOURCES/STUDY SETTING: Data sources for this paper are previous published studies and reviews comparing self-rated with externally rated data. STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: This is a psychometric conceptual paper. PRINCIPAL FINDINGS: We define two types of externally rated data: proxy data and other-rated data. Proxy data refer to those collected from someone who speaks for a patient who cannot, will not, or is unavailable to speak for him or herself, whereas we use the term other-rater data to refer to situations in which the researcher collects ratings from a person other than the patient to gain multiple perspectives on the assessed construct. These two types of data differ in the way the measurement model is defined, the definition of the gold standard against which the measurements are validated, the analysis strategies appropriately used, and how the analyses are interpreted. There are many factors affecting the discrepancies between self- and external ratings, including characteristics of the patient, the proxy, and of the rated construct. Several psychological theories can be helpful in predicting such discrepancies. CONCLUSIONS: Externally rated data have an important place in health services research, but use of such data requires careful consideration of the nature of the data and how it will be analyzed and interpreted.

Data Collection↗
PubMed1991

Measurement and reliability: statistical thinking considerations.

Reliability is defined as the degree to which multiple assessments of a subject agree (reproducibility). There is increasing awareness among researchers that the two most appropriate measures of reliability are the intraclass correlation coefficient and kappa. However, unacceptable statistical measures of reliability such as chi-square, percent agreement, product moment correlation, as well as any measure of association and Yule's Y still appear in the literature. There are costs associated with improper measurements, unreliable diagnostic systems, inappropriate statistics and measures of reliability, and poor quality research. Costs are incurred when misleading information directs resources and talents into nonproductive avenues of research. The consequences of unreliable measurements and diagnosis are illustrated with some studies of schizophrenia.

Cost Allocation↗
PubMed2006

Agreement among adolescents, parents, and teachers on adolescent personality.

Agreement between adolescents, mothers, fathers, and teachers on adolescents' personality traits was investigated in a longitudinal study. The targets for personality ratings were the adolescents who participated in the European Youth Heart Study in Estonia. There were 593 participants in the first wave and 480 participants in the follow-up study 3 years later. Adolescents' self-reports as well as father, mother, and teacher ratings were collected using questionnaires to measure the five-factor model of personality. In both waves, inter-rater agreement was highest between mothers and fathers, was low to moderate for parent-self ratings, and was lowest for ratings between self and teacher, mother and teacher, and father and teacher. Test-retest correlations were moderate for parent and self-ratings but failed to reach statistical significance for three of the five teacher-rated traits, suggesting lower reliability of teacher ratings. Possible explanations for the low agreement between teachers and other judges are discussed.

Adolescent↗
PubMed2000

Organization of orthopaedic trauma services: a survey of the Orthopaedic Trauma Association.

OBJECTIVES: This study was undertaken to collect information about the organization of orthopaedic trauma services in different types of hospitals, with particular emphasis on hospital support arrangements in different practice situations. DESIGN: A survey was sent to all members of the Orthopaedic Trauma Association (OTA) as part of the organization's newsletter. Fractoids. In addition, the survey was distributed by the OTA's E-mail discussion list, ORT-1. MAIN OUTCOME MEASUREMENTS: The survey included questions about the size and nature of the hospital, resident involvement, academic affiliation, number of orthopaedic physician staff, training of the staff, presence of an organized orthopaedic trauma service, distribution of call and patients, and hospital support. RESULTS: Fifty-seven responses were received from North American centers, of which six were duplications. Responses came from institutions of all types and sizes, although most came from urban, Level 1 trauma centers with academic affiliation. Twenty-nine hospitals had a designated orthopaedic trauma service, and twenty-six had a director. Eighteen institutions had ancillary staff (nurses, physician's assistants, etc.) assigned to the orthopaedic trauma service. Hospitals with an academic affiliation were statistically more likely to have a designated orthopaedic trauma service and to distribute trauma patients by subspecialty expertise. In hospitals with a designated orthopaedic trauma service or director, it was more common to have ancillary support staff and to have it funded by the hospital, although the differences did not rise to statistical significance. CONCLUSIONS: There are differences in organization of orthopaedic trauma care between hospitals, which may be related to hospital size, academic affiliation, and orthopaedic department organization. Further study is necessary to determine whether organizational differences translate into differences in patient outcome after trauma.

Benchmarking↗
PubMed2005

Overdiagnosis and overtreatment of breast cancer: overdiagnosis and overtreatment in service screening.

Screening mammography has been shown to be effective for reducing breast cancer mortality. According to screening theory, the first expected consequence of mammography screening is the detection of the disease at earlier stages and this diagnostic anticipation changes the population incidence curve, with an observed increase in incidence rates at earlier ages. It is unreasonable to expect that the age-specific incidence will ever return to pre-screening levels or to anticipate a significant reduction of incidence at older ages immediately after the first screening round. The interpretation of incidence trends, especially in the short term, is difficult. Methodology for quantification of overdiagnosis and statistical modelling based on service screening data is not well developed and few population-based studies are available. The overtreatment issue is discussed in terms of appropriateness of effective treatment considering the question of chemotherapy in very early stages and the use of breast conserving surgery.

Breast Neoplasms↗