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PubMed2001

The political context of social inequalities and health.

This analysis reflects on the importance of political parties, and the policies they implement when in government, in determining the level of equalities/inequalities in a society, the extent of the welfare state (including the level of health care coverage by the state), the employment/unemployment rate, and the level of population health. The study looks at the impact of the major political traditions in the advanced OECD countries during the golden years of capitalism (1945-1980) -- social democratic, Christian democratic, liberal, and ex-fascist -- in four areas: (1) the main determinants of income inequalities, such as the overall distribution of income derived from capital versus labor, wage dispersion in the labor force, the redistributive effect of the welfare state, and the levels and types of employment/ unemployment; (2) levels of public expenditures and health care benefits coverage; (3) public support of services to families, such as child care and domiciliary care; and (4) the level of population health as measured by infant mortality rates. The results indicate that political traditions more committed to redistributive policies (both economic and social) and full-employment policies, such as the social democratic parties, were generally more successful in improving the health of populations, such as reducing infant mortality. The erroneous assumption of a conflict between social equity and economic efficiency, as in the liberal tradition, is also discussed. The study aims at filling a void in the growing health and social inequalities literature, which rarely touches on the importance of political forces in influencing inequalities. The data used in the study are largely from OECD health data for 1997 and 1998; the OECD statistical services; the comparative welfare state data set assembled by Huber, Ragin and Stephens; and the US Bureau of Labor Statistics.

Adolescent↗
PubMed2005

Variation in quality of men's health care by race/ethnicity and social class.

BACKGROUND: Until recently, minority and poor men have been characterized as "an invisible population," overlooked by public and private efforts to improve the health status of women, children, and the elderly. OBJECTIVE: This study compares the health care experiences of racial and ethnic minority men with that of white men, and low socioeconomic status with those of higher status. MEASURES/SUBJECTS: Quality-of-care measures in multiple clinical domains are evaluated. The authors use data from several databases, including the National Health Interview Survey, Medical Expenditure Panel Survey, and Health Care Cost and Utilization Project State Inpatient Database. The relative difference between each racial/ethnic and socioeconomic group and a fixed reference group is used to assess differences in use of services. Statistical significance is assessed using z tests. RESULTS: Hispanic men were much less likely to receive colorectal cancer screening (relative risk [RR] range, 0.61-0.69), cardiovascular risk factor screening and management (RR, 0.84-0.88), and vaccinations (RR, 0.47-0.94). Black and Asian men were significantly less likely to have received selected preventive services (adult immunization and colorectal cancer screening). The differences in end-stage renal disease care that black and white men received were statistically significant (RR, 0.39-0.97), with black men consistently receiving worse care. For some measures of management of end-stage renal disease, Asian men received care that was similar to or better than that received by non-Hispanic whites. CONCLUSION: Minority men are at a markedly elevated risk for the receipt of poor health care quality. However, generalizations about "minority" men are likely to be misleading and incomplete. There is a considerable variation in the magnitude, direction, and significance of these risks.

Adolescent↗
PubMed2001

The impact of a community mobilization project on health-related knowledge and practices in Cameroon.

The analyses presented in this paper document the impact of a community mobilization effort in Cameroon. Between 1997 and 1998, a local non-governmental organization worked with community associations, Njangi, in one urban and one rural location to promote knowledge and positive practices concerning family planning, sexually transmitted diseases, and treatment of common childhood diseases. Based on a multi-tiered structure, the project involved selecting and training two prominent and influential members of each community as "relais" or middlemen. The "relais" then trained mobilizers from participating Njangis to provide relevant information and help to mobilize their fellow members in favor of the positive attitudes and practices promoted by the project. The project was evaluated using baseline and follow-up measurement of pertinent indicators, and service statistics. Results suggest that the intervention had significant influence in the rural location with noticeable positive effects on knowledge and practices of family planning, knowledge and attitudes about HIV/AIDS and STIs, and use of health services. In the urban location, for programmatic and extraneous factors, the intervention was not effective. The paper discusses the lessons learnt from the intervention and offers pertinent suggestions for replicating the intervention in rural settings.

Adolescent↗
PubMed2005

Effectiveness of depot-holders introduced in urban areas: evidence from a pilot in Bangladesh.

Depot-holders are women from the community who promote good health practice and use of clinics. They keep a stock of contraceptives and oral rehydration salts to supply other women and are paid some incentives. In 2003, the NGO Service Delivery Program (NSDP) introduced depot-holders in three types of urban area in Bangladesh as a pilot. This evaluation study was carried out to: (a) establish a baseline for measuring the impact of activities of depot-holders on a comprehensive range of indicators in the long-term, (b) make a preliminary assessment of the impact on the use of selected services of the essen-tial services package (ESP) and other indicators at the end of the pilot phase, and (c) assess the cost of introducing depot-holders and running their activities for a year. Data from the baseline and end of pilot household surveys, together with service statistics from the intervention and comparison areas, were used for assessing the changes in clinic use and commodity distribution. The study found evidence that the depot-holders transferred knowledge to women in the community, provided services, and referred women to clinics run by non-governmental organizations (NGOs). There was a large increase in the number of client contacts at the NGO clinics and in the quantity of oral contraceptive pills and oral re-hydration salts distributed by the NGOs, mostly attributable to the activities of the depot-holders. The estimated cost per depot-holder per year was Tk 15,241 (U.S. dollars 262). Overall, the performance of the depot-holders in the pilot phase suggests that they can be introduced in different types of urban area and can be effective in their dual role as providers and promoters of services.

Adolescent↗
PubMed2003

Analysis of primary health care utilisation in south-western Finland--a tool for management.

Long-term health care planning is presently not based on the needs of the population at the local level in Finland but rather, it is based on retroactive economic values and already realised budget in hospital and primary health care. The existing health care structure and its health care practices continue to guide the supply of services. While we have the most extensive databases on primary health care and hospital services, such tools are not used in the broadest possible sense in the present health care planning at the local level. Simple and informative indicators available to health care planners and decision-makers from databases at the local level were used to appraise the use of health care services. Statistical profiles of health care clients were classified by age groups within the health authority area (population of 13,000) of Paimio-Sauvo in south-western Finland with the intent to explain utilisation of primary health care services, their coverage, and repeat visits as well as groups not using those services. Physicians recorded reasons for each patient visit with the ICD-10 categories. In the case municipalities, primary health care services provided 100% coverage to children of 0-6 years of age and more than 70% coverage to other groups. Most primary health care expenditures were assessed for people 65 years or older in 2000. As an example of a municipality, hospital and primary health care expenditures within Paimio varied from 24 to 30.4% of the total obligations for the last 10 years.

Adolescent↗
PubMed2005

Do we know what people die of in the emergency department?

OBJECTIVE: To establish the discrepancy rate between the predicted cause of death and the actual cause of death as determined by postmortem examination result, for all deaths in the emergency department reported to the Scottish Procurator Fiscal and subsequently undergoing postmortem examination. METHODS: A prospective study of all patients who were dead on arrival or died in the emergency department of a busy Glasgow hospital over a 12 month period. The most senior emergency physician present at the time of death predicted the cause of death. This was then compared to the actual postmortem examination determined cause of death and was considered either to be correct or incorrect. RESULTS: During the study period, 146 patients were pronounced dead in the department. Of these, 81 patients (age range 39-99 years, median 71; male:female 2.5:1) had death certificates issued, 63 patients (age range 26 days to 99 years, median 48; male:female 2.4:1) had a postmortem performed by the forensic pathologist, and two patients underwent a "view and grant". Of the 63 deaths reported to the Procurator Fiscal, the emergency physician attributed 51 (80.1%) to non-trauma, 9 (14.2%) to trauma, and in 3 (4.7%) cases were uncertain. Of the 63 (39.7%) deaths, 25 were inaccurately predicted (99% confidence interval 24.3% to 56.6%; p<0.0)1. Cardiovascular related and drugs poisoning deaths occurred most commonly. They were also the most accurately predicted cause of deaths. Intracranial events, pulmonary thromboembolism, and airway obstruction were also frequently predicted, but were often wrong. CONCLUSIONS: This study highlights the difficulties in accurately identifying cause of death for patients who die suddenly. This could have implications for the accuracy of health service statistics.

Adolescent↗
PubMed2006

Needle syringe acquisition and HIV prevention among injecting drug users: a treatise on the "good" and "not so good" public health practices in South Asia.

This article describes the prevalence of HIV/AIDS and other bloodborne infections is well established among injection drug user (IDU) populations in South Asia (SA). IDU populations in SA are diverse and display different demographic and socioeconomic profiles. The current provision of sterile injecting equipment as part of public health initiatives is suboptimal. Although some needle and syringe exchange programs (NSEPs) operate in the region, pharmacies and "friends" continue to be a major source of syringe acquisition. It is suggested that the cost of syringes in the region is significantly higher in real terms than in several other countries and negatively impacts on the ability of IDUs to acquire needles and syringes. In addition, existing NSEPs offer poor coverage both at the population and individual level. Their effective functioning is hampered by resource constraints, ambivalent policy positions, little attention to quality, and environmental factors. Secondary syringe exchange is a nascent phenomenon in SA that needs to be adequately documented and evaluated. Urgent attention needs to be given to developing alternative models of needle syringe delivery to scale-up HIV prevention interventions for IDUs. This study was conducted in the first quarter of 2004 and updated in 2006. We used key informants, previously unpublished and published data from research studies, and interventions programs, service statistics, and primary data to inform this study.

Asia↗
PubMed2006

Utilization of family planning services in the Governorate of Zarqa, Jordan.

Quantitative and qualitative methods are used to explore family planning (FP) utilization in four clinics with different models of provision in Zarqa Governorate in Jordan. Constraints to utilization at the service level are identified based on service observations and the perspectives of providers. Service statistics, clinic observations, and focus group discussions were used to compare utilization patterns and to evaluate the strengths and weaknesses of the different models of provision. Findings show that FP provision is still fragmented and "techno-patriarchal" in Jordan. Strengthening coordination mechanisms between the service sectors and addressing men are important strategies to increase FP utilization that are transferable to other countries of the Middle East and the developing world.

Adolescent↗
PubMed1999

Risk-adjusted in-hospital death rates for peer hospitals in rural and urban regions.

The purpose of this research project was to compare inpatient mortality rates for rural hospitals with mortality rates of urban hospitals of given sizes and ranges of service. Statistical adjustments for risk were made in the probability of death during hospitalization for 43,000 patients across 166 hospitals by age, gender, principal diagnosis, principal surgical procedure, characteristics of the secondary diagnoses, and whether or not cancer was a secondary diagnosis. Eighty-three small hospitals that had a relatively unspecialized range of services constituted the study group. Patient characteristics of this study group were moderately representative of the national population. A standardized score was calculated for each hospital using a formula based on the actual hospital death rate and the death rate expected for a given hospital with patients of the same demographic and medical characteristics. Patients admitted to hospitals in nonmetropolitan areas had a mortality rate of 0.41 percent compared with a mortality rate of 0.66 percent in peer hospitals in metropolitan areas. After mortality rates were risk-adjusted and converted to z scores, nonmetropolitan areas had an average z of +0.16, and metropolitan areas had an average z of -0.25, where positive z scores reflect a lower-than-average adjusted mortality rate. The metropolitan-nonmetropolitan (urban-rural) difference was not statistically significant, but it is meaningful in that rural hospitals tended to have a lower adjusted mortality rate than urban hospitals of the same size and type, indicating that rural hospitals had the same or lower adjusted mortality rates. The possibility of urban hospitals having riskier patients was minimized but could not be definitively ruled out. Taken together with other studies, the data are consistent with the view that small rural hospitals generally make appropriate transfer decisions for severely ill patients and provide quality care for retained patients.

Adolescent↗
PubMed2006

Advocacy and coverage of needle exchange programs: results of a comparative study of harm reduction programs in Brazil, Bangladesh, Belarus, Ukraine, Russian Federation, and China.

To prevent or mitigate an AIDS epidemic among injecting drug users (IDUs), effective activities need to be implemented on a large enough scale to reach and assist sufficient numbers of drug users and thereby change their risk behaviors related to drug use and sex. Recent work by UNAIDS on "high coverage sites", adopting the above strategies, has shown that one of the key elements in achieving high coverage is ongoing and sophisticated advocacy. High coverage harm reduction sites were studied through literature search and site visits, including key informant interviews, review of service statistics, and data analysis, in order to document the steps that led to scaling up, the way coverage was defined in these sites, and the lessons learned from their efforts. Syringe-exchange programs can achieve high coverage of IDUs. Monitoring to determine regular reach (those who are in regular contact with harm reduction services) should be added to uniform data collection carried out by harm reduction programs. Advocacy is crucial to achieving high coverage.

Bangladesh↗
PubMed2005

Health care providers and facilities: health facilities--2005. End of Year Issue Brief.

The mission of every hospital in America is to serve the health care needs of individuals in their communities, 24 hours a day, seven days a week. Their task, and the task of their medical staff, is to continually care for and to cure their patients. American health facilities are said to provide the best, most sophisticated, and most beneficial health care in the world. However, a hospital's ability to care for each patient who walks through their doors is continuously challenged on numerous fronts--the shortage of key hospital personnel, the increased cost of caring for the uninsured, the continued problem of medical errors, and the growth of niche and specialty hospitals. As of 2002, there were 5,794 registered hospitals in the United States, according to the most recent data available from the American Hospital Association (AHA). The AHA also states that there are 4,927 community hospitals, which includes nongovernmental, non-profit hospitals, investor-owned (for-profit) hospitals, and hospitals owned by state and local governments. The AHA defines community hospitals as all non-federal, short-term general and other specialty hospitals. Specialty hospitals include obstetrics and gynecology, rehabilitation, orthopedic and other individually described specialty services. Statistics provided by the AHA indicate that the number of rural and urban community hospitals is approximately equal--2,178 rural hospitals compared to 2,749 urban hospitals.

Accounts Payable and Receivable↗
PubMed2004

Health care providers and facilities issue brief: health facilities: year end report-2004.

American health facilities are said to provide the best health care in the world. But hospitals are continually challenged by staff shortages, patient safety and medical errors, uninsured patients, and the growth of specialty hospitals. This issue brief provides an analysis of the issues that challenge hospitals' ability to provide quality care for patients. Moreover, the issue brief defines each issue, including staffing mandates, patient safety and medical errors, emergency hospitals, billing practices, and niche and specialty hospitals, outlines the arguments for and against each issue, and finally details and characterizes state legislative activity in regard to each issue. As of 2002, the most recent data available from the American Hospital Association (AHA), there were 5,794 registered hospitals in the United States. The AHA also states that there are 4,927 community hospitals, which includes non-governmental non-profit hospitals, investor-owned (for-profit) hospitals, and hospitals owned by state and local governments. The AHA defines community hospitals as all non-federal, short-term general, and other specialty hospitals. Specialty hospitals include obstetrics and gynecology, rehabilitation, orthopedic, and other individually described specialty services. Statistics provided by the AHA indicate that the number of rural and urban community hospitals is approximately equal--2,178 rural hospitals compared to 2,749 urban hospitals. However, this statistic alone does not address the quality of care in urban and rural settings. It does not address the total expenditures in rural and urban hospitals, nor does it address staffing levels.

Accounts Payable and Receivable↗
PubMedDate not supplied

Quarterly versus monthly supervision of CBD family planning programs: an experimental study in northeast Brazil.

The cost-effectiveness of reducing the frequency of routine supervision from monthly to quarterly was evaluated in a closely controlled field experiment conducted in a community-based distribution program in Piaui State in northeast Brazil. The results demonstrated substantial potential savings in supervisors' salaries and travel at no cost to program performance (new acceptors, revisits, distributor turnover). A possible reason for this finding was that most supervisory visits were primarily concerned with collecting inventory and service statistics, which probably contributed little to post performance. It was suggested that the number of supervisors and the frequency of supervision should be linked to productive rather than routine supervisory activities.

Brazil↗
PubMed1993

Available epidemiologic data on New York's Latino population: a critical review of the literature.

The increasing diversity of New York's Latino population creates complex challenges for the health care provider and planner, such as how to plan for divergent health risks, disease patterns, and health behaviors. However, most research on Latinos has been done in the southwestern United States. This paper reviews the epidemiologic data published since 1980 on Latino groups in New York State. The review covers the following areas: maternal and child health, infectious diseases, depression, tobacco and substance use, chronic diseases, neoplasms, and mortality statistics. We compare New York data with studies done in other areas of the United States. We identify serious methodological shortcomings in the epidemiological assessment of New York's Latino population, including (1) imprecise definition of "Latino," (2) misclassification, (3) census undercount of minority groups, and (4) lack of data on socioeconomic status. We argue that the epidemiological and cultural diversity of Latino groups demands the inclusion of such variables as place of birth, length of stay, and language preference in research and service statistics. This would facilitate targeted program planning and help to determine environmental, sociopolitical, behavioral, and genetic influences on diseases.

Adult↗
PubMed1997

Children's health care use in the Healthy Kids Program.

BACKGROUND: In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix. METHODS: Each HMO provided child-specific health care use data including Physician's Current Procedural Terminology codes and International Classification of Diseases, 9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate chi2 statistics. RESULTS: A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 +/- 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences. CONCLUSIONS: The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program.

Child↗
PubMed1988

School-based clinics: their role in helping students meet the 1990 objectives.

Service statistics and observations from site visits across the country indicate that school-based clinics (SBCs) may be having an impact on several of the problems targeted in the 1990 health objectives, including unplanned pregnancy and substance abuse. At least 120 junior and senior high schools in 61 communities are currently operating or developing clinics. Growth is attributed to increasing concern about high-risk youth, especially among educators in their roles of "surrogate parents"; to disillusion with categorical interventions and a movement toward more comprehensive services; and to student, parent, school, and community approval of the new programs. This article describes the comprehensive school-based clinic model, including its history, organizational strategies, school/community partnerships, and services.

Adolescent↗
PubMed2002

[Possibilities of utilising official statistics for health services research].

This report deals with the experiences and problems with using official statistics on a limited area level of Germany's 440 administrative districts. The data comprised health-related issues and were used for an ecological analysis of the determinants of hospital use. We obtained health statistics data from homepages of the German health report, the Federal statistics office, and the 16 statistics offices of the Federal states. We also made use of the data base of the joint regional statistics published by the Federal and regional statistics offices. Finally, there was a co-ordinated inquiry to the regional statistics offices about the supply of data on mortality, hospital discharges, structure of hospital care and several socio-economic indicators. The process of data collecting was mostly unproblematic. On the other hand, not all of the data were available on a limited area level in a satisfying form and quality. For reasons of data protection some information of small districts was transmitted incompletely. Additionally, there are procedural differences between regional statistics offices regarding the differentiation between some variables and in the exchange of data between the federal states. Finally, some problems were due to varying age classifications for different health indicators. For health services research the use of official statistics becomes increasingly comfortable via health reports and Internet. However, for specific questions of research some problems still remain, rising from missing standardised health indicators and deficient availability of limited area health data. Data collection is exacerbated by restrictive interpretation of data protection acts and the different handling of data inquiries in the regional statistics offices. Finally, there is a lack of data on morbidity and use of ambulatory care.

Data Collection↗
PubMed2005

Cost and results of information systems for health and poverty indicators in the United Republic of Tanzania.

OBJECTIVE: To examine the costs of complementary information generation activities in a resource-constrained setting and compare the costs and outputs of information subsystems that generate the statistics on poverty, health and survival required for monitoring, evaluation and reporting on health programmes in the United Republic of Tanzania. METHODS: Nine systems used by four government agencies or ministries were assessed. Costs were calculated from budgets and expenditure data made available by information system managers. System coverage, quality assurance and information production were reviewed using questionnaires and interviews. Information production was characterized in terms of 38 key sociodemographic indicators required for national programme monitoring. FINDINGS: In 2002-03 approximately US$ 0.53 was spent per Tanzanian citizen on the nine information subsystems that generated information on 37 of the 38 selected indicators. The census and reporting system for routine health service statistics had the largest participating populations and highest total costs. Nationally representative household surveys and demographic surveillance systems (which are not based on nationally representative samples) produced more than half the indicators and used the most rigorous quality assurance. Five systems produced fewer than 13 indicators and had comparatively high costs per participant. CONCLUSION: Policy-makers and programme planners should be aware of the many trade-offs with respect to system costs, coverage, production, representativeness and quality control when making investment choices for monitoring and evaluation. In future, formal cost-effectiveness studies of complementary information systems would help guide investments in the monitoring, evaluation and planning needed to demonstrate the impact of poverty-reduction and health programmes.

Health Status Indicators↗