The need for an integrated approach to the provision of essential health care services: a study from the Gambia.
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Developing Countries↗
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Factors related to antenatal clinic choice and reported activities of antenatal care clinics by pregnant women in Gulele district, Addis Abeba.
Two-hundred-seventy pregnant women in the third trimester in 24 kebeles of Gulele district, Addis Abeba were included in the study to assess the factors associated with the choice of antenatal care (ANC) clinics and the women's views concerning activities at antenatal care clinics. Questionnaire were administered to pregnant women at their homes by trained assistants. Majority of the respondents attended ANC in a health station and the most frequent reason for choice of place of attendance was closeness of health institution to which the pregnant woman lives followed by little or no expenses for antenatal care. One fourth of the women attending antenatal care said that health education is never given at the health institution where they attend antenatal care. About 80% of the attendants reported that their blood pressure was always taken. Blood examinations were said to have been performed for 85.6% of the attendants and 74.1% said their urine was checked. We recommend that activities of ANC clinics be assessed thoroughly by different methods and well designed studies addressing the effect of ANC attendance on pregnancy outcome. Refresher courses for health workers on health education and maternal and child health are suggested.
Adolescent↗
Family planning issues relating to maternal and infant mortality in the United States.
Both maternal and infant death rates in the United States are much higher than in many developed countries. The interrelationships between abortions and maternal and infant mortality have been analyzed on the basis of data from the 1970s and 1980s. The legalization of abortions in 1973 resulted in a marked increase in legal abortions and marked reductions in maternal and infant mortality over the course of the 1970s. However, a wide variation in abortion rates and in the number of abortion facilities indicates that such facilities were not readily available to all segments of the population in some areas. This probably accounts in part for higher maternal and infant death rates in such areas. Smoking, small weight gain, use of alcohol and drugs in pregnancy, and excessive maternal youth or age affected the outcome of pregnancy and contributed to high rates of infant death. Infant death rates were especially high among newborns of teenagers and young adult mothers; relatively high proportions of these newborns had low birthweights; a large share of the pregnancies involved were unintended; and slightly over half of the unintended pregnancies in teenagers and young women resulted in abortion. Comparisons with findings in Sweden reveal that the rates of unplanned pregnancy, abortion, and infant mortality were all much higher in the United States than in Sweden. The differences are attributed to better contraceptive services, which were made available free or very inexpensively in Sweden. Also, the frequency of low weight births was much lower in Sweden.
Abortion, Legal↗
Factors that determine prevalence of use of contraceptive methods for men.
Globally, men have not shared equally with women the responsibility for fertility regulation. While family planning efforts have been directed almost exclusively toward women, the lack of male involvement may also reflect the limited options available to men. Current methods for men are either coitus-dependent, such as the condom or withdrawal, or permanent, such as vasectomy. The 20-year history of social science research on male contraceptive methods is examined here in terms of the human and method factors related to the acceptability of hypothetical methods and the prevalence of use of existing methods. New male methods, particularly if reversible, may alter men's willingness to accept or share responsibility for the control of fertility. Research opportunities in the areas of gender, decision-making, communication, health education, and service delivery will be enhanced when methods for women and men are comparable.
Contraception↗
Telecommunications and multimedia systems in education: what developments for radiology?
What are the new perspectives for the radiologist with the development of new technologies of telecommunications? At present, when digitization of most biomedical images has become a reality, problems of remote transmission are simplified. However, telematic literacy is necessary to the radiologist. It is already possible through multimedia supports, as CD-ROM and Internet "navigation". Which are the modalities to access "the network of networks"? Through Internet, hypertexs can be consulted, databases can be accessed, programs and printings can be retrieved, electronic mail can be exchanged. The CD-ROM is a further source of knowledge, especially effective in education due to multimedia and hypertext technology. In this context in the education of the radiologist, the hypertext version of a radiology text, finds its place. It is conceived to offer to each user an individualized approach to learning.
Computer Communication Networks↗
Clinical update: impact of HIV protease inhibitors on the treatment of HIV-infected tuberculosis patients with rifampin.
In 1995 and 1996, the Food and Drug Administration (FDA) approved three products in the new protease inhibitor class of drugs--saquinavir (Invirase), ritonavir (Norvir), and indinavir (Crixivan). Another drug in this class of agents, nelfinavir (Viracept) (Agouron Pharmaceuticals), is expected to be available soon from the manufacturer through an expanded-access program. All four drugs, which inhibit HIV protease and thus interfere with viral maturation and replication, are the most potent antiretroviral agents available to treat patients with HIV disease. However, these protease inhibitors interact with rifamycin derivatives, such as rifampin and rifabutin, which are used to treat and prevent the mycobacterial infections commonly observed in HIV-infected patients. Rifamycins accelerate the metabolism of protease inhibitors (through induction of hepatic P450 cytochrome oxidases), resulting in subtherapeutic levels of the protease inhibitors. In addition, protease inhibitors retard the metabolism of rifamycins, resulting in increased serum levels of rifamycins and the likelihood of increased drug toxicity. This report describes approaches for managing patients who are candidates for or who are undergoing protease inhibitor therapy when tuberculosis (TB) is diagnosed and presents interim recommendations for managing these patients until additional data are available and formal guidelines are issued.
Anti-HIV Agents↗
Hospital mergers and reproductive health care.
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Catholicism↗
The provision of public-sector services by family planning agencies in 1995.
Results from a 1995 survey of a nationally representative sample of 603 publicly funded family planning agencies reveal that 96% rely on federal funding, 60% on state funding and 40% on local funding to provide family planning and other services. Although only 25% of the contraceptive clients served by these publicly funded agencies--including health departments, hospitals, Planned Parenthood affiliates, independent agencies and community and migrant health centers--are Medicaid recipients, 57% have incomes below the federal poverty level and an additional 33% have incomes of 100-250% of the poverty level. Some 40% of the recipients of family planning services are black, Hispanic or from other minority groups, and 30% are younger than 20. Each agency employs an average of three physicians who together provide approximately seven hours of care per week and seven midlevel clinicians who provide 71 hours of care per week. The pill is the only contraceptive method provided by all agencies, but 96% provide the injectable; at least 90% spermicide, the condom and the diaphragm; 78% periodic abstinence; and 59% the implant. The remaining methods are provided by fewer than 50% of agencies. Almost 70% of agencies have at least one special program of outreach, education or services to meet the needs of teenagers, but far fewer have special programs for such hard-to-reach groups as the homeless, the disabled or substance users.
Family Planning Services↗
Family planning service provision in rural areas: a survey in Washington State.
CONTEXT: Women in rural areas are highly dependent on public clinics for family planning services, yet little information has been collected on rural family planning providers, especially on their funding and operation. METHODS: All 31 family planning clinic sites in rural Washington State were surveyed about their sponsorship, staffing, service provision and population coverage. RESULTS: Clinic sites were located in 25 of the 53 discrete rural health service areas of Washington State. While the three wealthiest areas had clinics, eight of the poorest areas had no clinics. Eight clinics were Planned Parenthood affiliates, eight were private freestanding clinics and 15 were local health department sites. Clinic sites were small (with the equivalent of 2.4 full-time staff members, on average) and offered a mean of 18 of 43 potential reproductive and women's health care services; general primary care services were rarely provided. Only one clinic offered abortions. CONCLUSION: Family planning clinics in rural Washington State offer an important but limited number of services. Many rural areas have no local family planning clinic. Given these clinics' reliance on federal and state funding, decreased public support might seriously impair family planning provision in rural areas.
Adult↗
[Preparatory courses for applicants for medical studies].
From 1991, the First Medical Faculty of the Charles University arranges for applicants for the medical study two-semester preparatory courses paid by the applicants. Their purpose is to improve knowledge of high-school physics, chemistry and biology with orientation to model questions published by the faculty [1, 2, 3]. Variants of 100-questions sets for the examination are generated by a computer and they are altered every year [4]. Two types of preparatory courses are available. Type A--every Monday and Tuesday between 17.00 and 18.45, physics and chemistry in odd weeks, biology and Latin in even weeks. Latin is not a discipline considered during the admission examination, however, managing of its basic knowledge facilitates not only understanding problems considered in the other disciplines, but it is particularly useful for learning the special terminology in the first year of the study of medicine. Course of type B is held once a month, on Saturdays between 8.30 and 14.00 and it is particularly designed for applicants residing beyond the capital city of Prague. In the course of 10 semesters implemented, 980 and 1,410 students passed through courses of type A and B, respectively [5, 6]. The purpose of our analysis was to evaluate the difference between results of admission procedure of applicants who participated and of those who did not participate in the preparatory course. Basic data were yielded by the Department of Students of the Deans Office. We considered the number of applicants, their results in the course of their four years of study at high schools and the number of points acquired in physical, chemical and biological tests. We furthermore obtained applications for preparatory courses in school years 1993/94 and 1994/95. The results were processed with the help of data base programs Access and Excel (Microsoft). In each of the years of interest, the applicants were divided into four groups depending on the type of the study: 1--medicine (L) and 2--stomatology (S) or depending on whether 3--they were registered in preparatory courses or 4--not. The analysis carried out resulted in the following conclusion: a--both groups of applicants (registered and not registered in preparatory courses) had comparable study results during the last four years of their high-school study; b--in the admission procedure, students, who passed through preparatory courses, achieved undoubtedly better results in comparison with those who did not pass through these course, which holds in medicine as well as stomatology; c--there was about the same improvement of knowledge of physics, chemistry and biology in both types of the preparatory courses.
Curriculum↗
Building a foundation for systems change: increasing access to physical activity programs for older adults.
Although 25% of U.S. adults are physically inactive, this percentage increases dramatically for older adults. Organizational change theory guided a state health department in identifying system gaps and developing strategies to expand programming for seniors. A survey of provider agencies in New Jersey assessed (a) capacity for physical activity programs for older adults, (b) accessibility of programs, and (c) barriers to providing programs. One hundred sixty agencies provided physical activity programs to almost 184,000 individuals annually. Fewer than one half of the agencies provided exercise programs for people with disabilities, and only 44% provided in-home programs. Eighty-two percent of program providers wanted to expand programming but cited lack of trained instructors and peer leaders, inadequate facility space, insufficient funding, and limited transportation resources as barriers. Sustaining older adult behavior change requires infrastructure that will ensure access to diverse physical activities. This article provides strategies to expand access to physical activity programs for older adults.
Aged↗
A program to improve access to health care among Mexican immigrants in rural Colorado.
CONTEXT: Migration to the United States from Mexico is increasing every year. Mexican immigrants tend to be poor, uninsured, monolingual Spanish speakers without adequate access to appropriate medical care. As a further barrier, many are also undocumented. PURPOSE: This article describes a program developed to improve access to health care among Mexican immigrants in northern Colorado. METHODS: The program was implemented by a migrant/community health center in rural northern Colorado based on findings from an in-depth health needs survey of the target population. The program consists of community outreach services vertically integrated into the main medical clinics, which comprise Salud Family Health Centers. A mobile unit went to nontraditional areas identified by community workers as gathering places for Mexican immigrants. Services provided included preventive health care (screening for diabetes, hypertension, mental health problems, dental problems, and HIV); education; and primary care for acute problems. Patients were referred to a health care home for ongoing care. RESULTS: In the first 6 months, 1,553 Mexican immigrants were seen on the mobile unit. Hypertension and psychosocial problems were the most common problems in this population. Thirty-five percent of patients who received consultation in the mobile unit have visited any of the clinics for follow-up within the following year. CONCLUSIONS: A community-based mobile outreach program targeted toward Mexican immigrants can be effective in uncovering medical and mental illness and in directing patients to a health care home. This is an important first step in eliminating health disparities among this population.
Adolescent↗
An ABCD program to increase access to dental care for children enrolled in Medicaid in a rural county.
OBJECTIVES: The Access to Baby and Child Dentistry (ABCD) Program addresses the needs of families in obtaining dental care. In this study, the program was evaluated in rural Stevens County, Washington. Aims were to assess utilization of dental services, average dental expenditures per child, and oral health status. METHODS: Medicaid-enrolled children aged 1-4 years were randomly assigned to the ABCD program (n=216) or to regular benefits (n=221). An outreach worker contacted each ABCD family and provided an orientation. Dental care utilization and expenditures were calculated from claims. A posttest-only design was used to evaluate oral health status. RESULTS: An enrollment effect was seen in ABCD, but the difference between groups was not sustained. There was a doubling of utilization between groups for the youngest cohort, while the others showed no differences. In the first year the rate was higher for the entire ABCD group than for the children not in ABCD (34.0% vs 24.7%). Thirty-three percent of ABCD children (70/212) who had visited the dentist had >1 appointment compared to 21.5 percent (47/219) for the children not in ABCD who had visited the dentist. There was no overall difference in expenditures, while expenditures for preventive services were greater for ABCD. ABCD children had fewer teeth with initial caries. The average incremental cost per child per initial lesion prevented was 31.44 dollars. CONCLUSION: ABCD most benefited the youngest cohort of children and improved health.
Child, Preschool↗
Effect of the North Carolina State Children's Health Insurance Program on Beneficiary Access to Care.
BACKGROUND: In the fall of 1998, North Carolina implemented its State Children Health Insurance Program, North Carolina Health Choice for Children (NCHC). This stand-alone, fee-for-service program quickly enrolled large numbers of children and has been considered one of the State Children Health Insurance Program success stories. OBJECTIVE: To explore the perceptions of parents of children enrolled in NCHC regarding their children's access to health care services before and after enrollment in the NCHC. DESIGN AND SETTING: Qualitative and quantitative data analyses are combined to assess program effectiveness. Two waves of surveys were fielded. A baseline survey asked parents of children newly enrolled in NCHC questions about their child's health experiences before enrollment in NCHC. Parents who responded with baseline data were resurveyed 1 year later to collect information on their child's experiences while insured by NCHC. PARTICIPANTS: Parents of 987 children newly enrolled in NCHC in the summer of 2000, randomly chosen within 3 age group strata. RESULTS: The NCHC has been successful in improving access to health care for low-income children. Parents reported that the program helped make health services financially accessible to their children, enabling them to get needed physician's care, eyeglasses, or prescription drugs. A significantly higher percentage of children received care in the private sector, increasing from 62% to 75% for well-child care visits and 67% to 78% for acute care. The percentage of children with unmet medical needs dropped significantly from 20% to just 2% after enrollment in NCHC. The improvement in access to care is much more striking for the older age groups and for children who were uninsured prior to NCHC enrollment (rather than those who graduated from Medicaid into the program). Despite these gains, there are still substantial numbers of children who are not receiving age-appropriate well-child care. CONCLUSION: The NCHC has successfully improved access to care for its enrollees.
Adolescent↗
An organized pilot program promoting web access to picture archiving and communications system data: emphasis on offices outside the host institution.
A formal Pilot Program for Web-based access to a host picture archiving and communication system (PACS) can augment the transition to filmless radiology. Beyond the technical issues of PCs and networks, appropriate legal input and documentation is necessary. While it is important to be in line with overall institutional priorities with regard to online access strategies, it is important to recognize that the Radiology Department has the greatest stake in successfully going filmless, and that it is incumbent upon the Radiology Department itself to take on outreach efforts to the medical community at large. The MMC Web Access Pilot Project has been successful in helping key non-MMC offices overcome the issues associated with preparing for and mastering Web access to PACS images. The benefit has been mutual, and MMC is now able to provide better advice to new offices that are coming online, as well as sharpening its focus on logistical issues that need to be resolved if we are to eliminate film from medical practice.
Humans↗
9-1-1: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee.
The sooner a person who is experiencing symptoms and signs of an acute myocardial infarction (AMI) (including out-of-hospital cardiac arrest) receives medical treatment, the greater his or her chances of survival and limitation of infarct size. A universal 9-1-1 emergency telephone system makes it possible for AMI patients or those around them to easily and quickly call for help and for emergency medical services (EMS) personnel to rapidly and accurately locate the patient. This article by the Access to Care Subcommittee of the National Heart Attack Alert Program (NHAAP) Coordinating Committee describes the history of 9-1-1, its key elements, its current implementation status, and existing State legislation and standards. Currently, approximately 78% of the United States population, mainly in urban areas, has access to a 9-1-1 system. Approximately 195 United States cities with a population of greater than 100,000 people have access to enhanced 9-1-1. It is the contention of the NHAAP that 9-1-1 services should be universally available to all Americans to ensure seamless access to EMS and, potentially, early detection, evaluation, and treatment for AMI. This article reports several key recommendations for achieving this goal.
Death, Sudden, Cardiac↗
Staffing and equipping emergency medical services systems: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee.
Each year, about 1,250,000 people in the United States experience an acute myocardial infarction (AMI). Emergency medical services (EMS) systems play a key part in the prehospital care and transportation of AMI patients. Rapid, state-of-the-art treatment by EMS personnel is essential for improving AMI survival and outcomes, as dramatized by the patient who is the victim of out-of-hospital cardiac arrest. In order to improve the prehospital care provided to AMI patients, this article by the Access to Care Subcommittee of the National Heart Attack Alert Program Coordinating Committee makes a number of recommendations regarding the staffing and equipping of EMS systems. The recommendations cover the "chain of survival" concept, universal and enhanced 9-1-1, emergency medical dispatching, ground ambulance specifications, automated external defibrillators, advanced life support coverage, medical direction, 12-lead electrocardiograms, and prehospital thrombolysis.
Ambulances↗
The Ability Program: improving statewide access to assistive technology for adults with disabilities.
In 1995, the Kate B. Reynolds Charitable Trust awarded $2.4 million to support the Ability Program, a statewide initiative to improve awareness of and access to assistive technology for adult North Carolinians with disabilities. This coordinated effort resulted in 11 funded projects, each using a different approach to deliver assistive technology to persons in rural communities. An overall management, technical assistance, and evaluation program ensured coordinated use of the Trust's funds. This paper describes the development and implementation of the Ability Program in North Carolina, accomplishments of program grantees, and results of a comprehensive program evaluation system used to document process and outcome measures. After 2 years of operation, the type and extent of assistive technology services for adults with disabilities in North Carolina increased as a result of the Ability Program.
Activities of Daily Living↗