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Does use of a government service depend on distance from the health facility?

HEALTH POLICY AND PLANNING 1999年第2期14卷 191-197页

作者： NoorAli, R Luby, S Rahbar, MH Aga Khan Univ Dept Community Hlth Sci Karachi 74800 Pakistan

To reduce mortality from common childhood illnesses such as diarrhoea and upper respiratory infections, it is important that health services are available and used appropriately. Physical accessibility to a health facility may influence its use, particularly in rural areas. We assessed whether use of government services for treatment of the three most common acute childhood illnesses (fever, diarrhoea and upper respiratory infections) was influenced by the physical accessibility of the government primary health care centres. We analyzed data from a household survey which was collected between November 1992 and January 1993, from 139 randomly selected villages located around 14 government facilities in Thatta, a rural district of Pakistan. There were 691 children under 5 years of age who suffered from the three acute illnesses;85% of these children used either a government or a private service. Children living at less than 4 km from a government facility made 22% less use of that facility than those living 4 km or more away. After controlling for the effects of distance from a private facility and treatment cost in a multiple logistic regression model, children living less than 4 km from a government facility were no more likely to use the facility than those living 4 km or more away (Adjusted Odds Ratio: 1.01, 95% Confidence Interval: 0.68-1.50). These results suggest that factors other than distance are the primary determinants of use of government services for treating children in the Thatta district. To increase the use of government health services, policymakers should assess carefully the factors determining the use of existing facilities, before they plan the building of more health facilities. Further studies are needed to examine the management of health facilities and the clients' perception of health-care providers.

关键词：卫生服务范围社区卫生中心/利用人口统计学发展中国家卫生服务易得程度卫生服务研究健康状况指标巴基斯坦/流行病学病人接受卫生保健的程度/统计学和数值数据公共卫生管理乡村卫生服务/利用旅行儿童学龄前人类

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Determinants of patient choice of medical provider: a case study in rural China

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HEALTH POLICY AND PLANNING 1998年第3期13卷 311-322页

作者： Yip, WC Wang, H Liu, YL Harvard Univ Sch Publ Hlth Boston MA 02115 USA Beijing Med Univ Training Ctr Hlth Management Beijing 100083 Peoples R China

This study examines the factors that influence patient choice of medical provider in the three-tier health care system in rural China: village health posts, township health centres, and county (and higher level) hospitals. The model is estimated using a multinomial legit approach applied to a sample of 1877 cases of outpatient treatment from a household survey in Shunyi county of Beijing in 1993. This represents the first effort to identify and quantify the impact of individual factors on patient choice of provider in China. The results show that relative to self-pay patients, Government and Labour Health Insurance beneficiaries are more likely to use county hospitals, while patients covered by the rural Cooperative Medical System (CMS) are more likely to use village-level facilities. In addition, high-income patients are more likely to visit county hospitals than low-income patients. The results also reveal that disease patterns have a significant impact on patient choice of provider, implying that the ongoing process of health transition will lead people to use the higher quality services offered at the county hospitals. We discuss the implications of the results for organizing health care finance and delivery in rural China to achieve efficiency and equity.

关键词：中国选择行为社区卫生中心/利用卫生保健调查卫生政策健康状况医院社区/利用收入保险健康组织状况研究病人接受卫生保健的程度/统计学和数值数据乡村卫生服务/分类乡村卫生服务/利用农村人口社会经济因素人类

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Inappropriate use of an accident and emergency department:: Magnitude, associated factors, and reasons -: An approach with explicit criteria

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ANNALS OF EMERGENCY MEDICINE 2001年第6期37卷 568-579页

作者： Sempere-Selva, T Peiró, S Sendra-Pina, P Martínez-Espín, C López-Aguilera, I Fdn Inst Invest Serv Salud Valencia 46008 Spain Hosp Morales Meseguer Serv Urgencias Murcia Spain Hosp Gen Univ Serv Urgencias Elche Spain

Background: We evaluate the appropriateness of medical visits to the accident and emergency department (A&ED) of a university hospital using an instrument based on explicit and objective criteria, analyze the association between inappropriate visits and certain factors, and identify reasons for inappropriate use. Methods: This concurrent review of a random sample of 2,980 adult medical patients' visits to the A&ED of the hospital of Elche uses the Hospital Urgencies Appropriateness Protocol, an instrument based on explicit criteria. We analyze the association between inappropriate use and specific factors, and provide a descriptive analysis of reasons for inappropriate use assigned by A&ED staff. Results: Of the total number, 882 (29.6%) of the visits were evaluated as inappropriate. Inappropriate use was associated with younger patients, use of own means of transportation, referral by the hospital, certain months of the year, and certain diagnostic groups of lesser severity. The most frequent reasons for inappropriate use were the patients' greater trust in the hospital than primary care (451 [51.1%]), inappropriate use of services by patients (160 [18.1%]), and inappropriate referrals by primary care physicians (142 [16.1%]). Conclusion: Inappropriate use represents an important percentage of use of the A&ED. Many reasons contribute to it, although foremost among them is patient preference (and the convenience and accessibility) of these services compared with primary care.

关键词：年龄因素住院期间审核交叉研究诊断相关患者组/分类诊断相关患者组/统计学和数值数据急诊室医院/利用卫生服务滥用/统计学和数值数据卫生服务研究医院公立/利用医院大学/利用病人接受卫生保健的程度/心理学病人接受卫生保健的程度/统计学和数值数据初级卫生保健/利用问卷调查转诊和会诊/组织和管理居住特征/统计学和数值数据危险因素疾病严重程度指数西班牙/流行病学运输/统计学和数值数据成年人老年人女(雌)性人类男(雄)性中年人

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Patient preferences in coronary revascularization

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AMERICAN HEART JOURNAL 1999年第6期137卷 1153-1162页

作者： Hornberger, J Bloch, DK Hlatky, MA Baumgartner, W Stanford Univ Sch Med Dept Hlth Res & Policy Stanford CA 94305 USA Stanford Univ Sch Med Dept Med Stanford CA 94305 USA Johns Hopkins Hosp Dept Surg Baltimore MD 21287 USA

Background This study was performed to assess patient preferences for consequences of 3 coronary revascularization procedures: angioplasty, conventional coronary bypass surgery, and minimally invasive coronary bypass surgery. Method A nationwide sample of 3 types of respondents was recruited: respondents with no heart disease (n = 89), respondents with heart disease who had not undergone cardiac surgery (n = 97), and respondents with heart disease who had undergone cardiac surgery (n = 118). Results Sixty-two percent ranked the risk of repeal revascularization as the most important concern, followed by postprocedure pain (22%), time to recovery of physical functioning (8%), time in hospital (4%), and body appearance (4%). Respondents preferred angioplasty to conventional and minimally invasive cardiac surgery if the 3-year risk of repeat revascularization with angioplasty were to decline to less than 28% and 21%, respectively. Conclusion These data suggest that patient preference should influence individual and policy recommendations when choosing among coronary revascularization procedures.

关键词：病人接受卫生保健的程度/统计学和数值数据病人记账和收款/经济学病人记账和收款/统计学和数值数据预后问卷调查随机分配再治疗/统计学和数值数据美国

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Provision of primary care by office-based rheumatologists - Results from the National Ambulatory Medical Care surveys, 1991-1995

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ARTHRITIS AND RHEUMATISM 1999年第3期42卷 409-414页

作者： Ward, MM Vet Affairs Palo Alto Hlth Care Syst Palo Alto CA 94304 USA Stanford Univ Sch Med Stanford CA 94305 USA

Objective. To determine the extent to which office-based rheumatologists provide primary care to patients without rheumatic diseases or provide principal care to patients with rheumatoid arthritis (RA), Methods. The National Ambulatory Medical Care Survey was used to determine national probability estimates of the nature and types of conditions treated by office-based rheumatologists in 1991-1995. At each of 1,074 patient visits, the rheumatologists recorded up to 3 diagnoses and 3 patient-reported reasons for the visit, as well as information on the treatments provided at the visit. Results. In only 9.8% of new consultations and 11.9% of return visits was neither a rheumatic disease diagnosis nor a musculoskeletal complaint recorded, indicating that the rheumatologist was likely acting as a primary care provider at a minority of patient visits. Among continuing patients with RA, the patient's primary reason for the visit was something other than a musculoskeletal complaint in only 9.9% of visits, and any nonrheumatic complaint was recorded in 30.4% of visits, indicating that at only some visits was the rheumatologist acting as the principal caregiver. In addition, only 31.1% of visits included the provision of medication for a nonrheumatic condition. Conclusion. In 1991-1995, most visits to rheumatologists involved the provision of specialized or consultative care to patients with rheumatic diseases or musculoskeletal complaints, and few visits were made by patients without either indication. Provision of principal care by rheumatologists to patients with RA is not currently widespread.

关键词：门诊医疗/人力门诊医疗/利用卫生保健调查诊室就医/利用病人接受卫生保健的程度/统计学和数值数据医师的作用初级卫生保健/人力初级卫生保健/利用转诊和会诊/统计学和数值数据风湿病学/人力风湿病学/统计学和数值数据美国青少年成年人女(雌)性人类男(雄)性中年人

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The immunization programme in Bangladesh: impressive gains in coverage, but gaps remain

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HEALTH POLICY AND PLANNING 1999年第1期14卷 49-58页

作者： Jamil, K Bhuiya, A Streatfield, K Chakrabarty, N USAID Bangladesh Amer Embassy Dhaka Bangladesh Johns Hopkins Univ Dept Populat Dynam Baltimore MD 21218 USA Int Ctr Diarrhoeal Dis Res Dhaka Bangladesh Populat Council Dhaka Bangladesh

The paper reviews the achievements in tetanus immunization coverage and child immunization in Bangladesh. It uses data from the 1993-94 Bangladesh Demographic and Health Survey to identify and examine the programmatic and non-programmatic factors that influence the coverage of tetanus (TT) immunization during pregnancy, and full immunization among children 12-23 months old in rural Bangladesh. The purpose of this analysis is to identify the areas that need further programme attention. The logistic regression results show that the coverage of TT immunization was significantly associated with proximity to outreach clinics and the presence of a health worker in the community. Home visits by health/family planning fieldworkers and the proximity to outreach clinics had larger influences on TT coverage of poorer households compared to those better-off. The effect of distance to static clinics varied by regions. Among children, full immunization coverage (coverage of all of BCG, DPT1, DPT2, DPT3, Polio1 Polio2, Polio3) was significantly associated with distance to outreach clinics, the greater the distance to the clinics, the less the likelihood of immunization.

关键词：孟加拉国社区卫生服务/组织和管理发展中国家卫生服务研究免疫接种规划/组织和管理免疫接种规划/发展趋势免疫接种规划/利用 Logistic模型病人接受卫生保健的程度/统计学和数值数据产前保健/标准产前保健/统计学和数值数据方案评价农村人口社会经济因素破伤风类毒素/投药和剂量成年人儿童女(雌)性人类婴儿妊娠

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First-contact incidence rate of schizophrenia on Barbados

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BRITISH JOURNAL OF PSYCHIATRY 1999年第1期175卷 28-33页

作者： Mahy, GE Mallett, R Leff, J Bhugra, D Univ W Indies Queen Elizabeth Hosp Sch Clin Med & Res St Michael Barbados

Background The incidence rate for broad schizophrenia among second-generation African-Caribbean people in the United Kingdom has been reported as high. Ethnicity. migration and psychosocial stressors have been suggested as causal factors. Aims To determine the incidence of schizophrenia for the whole population of Barbados using an identical methodology to two previous studies in Trinidad (Bhugra et al, 1996) and London (Bhugra et al, 1997). Method A 12-month study of all persons in the 18-54-year age group presenting with a psychosis for the first time was carried out on the population of Barbados. Information was collected using World Health Organization screening and measurement instruments. Results On an island of just over a quarter of a million, 40 out of the 53 patients th at met the inclusion criteria we re categorised as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10000 (95% CI1.97-3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10000 (95% CI2.3-4.1), which is significantly lower than the comparable rate for London's African - Caribbeans of 6.6/10000 (95% CI4.5-8.7). Conclusions The very high rate for broad schizophrenia among African Caribbean people in the UK is probably due to environmental factors. Declaration of interest Support received from the Sainsbury Family Charitable Trusts.

关键词：巴巴多斯/流行病学巴巴多斯/人种学发病率伦敦/流行病学病人接受卫生保健的程度/统计学和数值数据危险因素精神分裂症/流行病学精神分裂症/人种学精神分裂症/治疗社会经济因素青少年成年人女(雌)性人类男(雄)性中年人

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A randomised controlled trial of flexibility in routine antenatal care

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BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 2000年第10期107卷 1241-1247页

作者： Jewell, D Sharp, D Sanders, J Peters, TJ Univ Bristol Div Primary Hlth Care Bristol BS8 2PR Avon England Univ Bristol Dept Social Med Bristol BS8 2PR Avon England

Objective To assess changes in satisfaction associated with a flexible approach to antenatal care schedules offered to women at low obstetric risk. Design Randomised controlled trial. Setting Eleven primary care centres providing midwifery care in Avon. Participants Six hundred and nine women at low risk of obstetric complications presenting for antenatal care. Methods A standard antenatal care schedule ('traditional care') was compared with a schedule based on a minimum number of visits and additional visits with timing agreed between women and midwives ('flexible care'). Main outcome measures Women's attitudes to pregnancy and motherhood using a subscale of the Maternal Adjustment and Maternal Attitudes scale, satisfaction with antenatal care, and perception of the speed of recognition of antenatal complications. Results There was no difference between the two groups in terms of attitudes to pregnancy and motherhood (mean difference on Maternal Adjustment and Maternal Attitudes scale -0.64, 95% CI -1.39 to 0.11, P = 0.068) and no difference in the proportions of women reporting antenatal problems as soon as possible (traditional group 74.5%, flexible group 76.4%, difference -2%, 95% CI -12.1 to 8.2, P = 0.70). Women receiving traditional care reported higher levels of satisfaction for the care provided by community midwives (P < 0.01). Women receiving flexible care were more likely to report having a choice over the number and timing of their antenatal visits (P < 0.001), but were also more likely to report that they would like to have been seen more often (P < 0.01). There was no difference between the groups in rates of obstetric complications. Conclusions An imposed reduction in antenatal visits has been reported to increase dissatisfaction in other studies. In this study, encouraging women to adopt a flexible approach to antenatal care resulted in a similar finding. Successful implementation of such approaches may depend on more careful selection of women who

关键词：适应心理学病人预约和时间安排健康态度队列研究助产学母亲/心理学病人接受卫生保健的程度/统计学和数值数据病人满意度妊娠/心理学产前保健/方法成年人女(雌)性人类

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Attitudes to 'Kaponya Mafumo': the terminators of pregnancy in urban Zambia

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HEALTH POLICY AND PLANNING 2000年第2期15卷 186-193页

作者： Webb, D UNICEF Zambia.

As part of a larger study of adolescent sexual and reproductive health in urban Zambia, the issue of unwanted pregnancy and abortion was considered through the examination of the perceptions of both adolescents and adults. Young people rank sexual health as their primary health issue, and sexual behaviour is integrally linked into other aspects of their lives. Pregnancies were deemed to be a common occurrence amongst the adolescents, with an estimated two-thirds of unwanted pregnancies ending in unsafe abortion. The decision to abort is primarily determined by the reaction of the boyfriend and his willingness to accept paternity and the associated financial implications. Other crucial influences are the desire to stay in school and the stigma attached to unwanted pregnancy. The decision-making process regarding the abortion itself is related to the perceived advantages and disadvantages of various service providers. Around 40% of the respondents stated that in the event of an abortion being carried out, it would be performed either by the girl herself or with the assistance of other non-medical personnel. Less popular but still significant are traditional healers and private doctors. Formal health services tend to be rejected due to their poor perception by young people, centred on the lack of privacy and confidentiality, and the de facto illegal nature of abortion itself. The services of nurses are sought, but outside of the clinic setting. The most popular method of self-induced abortion is overdosing on chloroquine. Other methods involve the use of traditional medicines such as various types of roots, as well as more modern methods such as ingesting washing powder. Recommendations for policy-makers concentrate on the improvement of formal, 'youth friendly' health services and the development of appropriate outreach education methods which address specific concerns widely held by young people.

关键词：堕胎药/投药和剂量流产人工/方法流产人工/利用决策集中研讨小组健康知识态度实践卫生政策病人接受卫生保健的程度/统计学和数值数据妊娠青少年期/心理学妊娠青少年期/统计学和数值数据妊娠不想要的/统计学和数值数据患病率城市卫生赞比亚青少年成年人儿童女(雌)性人类男(雄)性妊娠

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Factors affecting home delivery in the Kathmandu valley, Nepal

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HEALTH POLICY AND PLANNING 1998年第2期13卷 152-158页

作者： Bolam, A Manandhar, DS Shrestha, P Ellis, M Malla, K Costello, AM Inst Child Hlth Ctr Int Child Hlth London WC1N 1EH England Matern Hosp MIRA Project Kathmandu Nepal

This nested case-control study compares the characteristics of mothers having home or institutional deliveries in Kathmandu, Nepal, and explores the reasons given by mothers for a home delivery. The delivery patterns of mothers were identified in a cross-sectional survey of two communities: an urban area of central Kathmandu (Kalimati) and a peri-urban area (Kirtipur and Panga) five kilometres from the city centre. 357 pregnant women were identified from a survey of 6130 households: 183 from 3663 households in Kirtipur and Panga, 174 from 2467 households in Kalimati. Methods involved a structured baseline household questionnaire and detailed follow-up of identified pregnant women with structured and semi-structured interviews in hospital and the community. The main outcome measures were social and economic household details of pregnant women;pregnancy and obstetric details;place of delivery;delivery attendant;and reasons given for home delivery. The delivery place of 334/357 (94%) of the pregnant women identified at the survey was determined. 272 (81%) had an institutional delivery and 62 (19%) delivered at home. In univariate analysis comparing home and institutional deliverers, maternal education, parity, and poverty indicators (income, size of house, ownership of house) were associated with place of delivery. After multivariate analysis, low maternal educational level (no education, OR 5.04 {95% CI 1.61-15.8}, class 1-10, OR 3.36 {1.04-10.8} compared to those with higher education) and multiparity (OR 3.1 {1.63-5.74} compared to primiparity) were significant risk factors for a home delivery. Of home deliverers, only 24% used a traditional birth attendant, and over half were unplanned due to precipitate labour or lack of transport. We conclude that poor education and multiparity rather than poverty per se increase the risk of a home delivery in Kathmandu. Training TBAs in this setting would probably not be cost-effective. Community-based midwife-run delivery units

关键词：病例对照研究社区卫生服务/组织和管理社区卫生服务/利用产房/标准产房/统计学和数值数据产房/利用人口统计学教育程度卫生保健调查家庭分娩/标准家庭分娩/统计学和数值数据家庭分娩/利用产妇死亡率助产学尼泊尔/流行病学病人接受卫生保健的程度/统计学和数值数据危险因素成年人女(雌)性人类妊娠

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