Tuberculosis in Bombay: new insights from poor urban patients.
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This study explores the health seeking behaviour of poor male and female tuberculosis patients in Bombay, and examines their perceptions of the causes and effects of the disease on their personal lives. Sixteen patients who attended an NGO's tuberculosis clinic were interviewed in-depth. Almost equal numbers of respondents stated 'germs' and 'worry' as the cause of tuberculosis. Men worried about loss of wages, financial difficulties, reduced capacity for work, poor job performance, and the consequences of long absence from work. Women were concerned about rejection by husband, harassment by in-laws, and the reduced chances of marriage (for single women), in addition to their concerns about dismissal from work. During the first two months of symptoms most patients either did nothing or took home remedies. When symptoms continued, private practitioners were the first source of allopathic treatment; they were generally unable to correctly diagnose the disease. Respondents shifted to municipal and NGO health services when private treatment became unaffordable. Respondents shifted again to NGO-based services because of the poor quality of municipal tuberculosis control services. The wage-earning capacity of both men and women was affected, but women feared loss of employment whereas men, being self-employed, lost wages but not employment. Married men and single women perceived a greater level of family support to initiate and complete treatment. Married women tried, often unsuccessfully, to hide their disease condition for fear of desertion, rejection or blame for bringing the disease. Women dropped out from treatment because of the pressure of housework, and the strain of keeping their condition secret particularly when the reasons for their movements outside the home were routinely questioned. Health programmes will have to be sensitive to the different needs and concerns of urban men and women with tuberculosis; in the case of women, health care providers will have to make particular efforts to identify and treat married women with tuberculosis completely. (+info)
Understanding lay perspectives: care options for STD treatment in Lusaka, Zambia.
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Understanding lay persons' perceptions of STD care is critical in the design and implementation of appropriate health services. Using 20 unstructured group interviews, 10 focus group discussions and 4 STD case simulations in selected sub-populations in Lusaka, we investigated lay person perspectives of STD services. The study revealed a large diversity of care options for STD in the communities, including self-care, traditional healers, medicine sold in the markets and streets, injections administered in the compounds, private clinics, health centres and hospital. The factors identified as influencing care seeking behaviour are: lay referral mechanisms, social cost, availability of care options, economics, beliefs, stigma and quality of care as perceived by the users. (+info)
Risks and benefits of coronary angioplasty: the patients perspective: a preliminary study.
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OBJECTIVES: To describe what cardiac patients in Northern Ireland understand to be the benefits of coronary angioplasty and assess the extent to which they have been able to make informed choices about their treatment. DESIGN: An interview based questionnaire survey completed after the patients had undergone coronary angiography, within hours of treatment counselling. SUBJECTS: 150 patients consecutively recruited from two regional cardiology centres in Belfast, Northern Ireland. MAIN OUTCOME MEASURES: The perceived complication rate and the perceived gain in life expectancy from coronary angioplasty. RESULTS: Although most subjects had asked the consultant questions, 70% (n = 104) thought that they contributed negligibly or not at all to the treatment decision. Although 75% (n = 112) recalled discussing the complication rate from the procedure, only 27% accurately estimated this rate (as between 0.5 and 1.5%). Eighty eight per cent (n = 131) thought that their mortality risks would be substantially or greatly reduced by having the procedure. The patients anticipated a gain in life expectancy of some 10 years (median) and this was significantly in excess of the potential gain in life expectancy which dietary prudence to lower blood cholesterol, not smoking, and taking more exercise might produce (median 5 years respectively; P < 0.0001, Wilcoxon matched pairs signed rank test). CONCLUSIONS: Patients vastly overrate the capacity of angioplasty to control their disease: angioplasty is seen as more effective than risk factor modification. (+info)
The use of formal and informal services for antenatal care and malaria treatment in rural Uganda.
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The study aimed to analyze reasons for the use or non-use of antenatal care services and malaria treatment among pregnant women living in rural areas in Uganda. Focus group discussions with pregnant women, in-depth interviews with key informants (Traditional Birth Attendants (TBAs) and health workers) and a structured questionnaire administered to pregnant women were used to collect the relevant information. Antenatal care attendance was irregular and few women knew that the purpose of attending antenatal care was to monitor both the growth of the baby and the health status of the woman. Parity significantly influenced antenatal care attendance, but level of education, religion and marital status did not. Fifty-five per cent of the women stated that they had delivered outside the formal health delivery system despite antenatal care attendance. All women in their second pregnancy had delivered their first child in the village, despite TBA training to the contrary. Malaria as perceived by pregnant women is common and multiple health service providers are used for its treatment. About 66% of the mothers reported having suffered from malaria during the current pregnancy; of these more than half had received treatment outside the formal health delivery system. Self-treatment with drugs bought from ordinary shops was commonly reported. Nearly all women (93.3%) knew about the antimalarial drug chloroquine and 83% thought that it was used for the treatment of malaria, not for its prevention. Some women believed that the drug could cause abortion. Health seeking behaviour was influenced by several factors, including the perceived high cost of antenatal care services, of conducting a delivery and treatment, and perceived inadequacy of services provided by the formal health system. Inadequacy of formal health services was perceived by users to be partly due to understaffing and to irregular supply of essential drugs. Intensive health education to pregnant women on the safety of chloroquine use in pregnancy, the importance and the need for regular antenatal care attendance are recommended. In addition, training of more TBAs and continued educational efforts to upgrade their knowledge, regular and adequate supply of essential drugs, and free health services for high-risk groups such as pregnant women are recommended to improve antenatal care services and drug prophylaxis use in pregnancy. (+info)
The validity and usage of resource utilization data among a group of primary care physicians.
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The use of individual resource utilization scores to compare primary care physicians (PCPs) has become more commonplace as managed care organizations (MCOs) increase their penetration into the US healthcare market. This study looks at the validity and usage of these scores among a group of PCPs within a multispecialty clinic that is part of an integrated managed care network. Personal interviews were conducted with PCPs; and reviews were done of the practice site paper charts, the computerized visit record system of the clinic and affiliated hospital, and the MCO-supplied resource utilization data on the 25 patients of each PCP on whom the most healthcare dollars were spent in 1995. As of October 1996, few PCPs had done more than a cursory review of their resource utilization data. None had identified the patients who use the most resources or developed any methods to proactively manage those patients with a history of high utilization. The clinic's communication systems alerted the PCPs less than 50% of the time when patients for whom they were responsible had high utilization of services. Patients appeared to be assigned to the incorrect PCP more than 20% of the time. All players in this managed care network--PCPs, clinic administration, and the MCO--must work together to improve the current system before resource utilization data are considered valid and are incorporated more fully into clinical practice. (+info)
Medicare HMOs: who joins and who leaves?
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Medicare risk health maintenance organizations (HMOs) are an increasingly common alternative to fee-for-service Medicare. To date, there has been no examination of whether the HMO program is preferentially used by blacks or by persons living in lower-income areas or whether race and income are associated with reversing Medicare HMO selection. This question is important because evidence suggests that these beneficiaries receive poorer care under the fee-for-service-system than do whites and persons from wealthier areas. Medicare enrollment data from South Florida were examined for 1990 to 1993. Four overlapping groups of enrollees were examined: all age-eligible (age 65 and over) beneficiaries in 1990; all age-eligible beneficiaries in 1993; all age-eligible beneficiaries residing in South Florida during the period 1990 to 1993; and all beneficiaries who became age-eligible for Medicare benefits between 1990 and 1993. The associations between race or income and choice of Medicare option were examined by logistic regression. The association between the demographic characteristics and time staying with a particular option was examined with Kaplan-Meier methods and Cox Proportional Hazards modeling. Enrollment in Medicare risk HMOs steadily increased over the 4-year study period. In the overall Medicare population, the following statistically significant patterns of enrollment in Medicare HMOs were seen: enrollment of blacks was two times higher than that of non-blacks; enrollment decreased with age; and enrollment decreased as income level increased. For the newly eligible population, initial selection of Medicare option was strongly linked to income; race effects were weak but statistically significant. The data for disenrollment from an HMO revealed a similar demographic pattern. At 6 months, higher percentages of blacks, older beneficiaries (older than 85), and individuals from the lowest income area (less than $15,000 per year) had disenrolled. A small percentage of beneficiaries moved between HMOs and FFS plans multiple times. These data on Medicare HMO populations in South Florida, an area with a high concentration of elderly individuals and with one of the highest HMO enrollment rates in the country, indicate that enrollment into and disenrollment from Medicare risk HMOs are associated with certain demographic characteristics, specifically, black race or residence in a low-income area. (+info)
Improving the quality of private sector delivery of public health services: challenges and strategies.
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Despite significant successes in controlling a number of communicable diseases in low and middle income countries, important challenges remain, one being that a large proportion of patients with conditions of public health significance, such as tuberculosis, malaria, or sexually transmitted diseases, seek care in the largely unregulated 'for profit' private sector. Private providers (PPs) often offer services which are perceived by users to be more attractive. However, the available evidence suggests that serious deficiencies in technical quality are often present. Evaluations of interventions to promote evidence-based care in high income countries have shown that multi-faceted strategies which increase provider knowledge have had some success in improving service quality. A wider range of factors needs to be considered in low and middle income countries (LMICs), especially factors which contribute to discrepancies between provider knowledge and practice. Studies have shown that PPs, especially, perceive or experience patient and community pressures to provide inappropriate treatments. LMIC governments also lack the capacity to enforce regulatory controls. Context-specific multi-faceted strategies are needed, including the local adaptation and dissemination to providers of relevant evidence, the education of patients and communities to adopt effective treatment-seeking and treatment-taking behaviour, and feasible mechanisms for ensuring and monitoring service quality, which may include a role for self-regulation by provider organizations or provider accreditation. Developing, implementing and evaluating strategies to improve the quality of service provision will depend on the involvement of the key stakeholders, including policy makers and PPs. Focusing on studies from Asia, Africa and Latin America, this paper develops a model for identifying the influences on PPs, mainly private medical practitioners, in their management of conditions of public health significance. Based on this, multi-faceted strategies for improving the quality of treatment provision are suggested. Interventions need to be inexpensive, practical, efficient, effective and sustainable over the medium to long term. Achieving this is a significant challenge. (+info)
Why include men? Establishing sexual health clinics for men in rural Bangladesh.
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Subsequent to recommendations from the 1994 United Nations International Conference on Population and Development, and given recent findings outlining the links between control of sexually transmitted infections (STIs) and a reduction in HIV incidence, many countries are now seeking to establish STI control programmes. In many cases this is through a policy of providing comprehensive reproductive health care through the maternal and child health/family planning (MCH-FP) system. This involves management of all reproductive tract infections including STIs. This paper demonstrates how such an approach may miss one of the largest target groups--men. In general, men are at higher risk of initially contracting STIs, but, once infected, their clinical management is usually simpler than treating equivalent infections in women. It is argued that these two factors alone make the inclusion of men in STI control programmes critical. The paper outlines the experiences of one programme in rural Bangladesh in establishing sexual health clinics for men within the existing service structure. In response to client demand, the clinics moved beyond simple STI care towards provision of comprehensive sexual health services. Finally, the paper argues that whilst including men in sexual health programmes should never be at the expense of providing services for women, excluding them from service provision may make the objectives of STI control programmes unattainable. (+info)