Biblioteca Digital

PURPOSE: To describe the procedures used in developing Clinical and Regulatory Protocols for primary care teams to use in the management of the most common scenarios of impaired vision in Southern Brazil. METHODS: A retrospective review of 1.333 referral forms from all primary care practitioners was performed in Ribeirão Preto city, during a 30-day period. The major ophthalmic diagnostic categories were evaluated from those referrals forms. The Clinical and Regulatory Protocols development process was held afterwards and involved scientific cooperation between a university and the health care system, in the form of workshops attended by primary care practitioners and regulatory system team members composed of health care administrators, ophthalmologists, and professors of ophthalmology and social medicine. RESULTS: The management of impaired vision was chosen as the theme, since it accounted for 43.6% of the ophthalmology-related referrals from primary care providers of Ribeirão Preto. The Clinical and Regulatory Protocols developed involve distinctive diagnostic and therapeutic interventions that can be performed at the primary care level and in different health care settings. The most relevant clinical and regulatory interventions were expressed as algorithms in order to facilitate the use of the Clinical and Regulatory Protocols by health care practitioners. CONCLUSIONS: These Clinical and Regulatory Protocols could represent a useful tool for health systems with universal access...

PURPOSE: To describe the procedures used in developing Clinical and Regulatory Protocols for primary care teams to use in the management of the most common scenarios of impaired vision in Southern Brazil. METHODS: A retrospective review of 1.333 referral forms from all primary care practitioners was performed in Ribeirão Preto city, during a 30-day period. The major ophthalmic diagnostic categories were evaluated from those referrals forms. The Clinical and Regulatory Protocols development process was held afterwards and involved scientific cooperation between a university and the health care system, in the form of workshops attended by primary care practitioners and regulatory system team members composed of health care administrators, ophthalmologists, and professors of ophthalmology and social medicine. RESULTS: The management of impaired vision was chosen as the theme, since it accounted for 43.6% of the ophthalmology-related referrals from primary care providers of Ribeirão Preto. The Clinical and Regulatory Protocols developed involve distinctive diagnostic and therapeutic interventions that can be performed at the primary care level and in different health care settings. The most relevant clinical and regulatory interventions were expressed as algorithms in order to facilitate the use of the Clinical and Regulatory Protocols by health care practitioners. CONCLUSIONS: These Clinical and Regulatory Protocols could represent a useful tool for health systems with universal access...

OBJECTIVE: To identify factors that lead people to visit a doctor in Brazil and assess differences between socioeconomic groups. METHODS: A cross-sectional study comprising 1,260 subjects aged 15 or more was carried out in southern Brazil. Demographic, socioeconomic, health needs and regular source of care data were analyzed concerning visits to a doctor within two months from the interview. Adjusted prevalence ratios and 95% confidence intervals were calculated using Poisson regression. RESULTS: Adjusted PR showed that women having stressful life events, health insurance, and a regular doctor increased the outcome. A dose-related response was found with self-reported health, and the probability of visiting a doctor increased with health needs. Analysis in the chronic disease group revealed that uneducated lower income subjects had a 62% reduction in the chance of visiting a doctor compared to uneducated higher income ones. However, as it was seen a significant interaction between income and education, years of schooling increased utilization in this group. CONCLUSIONS: Results suggest the existence of health inequity in the poorest group that could be overcome with education. Specific measures reinforcing the importance of having a regular doctor may also improve access in the underserved group.

In order to assess the prevalence of having a regular doctor, associated factors, and the effects on health services utilization, a cross-sectional study was performed in Rio Grande, Brazil, from January to May 2000. A total of 1,260 individuals 15 years or over were interviewed. Adjusted prevalence ratios and 95% confidence intervals were calculated, using a Poisson regression model. Some 37% of the sample had a regular doctor. Adjusted analysis revealed a direct and linear association with income. Female gender, age, private health insurance coverage, and chronic health problems were also associated with the outcome. Having a regular physician was associated with a 51% increase in clinical breast examination and a 62% increase in cervical cancer screening during the previous year, as well as a 98% increase in prostate cancer screening in the previous year in men 40 years or over. The study concluded that the prevalence of having a regular doctor in Brazil is low and is directly associated with socioeconomic factors. Individuals with a regular physician tend to have better access to health services. The promotion of consultation with a regular doctor among the population may improve health care quality and health services access, particularly in the poorest groups.

The Massachusetts Department of Public Health, in collaboration with the U.S. Centers for Disease Control and Prevention Environmental Public Health Tracking Program, initiated a 3-year statewide project for the routine surveillance of asthma in children using school health records as the primary data source. School district nurse leaders received electronic data reporting forms requesting the number of children with asthma by grade and gender for schools serving grades kindergarten (K) through 8. Verification efforts from an earlier community-level study comparing a select number of school health records with primary care provider records demonstrated a high level of agreement (i.e., > 95%). First-year surveillance targeted approximately one-half (n = 958 schools) of all Massachusetts’s K–8 schools. About 78% of targeted school districts participated, and 70% of the targeted schools submitted complete asthma data. School nurse–reported asthma prevalence was as high as 30.8% for schools, with a mean of 9.2%. School-based asthma surveillance has been demonstrated to be a reliable and cost-effective method of tracking disease through use of an existing and enhanced reporting structure.

The objective is to present training on the International Classification of Functioning, Disability and Health (ICF) prepared by the Disability Italian Network (DIN) and to present strategies of ICF dissemination in Italy. A description of DIN’s training methodology, prepared in collaboration with World Health Organization (WHO) experts, is provided within its practical applications in health, labour, rehabilitation and statistical sectors. The ICF–DIN Basic Course is eight hours long and focuses on ICF basic principles, structure and application in different settings. The ICF–DIN Advanced Course, three days long followed by three months of distance learning, assumes Basic Course completion, and focuses also on ICF–checklist’s coding and WHO–DAS II administration. The first training courses’ outcomes, held in Italy and addressed to health, social and labour professionals, are provided. The feedback received by participants at the end of the courses showed that the main mistake they made was to consider ICF as an assessment instrument. The ICF–DIN training course was crucial in explaining the correct use of the ICF as a classification and to show its impact and usefulness on daily practice, particularly in multidisciplinary teams. The ICF–DIN courses already carried out in Italy show that this teaching methodology teaches how to avoid incomplete applications...

OBJECTIVES: In response to low utilization of primary health services in rural areas, the Government of Punjab contracted with a local non-governmental organization (NGO) to manage the basic health units in one district. METHODS: To evaluate the performance of the contractor, health facility surveys, household surveys, and routinely collected information were used to compare the experimental district (Rahim Yar Khan, RYK) with a contiguous and equally poor district (Bahawalpur, BWP). RESULTS: The evaluation found that contracting led to more than a 50% increase in out-patient visits in RYK compared to BWP. There was also increased satisfaction of the community with health services. Technical quality of care was equally poor in both districts and contracting also had little effect on the coverage of preventive services. The latter was likely the result of the NGO not being given managerial responsibility over vaccinators and other community health workers. CONCLUSIONS: Despite methodological limitations, this study found that contracting in management achieved important goals at the same cost to the Government, implying a large increase in efficiency. Contracting in management worked reasonably well in this context and has now been significantly expanded. The approach provides a plausible means for large-scale improvements of poorly performing primary health care systems.

BACKGROUND: Social and environmental changes have accompanied the ongoing rapid urbanisation in a number of countries during recent decades. Understanding of its role in the health-risk transition is important for health policy development at national and local level. Thailand is one country facing many of the health challenges of urbanisation. OBJECTIVE: To identify potential associations between individual migration between rural and urban areas and exposure to specific social, economic, environmental and behavioural health determinants. DESIGN: Baseline data from a cohort of 87,134 Thai open university students surveyed in 2005 (mean age 31 years). Four urbanisation status groups were defined according to self-reported location of residence (rural: R or urban: U) in 2005 and when the respondent was 10 12 years old (yo). RESULTS: Fourty-four percent were living in rural areas in 2005 and when they were 10 12yo (Group RR: ruralites); 20% always lived in urban areas (UU: urbanites); 32% moved from rural to urban areas (RU: urbanisers); 4% moved in the other direction (UR: de-urbanisers). The ruralites and urbanites often were the two extremes, with the urbanisers maintaining some of the determinants patterns from ruralites and the deurbanisers maintaining patterns from urbanites. There was a strong relationship between urbanisation status...

Objective: The goal of this study was to identify mental, behavioral, and cognitive disorders that may be triggered or exacerbated during heat waves, predisposing individuals to heat-related morbidity and mortality. Design: Using health outcome data from Adelaide, South Australia, for 1993–2006, we estimated the effect of heat waves on hospital admissions and mortalities attributed to mental, behavioral, and cognitive disorders. We analyzed data using Poisson regression accounting for overdispersion and controlling for season and long-term trend, and we performed threshold analysis using hockey stick regression. Results: Above a threshold of 26.7°C, we observed a positive association between ambient temperature and hospital admissions for mental and behavioral disorders. Compared with non–heat-wave periods, hospital admissions increased by 7.3% during heat waves. Specific illnesses for which admissions increased included organic illnesses, including symptomatic mental disorders ; dementia ; mood (affective) disorders ; neurotic, stress related, and somatoform disorders ; disorders of psychological development ; and senility. Mortalities attributed to mental and behavioral disorders increased during heat waves in the 65- to 74-year age group and in persons with schizophrenia...

PURPOSE: The Determinants of young Adult Social well-being and Health longitudinal study draws on life-course models to understand ethnic differences in health. A key hypothesis relates to the role of psychosocial factors in nurturing the health and well-being of ethnic minorities growing up in the UK. We report the effects of culturally patterned exposures in childhood. METHODS: In 2002/2003, 6643 11-13 year olds in London, ~80 % ethnic minorities, participated in the baseline survey. In 2005/2006, 4782 were followed-up. In 2012-2014, 665 took part in a pilot follow-up aged 21-23 years, including 42 qualitative interviews. Measures of socioeconomic and psychosocial factors and health were collected. RESULTS: Ethnic minority adolescents reported better mental health than White British, despite more adversity (e.g. economic disadvantage, racism). It is unclear what explains this resilience but findings support a role for cultural factors. Racism was an adverse influence on mental health, while family care and connectedness, religious involvement and ethnic diversity of friendships were protective. While mental health resilience was a feature throughout adolescence, a less positive picture emerged for cardio-respiratory health. Both...

MBA Professional Report; The military health care system has been plagued by increasing health care costs for the past few decades. The military has implemented a couple of programs in an effort to control costs while maintaining quality health care for beneficiaries. The CHAMPUS program was DoD's first attempt to allow beneficiaries to receive care from civilian physicians for a small fee. This program was replaced with the Tricare program which offered a three option health plan and provided easy access to medical care for beneficiaries, but it failed to control costs. This project initially attempted to demonstrate that by increasing cost shares to beneficiaries associated with the Tricare program, greater efficiency and cost savings in the military health care system could be achieved. While unable to prove this, we found evidence of self-selection occurring among Tricare Standard enrollees. Standard enrollees are using inpatient and outpatient care at higher rates than their Prime counterparts. Analysis of this self-selection could have implications for future policy decisions concerning the military health care system.

Approved for public release; distribution is unlimited; Health capital in Russia is in steep decline. Today the Russian population is decreasing by more than 700,000 per annum. Life expectancy has decreased significantly since it peaked in the mid-1960s. Infectious diseases, including an emerging HIV/AIDS epidemic, are threatening to worsen Russia's health crisis and further overwhelm a dilapidated healthcare system. Soviet and Russian government policies aimed at preserving health capital have failed consistently. Government policies and intervention have contributed to the crisis. The purpose of this research was to determine a possible explanation for the continuity in ineffective government policy. The analysis indicates the influence of a paternalistic political culture permeates the political process. As a result, the government is free to pursue its own agenda without a significant degree of accountability to the population. Issues affecting health capital are not a priority of the government. The consequence, therefore, is short-sighted and uncoordinated government policy and programs that are underfunded. Long-term improvements to Russia's health capital will require a shift in the political culture. State-society relations must evolve to allow and encourage greater interaction between state officials and the general population. Without government accountability or inidividual responsiblity...

CHDS State/Local; The Medical Reserve Corps (MRC) was formed to provide a cadre of trained medical volunteers to support and strengthen the public health infrastructure and improve its' emergency preparedness level. Training policies and standards are left to the discretion of the local MRC coordinator so the program maintains its flexibility to meet community needs. Training varies from unit to unit, and there are no protocols in place to measure or evaluate the effectiveness of that training. According to recent studies and surveys, disaster operations are an unfamiliar role for most MRC volunteers and the public health workforce in general. Evidence also suggests that few medical and public health workers receive this important preparedness training. In 2005, MRC working group members developed a list of core competency recommendations to provide training guidance, but specific educational content to satisfy those competencies were not defined. This thesis offers specific training content guidelines and strategies for achieving competency. The MRC must be able to integrate into the disaster environment while working safely, effectively and efficiently. Standards will set the mark for success, enabling the MRC to respond in a coordinated manner and at a consistently higher level to any public health emergency.; Captain...

CHDS State/Local; Local public health systems must have the capacity to meet the surge requirements of a health emergency that requires an extraordinary increase in activity including the rapid prophylaxis of an effected community. According to recent studies of paid healthcare professionals, approximately forty percent may be unable or unwilling to report to work during catastrophic disasters, but these questions have not yet been asked in the volunteer community. The Medical Reserve Corps (MRC) is a group of medical volunteers with a primary mission of support to the public health system during periods of surge. This thesis surveyed the members of a county health department MRC to determine their ability and willingness to volunteer in a public health emergency. The survey also elicited information on barriers and enablers to response and perceptions of community preparedness. Both significant differences in the responses of paid versus volunteer health professionals regarding their ability and willingness and striking similarities in their responses regarding barriers and enablers to report to work were identified. Volunteer motivation, cognitive dissonance and the nature of self selected volunteers are examined as they relate to these findings and strategies to strengthen the ability and willingness of MRC units to respond with the public health system are suggested.; Office of Emergency Preparedness...

Objectives: We compared the health of single mothers affected by welfare reform with the health of a nationally representative sample of women to document the prevalence of poor health as single mothers experience the effects of welfare reform. Methods: We compared risk factors and measures of health among women randomly sampled from the welfare rolls with similar data from a nationally representative sample of women. Results: Women in our welfare recipient sample had higher rates of elevated glycosylated hemoglobin (≥6%; prevalence ratio [PR]=4.87; 95% confidence interval [CI]=2.69, 7.04), hypertension (systole ≥140 or diastole ≥90; PR=2.36; 95% CI=1.47, 3.24), high body mass index (≥30; PR=1.78; 95% CI=1.49, 2.08), and high-density lipoprotein cholesterol (≤35 mg/dL; PR=1.91; 95% CI=1.17, 2.65); lower peak expiratory flow; and less physical functioning. Current smoking rates were higher (PR=1.85; 95% CI=1.50, 2.19) and smoking cessation rates were lower (PR=0.62; 95% CI=0.37, 0.86) than in the national sample. Conclusions: Current and former welfare recipients bear a substantial burden of illness. Further studies are necessary to interpret our findings of worsened health in the wake of welfare reform.; George A. Kaplan...

Objective: Although patients' reports of health status and functioning have been shown to be reliable and valid measures for use in health care research, there is limited information on their practical utility in clinical settings. The purpose of this study was to determine if patients' reports of physical and psychosocial health status have prognostic value by predicting future hospitalstays in acute myocardial infarction (AMI) patients. Methods: Research design was an obsen1ational, longitudinal follow-up study involving a sample of /32 AMI patients recently discharged from nine commwlity hospitais. One hundred twelve patients (85%) completed the study. Patient reports of general health status, diagnosis-specific measures of health status, medica I history, and demographic characteristics were collected one to two months post AM/; follow-up data were gathered six months later to identify occurrence of new cardiac-related stays. Results: Poor psychosocial functioning and cardiac symptoms were significantly associated with the likelihood of being rehospitalized (odds ratios of 4.62 and 4.00). Multivariate results, however, show that poor psychosocial function and younger age-but not cardiac symptoms-are significant independent predictors of new hospital stays...

OBJETIVO: Identificar os fatores que levam uma pessoa a consultar o médico no Brasil e avaliar as diferenças entre grupos socioeconômicos. MÉTODOS: Foi realizado um estudo transversal com 1.260 pessoas de 15 anos ou mais no sul do Brasil. Foram analisados dados demográficos, socioeconômicos, de necessidade em saúde e de fonte definida para consulta quanto a visita ao médico nos últimos dois meses. Foram calculadas as razões ajustadas de prevalência (RP) e os Intervalos de Confiança de 95% (IC 95%), utilizando a regressão de Poisson. RESULTADOS: As RP ajustadas mostraram que mulher, eventos estressantes, seguro de saúde e médico de referência aumentaram a probabilidade do desfecho. Foi encontrada uma relação de tipo dose-resposta com auto-avaliação do estado de saúde, e a probabilidade de consultar aumentou a medida que a necessidade em saúde também aumentou. A análise no grupo com doença crônica evidenciou que o grupo de menor renda e sem escolaridade teve uma redução de 62% na probabilidade de visitar o médico em comparação com o grupo de maior renda e sem estudo. Contudo, como ocorreu interação significativa entre renda e educação, o tempo de estudo melhorou a utilização nesse grupo. CONCLUSÕES: Os resultados sugerem a existência de iniqüidade no grupo mais pobre que pode ser modificada pela educação. Medidas específicas reforçando a importância de ter um médico de referência podem também melhorar o acesso dos mais pobres.; OBJECTIVE: To identify factors that lead people to visit a doctor in Brazil and assess differences between socioeconomic groups. METHODS: A cross-sectional study comprising 1...

In order to assess the prevalence of having a regular doctor, associated factors, and the effects on health services utilization, a cross-sectional study was performed in Rio Grande, Brazil, from January to May 2000. A total of 1,260 individuals 15 years or over were interviewed. Adjusted prevalence ratios and 95% confidence intervals were calculated, using a Poisson regression model. Some 37% of the sample had a regular doctor. Adjusted analysis revealed a direct and linear association with income. Female gender, age, private health insurance coverage, and chronic health problems were also associated with the outcome. Having a regular physician was associated with a 51% increase in clinical breast examination and a 62% increase in cervical cancer screening during the previous year, as well as a 98% increase in prostate cancer screening in the previous year in men 40 years or over. The study concluded that the prevalence of having a regular doctor in Brazil is low and is directly associated with socioeconomic factors. Individuals with a regular physician tend to have better access to health services. The promotion of consultation with a regular doctor among the population may improve health care quality and health services access, particularly in the poorest groups.

OBJECTIVE: To identify factors that lead people to visit a doctor in Brazil and assess differences between socioeconomic groups. METHODS: A cross-sectional study comprising 1,260 subjects aged 15 or more was carried out in southern Brazil. Demographic, socioeconomic, health needs and regular source of care data were analyzed concerning visits to a doctor within two months from the interview. Adjusted prevalence ratios and 95% confidence intervals were calculated using Poisson regression. RESULTS: Adjusted PR showed that women having stressful life events, health insurance, and a regular doctor increased the outcome. A dose-related response was found with self-reported health, and the probability of visiting a doctor increased with health needs. Analysis in the chronic disease group revealed that uneducated lower income subjects had a 62% reduction in the chance of visiting a doctor compared to uneducated higher income ones. However, as it was seen a significant interaction between income and education, years of schooling increased utilization in this group. CONCLUSIONS: Results suggest the existence of health inequity in the poorest group that could be overcome with education. Specific measures reinforcing the importance of having a regular doctor may also improve access in the underserved group.

OBJECTIVE: To explore use-inequity in maternal health-care services in home-based skilled-birth-attendant (SBA) programme areas in Bangladesh. METHODS: Data from a community survey, conducted from February to May 2006, were analysed to examine inequities in use of SBAs, caesarean sections for deliveries and postnatal care services according to key socioeconomic factors. FINDINGS: Of 2164 deliveries, 35% had an SBA, 22.8% were in health facilities and 10.8% were by caesarean section. Rates of uptake of antenatal and postnatal care were 93% and 28%, respectively. There were substantial use-inequities in maternal health by asset quintiles, distance, and area of residence, and education of both the woman and her husband. However, not all inequities were the same. After adjusting for other determinants, the differences in the use of maternal health-care services for poor and rich people remained substantial [adjusted odds ratio (OR) 2.51 (95% confidence interval, CI: 1.68-3.76) for skilled attendance; OR 2.58 (95% CI: 1.28-5.19) for use of caesarean sections and OR 1.53 (95% CI: 1.05-2.25) for use of postnatal care services]. Complications during pregnancy influenced use of SBAs, caesarean-section delivery and postnatal care services. The number of antenatal carevisits was a significant predictor for use of SBAs and postnatal care...