A coverage plan for health centres in Murewa district in Zimbabwe: an example of action research

Good access to health facilities providing good first-level health care remains problematic in many developing countries. It is a hindrance to effective and efficient functioning of the hospital, as outpatient departments become overcrowded with patients from areas without health centres. In many cases the quality of care delivered to these patients is poor because within the district health system the hospital is not the best place for the supply of comprehensive, integrated and continuous care. Eventually, high hospital involvement in first-level care can jeopardize the delivery of adequate referral care for those patients who desperately need the hospital's technology and expertise. This paper provides an account of the way this problem was investigated and managed by the district health management team in the Murewa district in north-east Zimbabwe. The design of a comprehensive 'master plan' or 'coverage plan' is presented as well as the problems and difficulties encountered. The Murewa experience highlights the relevance of a coverage plan for rational and coherent health infrastructure planning at district level. The approach followed by the Murewa team illustrates the use of action research as an integral part of the management of district health systems.     

A manual on pediatric telephone triage

In 1985 in Zaire, a 12-week training course began in Kasongo district to prepare physicians to use sound management of primary and secondary health services, supervision of health centers, and commitment to team work to operate districts in an integrated way. Only 1 new physician trainee was accepted every 4 weeks. During the first week, trainees observed work at an outpatient clinic for 2-3 hours/day to learn about the links between the primary and secondary levels of health care. During the second week, they observed staff at an urban health center in Kasongo city so they could become familiar with strategies for diagnosis and treatment in curative consultations and with instructions for follow-up. During the third week, the trainees returned to the outpatient clinic to practice interviewing patients. During the fourth week, they observed work in a rural health center and in remote villages. During the second 4-week period, trainees worked in a hospital department of their choice to learn how to use files and to evaluate quality of care. They visited health centers 1-2 times/week to examine supervisory techniques of different resident physicians. Trainees were part of the health team during the third 4-week period. They were responsible for a hospital department and supervised health centers under a resident physician. The trainees also attended management committee meetings addressing quality of care, staff management, and feedback from health center supervisions. The cost for this health district management training was US $100/trainee. Between mid-1985 and mid-1988, 18 physicians underwent this training. 12 of these physicians are now working in health districts in Zaire. A follow-up survey in 1995 showed that most trainees were applying the requisite skills and knowledge acquired during the training. Further supervision or self-training, involving team analysis of problems and possible solutions, are needed. Factors contributing to the course's success include: an integrated health system under the direction of a health team, a large enough team to do student training but small enough to maintain communication, and active participation of trainees.     

Community mental health program efficiency

Six urban community mental health centers participated in a capitated payment system designed for persons with severe mental illness who frequently used the state hospital. The centers and their funding agency agreed that a chief outcome measure would be the length of time clients were able to remain enrolled in the outpatient program. Clients of the six agencies were quite similar to one another. During the 18-month study length of enrollment in the outpatient program did not vary among the agencies whereas agency expenditures varied by more than three-fold. Although some of this expenditure variation was due to economies of scale at larger agencies, different practice styles also contributed to variable efficiency.     

Health seeking behaviour and self-treatment for common childhood symptoms in rural Guatemala

This study was conducted in the Guatemalan highland department of Sacatepequez, in a sample of 146 rural women insured by the Social Security system. It examined their health care behaviour when their children presented common childhood symptoms such as diarrhoea, fever, cough and worms. The mothers generally sought help and treatment advice from an older woman in the family, and did so more often for diarrhoea (82%) and fever (64%) than for cough (43%) or worms (28%). Obtaining advice in a pharmacy or from a drug seller ranked second (range: 8%-38%, depending on the symptom), before the procurement of professional help at a medical service (range: 8%-23%). Traditional healers were hardly consulted (range: 0%-3%). In the case of self-treatment the women predominantly relied on Western drugs: around 80% in diarrhoea and fever, and above 50% in cough. Herbs and traditional external remedies were little used, except in cough (27% herbs) and worms (58% external remedies). None of the mothers reported ORS as home treatment for diarrhoea. Problems of geographical or financial accessibility could not explain the low utilisation of the Western health care system. The acceptability of public services, however, was poor. Largely because the Social Security clinic did not prescribe the "potent" modern drugs mothers preferred for the treatment of childhood symptoms--at least, not for uncomplicated illness episodes. Women hence turned to the--partially informal--private sector, which unabashedly responds to their demands. Clear away the discrepancy between the "rational" needs perceived by the official health sector and the demands of the population is one of the bigger challenges to health care planning in transitional communities such as the one studied.     

Exploratory eye movement dysfunctions in patients with schizophrenia: possibility as a discriminator for schizophrenia

Emergency oral health care, as conceived in Tanzania, is an on-demand service provided at a rural health center or dispensary by a Rural Medical Aide. The service includes: simple tooth extraction under local anesthesia, draining of abscesses, control of acute oral infection with appropriate drug therapy, first aid for maxillo-facial trauma, and recognition of oral conditions requiring patient referral for further care at the district or regional hospital dental clinic. The objective of the present study was to describe patient satisfaction with emergency oral health care services in rural Tanzania and determine the relative importance of factors influencing patient satisfaction. The study was carried out as a cross-sectional interview survey between April 1993 and May 1994 using a patient satisfaction questionnaire in rural villages in the Rungwe district of Tanzania. It included 206 patients aged 18 years or more who had received emergency oral health care between April 1993 and March 1994. Overall, 92.7% of the respondents reported that they were satisfied with the service. Patients who were married, had no formal education and lived more than 3 km from the dispensary were more likely to be satisfied with treatment. In a logistic regression model, a good working atmosphere at the dispensary, a good relationship between care provider and patients (art of care) and absence of post-treatment complications significantly influenced patient satisfaction with odds ratios of 10.3, 17.4 and 6.2, respectively.     

Peak oxygen uptake of 12-18-year-old boys living in a densely populated urban environment

The prevalence of self-reported alcohol and marijuana use, along with alcohol abuse as measured by the Short Michigan Alcoholism Screening Test, was assessed for a community-based sample (n = 123) of persons with spinal cord injury (SCI). Correlates of alcohol and marijuana use and alcohol abuse also were examined, including demographic variables, measures of impairment, disability, and handicap, SCI medical complications, and measures of subjective assessment such as health rating, health maintenance behaviors, depression, life satisfaction, perceived stress, pain, and social support. Prevalence of alcohol use (59%) and marijuana use (16%) in persons with SCI was less than that of comparison groups in the general population. However, prevalence of alcohol abuse (21%) exceeded that of general population studies. Participants who abused alcohol shared the following criteria: (1) perceived their overall health as worse than those who did not abuse alcohol; (2) were more depressed; and (3) experienced more stress in their lives than those who did not abuse alcohol. Participants who used marijuana were younger at the time of the study and were younger at injury. They were also more depressed and more stressed. The indications of alcohol abuse in one in five persons with SCI living in the community mandates that screening, treatment, and referrals be part of any rehabilitation treatment program.     

Effects of the antihypertensive drug efonidipine hydrochloride on albuminuria and renal histopathology in young spontaneously hypertensive rats with diabetes

We examined 199 consecutive referrals to the Lipid Clinic at the National hospital in 1995 in order to compare referral- and chart data on familial hyperlipidaemia, familial cardiovascular disease, diagnosis, and lifestyle. 78% of referrals were from general practitioners. Most of the referrals included information on familial hyperlipidaemia and cardiovascular disease and on diet, but did not specify a lipid diagnosis. Less than half of the referrals included information on smoking habits (which was almost always specified in the chart). Up to 80% did not include information on alcohol, body mass index and physical activity, which was also often missing in the chart. We conclude that the referring doctors, and to some extent the clinic physicians, identified patients with a familial risk of cardiovascular disease, but they did not appear to characterise important lifestyle habits related to cardiovascular risk.     

Impact of psychological and physical health, stressful events, and social support on subsequent mental health help seeking among older adults.

Factors that influence mental health help seeking among adults 55+ yrs were examined prospectively. A discriminant analysis significantly differentiated between 120 older adults needing and seeking services and a comparison group of 120 older adults not needing services. Prior to having sought help, help seekers demonstrated poorer psychological well-being, reported more physical health problems, reported a higher level of unpleasant stressful events, and perceived greater deficits in the amount of social support available to them in time of need. The vast majority of these older help seekers sought help for their mental health problems from a medical doctor rather than from a mental health center or clinic or from a minister. Significantly more help seekers than nonseekers experienced stressful events involving bereavement, social and economic loss, and new physical illness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of rotation on spatial attention

OBJECTIVE: To clarify whether out-of-hours health centre visits and referrals to hospital are equally distributed in the three different duty models being used for health care in southwestern Finland. DESIGN: A medical audit of 2926 health centre visits and 223 referrals to hospitals by general practitioners (GPs) on duty. The duty models were formed on the basis of a possibility to utilize a local health centre during nights and weekends. Two-month follow-up period. SETTING: Primary health care. Population 46438. MAIN OUTCOME MEASURES: Out-of-hours visits to health centres and referrals to hospital, and the effect of age and duty model on referrals and visits. RESULTS: Patients over 64 years of age received most of the referrals although they visited the health care centre less frequently than the 0-14 year-olds (p < 0.001). The people who had an opportunity to utilize their local health centres visited more during out-of-hours than those who did not have this opportunity (p < 0.001). CONCLUSIONS: The health centre visits were not equally distributed in the three examined duty models. The over 64 year-olds in particular had the least visits and the most referrals.     

The mental health of men with a psychiatric disorder or traumatic brain injury: Wives' labeling and husbands' perceived control.

Objective: To investigate the relations among wives' labeling of their husbands' psychiatric disorder or brain injury as an organic illness, the husbands' perceived control over their disabilities, and the husbands' mental health. Participants: 57 male clients of the Department of Rehabilitation, Israel's Ministry of Defence (26 with a psychiatric disorder and 31 with a traumatic brain injury) and their wives. Measures: Illness Labeling Questionnaire, the Perceived Control Over Illness Questionnaire, and the Mental Health Inventory. Results: Husbands' mental health was low but did not differ according to disability; wives' labeling of husbands' condition was negatively related to the husbands' mental health; husbands' perceived control was positively related to their mental health for both disabilities. Conclusion: Organic illness labels, even when adopted by the wives of the persons with the disability, seem to be negatively related to that person's mental health, whereas perceived control over a mental disorder or a brain injury seems to contribute positively to mental health, independently of how the disorder or injury is labeled. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness.

A cognitive-behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) was developed to address its high prevalence in persons with severe mental illness receiving treatment at community mental health centers. CBT was compared with treatment as usual (TAU) in a randomized controlled trial with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients assigned to CBT participated in the program. Intent-to-treat analyses showed that CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms. Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal thinking, psychosis, and vulnerability to hospitalizations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Compliance of frail elderly with health services prescribed at discharge from an acute-care geriatric ward

OBJECTIVES: A model of compliance by frail elderly with prescribed healthcare services was developed and tested. The discrepancy between primary care, geriatric and community health center (CLSC) services prescribed at discharge after comprehensive geriatric evaluation and treatment was measured, as were those services actually used during a 6-week interval (compliance). In this model, compliance was directly related to elders' intention to adhere to prescribed services, but this relationship was modified by organizational factors, reinforcing factors, and changes in health status during the observation period. Intention to adhere resulted from individual and reinforcing factors existing before discharge. METHODS: This model was tested on 211 patients discharged to community settings from an acute-care hospital geriatrics ward. Information was obtained through interviews with the patients or care givers and from hospital, outpatient, and local community health center charts. RESULTS: On average, patients used 56.9% of services prescribed; 13% of patients did not use any of the services prescribed for them, whereas 22% used all the services prescribed. Intention to adhere was influenced by patients' perception of the benefits of prescribed services and by their perception of the ease of access to transportation. Intention itself was not found to be an important determinant of overall compliance. Among organizational factors, having the ward staff make a follow-up appointment with the patients' family doctor and with the geriatric clinic before discharge and communication with the local community health center increased overall compliance. Moreover, patients who perceived they had access to transportation and to an accompanying person were more likely to comply. CONCLUSIONS: The results suggest that when discharging patients to the community, steps taken for them by the discharging healthcare providers will improve compliance.     

Defendants are clueless--the 30-day psychiatric observation

OBJECTIVE: To investigate the understanding and expectations of defendants referred to Valkenberg Hospital for 30-day observation. DESIGN: Defendants referred for 30 days of psychiatric assessment were surveyed by means of a semi-structured interview within 3 days of admission. PARTICIPANTS: One hundred consecutive referrals from the Western, Northern and Eastern Cape were considered; 88 were eventually entered into the study. RESULTS: All defendants were generally ignorant of the reasons for referral, but had a good understanding of court procedure and wrongfulness. Mentally ill subjects differed only in their not being able to distinguish between a guilty/not guilty plea. Most did not have legal representation, did not personally request the assessment and denied guilt of the alleged offence. CONCLUSIONS: Mental illness affects triability but not necessarily criminal responsibility. Disturbingly, most defendants were without legal representation and were unaware of the purpose, implications and possible outcomes of psychiatric observation. It is imperative that the legislation governing these aspects be reviewed.     

Perceived threat of illness and health protective behaviors in offspring of adults with non-insulin-dependent diabetes mellitus

Self-reported measures of perceived threat of illness, health protective behaviors, psychological well-being, and family modeling of health behaviors of 30 adults with a parental history of non-insulin-dependent diabetes mellitus (NIDDM) were compared with responses from 29 adults with a parental history of hypertension and 30 adults with no parental history of chronic illness. The NIDDM risk group reported significantly more perceived threats of NIDDM and hypertension and more weight-control efforts than the controls did. Reports of the NIDDM risk respondents concerning physician screening, healthy diet, and exercise did not differ from reports of individuals without a family history of NIDDM. Perceived threat, psychological well-being, and family modeling did not correlate with health-protective behaviors. The findings suggest that offspring of adults diagnosed with NIDDM perceive themselves to be at risk of NIDDM and engage in health behaviors, such as weight control, to protect themselves from NIDDM onset.     

Comparison by external quality assessment of performance of analytical systems for measurement of therapeutic drugs in serum

OBJECTIVES: To identify the predictors of perceived health and predictors of changes in perceived health in frail hospitalized older persons during the year after hospitalization. DESIGN: Both cross-sectional and longitudinal multivariate analysis of data from a cohort followed for 1 year. SETTING: Six hospital in a group practice model health maintenance organization (HMO) in Southern California. PARTICIPANTS: A total of 1889 persons aged 65 or older who met at least one of 13 inclusionary criteria for a randomized trial of Comprehensive Geriatric Assessment consultation at admission and completed three Functional and Health Status Questionnaires (FHSQ) during a 12-month period. MEASUREMENTS: Functional and health status measures included basic and intermediate activities of daily living (BADL and IADI) and social activities (SA) scales from the Functional Status Questionnaire as well as the mental health index (MHI) and current health perception (CHP), scales from the Medical Outcomes Study short from. Subject's severity of disease was measured by the Resource Demand Scale (RD Scale). RESULTS: In the cross-sectional analyses, MHI score, IADL score, RD Scale, history of falls during the 3 months before hospitalization, and female gender were significant predictors of perceived health in all models for each time point, BADL score, age, presence of incontinence, and ethnicity were significant in the model for baseline only, and SA score was significant in models for 3 months and 12 months only. In the longitudinal analyses, the baseline CHP score and the changes in MHI, IADL, and BADL score predicted CHP change from 0 to 3 months and from 3 to 12 months. CONCLUSIONS: Functional and psychosocial health indicators are the most important and most consistent predictors of perceived health. Our study showed that several predictors of perceived health in cross-sectional analysis did not predict changes in perceived health over a 1-year period. Hence, to fully understand the medical and social contributors to perceived health, a comprehensive approach using both cross-sectional and longitudinal analyses is necessary.     

Hypertension and sickness absence: the role of perceived symptoms

The association between perceived symptoms and absenteeism was examined in five groups of employed adults: normotensives, unaware hypertensives, aware and untreated hypertensives, aware and treated hypertensives, and falsely aware normotensives. Aware hypertensives (untreated and treated) and falsely aware normotensives had a higher average of perceived symptoms than normotensives, whereas unaware hypertensives had lower. The absenteeism rate across the groups showed a similar pattern. A significant interaction of perceived symptoms by study group on absenteeism was uncovered. Hypertensives and falsely aware normotensives who reported a low level of symptoms were not absent more than their normotensive counterparts. However, aware hypertensives and falsely aware normotensives who perceived a high symptoms level showed higher absenteeism than unaware hypertensives and normotensives with a similar level. This suggests that aware hypertensives have a greater tendency than both normotensives and unaware hypertensives to equate their symptoms with ill health and to act accordingly. Special attention should be directed to aware hypertensives who perceive a threat to their health.     

Interaction between Set1p and checkpoint protein Mec3p in DNA repair and telomere functions

OBJECTIVES: This article describes the implementation and impact of the first statewide condom social marketing intervention in the United States. METHODS: A statewide social marketing program made condoms freely available in 93 public health clinics, 39 community mental health centers, 29 substance abuse treatment sites, and more than 1000 businesses in neighborhoods with high rates of sexually transmitted diseases (STDs) and HIV. Surveys about condom use were conducted annually. RESULTS: Between 1994 and 1996, more than 33 million condoms were distributed without significant opposition. Over time, self-reported condom use at the last sexual encounter increased among African American women (from 28% in 1994 to 36% in 1996), particularly African American women with 2 or more sex partners (from 30% to 48%). Condom use at the last sexual encounter increased among African American men (from 40% in 1994 to an average of 54% in 1996). The number of reported sex partners did not increase. CONCLUSIONS: Condom social marketing can be successfully implemented in the United States. The widespread availability of free condoms is associated with increased condom use, particularly among persons at high risk for STDs and HIV.     

Mental illness stigma as a mediator of differences in Caucasian and South Asian college students' attitudes toward psychological counseling.

Previous research has established that Asian Americans use mental health services less frequently and hold poorer attitudes toward psychological counseling than Caucasians. The authors directly tested whether stigmatizing beliefs regarding mental illness might explain such differential attitudes toward counseling in a South Asian and Caucasian student sample. Using mediation analyses, the authors examined 2 aspects of stigma posited to affect help-seeking attitudes: personal stigmatizing views and perceptions of the public's stigmatizing views directed toward persons with mental illness. First, the authors found that Caucasian (n = 74) college students revealed more positive attitudes toward counseling than did South Asian (n = 54) students. Second, in terms of mediation, increased personal stigma, but not perceived stigma, expressed by South Asians partially mediated and accounted for 32% of the observed difference in attitudes toward counseling services. These findings support a long-standing conjecture in the literature regarding the increased significance of stigma processes on disparities in majority-minority help-seeking attitudes. They also suggest that efforts to reduce disparities in attitudes toward counseling for South Asian students specifically should incorporate interventions to reduce the increased stigma expressed by this community, particularly related to a desire for social distance from persons with a mental illness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fatal and non-fatal childhood injuries in Metropolitan Toronto, 1986-1991

OBJECTIVE: To estimate the prevalence of human immunodeficiency virus (HIV) infection among health care workers who donate blood. DESIGN: Point prevalence survey of blood donors. SETTING: 20 U.S. blood centers that participate in an ongoing interview study of HIV-seropositive blood donors. MEASUREMENTS: Prevalence rates for HIV in persons who reported being health care workers were measured directly for 6 of the 20 blood centers. For the other 14 centers, we derived the numerator from the interview study in the same manner used for the 6 centers; we estimated the denominator using blood collection logs at those centers and extrapolations from the survey completed at the 6 blood centers. RESULTS: Between March 1990 and August 1991, 8519 health care workers donated blood at 6 hospitals and other medical facilities. Three persons were HIV seropositive: Two reported being health care workers and having nonoccupational risk factors for HIV infection; the occupation and other possible risk factors of the third seropositive donor could not be determined. Therefore, the highest overall prevalence of HIV infection among health care worker donors at these 6 centers was 0.04% (3 of 8519; upper limit of 95% CI, 0.1%). We estimated that during the same period, approximately 36,329 health care workers were tested for HIV at all 20 centers. Twenty-seven persons infected with HIV who donated at hospitals were identified; 7 did not return for interviews, so their health care occupations could not be verified. Thus, the highest estimated overall prevalence of HIV infection among health care worker donors at the 20 centers was 0.07% (27 of 36,329; upper limit of CI, 0.1%). Of the 20 known health care worker donors, 11 reported nonoccupational risks for HIV infection; 3 of the remaining 9 health care workers described occupational blood exposures that could have resulted in transmission of HIV. CONCLUSIONS: Blood donors can serve as a sentinel cohort when evaluating the risk for occupationally acquired HIV infection. These findings suggest that among the many health care worker donors in this study, HIV infection attributable to occupational exposure was uncommon.