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1.
Upendra Bhojani Narayanan Devedasan Arima Mishra Stefaan De Henauw Patrick Kolsteren Bart Criel 《PloS one》2014,9(9)
Background
Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2.Methods
We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis.Result
There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients’ medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity.Conclusions
Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions. 相似文献2.
Maria Giné-Garriga Carme Martin-Borràs Anna Puig-Ribera Carlos Martín-Cantera Mercè Solà Antonio Cuesta-Vargas 《PloS one》2013,8(6)
Background
Effective promotion of exercise could result in substantial savings in healthcare cost expenses in terms of direct medical costs, such as the number of medical appointments. However, this is hampered by our limited knowledge of how to achieve sustained increases in physical activity.Objectives
To assess the effectiveness of a Primary Health Care (PHC) based physical activity program in reducing the total number of visits to the healthcare center among inactive patients, over a 15-month period.Research Design
Randomized controlled trial.Subjects
Three hundred and sixty-two (n = 362) inactive patients suffering from at least one chronic condition were included. One hundred and eighty-three patients (n = 183; mean (SD); 68.3 (8.8) years; 118 women) were randomly allocated to the physical activity program (IG). One hundred and seventy-nine patients (n = 179; 67.2 (9.1) years; 106 women) were allocated to the control group (CG). The IG went through a three-month standardized physical activity program led by physical activity specialists and linked to community resources.Measures
The total number of medical appointments to the PHC, during twelve months before and after the program, was registered. Self-reported health status (SF-12 version 2) was assessed at baseline (month 0), at the end of the intervention (month 3), and at 12 months follow-up after the end of the intervention (month 15).Results
The IG had a significantly reduced number of visits during the 12 months after the intervention: 14.8 (8.5). The CG remained about the same: 18.2 (11.1) (P = .002).Conclusions
Our findings indicate that a 3-month physical activity program linked to community resources is a short-duration, effective and sustainable intervention in inactive patients to decrease rates of PHC visits.Trial Registration
ClinicalTrials.gov NCT00714831相似文献3.
Jinyang Wang Xiaolin Zhang Yinglie Liu Xiaojian Pan Pingli Liu Zhaozhi Chen Taiqing Huang Zhengqin Xiong 《PloS one》2012,7(9)
Background
Evaluating the net exchange of greenhouse gas (GHG) emissions in conjunction with soil carbon sequestration may give a comprehensive insight on the role of agricultural production in global warming.Materials and Methods
Measured data of methane (CH4) and nitrous oxide (N2O) were utilized to test the applicability of the Denitrification and Decomposition (DNDC) model to a winter wheat – single rice rotation system in southern China. Six alternative scenarios were simulated against the baseline scenario to evaluate their long-term (45-year) impacts on net global warming potential (GWP) and greenhouse gas intensity (GHGI).Principal Results
The simulated cumulative CH4 emissions fell within the statistical deviation ranges of the field data, with the exception of N2O emissions during rice-growing season and both gases from the control treatment. Sensitivity tests showed that both CH4 and N2O emissions were significantly affected by changes in both environmental factors and management practices. Compared with the baseline scenario, the long-term simulation had the following results: (1) high straw return and manure amendment scenarios greatly increased CH4 emissions, while other scenarios had similar CH4 emissions, (2) high inorganic N fertilizer increased N2O emissions while manure amendment and reduced inorganic N fertilizer scenarios decreased N2O emissions, (3) the mean annual soil organic carbon sequestration rates (SOCSR) under manure amendment, high straw return, and no-tillage scenarios averaged 0.20 t C ha−1 yr−1, being greater than other scenarios, and (4) the reduced inorganic N fertilizer scenario produced the least N loss from the system, while all the scenarios produced comparable grain yields.Conclusions
In terms of net GWP and GHGI for the comprehensive assessment of climate change and crop production, reduced inorganic N fertilizer scenario followed by no-tillage scenario would be advocated for this specified cropping system. 相似文献4.
Background
The private sector plays a large role in health services delivery in low- and middle-income countries; yet significant gaps remain in the quality and accessibility of private sector services. Clinical social franchising, which applies the commercial franchising model to achieve social goals and improve health care, is increasingly used in developing countries to respond to these limitations. Despite the growth of this approach, limited evidence documents the effect of social franchising on improving health care quality and access.Objectives and Methods
We examined peer-reviewed and grey literature to evaluate the effect of social franchising on health care quality, equity, cost-effectiveness, and health outcomes. We included all studies of clinical social franchise programs located in low- and middle-income countries. We assessed study bias using the WHO-Johns Hopkins Rigour Scale and used narrative synthesis to evaluate the findings.Results
Of 113 identified articles, 23 were included in this review; these evaluated a small sample of franchises globally and focused on reproductive health franchises. Results varied widely across outcomes and programs. Social franchising was positively associated with increased client volume and client satisfaction. The findings on health care utilization and health impact were mixed; some studies find that franchises significantly outperform other models of health care, while others show franchises are equivalent to or worse than other private or public clinics. In two areas, cost-effectiveness and equity, social franchises were generally found to have poorer outcomes.Conclusions
Our review indicates that social franchising may strengthen some elements of private sector health care. However, gaps in the evidence remain. Additional research should include: further documentation of the effect of social franchising, evaluating the equity and cost-effectiveness of this intervention, and assessing the role of franchising within the context of the greater healthcare delivery system. 相似文献5.
Gabe de Vries Hiske L. Hees Maarten W. J. Koeter Suzanne E. Lagerveld Aart H. Schene 《PloS one》2014,9(1)
Objective
The purpose of the present study was to explore various stakeholder perspectives regarding factors that impede return-to-work (RTW) after long-term sickness absence related to major depressive disorder (MDD).Methods
Concept mapping was used to explore employees'', supervisors'' and occupational physicians'' perspectives on these impeding factors.Results
Nine perceived themes, grouped in three meta-clusters were found that might impede RTW: Person, (personality / coping problems, symptoms of depression and comorbid (health) problems, employee feels misunderstood, and resuming work too soon), Work (troublesome work situation, too little support at work, and too little guidance at work) and Healthcare (insufficient mental healthcare and insufficient care from occupational physician). All stakeholders regarded personality/coping problems and symptoms of depression as the most important impeding theme. In addition, supervisors emphasized the importance of mental healthcare underestimating the importance of the work environment, while occupational physicians stressed the importance of the lack of safety and support in the work environment.Conclusions
In addition to the reduction of symptoms, more attention is needed on coping with depressive symptoms and personality problems in the work environment support in the work environment and for RTW in mental healthcare, to prevent long term sickness absence. 相似文献6.
Background
Carbon credits are an increasingly prevalent market-based mechanism used to subsidize household water treatment technologies (HWT). This involves generating credits through the reduction of carbon emissions from boiling water by providing a technology that reduces greenhouse gas emissions linked to climate change. Proponents claim this process delivers health and environmental benefits by providing clean drinking water and reducing greenhouse gases. Selling carbon credits associated with HWT projects requires rigorous monitoring to ensure households are using the HWT and achieving the desired benefits of the device. Critics have suggested that the technologies provide neither the benefits of clean water nor reduced emissions. This study explores the perspectives of carbon credit and water, sanitation and hygiene (WASH) experts on HWT carbon credit projects.Methods
Thirteen semi-structured, in-depth interviews were conducted with key informants from the WASH and carbon credit development sectors. The interviews explored perceptions of the two groups with respect to the procedures applied in the Gold Standard methodology for trading Voluntary Emission Reduction (VER) credits.Results
Agreement among the WASH and carbon credit experts existed for the concept of suppressed demand and parameters in the baseline water boiling test. Key differences, however, existed. WASH experts’ responses highlighted a focus on objectively verifiable data for monitoring carbon projects while carbon credit experts called for contextualizing observed data with the need for flexibility and balancing financial viability with quality assurance.Conclusions
Carbon credit projects have the potential to become an important financing mechanism for clean energy in low- and middle-income countries. Based on this research we recommend that more effort be placed on building consensus on the underlying assumptions for obtaining carbon credits from HWT projects, as well as the approved methods for monitoring correct and consistent use of the HWT technologies in order to support public health impacts. 相似文献7.
8.
Ketevan Rtveladze Tim Marsh Laura Webber Fanny Kilpi David Levy Wolney Conde Klim McPherson Martin Brown 《PloS one》2013,8(7)
Introduction
Higher and lower-middle income countries are increasingly affected by obesity. Obesity-related diseases are placing a substantial health and economic burden on Brazil. Our aim is to measure the future consequences of these trends on the associated disease burden and health care costs.Method
A previously developed micro-simulation model is used to project the extent of obesity, obesity-related diseases and associated healthcare costs to 2050. In total, thirteen diseases were considered: coronary heart disease, stroke, hypertension, diabetes, osteoarthritis, and eight cancers. We simulated three hypothetical intervention scenarios: no intervention, 1% and 5% reduction in body mass index (BMI).Results
In 2010, nearly 57% of the Brazilian male population was overweight or obese (BMI ≥25 kg/m2), but the model projects rates as high as 95% by 2050. A slightly less pessimistic picture is predicted for females, increasing from 43% in 2010 to 52% in 2050. Coronary heart disease, stroke, hypertension, cancers, osteoarthritis and diabetes prevalence cases are projected to at least double by 2050, reaching nearly 34,000 cases of hypertension by 2050 (per 100,000). 1% and 5% reduction in mean BMI will save over 800 prevalence cases and nearly 3,000 cases of hypertension by 2050 respectively (per 100,000). The health care costs will double from 2010 ($5.8 billion) in 2050 alone ($10.1 billion). Over 40 years costs will reach $330 billion. However, with effective interventions the costs can be reduced to $302 billion by 1% and to $273 billion by 5% reduction in mean BMI across the population.Conclusion
Obesity rates are rapidly increasing creating a high burden of disease and associated costs. However, an effective intervention to decrease obesity by just 1% will substantially reduce obesity burden and will have a significant effect on health care expenditure. 相似文献9.
Objective
To determine whether the patient-clinician relationship has a beneficial effect on either objective or validated subjective healthcare outcomes.Design
Systematic review and meta-analysis.Data Sources
Electronic databases EMBASE and MEDLINE and the reference sections of previous reviews.Eligibility Criteria for Selecting Studies
Included studies were randomized controlled trials (RCTs) in adult patients in which the patient-clinician relationship was systematically manipulated and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Studies were excluded if the encounter was a routine physical, or a mental health or substance abuse visit; if the outcome was an intermediate outcome such as patient satisfaction or adherence to treatment; if the patient-clinician relationship was manipulated solely by intervening with patients; or if the duration of the clinical encounter was unequal across conditions.Results
Thirteen RCTs met eligibility criteria. Observed effect sizes for the individual studies ranged from d = −.23 to .66. Using a random-effects model, the estimate of the overall effect size was small (d = .11), but statistically significant (p = .02).Conclusions
This systematic review and meta-analysis of RCTs suggests that the patient-clinician relationship has a small, but statistically significant effect on healthcare outcomes. Given that relatively few RCTs met our eligibility criteria, and that the majority of these trials were not specifically designed to test the effect of the patient-clinician relationship on healthcare outcomes, we conclude with a call for more research on this important topic. 相似文献10.
Natalie Evans H. Roeline Pasman Tomás Vega Alonso Lieve Van den Block Guido Miccinesi Viviane Van Casteren Gé Donker Stefano Bertolissi Oscar Zurriaga Luc Deliens Bregje Onwuteaka-Philipsen 《PloS one》2013,8(3)
Background
Making treatment decisions in anticipation of possible future incapacity is an important part of patient participation in end-of-life decision-making. This study estimates and compares the prevalence of GP-patient end-of-life treatment discussions and patients’ appointment of surrogate decision-makers in Italy, Spain, Belgium and the Netherlands and examines associated factors.Methods
A cross-sectional, retrospective survey was conducted with representative GP networks in four countries. GPs recorded the health and care characteristics in the last three months of life of 4,396 patients who died non-suddenly. Prevalences were estimated and logistic regressions were used to examine between country differences and country-specific associated patient and care factors.Results
GP-patient discussion of treatment preferences occurred for 10%, 7%, 25% and 47% of Italian, Spanish, Belgian and of Dutch patients respectively. Furthermore, 6%, 5%, 16% and 29% of Italian, Spanish, Belgian and Dutch patients had a surrogate decision-maker. Despite some country-specific differences, previous GP-patient discussion of primary diagnosis, more frequent GP contact, GP provision of palliative care, the importance of palliative care as a treatment aim and place of death were positively associated with preference discussions or surrogate appointments. A diagnosis of dementia was negatively associated with preference discussions and surrogate appointments.Conclusions
The study revealed a higher prevalence of treatment preference discussions and surrogate appointments in the two northern compared to the two southern European countries. Factors associated with preference discussions and surrogate appointments suggest that delaying diagnosis discussions impedes anticipatory planning, whereas early preference discussions, particularly for dementia patients, and the provision of palliative care encourage participation. 相似文献11.
Edel Marie Quinn Mark A. Corrigan John O’Mullane David Murphy Elaine A. Lehane Patricia Leahy-Warren Alice Coffey Patricia McCluskey Henry Paul Redmond Greg J. Fulton 《PloS one》2013,8(11)
Background
Chronic ulcers affect roughly 60,000 Irish people, at a total cost of €600,000,000, or €10,000 per patient annually. By virtue of their chronicity, these ulcers also contribute a significant burden to tertiary outpatient vascular clinics.Objective
We propose utilizing mobile phone technology to decentralise care from tertiary centres to the community, improving efficiency and patient satisfaction, while maintaining patient safety.Methods
Bespoke mobile software was developed for Apples iPhone 4 platform. This allowed for the remote collection of patient images prospectively and their transmission with clinical queries, from the primary healthcare team to the tertiary centre. Training and iPhones were provided to five public health nurses in geographically remote areas of the region. Data were uploaded securely and user end software was developed allowing the review and manipulation of images, along with two way communication between the teams. Establishing reliability, patients were reviewed clinically as well as remotely, and concordance analysed. Qualitative data were collected through focus group discussion.Results
From October to December 2011 eight patients (61–83 yrs, mean 75.3 yrs) with chronic venous ulceration and their five public health nurses were recruited. Data were transmitted using 3 G, Edge, GPRS and WiFi, at a mean speed of 69.03 kps. Concordance was 100% for wound bed assessment, 80% for skin integrity/colour and 60% for exudate assessment. Focus group analysis explored the concept, practicalities and future applications of the system.Conclusions
With an evolving national data network, the secure transmission of clinical images is a safe alternative to regular clinic appointments for patients with chronic venous ulceration. With further development, and packaged as a freely downloadable application, this has the potential to support the community care of chronic wounds. 相似文献12.
Preciosa M. Coloma Martijn J. Schuemie Gianluca Trifirò Laura Furlong Erik van Mulligen Anna Bauer-Mehren Paul Avillach Jan Kors Ferran Sanz Jordi Mestres José Luis Oliveira Scott Boyer Ernst Ahlberg Helgee Mariam Molokhia Justin Matthews David Prieto-Merino Rosa Gini Ron Herings Giampiero Mazzaglia Gino Picelli Lorenza Scotti Lars Pedersen Johan van der Lei Miriam Sturkenboom 《PloS one》2013,8(8)
13.
Introduction
At least 36 countries are suffering from severe shortages of healthcare workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care. We performed a case study to evaluate a health service delivery model where a task-shifting approach to HIV care had been undertaken with tasks shifted from doctors to nurses and community health workers in rural Haiti.Methods
Data were collected using mixed quantitative and qualitative methods at three clinics in rural Haiti. Distribution of tasks for HIV services delivery; types of tasks performed by different cadres of healthcare workers; HIV program outcomes; access to HIV care and acceptability of the model to staff were measured.Results
A shift of tasks occurred from doctors to nurses and to community health workers compared to a traditional doctor-based model of care. Nurses performed most HIV-related tasks except initiation of TB therapy for smear-negative suspects with HIV. Community health workers were involved in over half of HIV-related tasks. HIV services were rapidly scaled-up in the areas served; loss to follow-up of patients living with HIV was less than 5% at 24 months and staff were satisfied with the model of care.Conclusion
Task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services with good clinical and program outcomes. Community health workers can provide essential health services that are otherwise unavailable particularly in rural, poor areas. 相似文献14.
Shankar Prinja Pankaj Bahuguna P. V. M. Lakshmi Tushar Mokashi Arun Kumar Aggarwal Manmeet Kaur K. Rahul Reddy Rajesh Kumar 《PloS one》2014,9(10)
Background
Emergency referral services (ERS) are being strengthened in India to improve access for institutional delivery. We evaluated a publicly financed and privately delivered model of ERS in Punjab state, India, to assess its extent and pattern of utilization, impact on institutional delivery, quality and unit cost.Methods
Data for almost 0.4 million calls received from April 2012 to March 2013 was analysed to assess the extent and pattern of utilization. Segmented linear regression was used to analyse month-wise data on number of institutional deliveries in public sector health facilities from 2008 to 2013. We inspected ambulances in 2 districts against the Basic Life Support (BLS) standards. Timeliness of ERS was assessed for determining quality. Finally, we computed economic cost of implementing ERS from a health system perspective.Results
On an average, an ambulance transported 3–4 patients per day. Poor and those farther away from the health facility had a higher likelihood of using the ambulance. Although the ERS had an abrupt positive effect on increasing the institutional deliveries in the unadjusted model, there was no effect on institutional delivery after adjustment for autocorrelation. Cost of operating the ambulance service was INR 1361 (USD 22.7) per patient transported or INR 21 (USD 0.35) per km travelled.Conclusion
Emergency referral services in Punjab did not result in a significant change in public sector institutional deliveries. This could be due to high baseline coverage of institutional delivery and low barriers to physical access. Choice of interventions for reduction in Maternal Mortality Ratio (MMR) should be context-specific to have high value for resources spent. The ERS in Punjab needs improvement in terms of quality and reduction of cost to health system. 相似文献15.
16.
Background and Aims
Rubus chamaemorus (cloudberry) is a herbaceous clonal peatland plant that produces an extensive underground rhizome system with distant ramets. Most of these ramets are non-floral. The main objectives of this study were to determine: (a) if plant growth was source limited in cloudberry; (b) if the non-floral ramets translocated carbon (C) to the fruit; and (c) if there was competition between fruit, leaves and rhizomes for C during fruit development.Methods
Floral and non-floral ramet activities were monitored during the period of flower and fruit development using three approaches: gas exchange measurements, 14CO2 labelling and dry mass accumulation in the different organs. Source and sink activity were manipulated by eliminating leaves or flowers or by reducing rhizome length.Key Results
Photosynthetic rates were lower in floral than in deflowered ramets. Autoradiographs and 14C labelling data clearly indicated that fruit is a very strong sink for the floral ramet, whereas non-floral ramets translocated C toward the rhizome but not toward floral ramets. Nevertheless, rhizomes received some C from the floral ramet throughout the fruiting period. Ramets with shorter rhizomes produced smaller leaves and smaller fruits, and defoliated ramets produced very small fruits.Conclusions
Plant growth appears to be source-limited in cloudberry since a reduction in sink strength did not induce a reduction in photosynthetic activity. Non-floral ramets did not participate directly to fruit development. Developing leaves appear to compete with the developing fruit but the intensity of this competition could vary with the specific timing of the two organs. The rhizome appears to act both as a source but also potentially as a sink during fruit development. Further studies are needed to characterize better the complex role played by the rhizome in fruit C nutrition.Key words: Allocation pattern, 14C labelling, carbon translocation, carbon reserves, cloudberry, defoliation, fruit production, gas exchange, Rubus chamaemorus, source–sink relationship, flowering 相似文献17.
Objective
There is limited evidence about levels of socio-economic and other differences in catastrophic health spending in Nigeria and in many sub-Saharan African countries. The study estimated the level of catastrophic healthcare expenditures for different healthcare services and facilities and their distribution across socioeconomic status (SES) groups.Methods
The study took place in four Local Government Areas in southeast Nigeria. Data were collected using interviewer-administered questionnaires administered to 4873 households. Catastrophic health expenditures (CHE) were measured using a threshold of 40% of monthly non-food expenditure. We examined both total monthly health expenditure and disaggregated expenditure by source and type of care.Results
The average total household health expenditure per month was 2354 Naira ($19.6). For outpatient services, average monthly expenditure was 1809 Naira ($15.1), whilst for inpatient services it was 610 Naira ($5.1). Higher health expenditures were incurred by urban residents and the better-off SES groups. Overall, 27% of households incurred CHE, higher for poorer socioeconomic groups and for rural residents. Only 1.0% of households had a member that was enrolled in a health insurance scheme.Conclusion
The worse-off households (the poorest SES and rural dwellers) experienced the highest burden of health expenditure. There was almost a complete lack of financial risk protection. Health reform mechanisms are needed to ensure universal coverage with financial risk protection mechanisms. 相似文献18.
Background
Considerable evidence suggests that communication inequality is one potential mechanism linking social determinants, particularly socioeconomic status, and health inequalities. This study aimed to examine how dimensions of health communication outcomes (health information seeking, self-efficacy, exposure, and trust) are patterned by socioeconomic status in Japan.Methods
Data of a nationally representative cross-sectional survey of 2,455 people aged 15–75 years in Japan were used for secondary analysis. Measures included socio-demographic characteristics, subjective health, recent health information seeking, self-efficacy in seeking health information, and exposure to and trust in health information from different media.Results
A total of 1,311 participants completed the questionnaire, giving a response rate of 53.6%. Multivariate logistic regression revealed that education and household income, but not employment, were significantly associated with health information seeking and self-efficacy. Socioeconomic status was not associated with exposure to and trust in health information from mass media, but was significantly associated with health information from healthcare providers and the Internet.Conclusion
Health communication outcomes were patterned by socioeconomic status in Japan thus demonstrating the prevalence of health communication inequalities. Providing customized exposure to and enhancing the quality of health information by considering social determinants may contribute to addressing social disparities in health in Japan. 相似文献19.
Introduction
On June 30, 2012, Interim Federal Health Program (IFHP) funding was cut for refugee claimant healthcare. The potential financial and healthcare impacts of these cuts on refugee claimants are unknown.Methods
We conducted a one-year retrospective chart review spanning 6 months before and after IFHP funding cuts at The Hospital for Sick Children, a tertiary care children''s hospital in Toronto. We analyzed emergency room visits characteristics, admission rates, reasons for admission, and financial records including billing from Medavie Blue Cross.Results
There were 173 refugee children visits to the emergency room in the six months before and 142 visits in the six months after funding cuts. The total amount billed to the IFHP program during the one-year of this study was $131,615. Prior to the IFHP cuts, 46% of the total emergency room bills were paid by IFHP compared to 7% after the cuts (p<0.001).Interpretation
After the cuts to the IFHP, The Hospital for Sick Children was unable to obtain federal health coverage for the vast majority of refugee claimant children registered under the IFHP. This preliminary analysis showed that post-IFHP cuts healthcare costs at the largest tertiary pediatric institution in the country increased. 相似文献20.