Impacts of Cash Transfer Programs on Rural Livelihoods: a Case Study in the Brazilian Amazon Estuary

We conducted a large household survey in a region of the Amazon estuary in Brazil to investigate the dependence of small farming households on government cash transfers and to identify the main factors that lead to better livelihood outcomes. The study examined the factors that contribute to heterogeneous household livelihoods and patterns of dependence on cash transfer programs. Multinomial logistic regression was used to evaluate household attributes affecting the level of dependence on cash transfers. Results indicate that households engage in a diversity of livelihood strategies, and vary in dependence on cash transfers. Lower levels of dependency are associated with higher levels of education and income from off-farm activities as well as larger property sizes and holdings in the várzea. Recognition of the causes and potential range of dependence on cash transfer programs adds decision-making capacity for policy makers seeking avenues to reduce dependence and increase program effectiveness.     

Integration of Leprosy Elimination into Primary Health Care in Orissa,India

Background

Leprosy was eliminated as a public health problem (<1 case per 10,000) in India by December 2005. With this target in sight the need for a separate vertical programme was diminished. The second phase of the National Leprosy Eradication Programme was therefore initiated: decentralisation of the vertical programme, integration of leprosy services into the primary health care (PHC) system and development of a surveillance system to monitor programme performance.

Methodology/Principal Findings

To study the process of integration a qualitative analysis of issues and perceptions of patients and providers, and a review of leprosy records and registers to evaluate programme performance was carried out in the state of Orissa, India. Program performance indicators such as a low mean defaulter rate of 3.83% and a low-misdiagnosis rate of 4.45% demonstrated no detrimental effect of integration on program success. PHC staff were generally found to be highly knowledgeable of diagnosis and management of leprosy cases due to frequent training and a support network of leprosy experts. However in urban hospitals district-level leprosy experts had assumed leprosy activities. The aim was to aid busy PHC staff but it also compromised their leprosy knowledge and management capacity. Inadequate monitoring of a policy of ‘new case validation,’ in which MDT was not initiated until primary diagnosis had been verified by a leprosy expert, may have led to approximately 26% of suspect cases awaiting confirmation of diagnosis 1–8 months after their initial PHC visit.

Conclusions/Significance

This study highlights the need for effective monitoring and evaluation of the integration process. Inadequate monitoring could lead to a reduction in early diagnosis, a delay in initiation of MDT and an increase in disability rates. This in turn could reverse some of the programme''s achievements. These findings may help Andhra Pradesh and other states in India to improve their integration process and may also have implications for other disease elimination programmes such as polio and guinea worm (dracunculiasis) as they move closer to their elimination goals.     

More Evidence on the Impact of India's Conditional Cash Transfer Program,Janani Suraksha Yojana: Quasi-Experimental Evaluation of the Effects on Childhood Immunization and Other Reproductive and Child Health Outcomes

Background

In 2005, India established a conditional cash transfer program called Janani Suraksha Yojana (JSY), to increase institutional delivery and encourage the use of reproductive and child health-related services.

Objective

To assess the effect of maternal receipt of financial assistance from JSY on childhood immunizations, post-partum care, breastfeeding practices, and care-seeking behaviors.

Methods

We use data from the latest district-level household survey (2007–2008) to conduct a propensity score matching analysis with logistic regression. We conduct the analyses at the national level as well as separately across groups of states classified as high-focus and non-high-focus. We carry out several sensitivity analyses including a subgroup analysis stratified by possession of an immunization card.

Results

Receipt of financial assistance from JSY led to an increase in immunization rates ranging from 3.1 (95%CI 2.2–4.0) percentage points for one dose of polio vaccine to 9.1 (95%CI 7.5–10.7) percentage points in the proportion of fully vaccinated children. Our findings also indicate JSY led to increased post-partum check-up rates and healthy early breastfeeding practices around the time of childbirth. No effect of JSY was found on exclusive breastfeeding practices and care-seeking behaviors. Effect sizes were consistently larger in states identified as being a key focus for the program. In an analysis stratified by possession of an immunization card, there was little to no effect of JSY among those with vaccination cards, while the effect size was much larger than the base case results for those missing vaccination cards, across nearly all immunization outcomes.

Conclusions

Early results suggest the JSY program led to a significant increase in childhood immunization rates and some healthy reproductive health behaviors, but the structuring of financial incentives to pregnant women and health workers warrants further review. Causal interpretation of our results relies on the assumption that propensity scores balance unobservable characteristics.     

The Outcome of Health Anxiety in Primary Care. A Two-Year Follow-up Study on Health Care Costs and Self-Rated Health

Background

Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety''s impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs.

Methodology/Principal Findings

1785 consecutive primary care patients aged 18–65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41–78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition.

Conclusions/Significance

Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.     

Impact of a Reference Center on Leprosy Control under a Decentralized Public Health Care Policy in Brazil

ObjectiveWe evaluated the profile of patients referred to the Fiocruz Outpatient Clinic, a reference center for the diagnosis and treatment of leprosy in Rio de Janeiro, RJ, and analyzed the origins and outcomes of these referrals.MethodsThis is an observational retrospective study based on information collected from the Leprosy Laboratory database at Fiocruz, Rio de Janeiro, RJ, Brazil. A total of 1,845 suspected leprosy cases examined at the reference center between 2010 and 2014 were included. The originating health service referrals and diagnostic outcomes were analyzed as well as the clinical and epidemiological data of patients diagnosed with leprosy.ResultOur data show that the profile of the patients treated at the Clinic has changed in recent years. There was an increase in both the proportion of patients with other skin diseases and those who had visited only one health service prior to our Clinic. Among the total 1,845 cases analyzed, the outcomes of 1,380 were linked to other diseases and, in 74% of these cases, a biopsy was not necessary to reach a diagnostic conclusion. A decrease in new leprosy case detection among our patients was also observed. Yet, among the leprosy patients, 40% had some degree of disability at diagnosis.ConclusionThe results of the present study demonstrated the importance of referral centers in support of basic health services within the decentralization strategy. But, the success of the program depends on the advent of new developmental tools to augment diagnostic accuracy for leprosy. However, it should be emphasized that for new diagnostic methods to be developed, a greater commitment on the part of the health care system regarding research is urgently needed.     

基层医疗卫生机构的基本医疗服务范围研究 ——基于常见病、多发病的视角

目的 基于常见病、多发病的视角界定基层医疗卫生机构的基本医疗服务范围。方法 以广东省A市为例,根据该市基本医疗保险参保人的微观数据,统计分析了该市的常见病、多发病,并对该市128个医疗机构进行问卷调查。结果 分别确定了社区卫生服务中心104个病种、乡镇卫生院101个病种、社区卫生服务站38个病种和村卫生室34个病种作为四类基层医疗卫生机构的基本医疗服务范围。结论 应依据四类基层医疗卫生机构的基本医疗服务范围从诊疗项目、药品目录、基层首诊制等方面进行政策调整与完善。     

砖厂含氟废气对环境污染与健康的影响

为研究砖厂含氟废气对环境与健康的影响,采用环境监测和农业生态学及卫生学方法进行全面系统的调查与研究．结果表明,砖厂含氟废气排放点周围的大气、土壤、农作物已受到不同程度的污染,砖厂周围种植的农作物含氟量明显高于对照点,附近的家禽（鸡）死亡率也明显高于建砖厂前,在砖厂附近的农村居民患病率明显高于建砖厂前,特别以呼吸系统疾病和骨质性疾病的患病率最为明显,因此,建砖厂时,应对周围环境污染及远期的健康影响予以重视     

公立医院纵向整合对医疗质量的影响研究

通过设定胃溃疡患者主诊断治疗效果和住院日的影响函数,利用样本整合前1年与整合后4年的相关数据,通过Logistic回归和多元线性回归分析了医院纵向整合对医疗质量的影响。结果发现,医院纵向整合对整合医院的治疗效果从整合后的第4年开始有显著性影响,对住院日没有显著性影响。     

A Patient-Centered Understanding of the Referral System in Ethiopian Primary Health Care Units

Background

Primary healthcare systems in sub-Saharan Africa have undergone substantial development in an effort to expand access to appropriate facilities through a well-functioning referral system. The objective of this study was to evaluate the current patterns of seeking prior care before arriving at a health center or a hospital as a key aspect of the referral system of the primary health care unit (PHCU) in three regions in Ethiopia. We examined what percentage of patients had either sought prior care or had been referred to the present facility and identified demographic and clinical factors associated with having sought prior care or having been referred.

Methods and Findings

We conducted a cross-sectional study using face-to-face interviews in the local language with 796 people (99% response rate) seeking outpatient care in three primary health care units serving approximately 100,000 people each and reflecting regional and ethnic diversity; 53% (N = 418) of the sample was seeking care at hospital outpatient departments, and 47% of the sample was seeking care at health centers (N = 378). We used unadjusted and adjusted logistic regression to identify factors associated with having been referred or sought prior care. Our findings indicated that only 10% of all patients interviewed had been referred to their current place of care. Among those in the hospital population, 14% had been referred; among those in the health center population, only 6% had been referred. Of those who had been referred to the hospital, most (74%) had been referred by a health center. Among those who were referred to the health center, the plurality portion (32%) came from a nearby hospital (most commonly for continued HIV treatment or early childhood vaccinations); only 18% had come from a health post. Among patients who had not been formally referred, an additional 25% in the hospital sample and 10% in the health center sample had accessed some prior source of care for their present health concern. In the adjusted analysis, living a longer distance from the source of care and needing more specialized care were correlated with having sought prior care in the hospital sample. We found no factors significantly associated with having sought prior care in the health center sample.

Conclusions

The referral system among health facilities in Ethiopia is used by a minority of patients, suggesting that intended connections between health posts, health centers, and hospitals may need strengthening to increase the efficiency of primary care nationally.     

Improved Detection of Common Variants Associated with Schizophrenia and Bipolar Disorder Using Pleiotropy-Informed Conditional False Discovery Rate

Several lines of evidence suggest that genome-wide association studies (GWAS) have the potential to explain more of the “missing heritability” of common complex phenotypes. However, reliable methods to identify a larger proportion of single nucleotide polymorphisms (SNPs) that impact disease risk are currently lacking. Here, we use a genetic pleiotropy-informed conditional false discovery rate (FDR) method on GWAS summary statistics data to identify new loci associated with schizophrenia (SCZ) and bipolar disorders (BD), two highly heritable disorders with significant missing heritability. Epidemiological and clinical evidence suggest similar disease characteristics and overlapping genes between SCZ and BD. Here, we computed conditional Q–Q curves of data from the Psychiatric Genome Consortium (SCZ; n = 9,379 cases and n = 7,736 controls; BD: n = 6,990 cases and n = 4,820 controls) to show enrichment of SNPs associated with SCZ as a function of association with BD and vice versa with a corresponding reduction in FDR. Applying the conditional FDR method, we identified 58 loci associated with SCZ and 35 loci associated with BD below the conditional FDR level of 0.05. Of these, 14 loci were associated with both SCZ and BD (conjunction FDR). Together, these findings show the feasibility of genetic pleiotropy-informed methods to improve gene discovery in SCZ and BD and indicate overlapping genetic mechanisms between these two disorders.     

Gendering Local Knowledge: Medicinal Plant Use and Primary Health Care in the Amazon

Local knowledge is becoming increasingly important in primary health care projects. However, these projects often incorporate local knowledge in an uncritical manner. One area where this is apparent is in the lack of attention paid to the gendered nature of local knowledge. I use one example, women's knowledge and use of medicinal plants in a low-income community in the Brazilian Amazon, to illustrate the links among authority, knowledge, and gender. In this article I argue that policy makers must pay attention to the relationships among authority, gender, and local knowledge and examine how the use of local knowledge in development strategies can affect existing (gendered) power relationships. Women's roles as managers of household health (which includes medicinal plant use) are a source of authority for them. Because of that, the way in which local knowledge is incorporated into primary health care programs can have a significant impact on women's authority.     

The Effect of Active Learning Methodologies on the Teaching of Pharmaceutical Care in a Brazilian Pharmacy Faculty

BackgroundIn recent years, pharmacists have been involved in expanded patient care responsibilities, for example patient counseling in self-medication, medication review and pharmaceutical care, which require graduates to develop the necessary competences. Consequently, reorientation of pharmacy education has become necessary. As such, active learning strategies have been introduced into classrooms to increase problem-solving and critical thinking skills of students. The objective of this study was to evaluate the performance and perceptions of competency of students in a new pharmaceutical care course that uses active learning methodologies.MethodsThis pharmaceutical care course was conducted in the first semester of 2014, in the Federal University of Sergipe. In the pharmaceutical care course, active learning methods were used, consisting of dialogic classroom expository, simulation and case studies. Student learning was evaluated using classroom tests and instruments that evaluated the perception of competency in pharmaceutical care practice. Furthermore, students'' satisfaction with the course was evaluated.ResultsThirty-three students completed the four evaluations used in the course (i.e., a discursive written exam, seminars, OSCE, and virtual patient); 25 were female (75.75%), and the median age was 23.43 (SD 2.82) years. The overall mean of student scores, in all evaluation methods was 7.97 (SD 0.59) on a scale of 0 to 10 points, and student performance on the virtual patient method was statistically superior to other methods. With respect to the perception of competency in pharmaceutical care practice, a comparison of pre- and post-test scores revealed statistically significant improvement for all evaluated competences. At the end of the semester, the students presented positive opinions of the pharmaceutical care course.ConclusionsThe results suggest that an active learning course can enhance the learning of pharmaceutical care competences. In future studies it will be necessary to compare active learning to traditional methods.     

Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea,Uganda, and Sierra Leone

BackgroundLittle is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs.ConclusionsNational health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.     

Negotiating the New Health Care System in Cape Town, South Africa: Five Case Studies of the Acutely Chronically Ill

This article examines the experiences of chronically ill disadvantaged patients in a newly reformed health care system against a backdrop of inequalities still prevalent in the wider postapartheid sociopolitical economy of the Western Cape, South Africa. Patients negotiated a hierarchy of spaces at the national level of transformation and policy and at community-, secondary-, and tertiary-level facilities. The institutionalization of patients meant that expensive medical treatment was mobilized in accordance with different stages of illness and that certain services were available only to "qualifying" categories of diagnoses.     

Modulation of the Primary Electron Transfer Rate in Photosynthetic Reaction Centers by Reduction of a Secondary Acceptor

Photosynthetic application of picosecond spectroscopic techniques to bacterial reaction centers has led to a much greater understanding of the chemical nature of the initial steps of photosynthesis. Within 10 ps after excitation, a charge transfer complex is formed between the primary donor, a “special pair” of bacteriochlorophyll molecules, and a transient acceptor involving bacteriopheophytin. This complex subsequently decays in about 120 ps by donating the electron to a metastable acceptor, a tightly bound quinone.

Recent experiments with conventional optical and ESR techniques have shown that when reaction centers are illuminated by a series of single turnover flashes in the presence of excess electron donors and acceptors, a stable, anionic ubisemiquinone is formed on odd flashes and destroyed on even flashes, suggesting that the acceptor region contains a second quinone that acts as a two-electron gate between the reaction center and subsequent electron transport events involving the quinone pool.

Utilizing standard picosecond techniques, we have examined the decay of the charge transfer complex in reaction centers in the presence of the stable semiquinone, formed by flash illumination with a dye laser 10 s before excitation by a picosecond pulse. In this state the decay rate for the charge transfer complex is considerably slower than when no electron is present in the quinone acceptor region. This indicates fairly strong coupling between constituents of the reaction center-quinone acceptor complex and may provide a probe into the relative positions of the various components.

     

儿童保健对早产儿生长和智力发育的影响及相关性研究

为了探究正常的儿童保健对早产儿生长和智力发育的影响,并明确早产儿的生长和智力发育分别与儿童保健的影响,本研究选取40例早产儿,随机分为对照组和观察组,每组20例。对照组进行常规育儿管理,观察组采用儿童保健管理。统计分析两组早产儿在0.5岁、1岁、1.5岁和2岁的生长(头围,体重和身高)和智力(智力和心理活动)发育情况及相关性。研究发现,儿童保健可明显促进早产儿的生长和智力发育,且正规儿童保健与早产儿的生长和智力发育呈正相关关系,均具有显著性差异。本研究结果说明,儿童保健可明显促进早产儿的生长和智力发育,具有重要的临床应用价值。     

县级公立医院改革对基层医疗机构实施基本药物制度影响分析

在对湖北省基层医疗机构实施基本药物制度现状总结的基础上,以系统论为指导,从理论上分析县级公立医院改革对基层医疗机构实施基本药物制度的影响,得出在县级公立医院改革特别是县级公立医院取消药品加成的过程中应配套相应措施：包括合理扩大基本药物省增补目录,将基层医疗机构基本药物补助纳入预算管理,建立多元化的基层医疗机构补偿途径,建立完善的县乡双向转诊模式等,以保证基层医疗机构有效实施基本药物制度和县级公立医院改革顺利推进。基层医疗机构顺利实施基本药物制度是落实医改政策的重要工作之一,各地政府在推进县级医院改革的过程中,应系统考虑调整相关卫生政策。     

医疗卫生行业综合监管主体研究

监管主体作为监管活动的执行者是医疗卫生行业监管的核心要素之一,厘清谁来监管以及监管主体的职责,是监管有效发挥作用的前提。我国医疗卫生行业监管主体则存在职能分散、定位不清和缺乏专业性等问题,同时支付方及行业协会的监管职能强调不足。建议在下一阶段针对上述问题进行改革,以便更好地发挥作用。