Health Service Characteristics Research Articles

Disparities in end-of-life care and place of death in people with malignant brain tumors – a Swedish registry study

Abstract Background Malignant brain tumors often lead to death. While improving future treatments is essential, end-of-life care must also be addressed. To ensure equitable palliative care, understanding place of death is crucial, as disparities may lead to inequity of care. This study aims to identify place of death in adults with malignant brain tumors in Sweden, and the potential associations with official palliative care status by the ICD-10 code Z-51.5, sociodemographic factors, health service characteristics, and healthcare service utilization. Methods A population-level registry study examined the place of death among adults who died of malignant brain tumors in Sweden from 2013-2019. Descriptive statistics, univariable and multivariable binary logistic regression analyses were performed. Results We identified 3 888 adults who died from malignant brain tumors. Of these, 64.4% did not receive an official palliative care status. Specialized palliative care was not utilized in 57.2% at the place of death, and in 80.0% of nursing home deaths. In the last month of life, 53.5% of hospital deaths involved one transfer, while 41.8% had two or more transfers. The odds ratio of dying in hospital versus at home was higher, with two or more transfers (OR 0.63(0.40,0.99)). The odds ratio of dying in hospital versus at home showed significant regional differences. Conclusions Despite the severity of their diagnosis, only a minority of patients utilized specialized palliative services at death, and this varied by the place of death. Significant regional disparities were found between hospital and home deaths, indicating unequal end-of-life palliative care in this patient group.

Gender-specific pathways in mental health crisis in adolescents, from consultation to (in)voluntary admission: a retrospective study

BackgroundA strong increase in mental health emergency consultations and admissions in youths has been reported in recent years. Although empirical evidence is lacking, gender differences in risk of admission may have contributed to this increase. A clearer understanding of the relationship, if any, between gender and various aspects of (in)voluntary care would help in more evidence-based service planning.MethodsWe analysed registry data for 2008–2017 on 3770 outpatient emergencies involving young people aged 12 to 18 years from one urban area in the Netherlands, served by outreaching psychiatric emergency services. These adolescents were seen in multiple locations and received a psychosocial assessment including a questionnaire on the severity of their problems and living conditions. Our aims were to (a) investigate the different locations, previous use of mental health service, DSM classifications, severity items, living conditions and family characteristics involved and (b) identify which of these characteristics in particular contribute to an increased risk of admission.ResultsIn 3770 consultations (concerning 2670 individuals), more girls (58%) were seen than boys. Boys and girls presented mainly with relationship problems, followed by disruptive disorders and internalizing disorders. Diagnostic differences diminished in hospitalisation. More specifically, disruptive disorders were evenly distributed. Suicide risk was rated significantly higher in girls, danger to others significantly higher in boys. More girls than boys had recently been in mental health care prior to admission. Although boys and girls overall did not differ in the severity of their problems, female gender predicted admission more strongly. In both boys and girls severity of problems and lack of involvement of the family significantly predicted admission. Older age and danger to others significantly predicted admission among boys, whereas psychosis, suicidality and poor motivation for treatment predicted admission among girls.ConclusionThere are different pathways for youth admission, which can partly be explained by different psychiatric classifications as well as gender-specific differences with regard to age, suicide risk, danger to others and the influence of motivation for treatment. Finally, for both genders, family desire for hospitalisation is also an important predictor.

Chronic diseases and determinants of community health services utilization among adult residents in southern China: a community-based cross-sectional study

BackgroundThe burden of chronic diseases has become a major public health concern, and high-efficiency use of community health services is essential in combating chronic diseases. This study described the status of chronic diseases in southern China and explored the determinants of health service utilization among adult residents.MethodsData were obtained from one part of community survey data from four counties in Ganzhou City, southern China. A multistage, stratified random sampling method was used to conduct a cross-sectional survey between 2018 and 2020. Overall, 7430 valid questionnaires were collected. A lasso-linear regression analysis was performed to explore the determinants of community health service utilization.ResultsAccording to the study, most participants (44.6%) reported having relatively good health, while 42.1% reported having moderate health. Chronic diseases were reported by 66.9% of the respondents. The three most prevalent self-reported chronic diseases were hypertension (22.6%), hyperlipidemia (5.9%), and diabetes (5.9%). Among residents with chronic diseases, 72.1% had one chronic disease, while the rest had multiple. Only 13.9% of residents frequently utilized community health services, while 18.9% never used them. Additionally, among residents who reported having chronic diseases, 14.1% had never attended community health services. Four categories of factors were the key determinants of community health service utilization: (1) personal characteristics, age, and sex; (2) health-related factors, such as family history, self-reported health conditions, and the number of chronic diseases; (3) community health service characteristics, such as satisfaction with and accessibility to community health services; and (4) knowledge of chronic diseases. Specifically, women tend to utilize healthcare services more frequently than men. Additionally, residents who are advanced in age, have a family history of chronic diseases, suffer from multiple chronic conditions, rate their self-reported health condition as poor, have a better knowledge about chronic diseases, have better accessibility to community health services, and have higher the satisfaction with community health services, tend to utilize them more frequently.ConclusionsGiven the limited healthcare resources, the government should promote the effective utilization of community health facilities as a critical community-based strategy to combat the growing threat of chronic diseases in southern China. The priority measures involve enhancing residents’ access to and satisfaction with community health services and raising awareness of chronic illnesses among older individuals with poor health status.

Do Public Health Service Characteristics Matter? Exploring the Make-or-Buy Decision in Local Health Departments

Public health services can be provided by local health departments (LHDs) or external contractors. This study aims to determine which characteristics of public health services, if any, influence the contracting out decision in local health departments. The transaction cost approach, market failure theory, and government failure theory provide theoretical frameworks for how two characteristics of public health services—asset specificity and service measurability—could impact the decision to make or buy in local health departments. This study employs a multinomial logistic regression model for analysis and uses multiple data sources. The findings suggest that public health agencies are less likely to deliver services internally at low and high levels of transaction costs, while more likely to produce services in-house at moderate levels of transaction costs. Furthermore, for services that are difficult to measure vendor performance, LHDs are less likely to choose complete contracting.

Cape York Kidney Care: service description and baseline characteristics of a client-centred multidisciplinary specialist kidney health service in remote Australia

BackgroundChronic Kidney disease (CKD) is over-represented amongst First Nation people with more than triple the rate of CKD in those aged 15 years and over. The impact of colonisation, including harmful experiences of health practices and research, has contributed to these health inequities. Cape York Kidney Care (CYKC) has been created as an unique service which provides specialist care that aims to centre the client within a multidisciplinary team that is integrated within the primary care setting of the remote health clinics in six communities in western Cape York, Australia. This research aims to describe the Cape York Kidney Care service delivery model, and baseline service data, including aggregated client health measures.MethodsThe model of care is described in detail. Review of the first 12 months of service provision has been undertaken with client demographic and clinical profile baseline data collected including kidney health measures. Participants are adults (> 18 years if age) with CKD grades 1–5. This data has been de-identified and aggregated.ResultsCYKC reviewed 204 individuals, with 182 not previously been reviewed by specialist kidney health services. Three quarters of clients identified as Aboriginal. The average age was 55 with a high level of comorbidity, with majority having a history of hypertension and Type 2 diabetes (average Hba1c 8.2%). Just under one third had cardiovascular disease. A large proportion of people had either Grade 2 CKD (32%) or Grade 3 CKD (~ 30%), and over half had severely increased albuminuria (A3), with Type 2 diabetes being the predominant presumed cause of CKD. Most clients did not meet evidence-based targets for diabetes, blood pressure or lipids and half were self-reported smokers. The proportion of clients reviewed represents 6.2% of the adult population in the participating First Nation communities.ConclusionThe CYKC model was able to target those clients at high risk of progression and increase the number of people with chronic kidney disease reviewed by specialist kidney services within community. Baseline data demonstrated a high burden of chronic disease that subsequently will increase risk of CKD progression and cardiovascular disease. People were seen to have more severe disease at younger ages, with a substantial number demonstrating risk factors for rapid progression of kidney disease including poorly controlled Type 2 diabetes and severely increased albuminuria. Further evaluation concerning implementation challenges, consumer and community satisfaction, and health outcomes is required.

Preferences of healthcare workers for provider payment systems in The Gambia’s National Health Insurance Scheme

BackgroundThe Government of The Gambia introduced a national health insurance scheme (NHIS) in 2021 to promote universal health coverage (UHC). Provider payment systems (PPS) are strategic purchasing arrangements that can enhance provider performance, accountability, and efficiency in the NHIS. This study assessed healthcare workers’ (HCWs’) preferences for PPS across major service areas in the NHIS.MethodsA facility-based cross-sectional study was conducted using a probability proportionate to size sampling technique to select an appropriate sample size. Health care workers were presented with options for PPS to choose from across major service areas. Descriptive statistics explored HCW socio-demographic and health service characteristics. Multinomial logistic regressions were used to assess the association between these characteristics and choices of PPS.ResultsThe majority of HCW did not have insurance coverage, but more than 60% of them were willing to join and pay for the NHIS. Gender, professional cadre, facility level, and region influenced HCW’s preference for PPS across the major service areas. The preferred PPS varied among HCW depending on the service area, with capitation being the least preferred PPS across all service areas.ConclusionThe National Health Insurance Authority (NHIA) needs to consider HCW’s preference for PPS and factors that influence their preferences when choosing various payment systems. Strategic purchasing decisions should consider the incentives these payment systems may create to align incentives to guide provider behaviour towards UHC. The findings of this study can inform policy and decision-makers on the right mix of PPS to spur provider performance and value for money in The Gambia’s NHIS.

Current findings and gaps in early initiation of breastfeeding practices in sub-Saharan African countries: A scoping review.

Early initiation of breastfeeding (EIBF) plays an important role in reducing neonatal and infant mortality. Sub-Saharan African countries have high rates of neonatal and infant mortality, as well as a low prevalence of EIBF. By conducting a scoping review, we aimed to determine the gaps and current understandings of EIBF in Sub-Saharan Africa. We conducted this scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) reporting guidelines, focusing on primary studies published from 2008 to 2021. We reviewed their titles and abstracts against the eligibility criteria, selecting the relevant ones to this study's criteria for a further full-text review. The identified determinants can be categorized into household, maternal, and health service characteristics. Regarding health service characteristics, many studies reported that cesarean section was strongly associated with the delayed initiation of breastfeeding. Institutional delivery and delivery by skilled birth attendants were also reported to be associated with the early initiation of breastfeeding. Others pointed out that place of residence and wealth index as two household characteristics that were strongly associated with EIBF, as well as maternal characteristics such as older maternal age and higher education status. We found that only eleven studies on the early initiation of breastfeeding have been conducted in Central and West Africa. Household, maternal, and health service factors have been reported to be associated with the early initiation of breastfeeding across many countries. More studies are needed to fill the current geographic gaps and investigate determinants that have not been examined. Future research should also cover interventions that have been effective in improving EIBF for women after caesarean sections in sub-Saharan Africa. Interventions that promote institutional delivery and deliveries by skilled attendants have the potential to improve the practice.

Child characteristics and health conditions associated with paediatric hospitalisations and length of stay: a population-based study

Paediatric hospital length of stay (LoS) is often used as a benchmark for resource use of hospitalisations. Previous studies have mostly focused on LoS of admissions for specific conditions or medical specialties. We aimed to conduct an evaluation of LoS of all paediatric hospitalisations exploring the frequency and characteristics; and associated childhood conditions. This population-based cross-sectional study included all hospital admissions in children aged <16 years between January 2017 and December 2019 in New South Wales, Australia. LoS was categorised into: day or overnight stay, 2-7, 8-21 and≥22 days. Socio-demographic and health service characteristics of each individual admission by LoS and age groups were evaluated. A total of 324,083 children had 518,768 admissions comprising 1,064,032 bed days. Most admissions wereday/overnight stays (71.9%) or 2-7 days (25.3%). While LoS >7 days represented 2.8% of total admissions, they accounted for 27% of total bed days. Children aged 1-4 years had the highest proportion of admissions (35%), with a majority lasting ≤7 days, whereas 45.6% of admissions ≥22 days were for children aged ≥12 years. Respiratory conditions, diseases of the digestive system and traumatic injuries were the most common reasons for hospitalization. LoS >7 days were more common in children from most disadvantaged backgrounds, residing further from hospital and those aged ≥12 years with mental health conditions. The majority of paediatric hospitalizations are for short stay and require programs that target acute conditions that can be managed in primary care. Interventions such as care coordination, tailored models of care and enhanced outpatient/community treatment programs for high-risk groups will help reduce extended LoS and improving child health and well-being. Australian National Health and Medical Research Council.

Health services for aboriginal and Torres Strait Islander children in remote Australia: A scoping review.

In Australia, there is a significant gap between health outcomes in Indigenous and non-Indigenous children, which may relate to inequity in health service provision, particularly in remote areas. The aim was to conduct a scoping review to identify publications in the academic and grey literature and describe 1) Existing health services for Indigenous children in remote Australia and service use, 2) Workforce challenges in remote settings, 3) Characteristics of an effective health service, and 4) Models of care and solutions. Electronic databases of medical/health literature were searched (Jan 1990 to May 2021). Grey literature was identified through investigation of websites, including of local, state and national health departments. Identified papers (n = 1775) were screened and duplicates removed. Information was extracted and summarised from 116 papers that met review inclusion criteria (70 from electronic medical databases and 45 from the grey literature). This review identified that existing services struggle to meet demand. Barriers to effective child health service delivery in remote Australia include availability of trained staff, limited services, and difficult access. Aboriginal and Community Controlled Health Organisations are effective and should receive increased support including increased training and remuneration for Aboriginal Health Workers. Continuous quality assessment of existing and future programs will improve quality; as will measures that reflect aboriginal ways of knowing and being, that go beyond traditional Key Performance Indicators. Best practice models for service delivery have community leadership and collaboration. Increased resources with a focus on primary prevention and health promotion are essential.

Adapting and testing a tool to map digital health resources use by older adults in Israel and Taiwan

Abstract Background Despite the potential of digital health tools for improving health outcomes, older adults are known to use digital health tools differently than younger adults. Focusing on needs of older populations is critical, as their numbers and proportions are projected to increase dramatically in the coming decades, both in Israel and in Taiwan. A bi-national collaboration was developed to map existing digital health resources available to older adults, as part of a larger study on digital health services use among older adults. Methods A mapping tool was adapted from the WHO classification of digital health interventions, based on the experience in the Taiwanese and Israeli health systems. The areas included public health, prevention, self- monitoring and self-care information and services in primary and tertiary care. The mapping documented digital resources offered by governmental/Ministry of Health, public primary care (HMOs), hospitals, and non-governmental organizations. Sources of information were institutional websites, evaluated by two specially trained reviewers for each organization who assigned a dichotomous value (yes/no) for each category. Interrater reliability was computed using a Kappa coefficient. Results The instrument included 17 categories and 44 sub-categories of digital resources, ranging from public health information for emergency situations to specific health service characteristics. To date, the Kappa coefficients range from 0.59-0.68 for NGO, MOH and hospital resources, considered substantial; for 3 HMOs, the values ranged from 0.41-0.49, considered moderate. Conclusions The mapping tool adapted to the countries’ digital resources allowed for bi-national research to compare/contrast the countries’ experience. The next stage of the study will validate the results through expert interviews, followed by an end user survey with older adults to assess both reported use of services and enabling digital health literacy skills. Key messages • To meet the needs of aging populations, attention needs to be given to their engagement with digital health services and resources. • Mapping digital health resources is essential for estimating how health needs are met nationally.

Gamifying rehabilitation: MILORD platform as an upper limb motion rehabilitation service

Motor learning is based on the correct repetition of specific movements for their permanent storage in the central nervous system (CNS). Rehabilitation relies heavily on the repetition of specific movements, and game scenarios are ideal environments to build routines of repetitive exercises that have entertaining characteristics. In this respect, the gamification of the rehabilitation program, through the introduction of game-specific techniques and design concepts, has gained attention as a complementary or alternative to routine rehabilitation programs. A gamified rehabilitation program promises to gain the patient's attention, to reduce the monotony of the process and preserve motivation to attend, and to create virtual incentives through the game, toward maintaining compliance to the “prescribed” program. This is often achieved through goal-oriented tasks and real-time feedback in the form of points and other in-game rewards. This paper describes MILORD rehabilitation platform, an affordable technological solution, which aims to support health professionals and enable remote rehabilitation, while maintaining health service characteristics and monitoring. MILORD is an end-to-end platform that consists of an interactive computer game, utilizing a leap motion sensor, a centralized user management system, an analysis platform that processes the data generated by the game, and an analysis dashboard presenting a set of meaningful features that describe upper limb movement. Our solution facilitates the monitoring of the patients' progress and provides an alternative way to analyze hand movement. The system was tested with normal subjects and patients and experts to record user's experience, receive feedback, identify any problems, and understand the system's value in monitoring and support motion defect and progress. This small-scale study indicated the capacity of the analysis to quantify the movement in a meaningful way and express the differences between normal and pathological movement, and the user experience was positive with both patients and normal subjects.

Experiences and Expectations of the Characteristics of Friendly Primary Health Services from the Perspective of Men: A Phenomenological Qualitative Study.

Inadequate men’s engagement with health services may be influenced by unmet needs and demands of the local men’s community. This study aimed to explore men’s experiences with primary health services and their expectations of the characteristics of friendly primary health services, from the perspective of men in Kelantan, Malaysia. A qualitative study using in-depth interviews was conducted with 15 men from six primary health facilities in Kelantan, Malaysia, who were selected based on maximum variation sampling. The data were transcribed and analyzed using the thematic analysis method. The study found that experiences with the existing primary health services were categorized into four subthemes: provision of health services, health promotion delivery, attributes of healthcare providers, and the physical environment of the health facilities. Meanwhile, the expectations of the characteristics of friendly primary health services were categorized into four subthemes: meeting the needs of men in primary health services, approaching men through effective health promotion strategies, standards of a healthcare provider from the viewpoint of men, and a comfortable physical environment for men. Prior experiences hugely influenced men’s expectations of friendly primary health services. Men want these health service characteristics customized to meet their needs, allowing them to use health services with confidence and comfort. Thus, to strengthen primary health services for men, it is essential to comprehend their prior experiences with and expectations of the services.

Norwegian health personnel’s compliance with new legislation on children of ill parents: an exploratory cross-sectional multicentre study

BackgroundIn 2010 the Norwegian Parliament introduced amendments to the Health Personnel Act requiring all health personnel to inform and offer help to their patients’ children and families. We evaluated whether health personnel adhered to their obligations outlined in the Act and investigated whether family and health services characteristics were associated with the degree of compliance with the legislation. Our study was part of a larger Norwegian multi-site study conducted in five health trusts across Norway, assessing the situation for families living with parental illness.MethodA cross-sectional study using quantitative data obtained from 518 patients 246 children and 278 health personnel was performed. All informants completed a questionnaire, including an instrument corresponding to the obligations in the legislation. Descriptive analyses, factor analysis and logistic regression analysis were used.ResultsThe legislation was only partially implemented in the clinics of the health trusts. Compared to estimates prior to the introduction of the new legislation, the situation had improved somewhat, but much work remains to be done to fulfil the obligations decreed by law. The more time-consuming the obligations were, the less often they were met. The substance abuse and mental health services followed up on their obligations to a greater extent than did the physical health services. Conversely, children of physically ill parents were better informed by their families than were children of parents with mental health and substance abuse disorders. When asked the same questions, reports from health personnel were more positive compared to those of children and patients regarding the legislation’s fulfillment.ConclusionData suggest that there has been a change in the support offered to children of ill parents. Additional work is required, however, for the Health Personnel Act to function as fully intended.

O92 - COVID-19 and beyond – changes to provision of maternity care and future plans in Victorian maternity services

BackgroundDue to the COVID-19 pandemic, rapid service changes were made to maternity care provision in Victorian maternity services. From March 2020 many routine face-to-face visits in pregnancy were replaced by telehealth (telephone or video), along with changes to routine screening. Many providers plan to continue these changes despite a lack of evidence to guide practice. We aimed to describe the changes in maternity care provision, understand the perceived impact and explore services’ future plans regarding these changes.MethodsA population-based cross-sectional study of midwifery managers of all Victorian public and private maternity services was conducted between March and October 2021. Questions explored health service characteristics, changes to maternity care delivery, telehealth practices, perceived impact of changes, and future plans.ResultsFifty percent of services (34/68, 27 public and 6 private) responded, with broad representation of location, birth numbers and size of service. Around 50% of all pregnancy visits became telehealth. There were multiple combinations of which visits were face-to-face and which were telehealth. No visit was conducted face-to-face by all responding services. Visits most likely to be face-to-face were at 39 and 40 weeks gestation (65%). For telehealth appointments there was an ad hoc approach to advising women on routine screening, e.g., measuring blood pressure (11% did not advise at all), fetal growth (26% – no specific strategy) and fetal heart rate (15% – no specific strategy). Over half (52%) would consider maintaining telehealth post-pandemic.ConclusionsEven in a single state there is great variation in telehealth timing, when pregnant women should have face-to-face visits, and what routine screening is maintained. In light of emerging evidence of some potentially poorer clinical outcomes associated with telehealth in pregnancy, these findings need to be considered.

Trends in HIV post-exposure prophylaxis following sexual exposure in Brazil (2011-2019).

We examined trends in the prevalence of post-exposure prophylaxis following sexual exposure (PEPSE) per million population (2011-2019) and the proportion of repeated PEPSE within 365 days of the first PEPSE dispensing (2011-2018) in Brazil. We also compared the prevalence of repeated PEPSE according to patient and health services characteristics in 2018. The prevalence of PEPSE increased 55.5% from 2011 to 2019. Repeated PEPSE increased 11.8%, reaching 8.4% among people with their first dispensing in 2018. The prevalence of repeated PEPSE was higher in cis men or trans women (versus cisgender women); homosexuals (versus heterosexuals); and people aged 25-29 years (versus other age groups). We also observed greater prevalence of repeated PEPSE in HIV services in populous cities or services with elevated caseloads. Our findings highlight the need for strategies to reduce repeated PEPSE and promote other HIV-prevention technologies, particularly among young adults, cisgender men, transgender women, and homosexuals.

Sociodemographic correlates of colorectal cancer screening completion among women adherent to mammography screening guidelines by place of birth

IntroductionColorectal cancer screening rates in the U.S. still fall short of national goals, while screening rates for other cancer sites, such as breast, remain high. Understanding characteristics associated with colorectal cancer screening among different groups of women adherent to breast cancer screening guidelines can shed light on the facilitators of colorectal cancer screening among those already engaged in cancer prevention behaviors. The purpose of this study was to explore which demographic characteristics, healthcare access factors, and cancer-related beliefs were associated with colorectal cancer screening completion among U.S. and foreign-born women adherent to mammography screening recommendations.MethodsAnalyses of the 2015 National Health Interview Survey were conducted in 2019. A sample of 1206 women aged 50–74 who had a mammogram in the past 2 years and were of average risk for colorectal cancer was examined. Logistic regression was used to determine demographic, health service, and health belief characteristics associated with colorectal cancer screening completion.ResultsFifty-five percent of the sample were adherent to colorectal cancer screening recommendations. Women over the age of 65 (AOR = 1.76, 95% CI 1.06–2.91), with any type of health insurance, and who were bilingual (AOR = 3.84, 95% CI 1.83–8.09) were more likely to complete screening, while foreign-born women (AOR = 0.53, 95% CI 0.34–0.83) were less likely. Cancer-related beliefs did not influence adherence. Stratified analyses by nativity revealed additional associations.ConclusionsDemographic and health service factors interact to influence colorectal cancer screening among women completing breast cancer screening. Colorectal cancer screening interventions targeting specific underserved groups and financing reforms may enhance women’s colorectal cancer screening rates.

Follow-up after post-partum psychiatric emergency department visits: an equity-focused population-based study in Canada

Emergency department visits for a psychiatric reason in the post-partum period represent an acute need for mental health care at a crucial time, but little is known about the extent of timely outpatient follow-up after these visits or how individual and intersecting social determinants of health influence this outcome. This study aimed to examine outpatient mental health care follow-up by a physician in the 30 days after an individual attended the emergency department for a psychiatric reason in the post-partum period and understand how social determinants of health affect who receives follow-up care. In this population-based cohort study, routinely collected health data from Ontario, Canada were accessed through ICES to identify all post-partum individuals whose sex was listed as female on their health card and who had attended an emergency department in Ontario before the COVID-19 pandemic for a psychiatric reason. Individuals admitted to hospital at the time of the emergency department visit, who died during the visit, or who left without being seen were excluded from the study. Ethnicity data for individuals were not collected. The primary outcome was the proportion of individuals with any outpatient physician (psychiatrist or family physician) visit for a mental health reason within 30 days of the index emergency department visit. Family physician mental health visits were identified using a validated algorithm for Ontario Health Insurance Plan-billed visits and mental health diagnostic codes for community health centre visits. We examined the associations between social determinants of health (age, neighbourhood income, community size, immigration, neighbourhood ethnic diversity) and who received an outpatient mental health visit. We used modified Poisson regression adjusting for the other social determinants of health, clinical, and health services characteristics to examine independent associations with follow-up, and conditional inference trees to explore how social determinants of health intersect with each other and with clinical and health services characteristics in relation to follow-up. We analysed data collected between April 1, 2008, and March 10, 2020, after exclusions we identified 12 158 people who had attended the emergency department for a psychiatric reason in the post-partum period (mean age 26·9 years [SD 6·2]; range 13-47); 9848 individuals lived in an urban area, among these 1518 (15·5%) were immigrants and 2587 (26·3%) lived in areas with high ethnic diversity. 5442 (44·8%) of 12 158 individuals received 30-day follow-up. In modified Poisson regression models, younger age, lower neighbourhood income, smaller community size, and being an immigrant were associated with a lower likelihood of follow-up. In the CTREE, similar variables were important, with several intersections between social determinants of health and between social determinants of health and other variables. Fewer than half of emergency department visits for a psychiatric reason in the post-partum period were followed by timely outpatient care, with social-determinants-of-health-based disparities in access to care. Improvements in equitable access to post-emergency department mental health care are urgently needed in this high-risk post-partum population. Department of Psychiatry, University of Toronto; Canadian Institutes of Health Research.

Geographic Access and Maternal Health Services Utilization in Sélingué Health District, Mali.

IntroductionMaternal mortality is one of the main causes of death for women of childbearing age in Mali, and improving this outcome is slow, even in regions with relatively good geographic access to care. Disparities in maternal health services utilization can constitute a major obstacle in the reduction of maternal mortality in Mali and indicates a lack of equity in the Malian health system. Literature on maternal health inequity has explored structural and individual factors influencing outcomes but has not examined inequities in health facility distribution within districts with moderate geographic access. The purpose of this article is to examine disparities in education and geographic distance and how they affect utilization of maternal care within the Sélingué health district, a district with moderate geographic access to care, near Bamako, Mali.MethodsWe conducted a cross sectional survey with cluster sampling in the Sélingué health district. Maternal health services characteristics and indicators were described. Association between dependent and independent variables was verified using Kendall’s tau-b correlation, Chi square, logistic regression with odds ratio and 95% confidence interval. Gini index and concentration curve were used to measure inequity.ResultsMost respondents were 20 to 24 years old. Over 31% of our sample had some education, 65% completed at least four ANC visits, and 60.8% delivered at a health facility. Despite this evidence of healthcare access in Sélingué, disparities within the health district contribute to inadequate utilization among approximately 40% of the women in our sample. The concentration index demonstrated the impact of inequity in geographic access,comparing women residing near and far from the referral care facility.ConclusionMaternal health services underutilization, within a district with moderate geographic access, indicates that deliberate attention should be paid to addressing geographic access even in such a district.

What we know about antibiotics prescribed by dentists in a Brazilian southeastern state.

The objective of this study was to analyze possible associations between antibiotic dental prescriptions in the public health service, health service characteristics, and social characteristics of the municipalities. Using the register of dispensing in the public health service of a state in the Southeast region of Brazil, in 2017 we analyzed patterns of antibiotic prescriptions by dentists. Data were obtained from the Integrated Pharmaceutical Services Management System (SIGAF, in Portuguese). The outcome variable was the number of Daily Defined Doses (DDD) per 1,000 residents/year in each municipality. CART (Classification and Regression Tree) technique was used to determine the influence of the following variables: populational social characteristics (Human Development Index, Gini Index, the proportion of rural population and proportion of families benefiting from the Bolsa Família Program) and oral health services characteristics (access to individual dental care, number of dentists and oral health teams per 1,000 residents, and percentage of preventive and restorative individual dental procedures. Data analysis was performed using IBM SPSS Statistics 21.0. Antibiotics were the medications most prescribed by dentists in the public health service, with penicillin being the most frequently prescribed class. The average DDD/1,000 residents/year for the 421 municipalities surveyed was 96.54 (range 0.008 and 619.660). Select factors were associated with antibiotic prescriptions including access to individual dental care (Adjusted p-value ≤0.001), a number of oral health teams/1,000 inhabitants (Adjusted p-value=0.001), and Gini Index (Adjusted p-value = 0.046). Access to oral health services and inequality were associated with the use of antibiotics.

Audit of acute psychiatric presentations during New Zealand's first COVID-19 national lockdown.

Objective:In this study, we aimed to identify service user demographic and clinical characteristics of an acute mental health service in South Auckland during the first New Zealand coronavirus-related lockdown.Method:We conducted a clinical audit of a sample of service users presenting to a district health board's acute adult mental health service during New Zealand’s level-4 lockdown in 2020 and made comparisons to a sample from 2019. We identified demographic factors, living situation, mode of referral, mode of assessment, diagnosis, substance use, risks, stressors, use of mental health act legislation and follow-up.Results:During the first level-4 lockdown fewer Ma¯ori were assessed, police referrals increased, specific stressors related to confinement were identified and there was an increase in risks relating to self-harm and harm to others.Conclusion:Service users had unique stressors and changing patterns of presentation during the level-4 New Zealand lockdown. In response to the changing needs of service users during a pandemic, we recommend optimising telehealth, enhancing connections with other essential services, development of digital interventions and care for frontline staff.