Area Health Service Research Articles

Telepsychiatry

Numerous challenges have limited access to mental health services in rural areas. Some of these barriers have included transportation, number of providers, poverty, and lack of insurance. The purpose of this review was to identify and coalesce the benefits of telepsychiatry for adults living in rural communities in the United States to determine if telepsychiatry has improved access and quality of care. The methodology for this study was a literature review that followed a systematic approach. It was found that several studies supported that telepsychiatry has improved access and quality of care available in rural environments. Simultaneously, telepsychiatry in mental healthcare has not been utilized as it should in rural adult populations due to lack of access, an overall shortage of providers, and poor distribution of psychiatrists. While there are still barriers that prevent widespread utilization, telepsychiatry can improve mental health outcomes by linking rural patients to high-quality mental healthcare services that follow evidence-based care and best practices.

Unwarranted geographic variation in paediatric health care in the United States and Norway.

We present the four US and Norwegian paediatric and neonatal health atlases and discuss the concept and causes of unwarranted geographic variation in paediatric health care. The four atlases analyse data from both publicly owned health registers, registers of insurance claims and quality registers. Healthcare utilisation is counted per recipient in predefined hospital service areas, adjusted for relevant confounders and presented as extremal ratios between the highest and lowest rate. The atlases describe geographic variation in rates for primary health care, hospital admissions, outpatient visits, treatment procedures and diagnostic testing. A difference in extremal ratios from 2 to 4 between health service areas are common, and for some procedures extremal ratios is even higher. Variation in healthcare utilisation of the magnitude described in these four atlases cannot be explained by differences in population morbidity or patient preferences and are therefore characterised as unwarranted variation. Individual provider preferences or supply of resources such as hospital beds may explain the observed variation.

Perceptions and experiences of health care professionals and staff with animal-assisted interventions in health care settings: a qualitative systematic review protocol.

The objective of this review is to examine the perceptions and experiences of health care professionals and staff in implementing or coordinating animal-assisted interventions in health care settings. Animal-assisted interventions are applied in the areas of health, education, and human services to help improve individuals' health and wellness. The positive effects of animal-assisted interventions on individuals have been shown in multiple health disciplines, from pediatrics to long-term care, and include outcomes such as decreased feelings of loneliness and increased feelings of support. The increase of animal-assisted interventions in human health has initiated growing research on health care professionals' perceptions and experiences of these interventions. No current qualitative systematic reviews have focused solely on health care professionals' and staff's perceptions of animal-assisted interventions. Conducting such a review will advance understanding of how these providers perceive and engage with animal-assisted interventions as well as their influence and role in coordinating these interventions. This review will consider qualitative primary studies that address the perceptions and experiences of health care professionals and staff in implementing or coordinating animal-assisted interventions in health care settings. Nine bibliographic databases will be systematically searched for published and unpublished studies by employing a three-step search strategy. Studies published from database inception to present and in English will be considered. Two reviewers will independently appraise the studies and extract qualitative data using the standardized JBI critical appraisal and data extraction instruments. Findings from the review will be categorized according to similarity in meaning, and categories will be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings. PROSPERO CRD42021258909.

Abstract PO-263: Racial equity and oral cancer: Exploring the relationship between dentist supply and the Black-White disparity in late stage diagnosis

Abstract Background: Oral cancer is one of the most common cancers for Black men in America, and a leading cause of cancer mortality. Like many other cancers, survival in Black adults lags behind Non-Hispanic White adults. One explanation for the mortality and survival gap may be due to the propensity for Black adults to be diagnosed at later stages. The prognosis for early stage oral cancer can be quite positive. Despite inconsistent screening reccomendations, dental professionals have established oral cancer screening as a standard of care for all comprehensive evaluations. However, in addition to the lack of access to dental coverage, limited availability of dental professionals may be, in part, driving the disparity in late stage diagnoses for Black Americans. Objective: This study aims to estimate the relationship between the Black-White disparity in late stage oral cancer diagnoses and the supply of dentists. Methodology: Data for this study comes from the Center for Disease Control (CDC) Wonder portal and the Agency for Healthcare Research and Quality (AHRQ) provider dataset. To develop a measure of Black-White disparity in late stage oral cancer diagnoses, first, the proportion of late stage diagnoses of all oral cancer diagnoses were obtained for both Non-Hispanic Black and Non-Hispanic White adults for years 2011-2015. Data was aggregated to Health Servica Area level and restricted to states in the Southeast. The outcome of interest was derived by the difference between the Non-Hispanic Black proportion of late stage diagnoses and the Non-Hispanic White proportion. This exploratory study utilized a linear regression model to estimate the relationship between this difference and the supply of dental professionals per capita in each paired Health Service Area (HSA). Results: The mean proportion of late stage diagnoses were 70.8% and 61.9% for Non-Hispanic Black and Non-Hispanic White adults, respectively. The mean difference in late stage diagnoses, at the HSA level, was approximately 8.0%. This differnce, appeared to decline as the per capita supply of dentists increased (Est = -0.03, p < 0.05). Putting this association in context, to reduce the Black-White disparity in late stage diagnoses by 1-percentage point, 33 dentists per 100,000 population must be added to the HSA. Conclusion: Greater availability to dental professionals may play an important role in reducing racial disparities in oral cancer. Still, this exploratory work is only the begining for inferring a causal relationhip between increasing dental supply and decreasing differences in late stage oral cancer diagnoses. Even under the assumption of causality, policies aiming to increase dental supply in shortage areas must ensure equitable and just access for Black communities. Citation Format: Jason Semprini. Racial equity and oral cancer: Exploring the relationship between dentist supply and the Black-White disparity in late stage diagnosis [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-263.

Factors associated with the death of healthcare workers due to COVID-19 in the state of Amapá, Brazil.

Introduction:Frontline healthcare workers providing care for COVID-19 are more likely to get infected and die compared with other professionals. Deaths or sick leaves due to COVID-19 can affect the smooth operation of health services in areas with shortage of workers.Objectives:To analyze factors associated with the death of healthcare workers due to COVID-19 in the state of Amapá, Brazil.Methods:Analytical cross-sectional study using COVID-19 data from Amapá between March 2020 and January 2021. The association of independent variables (sex, race/color, age group, region of residence, comorbidity) with death was analyzed by logistic regression.Results:Data from 1,258 workers were analyzed. The majority were women (67.7%; 852/1,258), multiracial (66.9%; 759/1,135), aged between 18 and 64 (98.3%; 1,226/1,247), with no comorbidity (86.6%; 1,090/1,258), from the Macapá metropolitan area (56.7%; 713/1,258). The mortality rate was 1.59%. Factors associated with death were: age group = 65 years (odds ratio = 10.43; 95% confidence interval [CI] = 2.78-39.11), comorbidity (odds ratio = 4.52; 95%CI = 1.74-11.74), and residence in the Macapá metropolitan area (odds ratio = 4.37; 95%CI = 1.25-15.29).Conclusions:The recognition of factors that may have caused the death of healthcare workers in Amapá can support the recommendation of protective measures for the most susceptible, such as switching to activities with lower exposure to the virus or teleworking.

Strategic Health Purchasing and Health System Performance in Nigeria

Purchasing has been adopted by many countries as a mechanism to achieve greater efficiency and improved responsiveness of services to patient demands. This study examined the effects of strategic health purchasing on health system performance in Nigeria. The data for the study was collected using a purposive sampling survey in the Akure metropolis. The results indicated a positive relationship between health system performance and purchasing strategy, payment mechanism and service utilisers with the regression coefficients of 0.30, 0.16 and 0.33. This implied that purchasing strategy, payment mechanism and service utilisers are likely to improve health system performance. The results also revealed a positive relationship between each of the health system performance measurement dimensions (life expectancy, the performance of different areas of health services, distribution of access to health facilities, fairness of health financing, prompt attention to medical needs and purchasing strategy, providers payment mechanism and service utilisers. It was concluded that health system performance can be improved by the implementation of strategic health purchasing. Therefore, paying for health care services should be made strategic and rules relating to auditing and accountability should be made more effective.

The role of the Mobile Mental Health Units in mental healthcare delivery in rural areas in Greece: current challenges and prospects.

The present paper aims to highlight the importance of Mobile Mental Health Units (MMHUs) in the delivery of mental health services in remote areas in rural Greece. Since the foundation of the first MMHUs in the eighties till nowadays, those services have expanded in many rural areas and there is some evidence that they are effective in the management of patients with severe mental disorders. The care of those patients seems to contribute to a significant reduction in voluntary and involuntary acute admissions and in length of hospital stay. Cost/effectiveness analysis studies have also shown favorable results. Besides their regular clinical work, MMHUs conduct research, such as epidemiologic surveys. Other research explores the care of elderly patients in rural areas and the care of immigrants that permanently reside in Greece. Other research involves the study of psychotic disorders in the rural context, such as the long-term outcome, the patients' functioning, and the long-term treatment with benzodiazepines. Current challenges for MMHUs involve staffing, particularly for those run by public hospitals, and the retainment of highly trained personnel. Other important challenges are related to the aging of the rural population and the refugee/migrant influx. The MMHUs of the islands that initially accept the refugee flow, have already faced an increased number of new referrals. Given the disparities in mental healthcare between rural and urban areas, further enhancement of the MMHUs' operation is required, as well as continuing training of their workforce. Research at the national level is needed and could be the basis for the design and staffing of new services. The establishment of valid and broadly accepted clinical indices to measure treatment outcomes would facilitate research and ensure the recording and evaluation of the MMHUs' work and their effectiveness as well; and would highlight their utility within the contemporary health system.

Cervical Cancer Screening Coverage - China, 2018-2019.

The World Health Organization set a 2030 target of 70% cervical cancer screening coverage for women aged 35-45 years. Coverage stood at 37% in China in 2015. In 2018-2019, China's cervical cancer screening coverage reached 43.4% in women aged 35-44 years and 36.8% in women aged 35-64 years. Screening coverage was still lower in rural areas as well as central and western regions; large variations existed across provincial-level administrative divisions. National and local policy and financial support should be maintained for cervical cancer screening, along with more targeted health education and outreach efforts and strengthened accessibility of health services in the rural areas and central and western regions.

Demographics and distribution of australia's medical immigrant workforce

BackgroundInternational medical graduates (IMGs) have made important contributions to Australian healthcare since colonization. Recent published data have documented source countries and characteristics of IMGs undertaking the examinations of the Australian Medical Council. However, information about those currently practicing in Australia is limited. ObjectiveTo analyze a cross section of IMGs currently practicing in Australia to determine patterns of change in donor countries, other demographic characteristics, geographical locations, and their areas of specialization. MethodsA random sample of all practitioners on a national database was interrogated for their country of first medical qualification. Those who qualified outside Australia were then analyzed for demographic variables such as age, gender, country of origin, and years of graduation and immigration. Their practice locations were matched to the Australian Bureau of Statistics geographical framework, and their specialties compared with those of a random sample of graduates from Australian medical schools. ResultsOver the approximately 60 years since those surveyed arrived in Australia, IMGs’ countries/regions of origin have changed from mainly the UK and Ireland to Southern Asia, in line with demographic changes in Australia as a whole. Most arrived soon after graduation, and IMGs are twice IMGs as likely as local graduates to be working in a rural area of workforce shortage. Compared with local graduates, significantly more IMGs are working in general practice. ConclusionsIMGs currently practicing in Australia make up a substantial proportion of the workforce and are more likely than local graduates to provide health services in regional and remote areas.

TRAJECTORIES AND PREDICTORS OF PERINATALANXIETY SYMPTOMS IN LOW-INCOME RURALAREA MOTHERS AT RISK OF ANXIETY

AIM: The goal of the study was to determine the trajectories of perinatal anxiety symptoms and their determinants among women who report with risk anxiety during pregnancy and live in a low-resource context in Sriperumbuthur, Chennai. Study Design: A Cross sectional study design METHADOLOGY: This cross-sectional study included 192 women from Sriperumbuthur, a low-income neighborhood in Chennai, who were selected at their rst prenatal visit if they scored 13 or higher on the Edinburgh Postnatal Anxiety Scale, were at least 18 years old, and were fewer than 29 weeks pregnant. Participants were followed up on at eight months gestation, three months postpartum, and twelve months postpartum. Growth mixture modelling was used to nd latent trajectories of anxiety symptoms based on the Hamilton Anxiety Scale (HAS). Because HAS scores did not differ between the control and intervention groups, all individuals were evaluated jointly. Using health, social, and economic variables of trajectories were studied to identify high-risk groups with more or more chronic rage symptoms. RESULTS:There were two trajectories identied: prenatal alone (88%) with moderate to severe symptoms at baseline that subsequently diminish; and antenatal and postnatal (12%) with severe anxiety symptoms during pregnancy and later in the postpartum period that subside to moderate levels at 3 months postpartum. Severe food hardship, intimate partner violence, reduced social support, more functional impairment, problematic drinking, and suicide risk are all predictors for the prenatal and postnatal trajectory. CONCLUSION: A small percentage of women who are at risk for anxiety prenatally remain at risk during pregnancy and can be distinguished from those who experience a spontaneous remission. These ndings should be included into identication and referral efforts, especially considering the scarcity of mental health services in low-income areas.

Probability of non-compliance to the consumption of Iron Tablets in pregnant women in Indonesia.

The low non-compliance to the consumption of Iron Tablets in pregnant women is an obstacle in the implementation of government programs to prevent and overcome the anemia problems in pregnant women. This study was conducted to determine the probability of non-compliance of pregnant women in the consumption of iron tablets in Indonesia. A cross-sectional study using the 2017 IDHS data. The sample was 12,466 women of childbearing age 15-49 years in Indonesia who consumed Iron Tablets during their last pregnancy. Univariate analysis used proportion measure, the bivariate analysis using chi-square test and multivariate used binary logistic regression test. Statistical analysis using SPSS-26 software. The level of non-compliance to the consumption of Iron Tablets during pregnancy in Indonesia is only 48.47%. The risk factors for quantity (p = 0.000, OR 2.085), and quality (p = 0.000, OR 1.655) Antenatal Care (ANC) was not good, examiners were pregnancy not health workers (p = 0.000, OR 1.816), residence in rural areas (p = 0.000, OR 1.262), and very poor socioeconomic status (p value = 0.000, OR 2.041) were significantly related to non-compliance with Iron Tablets consumption. The probability of non-compliance to the consumption of Iron Tablets in pregnant women with risk factors is 88%. Quantity of ANC and socioeconomic have a high influence on compliance to consumption of iron tablets, so it is important to bring nutrition workers at ANC activities to educate pregnant women about the benefits, side effects, and ways of consumption of iron tablets, reactivate supervisors for consumption of iron tablets, increase access health services in rural areas and families with low socioeconomic status, as well as providing free health care programs for the poor.

Integrating Telepsychiatry Into Rural Primary Care for Upstream Prevention: Feasibility Case Study of the Faith Net Program.

IntroductionFor decades, there has been a deficit of mental health services in rural areas of the United States. Beyond that longstanding need, the COVID-19 pandemic has reportedly increased the prevalence of unmet mental health needs among adults. Presently, many non-critical but urgent mental health concerns are first identified in rural emergency departments. This report describes the results of a 6-month feasibility case study of a program to integrate telepsychiatric triage “upstream” from emergency departments in rural primary care.MethodsAt routine primary care encounters in a single midwestern rural county, patients at risk for moderate-severe or severe depression, expressing thoughts of self-harm, or otherwise presenting in a way that raised clinical concern for mental or behavioral health, were referred to on-site telepsychiatric triage. Patients whose triage indicated further concern were provided six psychiatric and/or social work encounters for stabilization and treatment.Results68 patients were referred to telepsychiatric triage during the pilot study (.85% of the estimated adult population in the county). Of those, only two had a documented mental/behavioral health diagnosis prior to triage, but 46 were diagnosed with at least one psychiatric disorder during the program.ConclusionsThis model of telepsychiatric triage was feasible in rural primary care and may support identification and mitigation of unmet mental health needs.

Maternity research priorities in country Western Australia: a Delphi study.

Objective Health research priorities are commonly identified and resourced by strategic leaders. The importance of recognising the expertise of clinician-researchers is being prioritised by a national funding shift towards applied research. There is a dearth of evidence regarding research priorities for maternity care in rural and remote health in Australia. This study aimed to develop an evidence-based consensus of maternity research priorities in regional, rural, and remote areas of Australia's largest rural health service (by land area) in Western Australia. Methods A three-phased Delphi method was selected to achieve an interdisciplinary, evidence-based consensus on maternity research priorities within Western Australian Country Health Service. Results Across three study phases, 432 participants responded. Representation was from seven regions and all stakeholder roles within the regions. Phase 1 included 173 responses yielding 53 concepts categorised under five domains. Phase 2 involved 161 participants who prioritised concepts under domains of (i) workforce and education; (ii) health equity; (iii) Aboriginal health; (iv) logistics and health systems; and (v) clinical. Phase 3 included 96 participants revealing 15 maternity research priorities with the top four ranked concepts: 'recruitment and retention of staff'; 'care for women and families with vulnerabilities', 'models of care offering continuity' and 'systems efficiencies'. Conclusions The novel evidence provided in this study, in conjunction with a strong consensus on research priorities and an interdisciplinary approach, strengthens the findings of this study and amplifies the mandate of action without delay.

Obim pružanja preventivnih usluga od strane izabranih lekara u primarnoj zdravstvenoj zaštiti, u Republici Srbiji, u periodu od 2013. do 2017. godine

Introduction: In the Republic of Serbia, the capitation formula was introduced in 2012, as a payment for performance model for chosen medical doctors based on the number of patients, number of visits, financial value of prescribed prescriptions, as well as on the basis of the number of preventive health services provided in public primary health care facilities. Aim: The aim of this paper is to analyze the scope of preventive health services provided, which is used to evaluate the performance and to pay selected doctors according to the capitation formula, in primary health care institutions, in the Republic of Serbia, in the period between 2013 and 2017. Methods: The available data of the Institute of Public Health of Serbia 'Dr Milan Jovanović - Batut' (IPHS 'Batut'), in terms of the coverage of certain populations with health services, were analyzed, namely twenty-three different indicators, i.e., preventive services provided by chosen medical doctors in the area of health services for adults, children, and women's healthcare, in 166 primary health care institutions to which the payment model based on the capitation formula is applied (158 primary healthcare centers, three institutes for the health care of university students, and five institutes for the health care of workers). The trend of coverage of the above-mentioned services, in the period between 2013 and 2017 was examined, as well as the increase in the volume of preventive services, with fixed-base and chain indices. Results: Three out of twenty-three different health services showed a declining trend, namely the coverage of infants with ultrasound examinations for early detection of hip dysplasia, coverage of schoolchildren with preventive examinations at the ages of 8, 10, 12, and 14 years, as well as coverage of the adult population (older than 35 years) with preventive services. All other services had a stable trend in terms of coverage of target populations in the period from 2013 to 2017. Conclusion: Although most of the observed preventive health services had a stable trend of population coverage, their coverage was far below the recommended level, in the observed period.

Albanian Migrants in Cyclades: Contact with Mental Health Services and Implications for Practice

The purpose of this study was to examine the potential differences between Albanian migrants and Greeks in the islands of Paros and Antiparos with regard to seeking help from the local public mental health service, namely the Mobile Mental Health Unit of NE Cyclades Islands (EPAPSY-NGO). The study’s instruments include the Global Assessment of Functioning (GAF) and a questionnaire for recording psychosocial profile data and information concerning contact with the services. The results showed that significantly less Albanian migrants contacted the mental health services in the past in comparison to Greeks. When using the service, the Albanians were more likely to see a psychiatrist in the Unit, rather than a psychologist-psychotherapist, and they more often received prescriptions for medication. There was a significantly higher dropout rate among Albanian migrants. This study highlights the different aspects of access and use of mental health services among Albanian migrants compared with native residents. Further research should focus on the factors related to early dropouts and difficulties accessing mental health services in rural areas, in order to develop more focused and effective interventions and improve the quality of care provided.

Pennsylvania’s Transition to Medicaid Managed Long-Term Services and Supports

Implemented through five health plans, Ohio’s MyCare demonstration began in 2014 and was designed to coordinate primary, acute care, behavioral health and long-term services in the major urban areas of the state. Individuals who are dually eligible for both Medicaid and Medicare and who reside in specified geographic regions must enroll into a managed MyCare plan. MyCare beneficiaries are assigned to two primary categories: community well and those needing long-term services and supports (LTSS). Individuals receiving the integrated MyCare intervention were expected to have lower acute care hospitalizations, lower long-term nursing home use, better longevity and lower overall health and long-term care costs. Using a propensity score matching design, the evaluation compared MyCare enrollees to comparison group members in non-MyCare counties of the state, using Medicaid and Medicare claims data. The 120,000 MyCare program participants represented about half of the dual eligible individuals in the state.

Ohio's Large Scale Experiment on Integrated Care: Results and Implications for Long-Term Services Reform

Implemented through five health plans, Ohio’s MyCare demonstration began in 2014 and was designed to coordinate primary, acute care, behavioral health and long-term services in the major urban areas of the state. Individuals who are dually eligible for both Medicaid and Medicare and who reside in specified geographic regions must enroll into a managed MyCare plan. MyCare beneficiaries are assigned to two primary categories: community well and those needing long-term services and supports (LTSS). Individuals receiving the integrated MyCare intervention were expected to have lower acute care hospitalizations, lower long-term nursing home use, better longevity and lower overall health and long-term care costs. Using a propensity score matching design, the evaluation compared MyCare enrollees to comparison group members in non-MyCare counties of the state, using Medicaid and Medicare claims data. The 120,000 MyCare program participants represented about half of the dual eligible individuals in the state.

What a Pandemic Has Taught Us About the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia.

The COVID-19 pandemic coincided with a multi-national federally funded research project examining the potential for health and care services in small rural areas to identify and implement innovations in service delivery. The project has a strong focus on electronic health (eHealth) but covers other areas of innovation as well. The project has been designed as an ethnography to prelude a realist evaluation, asking the question under what conditions can local health and care services take responsibility for designing and implementing new service models that meet local needs? The project had already engaged with several health care practitioners and research students based in Canada, Sweden, Australia, and the United States. Our attention is particularly on rural communities with fewer than 5,000 residents and which are relatively isolated from larger service centres. Between March and September 2020, the project team undertook ethnographic and auto-ethnographic research in their own communities to investigate what the service model responses to the pandemic were, and the extent to which local service managers were able to customize their responses to suit the needs of their communities. An initial program theory drawn from the extant literature suggested that “successful” response to the pandemic would depend on a level of local autonomy, “absorptive capacity,*” strong service-community connections, an “anti-fragile†” approach to implementing change, and a realistic recognition of the historical barriers to implementing eHealth and other innovations in these types of rural communities. The field research in 2020 has refined the theory by focusing even more attention on absorptive capacity and community connections, and by suggesting that some level of ignorance of the barriers to innovation may be beneficial. The research also emphasized the role and power of external actors to the community which had not been well-explored in the literature. This paper will summarize both what the field research revealed about the capacity to respond well to the COVID-19 challenge and highlight the gaps in innovative strategies at a managerial level required for rapid response to system stress.*Absorptive Capacity is defined as the ability of an organization (community, clinic, hospital) to adapt to change. Organizations with flexible capacity can incorporate change in a productive fashion, while those with rigid capacity take longer to adapt, and may do so inappropriately.†Antifragility is defined as an entities' ability to gain stability through stress. Biological examples include building muscle through consistent use, and bones becoming stronger through subtle stress. Antifragility has been used as a guiding principle in programme implementation in the past.

The Performance of Slovenian Hospitals: The Development of Sustainable Business Model

Abstract Due to the Covid-19 epidemic, the Slovenian Government ended the project of rehabilitating Slovenian hospitals that showed negative financial operations by the end of 2016. The special Government Act provided one-time financial compensation and simultaneously tasked the hospitals with preparing rehabilitation programs. A case study applied the rehabilitation programs of 12 Slovenian hospitals and interviews with the directors of individual hospitals to collect data. In-depth analysis revealed several shortcomings that were identified and addressed with measures outlined in the rehabilitation programs. Most of them extend to the areas of activity, financial operations, and health services. The study results suggest that the transformation of the current operating mode of Slovenian hospitals in the direction of creating a sustainable business model would require the definition of sustainable objectives, reorganization and coordination of various institutional factors, and the support of such reform through normative and other systemic measures.

Female Genital Schistosomiasis (FGS) in Cameroon: A formative epidemiological and socioeconomic investigation in eleven rural fishing communities.

Female Genital Schistosomiasis (FGS) is most often caused by presence of Schistosoma haematobium eggs lodged in the female reproductive tract which results in chronic fibrosis and scarring. In Cameroon, despite high community prevalences of urine-patent S. haematobium infections, FGS has yet to be studied in depth. To shed light on the clinical prevalence and socioeconomic effects of FGS, we undertook a formative community-based epidemiological and qualitative survey. A cross sectional multidisciplinary study of 304 girls and women from 11 remote rural fishing communities in Cameroon was undertaken using parasitological sampling, clinical colposcopy, and interviews. The lived experiences of those with FGS were documented using a process of ethnography with participant observation and in-depth interviews. Amongst 304 women and girls aged >5 years (Median age: 18; Interquartile range: 9.6-28), 198 females were eligible for FGS testing and 58 adult women were examined by clinical colposcopy. Of these, 34 were positive for FGS (proportion: 58.6%; 95% CI: 45.8-70.4), younger girls showing a higher FGS prevalence, and older women not shedding eggs showing a pattern for cervical lesions from earlier infection. In a subset of women with FGS selected purposively (12/58), in-depth interviews with participant observation revealed out-of-pocket expenditures of up to 500USD related health spending for repeated diagnosis and treatment of gynecological illnesses, and 9 hours daily lost reproductive labour. Psychosocial unrest, loss in social capital, and despair were linked with sub-fertility and persistent vaginal itch. With our first formative evidence on prevalence, socioeconomic effects and experiences of FGS amongst women and girls in Cameroon, we have clarified to a new level of detail the deficit in provision of and access to peripheral health services in remote areas of Cameroon. Using this information, there is now strong evidence for national programs and services on women's health and schistosomiasis to update and revise policies targeted on prevention and management of FGS. We therefore stress the need for regular provision of Praziquantel treatment to adolescent girls and women in S. haematobium endemic areas, alongside better access to tailored diagnostic services that can detect FGS and appropriately triage care at primary health level.