Increased Service Use Research Articles

Effects of simple active referrals of different intensities on smoking abstinence and smoking cessation services attendance: a cluster-randomized clinical trial.

Proactive brief cessation advice by a lay counsellor combined with a referral to a smoking cessation service (active referral) is effective in increasing service use and quitting in community smokers. We compared the effect of two modified approaches to referrals on the cessation outcomes in community smokers. Three-arm cluster-randomized trial. General community in Hong Kong. Daily cigarette smokers (n=1163; 77.7% male). Participants were randomized to receive on-site active referral (OSR, n=395), where lay counsellors helped participants make appointments with a smoking cessation service of their choice plus tailored reminders; mobile text messaging referral (TMR, n=385), where participants were encouraged to use a smoking cessation service via text messages; or brief cessation advice only (control, n=383). The primary outcome was a self-reported 7-day point-prevalence abstinence at 6months post-treatment initiation. Secondary outcomes included 7-day point-prevalence abstinence at 3 and 18months, biochemically validated abstinence, smoking reduction and the use of cessation services at 3, 6 and 18months. Using intention-to-treat analysis, the OSR (17.7%) and TMR (17.1%) groups had significantly higher self-reported abstinence than the control (12.0%) group at 6months [odds ratio (OR) for OSR versus control=1.58, 95% confidence interval (CI)=1.06-2.36; OR for TMR versus control=1.52, 95% CI=1.01-2.28; both P<0.05]. The corresponding validated abstinence rates at 6months were 7.6, 7.8 and 3.9% (OR for TMR versus control=2.02, 95% CI=1.07-3.81; OR for TMR versus control=2.07, 95% CI=1.10-3.92; both P<0.05). Self-reported and validated abstinence were similar at 18months. OSR groups had higher rates of smoking cessation service use than the control group at all follow-ups (all P<0.001). The smoking reduction rates were similar in continuing smokers. Simple active referrals (in person or via text messaging) to smoking cessation services increased abstinence rates among smokers in Hong Kong compared with general brief cessation advice. On-site active referral increased the use of smoking cessation services compared with general brief cessation advice.

Use and predictors of health services among Australian children with mental health problems: A national prospective study

ObjectiveRetrospective, parent‐reported data suggest that 50% of Australian children with mental health disorders miss out on care. In a national sample, we aimed to determine the proportion receiving mental health services and associated characteristics, using prospective, objective data.MethodProspective analysis of linked Medicare Benefits Scheme (MBS)‐rebated mental health service use in children aged 8–9, 10–11, and 12–13-years, from the Longitudinal Study of Australian Children K cohort (N = 4,983). Analyses were conducted separately for children scoring above the cut points on the Strength and Difficulties Questionnaire (SDQ) emotional and externalising problems subscales. Characteristics were compared using logistic regressions.ResultsNine to 27% of children scoring above SDQ cut points accessed MBS‐rebated mental health services, typically from general practitioners, psychologists and paediatricians. Greater symptom severity, parent perception that child needs help, being a young boy and older were associated with increased service use. Children from more disadvantaged families or families speaking a language other than English were less likely to receive services for internalising problems.ConclusionIn the first prospective, objective analysis, most children do not receive mental health services.

Autism and attachment disorder symptoms in the general population: Prevalence, overlap, and burden

Background: Co-occurring trauma-related and neurodevelopmental problems are common in maltreated children. In population research and clinical practice, these tend to be considered separately. Overlapping health problems, that is, “multi-morbidity,” in adulthood is associated with increased service burden and costs, but this has not been investigated in childhood. Methods: Using well-validated parent-report questionnaires, we examined the overlap between symptoms of the neurodevelopmental disorder autism (autism spectrum disorder, ASD) and symptoms of the trauma- and stressor-related disorders (reactive attachment disorder [RAD] and disinhibited social engagement disorder [DSED]) in a representative general population sample of over 3,300 children aged 5–6 years of age. We investigated sociodemographic factors, service burden, and costs in association with these problems when considered separately and when co-occurring. Results: Nearly 2% of this population had symptoms suggestive of both ASD and RAD/DSED. High symptom scores for ASD were associated with male gender, (younger) age of mother at birth, and being in a single-parent family, while high symptom scores for RAD/DSED were associated with (younger) age of mother at birth, being in a single-parent family, and the number of accidents reported. Service use costs per likely case of both ASD and RAD/DSED in the preschool years were increased by £348.62 (95% confidence interval 121.04–391.11)—nearly double the costs of ASD alone. Conclusions: There is considerable overlap between symptoms of ASD and RAD/DSED in the general population, indicating that multi-morbidity is already present in childhood and is associated with increased service use and costs even in the preschool years.

P.383 Factors related to physical health monitoring in community-dwelling patients with schizophrenia spectrum disorder

Early interventions for psychosis have been shown to reduce psychotic symptoms and hospital use for first-episode patients, but the effect on suicidal and criminal behaviour has not been reliably determined. This study aimed to examine whether an early intervention for psychosis program (EPPIS) reduced criminal behaviour, suicide attempts, and hospital-based service use.The study utilized administrative data to match clients of EPPIS to historical controls. Regression was used to determine the effect of treatment by EPPIS on inpatient use, emergency department use, suicide attempts/deaths, and criminal accusations.A sample of 244 patients was matched to 449 controls. EPPIS patients had lower odds of being accused of a crime both during and after treatment. Suicidal behavior was less frequent among patients, both during treatment (p < 0.0001) and after (HR = 0.39; 95% CI: 0.17 to 0.94). During treatment there were more emergency department visits for the patients (RR = 2.54; 95% CI: 1.56 to 4.58), but no difference in inpatient usage compared to controls. Post-treatment, both emergency department and inpatient usage were higher among patients.EPPIS patients had reduced suicide attempts and criminal accusations. Increased emergency department use could indicate that encouraging treatment during a crisis may increase service use, while reducing suicidal and criminal behaviour.

Health care service for families with children at early risk of developmental delay: an All Our Families cohort study.

AimThis study examined children’s health care service use, mothers’ workforce participation, and mothers’ community engagement based on children’s risk of developmental delay.MethodWe used data from the All Our Families study, a prospective pregnancy cohort. Ages and Stages Questionnaire (ASQ) scores at year 2 indicated risk of developmental delay. To investigate the impact of risk of developmental delay when children were not diagnosed, a sensitivity analysis excluded reports of neurodevelopmental disorder (NDD) diagnosis at year 3. Outcomes were maternal reports of children’s health and allied health visits (and estimated costs), and maternal workforce participation and community engagement from year 2 to 3.ResultsAmong 1314 mother–child dyads, 209 (16%) children were classified as being at risk of developmental delay by the ASQ, and 42 (3%) had a reported diagnosis of NDD. Risk of developmental delay was related to increased use of allied health care services (incidence risk ratio 5.04 [year 3]; 95% confidence interval 2.49–10.2) and health visits (incidence risk ratio 1.33 [year 3]; 95% confidence interval 1.14–1.54). The average expected allied health costs were greater for children at risk versus not at risk of developmental delay. However, when excluding children with reported diagnoses of an NDD from this analysis, increased service use and costs in the remaining at‐risk population were not observed. Community engagement and workplace participation among families did not differ on the basis of risk of developmental delay.InterpretationThese results suggest increased health care service use by families of children at risk of developmental delay is driven by those receiving a diagnosis of an NDD in the subsequent year.What this paper adds Early developmental delay risk was related to health care service use and costs.Diagnosis of neurodevelopmental disorder drove increased health care service use and costs.Early developmental delay risk did not relate to parental workforce participation.Early developmental delay risk did not relate to community engagement participation.

Childhood bullying victimization, self-labelling, and help-seeking for mental health problems

PurposePrevious research found sustained high levels of mental health service use among adults who experienced bullying victimization during childhood. This could be due to increased psychopathology among this group, but other factors, such as self-perception as having a mental health problem, might contribute to increased service use. Additionally, the relationship between informal help-seeking for mental health problems and bullying victimization is incompletely understood.MethodsThe present study examined associations between the frequency of bullying victimization and both formal service use and informal help-seeking for mental health problems independent from psychopathology. Data on bullying victimization, service use, informal help-seeking for mental health problems, psychopathology, and self-labelling as a person with mental illness were collected among 422 young people aged 13–22 years.ResultsIn logistic regression models, controlling for past and current psychopathology and using no bullying victimization as the reference category, we identified a greater likelihood of mental health service use among persons who experienced frequent bullying victimization, as well as a greater likelihood of seeking informal help among persons who experienced occasional victimization. Increased self-identification as a person with mental illness completely mediated the positive association between frequent bullying victimization and mental health service use.ConclusionsOur findings suggest that services to support persons who experienced frequent bullying victimization should focus on improving empowerment and self-perception. Additionally, there might be unserved need for formal support among those who experienced occasional bullying victimization.

Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials

SummaryBackgroundMaternal and perinatal mortality are still unacceptably high in many countries despite steep increases in facility birth. The evidence that childbirth in facilities reduces mortality is weak, mainly because of the scarcity of robust study designs and data. We aimed to assess this link by quantifying the influence of major determinants of facility birth (cluster-level facility birth, wealth, education, and distance to childbirth care) on several mortality outcomes, while also considering quality of care.MethodsOur study is a secondary analysis of surveillance data on 119 244 pregnancies from two large population-based cluster-randomised controlled trials in Brong Ahafo, Ghana. In addition, we specifically collected data to assess quality of care at all 64 childbirth facilities in the study area. Outcomes were direct maternal mortality, perinatal mortality, first-day and early neonatal mortality, and antepartum and intrapartum stillbirth. We calculated cluster-level facility birth as the percentage of facility births in a woman's village over the preceding 2 years, and we computed distances from women's regular residence to health facilities in a geospatial database. Associations between determinants of facility birth and mortality outcomes were assessed in crude and multivariable multilevel logistic regression models. We stratified perinatal mortality effects by three policy periods, using April 1, 2005, and July 1, 2008, as cutoff points, when delivery-fee exemption and free health insurance were introduced in Ghana. These policies increased facility birth and potentially reduced quality of care.FindingsHigher proportions of facility births in a cluster were not linked to reductions in any of the mortality outcomes. In women who were wealthier, facility births were much more common than in those who were poorer, but mortality was not lower among them or their babies. Women with higher education had lower mortality risks than less-educated women, except first-day and early neonatal mortality. A substantially higher proportion of women living in areas closer to childbirth facilities had facility births and caesarean sections than women living further from childbirth facilities, but mortality risks were not lower despite this increased service use. Among women who lived in areas closer to facilities offering comprehensive emergency obstetric care (CEmOC), emergency newborn care, or high-quality routine care, or to facilities that had providers with satisfactory competence, we found a lower risk of intrapartum stillbirth (14·2 per 1000 deliveries at >20 km from a CEmOC facility vs 10·4 per 1000 deliveries at ≤1 km; odds ratio [OR] 1·13, 95% CI 1·06–1·21) and of composite mortality outcomes than among women living in areas where these services were further away. Protective effects of facility birth were restricted to the two earlier policy periods (from June 1, 2003, to June 30, 2008), whereas there was evidence for higher perinatal mortality with increasing wealth (OR 1·09, 1·03–1·14) and lower perinatal mortality with increasing distance from childbirth facilities (OR 0·93, 0·89–0·98) after free health insurance was introduced in July 1, 2008.InterpretationFacility birth does not necessarily convey a survival benefit for women or babies and should only be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safe-guarding uncomplicated births.FundingThe Baden-Württemberg Foundation, the Daimler and Benz Foundation, the European Social Fund and Ministry of Science, Research, and the Arts Baden-Württemberg, WHO, US Agency for International Development, Save the Children, the Bill & Melinda Gates Foundation, and the UK Department for International Development.

Impact of health service interventions on acute hospital use in community-dwelling persons with dementia: A systematic literature review and meta-analysis.

BackgroundPersons with dementia have twice the acute hospital use as older persons without dementia. In addition to straining overburdened healthcare systems, acute hospital use impacts patient and caregiver quality of life and is associated with increased risk of adverse outcomes including death. Reducing avoidable acute hospital use in persons with dementia is thus a global healthcare priority. However, evidence regarding the impact of health service interventions as defined by the Effective Practice and Organization of Care Cochrane Group on acute hospital use is scant and inconclusive. The aim of this systematic review and meta-analysis was to synthesize available evidence on the impact of health service interventions on acute hospital use in community-dwelling persons with dementia compared to usual care.MethodsData Sources: MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL (from 01/1995 to 08/2017). Study eligibility criteria: Randomised controlled trials measuring the impact of health service interventions on acute hospital use (proportion and mean number of emergency department visits and hospitalisations, mean number of hospital days, measured at 12 months, and at longest follow-up) in community-dwelling persons with dementia, compared to usual care. Study selection, appraisal and synthesis methods: Reviewers independently identified studies, extracted data, and assessed the risk of bias, with the Cochrane risk of bias tool. Authors of relevant trials were queried about unpublished data. Random effects model was used for meta-analyses. Effect heterogeneity was assessed through prediction intervals, and explored using sub-group analyses.FindingsSeventeen trials provided data on 4,549 persons. Unpublished data were obtained for 13 trials, representing 65% of synthesized data. Most interventions included a case management or a self-management component. None of the outcome comparisons provided conclusive evidence supporting the hypothesis that these interventions would lead to a decrease in acute hospital use. Furthermore, prediction intervals indicated possible and important increased service use associated with these interventions, such as emergency department visits, hospital admissions, and hospital days. Subgroup analyses did not favour any type of intervention. A limitation of this study is the inclusion of any type of health service intervention, which may have increased the observed heterogeneity.ConclusionDespite a comprehensive systematic review and meta-analysis, including predominantly unpublished data, no health service intervention beyond usual care was found to reduce acute hospital use in community-dwelling persons with dementia. An important increase in service use may be associated with these interventions. Further research is urgently needed to identify effective interventions for this vulnerable population to limit rising acute hospital use, associated costs and adverse outcomes. Systematic review registration PROSPERO CRD42016046444.

Social Marketing of Mental Health Treatment: California's Mental Illness Stigma Reduction Campaign.

Objectives. To understand the processes involved in effective social marketing of mental health treatment. Methods. California adults experiencing symptoms of probable mental illness were surveyed in 2014 and 2016 during a major stigma reduction campaign (n = 1954). Cross-sectional associations of campaign exposure with stigma, treatment overall, and 2 stages of treatment seeking (perceiving a need for treatment and use conditional on perceiving a need) were examined in covariate-adjusted multivariable regression models. Results. Campaign exposure predicted treatment use overall (odds ratio [OR] = 1.82; 95% confidence interval [CI] = 1.17, 2.83). Exposure was associated with perceived need for services (OR = 1.64; 95% CI = 1.09, 2.47) but was not significantly associated with treatment use in models conditioned on perceiving a need (OR = 1.52; 95% CI = 0.78, 2.96). Exposure was associated with less stigma, but adjustment for stigma did not affect associations between exposure and either perceived need or treatment use. Conclusions. The California campaign appears to have increased service use by leading more individuals to interpret symptoms of distress as indicating a need for treatment. Social marketing has potential for addressing underuse of mental health services and may benefit from an increased focus on perceived need.

State Mandate Laws for Autism Coverage and High-Deductible Health Plans.

Most states have passed insurance mandates requiring health plans to cover services for children with autism spectrum disorder (ASD). Research reveals that these mandates increased treated prevalence, service use, and spending on ASD-related care. As employer-sponsored insurance shifts toward high-deductible health plans (HDHPs), it is important to understand how mandates affect children with ASD in HDHPs relative to traditional, low-deductible plans. Insurance claims for 2008-2012 for children covered by 3 large US insurers (United Healthcare, Aetna, and Humana) available through the Health Care Cost Institute were used to compare the effects of mandates on ASD-related spending for children in HDHPs and traditional health plans. Relative to children in traditional plans, mandates were associated with higher average monthly spending increases for children in HDHPs. Mandate-attributable spending differences between children enrolled in HDHPs relative to traditional plans were $77 for ASD-specific services (95% confidence interval [CI]: $10 to $144), $125 for outpatient health services (95% CI: $26 to $223), and $144 for all health services (95% CI: $36 to $253). These spending differentials were driven by differences in plan spending and not out-of-pocket (OOP) spending. Spending on ASD-related services attributable to autism mandates was higher among children in HDHPs, but higher spending did not translate into a greater OOP burden. For families with consistently high health care expenditures on ASD-related services, high-deductible products may be worth considering in the context of mandate laws. Families in mandate states with children with ASD enrolled in HDHPs were able to increase service use without paying more OOP.

Barrier or stressor? The role of discrimination experiences in health service use

BackgroundDiscrimination is a well-established stressor that is substantially associated with poor health and a known contributor to health inequalities. However, the role of discrimination in health service use is less explored. This study will take an intersectional approach to investigate differences in health service use and examine the role of discrimination experiences.MethodsData on health service use were assessed in a diverse inner London sample of 1052 participants in the South East London Community Health (SELCoH) Study. Latent class analysis (LCA) was used to define classes of intersectional social status using multiple indicators of socioeconomic status (SES), ethnicity and migration status. Adjusted associations between intersectional social status and discrimination experiences with health service use indicators are presented.ResultsUsing latent class analysis allowed us to identify an intersectional social status characterized by multiple disadvantage that was associated with decreased secondary physical health service use and a class characterized by both privilege and disadvantage that was associated with increased health service use for mental disorder after controlling for age, gender and health status. Anticipated discrimination was also associated with increased service use for mental disorder in adjusted models. There was no evidence to suggest that discrimination experiences were acting as a barrier to health service use.ConclusionsThis study highlights the complex ways in which discrimination experiences may increase the need for health services whilst also highlighting differences in health service use at the intersection of ethnicity, migration status and SES. Findings from this study illustrate the importance of measuring multiple levels of discrimination and taking an intersectional approach for health service use research.

Do household living arrangements explain gender and ethnicity differences in receipt of support services? Findings from LiLACS NZ Māori and non-Māori advanced age cohorts

AbstractServices providing practical support are a key component in the spectrum of social care assisting older people to age in place. Te Puāwaitanga o Ngā Tapuwae Kia Ora Tonu/Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ), a longitudinal study of Māori and non-Māori in advanced age, aims to determine predictors of successful ageing and to understand trajectories of health and wellbeing. This paper investigates whether household living arrangements (living alone or with others) might explain previously reported gender and ethnic differences in support service utilisation. We had shown that women and non-Māori received more services than men and Māori despite better health. The results of analyses in this paper show that, as expected, poorer physical function led to increased service use. After controlling for functional status, household living arrangements (living alone) were the next strongest driver of service use. In a fully adjusted model, previously observed differences around gender and ethnicity were no longer significant predictors of support service use. However, gender and ethnicity do shape living arrangements in advanced age. Women in advanced age are more likely to live alone, consequently needing more outside support, whereas men are more likely to have a spouse/partner able to provide care. Māori are more likely to live in multigenerational households, the care available at home meaning they are less likely to qualify for formal support. This study points to a need for understanding how gender and ethnicity interact with living arrangements and suggests that inequities may not be absent when the presence of others in a household renders an older person ineligible for formal care.

The impact of reducing and eliminating user fees on facility-based delivery: a controlled interrupted time series in Burkina Faso.

User fee reduction and removal policies have been the object of extensive research, but little rigorous evidence exists on their sustained effects in relation to use of delivery care services, and no evidence exists on the effects of partial reduction compared with full removal of user fees. We aimed to fill these knowledge gaps by assessing sustained effects of both partial reduction and complete removal of user fees on utilization of facility-based delivery. Our study took place in four districts in the Sahel region of Burkina Faso, where the national user fee reduction policy (SONU) launched in 2007 (lowering fees at point of use by 80%) co-existed with a user fee removal pilot launched in 2008. We used Health Management Information System data to construct a controlled interrupted time-series analysis and examine both immediate and sustained effects of SONU and the pilot from January 2004 to December 2014. We found that both SONU and the pilot led to a sustained increase in the use of facility-based delivery. SONU produced an accumulative increase of 31.4% (P < 0.01) over 8 years in the four study districts. The pilot further enhanced utilization and produced an additional increase of 23.2% (P < 0.001) over 6 years. These increasing trends did not continue to reach full coverage, i.e. ensuring that all women had a facility-based delivery. Instead, they stabilized 3 years and 4 years after the onset of SONU and the pilot, respectively. Our study provides further evidence that user fee reduction and removal policies are effective in increasing service use in the long term. However, they alone are not sufficient to achieve full coverage. This calls for the need to implement additional measures, targeting for instance geographical barriers and knowledge gaps, to achieve the target of all women delivering in the presence of a skilled attendant.

Health service utilization and related costs attributable to diabetes.

To estimate the health service use and direct healthcare costs attributable to diabetes using best available data and methods. A nationally representative sample of adults aged ≥50 years was analysed (n=8107). Health service use in the previous 12 months included the number of general practitioner visits, outpatient department visits, hospital admissions, and accident and emergency department attendances. Multivariable negative binomial regression was used to estimate the associations between diabetes and frequency of visits. Average marginal effects were applied to unit costs for each health service and extrapolated to the total population, calculating the incremental costs associated with diabetes. The prevalence of diabetes was 8.0% (95% CI: 7.4, 8.6). In fully adjusted models, diabetes was associated with additional health service use. Compared to those without diabetes, people with diabetes have, on average, 1.49 (95% CI: 1.10, 1.88) additional general practitioner visits annually. Diabetes was associated with an 87% increase in outpatient visits, a 52% increase in hospital admissions and a 33% increase in accident and emergency department attendances (P<0.001). The incremental cost of this additional service use, nationally, is an estimated €88,894,421 annually, with hospital admissions accounting for 67% of these costs. Using robust methods, we identified substantially increased service use attributable to diabetes across the health system. Our findings highlight the urgent need to invest in the prevention and management of diabetes.

Trauma and Aging.

The aim of this paper is to present a succinct summary of the major scientific findings on trauma, posttraumatic stress disorder (PTSD), and aging over the past few years. There have been several reports from longitudinal investigations using representative samples of veterans regarding traumatic exposure and subsequent effects on health and functioning. There has also been further documentation of the significant association between PTSD and dementia as well as accelerated aging in late life. Several studies indicate that older adults with PTSD are at risk of not receiving timely and appropriate mental health treatment, indicating that targeted outreach could be helpful in increasing service use and improving care. The current knowledge base would benefit from more research on traumatized older adults from non-industrialized countries, as well as those in North America from diverse backgrounds, including ethnic and racial minorities, women, and those with cognitive impairments. Studies limited to adults aged 65 and over as well as those addressing disparities in the availability of mental health-related services within this population are warranted.

Temporal changes in the incidence of treated psychiatric and neurodevelopmental disorders during adolescence: an analysis of two national Finnish birth cohorts

Comprehensive overviews of the temporal changes in treated psychiatric and neurodevelopmental disorders during adolescence are scarce. We reviewed data from two national cohorts, 10 years apart, to establish the change in use of specialised services for psychiatric and neurodevelopmental diagnoses in Finland. We compared the nationwide register-based incidence of psychiatric and neurodevelopmental diagnoses between the 12th birthday and 18th birthday of adolescents born in Finland in 1987 and 1997. Adolescents who emigrated or died before their 12th birthday and those with missing covariate data were excluded, as were those who, when aged 11 years, had lived in a municipality belonging to a hospital district with obviously incomplete data reports during any follow-up years in our study. Our primary outcomes were time to incident specialised service use for any psychiatric or neurodevelopmental disorder and for 17 specific diagnostic classes. We also investigated whether adolescents who died by suicide had accessed specialised services before their deaths. The cumulative incidence of psychiatric or neurodevelopmental disorders increased from 9·8 in the 1987 cohort to 14·9 in the 1997 cohort (difference 5·2 percentage points [95% CI 4·8-5·5]) among girls, and from 6·2 in the 1987 cohort to 8·8 in the 1997 (2·6 percentage points [2·4-2·9]) among boys. The hazard ratio for the overall relative increase in neurodevelopment and psychiatric disorders in the 1997 cohort compared with the 1987 cohort was 1·6 (95% CI 1·5-1·8) among girls and 1·5 (1·4-1·6) among boys. Of the studied diagnostic classes, we noted significant (ie, p<0·001) relative increases for ten of 17 diagnoses among girls and 11 among boys. Of the adolescents who died by suicide before age 18, only five of 16 in the 1987 cohort and two of 12 in the 1997 cohort had used specialised services in the 6 months before their death. The large absolute rise in service use for psychiatric or neurodevelopmental disorders points to the need to deliver effective treatment to a rapidly increased patient population, whereas the relative increase in specific diagnoses should inform clinical practice. Despite increasing service use, identification of adolescents at risk of suicide remains a major public health priority. Academy of Finland, Brain and Behavior Research Foundation, Finnish Medical Foundation.

Unmet supportive care needs, health status and minimum costs in survivors of malignant melanoma.

We explored the relationship between unmet care needs, health status, health utility and costs in people treated for melanoma via a cross-sectional follow-up survey (N=455) 3months to 5years after complete resection of stage I-III cutaneous malignant melanoma. 51% (n=232) had unmet care needs. This group had higher mean resource use, estimated conservatively (£28 vs. £10 per person) and worse overall health. Mean health-related utility index (AQoL6D) was 0.763 (95% CI 0.74; 0.79) in those with self-reported unmet need vs. 0.903 (0.89; 0.92) in those with no unmet need. Melanoma survivors with unmet need had worse outcomes in terms of anxiety (HADS 6.86 vs. 4.29), depression (HADS 4.29 vs. 2.01), overall quality of life (QoL: FACT-M 84.2 vs. 96.5). Higher resource use was associated with younger age (rs =-.29, p<.001), older school-leaving age (rs =.21, p<.001), reduced health utility (rs =-.14, p=.005), higher anxiety (rs =.22, p<.001), higher depression (rs =.16, p=.001) and lower QoL (overall rs =-.24, p<.001; melanoma QoL rs =-.20, p<.001; surgery QoL rs =-.19, p<.001). Lower health outcomes indicate increased service use, suggesting that interventions to address unmet need and improve health outcomes may reduce health costs. Integrated clinical and economic evaluations of interventions that target unmet need in melanoma survivors are required.

Participation and interest in support services among family caregivers of older adults with cancer.

The purpose of this study was to describe distressed and underprepared family caregiver's use of and interest in formal support services (eg, professional counseling, education, organizational assistance). Cross-sectional mail survey conducted in communities of 8 cancer centers in Tennessee, Alabama, and Florida (response rate: 42%). Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers reported support service use and completed validated measures of depression, anxiety, burden, preparedness, and health. Caregivers (n=294) were on average age 65years and mostly female (73%), White (91%), and care recipients' spouse/partner (60%); patients averaged 75years were majority male (54%) with lung cancer (39%). Thirty-two percent of caregivers reported accessing services while 28% were "mostly" or "extremely" interested. Thirty-five percent of caregivers with high depressive symptoms (n=122), 33% with high anxiety symptoms (n=100), and 25% of those in the lowest quartile of preparedness (n=77) accessed services. Thirty-eight percent of those with high depressive symptoms, 47% with high anxiety symptoms, and 36% in the lowest quartile of preparedness were "mostly" or "extremely" interested in receiving services. Being interested in support services was significantly associated with being a minority, shorter durations of caregiving, and with higher stress burden. A large proportion of family caregivers, including those experiencing depression and anxiety symptoms and who were underprepared, are not using formal support services but have a strong interest in services. Strategies to increase service use may include targeting distressed caregivers early in their caregiving experience.

Factors associated with participating in formal support services among family caregivers of older adults with poor-prognosis cancers.

21 Background: Family caregivers of persons with cancer are at high risk for distress and may benefit from formal support services. The purpose of this study was to describe cancer family caregiver’s use of and desire for formal support services. Methods: Cross-sectional mail survey conducted in communities of eight cancer centers in Tennessee, Alabama, and Florida. Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers reported support service use and completed validated measures of depression, anxiety, burden, preparedness, and health. Results: Caregivers(n = 294) were on average age 65.5 years and mostly female (72.8%), white (91.2%), and care recipients’ spouse/partner (60.2%). Patients averaged 75.3 years and were mostly male (54.4%). Formal support services were used by 32.0% (n = 94) of all caregivers; 4.4% used therapy or counseling, 19.7% received education and training; and 11.2% received assistance from local, state, or national organizations. Twenty-eight percent of all caregivers were “mostly or “extremely” interested in receiving support services; of those, 44% had high depressive symptoms, 52.3% had high anxiety symptoms, and 36.4% in the lowest quartile of preparedness. In multivariate analyses, participation in services was significantly associated with lower objective burden, higher preparedness, not working, and not being the patient’s spouse. Being “mostly” or “extremely” interested in support services was significantly associated with being a minority, shorter durations of caregiving, and with higher stress burden. Conclusions: While distressed and underprepared family caregivers reported strong interest in formal support services, only a small proportion accessed these services. Strategies to increase service use may include targeting those caregivers who are still early in their caregiving experience and who report high stress burden.

Interventions to increase use of services; Mental Health Awareness in Nigeria

BackgroundMental health services in Nigeria consist mainly of large government psychiatric hospitals and there are very few mental health professionals to serve the large population of the country. However, more recently, community mental health services, which have been shown to improve access to care and clinical outcomes are beginning to develop in some locations. Despite efforts to promote more accessible services, low levels of knowledge about effective treatment of mental disorders means that even where these services are available, a very small proportion of people utilise these services. Therefore interventions to increase service use are an essential component of health system.MethodsThis intervention was designed to increase use of a mental health services through the work of community-based Village Health Workers. Fifteen Village Health Workers in each Local Government Area (district) were selected and trained to create mental health awareness in communities. Their function also include identification and referral of persons with mental illness to trained mental health nurses in the clinics. Attendance data prior to and after intervention were collected and compared.ResultsThe incident rate for initial period of intervention is five times higher than the baseline rate (95% CI; 3.42–7.56; p < 0.001) though this diminished in the long term, levelling off above initial baseline.ConclusionsThis study demonstrated that addition of awareness raising using volunteers in communities as part of health programme implementation can increase services use by a population. Mechanisms such as informing populations of the existence of a service which they were previously lacking; explanation of causation of mental illness and achieving community leaders’ support for a new service can make investment in services more efficient by increasing attendance.