Key Health Services Research Articles

Issues for reregulation of private hospital insurance in Australia.

Objective The aim of this study is to explore policy paths towards private health insurance (PHI) reform that might reduce out-of-pocket costs, restore public confidence and allow insurers to finance value-based care. Methods This study used thematic analysis of semi-structured interviews with informed opinion holders, including a politician, three former senior public servants and an industry lobbyist. Critical analysis of peer reviewed and grey literature was also conducted. Results PHI regulation is contributing to unexpected out-of-pocket expenses and low-value care. Modification of existing tax incentives would be incapable of significantly increasing PHI coverage. Regulatory reform could restore confidence among policy holders by promoting value-based care, wherein health outcomes are measured and incentivised with remuneration. Conclusions Targeted relaxation of out-of-hospital restrictions should be explored to promote value-based competition and facilitate bundled payments for chronic disease management and community services. To address out-of-pocket diagnostic and procedural costs, insurers should have more responsibility for private specialist's fees, including by financing the entire provider's bill through insurance and redirecting the Medicare Benefits Schedule fee to the insurer. What is known about the topic? Healthcare expenditure and out-of-pocket costs have grown rapidly, while confidence and depth of coverage in private health insurance has declined, as has the fiscal appetite for expanding public financing for health care. What does this paper add? This paper outlines the regulatory and policy factors that are contributing to low-value care and unmet expectations from insurance policy holders. It also maps the strategic terrain of the non-government health sector and considers feasible policy options for reforming the PHI industry that do not increase drawings on the public purse. What are the implications for practitioners? An appreciation of the ongoing challenges to financing value-based care provision will inform key stakeholders, including policymakers and health service providers, as reforms are debated and implemented.

Maintaining essential health services during the pandemic in Bangladesh: the role of primary health care supported by routine health information system

In the initial phase of the coronavirus disease 2019 crisis, Bangladesh’s health systems faced competing demands to respond to the pandemic and concurrently maintain the continuity of essential health service delivery, particularly at the primary care level. Bangladesh’s established network of primary care health facilities, the country’s backbone for delivering essential health services, routinely feed data into the national health information system, the District Health Information Software 2 platform, which provides near real-time data on the utilization of essential health services, visualized through user-friendly integrated dashboards. Trend analyses of these data showed that by April and May 2020 there had been sharp reductions in the utilization of key essential health services across all levels of care.Early and continuous monitoring and analysis of these data informed public health policy-makers and health facility managers on rapid response strategies to restore the availability and use of essential health services. Through corrective policy measures and targeted interventions, Bangladesh’s primary health care network provided a critical platform for Bangladesh to build back most of its essential health services by October 2020. Bangladesh’s experience highlights the critical role of primary-level health facilities as a touchpoint for monitoring population access to services and as a staging point for implementation of strategies and interventions that rebuild and strengthen health service delivery towards achieving universal health coverage and more resilient health systems.

Demedicalisation of HIV interventions to end HIV in the Asia-Pacific.

Despite the challenges to the HIV response in the Asia-Pacific, a demedicalisation of HIV intervention has been demonstrated to be an important strategy to maximise the uptake of HIV prevention tools among key populations in this region. Demedicalisation of HIV interventions translates medical discourse and shifts the paradigm from a disease-focused to a people-centred approach. It also recognises real-life experiences of key populations in the HIV response by empowering them to voice their needs and be at the forefront of the epidemic control. We further categorise a demedicalisation approach into three frameworks: (1) the demystification of clinical or medical concerns; (2) the destigmatisation of people living with HIV; and (3) the decentralisation of healthcare services. This article reviewed the demedicalisation framework by looking at the HIV intervention examples from countries in the Asia-Pacific, which included: (1) a study on drug-drug interaction between pre-exposure prophylaxis and feminising hormone treatment for transgender women; (2) the roles of key population-led health services; and (3) certification of key population lay providers.

Piloting a city health adaptation typology with data from climate-engaged cities: Toward identification of an urban health adaptation gap

Climate change has important population health impacts, and cities are often on the frontlines. However, health is reported to be less active in climate adaptation than other sectors. To contribute to better understanding urban health adaptation efforts and identifying gaps we developed a City Climate Health Adaptation Typology and tested it with adaptation actions of 106 large world cities (population > 1 million) reported to a major publicly-available adaptation database. We found two-thirds of actions of these ‘active adapter’ cities were health-associated. Half were health information activities (e.g., hazard mapping, early warnings); and nearly one-third addressed climate-relevant health determinants in the urban built environment (e.g., green space). Forty percent of cities were in low- or middle-income countries. Our proposed typology provides a systematic framework for monitoring and comparing city health adaptation actions. Reported city actions are suggestive of increasing depth and breadth of urban health-associated adaptation. However, even among these adaptation-engaged cities, a health adaptation gap was apparent in key climate health services (e.g., mental health), and in climate-related public health governance and capacity building. The COVID-19 pandemic has demonstrated pressing need for strong public health institutions. We recommend better integration of public health agencies into local climate action planning, enhanced modes of collaboration between health and non-health agencies and with non-governmental actors, and strengthening of city public health adaptive capacity including through networking.

Not just money: what mothers value in conditional cash transfer programs in India

IntroductionConditional cash transfers (CCTs) have become an important policy tool for increasing demand for key maternal and child health services in low/middle-income countries. Yet, these programs have had variable success...

Characterising the scale-up and performance of antiretroviral therapy programmes in sub-Saharan Africa: an observational study using growth curves

ObjectivesThe rate of change in key health indicators (eg, intervention coverage) is an understudied area of health system performance. Rates of change in health services indicators can augment traditional measures...

Sexual dating violence victimization and adolescent psychological distress in Rio de Janeiro, Brazil

Abstract Background Studies from high income countries showed physical and psychological dating violence associated with poor mental health (MH) outcomes, including depressive symptoms and suicide attempts. However, sexual dating violence (SDV) has received less attention, especially in low middle-income countries like Brazil. This study investigated the prevalence and the effect of SDV victimization on MH in adolescent students from Rio de Janeiro, Brazil. Methods This is a school-based study comprising 550 students enrolled in 13 high schools. Only adolescents reporting at least one romantic relationship in the prior twelve months were eligible. SDV and MH were measured using the Conflict in Adolescent Dating Relationships Inventory (CADRI) and General Health Questionnaire (GHQ-12), respectively. Frequency of SDV was assessed in the aggregate and by specific sociodemographic subgroups. Multivariate logistic models were employed to study the relationship between SDV victimization and MH status. Direct Acyclic Graphs steared the covariates selection process: skin color, maternal education, history of child sexual abuse, and sex. Results The prevalence of SDV victimization experienced over the last 12 months was 16.5%. SDV victimization was a significant risk factor for MH problems (OR = 2.04; 95%CI: 1.01 - 4.15). Conclusions The high prevalence of SDV among students in the sample was striking. Its relationship with psychological suffering highlights the importance of involving schools and health services in actions aimed at reducing all forms of SDV and at mitigating its consequences. The findings also indicate that mental health professionals should regurlarly investigate SDV victimization among adolescents reporting MH symptoms. Key messages Rio de Janeiro schools and health services need to join efforts to develop and implement actions aimed at the prevention of sexual dating violence. Health professionals might investigate if adolescents with psychological distress are also victims of sexual dating violence.

Barriers to exercise among participants of a bariatric surgery program from a Brazilian capital

Abstract The aim of this study was to analyze the perceived barriers to exercise and its associated factors among participants of a bariatric surgery program, in a reference hospital, from a Brazilian northeastern capital. Therefore, the Scale of Benefits and Barriers to Exercise (EBBS), which used only the domains related to the dimension of the barriers that evaluate them in four subdimensions (physical effort, environmental, time and family) was applied with 289 patients (49 men and 240 women) with a mean age of 43 years (SD 8.6), who were in the pre (n = 81) or post (n = 208) operative period. It was collected information about their sex, age, weight and height (for BMI calculation), exercise (WHO recommendations were used), and if they had already undergone bariatric surgery. To analyze the associations and estimate the prevalence ratios of the variables in relation to the barriers, Poisson Regression was used. The level of significance was set at 5%. In the general assessment of barriers, it was found that physically active patients (PR = 0.78 95% CI = 0.72-0.83 p < 0.001) have less perception of barriers than inactive ones. In the physical effort and environmental subdimensions, the assets (PR = 0.82 CI95% = 0.76-0.88 p < 0.001 and PR = 0.78 CI95% = 0.73-0.84 p < 0.001, respectively) and those who have already undergone bariatric surgery (PR = 0.88 CI 95% 0.80-0.97 p = 0.014 and PR = 0.88 CI 95% = 0.80-0.96 p = 0.006, respectively) have lower perception of barriers. Those over 42 years of age (PR = 0.88 CI95% 0.81-0.95 p < 0.001) and the active ones (PR = 0.79 CI95% = 0.73-0.85 p < 0.001) have lower perception of barriers of the time sub-dimension. In the family sub-dimension, there was no association between the variables studied and the perception of barriers. It was concluded that being physically inactive, not having undergone bariatric surgery and being under 42 years old is associated with a greater perception of barriers to exercise. Key messages The health service can use the findings to track those most likely to use barriers to exercise. The health service can propose personalized physical activities to reduce barriers to exercise.

Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline

ABSTRACTBackgroundProgress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development.ObjectiveThis article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries.MethodsWe conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key determinants of child linear growth and contemporaneous changes in linear growth outcomes over time.ResultsAmong the basic determinants of stunting assessed within regression-decomposition analyses, improvement in asset index score was a consistent and strong driver of improved linear growth outcomes. Increased parental education was also a strong predictor of improved child growth. Of the underlying determinants of stunting, reduced rates of open defecation, improved sanitation infrastructure, and improved access to key maternal health services, including optimal antenatal care and delivery in a health facility or with a skilled birth attendant, all accounted for substantially improved child growth, although the magnitude of variation explained by each differed substantially between countries. At the immediate level, changes in several maternal characteristics predicted modest stunting reductions, including parity, interpregnancy interval, and maternal height.ConclusionsUnique sets of stunting determinants predicted stunting reduction within countries that have reduced stunting. Several common drivers emerge at the basic, underlying, and immediate levels, including improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning. Further data collection and in-depth mixed-methods research are required to strengthen recommendations for those countries where the stunting burden remains unacceptably high.

Restrictions On USGlobal Health Assistance Reduce Key Health Services In Supported Countries.

The 2017 expanded Mexico City Policy prohibits non-US-based nongovernmental organizations from receiving US global health assistance if they either perform or refer for abortion services. We study the effects of the expanded policy on implementing partners of US-funded HIV programming by the President's Emergency Plan for AIDS Relief (PEPFAR) via a primary survey in all recipient countries and key-informant interviews in South Africa and the Kingdom of Eswatini (May-November 2018). Survey results showed that 28percent (56 of 198) of organizations reported stopping or reducing at least one service in response to the policy. Reported service reductions included reducing the delivery of information about sexual and reproductive health, pregnancy counseling, contraception provision, and HIV testing and counseling. Interview data highlighted how these reductions were often a result of decreased patient flows or implementation of the expanded policy beyond what is required. Reductions disproportionately harmed pregnant women, youth, and key populations such as sex workers and men who have sex with men. Reduced delivery of sexual and reproductive health services has the potential to negatively affect many intended beneficiaries of PEPFAR funding, especially in areas with high HIV prevalence. Policy makers must respond to disruptions in service delivery and end any implementation that undermines US investment in high-quality HIV and sexual and reproductive health services.

Women's decision-making autonomy in the household and the use of maternal health services: An Indonesian case study

ObjectivesThe study aimed to examine the influence of Indonesian women's decision-making within the household regarding the use of maternal health services. It explored whether women who had high involvement in household decision-making experienced a higher likelihood of using antenatal care services, delivery services assisted by skilled birth attendance, and facility-based delivery compared to those with limited autonomy. MethodsThe study used the individual subset data on women from the 2017 Indonesia Demographic and Health Survey, which included 3435 women of reproductive age (15–49 years) who had given birth within one year preceding the survey. The study also used the Women's Participation Index to measure women's decision-making autonomy in the household. Descriptive statistics and multiple logistic regression analyses were conducted to identify the association of women's autonomy with the use of three key maternal health services. ResultsThe Women's Participation Index had a significant positive relationship to adequate antenatal care service use, but no effect on the use of skilled birth attendance and facility-based delivery, after adjusting for maternal and sociodemographic variables. Women with more autonomy experienced 1.7 (95% confidence interval: 1.17–2.45) times higher odds of using adequate antenatal care services. In addition, the likelihood of the utilization of adequate antenatal care services, skilled birth attendance, and facility-based delivery was higher among women who were age ≥35 years at birth, attained a higher education level, and were in the richest quintile compared to their respective counterparts. ConclusionWomen's decision-making autonomy had a significant effect on the use of adequate antenatal care services only. Initiatives that are more gender-sensitive to promote husband involvement should be conducted to increase men's awareness of the importance of maternal health services.

Cost-effectiveness of SMS appointment reminders in increasing vaccination uptake in Lagos, Nigeria: A multi-centered randomized controlled trial

ObjectiveIt is expected that mHealth largely contribute to increasing the coverages of key maternal and child health services. This study aims to estimate the cost-effectiveness of the SMS text reminders in clients’ return visits to the health facilities for child vaccinations (incl. vitamin A supplementations), antenatal care (ANC) and family planning (FP), in urban communities of Lagos, Nigeria. MethodsA multi-centered randomized control trial was conducted at 33 primary health centers (PHCs) in Lagos, Nigeria. All the clients having visited any of the 33 PHCs for child vaccinations, ANC and FP were randomly assigned either to intervention group or to control group.The participants in the intervention group were sent an SMS text reminder two days before their appointments. Those not having showed up on the appointment dates received an additional SMS text reminder seven days after original appointment dates as defaulter tracing. The primary outcome was whether a client made return visit to PHCs for the upcoming appointments. ResultsOf 12,779 appointments for 9,368 clients during the period of 1stApril to 30thJune 2019, 12,175 were included in the analysis. The return rate for child vaccinations in the intervention group was significantly higher (p < 0.001) by 4.8% − 6.0% than that in the control group, consistently across all the five different timings (on time as scheduled, and by 7 days, 14 days, 30 days, and 3 months after appointment dates). No significant difference between the two groups was detected in the increase in return rates for ANC and FP services. The incremental recurrent cost was estimated at 7.90 US Dollars per return case. ConclusionSMS text reminders led to a significant increase in the number of return visits for child vaccinations, Lagos, Nigeria, while no significant increase in return visits was confirmed for ANC and FP appointments.

House passes FY 2021 spending bill with SAMHSA increases

The U.S. House of Representatives last week approved its Labor–Health and Human Services (HHS) spending bill for FY 2021, which includes major funding increases for the Substance Abuse and Mental Health Service Administration (SAMHSA), along with level funding for key mental health programs and services.

Psychosocial adaptation to climate change in High River, Alberta: implications for policy and practice.

Psychosocial adaptation to climate change-related events remains understudied. We sought to assess how the psychosocial consequences of a major event were addressed via public health responses (e.g., programs, policies, and practices) that aimed to enhance, protect, and promote mental health. We report on a study of health and social service responses to the long-term mental health impacts of the 2013 Southern Alberta flood, in High River, Alberta. Qualitative research methods included (i) telephone interviews (n = 14) with key informant health and social services leaders, (ii) four focus group sessions with front-line health and social services workers (n = 14), and (iii) semi-structured interviews with a sample of community members (n = 18) who experienced the flood. We conducted a descriptive thematic analysis, with a focus on participants' perceptions and experiences. Findings of this study suggest (1) the long-term psychosocial impacts of extreme weather and climate change require sustained recovery interventions rooted in local knowledge and interdisciplinary action; (2) there are unintended consequences related to psychosocial interventions that can incite complex emotions and impact psychosocial recovery; and (3) perceptions of mental health care, among people exposed to climate-related trauma, can guide climate change and mental health response and recovery interventions. Based on this initial exploration, policy and practice opportunities for public health to enhance psychosocial adaptation to our changing climate are highlighted.

Barriers and facilitators to growth monitoring and promotion in Nepal: Household, health worker and female community health volunteer perceptions.

Growth monitoring and promotion (GMP) is both a service for diagnosing inadequate child growth in its earliest stages and a delivery platform for nutrition counselling. The widespread use of GMP services in developing countries has the potential to substantially reduce persistent child undernutrition through early diagnosis and by linking caregivers and their children to key health and nutrition services. However, researchers have questioned the effectiveness of GMP services, which are frequently undermined by underdeveloped health systems and inconsistent implementation. This analysis examined both supply‐ and demand‐side factors for GMP utility in Nepal from the perspectives of beneficiaries and service providers, particularly focusing on three components of GMP: growth assessment, analysis of growth status and counselling. The most common factors influencing GMP uptake included beneficiaries' perceptions of the relative importance of GMP and the knowledge and skill of frontline workers. Both providers and beneficiaries viewed GMP as a secondary health and nutrition activity and therefore less important than curative services. We found deficits in GMP‐related knowledge and skills among providers (i.e. health workers and female community health volunteers), as well as indications of poor training quality and coverage. Furthermore, we found variation in GMP utilization by maternal age, education and residency (alone, nuclear or extended), as well as household socio‐economic well‐being and rurality. This study is the first to assess factors influencing both beneficiaries and service providers for GMP utilization. Further research is needed to explore the implementation of improved GMP protocols and to evaluate facility‐level implementation barriers.

What matters to patients? A timely question for value-based care.

BackgroundOur healthcare system is moving towards patient-centered and value-based care models that prioritize health outcomes that matter to patients. However, little is known about what aspects of care patients would prioritize when presented with choices of desirable attributes and whether these patient priorities differ based on certain demographics.ObjectiveTo assess patients’ priorities for a range of attributes in ambulatory care consultations across five key health service delivery domains and determine potential associations between patient priorities and certain demographic profiles.MethodsUsing a What Matters to You survey patients ranked in order of importance various choices related to five health service domains (patient-physician relationship, personal responsibility, test/procedures, medications, and cost). Subjects were selected from two Johns Hopkins affiliated primary care clinics and a third gastroenterology subspecialty clinic over a period of 11 months. We calculated the percentage of respondents who selected each quality as their top 1–3 choice. Univariate and multivariate analyses determined demographic characteristics associated with patient priorities.ResultsHumanistic qualities of physicians, leading a healthy lifestyle, shared decision making (SDM) for medications and tests/procedures as well as knowledge about insurance coverage were the most frequently ranked choices. Privately insured and more educated patients were less likely to rank humanistic qualities highly. Those with younger age, higher educational attainment and private insurance had higher odds of ranking healthy lifestyle as a top choice. Those with more education had higher odds of ranking SDM as a top choice.ConclusionsIdentifying what matters most to patients is useful as we move towards patient-centered and Value Based Care Models. Our findings suggest that patients have priorities on qualities they value across key health service domains. Multiple factors including patient demographics can be predictors of these priorities. Elucidating these preferences is a challenging but a valuable step in the right direction.

Give the community the tools and they will help finish the job: key population-led health services for ending AIDS in Thailand.

Give the community the tools and they will help finish the job: key population-led health services for ending AIDS in Thailand.

Models of maternal and child healthcare for African refugees: protocol for an exploratory, mixed-methods study

IntroductionThere is a paucity of research examining models of maternal and child health (MCH) care for refugees in high-income countries. Attention has focused on tailoring existing healthcare services to meet...

Evaluation of a new set of indicators for mental health care implemented in Madhya Pradesh, India: a mixed methods study

BackgroundMental health information systems are, in general, inadequate and unreliable in India. We have developed key mental health indicators for measuring mental health service coverage in primary care. This study aims to evaluate the use of these new indicators in seven health care facilities in Sehore District of Madhya Pradesh in India.MethodsThe study employed a mixed methods approach. We conducted: a qualitative study (n = 26) with health workers, Health Management Information Systems (HMIS) staff, project coordinators and supervisors; a review of case records (n = 61 at time 1 and n = 74 at time 2); and a structured questionnaire (n = 26) with health workers. The performance, user-friendliness, appropriateness, perceived utility and sustainability of the use of new mental health indicators was assessed.ResultsHigh levels of completion, and correctness of completion, of the new mental health indicators were found for the case records. The simplicity of the forms, as well as technical support from the project team, contributed to acceptability and feasibility of implementation. Perceived sustainability of the new forms was, however, affected by the overstretched primary care staff. Further work is needed to support the integration of mental health with routine HMIS.ConclusionThis study demonstrated that the implementation of key mental health service delivery indicators in Sehore District primary care facilities was feasible. Technical assistance was imperative in maintaining the performance of the indicators over the two studied time points. The integration of mental health indicators in routine health information systems, and political buy-in, are needed to monitor and sustain community mental health programmes in India.

Filling the human resource gap through public-private partnership: Can private, community-based skilled birth attendants improve maternal health service utilization and health outcomes in a remote region of Bangladesh?

BackgroundIn Sunamganj there are fewer than four skilled providers per 10,000 population and just 27% of births are assisted by a skilled attendant. We evaluate a private community skilled birth attendant (P-CSBA) model, developed through the GSK-CARE Frontline Health Worker Programme, designed to address this gap and report on changes in service utilization and health outcomes from baseline to three years post-baseline.MethodsThis analysis presents the results of a pre-post cross sectional design. A baseline survey (n = 1800) was conducted using a multistage cluster sampling approach. Three years post-baseline a second cross-sectional survey (n = 1755) was conducted across the same project area. To describe demographic characteristics of the study participants descriptive statistical techniques were used as appropriate. Logistic and multiple logistic regression, controlling for a comprehensive set of covariates, were used to assess odds ratios for key maternal health behaviors and outcomes.ResultsBirth planning and the use of key maternal health services improved from baseline to follow-up. There was a dramatic increase in the proportion of respondents reporting skilled attendance at birth (aOR: 2.18, p = .001). Women also reported significantly fewer complications during the prenatal (aOR: .30, p<.001), labor and delivery (aOR: 0.41, p<.0001) and postnatal periods (aOR: 0.32, p<.0001).ConclusionPrivate-sector approaches, when coupled with robust efforts to strengthen and collaborate with the public sector, can work successfully to deliver services in underserved communities. The success of this model lends credence to the growing appreciation that reaching our development targets will require governments to work in partnership with private sector actors and highlights the potential of private-public partnerships as we drive towards universal health coverage.