Public Sector Clinics Research Articles

Factors that affect the quality of cytologic cervical cancer screening along the Mexico–United States border

OBJECTIVE: The purpose of this study was to identify the factors that affect the quality of cytologic cervical cancer screening conducted in public sector clinics in Sonora, Mexico. STUDY DESIGN: We assessed the quality of cervical cytology before and after a 2-hour training session and the implementation of cervical spatulas and endocervical brushes. Additionally, we conducted a cross-sectional study of reproductive aged women who attended public clinics in paired border communities in Sonora and Arizona. Cervical cytologic specimens (n = 2436) were collected and compared for adequacy and cytologic diagnosis and for the prevalence of human papillomavirus infection. RESULTS: The training intervention achieved significantly improved the rates of satisfactory but limited smears and unsatisfactory smears. The cross-sectional study revealed comparable quality indicators for cytologic specimens that were collected in Sonora and Arizona clinics. CONCLUSION: A high-quality cytology-based cervical cancer screening program is possible in public sector clinics in Sonora, with indicators similar to those achieved in comparable Arizona clinics.

Trauma within the psychiatric setting: a preliminary empirical report.

Recent studies show that trauma victim(Mueser et al., 1998; Switzer et al., 1999). Posttraumatic stress disorder (PTSD) is ization (51%–98%) and posttraumatic stress disorder (42%) are highly prevalent among considered to be chronic and debilitating, with high rates of co-occurring Axis I and persons with severe mental illness (schizophrenia, bipolar disorder) who are served Axis II mental health disorders (Keane & Wolfe, 1990), and with serious adverse efwithin public-sector mental health clinics fects on social, familial, and occupational functioning (Frueh, Turner, Beidel, & CaKaren J. Cusack, Ph.D., is a Project Director in hill, 2001). Furthermore, evidence indithe South Carolina Department of Mental cates that PTSD is associated with nearly Health. B. Christopher Frueh, Ph.D., is an Assothe highest rate of medical and mental ciate Professor in the Department of Psychiatry and Behavioral Sciences at the Medical Univerhealth service use, making it one of the sity of South Carolina, and a Staff Psychologist costliest mental disorders (Greenberg et at the Veterans Affairs Medical Center, Charlesal., 1999). Given this, it is clear that trauma ton, South Carolina. Thom Hiers, Ph.D., is Exhas a prominent impact on public health ecutive Director of the Charleston/Dorchester Mental Health Center. Samantha Suffolettaand it should be of great interest to those Maierle, Ph.D., is a Project Coordinator in the concerned with public mental health adDepartment of Psychiatry and Behavioral Sciministration and policy. However, trauma ences at the Medical University of South Carosurvivors tend to receive inadequate menlina. Sandy Bennett, BSW, LMSW, is a Social tal health services (Amaya-Jackson et al., Worker and Consumer Affairs Coordinator in the South Carolina Department of Mental 1999; Frueh et al., 2002) and they may, in Health. fact, be especially vulnerable to additional This work was partially supported by a grant traumatic and/or iatrogenic experiences from the Ensor Foundation to Dr. Cusack, and that may routinely occur within the psychia grant from the National Institute of Health (MH01660) to Dr. Frueh. atric setting (Cohen, 1994; Frueh et al., Address for correspondence: Karen J. Cu2000). sack, Ph.D., Charleston/Dorchester Community Clearly, modern psychiatric hospitals are Mental Health Center, 701 East Bay St., MSC/ a far cry from the “Old Bedlam” of London, 1110, Charleston, SC 29403. E-mail: KJC42@ where “Inmates were chained, whipped, and CHAMHC.DMH.STATE.SC.US.

Treatment of out‐patients with complicated benzodiazepine dependence: comparison of two approaches

To evaluate whether gradual benzodiazepine taper combined with cognitive-behavioural treatment is more effective than standard treatment for patients with dependence in out-patient clinics. A randomized, controlled clinical trial, using standard questionnaires and serum and urine tests. Four public-sector out-patient clinics for alcohol and drug abusers in Helsinki. Seventy-six patients with benzodiazepine dependence (DSM-III-R). Patients taking high doses of the drug or with alcohol use disorders were included to obtain a subject group representative of usual clinical practice. Subjects received gradual benzodiazepine taper combined with cognitive-behavioural therapy (experimental group) or standard withdrawal treatment not scheduled by the researchers (control group). The outcome was measured in terms of attaining a state of abstinence or by a decrease in the dosage during the study period of up to 12 months' duration. No statistically significant differences in the outcomes were observed between the groups. A total of 13% of the experimental group and 27% of the control group were able to discontinue drug use. In addition 67% of the experimental group and 57% of the control group were able to decrease the dose. The search continues for improved methods of helping patients with complicated benzodiazepine dependence.

Working with public sector clinics to provide adolescent-friendly services in South Africa

Health care facilities can play an important role for adolescents in preventing health problems, in promoting sexual and reproductive health and in shaping positive behaviours. Extensive research has established that South African public health facilities are failing to provide adolescent-friendly health services. The National Adolescent-Friendly Clinic Initiative (NAFCI) is an accreditation programme designed to improve the quality of adolescent health services at the primary care level and strengthen the public sector's ability to respond to adolescent health needs. The key objectives of the programme are to make health services more accessible and acceptable to adolescents, establish national standards and criteria for adolescent health care in clinics throughout the country, and build the capacity of health care workers to provide quality services. One of the indicators for success of NAFCI will be increased utilisation of public sector clinics by adolescents. NAFCI is an integral component of the largest, most innovative, public health programme ever launched in South Africa, LoveLife. Achieving NAM accreditation involves clinic self-appraisals, quality improvements, external assessments and award of achievement stars. NAFCI is currently being piloted in ten government clinics in South Africa.

Is the Diaphragm a Viable Option for Women in Turkey?

Diaphragms were offered to women as a contraceptive option during counseling sessions at four family planning clinic sites in western Turkey: two public-sector clinics (one in Capa Istanbul; the other in Izmir) and two private-sector clinics (one in Incirli Istanbul; the other in Denizli). Women who chose the diaphragm were interviewed at enrollment and were invited for follow-up visits with a physician at 2 weeks and at any time thereafter. Demographic information was also collected from an additional 740 women who chose another contraceptive method and focus-group discussions were conducted with diaphragm users and their partners with users of other methods and with service providers. Overall 166 women selected the diaphragm and 161 enrolled in the study. Initial acceptance rates were higher at the two private clinics (14% and 6%) than at the two public clinics (3% and 1%). At the public-sector clinics diaphragm users were better educated and more likely to be professionally employed than were women who selected other contraceptive methods. In Capa 42% of women who chose the diaphragm were university graduates compared with 7% of those who chose another method. Despite differences between the two private clinics in clients educational levels no such differences existed between diaphragm acceptors and users of alternative methods at each site. Among women who chose the diaphragm 47% said they had sex four times or more per week compared with 29% of those using another contraceptive. More than half of the women who selected the diaphragm (59%) cited safety and freedom from side effects as the reason for their choice of contraceptive. A similar percentage of clients who used other methods (58%) cited effectiveness. 50% of diaphragm users had discontinued by 6 months and 66% had done so by 12 months. A small proportion of clients in both private- and public-sector clinics were interested in using the diaphragm and found it acceptable. In less-developed countries the diaphragm may be a viable contraceptive option when providers are able to provide adequate information and support. (authors)

Knowledge, Attitudes, and Practices of Parents of Asthmatic Children in Cape Town

To obtain information useful to asthma care in a relatively poor, high asthma prevalence population, a focus group study was undertaken with 72 parents of children with asthma or recurrent wheezing. There was a reasonable level of understanding of the causes of asthma, although variable acceptance of the diagnosis. Willingness to undertake home management of acute episodes and environmental control measures was high. Reported treatment was characterized by reliance on syrups, use of home remedies, resistance to inhaled therapy, and relatively low compliance with prescribed treatment. There was agreement on the poor level of service offered by doctors and public sector clinics. Asthma education in this population needs to build on what parents know and accept, but stress the relative safety of inhaled therapy, the need for maintenance therapy, and the value of pre-exercise prophylaxis, house dust mite control, and smoking cessation. There is an urgent need to improve the quality of asthma care provided by public sector clinics.

STD syndrome packets: improving syndromic management of sexually transmitted diseases in developing countries.

To design, introduce, and evaluate "STD syndrome packets" containing recommended drugs for each syndrome, four condoms, a partner treatment card, and a patient information leaflet, with the goal of improving sexually transmitted disease (STD) case management. Packet design evolved around available packaging technology, informed by pilot testing with nurses working in primary care clinics, doctors in private medical practices, and patients with an STD, in Hlabisa, South Africa. Evaluation 1 year later included analysis of distribution records and interviews with 16 nurses and 64 patients. A cheap packet (2 U. S. cents each, excluding contents) compatible with current legislation was designed and introduced to six public sector clinics and as a short pilot to five private medical practices. Four thousand eighty-five packets were distributed to the clinics, equivalent to approximately 115% of the STDs reported over that period. All 16 nurses reported using the packets, but only 63% did so all the time because of occasional supply problems. All believed the packets improved treatment by saving time (75%), improving supply of condoms and partner cards (44%), and making treatment easier (56%). Patients also responded positively, and most said they would buy a packet (up to $5) at a pharmacy (84%) or store (63%) if available. The STD syndrome packets have the potential to improve STD syndromic management by standardizing therapy and improving the supply of condoms, partner cards, and information leaflets. Packets are popular with practitioners and patients, but consistent supply is essential for maximal impact. There may be scope for social marketing of the packets, which could further increase use.

Unmet mental health needs of women in public-sector gynecologic clinics

We examined the mental health needs of poor young women seen in public-sector gynecologic settings. Participants were 205 ethnically diverse women, mean age 29 years, seen by gynecologists at San Francisco General Hospital, all either uninsured or receiving public medical assistance. An interview with an instrument designed to diagnose mood, anxiety, alcohol, and eating disorders in medical patients, the Prime-MD, was used to assess current mental disorders. Any history of sexual or other physical assault was recorded. Receipt of primary care was scored for comprehensiveness. The rates of current psychiatric disorders were extremely high; 21.5% had current major depression. The prevalence of anxiety disorders was also elevated among these women. Many had a history of sexual trauma, and 28% had been the victims of unwanted intercourse. Finally, many reported behaviors that pose serious health risks. For example, 32% smoked and 2% used illicit drugs. Fewer than half had access to comprehensive primary medical care. Young, poor women who seek care in public-sector gynecologic clinics would benefit from comprehensive medical care addressing their psychosocial needs.

Increasing the Availability of Vasectomy In Public-Sector Clinics

A program designed to improve the availability of vasectomy in public-sector clinics trained physicians at 43 facilities in no-scalpel vasectomy between 1993 and 1995. Among the 38 clinics that responded to a follow-up survey in 1996, the number of clinics providing vasectomies rose from 23 to 32, an increase of almost 40%, while the number of vasectomies performed rose by 18%. Seventeen of the 32 clinics performed more vasectomies after the training; 10 of the 17 had not previously provided the procedure. In-depth interviews with staff from seven sites that experienced large caseload increases and from seven that experienced decreases identified three elements for the successful establishment or expansion of vasectomy services-sufficient numbers of trained providers, funds to subsidize vasectomies for men who cannot afford them and activities to raise awareness about the availability of low-cost or free vasectomy.

Progress Toward Integrating Hepatitis B Vaccine Into Routine Infant Immunization Schedules in the United States, 1991 Through 1994

Objective. We assessed progress toward universal infant immunization against hepatitis B, which was first recommended in November 1991. Methods. Multiple data sources were used to describe vaccination policies and trends in infant hepatitis B vaccine coverage. Results. As of June 1993, 51% of the 63 local, state, and territorial immunization programs recommended hepatitis B vaccination of all newborns shortly after birth. The number of first dosages of hepatitis B vaccine administered to infants in public sector clinics increased rapidly from late 1992 to 1993, and at the end of 1993 was approximately two thirds the number of first dosages of other infant antigens. In a nationwide survey of hospital nurseries 47% offered hepatitis B vaccine to all newborns. Of 3982 sampled newborns in these hospitals, 36.2% had been vaccinated before discharge. In San Francisco and Connecticut, where public health officials encouraged hospitals to offer hepatitis B vaccination, first-dose coverage at discharge was 82.3% in 1994 and 69.1% in 1993, respectively. Coverage was higher in healthier infants and lower in infants of older or bettereducated mothers. Results from the National Health Interview Survey demonstrate that three-dose completion at 12 months of age increased from less than 1% of children born in 1989 to 40% of children born in the fourth quarter of 1992. Vaccination at birth increased from less than 1% of infants born in 1989 to 32% of infants born in the second half of 1993. Conclusions. Infant hepatitis B vaccination has expanded rapidly since national recommendations were made; however, universal coverage has not been achieved.

Continuing Risk for Hepatitis B Virus Transmission Among Southeast Asian Infants in Louisiana

Implementation and evaluation of a hepatitis B vaccination program for Southeast Asian infants in Louisiana. A baseline seroprevalence survey of hepatitis B virus (HBV) infection in US-born Southeast Asian children was conducted in 1991 before the implementation of a vaccination program. Hepatitis B vaccination and postvaccination serologic testing of survey participants 10 years of age and younger was performed. Eighteen months after the hepatitis B vaccine was integrated into infant immunization schedules in July 1993, a vaccination coverage survey was performed. Baseline serologic testing was conducted on 96% of persons from 225 randomly selected households in a Southeast Asian community in Louisiana. Of 676 US-born children, 28 (4.1%) had chronic HBV infection; 61% of children with chronic HBV infection were born to hepatitis B surface antigen (HBsAg)-negative women. Among children born to HBsAg-negative women, the prevalence of chronic HBV infection increased with age, reaching 7.3% for children 13 to 16 years of age. Children born to HBsAg-negative women and living with carriers were 5.4 times more likely to have evidence of HBV infection than were children who did not live with carriers. Before the survey, only one child had received three doses of hepatitis B vaccine. In July 1993, 43% of Southeast Asian infants 9 to 18 months of age born in Louisiana had received three doses of hepatitis B vaccine. Infants who received immunizations from private providers were more likely to be fully vaccinated than were infants who received services from public sector clinics (prevalence ratio, 2.1; 95% confidence interval, 1.4, 3.1). HBV transmission occurs throughout childhood in US-born Southeast Asian children, and the prevalence of chronic HBV infection approaches that of the country of origin. Few US-born Southeast Asian children have received hepatitis B vaccine. Because of the high rates of early childhood HBV transmission and the high risk of chronic infection in Asian and Pacific Islander communities, prevention efforts should be enhanced to ensure that all Asian and Pacific Islander infants receive hepatitis B vaccine in the first 12 months of life and that older children are vaccinated.

The paucity of breast-feeding in an urban clinic population.

The lack of breast-feeding among mother-infant dyads utilizing public sector clinics in Los Angeles is presented in this brief study. Whereas the middle and educated classes have begun a resurgence of breast-feeding, this renaissance is missing among the poor. Awareness, health education (by peer advocates), early intervention and reassurance by all levels of health providers is suggested to prevent the dissolution of the lactation bond among the population least apt to breast-feed.