Urban Primary Health Care Clinic Research Articles

Effect of a Legal Clinic Program Within an Urban Primary Health Care Center on Social Determinants of Health: A Program Evaluation.

Individuals living in poverty often visit primary healthcare clinics for health problems stemming from unmet legal needs. We examined the impact of a medical-legal partnership on improving the social determinants of health (SDoH), health-related quality of life, and perceived health status of attendees of a Legal Clinic Program (LCP). This was a pre-post program evaluation of a weekly LCP established within an urban primary healthcare clinic to provide free legal consultation. Patients aged 18 years or older were either approached or referred to complete a screening tool to identify potential legal needs. Those identified with potential legal needs were offered an appointment with LCP lawyers who provided legal counsel, referrals, and services. For those who attended the LCP, changes in SDoH and health indicators were collected via a self-reported survey 6 months after they attended the LCP and compared to their baseline scores using paired t-tests, McNemar's test for paired proportions, and the Wilcoxon Signed Rank Test for related samples. During the 6-month evaluation period, 31 participants attended the LCP and completed both the baseline and 6-month surveys; 67.8% were female, 64.5% were white, 90.3% were not working full-time, and 61.3% had a household income of $700 to 1800 per month. At follow-up, 25.8% were receiving at least 1 new benefit and there was a statistically significant reduction in food insecurity (35.5% vs 9.7%, P < .05). Also, perceived health status using the visual analog scale (ranges from 0 to 100) significantly improved from 42.5 points (SD = 25.3) at baseline to 56.6 points (SD = 19.6) after 6 months (P < .05). The LCP has the potential to improve the health and wellbeing of patients in primary healthcare clinics by addressing unmet legal needs and SDoH.

Effectiveness, safety and economic viability of daycare versus usual hospital care management of severe pneumonia with or without malnutrition in children using the existing health system of Bangladesh: a cluster randomised controlled trial.

We aimed to define clinical and cost-effectiveness of a Day Care Approach (DCA) alternative to Usual Care (UC, comparison group) within the Bangladesh health system to manage severe childhood pneumonia. This was a cluster randomised controlled trial in urban Dhaka and rural Bangladesh between November 1, 2015 and March 23, 2019. Children aged 2-59 months with severe pneumonia with or without malnutrition received DCA or UC. The DCA treatment settings comprised of urban primary health care clinics run by NGO under Dhaka South City Corporation and in rural Union health and family welfare centres under the Ministry of Health and Family welfare Services. The UC treatment settings were hospitals in these respective areas. Primary outcome was treatment failure (persistence of pneumonia symptoms, referral or death). We performed both intention-to-treat and per-protocol analysis for treatment failure. Registered at www.ClinicalTrials.gov, NCT02669654. In total 3211 children were enrolled, 1739 in DCA and 1472 in UC; primary outcome data were available in 1682 and 1357 in DCA and UC, respectively. Treatment failure rate was 9.6% among children in DCA (167 of 1739) and 13.5% in the UC (198 of 1472) (group difference,-3.9 percentage point; 95% confidence interval (CI),-4.8 to-1.5, p=0.165). Treatment success within the health care systems [DCA plus referral vs. UC plus referral, 1587/1739 (91.3%) vs. 1283/1472 (87.2%), group difference 4.1 percentage point, 95% CI, 3.7 to 4.1, p=0.160)] was better in DCA. One child each in UC of both urban and rural sites died within day 6 after admission. Average cost of treatment per child was US$94.2 (95% CI, 92.2 to 96.3) and US$184.8 (95% CI, 178.6 to 190.9) for DCA and UC, respectively. In our population of children with severe pneumonia with or without malnutrition, >90% were successfully treated at Day care Clinics at 50% lower cost. A modest investment to upgrade Day care facilities may provide a cost-effective, accessible alternative to hospital management. UNICEF, Botnar Foundation, UBS Optimus Foundation, and EAGLE Foundation, Switzerland.

Facilitators and barriers to professional nurses implementing integrated services in urban primary health care clinics in Kavango East region, Namibia.

The World Health Organization (WHO) has advocated for the implementation of people-centred and integrated health services. Although there is growing evidence of integration's benefits for sexual and reproductive health, human immunodeficiency virus (HIV) and rights, health services face tremendous resource constraints when it comes to integrating these services. The aim of study was to explore and describe the facilitators and barriers to professional nurses implementing the person-centred model of integrated services in urban primary health care clinics in the Kavango East region, Namibia. We interviewed professional nurses from urban primary health care clinics in low-resourced settings in Rundu health district, Kavango East region, Namibia. This study employed a qualitative approach utilising an explorative, descriptive and contextual strategy. Semistructured interviews were used to collect the data. Fifteen participants were selected using a purposive sampling technique. The interviews were audio recorded, transcribed verbatim and coded, before the data were analysed using thematic analysis. The data analysis led to the emergence of the following four themes: understanding integrated services; facilitators for implementing integrated services; barriers to the implementation of integrated services; and improvement measures for implementing integrated services. Findings showed that the implementation of integrated services faces many barriers, which are related to lack of human resources skills, a lack of essential supplies and space constraints. These findings will hopefully create an awareness and understanding of the facilitators and barriers that professional nurses face in the implementation of integrated services for urban primary health care in the Namibian urban context.Contribution:The study's findings can be used to develop strategies and ongoing interventions that focus on addressing the barriers professional nurses face in the implementation of integrated services in both urban and rural primary health care settings.

Sociocultural influences on asthma self-management in a multicultural society: A qualitative study amongst Malaysian adults.

BackgroundSupported self‐management improves asthma outcomes, but implementation requires adaptation to the local context. Barriers reported in Western cultures may not resonate in other cultural contexts. We explored the views, experiences and beliefs that influenced self‐management among adults with asthma in multicultural Malaysia.MethodsAdults with asthma were purposively recruited from an urban primary healthcare clinic for in‐depth interviews. Audio‐recordings were transcribed verbatim and analysed thematically.ResultsWe interviewed 24 adults. Four themes emerged: (1) Participants believed in the ‘hot and cold’ concept of illness either as an inherent hot/cold body constitution or the ambient temperature. Hence, participants tried to ‘neutralize’ body constitution or to ‘warm up’ the cold temperature that was believed to trigger acute attacks. (2) Participants managed asthma based on past experiences and personal health beliefs as they lacked formal information about asthma and its treatment. (3) Poor communication and variable advice from healthcare practitioners on how to manage their asthma contributed to poor self‐management skills. (4) Embarrassment about using inhalers in public and advice from family and friends resulted in a focus on nonpharmacological approaches to asthma self‐management practice.ConclusionsAsthma self‐management practices were learnt experientially and were strongly influenced by sociocultural beliefs and advice from family and friends. Effective self‐management needs to be tailored to cultural norms, personalized to the individuals' preferences and clinical needs, adapted to their level of health literacy and underpinned by patient–practitioner partnerships.Patient and Public ContributionsPatients contributed to data. Members of the public were involved in the discussion of the results.

Innovations in Addressing Mental Health Needs in Humanitarian Settings: A Complexity Informed Action Research Case Study

Addressing mental health challenges in humanitarian settings, where needs are many and resources are scarce, requires innovative solutions. In this manuscript, we describe a quantum complexity informed intervention, Communication for Whole Health (CWH), developed at the request of a large Jordanian healthcare NGO to address mental health needs of patients and staff. In the humanitarian aid context, this health domain is referred to by the acronym MHPSS (mental health and psychosocial support). The focus of this participatory action research project, presented here as a case study, was the collaborative elaboration of an MHPSS intervention in an urban primary healthcare clinic serving mostly Syrian refugees. The intervention capitalizes on the synergistic effects generated from the systemic nature of communication where every interaction is an intervention, and the health implications of research demonstrating communication is bioactive. Rather than treating mental health as an add-on medical specialty targeting patients with “psychiatric disorders,” systemic MHPSS starts from the premise that everyone has mental health, which is inextricably linked to physical and social health. Emphasis is on integrating awareness of mental health as part of whole health and taking advantage of every interaction to facilitate well-being for patients and staff. The intervention facilitated the transformation of the communication ecology of the clinic from a culture of reactivity to a culture of receptivity by strengthening communication resources and practices. Staff reported feeling more empowered to help patients and displayed increased motivation to find innovative ways to use available resources. They felt better equipped to manage their own stress response and support coworkers. Patients learned basic stress management skills, helping them better manage chronic health conditions, and reported sharing this information with family members. Staff reported many examples of patients responding positively to interventions to reduce patient reactivity, leading to beneficial behavior change and improved health outcomes. Results suggest a systemic MHPSS approach can contribute to ameliorating health inequities by expanding resources for patients and staff, empowering them to act into their current circumstances to support whole health. The CWH approach has potential in similar contexts to address mental health needs in a cost-effective and impactful way.

Willingness to Pay for Health Insurance among Urban Poor: An Evidence from Urban Primary Health Care Project in Bangladesh

Background and Objective: With the growing concern over treatment cost in health care and the desire to improve the effectiveness and equality of healthcare financing and the quality of the care, policy-makers have turned their attention to health insurance, especially, for the poor. This study attempted to determine the willingness to pay for health insurance among the mothers who utilized the urban primary health care clinic (UPHCC) for maternal and child health.&#x0D; Methods: This cross-sectional study was carried out in the working areas of UPHC Project in Bangladesh following two-stage cluster sampling technique to select the participants. Data were collected from 3949 women aged 15-49 years having at least one child aged two years or less. The data on willingness to pay for health insurance was collected using the contingent valuation method with bidding style. Data analysis was done by SPSS 22.0 version. Two generalized linear models with binary logit link function and normal identity link function were developed to identify the potential predictors for willingness to pay for monthly health insurance.&#x0D; Results: Three-fifths (67.5%) of the respondents agreed to pay for monthly health insurance. The median monthly premium for health insurance was BDT 15.5. Multivariate analysis revealed that utilization of UPHC clinic, quality of life, family size, age, wealth index, level of education, husband and respondent’s occupation, ownership status of the house, religion and family income appeared to be potential predictors for health insurance (p&lt;0.05). However, utilization of UPHC clinic and quality of life appeared to be important predictors across all the models.&#x0D; Conclusion: A large proportion of the community agreed to pay premium for health insurance. Based on the finding of the current study the policy makers might consider introducing a scheme for health insurance especially among the urban poor.&#x0D; Bangladesh Journal of Medical Science Vol.19(3) 2020 p.433-443

Does Entitlement Card ensure Utilization of Urban Primary Healthcare Clinic in Bangladesh?

Background: Although Bangladesh substantial­ly reduced 40% maternal death in the last deca­des, it is still challenging, especially among the ur­ban poor. The achievements are not equitable bet­ween different economic quintiles and bet­ween the rich and the urban poor. This study aims to examine the extent to which the entitle­ment card affects the utilization of maternal and child health care and identifies other factors that influence MCH services. Subjects and Method: This cross-sectional study was carried out in the working areas of the Ur­ban Primary Healthcare Project (UPHCP) in Bang­ladesh. A two-stage cluster sampling tech­ni­que was used to select the participants. A total of 3,949 women aged 15-49 years, having at least one child aged two years or less were selected for this study. The data were collected through face-to-face inter­views. The data were analyzed using multinomial logistic regression. Results: The proportion of utilization of UPH­CC was 49.9%. One-fourth (26.6%) of them fully utilized it and another 23.3% utilized it partially. Stepwise multinomial logistic regression analysis revealed that those who had an Entitlement Card from the UPHC project were 11.75 times (95% CI= 9.481, 14.549; p= 0.001) more likely to fully Utilized and 3.64 times (95% CI= 3.643, 2.911; p= 0.001) likely be utilized partially compared to non-utilizer. Respondents having no formal edu­cation utilized UPHCC fully (AOR=2.32; 95% CI= 1.46, 3.68; p= 0.001) and partially (AOR= 1.76; 95% CI= 1.12, 2.77; p= 0.014) used UPHCC. It was 3.08 (95% CI= 2.03, 4.67; p= 0.001) times for fully and 2.71 (95% CI= 1.82, 4.04; p= 0.001) times for partially utilized UPHCC compared to non-users among the primary level of education. Small family size (≤4) and monthly family in­come in the range of BDT 10,000 above were likely to utilise UPHCC. However, non-Muslims were less likely to Utilized UPHCC. Conclusion: Apart from the entitlement card, other factors such as monthly income BDT> 10,000, small family size, no formal educated mo­ther appeared to be potential predictors for utilization of the Urban Primary Health care clinic. Keywords: entitlement card, maternal care, Utilization, urban primary healthcare Correspondence: Md Mizanur Rahman. Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Universiti Malaysia Sa­rawak. Email: rmmizanur@unimas.my, rmizanur1958@gmail.com. Journal of Maternal and Child Health (2020), 5(2): 213-225 https://doi.org/10.26911/thejmch.2020.05.02.12

Delayed Vaccination in Infants in an Urban Health Center in Delhi, India: Evidence from a Retrospective Audit of Secondary Data

Background: Delayed vaccination in infants significantly increases the susceptibility window for vaccine preventable diseases. Objective: We conducted a retrospective audit of secondary data to determine the rates of delayed vaccination among infants reporting for routine immunization at an urban primary healthcare clinic in Delhi, India. Methods: Data were extracted from the manual register of the health clinic and entered in MS-Excel 2013. Results: We analyzed a total of 811 vaccination encounters in infants. Delayed vaccination was observed in 144 (17.8%) vaccination encounters. The proportion of delayed vaccination encounters progressively increased from penta-1 (lowest) to penta-3 (highest). However, the proportion of overall delayed vaccination encounters did not differ significantly across gender (P = 0.71). Conclusions: Delayed vaccination among infants continues to exist as a significant but largely avoidable public health challenge in certain health settings in India.

The Cost of Acute Respiratory Infections With Cough Among Urban Aboriginal and Torres Strait Islander Children.

Introduction: Acute respiratory infections with cough (ARIwC) contribute considerably to childhood morbidity, yet few studies have examined the cost of these illnesses among Australian children. Moreover, of the few studies that have, none are inclusive of Aboriginal and/or Torres Strait Islander children, despite this population experiencing a greater burden of respiratory illnesses. This study aimed to determine the costs of ARIwC among urban Aboriginal and/or Torres Strait Islander children from the perspective of caretakers, the public healthcare system, and employers.Methods: This cost of illness study used data collected from Aboriginal and/or Torres Strait Islander children aged <5 years enrolled in a 12 month prospective cohort study conducted through an urban primary healthcare clinic in Queensland, Australia. Illness-related resource use was collected for each episode of ARIwC reported, and costed at market rates. Linear regression was used to (a) examine cost per episode by season of illness onset and cough duration and (b) examine cost per month of observation by baseline child and family characteristics.Results: During the study period, a total of 264 episodes of ARIwC were reported among 138 children. The total mean cost was estimated to be $AU252 per non-hospitalized episode (95%CI 169–334). Caretakers, the public healthcare system and employers incurred 44, 39, and 17% of costs per episode, respectively. After accounting for months of completed follow-ups, the total mean cost per child per year was estimated to be $991 (95%CI 514–1468). Winter episodes and episodes resulting in chronic cough were associated with significantly higher costs per episode. A prior history of wheezing, connections to traditional lands and parent/guardian belief that antibiotics should be given until symptoms resolved were associated with significantly higher cost per child month of observation.Conclusion: The cost of ARIwC in this predominantly disadvantaged population is substantial, particularly for caretakers and this needs to be considered in both clinical management and public health initiatives. The importance of cultural factors on health and burden of illness should not be overlooked. Further research into the prevention of chronic cough may play an important role in reducing the economic burden of pediatric respiratory infections.

Understanding health talk in an urban Aboriginal and Torres Strait Islander primary healthcare service: a cross-sectional study.

Health literacy is an important determinant of health status. This cross-sectional study aimed to describe the prevalence of adequate health literacy among Aboriginal and Torres Strait Islander patients or their carers including parents of sick children attending an urban primary healthcare clinic in Australia, and their experiences of communication with General Practitioners (GPs). A questionnaire, including questions from the Brief Health Literacy Screen (BHLS) and questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS): Communication with Provider, was administered to 427 participants. Descriptive statistics, Pearson's Chi-Square test and logistic regression analysis were used to describe the prevalence and risk factors associated with health literacy and any associations between the CAHPS questions and health literacy. In total, 72% of participants had adequate health literacy. An age of ≥50 years was independently associated with inadequate health literacy, and completion of secondary or post-secondary schooling was protective. Communication questions that identified areas for improvement included less use of incomprehensible medical words and more frequent use of visual aids. The study provides useful information on health literacy among Aboriginal and Torres Strait Islander patients, or their carers, and their experiences of communication with GPs. Further population-based research is required to investigate the effect of health literacy on health outcomes of Aboriginal and Torres Strait Islander patients.

Risks for communication delays and disorders in infants in an urban primary healthcare clinic

Background. Many risk factors may result in a communication delay. Reliable identification methods are essential to identify infants at risk of communication difficulties in the primary healthcare context. Literature on identifying both at-risk and established risk factors associated with communication disorders in South Africa is limited. Objective. To identify and describe risk factors for communication delays in infants 0 - 12 months of age at Daspoort Polyclinic in Gauteng. Methods. A structured interview schedule was utilised to conduct an interview with the caregiver participants. Convenience sampling was used to select 96 caregiver participants. Results. The results obtained indicated that all infant participants presented with exposure to one or more risk factors that may possibly impact communication development. High frequencies of risk factors included colds and/or flu during pregnancy, previous miscarriages, maternal smoking, low educational levels and unemployment. Conclusion. The high frequency of at-risk conditions within the Daspoort population justifies the importance of implementation of early communication intervention services in primary healthcare.

Risks for communication delays and disorders in infants in an urban primary healthcare clinic

Background. Many risk factors may result in a communication delay. Reliable identification methods are essential to identify infants at risk of communication difficulties in the primary healthcare context. Literature on identifying both at-risk and established risk factors associated with communication disorders in South Africa is limited. Objective. To identify and describe risk factors for communication delays in infants 0 - 12 months of age at Daspoort Polyclinic in Gauteng. Methods. A structured interview schedule was utilised to conduct an interview with the caregiver participants. Convenience sampling was used to select 96 caregiver participants. Results. The results obtained indicated that all infant participants presented with exposure to one or more risk factors that may possibly impact communication development. High frequencies of risk factors included colds and/or flu during pregnancy, previous miscarriages, maternal smoking, low educational levels and unemployment. Conclusion. The high frequency of at-risk conditions within the Daspoort population justifies the importance of implementation of early communication intervention services in primary healthcare.

Healthcare providers’ knowledge, attitudes and practices towards medical male circumcision and their understandings of its partial efficacy in HIV prevention: Qualitative research in KwaZulu-Natal, South Africa

BackgroundMedical male circumcision has been shown to reduce HIV transmission to an uninfected male partner. In South Africa, medical male circumcision programs were rolled-out in 2010. ObjectivesPrior to roll-out, we explored healthcare providers’ knowledge, attitudes and practices about medical male circumcision and their understandings of partial efficacy for HIV prevention. DesignWe conducted qualitative research, using in-depth interviews. SettingParticipants were from three rural and three urban primary healthcare clinics, randomly selected in eThekwini District, KwaZulu-Natal. Participants25 healthcare providers (including nurse managers, nurses and counselors) were purposively selected from the clinics. MethodsIn-depth interviews were recorded, transcribed and translated. Independent researchers reviewed the transcripts and developed a codebook based on emergent themes, using thematic analysis. NVivo 8 was used to facilitate data management, coding and analysis. ResultsAlthough most providers had heard that medical male circumcision can reduce risk of HIV acquisition in men, most did not have accurate scientific understandings of this. Some providers had misperceptions about the limited/partial protection medical male circumcision offers. Many had concerns that their communities would misunderstand it, causing increased risky sexual behavior. ConclusionsThese data provide a baseline of providers’ understandings of medical male circumcision prior to roll-out, and can be used to compare current data and ensure accurate messaging to clients. Healthcare provider messaging should build client understandings of the meaning of partially efficacious technologies.

Antidepressant and Group Psychosocial Treatment for Depression: A Rater Blind Exploratory RCT from a Low Income Country

Research in the West shows that group psychological intervention together with an antidepressant treatment leads to more effective treatment of a depressive disorder. There are no treatment trials from low income countries comparing the efficacy of antidepressant treatment with a group psychological intervention. To conduct a feasibility trial to compare the efficacy of an antidepressant to a group psychosocial intervention, for low income women attending primary health care in Karachi, Pakistan. This was a preliminary RCT in an urban primary health care clinic in Karachi, Pakistan. Consecutive eligible women scoring >12 on the CIS-R and >18 on Hamilton Depression Rating Scale (HDRS) (n = 66) were randomly assigned to antidepressants or a psychosocial treatment in group settings. The primary outcome measure was HDRS score; secondary outcome measures were disability and quality of life. More than half of the patients in both groups improved (50% reduction in HDRS scores); at end of therapy at 3 months 19 (59.4%) vs 18 (56.2%), and at 6-month follow-up 21(67.7%) vs 20(62.5%) for antidepressants and psychosocial intervention respectively. Although HDRS, BDQ and EQ5-D scores all improved considerably in both groups from start to end of treatment, and these improvements were largely maintained after a further 3 months, the differences between the two treatments were not statistically significant. Psychosocial intervention was as effective as antidepressants in reducing depression and in improving quality of life and disability at the end of therapy. However, these findings need further exploration through a larger trial.

Record Keeping Systems for Quality Improvement in Urban Primary Health Care Clinics

Record Keeping Systems for Quality Improvement in Urban Primary Health Care Clinics

Does provider‐initiated counselling and testing (PITC) strengthen early diagnosis and treatment initiation? Results from an analysis of an urban cohort of HIV‐positive patients in Lusaka, Zambia

IntroductionBuilding on earlier works demonstrating the effectiveness and acceptability of provider-initiated counselling and testing (PITC) services in integrated outpatient departments of urban primary healthcare clinics (PHCs), this study seeks to understand the relative utility of PITC services for identifying clients with early-stage HIV-related disease compared to traditional voluntary testing and counselling (VCT) services. We additionally seek to determine whether there are any significant differences in the clinical and demographic profile of PITC and VCT clients.MethodsRoutinely collected, de-identified data were collated from two cohorts of HIV-positive patients referred for HIV treatment, either from PITC or VCT in seven urban-integrated PHCs. Univariate and multivariate analyses were conducted to compare the two cohorts across demographic and clinical characteristics at enrolment.ResultsForty-five per cent of clients diagnosed via PITC had CD4<200, and more than 70% (i.e. two thirds) had CD4<350 at enrolment, with significantly lower CD4 counts than that of VCT clients (p<0.001). PITC clients were more likely to be male (p=0.0005) and less likely to have secondary or tertiary education (p<0.0001). Among those who were initiated on antiretroviral therapy (ART), PITC clients had lower odds of initiating treatment within four weeks of enrolment into HIV care (adjusted odds ratio, or AOR: 0.86; 95% confidence interval, or CI: 0.75–0.99; p=0.035) and significantly lower odds of retention in care at six months (AOR: 0.84; CI: 0.77–0.99; p=0.004).ConclusionsIn Lusaka, Zambia, large numbers of individuals with late-stage HIV are being incidentally diagnosed in outpatient settings. Our findings suggest that PITC in this setting does not facilitate more timely diagnosis and referral to care but rather act as a “safety net” for individuals who are unwilling or unable to seek testing independently. Further work is needed to document the way provision of clinic-based services can be strengthened and linked to community-based interventions and to address socio-cultural norms and socio-economic status that underpin healthcare-seeking behaviour.

Promoting physical activity in sedentary elderly Malays with type 2 diabetes: a protocol for randomised controlled trial

IntroductionLike many countries Malaysia is facing an increase in the number of people with type 2 diabetes mellitus diabetes (T2DM) and modifiable lifestyle factors such as sedentary behaviour are important...

Depressive symptomatology as a risk factor for increased health service utilization among elderly patients in primary care

Depression may play an important role in determining frequent physician visits in the older population. Our aim is to examine the relationships between socio-demographic variables, co-morbidity, memory complaints, functional status, depressive symptomatology, and health care utilization among community dwelling older patients. The study was conducted in urban primary health care clinics in Beer-Sheva, Israel. Two groups were identified: low care utilizers (LCU), with ≤6 visits to family physicians (FP)/year and high care utilizers (HCU) with ≥16 visits to FP/year. Data were collected during a structured face-to-face individual interview. The study population included 180 patients, of them 86 (47.7%) were LCU and 94 (52.2%) were HCU. In all clinical measurements the HCU group indicators were statistically significant worse off than the LCU group: average depressive symptoms (5.6 vs. 2.5, p < 0.01), memory complaints (57.5% vs. 23.3%, p < 0.01), Barthel Index (BI) (89.9 vs. 96.0, p < 0.001), OARS (10.8 vs. 12.5, p < 0.01), and co-morbidity: total cumulative score (TCS) of Charlson comorbidity index (CCI) (2.2 vs. 1.3, p < 0.01). Our study raises the possibility that at least one of the reasons for over-utilization of health services by older residents in the community is depressive symptomatology.

Factors affecting quality of care in family planning clinics: A study from Iran

Despite good contraceptive coverage rates, recent studies in Iran have shown an alarmingly high incidence of unplanned pregnancy. To determine factors affecting quality of family planning services, a cross-sectional study was performed from June to August 2006 on women visiting urban Primary Health Care clinics in a provincial capital in western Iran. The primary focus of the study was on provider-client interaction. We used a slightly edited version of a UNICEF checklist and a convenient sampling method to assess quality of care in 396 visits to the family planning sections at 25 delivery points. Poor performance was observed notably in Counselling and Choice of method sections. In logistic regression analysis, the following factors were found to be associated with higher quality of care: provider experience [OR (odds ratio)=1.9, CI(0.95) (confidence interval)=1.2-3.0], low provider education (OR=6.7, CI(0.95)=4.0-10.8), smaller workload at the clinic (OR=3.7, CI(0.95)=2.0-6.7), and 'new client' status (OR=4.2, CI(0.95)=2.6-6.7). This study identified the issues of counselling and information exchange as the quality domains in serious need of improvement; these areas are expected to be the focus of future training programmes for care providers. Also, priority should be given to devising effective supervision mechanisms and on-the-job training of senior nursing and midwifery graduates to make them more competent in delivering basic family planning services.

HIV and Sexually Transmitted Infections among Women Presenting at Urban Primary Health Care Clinics in Two Cities of sub-Saharan Africa

In a cross-sectional study, 786 consenting women from two cities in Africa, Harare and Moshi, attending primary health care clinics were interviewed, examined and tested for HIV and other sexually transmitted infections (STIs). The aim of the study was to assess and compare differences in the characteristics that may affect the prevalence of HIV/STIs among women in the two cities. Multivariate analysis was used to generate odds ratio. STIs and behaviour characteristics among this low risk group of women could not fully explain the higher HIV prevalence in Zimbabwe, 29.3% compared to 11.5% in Tanzania (p < 0.01). Interventions should target identified risk factors with particular attention to youths.