Medical Assistance

Background: This study is the first to examine associations between several area-based socioeconomic factors and human papillomavirus (HPV) vaccine uptake among boys in the United States (U.S.). Methods: Data from the 2012-2013 National Immunization Survey-Teen restricted-use data were analyzed to examine associations of HPV vaccination initiation (receipt of ≥1 dose) and series completion (receipt of three doses) among boys aged 13-17 years (N = 19,518) with several individual-level and ZIP Code Tabulation Area (ZCTA) census measures. Multivariable logistic regression was used to estimate the odds of HPV vaccination initiation and series completion separately. Results: In 2012-2013 approximately 27.9% (95% CI 26.6%-29.2%) of boys initiated and 10.38% (95% CI 9.48%-11.29%) completed the HPV vaccine series. Area-based poverty was not statistically significantly associated with HPV vaccination initiation. It was, however, associated with series completion, with boys living in high-poverty areas (≥20% of residents living below poverty) having higher odds of completing the series (AOR 1.22, 95% CI 1.01-1.48) than boys in lowpoverty areas (0-4.99%). Interactions between race/ethnicity and ZIP code-level poverty indicated that Hispanic boys living in high-poverty areas had a statistically significantly higher odds of HPV vaccine initiation (AOR 1.43, 95% CI 1.03-1.97) and series completion (AOR 1.56, 95% CI 1.05-2.32) than Hispanic boys in low-poverty areas. Non-Hispanic Black boys in high poverty areas had higher odds of initiation (AOR 2.23, 95% CI 1.33-3.75) and completion (AOR 2.61, 95% CI 1.06-6.44) than non-Hispanic Black boys in low-poverty areas. Rural/urban residence and population density were also significant factors, with boys from urban or densely populated areas having higher odds of initiation and completion compared to boys living in non-urban, less densely populated areas. Conclusion: Higher HPV vaccination coverage in urban areas and among racial/ethnic minorities in areas with high poverty may be attributable to factors such as vaccine acceptance, health-care practices, and their access to HPV vaccines through the Vaccines for Children Program, which provides free vaccines to uninsured and under-insured children. Given the low HPV vaccination rates among boys in the U.S., these results provide important evidence to inform public health interventions to increase HPV vaccination.

Assessments of subnational progress and performance coverage within countries should be an integral part of health sector reviews, using recent data from multiple sources on health system strength and coverage. As part of the midterm review of the national health sector strategic plan of Tanzania mainland, summary measures of health system strength and coverage of interventions were developed for all 21 regions, focusing on the priority indicators of the national plan. Household surveys, health facility data and administrative databases were used to compute the regional scores. Regional Millennium Development Goal (MDG) intervention coverage, based on 19 indicators, ranged from 47% in Shinyanga in the northwest to 71% in Dar es Salaam region. Regions in the eastern half of the country have higher coverage than in the western half of mainland. The MDG coverage score is strongly positively correlated with health systems strength (r = 0.84). Controlling for socioeconomic status in a mu...

Many states have worked tirelessly over the past two years to develop health insurance exchanges and prepare for the expansion of their Medicaid programs in order to meet the requirements of the Patient Protection and Affordable Care Act. Programs to expand coverage, however, do not necessarily ensure seamlessness for many individuals who are likely to experience shifts in program eligibility due to changing circumstances (e.g., income fluctuations, family composition changes, etc.). A number of states are actively working to limit the impact of changes in program eligibility by developing policies that limit either the incidence of program eligibility changes and/or the impact those changes have on individual consumers. Various emerging state approaches take into account program history, the desire for state flexibility, and the political and operational challenges states face in developing coverage expansions that work for consumers, stakeholders, and policy makers.

This review examines evidence on the most effective approaches to managing and compensating village health workers (VHWs). Management models considered include supervision by health facilities, health facility community committees, other local development committees, and senior VHWs. Compensation methods reviewed encompass unpaid roles, in-kind incentives, community-funded payments, fixed stipends, and performance-based payments. Where applicable, information on the amount of compensation provided is also included. The review aims to identify best practices that support the effective performance and sustainability of VHW programs.

Background: Multimorbidity is a public health problem with high prevalence and important consequences. The aim of this paper was to verify the prevalence and distribution of multimorbidity in Brazilian older adults. Methods: A population-based survey was carried out in 2008 through face-to-face interviews with 1593 older adults (aged 60 or over) living in Bagé, a medium-sized city in Southern Brazil. Multimorbidity was evaluated by 17 morbidities and operationalized according to two cutoff points: 2 or more and 3 or more morbidities. Descriptive analysis examined the occurrence of multimorbidity by demographic, socioeconomic and health services variables. Observed and expected dyads and triads of diseases were calculated. Results: From total sample, 6 % did not have morbidities. Mean morbidity was 3.6. Morbidities showing higher prevalence were high blood pressure -HBP -(55.3 %) and spinal column disease (37.4 %). The percent of participants with multimorbidity was 81.3 % (95 % CI: 79.3; 83.3) for 2 or more morbidities and 64.0 % (95 % CI: 61.5; 66.4) for 3 or more morbidities. In both measures occurrence was higher among women, the more elderly, less socioeconomic status, the bedridden, those who did not have a health private plan, those who used health services and those living in Family Health Strategy catchment areas. We found 22 dyads of morbidities with prevalence 10 % or more and 35 triads with prevalence 5 % or more. The most prevalent observed pair and triplet of morbidities were HBP and spinal column disease (23.6 %) and HBP, rheumatism/arthritis/arthrosis and spinal column disease (10.6 %), respectively. Conclusions: Multimorbidity frequency was high in the sample studied, in keeping with percentage found in other countries. The social inequities identified increase the health system challenges for the management of multimorbidity, requiring a comprehensive and multidimensional care. The combinations of diseases can provide initial input to include multimorbidity in Brazilian clinical protocols.

The activities described in this report were made possible with the financial support of the European Union, and documenting these activities was made possible with the financial support of the Swiss Agency for Development and Cooperation (SDC). Finally, the report team would like to express their gratitude to Mayors, Councilors, Deputy Commissioners, Additional Deputy Commissioners, Secretaries and other staff of the municipal authorities, Civil Surgeons, health officers and staff of Concern Worldwide, SAJIDA Foundation, Dhaka Ahsania Mission, Christian Aid, Resource Integration Centre, owners / managers of the private hospitals participating under the voucher scheme and the beneficiaries of the scheme, who all contributed to the information presented in this report.

The purpose of this study was to determine the association between adherence to prescribed antiepileptic medication in a convenience sample of caregivers (n = 100) of children diagnosed with epilepsy, ages 2Y14 years, and caregivers' beliefs about the medication. Using the Beliefs about Medication Questionnaire and Medication Adherence Report Scale, caregivers were questioned about beliefs of necessity and concerns associated with medication adherence. Using bivariate linear regression, no significant correlation was found between necessity for antiepileptic drug treatment or caregiver's concerns and medication adherence. Nevertheless, although only 28% of the respondents reported complete adherence, the majority of caregivers perceived their child's medication was necessary to maintain good health. Educational aspects and social desirability in this setting may have contributed to the discordance between adherence and caregivers' beliefs.

За ст. 368-4 Кримінального кодексу України (далі — ККУ) криміналізовано діяння підкуп особи, яка надає публічні послуги. Проблематика складу злочину була предметом численних lосліджень, у тому числі на рівні дисертаційних праць, зокрема О. С. Перешивко, Ю. О. Чернеги. Проте перманентною залишається дискусія щодо визначення кола осіб, які в ККУ позначені як «інша особа, яка не є державним службовцем, посадовою особою місцевого самоврядування, але провадить професійну діяльність, пов’язану з наданням публічних послуг». Таке формулювання на правничий порядок денний гостро ставить питання медичного працівника як суб’єкта відповідальності за окресленою статтею та належність його до кола інших осіб, які провадить професійну діяльність, пов’язану з наданням публічних послуг.

Background: Medical tourism is the practice of traveling across international boundaries in order to access medical care. Residents of low-to-middle income countries with strained or inadequate health systems have long traveled to other countries in order to access procedures not available in their home countries and to take advantage of higher quality care elsewhere. In Mongolia, for example, residents are traveling to China, Japan, Thailand, South Korea, and other countries for care. As a result of this practice, there are concerns that travel abroad from Mongolia and other countries risks impoverishing patients and their families. Methods: In this paper, we present findings from 15 interviews with Mongolian medical tourism stakeholders about the impacts of, causes of, and responses to outbound medical tourism. These findings were developed using a case study methodology that also relied on tours of health care facilities and informal discussions with citizens and other stakeholders during April, 2012. Results: Based on these findings, health policy changes are needed to address the outflow of Mongolian medical tourists. Key areas for reform include increasing funding for the Mongolian health system and enhancing the efficient use of these funds, improving training opportunities and incentives for health workers, altering the local culture of care to be more supportive of patients, and addressing concerns of corruption and favouritism in the health system. Conclusions: While these findings are specific to the Mongolian health system, other low-to-middle income countries experiencing outbound medical tourism will benefit from consideration of how these findings apply to their own contexts. As medical tourism is increasing in visibility globally, continued research on its impacts and context-specific policy responses are needed.

Background: India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world's largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women's access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women's use of maternal health services in Gujarat and Tamil Nadu. Methods: Using the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section. Results: Tamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women's education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands' education predicted institutional delivery in Gujarat. Conclusions: Overall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.

In an era of fiscal constraint, growing poverty, increased uninsuredness, medical liability problems, and increasing costs of maternity care, public and private financing mechanisms are changing rapidly and the service delivery system is increasingly fragmented. Despite the almost mercurial changes in the system, data from national studies show that access to care is a major problem affecting all childbearing women. This paper describes the three groups of women who require comprehensive maternity care, their insurance coverage, and the gaps for each group. It describes proposals which are currently under development to reduce uninsuredness and produce universal access and, in addition, presents an alternative plan for universal maternity care.

Objective. To compare the self-perceived health, use of health services and unmet need for health care (UNHC) among immigrants and native populations of Southeast Spain. Materials and methods. Cross-sectional study of two representative samples of 1150 immigrants, and 1303 native participants from the National Health Survey. A single database was created with specific weights for each sample, and prevalence ratios (PR) were estimated by multivariate regression. Results. Moroccans, Ecuadorians and Eastern Europeans (EE) reported poorer health than the native population (PRs [CI95%]: 2.45 [1.91-3.15]; 1.51 [1.28-1.79] and 1.44 [1.08-1.93], respectively). Immigrants made greater use of emergencies that natives (except for EE) and had lower use of medication. Moroccan showed the greatest difference in the frequency of UNHC (PR [CI95%]:12.20 [5.25 - 28.37]), mainly because of working limitations (46%). Conclusions. The health status and use of health services among immigrants differ sign...

With the Affordable Care Act set to expand insurance coverage to millions more Americans next year, existing discretionary health programs that receive federal support might find themselves competing for funds as the health reform law is fully implemented. To assess the implications the Affordable Care Act might have on discretionary health programs, we focused on state AIDS Drug Assistance Programs, which provide free medications to low-income HIV patients. We conducted semistructured interviews with program managers from twenty-one states. Many of the managers predicted that their programs will change focus to provide "wrap-around services," such as helping newly insured clients finance out-of-pocket expenses, including copays, deductibles, and premiums. Although program managers acknowledged that they must adapt to a changing environment, many said that they were overwhelmed by the complexity of the Affordable Care Act and some expressed fear that state AIDS Drug Assistance Programs would be eliminated entirely. To remain viable, such programs must identify and justify the need for services in the context of the Affordable Care Act and receive sufficient political support and funding. Although the Affordable Care Act seeks to increase access to health care and strengthen consumer protections, little attention has been given to the law's potential impact on discretionary health care programs that target specific populations. For example, the federal Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration administer a number of discretionary programs for HIV/AIDS patients, children with special needs, substance abusers, and the mentally ill. Policy makers may now perceive that there is less need for these services and in turn shift their attention toward funding various provisions of the Affordable Care Act instead. To examine the impact the Affordable Care Act might have on existing discretionary health care programs, we interviewed managers of state AIDS Drug Assistance Programs, federally funded programs that provide drug coverage for low-income HIV patients. Because the program is up for congressional reauthorization this year, program officials and advocates are concerned about its fate. We asked AIDS Drug Assistance Program managers their views

With the Affordable Care Act set to expand insurance coverage to millions more Americans next year, existing discretionary health programs that receive federal support might find themselves competing for funds as the health reform law is fully implemented. To assess the implications the Affordable Care Act might have on discretionary health programs, we focused on state AIDS Drug Assistance Programs, which provide free medications to low-income HIV patients. We conducted semistructured interviews with program managers from twenty-one states. Many of the managers predicted that their programs will change focus to provide "wrap-around services," such as helping newly insured clients finance out-of-pocket expenses, including copays, deductibles, and premiums. Although program managers acknowledged that they must adapt to a changing environment, many said that they were overwhelmed by the complexity of the Affordable Care Act and some expressed fear that state AIDS Drug Assistance Programs would be eliminated entirely. To remain viable, such programs must identify and justify the need for services in the context of the Affordable Care Act and receive sufficient political support and funding. Although the Affordable Care Act seeks to increase access to health care and strengthen consumer protections, little attention has been given to the law's potential impact on discretionary health care programs that target specific populations. For example, the federal Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration administer a number of discretionary programs for HIV/AIDS patients, children with special needs, substance abusers, and the mentally ill. Policy makers may now perceive that there is less need for these services and in turn shift their attention toward funding various provisions of the Affordable Care Act instead. To examine the impact the Affordable Care Act might have on existing discretionary health care programs, we interviewed managers of state AIDS Drug Assistance Programs, federally funded programs that provide drug coverage for low-income HIV patients. Because the program is up for congressional reauthorization this year, program officials and advocates are concerned about its fate. We asked AIDS Drug Assistance Program managers their views

Objective. To investigate (1) the relative contributions of family and contextual characteristics to observed variation in disenrollment rates from the State Children's Health Insurance Program (SCHIP), and (2) whether context explains observed family‐level patterns.Data Sources. We use secondary data on 24,628 families enrolled in New Jersey's SCHIP program (NJ KidCare), and county‐level data from the Area Resource File, the Census, and the NJ FamilyCare provider roster.Study Design. Information on family characteristics, SCHIP plan, and dates of enrollment and disenrollment are taken from NJ KidCare administrative records, which provided surveillance data from January 1998 through April 2000.Data Collection/Analysis. We estimate a multilevel discrete‐time‐hazards model of SCHIP disenrollment.Findings. Families enrolled in plans involving cost‐sharing, blacks, and those with only one enrolled child have higher than average rates of disenrollment. Disenrollment rates for bla...

n Public insurance programs paid for 65% of the 1.7 million births resulting from unintended pregnancies that year, compared with 36% of births resulting from intended pregnancies. n There were 2.0 million publicly funded births in 2008; of those, 1.1 million, or 53%, resulted from unintended pregnancies. n Government expenditures on births resulting from unintended pregnancies nationwide totaled $12.5 billion in 2008. n In the absence of the publicly funded family planning effort, the annual public costs of births from unintended pregnancy would have been twice as high-$25 billion, rather than the $12.5 billion estimated in this report.

This study examined the relationship between Community Health Centers' (CHCs) quality of care measures and their financial performance. Using a national sample of 992 CHCs, we also tested the mediating effect of patient visits per patient per disease on the association between clinical and financial performances. Our study's findings showed that quality of care was related to the CHCs' financial performance. For example, one percent increase in a health outcome variablecontrolled hypertension was associated with 0.023 percent increase in their financial performance. Health care providers need to develop strategies that balance improving their organization's financial performance and providing the best care for their patients. As such, this study's findings can assist CHC administrators and other stakeholders to make informed decisions when considering quality improvement initiatives by understanding that a focus on quality of care can affect not only patients' health but also the fiscal health of provider organizations.

This study aimed at examine the number of planned and acute hospital admissions during 1 year among people 65+ and its relation to municipal care, outpatient care, multimorbidity, age and sex. Four thousand nine hundred and seven individuals having one or more admissions during 2001 were studied. Data were collected from two registers and comparisons were made between those having one, two and three or more hospital stays and between those with and without municipal care and services. Linear regression was used to examine factors predicting number of acute and planned admissions. Fifteen percent of the sample had three or more hospital stays (range 3-15) accounting for 35% of all admissions. This group had significantly more contacts in outpatient care with physician (median number of contacts (md) = 15), compared to those with one (md: 8), or two admissions (md: 11). Main predictors for number of admissions were number of diagnosis groups and number of contacts with physician in outpatient care. Those who are frequently admitted to hospital constitute a small group that consume a great deal of inpatient care and also tend to have frequent contacts in outpatient care. Thus interventions focusing on frequent admissions are needed, and this requires collaboration between outpatient and hospital care.

Purpose: To determine uptake, barriers and outcomes in the follow-up of patients referred for free-of-charge, expedited cataract surgery in the Sao Paulo Eye Study (SPES). Methods: SPES was a population-based study of urban, low-middle income residents aged ≥50 years. Presenting visual acuity (PVA), best-corrected visual acuity, refraction, and slit-lamp examination were performed in 3677 participants. For subjects with cataract as a principal cause of best-corrected visual acuity ≤20/40, surgery was offered free of charge. Two years after the baseline study, surgery uptake, barriers to surgery, and visual outcomes were analyzed. Results: Among 210 (5.71%) participants who had a cataract surgery indication at baseline, 164 (78.1%) were successfully contacted and 55 (33.5%) reported being operated on for cataract, with 51 agreeing to be re-examined. In a multiple logistic regression model, age, sex, schooling, previous cataract surgery, and PVA at baseline were not significantly asso...

OVERVIEW -This background paper provides an overview of organized programs that provide access to prescription drug products for uninsured persons, with an emphasis on manufacturer-sponsored pharmacy assistance programs (PAPs) and the federal 340B drug pricing program. It summarizes the chief characteristics of these programs and reviews concerns regarding the reach and efficiency of these efforts. The paper begins with a brief examination of the number of people who lack insurance coverage for prescription drugs and discusses the influence of this gap in coverage on health status. The paper also describes informal mechanisms providers frequently use to help uninsured patients fill their prescriptions, such as sample dispensing. The paper briefly explores the impact of Medicare Part D on both manufacturer-sponsored PAPs and state pharmacy assistance programs that have not traditionally focused on the under-65 uninsured population.

Scientists have written numerous papers studying different aspects of health systems in the world. Comparing health systems in the world is essential for policymakers to learn from each other to make healthcare services effective with better outcomes and decrease the cost of healthcare services. In the world, countries have different health systems. The difference in the health systems is a combination of components that are specific to each country based on the financial status of healthcare, workforce, and infrastructures. This paper will evaluate the contrast of Canadian and American health systems payment systems, timely access, and healthcare quality outcomes. Both countries are well-developed countries that have a health system with excellent infrastructure and effective healthcare services. However, the system operates differently in both countries. America does not have a universal healthcare plan and spends more money per capita compared to Canada. The United States has a lower rank than its peer, underperforms in maternal mortality, infant mortality, preventable deaths, and life expectancy. On the other hand, Canada has a universal healthcare plan for all Canadian residents and performs better in life expectancy, infant mortality, and maternal mortality. However, waiting for specialized care is longer than in the United States.

This study investigates the socioeconomic, cultural and community factors influencing substance abuse and evaluates the effectiveness of prevention and treatment programs among the clients of Silchar New Life Foundation in Northeast India. Using a cross sectional survey design and quantitative data was collected from 51 registered clients through a structured questionnaire. The survey explored demographic profiles, community attitudes and the perceived effectiveness of substance abuse interventions. Respondents were predominantly young adults aged 18-34 with a balanced gender and marital status distribution. Educational attainment varied with the majority having completed high school. Employment status showed significant diversity with notable portions employed full time, part time or unemployed. Income levels ranged widely reflecting the socioeconomic diversity of the sample. Community attitudes toward substance abuse vary with a mix of permissive, neutral and stigmatizing views. Cultural beliefs and media portrayal were noted as significant influencers of substance abuse behaviors. The effectiveness of prevention and treatment programs was generally viewed positively though barriers such as stigma and fear of legal consequences and limited treatment options were identified. Education and awareness campaigns emerged as the most effective strategies for prevention while the role of religious institutions in treatment was highly regarded.

Background: Malaria prevalence and transmission intensity in Tanzania is heterogeneous with spatial and temporal variations between geographical areas and ecological systems. The objective of this study was to determine the prevalence of malaria, anaemia and nutritional status in relation to livelihoods, ecosystem and health systems in Kilosa District in central Tanzania. Methods: This study was conducted in four villages, two characterised by rice irrigation ecosystem and the other two by dry savannah ecosystem and pastoral livelihoods. In each ecosystem, one of the villages had a healthcare facility. Schoolchildren were screened for malaria infection using malaria rapid diagnostic test (mRDT) and microscopy and they were assessed for their anaemia and nutritional statuses. Results: A total of 1,019 school children (age = 4-16 years) were screened for malaria infection. The overall prevalence of Plasmodium falciparum infection was 10.6 % and 4.5 % by mRDT and microscopy, respectively. Children from pastoral villages had lower (2.9 %) prevalence of malaria than their counterparts (18.2 %) in the rice irrigation villages. A significantly high risk of malaria was observed among children in rice irrigation than in the pastoral ecosystem (OR: 0.13; 95%CI 0.07, 0.23). Children living in areas with health care facilities had a low odd of malaria infection by 45 % (OR: 0.55; 95 % CI = 0.35, 0.86). Overall, the prevalence of anaemia in the district was 43.4 % (n = 775); and 58.3 % of those with severe anaemia were among children from the pastoral villages. Anaemia was significantly higher among children not using mosquito nets (p = 0.049); and among those with malaria infection (p <0.001). The majority (96 %) of the children had Body Mass Index less than 18.5 kg/m 2 which indicate high proportion of underweight. Conclusion: There are significant variations in the risk of acquiring malaria infection between different ecosystems and livelihoods. These findings suggest that malaria control programmes must take into account ecosystems and livelihoods of the targeted population through an integrated management of malaria and nutrition approach.

Over a few decades, there is a steady accretion of life expectancy in many countries. Significant advances in modern healthcare technologies, medicines and overall health care awareness gave many to lead a prolonged healthy life. Over the past few years, there has been a huge demand for unobtrusive health monitoring systems from both medical professionals and the general populace to use these technologies for understanding the general health well being in order to improve life longevity. However, most of the available technologies for health monitoring are difficult for the general populace to access and most of the developed health monitoring systems are either deployed in a controlled environment or in healthcare facilities, thus severely limiting the ease of access to many, especially the elderly people. For effective health management of elderly people, evidence-based decision making, continuously monitoring the health status of the elderly demographic is paramount. In order to address these issues, we developed an innovative smart IoT based outdoor health monitoring system. The proposed system collects information about the mobility, posture, and overall gait of the person in an easy to access public outdoor setting such as parks, supermarkets etc. It is quite evident from multiple studies, that analysing the gait can be a useful tool in early detection of the declining health of individuals, as mobility is a key factor in any individual's well being. Also, detecting gait disorders earlier will allow for functional relief to the health care system with the possibility of reducing the number and severity of gait disorders through early intervention.

RESUMO Este estudo avaliou a relação entre qualidade de vida e rede de apoio social dos pacientes das unidades de cuidados continuados do Algarve, através de WHOQOL-BREF e ASSIS. Participaram 92 pacientes, com idades entre 34-101 anos: muito idosos (40,2%), sexo feminino (58,7%), viúvas (40,2%), classe média-alta (46,8%), coabitando com o cônjuge (43,2%), e parcialmente dependentes (72,5%). As redes de apoio emocional, material e informativo eram compostas maioritariamente por familiares. Observamos relações significativas entre o apoio informativo e os domínios físico, relações sociais e ambiente da qualidade de vida (p&lt;0,05). Os resultados sugerem uma percepção e satisfação com a saúde razoáveis, mas inferiores no domínio físico. A necessidade de apoio informativo esteve negativamente associada aos domínios psicológico e relações sociais da qualidade de vida.

Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative Commons Attribution, que permite uso, distribuição e reprodução em qualquer meio, sem restrições, desde que o trabalho original seja corretamente citado. Critérios epidemiológicos definem o quanto uma doença é rara. A definição da prevalência na população fica entre 6 e 8% segundo dados europeus e norte-americanos , ou 65 pessoas para 100 mil habitantes. A locução "doença rara" atribui um dinamismo positivo ao fato de que cada grupo de pessoas que vive com determinada doença varia muito em tamanho, sendo considerado reduzido do ponto de vista epidemiológico. Contudo, quando agrupadas pela característica "rara", essas doenças se tornam mais visíveis epidemiologicamente. Merece atenção nessa reflexão, o esforço em reconhecer a presença das pessoas que vivem com doenças raras no Brasil, sua organização associativa e seus movimentos como grupos de interesse qualificados. E aqui nos referimos não sobre a distribuição das doenças na população, mas sobre a agência das pessoas organizadas como grupos de interesses, que por meio de interações mistas 5,6 concorrem em arenas públicas, organizam agendas que invadem as ruas 7 , os espaços acadêmicos , o cenário legislativo e o judiciário. A Política Nacional das Pessoas com Doenças Raras no SUS, promulgada em 2014 12 , tem como antecedentes o manifesto público de diversas associações reunidas em 2011 13 , a Política Nacional de Atenção Integral em Genética Clínica de 2009 14 , e como seu desdobramento mais recente, em 2016, a habilitação pelo Ministério da Saúde de sete estabelecimentos de saúde como serviços de referência, no Distrito Federal, Rio de Janeiro, Porto Alegre (Rio Grande do Sul), Curitiba (Paraná), Anápolis (Goiás), Recife (Pernambuco) e Santo André (São Paulo) . Nesse cenário, o movimento associativo merece ser analisado à luz do modelo de arenas sociais revisto por Celina Souza 16 . Segundo a autora, "para que uma determinada circunstância ou evento se transforme em um problema, é preciso que as pessoas se convençam de que algo precisa ser feito" 16 (p. 32). Os formuladores de políticas e os tomadores de decisão são influenciados a ignorar ou se interessar pelo problema, numa relação dinâmica com a comunidade de especialistas. Dessa comunidade fazem parte não somente os profissionais e pesquisadores, mas também aqueles que têm a autoridade do conhecimento adquirido pela experiência pessoal, como as famílias. No caso das necessidades das pessoas que vivem com doenças raras, essa comunidade é composta não só pelas próprias pessoas e seus familiares -principalmente quando a doença rara é da criança ou do adolescente -mas também por aquelas que conjugam esforços e recursos para ver suas demandas alcançadas em perspectiva futura, ou seja, "eles são cruciais para a sobrevivência e o sucesso de uma ideia e para colocar o problema na agenda pública" 16 (p. 32).

Background & objectives-Six million US children have no health insurance, and substantial racial/ethnic disparities exist. The design, methods, and baseline characteristics are described for Kids' Health Insurance by Educating Lots of Parents (Kids' HELP), the first randomized, clinical trial of the effectiveness of Parent Mentors (PMs) in insuring uninsured minority children. Methods & research design-Latino and African-American children eligible for but not enrolled in Medicaid/CHIP were randomized to PMs, or a control group receiving traditional Medicaid/CHIP outreach. PMs are experienced parents with ≥ 1 Medicaid/CHIP-covered children. PMs received two days of training, and provide intervention families with information on Medicaid/CHIP eligibility, assistance with application submission, and help maintaining coverage. Primary outcomes include obtaining health insurance, time interval to obtain coverage, and parental satisfaction. A blinded assessor contacts subjects monthly for one year to monitor outcomes. Results-Of 49,361 candidates screened, 329 fulfilled eligibility criteria and were randomized. The mean age is seven years for children and 32 years for caregivers; 2/3 are Latino, 1/3 are African-American, and the mean annual family income is $21,857. Half of caregivers were unaware that their uninsured child is Medicaid/CHIP eligible, and 95% of uninsured children had prior insurance. Fifteen PMs completed two-day training sessions. All PMs are female and minority, 60% are unemployed, and the mean annual family income is $20,913. Post-PM-training, ✰ Clinical Trials.gov NCT01264718

 To evaluate if government-funded vision care support programs facilitate access to eye care providers amongst low-income individuals in Canada Methods  Systematically reviewed government-funded low-income vision care support programs in the 10 Canadian provinces: eligibility criteria, coverage policies and amount of assistance provided  Compared the self-reported utilization of eye care providers between the economically deprived vs. others  Data from the Canadian Community Health Survey (CCHS) Healthy Aging 2008/09 Results Age group Frequency of Government Coverage Provinces <20 Once every year Alberta (0-18), BC (0-15), Ontario (0-19), Quebec (0-17), Saskatchewan (0-17) Once every 2 years Manitoba (0-17), Nova Scotia (0-9

Globally, there is a significant challenge in the acceptability and utilization of mental health services. This issue is particularly pronounced in low- and middle-income countries (LMICs). This study, grounded in the socioecological model, explores the recommendations and perspectives of family caregivers and service providers on improving mental health service utilization in the Bolgatanga Municipality of the Upper East Region of Ghana. A descriptive qualitative research design was employed to explore the views of 15 family caregivers, two service providers, and two mental health service managers on strategies to improve mental health service utilization. From February to March 2023, individual in-depth interviews were conducted, with data collection and analysis occurring concurrently. Participants recommended interventions at multiple levels. At the community level, they suggested increasing mental health awareness. At the organizational level, they emphasized the need to improve staff attitudes, address staffing shortages, and resolve transportation challenges. At the policy level, key suggestions included incorporating mental health services into the National Health Insurance Scheme (NHIS) and increasing access to specialist mental health services. The study provides actionable recommendations to improve mental health service utilization. These include enhancing community awareness about mental health, increasing staffing levels, addressing negative attitudes among health professionals, ensuring the availability of specialist mental health services, and integrating mental healthcare into the NHIS. Implementing these recommendations could significantly enhance the uptake of mental health services in Ghana.

Purpose-To determine uptake, barriers and outcomes in the follow-up of patients referred for free-of-charge, expedited cataract surgery in the Sao Paulo Eye Study (SPES). Methods-SPES was a population-based study of urban, low-middle income residents ≥50 years old. Presenting (PVA) and best-corrected (BCVA) visual acuity, refraction, and slit-lamp examination were performed in 3,677 participants. For subjects with cataract as a principal cause of BCVA ≤ 20/40, surgery was offered free-of-charge. Two years after the baseline study, surgery uptake, barriers to surgery, and visual outcomes were analyzed. Results-Among 210 (5.71%) participants who had cataract surgery indication at baseline, 164 (78.1%) were successfully contacted and 55 (33.5%) reported being operated on for cataract, with 51 agreeing to be reexamined. In a multiple logistic regression model, age, gender, schooling, previous cataract surgery, and PVA at baseline were not significantly associated with surgery uptake. Co-existing health conditions (20.4%), fear of surgery (12.2%) and fear of losing eyesight (11.6%) were the most frequent barriers for cataract surgery adherence. Among the 69 eyes operated on in the interval between baseline and follow-up, PVA ≥20/63 was observed in 50 (72.6%; 95% confidence interval 62.2%-82.3%), PVA <20/63-20/200 in 11 (15.9%; 8.9%-22.9%) and PVA <20/200 in 8 (11.6%; 5.3%-17.9%). Conclusions-Quality of surgery is an increasing determinant of uptake rates. Although free-ofcharge and expedited cataract surgery were offered, surgical outcomes might have influenced the low uptake. Besides cataract surgery campaigns, improvement of surgeon skills, accurate biometry, treatment of ocular comorbidities, postoperative follow-up, and eye-care education are needed.

In our previous work, we demonstrated underutilization of the AIDS Drug Assistance Program (ADAP) at an HIV clinic in Alabama. In order to understand barriers and facilitators to utilization of ADAP, we conducted focus groups of ADAP enrollees. Focus groups were stratified by sex, race, and historical medication possession ratio as a measure of program utilization. We grouped factors according to the social-ecological model. We found that multiple levels of influence, including patient and clinic-related factors, influenced utilization of antiretroviral medications. Patients introduced issues that illustrated high-priority needs for ADAP policy and implementation, suggesting that in order to improve ADAP utilization, the following issues must be addressed: patient transportation, ADAP medication refill schedules and procedures, mailing of medications, and the ADAP recertification process. These findings can inform a strategy of approaches to improve ADAP utilization, which may have widespread implications for ADAP programs across the United States.

Objective: To describe the 3-year long experience of addressing disruptive events by medical staff in a private hospital. Methods: The cross-sectional study that was conducted between 2020 and 2022, involved collection, analysis, and management of suspected cases of disruptive behavior by medical staff. Results: Relevant information was collected from reports issued by health care leaders (69%), anonymous reports accessed from the health institution’s intranet tool “SINAPSE” (19%), the compliance center (5%), customer attendance service (3.7%), the hospital board (2.3%), and the medical practice department (1%). Surgical specialties were responsible for 70.3% of the disruptive incidents, and the average time to outcome was 24.5 days, with most solutions involving guided education of physicians (92.7%). Conclusion: Management of disruptive behavior by medical staff is essential for the prevention of unsafe work environments and strengthening a culture of safety.

The vast amounts of unstructured data in healthcare, such as patient records and research documents, require advanced tools to extract meaningful information efficiently. This research introduces an AI-driven Medical Assistance system utilizing state-of-the-art NLP technologies, including Meta's Llama 3 model. The system extracts medical data from PDFs and CSVs, processes it into meaningful chunks, and creates semantic embeddings stored in a Pinecone vector database. This semantic index serves as the foundation of a knowledge base for medical query response, offering healthcare professionals a tool for efficient and accurate decision-making. We leverage frameworks like LangChain for NLP integration, and Flask for frontend development, while building a scalable system to improve healthcare data processing.

Over a few decades, there is a steady accretion of life expectancy in many countries. Significant advances in modern healthcare technologies, medicines and overall health care awareness gave many to lead a prolonged healthy life. Over the past few years, there has been a huge demand for unobtrusive health monitoring systems from both medical professionals and the general populace to use these technologies for understanding the general health well being in order to improve life longevity. However, most of the available technologies for health monitoring are difficult for the general populace to access and most of the developed health monitoring systems are either deployed in a controlled environment or in healthcare facilities, thus severely limiting the ease of access to many, especially the elderly people. For effective health management of elderly people, evidence-based decision making, continuously monitoring the health status of the elderly demographic is paramount. In order to ...

in t9'76, at .lea~t 85% of tile lsraeii population was insured 'for medical care in l,.,,ur sick ~',mds. Three quarters of the insured population were members of rl~e larges~. Ow Ilis~adr.mh Sick .Fund which belongs to the Labour Federation. i Tile Labour Puny. whirls formed the Government untit 1977, supported the ttistadrut5 Sick Fund in several ways. The F.und ne~er had effective budget const~ain~t. The generous government finance allowed corlsla.laI increa.~e in quantity and quality.of medical sere-ices according to fhe scientific and teclmelogical change~. Ahhough not all workers we,re-free to choose their tick fund, the.~:e exisled m !he .cities compelition between four funds. The other thtee s:ma]ier funds were aIso ~en-p~ofit organizations which fought for equM support. All tSJnds cover most medical ca~e services wi'lh the exception of dental care and med~c~'l ap.pliances (spectacles, orthopaedic, etc.t and supphed directly most of t]le medical services given outside hospitals. The l tistadrmh Sick thind owt~;s about 30% of the .general hospitals" beds and hospita'lizes its members m ethel public ho.~pitz]s which belong either to the government o'r to charities and municipalities. According 1o t,he Central Bureau of St,atistics. "~ nalional expenditure on ~ledical cadre lr~ 1975-76 was 7% of aggregate consumplion. In another study. ~ al~e Bureau found ~hat htm.~t.'. holds devoted only 3-7% of their consumption Io medical care, distributed in ti~e fl:4lk~wW, g way: 1-3% :for insurance in ~he ,~ick funds, 1-3%for denial ca,re and 1-17/7. tk~r ~,thcr services. including 0-4% for pri~ate doctor c~re, The rest of the 1-]% "othe.r services" c~wcE., uni~sured services, such as hospitalization of the chronically ill. One can deduce ,from these figures t1:;11 households financed only a .minor paa't of the sick-funds" budgets,. Employers rand +he Government met most of the sick funds' expenses, Medical care supplied by sick funds ~nd hv the government is still provided to memberr; of the.sick fl,mds without direct p~yment. The funds, which had no real budge| constraims on their expenditures had J~, reason .ik~ acting eft]ciently wMle providing medical services. 'The cort~umcr's p~eference, us~alty expressed through Iris market demand and p~yment, is absent 'in most of ~t'te health-services. Medical care, however, may not Ieflect co~sumers" preferer~ces. A stud} of the demand fc, t private substitutes-for insured services can indicate deficiencies in the t~mvi.~,~.~ ,~f hoe public services. It can also .reflect eonsmne~s" preferences c(mcernir~g Ihe cove~ag;. :,.]esi~e~.~ ~"~m~ I'he he~kh insurance program° Members of sick funds can see their doctor without paymenl. In cases of eme.rgen.cy, on the Sabbath or at night,-tliey can see the doctor.on da~ty and the~ ~'isits to a clinic or house c,~ts are also covered by the funds. Arrangernems for supply of drugs varies beaween the funds. Most of.the insured are members of the ltisladruth Sick Fund, .which until 1975-76 pro~'ided .medicines without laayrrlent. The,'eafter it tbllowed the practice of other funds of c]~arging for d~em, in thi~ cast at the rate of I Israeli pound i.e. about $0-05 per item. in addi1[im, ~tae fuud sells several medicines, such as Aspirin, very cheaply: a packet of ten labtets costs.agorot $0.(12, Dft~gs prescribed by p:rivate physicians are also covered, if the Fund's doctor agrees to the treau~aeut.

Administrative and legal requirements and, in particular, federal and state government health care assistance and social services program regulations all combine to add complexity to the management and operation of ambulatory and inpatient health programs. This paper describes how constantly changing government regulations and differences in interpretations and definitions have been expensive, time-consuming and sometimes detrimental to health care delivery for two large management and clinical computer.based information systems.

Background: There are increasing efforts and attention focused on the delivery of mental health services in primary care in low resource settings (e.g., mental health Gap Action Programme, mhGAP). However, less attention is devoted to systematic approaches that identify and address barriers to the development and uptake of mental health services within primary care in low-resource settings. Our objective was to prepare for optimal uptake by identifying barriers in rural Liberia. The country's need for mental health services is compounded by a 14-year history of political violence and the largest Ebola virus disease outbreak in history. Both events have immediate and lasting mental health effects. Methods: A mixed-methods approach was employed, consisting of qualitative interviews with 22 key informants and six focus group discussions. Additional qualitative data as well as quantitative data were collected through semi-structured assessments of 19 rural primary care health facilities. Data were collected from March 2013 to March 2014. Results: Potential barriers to development and uptake of mental health services included lack of mental health knowledge among primary health care staff; high workload for primary health care workers precluding addition of mental health responsibilities; lack of mental health drugs; poor physical infrastructure of health facilities including lack of space for confidential consultation; poor communication support including lack of electricity and mobile phone networks that prevent referrals and phone consultation with supervisors; absence of transportation for patients to facilitate referrals; negative attitudes and stigma towards people with severe mental disorders and their family members; and stigma against mental health workers. Conclusions: To develop and facilitate effective primary care mental health services in a post-conflict, low resource setting will require (1) addressing the knowledge and clinical skills gap in the primary care workforce; (2) improving physical infrastructure of health facilities at care delivery points; and (3) implementing concurrent interventions designed to improve attitudes towards people with mental illness, their family members and mental health care providers.

The article studies medical assistance – the main direction of social maintenance system stated by Soviet government – as exemplified by Yenisseyskaya Province. Yenisseyskaya Province is valuable through its vast territory of 2.34 million square kilometers, its geographical distance from economic and cultural centres of Russia, its underpopulation, absence of well-developed traffic and social infrastructure, and severe natural and climatic conditions. Soviet Power finally established here in January 1920 and, as compared to other Siberian provinces, did not face any serious opposition in this region. The article is based on the documents from State Archive of Krasnoyarsk Krai and published sources. These data allowed revealing limitation of resources (both material and human) in the sphere of medical assistance and service. There is a confirmed statement in research literature that states the fact that during the period of Revolution and the Civil War (October 1917–1920) they did no...

Introduction People in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system. Methods Using mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child's respiratory symptoms.

Background: The Chiranjeevi Yojana (CY) is a large public-private partnership program in Gujarat, India, under which the state pays private sector obstetricians to provide childbirth services to poor and tribal women. The CY was initiated statewide in 2007 because of the limited ability of the public health sector to provide emergency obstetric care and high out-of-pocket expenditures in the private sector (where most qualified obstetricians work), creating financial access barriers for poor women. Despite a million beneficiaries, there have been few reports studying CY, particularly the proportion of vulnerable women being covered, the expenditures they incur in connection with childbirth, and the level of subsidy provided to beneficiaries by the program. Methods: Cross-sectional facility based the survey of participants in three districts of Gujarat in 2012-2013. Women were interviewed to elicit sociodemographic characteristics, out-of-pocket expenditures, and CY program details. Descriptive statistics, chi square, and a multivariable logistic regression were performed. Results: Of the 901 women surveyed in 129 facilities, 150 (16 %) were CY beneficiaries; 336 and 415 delivered in government and private facilities, respectively. Only 36 (24 %) of the 150 CY beneficiaries received a completely cashless delivery. Median out-of-pocket for vaginal/cesarean delivery among CY beneficiaries was $7/$71. The median degree of subsidy for women in CY who delivered vaginally/cesarean was 85/71 % compared to out-of-pocket expenditure of $44/$208 for vaginal/cesarean delivery paid by non-program beneficiaries in the private health sector. Conclusions: CY beneficiaries experienced a substantially subsidized childbirth compared to women who delivered in non-accredited private facilities. However, despite the government's efforts at increasing access to delivery services for poor women in the private sector, uptake was low and very few women experienced a cashless delivery. While the long-term focus remains on strengthening the public sector's ability to provide emergency obstetric care, the CY program is a potential means by which the state can ensure its poor mothers have access to necessary care if uptake is increased.

 To evaluate if government-funded vision care support programs facilitate access to eye care providers amongst low-income individuals in Canada Methods  Systematically reviewed government-funded low-income vision care support programs in the 10 Canadian provinces: eligibility criteria, coverage policies and amount of assistance provided  Compared the self-reported utilization of eye care providers between the economically deprived vs. others  Data from the Canadian Community Health Survey (CCHS) Healthy Aging 2008/09 Results Age group Frequency of Government Coverage Provinces <20 Once every year Alberta (0-18), BC (0-15), Ontario (0-19), Quebec (0-17), Saskatchewan (0-17) Once every 2 years Manitoba (0-17), Nova Scotia (0-9

Free healthcare obviously works when a partner from abroad supplies a health centre or a health district with medicines and funding on a regular basis, provides medical, administrative and managerial training, and gives incentive bonuses and daily subsistence allowances to staff. The experiments by three international NGO in Burkina Faso, Mali and Niger have all been success stories. But withdrawing NGO support means that health centres that have enjoyed a time of plenty under NGO management will return to the fold of health centres run by the state in its present condition and the health system in its present condition, with the everyday consequences of late reimbursements and stock shortages. The local support given by international NGOs has more often than not an effect of triggering an addiction to aid instead of inducing local sustainability without infusion. In the same way, scaling up to the entire country a local pilot experiment conducted under an NGO involves its insertion...

Lisbon, one of Europe's oldest cities, still maintains the marks of its early history and rich medical heritage. As the legend recounts, Ulysses founded and named the city Ulissipo or Olissipo. Portugal emerged as a nation-state in the early 12th century. Notwithstanding, Chalcolithic trepanned skulls already highlight our medical history. Traces from the Roman cult to Aesculapius are still in plain sight among vestiges of Jewish and Arabic settlements, and its glory as the capital of a great empire, leading the trade of Eastern products and exotic materia medica, in the sixteenth century. Museums and monuments near the Tagus River are some of the most appealing records of our collective memory. The Abstract Book of the 46th ISHM Congress, September 3-7, 2018, Lisbon, Portugal, discloses an insightful summary of a memorable and valuable event.

Maria do Sameiro Barroso
48th ISHM Vice-President

While the recession increased demands on the health care safety net as Americans lost jobs and health insurance, the impact on safety net providers has been mixed and less severe--at least initially--than expected in some cases, according to a new study of five metropolitan communities by the Center for Studying Health System Change (HSC). Even before the recession, many safety net providers reported treating more uninsured patients and facing tighter state and local funding. Federal expansion grants for community health centers during the past decade, however, have increased capacity at many health centers. And, programs to help direct people to primary care providers may have helped stem the expected surge in emergency department use by the uninsured during the downturn. Federal stimulus funding--the 2009 American Recovery and Reinvestment Act--has assisted hospitals and health centers in weathering the economic storm, helping to offset reductions in state, local and private funding. And, the economic downturn has generated some potential benefits, including lower rents and broader employee applicant pools. While safety net providers have adopted strategies to stay financially viable, many believe they have not yet felt the full impact of the deepest recession since the Great Depression.