Frequently used healthcare services in urban slums of Dhaka and adjacent rural areas and their determinants.

BACKGROUND: To compare patterns of healthcare service user preference between urban slums in Dhaka and adjacent rural areas and to identify key determinants of those preferences. METHODS: The data were collected through baseline surveys conducted in 2008 and 2009. A total of 3207 subjects aged 10-90 years were systematically selected from 12 big slums in Dhaka and 3 rural villages outside Dhaka. RESULTS: Two frequently used healthcare sources utilized in 1 month preceding the baseline survey were pharmacies (slum, 42.6%; rural, 30.1%) and government hospitals/clinics (GVHC; slum, 13.5%; rural, 8.9%). According to the multilevel logistic regression analysis adjusted for age, sex and marital status, the likelihood of using pharmacies and GVHC were higher for those subjects who used non-hygienic toilets, who reported food deficiency at a family level, who expressed dissatisfaction about family income and who stated poor health status. Some more factors namely overweight, living in permanently structured house, smoking bidis and less frequency of watching TV were associated with higher likelihood of using GVHC. CONCLUSIONS: Pharmacy was the most dominant healthcare service in both areas. As persons running pharmacies often provide poor quality of healthcare services, they need continuous training and back-up supports to improve their quality of services and to strengthen the overall healthcare system in Bangladesh.

Building capacity for a transformation initiative: system redesign at Denver Health.

BACKGROUND: This article examines the development of transformation initiatives-deliberate attempts to achieve systemic changes and rapid performance improvements. Accounts of transformation initiatives often reveal little about past organizational and contextual conditions that contributed to success. Instead, these accounts concentrate on change barriers. PURPOSE: We seek to restore balance to this field by examining how antecedent system capacities contributed to a successful transformation initiative. METHODOLOGY: This article presents a case study of the first 2 years of a system redesign initiative at an integrated safety-net health system and provides a historical analysis of developments during the decade preceding the redesign. FINDINGS: Beginning in the mid-1990 s, Denver Health benefited from strong municipal support for its development and expansion. Gradually, it developed its financial and human resources, organizational structure, change strategy, change-management capabilities, information technology, and physical plant. These antecedent capacities all contributed to the implementation of the 2004 system redesign and helped Denver Health overcome several constraints. IMPLICATIONS: Transformation initiatives may build on existing features and resources, even as they overcome or depart from others. The Denver Health case study helps researchers identify positive antecedents to transformation initiatives, assess the success of such initiatives in terms of implementation progress and outcomes, and recognize complementary contributions of incremental and episodic changes. The study alerts practitioners to the importance of assuring that change efforts rest on solid organizational foundations.

Rural-Urban Difference in Workplace Supports and Impacts for Employed Caregivers.

PURPOSE: This study examines rural-urban differences in employed caregivers' access to workplace supports, negative impacts of caregiving on work, and the association between work and caregiver strain, which can have negative impacts on health. METHODS: We used a cross-sectional analysis of employed caregivers (n = 635) from the 2015 Caregiving in the US survey, including bivariate comparisons of caregiver characteristics, access to workplace benefits, and workplace impacts by rural-urban location, as well as ordered logistic regression models to assess the relationship between workplace benefits and impacts and caregiver strain, stratified by rural-urban location. FINDINGS: Employed rural caregivers had significantly fewer workplace benefits available to them (1.3 out of 5 vs 1.9, P < .001), compared with urban caregivers. In particular, employed rural caregivers were less likely to have access to telecommuting, employee assistance programs, and paid leave. For the full sample, having more negative workplace impacts was associated with greater caregiver strain (adjusted odds ratio [AOR]: 1.65, P < .001); for employed rural caregivers, using paid help for caregiving was associated with more strain (AOR: 4.39, P < .05). CONCLUSIONS: More should be done to support all employed caregivers, especially those in rural locations who have more limited access to workplace supports and who may be more negatively impacted by the financial toll of caregiving and of missing work because of caregiving responsibilities. Interventions could range from employer-initiated programs to local, state, or national policies to improve supports provided to employed caregivers in urban and rural areas.

Disparities in complementary and alternative medical therapy recommendations for children in two different socioeconomic communities.

OBJECTIVE: To compare the content, quality, and cost of recommendations for children made by complementary and alternative medicine (CAM) retailers within 2 New York City neighborhoods of divergent socioeconomic status (SES). METHODS: Posing as consumers, researchers sought recommendations from CAM retailers for 2 clinical scenarios: 1) a febrile 6-week-old and 2) a 4-year-old with an upper respiratory infection (URI). All retailers selling CAM therapies outside the direction of a licensed provider within East Harlem (EH) and the Upper East Side (UES) were eligible and mapped. The febrile infant scenario was posed at sites in business in March (n = 23) and the URI scenario at sites that remained in business in April (n = 20) of 2004. RESULTS: In response to the febrile infant scenario, 33% of UES retailers referred to a MD, 0% to the emergency department, and 47% made other recommendations-of which 43% were not indicated. In EH, 50% referred to a MD, 5% to the emergency department, and 37% made other recommendations. The mean price of UES recommendations was Dollars 9.66, whereas EH was Dollars 2.33 (P = .04). In response to the URI scenario, 93% of UES and 83% of EH retailers made recommendations. The mean price of UES recommendations was Dollars 10.55 while EH was Dollars 4.26 (P = .002). CONCLUSIONS: Complementary and alternative medicine retailers made numerous recommendations for children, including some that were contraindicated for age. East Harlem retailers tended to refer an infant with a potentially serious condition to the emergency department or to an MD and made less expensive recommendations than their UES counterparts.

'Poorly defined': unknown unknowns in New Zealand Rural Health.

There is a considerable mismatch between the population that accesses rural healthcare in New Zealand and the population defined as 'rural' using the current statistics New Zealand rural and urban categorisations. Statistics New Zealand definitions (based on population size or density) do not accurately identify the population of New Zealanders who actually access rural health services. In fact, around 40% of people who access rural health services are classified as 'urban' under the Statistics New Zealand definition, while a further 20% of people who are currently classified as 'rural' actually have ready access to urban health services. Although there is some recognition that current definitions are suboptimal, the extent of the uncertainty arising from these definitions is not widely appreciated. This mismatch is sufficient to potentially undermine the validity of both nationally-collated statistics and also any research undertaken using Statistics New Zealand data. Under these circumstances it is not surprising that the differences between rural and urban health care found in other countries with similar health services have been difficult to demonstrate in New Zealand. This article explains the extent of this mismatch and suggests how definitions of rural might be improved to allow a better understanding of New Zealand rural health.

200 city survey. JEMS 2001 annual report on EMS operational & clinical trends in large, urban areas.

This year's survey offered examples of evolving partnerships between the public and EMS providers with a growing number of systems implementing PAD programs. The apparent influence of a communication center's managing agency on prioritization strategies is concerning. However, further study is needed. EMS managers must pay careful attention to comm center practices and technology to ensure their ability to support response prioritization and the efficient management of EMS resources. The small reduction in the use of hot response (lights and siren) to every request for service is disappointing in light of medical literature and position statements that condemn this practice. Resource response can be safely prioritized using today's EMD protocol systems. Prioritization and changing response [figure: see text] time requirements to address impending revenue and service demand changes will require additional standardization of methodologies and reporting of response times to relate this measure to other system performance indicators (e.g., patient morbidity/mortality, cost, customer satisfaction, etc.). The future presents a difficult road for system administrators. However, the adoption of a growing number of information-management tools and changes in procedures and dispatch processes offer potential solutions. The increased use of hand-held computers or personal digital assistant (PDAs) to gather and provide information and the almost universal use of CAD will aid providers in performing the research necessary to change response time performance requirements, improving EMS system efficiency. Use of this technology will also likely improve patient care and reimbursement through more timely and accurate reporting and analysis. The medical director's role will be critical to ensuring potential changes don't compromise patient care. Obtaining a better understanding of how much time can safely elapse between the time of the 9-1-1 call and when patient-care activities commence will be an important component of future strategies. More sophisticated EMD, CAD and AVL technologies will also play an indispensable role in reforming system design and daily operations. In light of the events of Sept. 11 and events yet to occur, EMS managers and providers face significant operational challenges. Overcoming these challenges will require leadership, a willingness to question and change tradition and the ability to cope with the discomfort of changing demands and uncertainty. Maintaining the hard-fought successes of EMS will increasingly require more imagination and the willingness of current and future practitioners to study, develop and implement innovative approaches to addressing future requirements.

[The specificity of organization of the consultative-and-diagnostic service for the adult population in a big city]. / Osobennosti organizatsii konsul'tativno-diagnosticheskoi pomoshchi vzroslomu naseleniiu krupnogo goroda.

The volume and structure of the diagnostic services and of the medical aid appealability were analyzed for the Eastern Administrative District of Moscow by the example of a stage-2 diagnostic-and-consultative center. The analysis was made on the basis of 80233 receipts of patients for the period of January-April 2003. Three types of patients' flow were defined with respect to the purpose of visit: consultative aid (CA, 17.3%), consultative-and-diagnostic aid (CDA, 16.2%) and diagnostics (D, 66.5%). Differences are shown in the structure of appealability by the classes of diseases (nosological forms of diseases) and according to groups of patients. Consultations are mostly provided in cases of diseases of the endocrine system (20.9%), digestive system (20.2%) blood-circulation system (18.0%) and urogenital system (14.6%). Patients with urogenital disease (31.1%) and with blood-circulation lesions (13.5%) were found to be predominant in the CDA group. The structure of appealability is defined for the classes of diseases, their nosological forms and for medical specialties. It is pointed out that 52.1% of patients visited their general practitioners. Patients visited most often the doctors of the below specialties: oncology--16.1%, endocrinology and cardiology 12.3%, general practitioner--11.5% and gastroenterology--78%. The rate of visits was evaluated for the classes of diseases and medical fields; the estimated distribution of appealability was estimated with respect to the rate of visits. The structure of diagnostic examinations was analyzed by types, purpose, and classes of diseases (nosological forms).

On the spatial inequalities of institutional versus home births in Ghana: a multilevel analysis.

Spatial inequalities related to the choice of delivery care have not been studied systematically in Sub-Saharan Africa where maternal and perinatal health outcomes continue to worsen despite a range of safe motherhood interventions. Using retrospective data from the 1998 and 2003 Demographic and Health Surveys, this paper investigates the extent of changes in spatial inequalities associated with type of delivery care in Ghana with a focus on rural-urban differentials within and across the three ecological zones (Savannah, Forest and Coastal). More than one-half of births in Ghana continue to occur outside health institutions without any skilled obstetric care. While this is already known, we present evidence from multilevel analyses that there exist considerable and growing inequalities, with regard to birth settings between communities, within rural and urban areas and across the ecological zones. The results show evidence of poor and disproportionate use of institutional care at birth; the inequalities remained high and unchanged in both urban and rural communities within the Savannah zone and widening in urban communities of the Forest and Coastal zones. The key policy challenges in Ghana, therefore, include both increasing the uptake of institutional delivery care and ensuring equity in access to both public and private health institutions.

The "vertical response time": barriers to ambulance response in an urban area.

BACKGROUND: Ambulance response time is typically reported as the time interval from call dispatch to arrival on-scene. However, the often unmeasured "vertical response time" from arrival on-scene to arrival at the patient's side may be substantial, particularly in urban areas with high-rise buildings or other barriers to access. OBJECTIVES: To measure the time interval from arrival on-scene to the patient in a large metropolitan area and to identify barriers to emergency medical services arrival. METHODS: This was a prospective observational study of response times for high-priority call types in the New York City 9-1-1 emergency medical services system. Research assistants riding with paramedics enrolled a convenience sample of calls between 2001 and 2003. RESULTS: A total of 449 paramedic calls were included, with a median time from call dispatch to arrival on-scene of 5.2 minutes. The median on-scene to patient arrival interval was 2.1 minutes, leading to an actual response interval (dispatch to patient) of 7.6 minutes. The median on-scene to patient interval was 2.8 minutes for residential buildings, 2.7 minutes for office complexes, 1.3 minutes for private homes (less than four stories), and 0.5 minutes for outdoor calls. Overall, for all calls, the on-scene to patient interval accounted for 28% of the actual response interval. When an on-scene escort provided assistance in locating and reaching the patient, the on-scene to patient interval decreased from 2.3 to 1.9 minutes. The total dispatch to patient arrival interval was less than 4 minutes in 8.7%, less than 6 minutes in 28.5%, and less than 8 minutes in 55.7% of calls. CONCLUSIONS: The time from arrival on-scene to the patient's side is an important component of overall response time in large urban areas, particularly in multistory buildings.

Self-reported patterns of health services utilisation: an urban-rural comparison in South Australia.

OBJECTIVE: To compare self-reported patterns of health service utilisation among residents of urban and rural South Australia. DESIGN, SETTING AND MAIN OUTCOME MEASURES: Secondary analysis of data generated by computer-assisted telephone interviews of 7377 adults done in 1995-6. Respondents were asked if they had used each of 18 different health services during the previous 12 months. Residence was classified in three ways: (1) capital city versus rest of the state, (2) by the Rural, Remote and Metropolitan Areas classification (RRMA) and (3) by the Accessibility and Remoteness Index for Australia classification (ARIA). RESULTS: General practitioner services were most frequently used, by approximately 89% of respondents. Only 4% reported not using any service. Comparing capital city with rest of the state, modest but statistically significant differences in utilisation (P < 0.01) were measured for nine services. In eight of these nine, utilisation was higher among rural residents. Analysing by RRMA, eight services were reportedly used differently and seven of these were the same as those identified from the capital city versus rest of state comparison. Across the five ARIA categories, six previously identified services were reported as being used differentially. Overall, rural residents had a higher than expected rate of moderate and high level of health service use. CONCLUSIONS: Self-reported use of a range of health services was broadly similar across urban and rural South Australia, with most cases of higher use were reported from rural areas rather than urban areas. Similar results were obtained when residence was classified in the three different ways.