Benefits, challenges, and strategies related to using presumptive recommendations for HPV vaccination: A qualitative study with rural and non-rural-serving primary care professionals.

HPV vaccination coverage remains far below the national target of 80% among US adolescents, particularly in rural areas, which have vaccine uptake rates that are 10% points lower than non-rural areas on average. Primary care professionals (PCPs) can increase coverage by using presumptive recommendations to introduce HPV vaccination in a way that assumes parents want to vaccinate. Through semi-structured interviews, we explored PCPs' experiences and perceptions of using presumptive recommendations in rural- and non-rural-serving primary care clinics in North Carolina. Thematic analysis revealed that most PCPs in rural and non-rural contexts used presumptive recommendations and felt the strategy was an effective and concise way to introduce the topic of HPV vaccination to parents. At the same time, some PCPs raised concerns about presumptive recommendations potentially straining relationships with certain parents, including those who had previously declined HPV vaccine or who distrust medical authority due to their past experiences with the healthcare system. PCPs dealt with these challenges by using a more open-ended approach when introducing HPV vaccination to parents. In conclusion, our findings suggest that PCPs in both rural and non-rural settings see value in using presumptive recommendations to introduce HPV vaccination, but to adequately address concerns and ensure increased HPV vaccine uptake, PCPs can use simple and culturally sensitive language to ensure fully informed consent and to maintain parental trust. And to further strengthen HPV vaccine discussions, PCPs can utilize other effective HPV communication techniques, like the Announcement Approach, in discussing HPV vaccinations with hesitant parents.

Low HBV knowledge is associated with low HBV vaccination uptake in general adult population despite incentivization of HBV vaccination.

BACKGROUND: Hepatitis B virus (HBV) vaccination in Vietnamese adults remains low and unequally distributed. We conducted a study on HBV-naïve adults living in Ho Chi Minh City, Viet Nam, to determine barriers associated with HBV vaccination uptake after removing the financial barrier by providing free coupons for HBV vaccination. METHODS: After being screened for HBsAg, anti-HBs, and anti-HBc, 284 HBV-naïve study participants aged 18 and over (i.e., negative for HBsAg, anti-HBs, and anti-HBc total) were provided free 3-dose HBV vaccine coupons. Next, study participants' receipt of 1st, 2nd, and 3rd doses of HBV vaccine was documented at a pre-specified study healthcare facility, where HBV vaccines were distributed at no cost to the participants. Upon study entry, participants answered questionnaires on sociodemographics, knowledge of HBV and HBV vaccination, and related social and behavioral factors. The proportions of three doses of HBV vaccine uptake and their confidence intervals were analyzed. Associations of HBV vaccine initiation with exposures at study entry were evaluated using modified Poisson regression. RESULTS: 98.9% (281 of 284) of study participants had complete data and were included in the analysis. The proportion of participants obtaining the 1st, 2nd, and 3rd doses of HBV vaccine was 11.7% (95% Confidence Interval [95% CI] 8.0-15.5%), 10.7% (95%CI 7.1-14.3%), and 8.9% (95%CI 5.6-12.2%), respectively. On the other hand, participants were more likely to initiate the 1st dose if they had adequate knowledge of transmission (adjusted relative risk [aRR] = 2.58, 95% CI 1.12-5.92), adequate knowledge of severity (aRR = 6.75, 95%CI 3.38-13.48), and annual health-checking seeking behavior (aRR = 2.04, 95%CI 1.07-3.87). CONCLUSION: We documented a low HBV vaccination uptake despite incentivization. However, increased vaccine initiation was associated with better HBV knowledge and annual health check-up adherence. When considering expanding HBV vaccination to the general adult population, we should appreciate that HBV knowledge is an independent predictor of vaccine uptake.

Clostridioides difficile infection, recurrence and the associated healthcare consumption in Sweden between 2006 and 2019: a population-based cohort study.

BACKGROUND: Clostridioides difficile infection (CDI) causes a major burden to individuals and society, yet the impact may vary depending on age, sex, underlying comorbidities and where CDI was acquired (hospital or community). METHODS: This Swedish nationwide population-based cohort study (2006-2019) compared all 43,150 individuals with CDI to their 355,172 matched controls (first year and entire follow-up). Negative binomial regression models compared the cumulated length of stay, number of in-hospital admissions, outpatient visits and prescriptions after the first CDI episode expressed as incidence rate ratios (IRR) and 95% confidence intervals for the entire follow-up. RESULTS: Overall, 91.6% of CDI cases were hospital acquired, and 16.8% presented with recurrence(s); 74.8%of cases were ≥ 65 years and 54.2% were women. Compared to individuals without CDI, in-hospital stay rates were 18.01 times higher after CDI (95% CI 17.40-18.63, first-year: 27.4 versus 1.6 days), 9.45 times higher in-hospital admission (95% CI 9.16-9.76, first-year: 2.6 versus 1.3 hospitalisations), 3.94 times higher outpatient visit (95% CI 3.84-4.05, first-year: 4.0 versus 1.9 visits) and 3.39 times higher dispensed prescriptions rates (95% CI 3.31-3.48, first-year: 25.5 versus 13.7 prescriptions). For all outcomes, relative risks were higher among the younger (< 65 years) than the older (≥ 65 years), and in those with fewer comorbidities, but similar between sexes. Compared to those without recurrence, individuals with recurrence particularly showed a higher rate of hospital admissions (IRR = 1.18, 95% 1.12-1.24). Compared to community-acquired CDI, those with hospital-acquired CDI presented with a higher rate of hospital admissions (IRR = 7.29, 95% CI 6.68-7.96) and a longer length of stay (IRR = 7.64, 95% CI 7.07-8.26). CONCLUSION: CDI was associated with increased health consumption in all affected patient groups. The majority of the CDI burden could be contributed to hospital-acquired CDI (~ 9/10), older patients (~ 3/4) and those with multiple comorbidities (~ 6/10 Charlson score ≥ 3), with 1/5 of the total CDI burden contributed to individuals with recurrence. Yet, relatively speaking the burden was higher among the younger and those with fewer comorbidities, compared to their peers without CDI.

When the smoke gets in your lungs: short-term effects of Indonesia's 2015 forest fires on health care use.

BACKGROUND: The forest fires that ravaged parts of Indonesia in 2015 were the most severely polluting of this century but little is known about their effects on health care utilization of the affected population. We estimate their short-term impact on visit rates to primary and hospital care with particular focus on visits for specific smoke-related conditions (respiratory disease, acute respiratory tract infection (ARTI) and common cold). METHOD: We estimate the short-term impact of the 2015 forest fire on visit rates to primary and hospital care by combining satellite data on Aerosol Optical Depth (AOD) with administrative records from Indonesian National Health Insurance Agency (BPJS Kesehatan) from January 2015-April  2016. The 16 months of panel data cover 203 districts in the islands of Sumatra and Kalimantan before, during and after the forest fires. We use the (more efficient) ANCOVA version adaptation of a fixed effects model to compare the trends in healthcare use of affected districts (with AOD value above 0.75) with control districts (AOD value below 0.75). Considering the higher vulnerability of children's lungs, we do this separately for children under 5 and the rest of the population adults (> 5), and for both urban and rural areas, and for both the period during and after the forest fires. RESULTS: We find little effects for adults. For young children we estimate positive effects for care related to respiratory problems in primary health care facilities in urban areas. Hospital care visits in general, on the other hand, are negatively affected in rural areas. We argue that these patterns arise because accessibility of care during fires is more restricted for rural than for urban areas. CONCLUSION: The severity of the fires and the absence of positive impact on health care utilization for adults and children in rural areas indicate large missed opportunities for receiving necessary care. This is particularly worrisome for children, whose lungs are most vulnerable to the effects. Our findings underscore the need to ensure ongoing access to medical services during forest fires and emphasize the necessity of catching up with essential care for children after the fires, particularly in rural areas.

A qualitative study on the adaptation of community programmes for the promotion of early detection and health-seeking of perinatal depression in Nepal.

BACKGROUND: Despite the high burden of perinatal depression in Nepal, the detection rate is low. Community-based strategies such as sensitization programmes and the Community Informant Detection Tool (CIDT) have been found to be effective in raising awareness and thus promoting the identification of mental health problems. This study aims to adapt these community strategies for perinatal depression in the Nepalese context. METHODS: We followed a four-step process to adapt the existing community sensitization program manual and CIDT. Step 1 included in-depth interviews with women identified with perinatal depression (n=36), and focus group discussions were conducted with health workers trained in community mental health (n=13), female community health volunteers (FCHVs), cadre of Nepal government for the prevention and promotion of community maternal and child health (n=16), and psychosocial counsellors (n=5). We explored idioms and understanding of depression, perceived causes, and possible intervention. Step 2 included draft preparation based on the qualitative study. Step 3 included a one-day workshop with the psychosocial counsellors (n=2) and health workers (n=12) to assess the understandability and comprehensiveness of the draft and to refine the content. A review of the CIDT and community sensitization program manual by a psychiatrist was performed in Step 4. RESULTS: The first step led to the content development for the CIDT and community sensitization manual. Multiple stakeholders and experts reviewed and refined the content from the second to fourth steps. Idioms of depression and commonly cited risk factors were incorporated in the CIDT. Additionally, myths of perinatal depression and the importance of the role of family were added to the community sensitization manual. CONCLUSION: Both the CIDT and community sensitization manual are grounded in the local context and are simple, clear, and easy to understand.

COVID-19 vaccine acceptance among pregnant women: a multicentre cross-sectional survey in Port Harcourt, Nigeria.

Introduction: effective COVID-19 vaccines for the prevention of severe illness have been available for more than one year now. This study was carried out to ascertain vaccine hesitancy and its associations among pregnant women receiving antenatal care in Port Harcourt, a large cosmopolitan town in Nigeria. Methods: we conducted a cross-sectional online survey over 2 months among consenting pregnant women receiving antenatal care in the 3 largest obstetric service centers in Port Harcourt to evaluate COVID-19 vaccine hesitancy and its associations. Results: the prevalence of vaccine hesitancy was 669 (72.2%). Of the respondents, 27 (2.9%) had been infected or had a close family member infected with SARS-CoV-2, and 897 (96.8%) of them had heard of the COVID-19 vaccine; however, only 133 (14.4%) had been vaccinated against COVID-19. The safety of the mother in 260 (32.8%) and the safety of the unborn baby in 114 (14.4%) of the respondents were the reasons for vaccine hesitancy. A small proportion of women 7(0.9%) were hesitant on religious grounds. Tertiary education, use of childhood immunization for previous infants delivered, and availability of COVID-19 vaccine in the antenatal clinic at no cost to the women, were statistically significant predictors of vaccine uptake among the respondents. Conclusion: the prevalence of vaccine hesitancy among pregnant women in Port Harcourt was 72.2%. Higher academic achievement and availability of the COVID-19 vaccine in the antenatal clinic were predictors of vaccine uptake, while reasons for hesitancy were mostly due to safety concerns for the mother and unborn baby.

Costs and health care resource utilization among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia.

BACKGROUND: Chronic lymphocytic leukemia (CLL) is the most common type of leukemia. However, published studies of CLL have either only focused on costs among individuals diagnosed with CLL without a non-CLL comparator group or focused on costs associated with specific CLL treatments. An examination of utilization and costs across different care settings provides a holistic view of utilization associated with CLL. OBJECTIVE: To quantify the health care costs and resource utilization types attributable to CLL among Medicare beneficiaries and identify predictors associated with each of the economic outcomes among beneficiaries diagnosed with CLL. METHODS: This retrospective study used a random 20% sample of the Medicare Chronic Conditions Data Warehouse (CCW) database covering the 2017-2019 period. The study population consisted of individuals with and without CLL. The CLL cohort and non-CLL cohort were matched using a 1:5 hard match based on baseline categorical variables. We characterized economic outcomes over 360 days across cost categories and places of services. We estimated average marginal effects using multivariable generalized linear regression models of total costs and across type of services. Total cost was compared between CLL and non-CLL cohorts using the matched sample. We used generalized linear models appropriate for the count or binary outcome to identify factors associated with various categories of health care resource utilization, such as inpatient admissions, emergency department (ED) visits, and oncologist/hematologist visits. RESULTS: A total of 2,736 beneficiaries in the CLL cohort and 13,571 beneficiaries in the non-CLL matched cohort were identified. Compared with the non-CLL cohort, the annual cost for the CLL cohort was higher (CLL vs non-CLL, mean [SD]: $22,781 [$37,592] vs $13,901 [$24,725]), mainly driven by health care provider costs ($6,535 vs $3,915) and Part D prescription drug costs ($5,916 vs $2,556). The main categories of health care resource utilization were physician evaluation/management visits, oncologist/hematologist visits, and laboratory services. Compared with beneficiaries aged 65-74 years, beneficiaries aged 85 years or older had lower use and cost in maintenance services (ie, oncologist visits, hospital outpatient costs, and prescription drug cost) but higher use and cost in acute services (ie, ED). Compared with residency in a metropolitan area, living in a nonmetropolitan area was associated with fewer physician visits but higher ED visits and hospitalizations. CONCLUSIONS: The cooccurrence of lower utilization of routine care services, along with higher utilization of acute care services among some individuals, has implications for patient burden and warrants further study.

Non-use and inadequate use of cervical cancer screening among a representative sample of women in the United States.

Introduction: Women's adherence to the United States (U.S.) Preventive Services Task Force guidelines for cervical cancer screening was determined by examining predisposing, enabling, and needs factors from Andersen's Behavioral Model of Health Services Use conceptual framework. Methods: The outcome was operationalized as cervical cancer screening use, non-use, and inadequate-use. Multinomial logistic regression was conducted on data from the 2019 National Health Interview Survey of 7,331 eligible women aged 21-65. Results: Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Non-Users than those aged 21-29. Hispanic, Asian, and American Indian/Alaska Native (AIAN) women were more likely to be Non-Users than White women. More educated women were less likely to be Non-Users. Foreign-born women <10 years in the U.S. were more likely to be Non-Users than U.S.-born women. Women with financial hardship were less likely to be Non-Users. Poorer women and uninsured women were more likely to be Non-Users. Women with children in their household were less likely to be Non-Users than those without children. Women who had a well-visit in the past year were less likely to be Non-Users. Women with a history of human papillomavirus (HPV) vaccination were less likely to be Non-Users. Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Inadequate-Users. AIAN women were more likely to be Inadequate-Users. Women of other races were less likely to be Inadequate-Users. Employed women were less likely to be Inadequate-Users. Uninsured women were more likely to be Inadequate-Users. Women who had a well-visit within a year were less likely to be Inadequate-Users. Women with past HPV vaccination were more likely to be Inadequate-Users. Smokers were less likely to be Inadequate-Users. Discussion: Predisposing, enabling, and needs factors are differently associated with non-use and inadequate use of cervical cancer screening. Understanding factors associated with the use, non-use, and inadequate use of cervical cancer screening is crucial to avoid or curb unnecessary tests, increased costs to both society and individuals, and the ill-allocation of limited resources.

How internet healthcare information overflow affects farmers' healthcare consumption: insights from China.

Introduction: In the context of the deep coupling and synergistic development of digital villages and healthy villages, the development of China's rural society harbors a huge potential for medical and healthcare consumption. Methods: On the basis of theoretical research, a framework was constructed to analyze the influence mechanism of farmers' medical and healthcare consumption in the context of Internet medical information overflow, and empirically examines the research and analysis framework by using the 2020 China Household Tracking Survey data with the OLS model, mediation effect model, and instrumental variable method. Results: It is found that Internet medical information spillover has a "crowding-in effect" on farmers' healthcare consumption; Medical attendance behavior, economic capital utilize the intermediary effect between Internet medical information spillover and farmers' healthcare consumption. And there is age group heterogeneity in the effect of Internet medical information spillover on farmers' healthcare consumption, The ability of rural middle-aged and old-aged groups to recognize new things such as Internet medical information needs to be improved, so the overflow of Internet medical information will induce rural middle-aged and old-aged groups to generate a certain amount of medical and health care consumption. However, the impact on healthcare consumption is not sensitive to the youth cohort group. Discussion: The sinking of Internet medical resources should be accelerated in the future to promote the high-quality development of rural medical and health services, at the same time the "Internet + healthcare services" should be optimized to promote scientific and rational stratification of farmers' access to healthcare, and economic capital for farmers' access to health care should be improved in order to alleviate the burden of health care, etc.

Analysis of care-seeking and diagnosis delay among pulmonary tuberculosis patients in Beijing, China.

Background: Tuberculosis (TB) remains a significant public health challenge in China. Early detection and diagnosis of TB cases are crucial to interrupt disease transmission and prevent its progression. This study aims to describe the delay in seeking care and diagnosis among patients with pulmonary tuberculosis (PTB) and identify the influencing factors in two counties in Beijing. Methods: A retrospective analysis was carried out to investigate care-seeking and diagnosis delay in two counties in Beijing. Basic information of PTB patients from January 1 to December 31, 2021, was extracted from the Tuberculosis Information Management System of China (TBIMS), and all enrolled patients were interviewed via telephone using a standard questionnaire. Statistical description was performed using the median and interquartile range (IQR). Chi-square test and multivariate logistic regression model were used to analyze the influencing factors. Results: 537 patients were enrolled. The median duration of care-seeking and diagnosis delay was 11 (IQR: 5-26) days and 8 (IQR: 0-18) days, with 41.71 and 35.20% of patients experiencing delays (>14 days). The study found that being asymptomatic (OR = 2.791, 95%CI: 1.710-4.555) before seeking medical care and not attending work during treatment (OR = 2.990, 95%CI: 1.419-6.298) were identified as risk factors for care-seeking delay. Patients who were tracked (OR = 2.632, 95%CI: 1.062-6.521) and diagnosed at tuberculosis control and prevention institutions (OR = 1.843, 95%CI: 1.061-3.202) had higher odds of diagnostic delays. 44.69% of patients presented a total delay (>28 days), with a median duration of 25 (IQR: 13-39) days. A multivariate logistic regression analysis showed that healthy examination (OR = 0.136, 95%CI: 0.043-0.425) was a protective factor for total delay. Conclusion: Public interventions are necessary to improve the efficiency of PTB patients detection and treatment in Beijing. Medical services should focus on the target population and improve access to medical care to further reduce delays for PTB patients.

Why does the number of antenatal care visits in Ethiopia remain low?: A Bayesian multilevel approach.

INTRODUCTION: Antenatal care (ANC) visit is a proxy for maternal and neonatal health. The ANC is a key indicator of access and utilization of health care for pregnant women. Recently, eight times ANC visits have been recommended during the pregnancy period. However, nearly 57% of women received less than four ANC visits in Ethiopia. Therefore, the objective of this study is to identify factors associated withthe number of ANC visits in Ethiopia. METHODS: A community-based cross-sectional study design was conducted from March 21 to June 28/2019. Data were collected using interviewer-administered questionnaires from reproductive age groups. A stratified cluster sampling was used to select enumeration areas, households, and women from selected households. A Bayesian multilevel negative binomial model was applied for the analysis of this study. There is an intra-class correlation (ICC) = 23.42% and 25.51% for the null and final model, respectively. Data were analyzed using the STATA version 17.0. The adjusted incidence risk ratio (IRR) with 95% credible intervals (CrI) was used to declare the association. RESULT: A total of 3915 pregnant women were included in this study. The mean(SD) age of the participants was 28.7 (.11) years. Nearly one-fourth (26.5%) of pregnant women did not have ANC visits, and 3% had eight-time ANC visits in Ethiopia. In the adjusted model, the age of the women 25-28 years (IRR:1.13; 95% CrI: 1.11, 1.16), 29-33 years (IRR: 1.15; 95% CrI: 1.15, 1.16), ≥34 years (IRR:1.14; 95% CrI: 1.12, 1.17), being a primary school (IRR: 1.22, 95% CrI: 1.21, 1.22), secondary school and above (IRR: 1.26, 95% CrI: 1.26, 1.26), delivered in health facility (IRR: 1.93; 95% CrI: 1.92, 1.93), delivered with cesarian section (IRR: 1.18; 95% CrI: 1.18, 1.19), multiple (twin) pregnancy (IRR: 1.11; 95% CrI: 1.10, 1.12), richest (IRR:1.23; 95% CrI: 1.23, 1.24), rich family (IRR: 1.34, 95% CrI: 1.30, 1.37), middle income (IRR: 1.29, 95% CrI: 1.28, 1.31), and poor family (IRR = 1.28, 95% CrI:1.28, 1.29) were shown to have significant association with higher number of ANC vists, while, households with total family size of ≥ 5 (IRR: 0.92; 95% CrI: 0.91, 0.92), and being a rural resident (IRR: 0.92, 95% CrI: 0.92, 0.94) were shown to have a significant association with the lower number of ANC visits. CONCLUSION: Overall, 26.5% of pregnant women do not have ANC visits during their pregnancy, and 3% of women have eight-time ANC visits. This result is much lower as compared to WHO's recommendation, which states that all pregnant women should have at least eight ANC visits. In this study, the ages of the women 25-28, 29-33, and ≥34 years, being a primary school, secondary school, and above, delivered in a health facility, delivered with caesarian section, multiple pregnancies, rich, middle and poor wealth index, were significantly associated with the higher number of ANC visits, while households with large family size and rural residence were significantly associated with a lower number of ANC visits in Ethiopia.

Reducing time to differentiated service delivery for newly-diagnosed people living with HIV in Kigali, Rwanda: a pilot, unblinded, randomized controlled trial.

BACKGROUND: Differentiated service delivery (DSD) programs for people living with HIV (PWH) limit eligibility to patients established on antiretroviral therapy (ART), yet uncertainty exists regarding the duration on ART necessary for newly-diagnosed PWH to be considered established. We aimed to determine the feasibility, acceptability, and preliminary impact of entry into DSD at six months after ART initiation for newly-diagnosed PWH. METHODS: We conducted a pilot randomized controlled trial in three health facilities in Rwanda. Participants were randomized to: (1) entry into DSD at six months after ART initiation after one suppressed viral load (DSD-1VL); (2) entry into DSD at six months after ART initiation after two consecutive suppressed viral loads (DSD-2VL); (3) treatment as usual (TAU). We examined feasibility by examining the proportion of participants assigned to intervention arms who entered DSD, assessed acceptability through patient surveys and by examining instances when clinical staff overrode the study assignment, and evaluated preliminary effectiveness by comparing study arms with respect to 12-month viral suppression. RESULTS: Among 90 participants, 31 were randomized to DSD-1VL, 31 to DSD-2VL, and 28 to TAU. Among 62 participants randomized to DSD-1VL or DSD-2VL, 37 (60%) entered DSD at 6 months while 21 (34%) did not enter DSD because they were not virally suppressed. Patient-level acceptability was high for both clinical (mean score: 3.8 out of 5) and non-clinical (mean score: 4.1) elements of care and did not differ significantly across study arms. Viral suppression at 12 months was 81%, 81% and 68% in DSD-1VL, DSD-2VL, and TAU, respectively (p = 0.41). CONCLUSIONS: The majority of participants randomized to intervention arms entered DSD and had similar rates of viral suppression compared to TAU. Results suggest that early DSD at six months after ART initiation is feasible for newly-diagnosed PWH, and support current WHO guidelines on DSD. TRIAL REGISTRATION: Clinicaltrials.gov NCT04567693; first registered on September 28, 2020.

Improving linkage to HIV care following a reactive HIV self-testing result among men in KwaZulu-Natal, South Africa.

BACKGROUND: Despite the many interventions that have been implemented in sub-Saharan Africa to improve the uptake of HIV testing and antiretroviral (ART) initiation services, the rates at which men are tested for HIV and initiated on ART have remained consistently lower compared to those for women. We aim to investigate barriers and facilitators for linkage to care following HIVST positive results among men aged between 18 and 49 years, and use these findings to design an intervention to improve linkage to care among men in a high-HIV prevalent district in KwaZulu-Natal province, South Africa. METHODS: This multi-method study will be conducted over 24 months in eight purposively selected HIV testing and treatment facilities from December 2023 to November 2025. For the quantitative component, a sample of 197 HIV positive men aged 18-49 years old who link to care after HIV self-test (HIVST) will be recruited into the study. HIVST kits will be distributed to a minimum of 3000 men attending community services through mobile clinics that are supported by the Health Systems Trust, at different service delivery points, including schools, taxi ranks and other hotspots. The qualitative component will consist of in-depth interviews (IDIs) with 15 HIVST users and IDIs with 15 key informants. To design and develop acceptable, feasible, effective, and sustainable models for improving linkage to care, three groups of HIVST users (2*positive (N = 12) and 1*negative (N = 12)) will be purposively select to participate in a design workshop. Chi square tests will be used to identify social and demographic factors associated with linkage, while logistic regression will be used to identify independent factors. Kaplan Meier curves and cox proportional hazard models will be used to identify factors associated with time to event. Content and thematic approaches will be used to analyze the qualitative data. DISCUSSION: There remains an urgent need for designing and implementing innovative intervention strategies that are convenient and tailored for addressing the needs of men for improving HIV testing and linkage to care at early stages in resource-limited settings, to improve individual health outcomes, reduce transmission from HIV and minimize HIV-related mortality rates. Our proposed study offers several important innovations aimed at improving linkage to care among men. Our study targets men, as they lag the HIV continuum but are also under-researched in public health studies.

The cost of keeping patients waiting: retrospective treatment-control study of additional healthcare utilisation for UK patients awaiting elective treatment.

OBJECTIVE: Long waiting times for elective hospital treatments are common in many countries. This study seeks to address a deficit in the literature concerning the effect of long waits on the wider consumption of healthcare resources. METHODS: We carried out a retrospective treatment-control study in a healthcare system in South West England from 15 June 2021 to 15 December 2021. We compared weekly contacts with health services of patients waiting over 18 weeks for treatment ('Treatments') and people not on a waiting list ('Controls'). Controls were matched to Treatments based on age, sex, deprivation and multimorbidity. Treatments were stratified by the clinical specialty of the awaited hospital treatment, with healthcare usage assessed over various healthcare settings. Wilcoxon signed-rank tests assessed whether there was an increase in healthcare utilisation and bootstrap resampling was used to estimate the magnitude of any differences. RESULTS: A total of 44,616 patients were waiting over 18 weeks (the constitutional target in England) for treatment during the study period. There was an increase (p < 0.0004) in healthcare utilisation for all specialties. Patients in the Cardiothoracic Surgery specialty had the largest increase, with 17.9 [interquartile-range: 4.3, 33.8] additional contacts with secondary care and 17.3 [-1.1, 34.1] additional prescriptions per year. CONCLUSION: People waiting for treatment consume higher levels of healthcare than comparable individuals not on a waiting list. These findings are relevant for clinicians and managers in better understanding patient need and reducing harm. Results also highlight the possible 'false economy' in failing to promptly resolve long elective waits.

Experiences of oral pre-exposure prophylaxis use among heterosexual men accessing sexual and reproductive health services in South Africa: a qualitative study.

INTRODUCTION: South African men face a substantial burden of HIV and are less likely to test for HIV and initiate antiretroviral therapy if tested positive and more likely to die from AIDS-related causes than women. In addition to condoms and circumcision, guidelines provide for the use of daily oral pre-exposure prophylaxis (PrEP) as an HIV prevention intervention for any men who recognize their need and request PrEP. However, heterosexual men have not been a focus of PrEP programmes, and since its introduction, there is limited literature on PrEP use among men in South Africa. This study explores the experiences, motivators and barriers to oral PrEP use among heterosexual men accessing primary healthcare services in South Africa. METHODS: This study forms part of a mixed-methods implementation science study aimed at generating evidence for oral PrEP introduction and conducted in primary healthcare clinics in South Africa since 2018. Men aged ≥15 years who initiated oral PrEP and enrolled in a parent cohort study were purposefully invited to participate in an in-depth interview (IDI). Between March 2020 and May 2022, 30 men participated in IDIs exploring their motivators for PrEP use, and experiences with accessing health services. Interviews were audio recorded, transcribed and analysed thematically. RESULTS: The final analysis included 28 heterosexual men (18-56 years old). Motivations to initiate PrEP included fear of acquiring HIV, self-perceived vulnerability to HIV and mistrust in relationships; health systems factors which motivated PrEP use included the influence of healthcare providers, educational materials and mobile services. Perceived reduction in HIV vulnerability and changing proximity to partners were reasons for PrEP discontinuation. Side effects, daily-pill burden and stigma were noted as challenges to PrEP use. Health system barriers to PrEP use included limited PrEP availability, school and work demands, and inconsistent mobile clinic schedules. CONCLUSIONS: Our study reports on the experiences of heterosexual men accessing oral PrEP in real-world settings and contributes to the limited literature among this population. We highlight multiple levels which could be strengthened to improve men's PrEP use, including individual support, education among partners and communities, and addressing health system barriers to access.

Healthcare utilization patterns of individuals with depression after national policy to increase the mental health workforce in primary care: a data linkage study.

BACKGROUND: The deployment of the mental health nurse, an additional healthcare provider for individuals in need of mental healthcare in Dutch general practices, was expected to substitute treatments from general practitioners and providers in basic and specialized mental healthcare (psychologists, psychotherapists, psychiatrists, etc.). The goal of this study was to investigate the extent to which the degree of mental health nurse deployment in general practices is associated with healthcare utilization patterns of individuals with depression. METHODS: We combined national health insurers' claims data with electronic health records from general practices. Healthcare utilization patterns of individuals with depression between 2014 and 2019 (N = 31,873) were analysed. The changes in the proportion of individuals treated after depression onset were assessed in association with the degree of mental health nurse deployment in general practices. RESULTS: The proportion of individuals with depression treated by the GP, in basic and specialized mental healthcare was lower in individuals in practices with high mental health nurse deployment. While the association between mental health nurse deployment and consultation in basic mental healthcare was smaller for individuals who depleted their deductibles, the association was still significant. Treatment volume of general practitioners was also lower in practices with higher levels of mental health nurse deployment. CONCLUSION: Individuals receiving care at a general practice with a higher degree of mental health nurse deployment have lower odds of being treated by mental healthcare providers in other healthcare settings. More research is needed to evaluate to what extent substitution of care from specialized mental healthcare towards general practices might be associated with waiting times for specialized mental healthcare.

Multilevel analysis of determinants in postnatal care utilisation among mother-newborn pairs in India, 2019-21.

Background: Postnatal care (PNC) utilisation within 24 hours of delivery is a critical component of health care services for mothers and newborns. While substantial geographic variations in various health outcomes have been documented in India, there remains a lack of understanding regarding PNC utilisation and underlying factors accounting for these geographic variations. In this study, we aimed to partition and explain the variation in PNC utilisation across multiple geographic levels in India. Methods: Using India's 5th National Family Health Survey (2019-21), we conducted four-level logistic regression analyses to partition the total geographic variation in PNC utilisation by state, district, and cluster levels, and to quantify how much of theses variations are explained by a set of 12 demographic, socioeconomic, and pregnancy-related factors. We also conducted analyses stratified by selected states/union territories. Results: Among 149 622 mother-newborn pairs, 82.29% of mothers and 84.92% of newborns were reported to have received PNC within 24 hours of delivery. In the null model, more than half (56.64%) of the total geographic variation in mother's PNC utilisation was attributed to clusters, followed by 26.06% to states/union territories, and 17.30% to districts. Almost 30% of the between-state variation in mother's PNC utilisation was explained by the demographic, socioeconomic, and pregnancy-related factors (i.e. state level variance reduced from 0.486 (95% confidence interval (CI) = 0.238, 0.735) to 0.320 (95% CI = 0.152, 0.488)). We observed consistent results for newborn's PNC utilisation. State-specific analyses showed substantial geographic variation attributed to clusters across all selected states/union territories. Conclusions: Our findings highlight the consistently large cluster variation in PNC utilisation that remains unexplained by compositional effects. Future studies should explore contextual drivers of cluster variation in PNC utilisation to inform and design interventions aimed to improve maternal and child health.

Early Postnatal Care Utilization and Associated Factors Among Women Who Give Birth in the Last Six Weeks in Hosanna Town, Southern Ethiopia, 2022.

Background: The early postnatal period is defined as the first 48 h to 7 days after delivery. The early postnatal visit is especially the most critical time for the survival of mothers and newborns, particularly through early detection and management of postpartum complications. Despite the benefits, most mothers and newborns do not receive early postnatal care services from healthcare providers during the critical first few days after delivery. Objectives: This study is aimed at assessing the prevalence of early postnatal care utilization and associated factors among mothers who gave birth within the last 6 weeks in Hosanna town, Southern Ethiopia, from April 20 to May 30, 2022. Method: A community-based cross-sectional study was conducted in Hadiya Zone, Hosanna town, Southern Ethiopia. A simple random sample technique was used to recruit 403 mothers who had given birth in the previous 6 weeks from a family folder. Data was collected through face-to-face interviews using a standardized questionnaire. Binary logistic regression was used to assess the association between outcomes and explanatory variables, and the strength of the association was interpreted using an odds ratio with a 95% confidence interval. In our study, p values of 0.05 were considered statistically significant. Results: The prevalence of early postnatal care utilization among mothers who gave birth within 1 week of the study area was 25.8% (95% CI: 21.7-30.0). No formal and primary educational level of husband (AOR = 0.05, 95% CI: [0.02, 0.16]), antenatal care follow-up (AOR = 2.13, 95% CI: [1.11, 4.1]), length of hospital stay before discharge (≥24 h) (AOR = 0.3, 95% CI: [0.16, 0.55]), and information about early postnatal care utilization (AOR = 3.08, 95% CI: [1.72, 5.52]) were factors significantly associated with early postnatal care utilization. Conclusion: In comparison to World Health Organization standards, the study's overall prevalence of early postnatal care utilization was low. Early postnatal care use was significantly associated with antenatal care follow-up, the husband's educational level, knowledge of early postnatal care use, and length of stay at the health institution following birth. As a result, the strength of health facilities is to improve service provision, information education, and communication.

Primary Human Papillomavirus Test Uptake and Cervical Cancer Screening Trends in the Midwest, United States.

INTRODUCTION/OBJECTIVES: Despite U.S. Preventive Services Task Force and American Cancer Society endorsement of primary HPV screening, limited published data shows low uptake. PRIMARY AIM: Assess cervical cancer screening rates over time, particularly primary HPV test uptake, among patients in a midwestern practice. SECONDARY AIM: Evaluate associations between sociodemographics and screening adherence. METHODS: Cross-sectional study. Qualifying subjects and type of screening test used were identified by applying ICD-9, ICD-10, lab test, and CPT codes to the Unified Data Platform. Sociodemographics were found through the electronic health record. RESULTS: Primary HPV uptake represented <1% of annual screening from 1/2017 to 1/2022. On 1/1/2022, only 55% of 21 to 29 year old and 63% of 30 to 65 year old were up to date with screening among the studied population. For 21 to 29 year old, compared with White women, Black women were 28% less likely to be screened [RR = 0.72 (0.66-0.79)]. Compared with never-smokers, current smokers were 9% less likely to be screened [RR = 0.91 (0.87-0.96)], past smokers were 14% more likely [RR = 1.14 (1.09-1.2)]. Among 30 to 65 year old, compared with White women, Black women were 14% less likely to be screened [RR = 0.86 (0.81-0.9)]. Compared with never-smokers, current smokers were 21% less likely to be screened [RR = 0.79 (0.77-0.81)], past smokers were 6% less likely [RR = 0.94 (0.92-0.95)]. Jointly considering race, ethnicity, smoking status, Charlson score, and rurality, findings were similar for 21 to 29 year old; Black women were screened less than White women [RR = 0.73 (0.67-0.79)]; current smokers [RR = 0.9 (0.85-0.94)] and past smokers [RR = 1.12 (1.06-1.17)] were screened less than never smokers. For 30 to 65 year old, Black women were screened less than White women [RR = 0.83 (0.79-0.88)]; current smokers [RR = 0.8 (0.78-0.81)] and past smokers [RR = 0.95 (0.93-0.96)] were screened less than never smokers. CONCLUSIONS: Screening rates remained below the Healthy People 2030 goal of 79.2% over time, particularly for younger Black women and current smokers, with minimal use of primary HPV screening.

Rural-Urban Differences in Healthcare Use in Persons With Dementia Between 2000 and 2019: A Quebec Population-Based Study.

Background: Rural persons with dementia face medical services gaps. This study compares the health service utilization of rural and urban community-dwelling individuals with incident dementia. Methods: This study used a repeated annual cross-sectional cohort design spanning a period from 2000 to 2019 analyzing age-adjusted rates for 20 indicators of service use and mortality one year after diagnosis in Quebec administrative databases. Results: Of 237,259 persons, 20.1% were rural. Most rural persons had more emergency department visits and hospitalizations, shorter stays, less alternate level of care and fewer family physicians' and cognition specialists' visits. All groups had similar long-term care and mortality rates. Conclusion: Policy implications of these disparities are discussed.