Health care utilization by people with HIV on release from provincial prison in Ontario, Canada in 2010: a retrospective cohort study.

Limited evidence suggests that at the time of release from prison, people with HIV face barriers to health care, which may contribute to worsening HIV clinical outcomes. We aimed to describe health care utilization for people with HIV released from provincial prison in Ontario in 2010, and to compare rates of use with prisoner and general population controls. We used Ontario's administrative health records and data from the Ontario Ministry of Community Safety and Correctional Services on all persons released from provincial prison in 2010. We matched each person with HIV released from provincial prison by age and sex with three controls in each of three groups: people with no HIV released from provincial prison, people with HIV in the general population, and people with no HIV in the general population. We compared rates of use of primary care, non-primary ambulatory care, emergency departments, and hospitalization in the year after the first release from provincial prison in 2010 and in the corresponding period for matched controls. We identified 330 persons with HIV released from provincial prison in 2010. Their median time to first HIV-ambulatory care visit after prison release was 177 days (SD 136-239). Compared to all control groups, people with HIV released from provincial prison had higher rates of primary care use, unscheduled emergency department visits and hospital admissions at 30, 90 and 365 days after release. People with HIV released from provincial prison have a long time to first contact with HIV ambulatory care, and higher rates of health care utilization across health care settings. Interventions are required to facilitate post-release linkage to care for this population.

Effect of EMR implementation on clinic time, patient and staff satisfaction, and chart completeness in a resource-limited antenatal clinic in Kenya.

Electronic Medical Records (EMR) are thought to improve healthcare through a variety of means. However, the study of EMR implementation in resource-poor settings has been minimal. Moi Teaching and Referral Hospital (MTRH) is the second largest tertiary care centre in Kenya, hosting a busy antenatal clinic serving Eldoret and surrounding regions. The recent transition from written to electronic antenatal records at MTRH permits the opportunity to study whether this change improves quality of care, in terms of: TIME: Does the patient or healthcare worker spend the same amount of time at the encounter? SATISFACTION: Is the patient or healthcare worker more or less satisfied with the encounter? COMPLETENESS: Does the antenatal record do a better job of recording key information in the antenatal history? Our Objective wasto determine the effects of EMR implementation on an antenatal clinic in a resource-limited setting.

Characteristics and surgical success of patients presenting for repair of obstetric fistula in western Kenya.

OBJECTIVE: To carry out a large-scale retrospective review of patients who had undergone surgical repair of obstetric fistula in Kenya to determine patient characteristics and determinants of successful surgical repair. METHODS: The patient records of 483 surgical repairs of obstetric fistula treated by a single surgeon (H.M.) between January 2005 and July 2010 at 3 medical centers in western Kenya were retrospectively reviewed. Descriptive and bivariate statistical analyses were performed. RESULTS: Young women with some primary or no education and prolonged labor at the time of first delivery were most highly correlated with obstetric fistula formation. Success of fistula closure was 86% for first-time vesicovaginal fistula (VVF) repairs and 67% for first-time VVF combined with rectovaginal fistula (RVF) repairs. Among women who had previously attempted VVF or combined VVF/RVF repairs, 73% and 50% of fistulas, respectively, were repaired successfully. First-time repair was significantly associated with surgical success compared with patients with a history of previous repair attempts (P=0.027). CONCLUSION: Among Kenyan women presenting for fistula repair, fistula most was most highly correlated with a low level of education and prolonged labor. The findings are consistent with results reported from other countries in Sub-Saharan Africa.

Determinants of household food access among small farmers in the Andes: examining the path.

OBJECTIVE: Household food access remains a concern among primarily agricultural households in lower- and middle-income countries. We examined the associations among domains representing livelihood assets (human capital, social capital, natural capital, physical capital and financial capital) and household food access. DESIGN: Cross-sectional survey (two questionnaires) on livelihood assets. SETTING: Metropolitan Pillaro, Ecuador; Cochabamba, Bolivia; and Huancayo, Peru. SUBJECTS: Households (n = 570) involved in small-scale agricultural production in 2008. RESULTS: Food access, defined as the number of months of adequate food provisioning in the previous year, was relatively good; 41 % of the respondents indicated to have had no difficulty in obtaining food for their household in the past year. Using bivariate analysis, key livelihood assets indicators associated with better household food access were identified as: age of household survey respondent (P = 0.05), participation in agricultural associations (P = 0.09), church membership (P = 0.08), area of irrigated land (P = 0.08), housing material (P = 0.06), space within the household residence (P = 0.02) and satisfaction with health status (P = 0.02). In path models both direct and indirect effects were observed, underscoring the complexity of the relationships between livelihood assets and household food access. Paths significantly associated with better household food access included: better housing conditions (P = 0.01), more space within the household residence (P = 0.001) and greater satisfaction with health status (P = 0.001). CONCLUSIONS: Multiple factors were associated with household food access in these peri-urban agricultural households. Food security intervention programmes focusing on food access need to deal with both agricultural factors and determinants of health to bolster household food security in challenging lower- and middle-income country contexts.

An agriculture and health inter-sectorial research process to reduce hazardous pesticide health impacts among smallholder farmers in the Andes.

BACKGROUND: The use of highly hazardous pesticides by smallholder farmers constitutes a classic trans-sectoral 'wicked problem'. We share our program of research in potato and vegetable farming communities in the Andean highlands, working with partners from multiple sectors to confront this problem over several projects. METHODS: We engaged in iterative cycles of mixed methods research around particular questions, actions relevant to stakeholders, new proposal formulation and implementation followed by evaluation of impacts. Capacity building occurred among farmers, technical personnel, and students from multiple disciplines. Involvement of research users occurred throughout: women and men farmers, non-governmental development organizations, Ministries of Health and Agriculture, and, in Ecuador, the National Council on Social Participation. RESULTS: Pesticide poisonings were more widespread than existing passive surveillance systems would suggest. More diversified, moderately developed agricultural systems had lower pesticide use and better child nutrition. Greater understanding among women of crop management options and more equal household gender relations were associated with reduced farm pesticide use and household pesticide exposure. Involvement in more organic agriculture was associated with greater household food security and food sovereignty. Markets for safer produce supported efforts by smallholder farmers to reduce hazardous pesticide use.Participatory interventions included: promoting greater access to alternative methods and inputs in a store co-sponsored by the municipality; producing less harmful inputs such as compost by women farmers; strengthening farmer organizations around healthier and more sustainable agriculture; marketing safer produce among social sectors; empowering farmers to act as social monitors; and using social monitoring results to inform decision makers. Uptake by policy makers has included: the Ecuadorian Ministry of Health rolling out pesticide poisoning surveillance modeled on our system; the Ecuadorian Association of Municipalities holding a national virtual forum on healthier agriculture; and the Ecuadorian Ministry of Agriculture promulgating restrictions on highly hazardous pesticides in June 2010. CONCLUSION: Work with multiple actors is needed to shift agriculture towards greater sustainability and human health, particularly for vulnerable smallholders.

Municipal bylaw to reduce cosmetic/non-essential pesticide use on household lawns - a policy implementation evaluation.

BACKGROUND: Pesticide use on urban lawns and gardens contributes to environmental contamination and human exposure. Municipal policies to restrict use and educate households on viable alternatives deserve study. We describe the development and implementation of a cosmetic/non-essential pesticide bylaw by a municipal health department in Toronto, Ontario, Canada and assess changes in resident practices associated with bylaw implementation. METHODS: Implementation indicators built on a logic model and were elaborated through key informant interviews. Bylaw impacts on awareness and practice changes were documented through telephone surveys administered seasonally pre, during and post implementation (2003-2008). Multivariable logistic regression models assessed associations of demographic variables and gardening season with respondent awareness and practices. RESULTS: Implementation indicators documented multiple municipal health department activities and public involvement in complaints from commencement of the educational phase. During the enforcement phases only 40 warning letters and 7 convictions were needed. The number of lawn care companies increased. Among survey respondents, awareness of the bylaw and the Natural Lawn campaign reached 69% and 76% respectively by 2008. Substantial decreases in the proportion of households applying pesticides (25 to 11%) or hiring lawn care companies for application (15 to 5%) occurred. Parallel absolute increases in use of natural lawn care methods occurred among households themselves (21%) and companies they contracted (7%). CONCLUSIONS: Bylaws or ordinances implemented through education and enforcement are a viable policy option for reducing urban cosmetic pesticide use.