RESUMO
OBJECTIVE: States vary greatly in their support for home- and community-based services (HCBS) that are intended to help disabled seniors live in the community. This article examines how states' generosity in providing HCBS affects the risk of nursing home admission among older Americans and how family availability moderates such effects. METHODS: We conducted discrete time survival analysis of first long-term (90 or more days) nursing home admissions that occurred between 1995 and 2002, using Health and Retirement Study panel data from respondents born in 1923 or earlier. RESULT: State HCBS effects were conditional on child availability among older Americans. Living in a state with higher HCBS expenditures was associated with lower risk of nursing home admission among childless seniors (p <.001). However, the association was not statistically significant among seniors with living children. Doubling state HCBS expenditures per person aged 65 or older would reduce the risk of nursing home admission among childless seniors by 35%. DISCUSSION: Results provided modest but important evidence supportive of increasing state investment in HCBS. Within-state allocation of HCBS resources, however, requires further research and careful consideration about fairness for individual seniors and their families as well as cost effectiveness.
Assuntos
Financiamento Governamental/economia , Serviços de Assistência Domiciliar/economia , Instituição de Longa Permanência para Idosos/economia , Assistência de Longa Duração/economia , Casas de Saúde/economia , Admissão do Paciente/economia , Idoso , Idoso de 80 Anos ou mais , Cuidadores/economia , Estudos de Coortes , Redução de Custos/estatística & dados numéricos , Análise Custo-Benefício , Feminino , Gastos em Saúde , Humanos , Cobertura do Seguro/economia , Masculino , Medicaid/economia , Medicare/economia , Readmissão do Paciente/economia , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Planos Governamentais de Saúde/economia , Estados UnidosRESUMO
BACKGROUND: Despite being a preventable disease, cervical cancer claims the lives of almost half a million women worldwide each year. India bears one-fifth of the global burden of the disease, with approximately 130,000 new cases a year. In an effort to assess the need and potential for improving the quality of cervical cancer prevention and treatment services in Uttar Pradesh, a strategic assessment was conducted in three of the state's districts: Agra, Lucknow, and Saharanpur. METHODS: Using an adaptation of stage one of the World Health Organization's Strategic Approach to Improving Reproductive Health Policies and Programmes, an assessment of the quality of cervical cancer services was carried out by a multidisciplinary team of stakeholders. The assessment included a review of the available literature, observations of services, collection of hospital statistics and the conduct of qualitative research (in-depth interviews and focus group discussions) to assess the perspectives of women, providers, policy makers and community members. RESULTS: There were gaps in provider knowledge and practices, potentially attributable to limited provider training and professional development opportunities. In the absence of a state policy on cervical cancer, screening of asymptomatic women was practically absent, except in the military sector. Cytology-based cancer screening tests (i.e. pap smears) were often used to help diagnose women with symptoms of reproductive tract infections but not routinely screen asymptomatic women. Access to appropriate treatment of precancerous lesions was limited and often inappropriately managed by hysterectomy in many urban centers. Cancer treatment facilities were well equipped but mostly inaccessible for women in need. Finally, policy makers, community members and clients were mostly unaware about cervical cancer and its preventable nature, although with information, expressed a strong interest in having services available to women in their communities. CONCLUSION: To address gaps in services and unmet needs, state policies and integrated interventions have the potential to improve the quality of services for prevention of cervical cancer in Uttar Pradesh.
Assuntos
Países em Desenvolvimento , Programas de Imunização/tendências , Área Carente de Assistência Médica , Papillomaviridae/imunologia , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus , Displasia do Colo do Útero/prevenção & controle , Neoplasias do Colo do Útero/prevenção & controle , Vacinas Virais/uso terapêutico , Feminino , Previsões , Humanos , Infecções por Papillomavirus/virologia , Estados Unidos , Neoplasias do Colo do Útero/virologia , Displasia do Colo do Útero/virologiaAssuntos
Seleção de Pacientes , Serviços Preventivos de Saúde/normas , Neoplasias do Colo do Útero/prevenção & controle , Serviços de Saúde da Mulher/normas , Bolívia , Feminino , Educação em Saúde , Humanos , Serviços Preventivos de Saúde/organização & administração , Neoplasias do Colo do Útero/terapia , Serviços de Saúde da Mulher/organização & administraçãoRESUMO
En este trabajo se evalúan la organización y disponibilidad de servicios de prevención y tratamiento del cáncer cervicouterino en cuatro de los nueve departamentos de Bolivia y se identifican estrategias de intervención. De 2001 a 2002 un equipo multidisciplinario de 15 personas llevó a cabo en Bolivia una evaluación que comprendió una revisión bibliográfica sobre el cáncer cervicouterino en el país, entrevistas semiestructuradas con 583 partes interesadas y 56 observaciones de servicios de salud de diversos niveles. En un taller celebrado después del trabajo de campo se reunieron 60 líderes de todos los departamentos del país para revisar los resultados y determinar su prioridad, y para elaborar recomendaciones basadas en las pruebas científicas recaudadas con miras a fortalecer los servicios de prevención del cáncer cervicouterino. Bolivia tiene una de las tasas más altas de cáncer cervicouterino en el mundo. No obstante, no tiene ningún programa organizado ni tampoco ninguna estrategia destinada a lograr que el tamizaje del cáncer cervicouterino alcance una cobertura mínima de 80 por ciento, que es la meta establecida por el Ministerio de Salud y Previsión Social. Una buena parte de la población carece de información sobre los servicios para la prevención y el tratamiento de lesiones precancerosas, o no puede llegar a estos servicios con facilidad. Los proveedores de atención sanitaria en el sector público calculan que de 50 a 80 por ciento de las mujeres sometidas al tamizaje no regresan a su seguimiento porque no hay ningún sistema que garantice un seguimiento adecuado con fines de diagnóstico o tratamiento. Muchos prestadores de atención de salud desconocen que los frotis de Papanicolaou se usan para detectar lesiones precancerosas. Bolivia tiene una unidad establecida dentro del Ministerio de Salud y Previsión Social cuya función es crear, administrar y supervisar programas nacionales para la prevención y el tratamiento del cáncer cervicouterino. Dicha unidad, en coordinación con las autoridades sanitarias en cada uno de los departamentos del país, también busca fortalecer la imposición de normas nacionales, actividades de capacitación, e iniciativas comunitarias de tipo informativo o educativo. No obstante, los servicios de tamizaje no están debidamente vinculados con los de diagnóstico y tratamiento de lesiones precancerosas. Por añadidura, los servicios de diagnóstico y tratamiento no siempre abundan o son accesibles...
