The evolution trend of availability of China's community-based care services and its impact on the cognitive function of elderly people: 2008-2018.

BACKGROUND: To address the challenge of the aging population, community-based care services (CBCS) have been developed rapidly in China as a new way of satisfying the needs of elderly people. Few studies have described the evolution trend of availability of CBCS in rural and urban areas and evaluated their effectiveness. This study aims to show the availability of China's CBCS and further analyze the effect of the CBCS on the cognitive function of elderly people. METHODS: Longitudinal analysis was performed using data from the 2008 to 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). A total of 23937 observations from 8421 elderly people were included in the study. The Chinese version of the Mini-Mental State Examination (MMSE) was used to assess cognitive function. We aggregated similar CBCS to generate three binary variable categories (daily life support, emotional comfort and entertainment services, medical support and health services) indicating the availability of CBCS (1 = yes, 0 = no). Multilevel growth models were employed to estimate the association between CBCS and cognitive function while adjusting for many demographic and socioeconomic characteristics. RESULTS: The availability of CBCS increased a lot from 2008 to 2018 in China. Although the availability of CBCS in urban areas was higher than that in rural areas in 2008, by 2018 the gap narrowed significantly. Emotional comfort and entertainment services (B = 0.331, 95% CI = 0.090 to 0.572) and medical support and health services (B = 1.041, 95% CI = 0.854 to 1.228) were significantly and positively associated with cognitive function after adjusting for the covariates. CONCLUSION: There was a significant increase in the availability of CBCS from 2008 to 2018 in China. This study sheds light on the positive correlation between CBCS and cognitive function among Chinese elderly individuals. The results suggest that policymakers should pay more attention to the development of CBCS and the equity of the supply of CBCS in urban and rural areas.

Dietetic Workforce Capacity Assessment for Public Health Nutrition and Community Nutrition.

Worldwide, there is a continued rise in malnutrition and noncommunicable disease, along with rapidly changing dietary patterns, demographics, and climate and persistent economic inequality and instability. These trends have led to a national and global focus on nutrition-specific and nutrition-sensitive interventions to improve population health. A well-trained public health and community nutrition workforce is critical to manage and contribute to these efforts. The study describes the current public health and community nutrition workforce and factors influencing registered dietitian nutritionists (RDNs) to work in these settings and characterizes RDN preparedness, training, and competency in public health and community nutrition. The study was comprised of a cross-sectional, online survey of mostly US RDNs working in public health/community nutrition and semistructured telephone interviews with US-based and global public health and community nutrition experts. RStudio version 1.1.442 was used to manage and descriptively analyze survey data. Thematic analysis was conducted to evaluate expert interviews. Survey participants (n = 316) were primarily women (98%) and White (84%) with the RDN credential (91%) and advanced degrees (65%). Most reported that non-RDNs are performing nutrition-related duties at their organizations. Respondents generally rated themselves as better prepared to perform community nutrition vs public health functions. Interviews were conducted with 7 US-based experts and 5 international experts. Experts reported that non-RDNs often fill nutrition-related positions in public health, and RDNs should more actively pursue emerging public health opportunities. Experts suggested that RDNs are more desirable job candidates if they have advanced public health degrees or prior experience in public health or community nutrition and that dietetic training programs need to more rigorously incorporate public health training and experience. Significant opportunity exists to improve the preparedness and training of the current dietetic workforce to increase capacity and meet emerging needs in public health and community nutrition.

County-level Predictors of Growth in Community-based Primary Care Use Among Veterans.

BACKGROUND: The 2014 Choice Act expanded the Veterans Health Administration's (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans' primary care use in community settings. OBJECTIVES: The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities. DATA AND SAMPLE: A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings. ANALYSIS: We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth. RESULTS: Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2-3 percentage point (pp) increase in CBPC penetration growth (P<0.001). The presence of a VA facility was associated with a 1.7 pp decrease in CBPC penetration growth (P<0.001), while lower primary care provider supply was associated with a 0.6 pp increase in CBPC growth (P<0.001). CONCLUSION: CBPC as a proportion of all VA-purchased primary care was small but increased nearly 3-fold between 2015 and 2018. Greater increases in CBPC penetration were concentrated in rural counties and counties without a VA facility, suggesting that community care may enhance primary care access in rural areas with less VA presence.

Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery.

BACKGROUND: The Veterans Choice Act of 2014 increased the number of Veterans eligible for Department of Veterans Affairs (VA)-purchased care delivered in non-VA community care (CC) facilities. Driving >40 miles from home to a VA facility is a key eligibility criterion for CC. It remains unclear whether this policy change improved geographical access by reducing drive distance for Veterans. OBJECTIVES: Describe the driving distance for Veterans receiving cataract surgery in VA and CC facilities, and if they visited the closest-to-home facility or if they drove to farther facilities. SUBJECTS: Veterans who had cataract surgery in federal fiscal year 2015. MEASURES: We calculated driving miles to the Closest VA and CC facilities that performed cataract surgeries, and to the location where Veterans received care. RESULTS: A total of 61,746 Veterans received 83,875 cataract surgeries. More than 50% of CC surgeries occurred farther than the Closest CC facility providing cataract surgery (median Closest CC facility 8.7 miles vs. Actual CC facility, 19.7 miles). Most (57%) Veterans receiving cataract surgery at a VA facility used the Closest VA facility (median Closest VA facility 28.1 miles vs. Actual VA facility at 31.2 miles). In all, 26.1% of CC procedures occurred in facilities farther away than the Closest VA facility. CONCLUSIONS: Although many Veterans drove farther than needed to get cataract surgery in CC, this was not true for obtaining care in the VA. Our findings suggest that there may be additional reasons, besides driving distance, that affect whether Veterans choose CC and, if they do, where they seek CC.

Anesthesia services in Taiwan: A nationwide population-based study.

BACKGROUND: This study was conducted to provide an overview of anesthesia services in Taiwan from 2001 to 2010. METHODS: A retrospective population-based analysis was performed using data from Taiwan's National Health Insurance Research Database for the period 2001 to 2010. The results were stratified by patient sex, patient age, anesthesia type, and hospital setting. Categorical data are presented as totals and percentages. Linear regression was performed to analyze the anesthesia trends. RESULTS: The annual use of anesthesia increased continually from 964,440 instances in 2001 to 1,073,160 in 2010, totaling 10,076,600 cases with a total cost of 25.4 billion USD. The overwhelming majority (83.9%) of anesthesia cases was for anesthesia in an inpatient setting; general anesthesia accounted for 73.8% of anesthesia cases, and female patients outnumbered male patients (52.4% vs 47.6%). The average number of anesthesia cases was 44.2 per thousand of the population annually, but this percentage was much higher in elderly people (100.9 cases per thousand people annually). The annual number of anesthesia cases per thousand of the population increased from 104.4 in 2001 to 113.0 in 2010 in the oldest group (>80 years). By contrast, a considerable decline in use of anesthesia was discovered over the study period among those aged younger than 18 years. CONCLUSION: The use of anesthesia services in Taiwan has increased over the years. The relationships of age with anesthesia volume and cost were found to follow an inverse U-shaped pattern. Elderly people used anesthesia services more frequently. The planning of geriatric anesthesia services deserves attention, especially in continually aging societies such as Taiwan.

[Analysis of the Distribution of Community Pharmacies and Pharmacists in Miyagi Prefecture].

In Japan, the aging of the population is serious problem. The Ministry of Health, Labour and Welfare is constructing a new support system for elderly people called "Community-based integrated care system". In this system, community pharmacists are expected to play an important role as healthcare professionals for the whole community, including elderly people. Since pharmacists will be needed to manage community health in addition to their daily tasks, it is required to reassess the distribution of community pharmacies and pharmacists. In this study, we surveyed their distribution in Miyagi prefecture by using statistical data from public institutions and reevaluated the distribution to raise problems. Based on the numbers of community pharmacies and pharmacists per 1000 population in the whole Miyagi prefecture, each area was ranked to 2 categories and analyzed regarding population, aging rate and inhabitable land area. It was disclosed that the higher aging rate areas had the higher rate of category below the average of whole Miyagi prefecture, especially in the number of pharmacists. When the numbers of pharmacies and pharmacists per the inhabitable land area were used, the uneven distribution became clearer than when those per population were used. These findings suggested that it was important to characterize the areas by not only the ratios of community pharmacies and pharmacists to population numbers but also by the aging rates and inhabitable land area, which were related to the work efficiency of pharmacists and accessibility for resident to pharmacies.

New Data on Access to Mental Health and Addictions Services and Home and Community Care.

As the population ages, more Canadians need home care to help manage their health conditions and live safely at home. For Canadians of all ages, timely access to mental health and addictions services is an area of growing concern. The impact of the COVID-19 pandemic and its strain on health system resources have further highlighted the need to improve services in these areas. The Canadian Institute for Health Information (CIHI) is working with governments across Canada to bridge data gaps, develop indicators and publicly report results as part of a collective effort to improve access in these two sectors. Results for three new indicators were released by CIHI in 2020.

Syria's Devastating Legacy of War.

Nearly a decade of conflict leaves health and housing systems in shambles.

The association between the supply and utilization of community-based primary care and child health in a context of hospital-oriented healthcare system in urban districts of Guangdong, China: a panel dataset, 2014-2016.

BACKGROUND: Since 2009, the Chinese government has been reforming the healthcare system and has committed to reinforcing increased use of primary care. To date, however, the Chinese healthcare system is still heavily reliant on hospital-based specialty care. Studies consistently show an association between primary care and improved health outcomes, and the same association is also found among the disadvantaged population. Due to the "hukou" system, interprovincial migrants in the urban districts are put in a weak position and become the disadvantaged. Therefore, the aim of this study is to investigate whether greater supply and utilization of primary care was associated with reduced child mortality among the entire population and the interprovincial migrants in urban districts of Guangdong province, China. METHODS: An ecological study was conducted using a 3-year panel data with repeated measurements within urban districts in Guangdong province from 2014 to 2016, with 178 observations in total. Multilevel linear mixed effects models were applied to explore the associations. RESULTS: Higher visit proportion to primary care was associated with reductions in the infant mortality rate and the under-five mortality rate in both the entire population and the interprovincial migrants (p < 0.05) in the full models. The association between visit proportion to primary care and reduced neonatal mortality rate was significant among the entire population (p < 0.05) while it was insignificant among the interprovincial migrants (p > 0.05). CONCLUSIONS: Our ecological study based in urban districts of Guangdong province found consistent associations between higher visit proportion to primary care and improvements in child health among the entire population and the interprovincial migrants, suggesting that China should continue to strengthen and develop the primary care system. The findings from China adds to the previously reported evidence on the association between primary care and improved health, especially that of the disadvantaged.

Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports: Stakeholder Perspectives From 14 States.

OBJECTIVES: Trends over time in the United States show success in rebalancing long-term services and supports (LTSS) toward increased home- and community-based services (HCBS) relative to institutionalized care. However, the diffusion and utilization of HCBS may be inequitable across rural and urban residents. We sought to identify potential disparities in rural HCBS access and utilization, and to elucidate factors associated with these disparities. DESIGN: We used qualitative interviews with key informants to explore and identify potential disparities and their associated supply-side factors. SETTING AND PARTICIPANTS: We interviewed 3 groups of health care stakeholders (Medicaid administrators, service agency managers and staff, and patient advocates) from 14 states (n = 40). MEASURES: Interviews were conducted using a semistructured interview guide, and data were thematically coded using a standardized codebook. RESULTS: Stakeholders identified supply-side factors inhibiting rural HCBS access, including limited availability of LTSS providers, inadequate transportation services, telecommunications barriers, threats to business viability, and challenges to caregiving workforce recruitment and retention. Stakeholders perceived that rural persons have a greater reliance on informal caregiving supports, either as a cultural preference or as compensation for the dearth of HCBS. CONCLUSIONS/IMPLICATIONS: LTSS rebalancing efforts that limit the institutional LTSS safety net may have unintended consequences in rural contexts if they do not account for supply-side barriers to HCBS. We identified supply-side factors that (1) inhibit beneficiaries' access to HCBS, (2) affect the adequacy and continuity of HCBS, and (3) potentially impact long-term business viability for HCBS providers. Spatial isolation of beneficiaries may contribute to a perceived lack of demand and reduce chances of funding for new services. Addressing these problems requires stakeholder collaboration and comprehensive policy approaches with attention to rural infrastructure.

Community and health systems barriers and enablers to family planning and contraceptive services provision and use in Kabwe District, Zambia.

BACKGROUND: Unmet need for contraception results in several health challenges such as unintended pregnancies, unwanted births and unsafe abortions. Most interventions have been unable to successfully address this unmet need due to various community and health system level factors. Identifying these inhibiting and enabling factors prior to implementation of interventions forms the basis for planning efforts to increase met needs. This qualitative study was part of the formative phase of a larger research project that aimed to develop an intervention to increase met needs for contraception through community and health system participation. The specific study component reported here explores barriers and enablers to family planning and contraceptive services provision and utilisation at community and health systems levels. METHODS: Twelve focus group discussions were conducted with community members (n = 114) and two with healthcare providers (n = 19). Ten in-depth interviews were held with key stakeholders. The study was conducted in Kabwe district, Zambia. Interviews/discussions were translated and transcribed verbatim. Data were coded and organised using NVivo 10 (QSR international), and were analysed using thematic analysis. RESULTS: Health systems barriers include long distances to healthcare facilities, stock-outs of preferred methods, lack of policies facilitating contraceptive provision in schools, and undesirable provider attitudes. Community level barriers comprise women's experience with contraceptive side effects, myths, rumours and misconceptions, societal stigma, and negative traditional and religious beliefs. On the other hand, health systems enablers consist of political will from government to expand contraceptive services access, integration of contraceptive services, provision of couples counselling, and availability of personnel to offer basic methods mix. Functional community health system structures, community desire to delay pregnancy, and knowledge of contraceptive services are enablers at a community level. CONCLUSIONS: These study findings highlight key community and health systems factors that should be considered by policy, program planners and implementers in the design and implementation of family planning and contraceptive services programmes, to ensure sustained uptake and increased met needs for contraceptive methods and services.

Community vulnerability and stratified risk: Hegemonic masculinity, socioeconomic status, and HIV/AIDS in a sex work community in Kampala, Uganda.

This article examines the social patterning of health, economic uncertainty, hegemonic masculinity, and vulnerability among men who live and work in a low-income sex work community in Kampala, Uganda. This problematises the notion that vulnerable communities are homogenous, in demographics, economic status, and risk. This article draws on ethnographic data collected in 2016, including semi-structured interviews and participant observation. This article uses a stratified risk framework to describe the central finding of this study, which is that men's experience in Kataba is characterised by a struggle to fulfil the provider role that constitutes a core aspect of their socially ascribed gender role. In a context of economic scarcity, men's lives are fraught with strain and this intersects with other forms of risk. Finally, by focusing on community vulnerability rather than individual risk, this work contributes to theories of gender and sex work, and informs HIV/AIDS praxis.

Availability of Medicaid home- and community-based services for older Americans and people with physical disabilities.

This article provides an overview of Medicaid home- and community-based services (HCBS) for older adults and individuals with physical disabilities by describing eligibility criteria, availability, and types of services. All 50 state Medicaid programs provide supplementary HCBS in addition to mandatory services. The amount, type, and eligibility for HCBS varied widely between states. Variation in service provision and eligibility rules has led to a patchwork of services from state to state, with the same person eligible for services in one state but not another.

Programmatic factors associated with the limited impact of Community-Directed Treatment with Ivermectin to control Onchocerciasis in three drainage basins of South West Cameroon.

INTRODUCTION: The CDTI model is known to have enhanced community participation in planning and resource mobilization toward the control of onchocerciasis. These effects were expected to translate into better individual acceptance of the intervention and hence high Treatment Coverage, leading to a sustainable community-led strategy and reduction in the disease burden. A survey revealed that after 10-12 rounds of treatment, prevalence of onchocerciasis was still high in three drainage basins of South West Cameroon and transmission was going on. METHODS: We designed a three (3)-year retrospective (2012, 2013 and 2014), descriptive cross-sectional study to explore the roles of operational challenges in the failure of CDTI to control the disease as expected. We administered 83 semi-structured questionnaires and conducted 12 in-depth interviews with Chiefs of Bureau Health, Chiefs of Centers, CDDs and Community Heads. Descriptive statistics was used to explore indicators of performance which were supported with views from in-depth interviews. RESULTS: We found that community participation was weak; communities were not deciding time and mode of distributions. Only 6 (15.0%) of 40 Community Drug Distributors reported they were selected at general community meetings as required. The health service was not able to meet and discuss Community-Directed Treatment with Ivermectin activities with individual communities partly due to transportation challenges; this was mostly done through letters. Funding was reported to be inadequate and not timely. Funds were not available to conduct Community-Self Monitoring after the 2014 Mass Drug Administration. There was inadequate health staff at the frontline health facility levels, and some Chiefs of Center reported that Community-Directed Treatment with Ivermectin work was too much for them. The mean operational Community Drug Distributor-population ratio was 1 Community Drug Distributor per 317 populations (range: 194-464, expected is 1:250). Community Drug Distributor attrition rate was 14% (2012), 11% (2013) and 12% (2014) of total Community Drug Distributors trained in the region. Lack of incentive for Community Drug Distributor was primary reason for Community Drug Distributor attrition. Number of Community Drug Distributors trained together by health area ranged from 14 to 127 (mean ± SD = 51 ±32) with duration of training ranging from 4-7 hours (mean ± SD = 5.05 ± 1.09). The trainings were conducted at the health centers. Community Drug Distributors always conducted census during the past three distributions (Mean ± SD = 2.85 ± 0.58). Community-Self Monitoring was facing challenge. Several of the community heads, Chiefs of Bureau Health and Chiefs of Center agreed that Community-Self Monitoring was not being carried out effectively due to lack of incentives for monitors in the communities. CONCLUSION: Inadequate human resource, funding issues and transportation challenges during distribution periods reduced the ability of the health service to thoroughly sensitize communities and supervise CDTI activities. This resulted in weak community understanding, acceptance and participation in the process. CDTI in our study area did not achieve sustainable community-led campaign and this may have led to the reduced impact on Onchocerciasis.

A Feasibility Study of Supply and Demand for Diabetes Prevention Programs in North Carolina.

INTRODUCTION: Diabetes Prevention Programs (DPPs) have shown that healthy eating and moderate physical activity are effective ways of delaying and preventing type 2 diabetes in people with impaired glucose tolerance. We assessed willingness to pay for DPPs from the perspective of potential recipients and the cost of providing these programs from the perspective of community health centers and local health departments in North Carolina. METHODS: We used contingent valuation to determine how much potential recipients would be willing to pay to participate in DPPs under 3 different models: delivered by registered professionals (traditional model), by community health workers, or online. By using information on the minimum reimbursement rate at which public health agencies would be prepared to provide the 3 models, we estimated the marginal costs per person of supplying the programs. Matching supply and demand, we estimated the degree of cost sharing between recipients and providers. RESULTS: Potential program recipients (n = 99) were willing to pay more for programs led by registered professionals than by community health workers, and they preferred face-to-face contact to an online format. Socioeconomic status (measured by education and employment) and age played the biggest roles in determining willingness to pay. Leaders of public health agencies (n = 27) reported up to a 40% difference in the cost of providing the DPP, depending on the delivery model. CONCLUSION: By using willingness to pay to understand demand for DPPs and computing the provider's marginal cost of providing these services, we can estimate cost sharing and market coverage of these services and thus compare the viability of alternate approaches to scaling up and sustaining DPPs with available resources.