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1.
MMWR Morb Mortal Wkly Rep ; 69(4): 97-102, 2020 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-31999684

RESUMO

Identifying persons with human immunodeficiency virus (HIV) infection who are unaware of their status and linking them to care are critical steps in achieving viral suppression and reducing the risk for transmitting HIV (1). In 2017, 43% of new diagnoses of HIV infection were among persons who self-identify as blacks or African Americans (blacks) (2), who represent 13% of the U.S. population (3). Fewer blacks, compared with whites, were linked to HIV medical care within 90 days of diagnosis, retained in care, or virally suppressed (4). Ending the HIV Epidemic (EHE) is an initiative intended to reduce new HIV infections by 90% from 2020 to 2030 (5). EHE's Phase 1 is focused on 50 jurisdictions* that accounted for >50% of new diagnoses during 2016-2017 and seven states† with disproportionate HIV prevalence in rural areas (5). The purpose of this analysis was to examine HIV testing outcomes among blacks in high prevalence EHE jurisdictions, using CDC's 2017 National HIV Prevention Program Monitoring and Evaluation data. Blacks accounted for 43.2% of CDC-funded tests and 49.1% of new diagnoses of HIV infection. Seventy-nine percent of blacks with newly diagnosed HIV infection were linked to HIV medical care within 90 days (below the 2010 National HIV/AIDS Strategy goal of 85%), 71.4% interviewed for partner services, and 81.8% referred to prevention services. To achieve the goals of EHE, HIV prevention programs should focus on locally tailored evidence-based§ testing strategies to enhance and overcome barriers for linkage to and retention in care and reduce onward HIV transmission and HIV-related disparities.


Assuntos
Afro-Americanos/estatística & dados numéricos , Infecções por HIV/etnologia , Programas de Rastreamento/estatística & dados numéricos , Adolescente , Adulto , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/terapia , Disparidades nos Níveis de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Saúde da População Rural/etnologia , Saúde da População Rural/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto Jovem
2.
BJOG ; 127(1): 39-45, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31444892

RESUMO

OBJECTIVE: To explore the relation between famine exposure in early life and subsequent pregnancy loss, including stillbirth, and spontaneous abortion in adulthood. DESIGN: A population-based, partly ecological study. SETTING AND POPULATION: Individual data of 58 601 females born around the time of the Great Chinese Famine in 1959-1961. METHODS: Associations between the famine exposure in early life and pregnancy loss (stillbirth and spontaneous abortion) in adulthood were analysed using negative binomial regression, with the non-exposure group as reference, adjusting for region, highest education, monthly income, alcohol consumption, tobacco use, body mass index in 25-year-olds and metabolic equivalent. Further analyses were stratified by rural versus urban region. MAIN OUTCOME MEASURES: Continuous variables of times of stillbirths and spontaneous abortions were used according to the individual self-reported reproductive history. RESULTS: No association was found between famine exposure and spontaneous abortion. In contrast, females experiencing the famine during their prenatal period (incidence rate ratio = 1.15, 95% CI 1.00-1.33) or infant period (incidence rate ratio = 1.27, 95% CI 1.12-1.44) were more likely to report stillbirth in later adult life. Such an association appeared stronger in women living in rural regions. CONCLUSIONS: Early life exposure of famine was associated with an increased risk of stillbirth but not spontaneous abortion in adulthood. The strength of such an association appeared stronger in rural areas. Given the high potential for unmeasured confounding, these associations must be interpreted with caution. Regarding the potential implication that undernutrition in the fetal period is related to reproductive outcome in adulthood, fetal nutritional supply may play an important role in human reproduction. TWEETABLE ABSTRACT: Exposure to famine in early life was associated with increased pregnancy loss in adulthood.


Assuntos
Aborto Espontâneo/epidemiologia , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Natimorto/epidemiologia , Adulto , Idoso , Índice de Massa Corporal , China/epidemiologia , Feminino , Humanos , Estilo de Vida , Pessoa de Meia-Idade , Gravidez , Saúde da População Rural
3.
BJOG ; 127(1): 116-122, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31553136

RESUMO

OBJECTIVE: To estimate the risk for adverse perinatal outcomes for women who met the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria but not the two-step criteria for gestational diabetes mellitus (GDM). DESIGN: Population-level cross-sectional study. SETTING: Ontario, Canada. POPULATION: A total of 90 140 women who underwent a 75-g oral glucose tolerance test. METHODS: Women were divided into those who met the diagnostic thresholds for GDM by two-step criteria and were therefore treated, those who met only the IADPSG criteria for GDM and so were not treated, and those who did not have GDM by either criteria. MAIN OUTCOME MEASURES: Hypertensive disorders of pregnancy, preterm delivery, primary caesarean section, large-for-gestational-age, shoulder dystocia and neonatal intensive care unit admission. RESULTS: Women who met the IADPSG criteria had an increased risk for all adverse perinatal outcomes compared with women who did not have GDM. Women with GDM by two-step criteria also had an increased risk of most outcomes. However, their risk for large-for-gestational-age neonates and for shoulder dystocia was actually lower than that of women who met IADPSG criteria. CONCLUSION: Women who met IADPSG criteria but who were not diagnosed with GDM based on the current two-step diagnostic strategy, and were therefore not treated, had an increased risk for adverse perinatal outcomes compared with women who do not have GDM. The current strategy for diagnosing GDM may be leaving women who are at risk for adverse events without the dietary and pharmacological treatments that could improve their pregnancy outcomes. TWEETABLE ABSTRACT: Women who meet IADPSG criteria for GDM have an increased risk for adverse perinatal outcomes compared with women without GDM.


Assuntos
Diabetes Gestacional/epidemiologia , Resultado da Gravidez/epidemiologia , Cesárea/estatística & dados numéricos , Estudos Transversais , Feminino , Macrossomia Fetal/epidemiologia , Teste de Tolerância a Glucose/estatística & dados numéricos , Humanos , Hipertensão Induzida pela Gravidez/epidemiologia , Terapia Intensiva Neonatal/estatística & dados numéricos , Ontário/epidemiologia , Gravidez , Fatores de Risco , Saúde da População Rural , Saúde da População Urbana
4.
Ther Adv Cardiovasc Dis ; 13: 1753944719891691, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31797738

RESUMO

BACKGROUND: Myocardial infarctions (MIs) are the leading cause of death in the United States (US). Differences in MI mortality rates exist between rural and urban areas in the US. Early recognition of MI symptoms can lead to receiving prompt lifesaving treatment. In this study, we identified the influence of living in a rural area, rurality, on disparities in MI symptom awareness across the US. METHODS: We examined 2007 and 2009 Behavioral Risk Factor Surveillances System survey data using logistic regressions to model the impact of rurality on MI symptom awareness while controlling for sociodemographic and MI clinical factors. From the results of these models, we created a type of marginal probability, known as average adjusted predictions (AAPs) and the difference in AAPs, called average marginal effects (AMEs), to determine patterns of awareness for each MI symptom between rural, suburban, and urban areas. RESULTS: We found that there were similar odds and probabilities of being aware of all five MI symptoms between rural, suburban, and urban areas, although rural residents consistently had a slightly higher odds and probability of being aware of all five MI symptoms compared with suburban and urban residents. Rural, suburban, and urban residents had the highest probability of being aware of chest pain/discomfort (95.5-96.1%) and the lowest probability of being aware of jaw/back/neck pain (68.6-72.0%). After adjustment, more than 25% of rural, suburban, and urban residents were found to be unaware that jaw/back/neck pain and feeling weak/light-headed/faint were symptoms of MI. AMEs were greatest for all areas for jaw/back/neck pain (-3.5% to -3.2%) and smallest for chest pain/discomfort (-0.6% to -0.2%). CONCLUSIONS: The study's results highlight the need to increase awareness of the MI symptoms of jaw/back/neck pain and feeling weak/light-headed/faint to shorten hospital delay and time to treatment, especially for rural areas where cardiovascular disease mortality is high.


Assuntos
Conscientização , Conhecimentos, Atitudes e Prática em Saúde , Infarto do Miocárdio/epidemiologia , Saúde da População Rural , Adolescente , Adulto , Idoso , Angina Pectoris/epidemiologia , Dor nas Costas/epidemiologia , Tontura/epidemiologia , Dor Facial/epidemiologia , Feminino , Inquéritos Epidemiológicos , Disparidades em Assistência à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Cervicalgia/epidemiologia , Prognóstico , Fatores de Risco , Saúde Suburbana , Estados Unidos/epidemiologia , Saúde da População Urbana , Adulto Jovem
5.
Zhonghua Fu Chan Ke Za Zhi ; 54(12): 840-847, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31874474

RESUMO

Objective: To evaluate the feasible cervical cancer screening strategies in rural China. Methods: The study was based on the health industry scientific research project of National Health Commission in 2015, cervical cancer screening technology and demonstration research suitable for rural areas in China, we collected health economics and epidemiological parameters and established the unscreening model and screening model with Treeage Pro 2011 software. Combining with the data acquired from site investigation, including population screening, treatment-related clinical materials and cost data, we simulated the occurrence and the development of cervical cancer of rural women in China under different screening and intervention programs and predicted the screening effects [cumulative incidence, cumulative risk of disease, life years and quality adjusted life years (QALY) , gains] and costs after 20 years, and using health economic evaluation analysis (cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis). Screening programs included five screening strategies [visual inspection with acetic acid/lugol's iodine (VIA/VILI), careHPV, ThinPrep cytology test (TCT), careHPV+TCT, careHPV+VIA/VILI] and three screening intervals (1-year, 3-year, 5-year), a total of fifteen screening programs. Results: Compared with no screening, fifteen screening programs reduced the cumulative incidence by 22.65%-51.76%. Compared with TCT or VIA/VILI, for the same screening interval, the reduced cumulative incidence, the amounts of life-year saved and QALY and benefits gained of careHPV were the highest. The cost-effectiveness ratios of these screening programs ranged (0.44-3.24)×10(4) Yuan per life-year saved, cost-utility ratios ranged (0.15- 1.01)×10(4) Yuan per QALY, benefit-cost ratios ranged 7.73-59.10. The results of incremental costeffectiveness ratios showed that VIA/VILI every five years, VIA/VILI every three years, careHPV every five years, careHPV every three years and careHPV every year were dominant programs. Conclusions: VIA/VILI screening is cost-effective, careHPV is slightly more expensive but more effective. In rural China, careHPV screening every five years could be recommended. This study provides a basis for the determination of cervical cancer screening methods feasible for rural areas in China.


Assuntos
Detecção Precoce de Câncer/economia , Programas de Rastreamento/economia , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/prevenção & controle , China , Análise Custo-Benefício , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Cadeias de Markov , Programas de Rastreamento/métodos , Saúde da População Rural , Neoplasias do Colo do Útero/economia
6.
BMC Health Serv Res ; 19(1): 706, 2019 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-31619234

RESUMO

BACKGROUND: Despite the increasing burden of diabetes in Uganda, little is known about the quality of type 2 diabetes mellitus (T2DM) care especially in rural areas. Poor quality of care is a serious limitation to the control of diabetes and its complications. This study assessed the quality of care and barriers to service delivery in two rural districts in Eastern Uganda. METHODS: This was a mixed methods cross-sectional study, conducted in six facilities. A randomly selected sample of 377 people with diabetes was interviewed using a pre-tested interviewer administered questionnaire. Key informant interviews were also conducted with diabetes care providers. Data was collected on health outcomes, processes of care and foundations for high quality health systems. The study included three health outcomes, six elements of competent care under processes and 16 elements of tools/resources and workforce under foundations. Descriptive statistics were computed to determine performance under each domain, and thematic content analysis was used for qualitative data. RESULTS: The mean age of participants was 49 years (±11.7 years) with a median duration of diabetes of 4 years (inter-quartile range = 2.7 years). The overall facility readiness score was 73.9%. Inadequacies were found in health worker training in standard diabetes care, availability of medicines, and management systems for services. These were also the key barriers to provision and access to care in addition to lack of affordability. Screening of clients for blood cholesterol and microvascular complications was very low. Regarding outcomes; 56.8% of participants had controlled blood glucose, 49.3% had controlled blood pressure; and 84.0% reported having at least one complication. CONCLUSION: The quality of T2DM care provided in these rural facilities is sub-optimal, especially the process of care. The consequences include sub-optimal blood glucose and blood pressure control. Improving availability of essential medicines and basic technologies and competence of health workers can improve the care process leading to better outcomes.


Assuntos
Assistência à Saúde/normas , Diabetes Mellitus Tipo 2/terapia , Adulto , Assistência Ambulatorial/normas , Assistência Ambulatorial/estatística & dados numéricos , Pré-Escolar , Estudos Transversais , Diagnóstico Tardio , Diabetes Mellitus Tipo 2/diagnóstico , Medicamentos Essenciais , Feminino , Instalações de Saúde/normas , Instalações de Saúde/estatística & dados numéricos , Pessoal de Saúde/educação , Recursos em Saúde , Mão de Obra em Saúde/estatística & dados numéricos , Humanos , Hipoglicemiantes/uso terapêutico , Masculino , Pacientes Ambulatoriais/estatística & dados numéricos , Qualidade da Assistência à Saúde , Saúde da População Rural , Uganda
7.
BMC Health Serv Res ; 19(1): 684, 2019 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-31590662

RESUMO

BACKGROUND: This study aimed to assess the quality of antenatal care (ANC) women received in Migori county, Kenya-including both service provision and experience dimensions-and to examine factors associated with each dimension. METHODS: We used survey data collected in 2016 in Migori county from 1031 women aged 15-49 who attended ANC at least once in their most recent pregnancy. ANC quality service provision was measured by nine questions on receipt of recommended ANC services, and experience of care by 18 questions on information, communication, dignity, and facility environment. We summed the responses to the individual items to generate ANC service provision and experience of care scores. We used both linear and logistic regression to examine predictors. RESULTS: The average service provision score was 10.9 (SD = 2.4) out of a total of 16. Most women received some recommended services once, but not at the frequency recommended by the Kenyan Ministry of Health. About 90% had their blood pressure measured, and 78% had a urine test, but only 58 and 14% reported blood pressure monitoring and urine test, respectively, at every visit. Only 16% received an ultrasound at any time during ANC. The average experience score is 27.3 (SD = 8.2) out of a total score of 42, with key gaps demonstrated in communication. About half of women were not educated on pregnancy complications. Also, about one-third did not often understand the purposes of tests and medicines received and did not feel able to ask questions to the health care provider. In multivariate analysis, women who were literate, employed, and who received all their ANC in a health center had higher experiences scores than women who were illiterate (coefficient = 1.52, CI:0.26,2.79), unemployed (coefficient = 2.73, CI:1.46,4.00), and received some ANC from a hospital (coefficient = 1.99, CI: 0.84, 3.14) respectively. The wealthiest women had two times higher odds of receiving an ultrasound than the poorest women (OR = 2.00, CI:1.20,3.33). CONCLUSION: Quality of ANC is suboptimal in both service provision and experience domains, with disparities by demographic and socioeconomic factors and facility type. More efforts are needed to improve quality of ANC and to eliminate the disparities.


Assuntos
Assistência à Saúde/normas , Complicações na Gravidez/terapia , Cuidado Pré-Natal/normas , Qualidade da Assistência à Saúde , Adolescente , Adulto , Feminino , Humanos , Quênia , Modelos Logísticos , Pessoa de Meia-Idade , Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Saúde da População Rural , Fatores Socioeconômicos , Inquéritos e Questionários , Adulto Jovem
8.
BMC Health Serv Res ; 19(1): 756, 2019 Oct 26.
Artigo em Inglês | MEDLINE | ID: mdl-31655588

RESUMO

BACKGROUND: Village Health and Nutrition Days (VHNDs) are a cornerstone of the Government of India's strategy to provide first-contact primary health care to rural areas. Recent government programmes such as the Janani Suraksha Yojana (JSY) and Mission Indradhanush (MI) have catalysed important changes impacting VHNDs. To learn how VHNDs are currently being delivered, we assessed the fidelity of services provided as compared to government norms in a priority district of Uttar Pradesh. METHODS: We fielded a cross-sectional study of VHNDs to provide a snapshot of health services functioning. Process evaluation data were collected via administrative sources, non-participant observation using a standardised form, and structured questionnaires. Questionnaires were designed using a framework to assess implementation fidelity. Key respondents were VHND participants, front-line workers involved in VHND delivery, and VHND non-participants (pregnant women due for antenatal care or children due for vaccination as per administrative records). Results were summarised as counts, frequencies, and proportions. RESULTS: In the 30 villages randomly selected for inclusion, 36 VHNDs were scheduled but four (11.1%) were cancelled and one VHND was not surveyed. Vaccination and antenatal care were offered at 96.8% (30/31) and child weighing at 83.9% (26/31) of VHNDs. Other normed services were infrequently provided or completely absent. Health education and promotion were particularly weak; institutional delivery was the only topic discussed in a majority of VHNDs. The true proportion of any serious problem impeding vaccine delivery was 47.2% (17/36), comprising 4 VHND cancellations and 13 VHNDs experiencing vaccine shortages. Of the 13 incidents of vaccine shortage, 11 related to an unexpected global shortage of injectable polio vaccine (IPV). Over the 31 VHNDs, 37.8% (171 of the 452 scheduled beneficiaries) did not participate. Analysis of missed opportunities for vaccination highlighted inaccuracies in beneficiary identification and tracking and demand side-factors. CONCLUSIONS: The transformative potential of VHNDs to improve population health is only partially being met. A core subset of high-priority services for antenatal care, institutional delivery, and vaccination associated with high-priority government programmes (JSY, MI) is now being provided quite successfully. Other basic health promotion and prevention services are largely not provided, constituting a critical missed opportunity.


Assuntos
Transtornos da Nutrição Infantil/prevenção & controle , Serviços de Saúde Materno-Infantil/organização & administração , Serviços de Saúde Rural/organização & administração , Saúde da População Rural/estatística & dados numéricos , Adulto , Criança , Transtornos da Nutrição Infantil/epidemiologia , Estudos Transversais , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Índia/epidemiologia , Masculino , Gravidez , Cuidado Pré-Natal/organização & administração , Inquéritos e Questionários , Vacinação
9.
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 11(5): 1319-1325, out.-dez. 2019. tab, ilus, graf
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1022203

RESUMO

Objective: The study's goal has been to analyze if environmental or occupational exposure to pesticides can produce changes in pregnant women living in a countryside municipality. Methods: The participants of this study were twenty-three pregnant women, who both answered a questionnaire and donated biological material in order to perform Micronucleus (MN) Tests in lymphocytes, oral epithelial cells, and also for measuring the enzyme activity of erythrocyte acetylcholinesterase. Results: Considering the total analyzed samples, the following was found: an average of 8 ± 2.92 MN/1000 oral epithelial cells from urban participants; an average of 6.82 ± 3.43 MN/1000 oral epithelial cells from rural participants; and 100% of the microscope slides contained cells with two MN, which shows high intensity lesions to the DNA. There was found a high frequency of spontaneous abortions (34.8%), greater than in Brazil. Conclusion: The exposure of pregnant women living in a countryside municipality to pesticides may increase the rate of spontaneous abortions, as well as the chances of mutagenic effects


Objetivo: Analisar se a exposição ambiental ou ocupacional aos agrotóxicos causa alterações em gestantes residentes em um município rural. Métodos: Compuseram a amostra 23 gestantes, que responderam a um questionário e doaram amostras biológicas para a realização dos testes de micronúcleos (MN) em linfócitos, em células do epitélio oral, e para a dosagem da atividade da enzima acetilcolinesterase eritrocitária. Resultados: Obteve-se uma média de 8 ± 2,92 MN/1000 células do epitélio oral analisadas em amostras de participantes da zona urbana, 6,82 ± 3,43 MN/1000 de participantes da zona rural, e 100% das lâminas continham células com dois MN, o que demonstra lesões ao DNA de maior intensidade. Encontrou-se uma frequência elevada de casos de abortos espontâneos (34,8%), superior à encontrada no Brasil. Conclusão: A exposição de gestantes residentes em um município rural aos agrotóxicos eleva a taxa de abortos espontâneos, bem como as chances de ocorrência de efeitos mutagênicos


Objetivo: Analizar si la exposición ambiental o ocupacional a los agrotóxicos causa cambios en gestantes residentes en un municipio rural. Métodos: Compusieron la muestra 23 gestantes, que respondieron a un cuestionario y donaron muestras biológicas para la realización de las pruebas de micronúcleos (MN) en linfocitos, en células del epitelio oral, y para la dosificación de la actividad de la enzima acetilcolinesterasa eritrocitaria. Resultados: Se obtuvieron una media de 8 ± 2,92 MN / 1000 células del epitelio oral analizadas en muestras de participantes de la zona urbana, 6,82 ± 3,43 MN / 1000 de participantes de la zona rural, y el 100% de las láminas contenían células con dos MN, lo que demuestra lesiones al ADN de mayor intensidad. Se encontró una frecuencia elevada de casos de abortos espontáneos (34,8%), superior a la encontrada en Brasil. Conclusión: La exposición de gestantes residentes en un municipio rural a los agrotóxicos eleva la tasa de abortos espontáneos, así como las posibilidades de ocurrencia de efectos mutagênicos


Assuntos
Humanos , Feminino , Gravidez , Adolescente , Adulto , Agroquímicos/toxicidade , Aborto , Testes de Mutagenicidade/métodos , Acetilcolinesterase/farmacologia , Saúde da População Rural/estatística & dados numéricos , Exposição Ocupacional/efeitos adversos
10.
Actas dermo-sifiliogr. (Ed. impr.) ; 110(8): 653-658, oct. 2019. mapas, ilus, graf, tab
Artigo em Espanhol | IBECS | ID: ibc-185503

RESUMO

Introducción: La teledermatología (TD) ha sido implementada en Chile como estrategia de salud para suplir el déficit de dermatólogos y aumentar la resolutividad de la atención primaria. Esta estrategia fue implementada en la Provincia de Palena en 2013, sin un análisis de las atenciones brindadas hasta la fecha. Material y métodos: Estudio descriptivo, transversal, de concordancia inter-observador. Se analizan todas las consultas por TD de Ayacara, Chaitén, Futaleufú y Palena desde 2013 a 2017. Datos obtenidos de plataforma MINSAL. Concordancia diagnóstica calculada con índice kappa. Resultados: Total 326 consultas de TD con promedio de edad de 35,8 años (DE: 22,4), en su mayoría de sexo femenino (59,8%). Mayoría de TD originadas en Palena, con un 40,8%. Tiempo de respuesta promedio de 12,6 días (DE: 22,8), disminuyendo a 6,4 días (DE: 5,2) tras la incorporación de dermatólogo en el Hospital de Puerto Montt (p = 0,0005). Concordancia diagnóstica moderada entre el médico general y el dermatólogo, con índice kappa de 0,5. Un 20,6% de las consultas requirió evaluación presencial. Tiempo de respuesta promedio de 12,6 días (DE: 22,8), aumentando a 25,7 días (DE: 41,2) sí requirió evaluación presencial (p < 0,0001). Conclusiones: La TD es una herramienta diagnóstica y terapéutica necesaria para el médico general en zonas aisladas. La concordancia diagnóstica moderada es similar a estudios internacionales, pero inferior a estudios nacionales. Es relevante el menor tiempo de respuesta al incorporar un dermatólogo al servicio. La diferencia significativa entre el tiempo de respuesta de la consulta presencial versus la teleasistida requiere una mejor gestión asistencial


Background: Teledermatology was introduced in Chile to make up for the lack of dermatologists and improve the primary care system's ability to resolve problems. This strategy was implemented in the province of Palena in 2013, but outcomes were not analyzed and reported until now. Material and methods: Descriptive, cross-sectional study with analysis of inter-rater agreement on diagnoses. All the teledermatology consultations made on behalf of patients in Ayacara, Chaitén, Futaleufú, and Palena from 2013 through 2017 were analyzed. Data were extracted from the MINSAL platform. The κ statistic was used to assess diagnostic agreement. Results. A total of 326 teledermatology consultations were made. The mean (SD) age of the patients was 35.8 (22.4) years. The majority (59.8%) were female. Palena generated the largest volume of cases (40.8%). The mean time until a teledermatology diagnosis was given was 12.6 (22.8) days. This response time decreased to 6.4 (5.2) days after a staff dermatologist from Hospital Puerto Montt joined the program (P = .0005). Diagnosis concordance between the general practitioner and the dermatologist was moderate (κ = 0.5). Physical examination by the dermatologist at the hospital of reference (Puerto Montt) was necessary for 20.6% of the patients, and time until a definitive diagnosis for the patient took longer in such cases (25.7 (41.2) days) than for the cases that didn't need a physical evaluation at the Hospital of Puerto Montt (P < .0001). Conclusions. Teledermatology provides a necessary diagnostic and therapeutic resource for general practitioners in isolated locations. Diagnostic agreement is moderate between the generalist and the specialist, similar to agreement in international studies but lower than agreement reported in other Chilean studies. The reduction in diagnostic response time after incorporation of a dermatologist on staff at the hospital of Puerto Montt was significant. The significant difference between the time for diagnosis under teledermatology and the delay when physical examination is required at the hospital of Puerto Montt identifies an aspect of care management to improve


Assuntos
Humanos , Masculino , Feminino , Adulto , Teledermatologia , Telemedicina para as Zonas Rurais e Remotas , Epidemiologia Descritiva , Hospitais Rurais , Saúde da População Rural , Chile , Estudos Transversais , População Rural/estatística & dados numéricos
11.
J Stroke Cerebrovasc Dis ; 28(11): 104358, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31519456

RESUMO

BACKGROUND: The majority of studies on multimorbidity have been in aging populations and there is a paucity of data on individuals following stroke. OBJECTIVE: In order to better understand the overall complexity of the stroke population in rural Kentucky, we examined the prevalence of multimorbidity that impact the overall long-term health and health care for these individuals. METHODS: A secondary analysis examined whether there are gender or age differences in this stroke population related to the prevalence of multimorbidity. A total of 5325 individuals, 18 years of age and older, seen at an academic medical center for the primary diagnosis of acute ischemic stroke or transient ischemic attack between the years of 2010-2017 were identified using the Kentucky Appalachian Stroke Registry. Descriptive analysis was used to report the prevalence of each comorbidity in the rural population by age group, gender, and level of multimorbidity by looking at concurrent frequencies. RESULTS: Overall, hypertension, dyslipidemia, tobacco use, diabetes, and obesity were the comorbidities with the highest prevalence in our population irrespective of gender. Over 78% (n = 4153) of the individuals had 3 or more comorbidities while 61% (n = 3285) had at least 3 out of the top 5 comorbidities (hypertension, hyperlipidemia, tobacco, obesity, diabetes). With respect to age, 15% (n = 795) of the sample was under the age of 50, while 32% (n = 1704) were between the age of 50 and 64 and 53% (n = 2826) of the sample were 65 years or older. CONCLUSIONS: The results of this study indicate the majority of individuals affected by stroke in rural Appalachia Kentucky have multimorbidity. In addition, almost half of these individuals are having their strokes at a younger age, which will require a shift in the focus for therapeutic interventions (eg, reintegration into the workforce versus just community reintegration).


Assuntos
Ataque Isquêmico Transitório/epidemiologia , Multimorbidade , Saúde da População Rural , Acidente Vascular Cerebral/epidemiologia , Idade de Início , Idoso , Região dos Apalaches/epidemiologia , Feminino , Nível de Saúde , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Prevalência , Sistema de Registros , Medição de Risco , Fatores de Risco , Serviços de Saúde Rural , Fatores Sexuais , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Reabilitação do Acidente Vascular Cerebral
12.
Nat Commun ; 10(1): 4337, 2019 09 25.
Artigo em Inglês | MEDLINE | ID: mdl-31554811

RESUMO

Substantial quantities of air pollution and related health impacts are ultimately attributable to household consumption. However, how consumption pattern affects air pollution impacts remains unclear. Here we show, of the 1.08 (0.74-1.42) million premature deaths due to anthropogenic PM2.5 exposure in China in 2012, 20% are related to household direct emissions through fuel use and 24% are related to household indirect emissions embodied in consumption of goods and services. Income is strongly associated with air pollution-related deaths for urban residents in which health impacts are dominated by indirect emissions. Despite a larger and wealthier urban population, the number of deaths related to rural consumption is higher than that related to urban consumption, largely due to direct emissions from solid fuel combustion in rural China. Our results provide quantitative insight to consumption-based accounting of air pollution and related deaths and may inform more effective and equitable clean air policies in China.


Assuntos
Poluição do Ar/análise , Exposição Ambiental/estatística & dados numéricos , Mortalidade Prematura/tendências , Saúde da População Rural/estatística & dados numéricos , Fatores Socioeconômicos , Saúde da População Urbana/estatística & dados numéricos , Poluição do Ar/efeitos adversos , Grupo com Ancestrais do Continente Asiático/estatística & dados numéricos , China , Exposição Ambiental/efeitos adversos , Exposição Ambiental/análise , Política Ambiental/legislação & jurisprudência , Política Ambiental/tendências , Características da Família , Humanos , Mortalidade Prematura/etnologia , Material Particulado/análise
13.
J Consult Clin Psychol ; 87(10): 952-961, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31556671

RESUMO

OBJECTIVE: This retrospective study describes the role of behavioral health in an addiction medicine program integrated in a primary care clinic, and evaluates retention, substance use, and mental health symptoms for patients in a rural underserved community. METHOD: Data were abstracted from records of patients referred for buprenorphine treatment of opioid use disorder (N = 101; 45% female, 23% Native Hawaiian or Pacific Islander, Mage = 42.5, SD = 12.75). Among patients prescribed buprenorphine (n = 61), most had comorbid substance-related diagnoses (72% with tobacco use, 75% with at least one other substance use disorder) and non-substance-related mental health diagnoses (77%), most commonly depression and anxiety. Integrated sessions with a behavioral health provider and a buprenorphine-waivered prescriber occurred weekly to monthly. Participants completed depression and anxiety questionnaires (Patient Health Questionnaire-9 and Generalized Anxiety Disorder Scale-7) and provided urine samples at each visit. RESULTS: Most patients (72%) were retained for at least 3 months, with early dropout associated with higher initial depression and anxiety scores. Inconsistent urine drug tests (i.e., those positive for illicit/nonprescribed substances) were significantly more common at treatment initiation (74%) than during the most recent visit (43%, p < .001), and were associated with baseline substance and other mental health factors, as well as shorter treatment duration. Generalized estimating equations models suggested time-based improvements in depression and anxiety symptoms, especially for patients retained for at least 3 months. CONCLUSIONS: Integrating wraparound addiction treatment within a rural primary care setting is feasible and associated with improved mental health and retention outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).


Assuntos
Medicina do Vício , Buprenorfina/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Atenção Primária à Saúde , Saúde da População Rural , Adulto , Transtornos de Ansiedade/complicações , Buprenorfina/administração & dosagem , Transtorno Depressivo/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas de Entorpecentes/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/complicações , Estudos Retrospectivos
14.
BMC Public Health ; 19(1): 1273, 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31533683

RESUMO

BACKGROUND: SIPsmartER is a 6-month evidenced-based, multi-component behavioral intervention that targets sugar-sweetened beverages among adults. It consists of three in-person group classes, one teach-back call, and 11 automated phone calls. Given SIPsmartER's previously demonstrated effectiveness, understanding its adoption, implementation, and potential for integration within a system that reaches health disparate communities is important to enhance its public health impact. During this pilot dissemination and implementation trial, SIPsmartER was delivered by trained staff from local health districts (delivery agents) in rural, Appalachian Virginia. SIPsmartER's execution was supported by consultee-centered implementation strategies. METHODS: In this mixed-methods process evaluation, adoption and implementation indicators of the program and its implementation strategy (e.g., fidelity, feasibility, appropriateness, acceptability) were measured using tracking logs, delivery agent surveys and interviews, and fidelity checklists. Quantitative data were analyzed with descriptive statistics. Qualitative data were inductively coded. RESULTS: Delivery agents implemented SIPsmartER to the expected number of cohorts (n = 12), recruited 89% of cohorts, and taught 86% of expected small group classes with > 90% fidelity. The planned implementation strategies were also executed with high fidelity. Delivery agents completing the two-day training, pre-lesson meetings, fidelity checklists, and post-lesson meetings at rates of 86, 75, 100, and 100%, respectively. Additionally, delivery agents completed 5% (n = 3 of 66) and 10% (n = 6 of 59) of teach-back and missed class calls, respectively. On survey items using 6-point scales, delivery agents reported, on average, higher feasibility, appropriateness, and acceptability related to delivering the group classes (range 4.3 to 5.6) than executing missed class and teach-back calls (range 2.6 to 4.6). They also, on average, found the implementation strategy activities to be helpful (range 4.9 to 6.0). Delivery agents identified strengths and weakness related to recruitment, lesson delivery, call completion, and the implementation strategy. CONCLUSIONS: In-person classes and the consultee-centered implementation strategies were viewed as acceptable, appropriate, and feasible and were executed with high fidelity. However, implementation outcomes for teach-back and missed class calls and recruitment were not as strong. Findings will inform the future full-scale dissemination and implementation of SIPsmartER, as well as other evidence-based interventions, into rural health districts as a means to improve population health.


Assuntos
Sacarose na Dieta/administração & dosagem , Educação em Saúde/métodos , Promoção da Saúde/métodos , População Rural/estatística & dados numéricos , Adulto , Região dos Apalaches , Bebidas/estatística & dados numéricos , Feminino , Humanos , Obesidade/prevenção & controle , Saúde da População Rural , Virginia
15.
BMC Health Serv Res ; 19(1): 654, 2019 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-31500617

RESUMO

BACKGROUND: Integration of medical insurance schemes has been prioritized as one of the key strategies to address inequity in China's health system. The first pilot attempt to integrate started in 2003 and later expanded nationwide. This study aims to assess its intended impact on inequity in inpatient service utilization and identify the main determinants contributing to its ineffectiveness. METHODS: A total of 49,365 respondents in the pilot integrated area and 77,165 respondents in the non-integration area were extracted from the Fifth National Health Services Survey. A comparative analysis was conducted between two types of areas. We calculate a concentration index (CI) and horizontal inequity index (HI) in inpatient service utilization and decompose the two indices. RESULTS: Insurance integration played a positive role in reducing inequality in inpatient service utilization to some extent. A 13.23% lower in HI, a decrease in unmet inpatient care and financial barriers to inpatient care in the pilot integrated area compared with the non-integration area; decomposition analysis showed that the Urban-Rural Residents Basic Medical Insurance, a type of integrated insurance, contributed 37.49% to reducing inequality in inpatient service utilization. However, it still could not offset the strong negative effect of income and other insurance schemes that have increased inequality. CONCLUSIONS: The earlier pilot attempt for integrating medical insurance was not enough to counteract the influence of factors which increased the inequality in inpatient service utilization. Further efforts to address the inequality should focus on widening access to financing, upgrading the risk pool, reducing gaps within and between insurance schemes, and providing broader chronic disease benefit packages. Social policies that target the needs of the poor with coordinated efforts from various levels and agencies of the government are urgently needed.


Assuntos
Doença Crônica/tendências , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Idoso , China , Utilização de Instalações e Serviços , Feminino , Humanos , Renda/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/estatística & dados numéricos , Saúde da População Rural/estatística & dados numéricos , Fatores Socioeconômicos , Inquéritos e Questionários , Saúde da População Urbana/estatística & dados numéricos , Adulto Jovem
17.
BMC Health Serv Res ; 19(1): 626, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31481056

RESUMO

BACKGROUND: Regional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery. We aimed to estimate regional variation in medical costs for people living with HIV (PLHIV), adjusting for demographics and case-mix. METHODS: We conducted a retrospective cohort study using linked health administrative databases of PLHIV, from 2010 to 2014, in British Columbia (BC), Canada. Quarterly health care costs (2018 CAD) were derived from inpatient, outpatient, prescription drugs, antiretroviral therapy (ART), and HIV diagnostics. We used a two-part model with a logit link for the probability of incurring costs, and a log link and gamma distribution for observations with positive costs. We also estimated quarterly utilization rates for hospitalization-, physician billing- and prescription drug-days. Primary variables were indicators of individuals' Health Service Delivery Area (HSDA). We adjusted cost and utilization estimates for demographic characteristics, HIV-disease progression, and comorbidities. RESULTS: Our cohort included 9577 PLHIV (median age 45.5 years, 80% male). Adjusted total quarterly costs for all 16 HSDAs were within 20% of the provincial mean, 8/16 for hospitalization costs, 16/16 for physician billing costs and 10/16 for prescription drug costs. Northern Interior and Northeast HSDAs had 38 and 44% lower quarterly non-ART prescription drug costs, and 2 and 5% higher quarterly inpatient costs, respectively. CONCLUSIONS: We observed limited variation in medical care costs and utilization among PLHIV in BC. However, lower levels of outpatient care and higher levels of inpatient care indicate possible barriers to accessing care among PLHIV in the most rural regions of the province.


Assuntos
Fármacos Anti-HIV/economia , Infecções por HIV/economia , Adulto , Assistência Ambulatorial/economia , Fármacos Anti-HIV/uso terapêutico , Colúmbia Britânica/epidemiologia , Estudos de Coortes , Comorbidade , Bases de Dados Factuais , Progressão da Doença , Custos de Medicamentos , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Medicamentos sob Prescrição/uso terapêutico , Características de Residência , Estudos Retrospectivos , Saúde da População Rural
18.
BMC Public Health ; 19(1): 1087, 2019 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-31399048

RESUMO

BACKGROUND: In South Africa, the occurrence of the double burden of malnutrition is on the rise at a household level predisposing children and their mothers to negative health outcomes. However, few studies have been conducted at a household level. Therefore, we studied a double burden of malnutrition using child-mother pairs in a rural setting. METHODS: A cross-sectional quantitative survey was conducted among 508 child-mother pairs selected from primary schools using a multistage sampling in a rural Dikgale Health and Demographic Site in Limpopo Province, South Africa. Anthropometric measurements of children and mothers, and socio-demographic data were collected. WHO AnthroPlus was used to generate body-mass-index z-scores of children and the BMI was used to indicate overweight and obesity among the mothers. Mann Whitney test was used to compare the means of variables between sexes and age groups, while the prevalence of thinness and overweight/obesity were compared using a chi-square. Multivariate logistic regression with a stepwise backward elimination procedure, controlling for confounding, was used to determine the association between the thinness and overweight/obesity and the covariates. RESULTS: Twenty five percent (25%) of the children were thin, 4% were overweight and 1% obese, while mothers were overweight (27.4%) and 42.3% obesity (42.3%) were observed among the mothers. The odds of being thin were higher in boys than in girls (AOR = 1.53, 95%CI: 1.01-2.35). Overweight/obese mothers were more likely to have thin children (AOR = 1.48, 95% CI: 1.01-2.18) and less likely to have overweight/obese children (AOR = 0.18, 95%CI: 0.07-0.46). CONCLUSION: A double burden of malnutrition was observed on a household level with thinness among children and overweight/obesity among mothers. A need to address the dual problems of undernutrition and rapidly rising trends of overweight/obesity cannot be over-emphasized.


Assuntos
Desnutrição/epidemiologia , Vigilância da População , Saúde da População Rural/estatística & dados numéricos , Adulto , Criança , Estudos Transversais , Feminino , Humanos , Masculino , Mães/estatística & dados numéricos , Instituições Acadêmicas , África do Sul/epidemiologia
19.
J Stroke Cerebrovasc Dis ; 28(11): 104316, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31416762

RESUMO

BACKGROUND: Egypt is a densely populated country with living habits and health care services that differ from urban to rural regions. We aimed to study how characteristics of stroke vary among these regions. METHODS: This is a cross-sectional observational study of ischemic stroke, thus hemorrhagic and venous strokes were excluded. A total of 1475 ischemic stroke patients were recruited for analysis from a tertiary hospital in Cairo representing urban area and from a secondary care hospital in Suhag representing rural region. RESULTS: Analysis was done for 1143 ischemic stroke patients from urban and 332 from rural area. Onset to door was shorter in urban. Urban patients showed an older age and higher prevalence of hypertension and diabetes (65.9%, 48.6% respectively), while rural patients were characterized by female preponderance (51.5%), more dyslipidemia, smoking 44.6%, stroke in young 20.5%, atrial fibrillation 23.8% % and recurrent stroke 44.3%. Rural cases showed a severer deficit at onset and poorer outcome. CONCLUSION: Vascular risk factors, stroke type, and presentation tend to differ in Egypt according to the geographic distribution whether urban or rural. Studying patterns of such difference may aid in planning specific targeted preventive and therapeutic strategies for stroke in urban and rural Egypt.


Assuntos
Isquemia Encefálica/epidemiologia , Saúde da População Rural , Acidente Vascular Cerebral/epidemiologia , Saúde da População Urbana , Adulto , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Comorbidade , Estudos Transversais , Egito/epidemiologia , Feminino , Nível de Saúde , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Tempo para o Tratamento
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