Bypassing health facilities in rural Mozambique: spatial, institutional, and individual determinants.

BACKGROUND: Access to sexual and reproductive health (SRH) services is critical for such outcomes as pregnancy and birth, prenatal and neonatal mortality, maternal morbidity and mortality, and prevention of vertical transmission of infections like HIV. Health facilities are typically set up where they can efficiently serve the nearby targeted population. However, the actual utilization of health care can be complicated as people sometimes bypass the closest or nearby facilities for various reasons such as service quality. A better understanding of how people actually utilize health services can benefit future health resource allocation as well as health program planning. METHODS: In this study, we use prenatal care as an example of a basic, widely available service to investigate women's choice and bypassing of SRH facilities as well as potential influencing factors at the geographic, clinic, household, and individual levels. The data come from a population-based survey of women of reproductive age in rural Mozambique. The spatial pattern of utilization of health clinics for prenatal care is explored by geographical information system (GIS)-based spatial analysis. Logistic regression is fitted to test the hypotheses regarding the effect of distance, service quality, and household/individual-level factors on the bypassing of the nearest clinic. RESULTS: The results indicate that most women living near clinics tend to utilize the closest facilities for prenatal care and those who travel farther mainly do so to seek better services. Further, for women who live far from a clinic (> 5.5 km), service quality still plays an important role in the facility bypassing while the effect of distance is no longer significant. The bypassing of nearest facility is also affected by individual characteristics such as age, HIV status, and household economic conditions. CONCLUSIONS: The findings help to better understand health facility choice and bypassing in developing settings, in general, and in resource-limited Sub-Saharan settings, in particular. They offer valuable guidance for future health resource allocation and health service planning.

Approaches to the field recognition of potential thrombectomy candidates.

Systems of care for acute ischemic stroke are being challenged to implement processes that ensure rapid access to endovascular thrombectomy. Optimizing existing regionalized stroke thrombolysis programs for endovascular thrombectomy will require accurate field recognition of treatment candidates. We begin with a review of the development of early clinical tests for ischemic stroke, illustrating challenges relevant to future field tests for large vessel occlusion. Second, we discuss aspects of diagnosis, eligibility, feasibility, and system organization that are potentially relevant to the development and implementation of field tests and diversion criteria. These considerations may influence the choice and parametrization of field tests in individual jurisdictions. Third, we review the literature evaluating eight clinical tests for the field identification of probable large vessel occlusion. All candidate tests include evaluations for focal weakness, and six evaluate for cortical signs such as aphasia or gaze deviation. Most appear roughly comparable to the NIH Stroke Scale, but direct comparison between studies is inappropriate because of major methodological differences. Finally, we discuss our jurisdiction's approach to the field recognition of thrombectomy candidates. We contextualize diagnostic, eligibility, and system considerations within distinct metro and rural environments and propose a screen-and-consult model for the rural setting.