Exploring Sex Differences in Risk Factors and Quality of Life Among Tuberculosis Patients in Herat, Afghanistan: A Case-Control Study.

Objectives: Tuberculosis (TB) is a significant public health concern in Afghanistan, with a high burden of disease in the western province of Herat. This study explored the risk factors of TB and TB's impact on the quality of life of patients in Herat. Methods: A total of 422 TB patients and 514 controls were recruited at Herat Regional Hospital and relevant TB laboratories between October 2020 and February 2021. Data was collected through interviews using a structured questionnaire and the SF-36 questionnaire. Descriptive statistics, chi-square tests, Multivariate General Linear Model, and logistic regression analysis were used to analyze the data. Results: The results showed that male sex (p = 0.023), chronic disease (p = 0.038), lower education levels (p < 0.001), and worse health status (p < 0.001) were significantly associated with higher odds of TB infection. The study also found that TB patients had significantly lower quality of life scores in almost all components (p < 0.05). Conclusion: This study provides important insights into the specific ways in which TB affects the wellbeing of patients in Afghanistan. The findings highlight the importance of addressing the psychological and social dimensions of TB.

Factors affecting quality of life in hepatitis B patients in Herat, Afghanistan: A case-control study.

Hepatitis B virus is a global health concern with a high death rate in Afghanistan. Limited data exist on the disease's impact on quality of life in low-resource settings. This case-control study aims to identify potential risk factors and assess the quality of life among hepatitis B patients in Herat, Afghanistan, with a focus on sex differences. Understanding these factors can inform prevention, care, and sex-specific interventions. A cross-sectional study conducted at Herat Regional Hospital examined hepatitis B patients above 18 years old, between October 2020 and February 2021. The control group consisted of age and sex-matched individuals without a history of hepatitis B. Data were collected through a structured questionnaire covering socio-demographic characteristics, signs and symptoms of hepatitis B, and the SF-36 questionnaire for measuring the quality of life of study participants. Statistical analysis was performed using multivariate General Linear Models, and logistic regression. We identified several potential risk factors for hepatitis B infection, including male sex, younger age groups, tobacco use, lower education levels, rural residence, family history, weak social networks, specific family structures and underlying chronic diseases (p < .05). The study found that hepatitis B cases had significantly lower mean scores across all SF-36 components, indicating an overall reduced quality of life (p < .05). These differences were more pronounced in males, although females had lower scores in most components. Role limitations due to physical and emotional health were particularly affected. These findings highlight the urgent need for targeted interventions, sex-specific strategies, improved healthcare access and comprehensive policies. These findings can inform prevention efforts to improve the overall quality of life of people with hepatitis B in Afghanistan.

Predictors of Multimorbidity (Defined as Diabetes + Hypertension) Amongst Males Aged 15-54 in India: An Urban/Rural Split Analysis.

Objectives: This study aimed to determine which sociodemographic and lifestyle factors may act as predictors of multimorbidity (defined as diabetes + hypertension) amongst men aged 15-54 within urban and rural areas of India. Methods: Data from the latest 2019-2021 India NFHS-5 survey were utilized. Presumed cases of multimorbidity were defined as men who had DM + HTN. A total of 22,411 men in urban areas and 66,768 rural men were analyzed using mixed-effect multi-level binary logistic regression models. Results: Various predictors were found to have a statistically significant association to multimorbidity. Urban areas: Age, region of residence, wealth, religion, occupation, and BMI. Rural areas: Age, education, region of residence, wealth, occupation, caste, BMI, alcohol consumption, media exposure, and tobacco consumption. Conclusion: Departing from the broad operational definitions often studied within literature, this study provided insight into one of the most prevalent specific multimorbidities across India. The urban/rural split analyses revealed substantial differences in high-risk characteristics across both areas, which have commonly been overlooked. These findings may better inform policymakers and assist in effectively reducing multimorbidity-related burden through area-specific preventative programs.

Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada.

INTRODUCTION: It is well-known that the way physicians are remunerated can affect delivery of health care services to the population. Fee-for-service (FFS) generally leads to oversupply of services, while capitation leads to undersupply of services. However, little evidence exists on the link between remuneration and emergency department (ED) visits. We fill this gap using two popular blended models introduced in Ontario, Canada: the Family Health Group (FHG), an enhanced/blended FFS model, and Family Health Organization (FHO), a blended capitation model. We compare primary care services and rates of emergency department ED visits between these two models. We also evaluate whether these outcomes vary by regular- and after-hours, and patient morbidity status. METHODS: Physicians practicing in an FHG or FHO between April 2012 and March 2017 and their enrolled adult patients were included for analyses. The covariate-balancing propensity score weighting method was used to remove the influence of observable confounding and negative-binomial and linear regression models were used to evaluate the rates of primary care services, ED visits, and the dollar value of primary care services delivered between FHGs and FHOs. Visits were stratified as regular- and after-hours. Patients were stratified into three morbidity groups: non-morbid, single-morbid, and multimorbid (two or more chronic conditions). RESULTS: 6184 physicians and their patients were available for analysis. Compared to FHG physicians, FHO physicians delivered 14% (95% CI 13%, 15%) fewer primary care services per patient per year, with 27% fewer services during after-hours (95% CI 25%, 29%). Patients enrolled to FHO physicians made 27% more less-urgent (95% CI 23%, 31%) and 10% more urgent (95% CI 7%, 13%) ED visits per patient per year, with no difference in very-urgent ED visits. Differences in the pattern of ED visits were similar during regular- and after-hours. Although FHO physicians provided fewer services, multimorbid patients in FHOs made fewer very-urgent and urgent ED visits, with no difference in less-urgent ED visits. CONCLUSION: Primary care physicians practicing in Ontario's blended capitation model provide fewer primary care services compared to those practicing in a blended FFS model. Although the overall rate of ED visits was higher among patients enrolled to FHO physicians, multimorbid patients of FHO physicians make fewer urgent and very-urgent ED visits.

Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal.

Objectives: (a) To quantify the level and changes in socioeconomic inequality in the utilization of antenatal care (ANC), institutional delivery (ID) and postnatal care (PNC) in Nepal over a 20-year period; (b) identify key drivers of inequality using decomposition analysis; and (c) identify geographical clusters with low service utilization to inform policy. Methods: Data from the most recent five waves of the Demographic Health Survey were used. All outcomes were defined as binary variables: ANC (=1 if ≥4 visits), ID (=1 if place of delivery was a public or private healthcare facility), and PNC (=1 if ≥1 visits). Indices of inequality were computed at national and provincial-level. Inequality was decomposed into explanatory components using Fairile decomposition. Spatial maps identified clusters of low service utilization. Results: During 1996-2016, socioeconomic inequality in ANC and ID reduced by 10 and 23 percentage points, respectively. For PND, the gap remained unchanged at 40 percentage points. Parity, maternal education, and travel time to health facility were the key drivers of inequality. Clusters of low utilization were displayed on spatial maps, alongside deprivation and travel time to health facility. Conclusion: Inequalities in the utilization of ANC, ID and PNC are significant and persistent. Interventions targeting maternal education and distance to health facilities can significantly reduce the gap.

Natural history of abdominal pain in family practice: Longitudinal study of electronic medical record data in southwestern Ontario.

OBJECTIVE: To examine the frequency, natural history, and outcomes of 3 subtypes of abdominal pain (general abdominal pain, epigastric pain, localized abdominal pain) among patients visiting Canadian family practices. DESIGN: Retrospective cohort study with a 4-year longitudinal analysis. SETTING: Southwestern Ontario. PARTICIPANTS: A total of 1790 eligible patients with International Classification of Primary Care codes for abdominal pain from 18 family physicians in 8 group practices. MAIN OUTCOME MEASURES: The symptom pathways, the length of an episode, and the number of visits. RESULTS: Abdominal pain accounted for 2.4% of the 15,149 patient visits and involved 14.0% of the 1790 eligible patients. The frequencies of each of the 3 subtypes were as follows: localized abdominal pain, 89 patients, 1.0% of visits, and 5.0% of patients; general abdominal pain, 79 patients, 0.8% of visits, and 4.4% of patients; and epigastric pain, 65 patients, 0.7% of visits, and 3.6% of patients. Those with epigastric pain received more medications, and patients with localized abdominal pain underwent more investigations. Three longitudinal outcome pathways were identified. Pathway 1, in which the symptom remains at the end of the visit with no diagnosis, was the most common among patients with all subtypes of abdominal symptoms at 52.8%, 54.4%, and 50.8% for localized, general, and epigastric pain, respectively, and the symptom episodes were relatively short. Less than 15% of patients followed pathway 2, in which a diagnosis is made and the symptom persists, and yet the episodes were long with 8.75 to 16.80 months' mean duration and 2.70 to 4.00 mean number of visits. Pathway 3, in which a diagnosis is made and there are no further visits for that symptom, occurred approximately one-third of the time, with about 1 visit over about 2 months. Prior chronic conditions were common across all 3 subtypes of abdominal pain ranging from 72.2% to 80.0%. Psychological symptoms consistently occurred at a rate of approximately one-third. CONCLUSION: The 3 subtypes of abdominal pain differed in clinically important ways. The most frequent pathway was that the symptom remained with no diagnosis, suggesting a need for clinical approaches and education programs for care of symptoms themselves, not merely in the service of coming to a diagnosis. The importance of prior chronic conditions and psychological conditions was highlighted by the results.

Enacting care by being experts and managing relationships: A discourse analysis of chief medical officer of health media briefings during the COVID-19 pandemic.

In Canada, Chief Medical Officers of Health (CMOHs) are responsible for protecting and promoting the health of their respective populations, but few studies have examined this role and its connections with the practice of medicine. In Canada and elsewhere, CMOHs and other public health physicians have articulated their actions as caring for their populations as patients. In order to understand the components of enacted care, this study is a functional discourse analysis of transcribed CMOH media briefings at three time points in five Canadian jurisdictions during the first full year of the COVID-19 pandemic (2020). Transcripts were coded and analysed in an iterative, comparative process to understand the content, actions and purpose of CMOH communication during media briefings. CMOHs used their public communications to enact their care of populations by "being experts" and "managing relationships". "Being experts" involved describing disease characteristics, assessing risk and evidence, framing risk and evidence, and making judgments about intervention and exemption. "Managing relationships" involved self-regulating emotions, acknowledging the emotions of others, seeking adherence and collaboration, and setting expectations and boundaries. The findings suggest that traditional biomedical roles were performed by CMOHs in media briefings, implying the existence of a patient (or multiple patient-like relationships) and supporting further research into the processes by which public health physicians care for populations as patients.

Effect of Reproductive and Lifestyle Factors on Anti-Mullerian Hormone Levels in Women of Indian Origin.

Background: Infertility is a world-wide problem and one third females. Over the years, anti-mullerian hormone (AMH) has emerged as a major marker of ovarian reserve. There is also increasing interest in determining the factors which can impact AMH levels. Aims: To correlate the association of reproductive and lifestyle factors on AMH levels in women of Indian origin. Settings and Design: Multicentric cross sectional study. Materials and Methods: The study was conducted using data extracted from the patient records of seven private fertility practices located in North India. Women who were attending these clinics for fertility treatment were requested to fill the questionnaire related to reproductive and lifestyle factors. Statistical Analysis used: Our outcome variable was level of AMH measured in the past 3 months, and was assessed as normal or low. All analyses were conducted using STATA 17. Results: We found a direct association of low AMH with increasing age, short cycles, amenorrhea and women with family history of premature menopause. We found a direct correlation of high AMH and women with polycystic ovary syndrome and those whose partners had Oligoasthenoteratozoospermia (OATS) or azoospermia. There was no correlation with smoking, sleep, diet, body mass index, cell phone or laptop use in our study. Conclusion: Reproductive and lifestyle factors may affect ovarian reserve and but there was a dearth of human studies in this area. To the best of our knowledge this is the first human study on the effect of AMH on Laptop and Cell phone use. We urgently need more studies to confirm or refute our findings so that we can counsel our patients well.

Effect of health systems strengthening in influencing maternal and neonatal health outcomes in Bungoma County, Kenya.

Introduction: maternal and neonatal health status indicators have steadily improved over time in Kenya. Significant challenges remain, including persistent inequities between population subgroups, and a health system that delivers variable quality care and inconsistent access to care. This paper highlights results of an ex-post evaluation to assess the impact of maternal and health systems strengthening intervention to improve newborn health outcomes in Bungoma County, Kenya, focusing on access to and quality of maternal and neonatal care. Methods: the study design was quasi-experimental, using household surveys to assess outcomes at baseline and end-line. Stratified cluster sampling was used to identify households, based on heath facility catchment areas. Inclusion criteria were women aged 18-49. Chi-square and fisher´s exact tests were used. Patched-up design was used to compare outcomes before and after the intervention and intervention and control sub-counties. Results: provision of transport vouchers decreased barriers to accessto health care, resulting in an increased number of deliveries in health facilities. Women in the end-line group were 95% more likely to deliver at a health facility compared to 74% at baseline. The intervention improved potential and effective access to antenatal care as well as deliveries in health facilities. This positively impacted quality of care provision in the sub-counties. Conclusion: key elements of health system strengthening included reducing cost barriers and enhancing the capacity of the health facilities to deliver high quality care. The intervention addressed commonly identified supply-and demand-side barriers, providing stronger evidence that addressing these hindrances would improve utilization of maternal and child health services.

Examining Variations in the Prevalence of Diagnosed Mood or Anxiety Disorders Among Migrant Groups in Ontario, 1995-2015: A Population-Based, Repeated Cross-Sectional Study.

BACKGROUND: International evidence on the frequency of mood or anxiety disorders among migrant groups is highly variable, as it is dependent on the time since migration and the socio-political context of the host country. Our objective was to estimate trends in the prevalence of diagnosed mood or anxiety disorders among recent (<5 years in Canada) and settled (5-10 years in Canada) migrant groups, relative to the general population of Ontario, Canada. METHODS: We used a repeated cross-sectional design consisting of four cross-sections spanning 5 years each, constructed using health administrative databases from 1995 to 2015. We included all Ontario residents between the ages of 16 and 64 years. We assessed differences in the prevalence of mood or anxiety disorders adjusting for age, sex, and neighbourhood-level income. We further evaluated the impact of migrant class and region of birth. RESULTS: The prevalence of mood or anxiety disorders was lower among recent (weighted mean = 4.10%; 95% confidence interval [CI], 3.59% to 4.60%) and settled (weighted mean = 4.77%; 95% CI, 3.94% to 5.61%) migrant groups, relative to the general population (weighted mean = 7.39%; 95% CI, 6.83% to 7.94%). Prevalence estimates varied greatly by region of birth and migrant class. We found variation in prevalence estimates over time, with refugee groups having the largest increases between 1995 and 2015. CONCLUSIONS: Our findings highlight the complexity of mood and anxiety disorders among migrant groups, and that not all groups share the same risk profile. These results can be used to help inform health service allocation and the development of supportive programs for specific migrant groups.

A Bayesian approach to estimating the population prevalence of mood and anxiety disorders using multiple measures.

AIMS: There is currently no universally accepted measure for population-based surveillance of mood and anxiety disorders. As such, the use of multiple linked measures could provide a more accurate estimate of population prevalence. Our primary objective was to apply Bayesian methods to two commonly employed population measures of mood and anxiety disorders to make inferences regarding the population prevalence and measurement properties of a combined measure. METHODS: We used data from the 2012 Canadian Community Health Survey - Mental Health linked to health administrative databases in Ontario, Canada. Structured interview diagnoses were obtained from the survey, and health administrative diagnoses were identified using a standardised algorithm. These two prevalence estimates, in addition to data on the concordance between these measures and prior estimates of their psychometric properties, were used to inform our combined estimate. The marginal posterior densities of all parameters were estimated using Hamiltonian Monte Carlo (HMC), a Markov Chain Monte Carlo technique. Summaries of posterior distributions, including the means and 95% equally tailed posterior credible intervals, were used for interpretation of the results. RESULTS: The combined prevalence mean was 8.6%, with a credible interval of 6.8-10.6%. This combined estimate sits between Bayesian-derived prevalence estimates from administrative data-derived diagnoses (mean = 7.4%) and the survey-derived diagnoses (mean = 13.9%). The results of our sensitivity analysis suggest that varying the specificity of the survey-derived measure has an appreciable impact on the combined posterior prevalence estimate. Our combined posterior prevalence estimate remained stable when varying other prior information. We detected no problematic HMC behaviour, and our posterior predictive checks suggest that our model can reliably recreate our data. CONCLUSIONS: Accurate population-based estimates of disease are the cornerstone of health service planning and resource allocation. As a greater number of linked population data sources become available, so too does the opportunity for researchers to fully capitalise on the data. The true population prevalence of mood and anxiety disorders may reside between estimates obtained from survey data and health administrative data. We have demonstrated how the use of Bayesian approaches may provide a more informed and accurate estimate of mood and anxiety disorders in the population. This work provides a blueprint for future population-based estimates of disease using linked health data.

Mental Health Services Provision in Primary Care and Emergency Department Settings: Analysis of Blended Fee-for-Service and Blended Capitation Models in Ontario, Canada.

Treating mental illnesses in primary care is increasingly emphasized to improve access to mental health services. Although family physicians (FPs) or general practitioners are in an ideal position to provide the bulk of mental health care, it is unclear how best to remunerate FPs for the adequate provision of mental health services. We examined the quantity of mental health services provided in Ontario's blended fee-for-service and blended capitation models. We evaluated the impact of FPs switching from blended fee-for-service to blended capitation on the provision of mental health services in primary care and emergency department using longitudinal health administrative data from 2007 to 2016. We accounted for the differences between those who switched to blended capitation and non-switchers in the baseline using propensity score weighted fixed-effects regressions to compare remuneration models. We found that switching from blended fee-for-service to blended capitation was associated with a 14% decrease (95% CI 12-14%) in the number of mental health services and an 18% decrease (95% CI 15-20%) in the corresponding value of services. This result was driven by the decrease in services during regular-hours. During after-hours, the number of services increased by 20% (95% CI 10-32%) and the corresponding value increased by 35% (95% CI 17-54%). Switching was associated with a 4% (95% CI 1-8%) decrease in emergency department visits for mental health reasons. Blended capitation reduced provision of mental health services without increasing emergency department visits, suggesting potential efficiency gain in the blended capitation model in Ontario.

Emergency department use following incentives to provide after-hours primary care: a retrospective cohort study.

BACKGROUND: Access to primary care outside of regular working hours is limited in many countries. This study investigates the relation between the after-hours premium, an incentive for primary care physicians to provide services after hours, and less-urgent visits to the emergency department in Ontario, Canada. METHODS: We analyzed a retrospective cohort of a random sample of Ontario residents from April 2002 to March 2006, and a subcohort of patients followed from April 2005 to March 2016. We linked patient and primary care physician data with emergency department visit data. We used fixed-effects regression models to analyze the association between the introduction of the after-hours premium, as well as subsequent increases in the value of the premium, and the number of monthly emergency department visits. RESULTS: The sample consisted of 586 534 patients between 2002 and 2006, and 201 594 patients from 2005 to 2016. After controlling for patient and physician characteristics, seasonality and time-invariant patient confounding factors, introduction of the after-hours premium was associated with a reduction of 1.26 less-urgent visits to the emergency department per 1000 patients per month (95% confidence interval -1.48 to -1.04). Most of this reduction was observed in after-hours visits. Sensitivity analysis showed that the monthly reduction in less-urgent visits to the emergency department was in the range of -1.24 to -1.16 per 1000 patients. Subsequent increases in the after-hours premium were associated with a small reduction in less-urgent visits to the emergency department. INTERPRETATION: Ontario's experience suggests that incentivizing physicians to improve access to after-hours primary care reduces some less-urgent visits to the emergency department. Other jurisdictions may consider incentives to limit less-urgent visits to the emergency department.

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada.

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.

The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review.

Access to after-hours primary care is problematic in many developed countries, leading patients to instead visit the emergency department for non-urgent conditions. However, emergency department utilization for conditions treatable in primary care settings may contribute to emergency department overcrowding and increased health system costs. This systematic review examines the impact of various initiatives by developed countries to improve access to after-hours primary care on emergency department and primary care utilization. We performed a systematic review on the impact of improved access to after-hours primary and searched CINAHL, EMBASE, MEDLINE, and Scopus. We identified 20 studies that examined the impact of improved access to after-hours primary care on ED utilization and 6 studies that examined the impact on primary care utilization. Improved access to after-hours primary care was associated with increased primary care utilization, but had a mixed effect on emergency department utilization, with limited evidence of a reduction in non-urgent and semi-urgent emergency department visits. Although our review suggests that improved access to after-hours primary care may limit emergency department utilization by shifting patient care from the emergency department back to primary care, rigorous research in a given institutional context is required before introducing any initiative to improve access to after-hours primary care.

Geographic variation in preventable hospitalisations across Canada: a cross-sectional study.

OBJECTIVE: The objective of this study is to examine the magnitude and pattern of small-area geographic variation in rates of preventable hospitalisations for ambulatory care-sensitive conditions (ACSC) across Canada (excluding Québec). DESIGN AND SETTING: A cross-sectional study conducted in Canada (excluding Québec) using data from the 2006 Canadian Census Health and Environment Cohort (CanCHEC) linked prospectively to hospitalisation records from the Discharge Abstract Database (DAD) for the three fiscal years: 2006-2007, 2007-2008 and 2008-2009. PRIMARY OUTCOME MEASURE: Preventable hospitalisations (ACSC). PARTICIPANTS: The 2006 CanCHEC represents a population of 22 562 120 individuals in Canada (excluding Québec). Of this number, 2 940 150 (13.03%) individuals were estimated to be hospitalised at least once during the 2006-2009 fiscal years. METHODS: Age-standardised annualised ACSC hospitalisation rates per 100 000 population were computed for each of the 190 Census Divisions. To assess the magnitude of Census Division-level geographic variation in rates of preventable hospitalisations, the global Moran's I statistic was computed. 'Hot spot' analysis was used to identify the pattern of geographic variation. RESULTS: Of all the hospitalisation events reported in Canada during the 2006-2009 fiscal years, 337 995 (7.10%) events were ACSC-related hospitalisations. The Moran's I statistic (Moran's I=0.355) suggests non-randomness in the spatial distribution of preventable hospitalisations. The findings from the 'hot spot' analysis indicate a cluster of Census Divisions located in predominantly rural and remote parts of Ontario, Manitoba and Saskatchewan and in eastern and northern parts of Nunavut with significantly higher than average rates of preventable hospitalisation. CONCLUSION: The knowledge generated on the small-area geographic variation in preventable hospitalisations can inform regional, provincial and national decision makers on planning, allocation of resources and monitoring performance of health service providers.

Ratios and determinants of maternal mortality: a comparison of geographic differences in the northern and southern regions of Cameroon.

BACKGROUND: While maternal mortality has declined worldwide in the past 25 years, this is not the case for Cameroon. Since there is a predominantly young population in this country, high maternal mortality ratios may persist. Maternal mortality ratios vary within countries, yet it is unknown if the North and South, the most distinct parts of Cameroon, differ in terms of ratios and determinants of maternal mortality. METHODS: This study explored ratios and determinants of maternal mortality in women of childbearing age (15-49 years) and assessed differences between the North and South. We used the Cameroon Demographic and Health Surveys (2004 and 2011) to extract a sample of 18,665 living or deceased women who had given birth. Multivariable logistic regression was used to explore the relationship between maternal mortality and sociocultural, economic and healthcare factors. RESULTS: Maternal mortality ratios were different for the two regions and increased in the North in 2011 compared to 2004. In the North, any level of education and being Muslim were protective against maternal mortality. Meanwhile, the odds of maternal mortality decreased with increasing age, and having secondary or higher education in the South. Domestic violence and ethnicity were associated with maternal death in the South. Increasing parity was protective of maternal death in both the North and South. CONCLUSIONS: Maternal mortality ratios and determinants varied between women of childbearing age in the North and South of Cameroon. These reinforce recommendations for region specific strategies that will improve health communication, community education programs, curb domestic violence and train more community health workers to connect pregnant women with the health system. Programs to reduce maternal death among women with low parity and little or no education should be national priority.

Levels and determinants of maternal mortality in northern and southern Nigeria.

BACKGROUND: Maternal mortality is still a major risk for women of childbearing age in Nigeria. In 2008, Nigeria bore 14% of the global burden of maternal mortality. The national maternal mortality ratio has remained elevated despite efforts to reduce maternal deaths. Though health disparities exist between the North and South of Nigeria, there is a dearth of evidence on the estimates and determinants of maternal mortality for these regions. METHODS: This study aimed to assess differences in the levels and determinants of maternal mortality in women of childbearing age (15-49 years) in the North and South of Nigeria. The Nigeria Demographic and Health Surveys (2008 and 2013) were used. The association between maternal mortality (outcome) and relevant sociocultural, economic and health factors was tested using multivariable logistic regression in a sample of 51,492 living or deceased women who had given birth. RESULTS: There were variations in the levels of maternal mortality between the two regions. Maternal mortality was more pronounced in the North and increased in 2013 compared to 2008. For the South, the levels slightly decreased. Media exposure and education were associated with maternal mortality in the North while contraceptive method, residence type and wealth index were associated with maternal death in the South. In both regions, age and community wealth were significantly associated with maternal mortality. CONCLUSIONS: Differences in the levels and determinants of maternal mortality between the North and South of Nigeria stress the need for efforts to cut maternal deaths through new strategies that are relevant for each region. These should improve education of girls in the North and access to health information and services in the South. Overall, new policies to improve women's socioeconomic status should be adopted.

Production of physician services under fee-for-service and blended fee-for-service: Evidence from Ontario, Canada.

We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.

Prevalence, characteristics, and patterns of patients with multimorbidity in primary care: a retrospective cohort analysis in Canada.

BACKGROUND: Multimorbidity is a complex issue in modern medicine and a more nuanced understanding of how this phenomenon occurs over time is needed. AIM: To determine the prevalence, characteristics, and patterns of patients living with multimorbidity, specifically the unique combinations (unordered patterns) and unique permutations (ordered patterns) of multimorbidity in primary care. DESIGN AND SETTING: A retrospective cohort analysis of the prospectively collected data from 1990 to 2013 from the Canadian Primary Care Sentinel Surveillance Network electronic medical record database. METHOD: Adult primary care patients who were aged ≥18 years at their first recorded encounter were followed over time. A list of 20 chronic condition categories was used to detect multimorbidity. Computational analyses were conducted using the Multimorbidity Cluster Analysis Tool to identify all combinations and permutations. RESULTS: Multimorbidity, defined as two or more and three or more chronic conditions, was prevalent among adult primary care patients and most of these patients were aged <65 years. Among female patients with two or more chronic conditions, 6075 combinations and 14 891 permutations were detected. Among male patients with three or more chronic conditions, 4296 combinations and 9716 permutations were detected. While specific patterns were identified, combinations and permutations became increasingly rare as the total number of chronic conditions and patient age increased. CONCLUSION: This research confirms that multimorbidity is common in primary care and provides empirical evidence that clinical management requires a tailored, patient-centred approach. While the prevalence of multimorbidity was found to increase with increasing patient age, the largest proportion of patients with multimorbidity in this study were aged <65 years.