Can universal patient-held health booklets promote continuity of care and patient-centred care in low-resource countries? The case of Mongolia.

BACKGROUND: A system of clinical records accessible by both patients and their attending healthcare professionals facilitates continuity of care and patient-centred care, thereby improving clinical outcomes. The need for such a system has become greater as the proportion of patients with chronic non-communicable diseases (NCDs) requiring ongoing care increases. This is particularly true in low-income and middle-income countries where the burden of these diseases is greatest. OBJECTIVE: To describe a nationwide patient-held health booklet (PHHB) system and investigate its use and completeness for clinical information transfer during chronic NCD outpatient visits in Ulaanbaatar, Mongolia. METHODS: Qualitative and quantitative methodologies were employed in this mixed-methods study. Structured interviews were used to study a sample of adult patients with chronic NCDs attending the outpatient departments (OPDs) of two large, public secondary care hospitals ; artefact reviews were used to analyse the content of the written documents relating to their clinical care; and snowball methodology was used to identify policy and training documents. RESULTS: 96% (379/395) brought handover documentation from previous provider/s: 94% had PHHBs, 27% other additional documents and 4% had nothing. 67% were referred from primary care and 44% referred back for follow-up. On leaving the OPD, irrespective of requirements for computer data entry, doctors provided written clinical information in the PHHB for 93% of patients. 84% of patients recalled being given verbal information. However, only 41% of the consultation with written information included all three key handover information items (diagnosis, management/treatment and follow-up). The PHHBs were the best completed type of document, with evidence that they were consulted by patients (80%), public (95%) and private (77%) providers. Living >1 hour away (OR=0.28; 95% CI 0.13 to 0.61) decreased the likelihood of receiving written management/treatment information; living >1 hour away (OR=0.48; 95% CI 0.27 to 0.87), comorbidity (OR=0.55; 95% CI 0.35 to 0.87) and returning to secondary care (OR=0.52; 95% CI 0.33 to 0.80) all independently decreased the likelihood of receiving written follow-up information. A Ministry order mandates the use of the booklet, but there were no other related policies, guidelines or clinician training. CONCLUSION: The universal PHHBs were well accepted, well used and the best completed handover documentation. The PHHBs provided a successful handover option for patients with chronic NCDs in Mongolia, but their completeness needs improving. There is potential for global application.

Physical and sexual violence, childhood sexual abuse and HIV/STI risk behaviour among alcohol-using women engaged in sex work in Mongolia.

Although the prevalence of human immunodeficiency virus (HIV) in Mongolia is low, it could increase without strategic prevention strategies. Female sex workers (FSWs) often experience barriers to prevention, including interpersonal violence. This study investigated if childhood sexual abuse (CSA) or recent physical or sexual violence was associated with HIV sexual risk behaviours and if CSA modified associations between recent violence and HIV sexual risk behaviours. Two-hundred twenty-two women who (1) were at least 18 years old and clients at the National AIDS Foundation; (2) reported vaginal or anal sex in the past 90 days in exchange for money or goods and (3) met criteria for harmful alcohol use in the past year were enrolled. In-person interviews assessed sexual risk behaviours and violence in childhood and adulthood. Negative binomial regression, ordinary least squares regression and modified Poisson regression were performed. Sexual risk with paying partners was associated with penetrative CSA and sexual violence by paying partners. CSA and recent violence were not associated with sexual risk behaviours with intimate partners. CSA modified the association between recent sexual violence and unprotected sex with intimate partners. Findings highlight the need for integrated violence and sexual risk reduction services to ensure safe and effective prevention for FSWs.

Reducing intimate and paying partner violence against women who exchange sex in Mongolia: results from a randomized clinical trial.

Women who exchange sex for money or other goods, that is, female sex workers, are at increased risk of experiencing physical and sexual violence from both paying and intimate partners. Exposure to violence can be exacerbated by alcohol use and HIV/STI risk. The purpose of this study is to examine the efficacy of a HIV/STI risk reduction and enhanced HIV/STI risk reduction intervention at decreasing paying and intimate partner violence against Mongolian women who exchange sex and engage in harmful alcohol use. Women are recruited and randomized to either (a) four sessions of a relationship-based HIV/STI risk reduction intervention (n = 49), (b) the same HIV/STI risk reduction intervention plus two additional motivational interviewing sessions (n = 58), or (c) a four session control condition focused on wellness promotion (n = 59). All the respondents complete assessments at baseline (preintervention) as well as at immediate posttest, 3 and 6 months postintervention. A multilevel logistic model finds that women who participated in the HIV/STI risk reduction group (OR = 0.14, p < .00), HIV/STI risk reduction and motivational interview group (OR = 0.46, p = .02), and wellness (OR = 0.20, p < .00) group reduced their exposure to physical and sexual violence in the past 90 days. No significant differences in effects are observed between conditions. This study demonstrates the efficacy of a relationship-based HIV/STI risk reduction intervention, a relationship-based HIV/STI risk reduction intervention combined with motivational interviewing, and a wellness promotion intervention in reducing intimate and paying partner violence against women who exchange sex in Mongolia. The findings have significant implications for the impact of minimal intervention and the potential role of peer networks and social support in reducing women's experiences of violence in resource poor settings.