Perceived need for treatment and non-utilization of outpatient psychotherapy in old age: two cohorts of a nationwide survey.

BEACKGROUND: Older adults with mental health problems may benefit from psychotherapy; however, their perceived need for treatment in relation to rates of non-utilization of outpatient psychotherapy as well as the predisposing, enabling, and need factors proposed by Andersen's Model of Health Care Utilization that account for these differences warrant further investigation. METHODS: We used two separate cohorts (2014 and 2019) of a weighted nationwide telephone survey in Germany of German-speaking adults with N = 12,197 participants. Across the two cohorts, 12.9% (weighted) reported a perceived need for treatment for mental health problems and were selected for further analyses. Logistic Generalized Estimation Equations (GEE) was applied to model the associations between disposing (age, gender, single habiting, rural residency, general health status), enabling (education, general practitioner visit) non-utilization of psychotherapy (outcome) across cohorts in those with a need for treatment (need factor). RESULTS: In 2014, 11.8% of 6087 participants reported a perceived need for treatment due to mental health problems. In 2016, the prevalence increased significantly to 14.0% of 6110 participants. Of those who reported a perceived need for treatment, 36.4% in 2014 and 36.9%in 2019 did not see a psychotherapist - where rates of non-utilization of psychotherapy were vastly higher in the oldest age category (59.3/52.5%; 75+) than in the youngest (29.1/10.7%; aged 18-25). Concerning factors associated with non-utilization, multivariate findings indicated participation in the cohort of 2014 (OR 0.94), older age (55-64 OR 1.02, 65-74 OR 1.47, 75+ OR 4.76), male gender (OR 0.83), lower educational status (OR 0.84), rural residency (OR 1.38), single habiting (OR 1.37), and seeing a GP (OR 1.39) to be related with non-utilization of psychotherapy; general health status was not significantly associated with non-utilization when GP contact was included in the model. CONCLUSION: There is a strong age effect in terms of non-utilization of outpatient psychotherapy. Individual characteristics of both healthcare professionals and patients and structural barriers may add to this picture. Effective strategies to increase psychotherapy rates in those older adults with unmet treatment needs are required.

[Sociodemographic and health-related determinants of health care utilisation and access to primary and specialist care: Results of a nationwide population survey in Germany (2006-2016)]. / Soziodemografische und gesundheitsbezogene Merkmale der Inanspruchnahme und des Zugangs zu haus- und fachärztlicher Versorgung ­ Ergebnisse einer deutschlandweiten Bevölkerungsbefragung von 2006 bis 2016.

BACKGROUND: The aim of this paper is to identify systematic differences due to sociodemographic and health-related determinants in outpatient healthcare utilisation and access in Germany for the period from 2006 to 2016. The study focuses on frequent users and those reporting particularly long wait times for their physician appointments, and it contributes to assessing the level of health equity in Germany. METHODS: The investigation draws on nine population surveys conducted by the German National Association of Statutory Health Insurance Physicians (NASHIP), which interviewed 42,925 respondents aged 18 and above. "Frequent users" were operationalised as those respondents who reported more than ten consultations with outpatient general practitioners (GPs) and specialists (SPs) in the preceding twelve months. Respondents who experienced wait times of more than one month for their last doctor appointment were categorised as "very long wait times". Sociodemographic determinants included age, gender, educational and occupational status, population and region of place of residence, as well as type of health insurance of the respondents. Health-related factors were self-assessed health status and reason for last medical consultation. Statistical analyses were conducted using bivariate and multivariate techniques (logistic regression). RESULTS: Utilisation: Frequent users of GPs and SPs are predominantly respondents in poor health, retirees and younger persons (18 to 34 years of age). Furthermore, people with a lower educational background consult their GPs significantly more often than people with higher levels of education. Also, patients with statutory health insurance coverage visit GPs more frequently than those having private health insurance, whereas the opposite holds true for SP consultations. Access: Very long wait times for GP and SP appointments were most often experienced by respondents who consult GPs and SPs for preventive medical check-ups or health screenings, have statutory health insurance, live in eastern Germany and who are above 60 years of age. In addition, people with higher levels of education are significantly more likely to experience wait times for SP appointments of more than one month than people with a lower educational background. The proportion of frequent users as well as of those reporting very long wait times for SP appointments has increased in Germany over the period examined. CONCLUSION: This study reveals that a high frequency of GP and SP consultations is primarily associated with self-assessed poor health, indicating that prioritisation is based on clinical need. In order to ensure the same needs-based prioritisation in the access to outpatient healthcare, regulatory measures are required to decrease wait times of more than one month for SP appointments, with a special focus on people with statutory health insurance coverage, residents of eastern Germany and the elderly.

Natural water purification and water management by artificial groundwater recharge.

Worldwide, several regions suffer from water scarcity and contamination. The infiltration and subsurface storage of rain and river water can reduce water stress. Artificial groundwater recharge, possibly combined with bank filtration, plant purification and/or the use of subsurface dams and artificial aquifers, is especially advantageous in areas where layers of gravel and sand exist below the earth's surface. Artificial infiltration of surface water into the uppermost aquifer has qualitative and quantitative advantages. The contamination of infiltrated river water will be reduced by natural attenuation. Clay minerals, iron hydroxide and humic matter as well as microorganisms located in the subsurface have high decontamination capacities. By this, a final water treatment, if necessary, becomes much easier and cheaper. The quantitative effect concerns the seasonally changing river discharge that influences the possibility of water extraction for drinking water purposes. Such changes can be equalised by seasonally adapted infiltration/extraction of water in/out of the aquifer according to the river discharge and the water need. This method enables a continuous water supply over the whole year. Generally, artificially recharged groundwater is better protected against pollution than surface water, and the delimitation of water protection zones makes it even more save.

Groundwater protection: what can we learn from Germany?

For drinking water security the German waterworks proceed on a comprehensive concept, i.e., the protection of all the regions from the recharge area to the client. It includes the protection of the recharge area by a precautionary management, a safe water treatment, a strict maintenance of the water distribution network, continuous control and an intensive training of staff. Groundwater protection zones together with effective regulations and control play a very important role. Three protection zones with different restrictions in land-use are distinguished. Water in reservoirs and lakes is also protected by Surface Water Protection Zones. Within the surrounding area the land-use is controlled, too. Special treatment is necessary if acidification happens caused by acid rain, or eutrophication caused by the inflow of sewage. Very important is the collaboration between waterworks and the farmers cultivating land in the recharge area in order to execute water-protecting ecological farming with the aim to reduce the application of fertilizers and plant protection agents. Probable financial losses have to be compensated by the waterworks.

Problems of drinking water treatment along Ismailia Canal Province, Egypt.

The present drinking water purification system in Egypt uses surface water as a raw water supply without a preliminary filtration process. On the other hand, chlorine gas is added as a disinfectant agent in two steps, pre- and post-chlorination. Due to these reasons most of water treatment plants suffer low filtering effectiveness and produce the trihalomethane (THM) species as a chlorination by-product. The Ismailia Canal represents the most distal downstream of the main Nile River. Thus its water contains all the proceeded pollutants discharged into the Nile. In addition, the downstream reaches of the canal act as an agricultural drain during the closing period of the High Dam gates in January and February every year. Moreover, the wide industrial zone along the upstream course of the canal enriches the canal water with high concentrations of heavy metals. The obtained results indicate that the canal gains up to 24.06x10(6) m3 of water from the surrounding shallow aquifer during the closing period of the High Dam gates, while during the rest of the year, the canal acts as an influent stream losing about 99.6x10(6) m3 of its water budget. The reduction of total organic carbon (TOC) and suspended particulate matters (SPMs) should be one of the central goals of any treatment plan to avoid the disinfectants by-products. The combination of sedimentation basins, gravel pre-filtration and slow sand filtration, and underground passage with microbiological oxidation-reduction and adsorption criteria showed good removal of parasites and bacteria and complete elimination of TOC, SPM and heavy metals. Moreover, it reduces the use of disinfectants chemicals and lowers the treatment costs. However, this purification system under the arid climate prevailing in Egypt should be tested and modified prior to application.