Accessibility of Antiretroviral Therapy in Ghana: Convenience of Access

The convenience of accessing antiretroviral therapy (ART) is important for initial access to care and subsequent adherence to ART. We conducted a qualitative study of people living with HIV/AIDS (PLWHA) and ART healthcare providers in Ghana in 2005. The objective of this study was to explore the participants' perceived convenience of accessing ART by PLWHA in Ghana. The convenience of accessing ART was evaluated from the reported travel and waiting times to receive care; the availability; or otherwise; of special considerations; with respect to the waiting time to receive care; for those PLWHA who were in active employment in the formal sector; the frequency of clinic visits before and after initiating ART; and whether the PLWHA saw the same or different providers at each clinic visit (continuity of care). This qualitative study used in-depth interviews based on Yin's case-study research design to collect data from 20 PLWHA and 24 ART healthcare providers as study participants. . Reported travel time to receive ART services ranged from 2 to 12 h for 30 of the PLWHA.. Waiting time to receive care was from 4 to 9 h. . While known government workers; such as teachers; were attended to earlier in some of the centres; this was not a consistent practice in all the four ART centres studied. . The PLWHA corroborated the providers' description of the procedure for initiating and monitoring ART in Ghana. . PLWHA did not see the same provider every time; but they were assured that this did not compromise the continuity of their care. Our study suggests that convenience of accessing ART is important to both PLWHA and ART healthcare providers; but the participants alluded to other factors; including open provider-patient communication; which might explain the PLWHA's understanding of the constraints under which they were receiving care. The current nation-wide coverage of the ART programme in Ghana; however; calls for the replication of this study to identify possible perception changes over time that may need attention. Our study findings can inform interventions to promote access to ART; especially in Africa

Improvements in diabetes management and outcomes in a Medicaid managed care system.

OBJECTIVE: To determine the impact of managed care on effectiveness of diabetes management in Tennessee, where a statewide Medicaid program (TennCare) delivers services through capitated managed care organizations (MCOs). RESEARCH DESIGN AND METHODS: This retrospective cohort study documented the health care utilization experiences and clinical outcomes of a convenience sample of Tennessee Medicaid enrollees with chronic diabetes before and after the initiation of TennCare. Exposures to recommended diabetic services and outcomes were compared before and after TennCare for 171 enrollees with diabetes in the state's largest academic MCO who met age, continuous enrollment, insurance, and diagnostic criteria for two years before (1992 and 1993) and two years after TennCare (1995 and 1996). Claims data were used to assess baseline characteristics and chart review data were used to assess health services utilization for 71% of cohort members (n = 121) for whom complete medical records were available. The paired t-test was used to compare exposures and outcomes before and after TennCare. RESULTS: Participants had an average of 6.4 outpatient clinic visits per year before TennCare vs. 8.2 visits per year after TennCare (P = .0009), 0.6 vs. 1.0 diabetic eye examinations (P = .0042), 0.2 vs. 0.5 foot examinations (P = .0358), 0.4 vs. 0.6 cholesterol assessments (P < .0001), and 0.5 vs. 1.0 glycosylated hemoglobin assessments annually (P < .0001). Average glycosylated hemoglobin decreased from 10.3 to 8.2 (P < .0001). Although hospitalizations and hospital days increased overall, there was no increase in emergency visits, preventable emergency visits, or preventable hospitalizations. CONCLUSIONS: Enrollees with diabetes experienced increases in utilization of recommended health services and improved glucose control following the initiation of Medicaid managed care. These improvements may reflect improved chronic disease care in a primary care gatekeeper system.

Prevention in managed care: obstacles and opportunities.

Managed care will present many new challenges to health care providers in their efforts to improve the quality of the preventive care their patients receive. Managed care will present both formidable obstacles to prevention and previously unknown opportunities to enhance population-based preventive services. Whether these opportunities are realized depends on the degree and quality of the involvement of health care providers in managed care institutions. Provider and public health input is particularly needed to promote the development of uniform preventive care standards, the development of information systems for continuous monitoring of preventive service delivery, and to enhance clinic-based preventive efforts, and the development of reimbursement mechanisms that provide incentives for prevention. Independent research and oversight is needed to show the impact of various types of managed care on preventive service delivery and quality of care. The effects of managed care on the preventive care that patients receive will ultimately be determined by the quality, priorities, and determination of the management.

Barriers to cancer screening.

Many barriers to cancer screening have been summarized and discussed. Barriers have been documented in all patient populations, but some groups such as ethnic minorities and the elderly face unique barriers. The barriers to cancer screening, are multifactorial, but much of the responsibility for change must lie with health care providers and the health care delivery industry. This is not to free the patient of all responsibility, but some significant barriers are beyond their direct control. Take, for example, socioeconomic status, disease knowledge, and culturally related perceptions and myths about cancer detection and treatment. The health care industry must do a better job identifying and overcoming these barriers. The significant effects of provider counseling and advice must not be underestimated. Patients must first be advised, and then further actions must be taken if they reject the screening advice. Did they refuse adherence to recommendations because they do not view themselves as susceptible, because of overwhelming personal barriers, or because of a fatalistic attitude toward cancer detection and treatment? If that is the case, physicians and health care institutions must attempt to change perceptions, educate, and personalize the message so that patients accept their disease susceptibility [table: see text]. Multiple patient and provider risk factors have been identified that can be used to target patients particularly at high risk for inadequate cancer screening and providers at high risk for performing inadequate screening. Research has clearly demonstrated the effectiveness of interventions to improve tracking of patient and physician compliance with screening recommendations. Further research is needed to show the impact of managed-care penetration and payer status on screening efforts, and incentive schemes need to be tested that reward institutions and third-party payers who develop uniform standards and procedures for cancer screening. The greatest responsibility lies with medical and health care institutions and those who determine the priorities of these institutions. Patient and physician barriers to mass cancer screening can be addressed by institutional support. If the quality of care delivered by providers, group practices, managed-care organizations, and HMOs is assessed with priority given to the regularity and consistency with which basic screening procedures are performed, cancer screening will undoubtedly receive greater attention in the clinic. Medical institutions must collaborate to develop standards for cancer screening with attention to the cost-effectiveness of various screening techniques to determine how limited resources can best be spent in cancer control. Such efforts should keep in mind "that a very small change implemented over a broad population may have a greater effect in absolute numbers than a large level of change applied in a small segment of the population."

Cultural issues in serving minority populations: emphasis on Mexican Americans and African Americans.

Patients' cultural beliefs may affect acceptance of health care, compliance, and treatment outcomes. This article discusses cultural views of health and illness, folk beliefs and customs, cultural barriers to care, and alternative health-care systems, with particular emphasis on Mexican Americans and African Americans, including curanderismo, rootwork, and voodoo. Physicians who wish to provide appropriate and acceptable care in a cross-cultural setting should integrate these beliefs with conventional medicine.

Principles of intercultural medicine in an internal medicine program.

Internal medicine and medicine-pediatric residents (n = 76) completed a questionnaire that measured variables including sociodemographics, family dynamics, cross-cultural exposure, and exposure to intercultural medicine principles. Questions were answered regarding perceptions of their patients and level of comfort discussing specific cultural variables. Gender, training status, and geographic background did not influence responses, but the responses of European-Americans (71%) vs. ethnic minorities and foreign medical graduates (29%) were significantly different. European-Americans were more likely to be men, less likely to have an urban background (p = .02), and their self-described socioeconomic status was uppermiddle to upper class (p = .02). European-Americans vs. all others differed in their perceptions of patients' financial support (p = .001), and reasons for doctor-patient miscommunications (p = .05). The European-Americans had significantly less exposure to friends and classmates (p = .002), and instructors (p = .0001) of ethnic origins different than their own prior to residency training. Our data support the inclusion of intercultural medicine principles in the general internal medicine curriculum.