Key Factors Influencing the Operationalization and Effectiveness of Telemedicine Services in Henan Province, China: Cross-Sectional Analysis.

BACKGROUND: Telemedicine has demonstrated its potential in alleviating the unbalanced distribution of medical resources across different regions. Henan, a province in China with a population of approximately 100 million, is especially affected by a health care divide. The province has taken a proactive step by establishing a regional collaborative platform for telemedicine services provided by top-tier provincial hospitals. OBJECTIVE: We aim to identify the key factors that influence the current operationalization and effectiveness of telemedicine services in Henan province. The insights gained from this study will serve as valuable references for enhancing the efficient operation of telemedicine platforms in low- and middle-income regions. METHODS: We analyzed service reports from the performance management system of telemedicine services in Henan province throughout 2020. Using descriptive statistics and graphical methods, we examined key influencing factors, such as management competency; device configuration; and hospital capability, capacity, and service efficacy, across hospitals at 2 different tiers. In addition, we used generalized linear models and multiple linear regression models to identify key operational factors that significantly affect the service volume and efficacy of 2 major telemedicine services, namely teleconsultation and tele-education. RESULTS: Among the 89 tier 3 hospitals and 97 tier 2 hospitals connected to the collaborative telemedicine platform, 65 (73%) and 55 (57%), respectively, have established standardized management procedures for telemedicine services. As the primary delivery method for telemedicine services, 90% (80/89) of the tier 3 hospitals and 94% (91/97) of the tier 2 hospitals host videoconferencing consultations through professional hardware terminals rather than generic computers. Teleconsultation is the dominant service type, with an average annual service volume per institution of 173 (IQR 37-372) and 60 (IQR 14-271) teleconsultations for tier 3 and tier 2 hospitals, respectively. Key factors influencing the service volume at each hospital include available funding, management competency, the number of connected upper tiers, and the number of professional staff. After receiving teleconsultations from tier 3 (65/89, 73%) and tier 2 (61/97, 63%) hospitals, patients reported significant improvements in their medical conditions. In addition, we observed that service efficacy is positively influenced by management competency, financial incentives, the number of connected upper or lower tiers, and the involvement of participating medical professionals. CONCLUSIONS: Telemedicine has become increasingly popular in Henan province, with a notable focus on teleconsultation and tele-education services. Despite its popularity, many medical institutions, especially tier 2 hospitals, face challenges related to management competency. In addition to enhancing the effectiveness of existing telemedicine services, health care decision-makers in Henan province and other low- and middle-income regions should consider expanding the service categories, such as including remote emergency care and telesurgery, which have promise in addressing crucial health care needs in these regions.

Care Alert Program in Chronic Recurrent ED Utilizing Patients.

Description The Care Alert program is designed to help navigate encounters with patient populations that are high utilizers of emergency department (ED) resources. These populations often have chronic medical conditions, have a poor understanding of their conditions, are unfamiliar with the EDs' role in the management of these conditions, and commonly lack outpatient resources. The Care Alert program intends to address the needs of this challenging patient population by designing individualized care plans that are approved through a multidisciplinary committee. Data from this study showed a 37% decrease in ED visits and a 47% decrease in hospitalizations during the initial 8 months of implementation.

COVID-19 Pandemic Preparedness in Egypt's Teaching Hospitals: A Needs Assessment Study.

INTRODUCTION: Regular collection and monitoring of data describing the dynamics of the utilization of healthcare services, especially in teaching hospitals (TH), which provide model quality medical services, are critical for COVID-19 pandemic preparedness. METHODS: The researchers analyzed data and information derived from service statistics reports from June 1st to July 15th, 2020 in terms of hospital resources, as well as utilization patterns of beds, ICU, and ventilators, for 11 screening hospitals affiliated with the General Organization of Teaching Hospitals and institutes in Egypt assigned by the Ministry of Health and Population to provide medical care for COVID-19 patients. Hospital indicators in terms of COVID-19 screening services, as well as utilization patterns of inpatient beds, ICU beds, and ventilators were computed. RESULTS: A total of 78,869 non-medical personnel and 2,176 medical personnel were presented with COVID-19 triage symptoms. Investigations conducted in the targeted 11 hospitals delineated that 22.2% of non-medical personnel and 27.9% of medical personnel were COVID-19 PCR-confirmed cases. The inpatient bed occupancy rate was 70% for non-medical patients and 67% for medical staff patients. For ICU, the bed occupancy rate was 92 % for non-medical patients and 88% for medical patients. Among the confirmed cases, 38% of medical patients utilized a ventilator vs. 36% of medical personnel cases. Hospital ranking according to utilization pattern among non-medical personnel, Hospital H ranked first in terms of the high load of screening services. Hospital C ranked first regarding the number of confirmed cases, whereas Hospital D ranked first for high ICU utilization among all teaching hospital ICU cases. With respect to medical personnel, Hospital G ranked first for the high load of screening services for the total studied cases. Hospital G ranked first for the number of confirmed cases. Hospital B ranked first regarding high ICU utilization among all teaching hospital ICU cases. CONCLUSION: Teaching hospitals have demonstrated preparedness for the COVID-19 pandemic by maintaining an inpatient bed occupancy rate of 70% or less and ventilator utilization at <40% of confirmed cases. However, the ICU bed occupancy rate was more than 90% indicating a shortage of resources. In addition, there is variance across hospitals regarding caseload for resource reallocation decisions.

Integridad de la información del subsistema estadístico de urgencias en el Hospital Provincial Manuel Ascunce Domenech, de Camagüey / Information integrity in the emergency statistics subsystem of Manuel Ascunce Domenech Provincial Hospital in Camagüey

Objetivo: se realizó un estudio de evaluación en el Departamento de Registros Médicos y Estadísticas del Hospital Provincial Manuel Ascunce Domenech, de Camagüey, durante el año 2012, con el objetivo de evaluar la integridad de la información del subsistema de urgencias. Métodos: para determinar el nivel de eficacia se aplicó una encuesta a los médicos que atienden el Cuerpo de Guardia. Se utilizó la matriz BAFI como instrumento gerencial. Resultados: los resultados obtenidos permiten calificar la integridad de la información estadística del Servicio de Urgencias como deficiente. La elevada pérdida económica ocasionada por la omisión del diagnóstico manifiesta la ineficiencia estadística del subsistema. Se evidencia un predominio de las debilidades sobre las fortalezas, la vulnerabilidad ante las amenazas y el poco aprovechamiento de las oportunidades. Recomendaciones: se recomienda la aplicación de la propuesta de acciones elaborada, con el propósito de revertir dicha situación(AU)

Objective: an evaluation study was conducted in the Department of Medical Records and Statistics of Manuel Ascunce Domenech Provincial Hospital in Camagüey during the year 2012, with the purpose of evaluating the integrity of the information stored in the emergency subsystem. Methods: determination of the level of efficacy was based on a survey given to doctors from the emergency service. The Innovative Power Balance Matrix was used as a management instrument. Results: integrity of the statistical information in the Emergency Service was evaluated as deficient, based on the results of the study. The considerable economic loss caused by the omission of diagnoses is evidence of the statistical inefficiency of the subsystem. It was found that weaknesses predominate over strengths, there is vulnerability to threats, and opportunities are hardly taken advantage of. Recommendations: it is recommended that the actions proposed are implemented, with a view to overcoming the present deficiencies(AU)

Integridad de la información del subsistema estadístico de urgencias en el Hospital Provincial Manuel Ascunce Domenech, de Camagüey / Information integrity in the emergency statistics subsystem of Manuel Ascunce Domenech Provincial Hospital in Camagüey

Objetivo: se realizó un estudio de evaluación en el Departamento de Registros Médicos y Estadísticas del Hospital Provincial Manuel Ascunce Domenech, de Camagüey, durante el año 2012, con el objetivo de evaluar la integridad de la información del subsistema de urgencias. Métodos: para determinar el nivel de eficacia se aplicó una encuesta a los médicos que atienden el Cuerpo de Guardia. Se utilizó la matriz BAFI como instrumento gerencial. Resultados: los resultados obtenidos permiten calificar la integridad de la información estadística del Servicio de Urgencias como deficiente. La elevada pérdida económica ocasionada por la omisión del diagnóstico manifiesta la ineficiencia estadística del subsistema. Se evidencia un predominio de las debilidades sobre las fortalezas, la vulnerabilidad ante las amenazas y el poco aprovechamiento de las oportunidades. Recomendaciones: se recomienda la aplicación de la propuesta de acciones elaborada, con el propósito de revertir dicha situación

Objective: an evaluation study was conducted in the Department of Medical Records and Statistics of Manuel Ascunce Domenech Provincial Hospital in Camagüey during the year 2012, with the purpose of evaluating the integrity of the information stored in the emergency subsystem. Methods: determination of the level of efficacy was based on a survey given to doctors from the emergency service. The Innovative Power Balance Matrix was used as a management instrument. Results: integrity of the statistical information in the Emergency Service was evaluated as deficient, based on the results of the study. The considerable economic loss caused by the omission of diagnoses is evidence of the statistical inefficiency of the subsystem. It was found that weaknesses predominate over strengths, there is vulnerability to threats, and opportunities are hardly taken advantage of. Recommendations: it is recommended that the actions proposed are implemented, with a view to overcoming the present deficiencies

Couple-friendly services in a metropolitan sexually transmitted disease clinic: views of clients and providers.

CONTEXT: Clients making clinic visits related to reproductive health might benefit from participation with their partner. There is little information available, however, on whether either clients themselves or clinic staff would feel comfortable with such a possibility. METHODS: The Multnomah County Health Department Sexually Transmitted Disease Clinic in Portland, Oregon, conducted a survey of 237 new clients in June 1994 to assess clients' and providers' responses to the idea of offering couple visits. RESULTS: Twenty-six percent of female clients and 16% of male clients were accompanied by their partner on their visit to the clinic. Eighty-seven percent of all clients favored the clinic's offering couple visits, 5% opposed the concept and 8% were undecided. Fifty-four percent would have wanted their partner to be with them during their present visit if this choice had been offered, and 62% would want their partner to join them in follow-up couple visits if this were recommended by their provider. Seventy-one percent had already discussed with their partner the reason for their immediate clinic visit, and 88% expected to discuss the visit with their partner afterward. Attitudes toward couple services were similar for male and female clients and did not vary by race or ethnicity. For more than one-fifth of clients, clinic staff reported that they would not recommend couple visits; however, many of these clients reported that they would prefer being accompanied by their partner. CONCLUSIONS: Appropriately designed couple-friendly options are likely to be generally accepted and moderately utilized by clients of varying backgrounds. Clinic staff may be more reluctant to involve clients' partners than the clients are themselves, however.

An assessment of care provided by a public sector STD clinic in Cape Town.

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

PIP: In South Africa's Western Cape Province, where sexually transmitted disease (STD) rates are high but HIV prevalence remains low, syndromic STD management in the public health services has been proposed as a strategy for curbing development of an AIDS epidemic. This study, conducted prior to the formal introduction of such a program, evaluated the quality of STD management at a local health authority clinic in Cape Town. 170 male and 161 female new clients presenting during the 6-week study period were enrolled. 76% of men and 81% of women reported they had never used a condom. Only 21% of male and 37% of female clients received health education concerning STD prevention during their visit. Contact slips to facilitate partner notification were provided to 28% of men and 25% of women. Condom use was discussed with just 25% of male and 36% of females. The most common clinical diagnosis made by staff was gonorrhea. According to the research physician's findings, 51 patients (40 men and 11 women) had genital ulcers, the majority of which were not detected by staff. Of 32 men and women diagnosed by staff clinicians as having no infections, 58% of men and 75% of women had at least 1 STD confirmed by laboratory testing. Overall, at least 16% of men and 61% of women left the clinic with 1 or more STD inadequately treated. These findings indicate that introduction of syndromic protocols in South Africa's public health services will not automatically improve STD diagnosis and treatment. Health education to correct misinformation about STDs, condom promotion and distribution, partner notification, and the validity of clinical diagnoses must be addressed.

Improving quality of sexually transmitted disease case management in rural South Africa.

OBJECTIVE: To measure quality of sexually transmitted disease (STD) syndromic case management and aspects of health-seeking behaviour at baseline in an intervention trial. SETTING: Ten rural primary care clinics, Hlabisa district, South Africa. DESIGN: Simulated patients (fieldworkers trained to present with STD syndromes) made a total of 44 clinic visits; 49 STD patients were interviewed when exiting clinics; facilities were assessed for availability of necessary equipment and drugs; 10 focus group discussions were held with staff; and STD syndrome surveillance was performed in all 10 clinics. RESULTS: A total of 9% of simulated patients were correctly managed (given correct drugs, plus condoms and partner notification cards), recommended drug treatment was given in only 41% of visits, and appropriate counselling was given in 48% of visits. Among patients leaving the clinic, although 39% waited over an hour to be seen and only 37% were consulted in private, all reported staff attitudes as satisfactory or good. Only six clinics had syndromic management protocols available, three reported intermittent drug shortages, and seven lacked partner notification cards. Focus group discussions revealed good staff knowledge about STD, but showed lack of training in syndromic management and low morale. Surveillance data showed that while 75% of those presenting for care did so within 1 week of symptom onset, 27% had been treated for an STD in the preceding 3 months, and only 6% of those treated were contacts. CONCLUSIONS: Quality of STD case management was poor despite good staff knowledge and availability of most essential resources. An intervention comprising staff training and STD syndrome packets has been designed to improve quality of case management.

PIP: The effectiveness of syndromic management of sexually transmitted disease (STD) patients--a strategy that has been proposed for introduction to South Africa's public health sector--depends on both the quality of case management and health-seeking behavior patterns. These issues were assessed in 10 rural primary care clinics in South Africa's Hlabisa district. Field workers trained to present with STD syndromes (simulation patients) made a total of 44 clinic visits. In addition, 49 actual STD patients were interviewed when exiting clinics, facilities were checked for availability of essential drugs and equipment, 10 focus group discussions were held with staff, and STD syndrome surveillance was performed. Among simulated patients, only 9% were correctly managed (i.e., given correct drugs, condoms, and partner notification cards); appropriate counseling was provided in just 48% of visits. All clients interviewed as they left the clinic reported satisfactory or good staff attitudes, even though 39% waited over 1 hour to be seen and only 37% were seen in privacy. Only 6 clinics had syndromic management cards available, 3 reported intermittent drug shortages, and 7 lacked partner notification cards. In focus groups, staff demonstrated adequate knowledge of STDs, but poor morale and a lack of training in syndromic management. Finally, surveillance data revealed that, although 75% of patients presented within 1 week of symptom onset, 27% had been treated for an STD in the past 3 months and only 6% of those treated were contacts. An intervention comprised of staff training and STD syndrome packets has been designed to improve the quality of STD case management in South Africa.

Patterns of general health care and STD services use among high-risk youth in Denver participating in community-based urine chlamydia screening.

BACKGROUND: In the United States, youth are at highest risk for STDs, and innovative programs have been called for to increase their access to essential STD-related services. To guide the development of such programs, locally relevant information is needed on current use of general health care and STD services in this population. GOAL: To study access to and use of general health care and STD services in a purposive sample of high-risk youth in inner-city Denver. STUDY DESIGN: An interview-based survey conducted as part of a community program for urine chlamydia screening targeting black and Hispanic youth 13 years to 25 years. RESULTS: Of 221 sexually experienced youth in the survey, 72% had accessed general health services in the past year and 39% reported an STD evaluation at any time in the past. Community and school clinics were reported by 50% as a source for general health care and by 62% as a source for STD services. STD clinics were reported by only 14% as a source for STD services. Routine checkups were the most important reasons to seek general health care, yet of those who went for a routine checkup, only 34% reported an STD evaluation. Although few barriers appeared to exist in accessing general health care, anticipated anxiety about procedures and results formed the major barrier to accessing STD services. CONCLUSIONS: Use of general health services was common in this population of high-risk adolescents; however, the provision of STD services as part of general health care visits appeared to be low. On the basis of these findings, a comprehensive STD prevention strategy may be envisioned, which would include provider interventions to increase the provision of STD prevention services in general health care settings; community interventions to enhance access to general health care and STD services; and community-based screening programs for those not able or willing to seek clinic-based services.

PIP: To guide the development of innovative programs to increase the access of US adolescents and young adults to sexually transmitted disease (STD) prevention and treatment services, data should be obtained at the local level from nonclinic-based samples comprised of those at greatest risk. Such a survey was conducted in Denver, Colorado, in 1996-97 by Youth in Action--a community-level chlamydia urine screening program. Questionnaires were completed by 221 of the 277 predominantly Black and Hispanic inner-city youth 13-25 years of age who underwent urine analysis during the study period. 25 (11%) reported a history of an STD. On urine screening, 10.7% of males and 12.9% of females tested positive for chlamydia. 72% had accessed general health services in the past year, primarily for routine checkups, and 39% reported an STD evaluation at any time in the past. Community and school clinics were identified by 50% as a source for general health care and by 62% as a source for STD services. Only 14% of respondents attended STD clinics. In multivariate analysis, the following factors were associated with an STD evaluation: recruitment in field settings, female gender, age above 16 years, non-Hispanic ethnicity, vaginal sex in the past 30 days, presence of chlamydia on urine screening, and a general health visit in the past year. Of concern was the finding that only 34% of youth who went for a general checkup reported an STD evaluation. These findings indicate needs for interventions to increase the provision of STD prevention services in general health care settings and community-based screening programs for those unable or unwilling to seek clinic-based services.

Can intrauterine device removals for bleeding or pain be predicted at a one-month follow-up visit? A multivariate analysis.

From 4%-14% of intrauterine device (IUD) users have their IUD removed due to bleeding or pelvic pain in the first year of use. Past studies have analyzed whether baseline patient information can help predict such removals, but no previous analysis has examined whether information provided at the recommended 1-month follow-up visit could improve such predictions. Using data from an international multicenter randomized controlled trial, 89 women with removals for bleeding and pain after the 1-month visit were compared with 2536 continuing users. Logistic regression indicated several significant predictors of removal. Women reporting intermenstrual bleeding since last menses were nearly three times more likely to have removals for bleeding or pain (odds ratio [OR] 2.9; 95% confidence interval [CI] 1.4-5.9). Similarly, those complaining of excessive menstrual flow were 3.5 times more likely to have removals within 12 months (95% CI 1.4-9.2). Women reporting these menstrual problems during scheduled revisits may benefit from counseling and treatment with nonsteroidal anti-inflammatory drugs (NSAID).

PIP: In the first year of use, 4-14% of IUD users have the device removed because of pelvic pain or bleeding. Identification of women at risk of removal for these reasons would enable targeted counseling and treatment, thereby reducing the frequency of removal requests. The hypothesis that problems reported at the 1-month follow-up visit can help to predict eventual IUD removal for pain or bleeding was investigated through use of data from a randomized controlled trial of IUD acceptors from 18 centers in 14 countries in Asia, Africa, and Latin America, who were followed for 1 year. The present analysis was restricted to 2536 women who received Copper T-380A or Multiload 250 IUDs. There were 89 removals for pain or bleeding during the study period. When baseline acceptor characteristics were considered, breast-feeding status was the most significant predictor of removal. Women not breast feeding at the time of IUD insertion were 2.8 times (95% confidence interval (CI), 1.5-5.2) as likely as those who were breast feeding to undergo removal for pain or bleeding in the 12 months after insertion. The following variables reported at the 1-month follow-up visit were significant predictors of removal: intermenstrual bleeding since last menses (odds ratio [OR], 1.9; 95% CI, 1.4-5.9), excessive menstrual flow (OR, 3.5; 95% CI, 1.4-9.2), and cessation of breast feeding since IUD insertion (OR, 2.2; 95% CI, 0.9-5.6). Although intermenstrual pelvic pain, spotting, and menstrual flow of more than 1 week's duration increased the risk of removal, they were not statistically significant predictors in this sample. Women who report intermenstrual bleeding or excessive menstrual flow at their 1-month follow-up visit may benefit from counseling and, in some cases, treatment with nonsteroidal anti-inflammatory drugs to reduce their risk of early IUD discontinuation.

Family planning needs and STD risk behaviours of female psychiatric out-patients.

BACKGROUND: There are few studies concerning the family planning needs of female chronic psychiatric patients. We aimed to determine the contraceptive needs and sexually transmitted disease (STD) risk-behaviours of female psychiatric out-patients. METHOD: Sixty-six female out-patients with major psychiatric disorders, including schizophrenia, bipolar disorder and mood disorders, completed a semi-structured interview (response rate = 63%) and were individually matched for age and ethnicity with 66 women who had never been treated for psychiatric illness. They answered questions on child-rearing and on their methods of contraception in relation to their attitudes towards pregnancy, as well as on their risk for STDs. RESULTS: Compared with controls, the female patients reported having had significantly more induced abortions and were significantly more likely to have given up their own children for others to raise. Heterosexually active psychiatric patients were significantly more likely than controls to have had more than one male sexual partner, to have been pressured into unwanted sexual intercourse, and to report having had sexual intercourse with a suspected bisexual over the preceding year. CONCLUSIONS: These results underscore the priority for developing programmes that reduce female psychiatric patients' risk for unwanted pregnancies and STDs.

PIP: 66 patients 18-50 years of age with chronic psychiatric disorders were interviewed using semistructured interviews at a community mental health center in Auckland, New Zealand, resulting in a response rate of 62.9%. Each patient was matched with a control for ethnicity and age. The psychiatric patients also completed the Mini-Mental State Examination. The interview covered demographic, obstetric, and gynecologic information and information on women's risk for unwanted pregnancies and STDs. The mean age of cases was 36.03 years and that of the controls was 36.20 years. The mean age of leaving school was around 16 years. The mean duration of psychiatric illness was 12.5 years. 24.2% of patients vs. 50.0% of controls were currently married or living with a male partner (p 0.005); 24.2% of patients vs. 54.5% of controls had a job (p 0.001); and 92.3% of patients vs. 36.4% of controls were receiving social welfare (p 0.001). 43 (65.1%) of the patients reported having been pregnant at least once, the total number of completed pregnancies being 80. 9 of the pregnancies ended in miscarriages, 17 in induced abortions, 2 in stillbirths, and 52 in live births. 58 (87.9%) controls had been pregnant at least once. 17 patients (39.5%) and 8 controls (13.8%) had had one or more induced abortions (p 0.01). There was no significant difference between the two groups with regard to miscarriages or stillbirths. 19 children of the patients were under 16 years of age and 8 of them were not living with their mothers. A significantly greater percentage of children of patients (42%), compared with the children of controls (3.8%), were not being reared by their biological mothers (p 0.001). 35 patients (55.4%) had had heterosexual intercourse within the past year. Only one patient had not used birth control. Heterosexually active patients (n = 35) were significantly more likely than heterosexually active controls (n = 52) to have had more than one male sexual partner, to report having been pressured into unwanted intercourse, and to have had intercourse with a bisexual person.

STD services for women at truck stop in Tanzania: evaluation of acceptable approaches.

AIDS continues to be the commonest cause of death in Tanzania among those aged between 15 and 45 years. Both ulcerative and non-ulcerative sexually transmitted diseases have been identified as major co-factors in HIV transmission. Certain groups including long distance truck drivers and their sexual partners have been reported as having a disporportionate effect on the transmission dynamics of STD including HIV, in a population. In 1993 African Medical and Research Foundation decided to add an STD component to their HIV/AIDS prevention programme along the Tanzania-Zambia highway which had been targeting truck drivers and their sexual partners through peer education and condom distribution since 1989. A study to evaluate the acceptability and feasibility of four different approaches of delivering STD services, was conducted over a period of one year. The approaches for delivering STD services were: special STD services offered twice a week at a site and at hours of the women's choice, special outreach services once every three months, or STD services integrated into the nearest Primary Health Clinic. Drugs were provided at three of the four interventions. 1,330 women at seven truckstops, participated in the evaluation study. The women were generally satisfied with all approaches that included the provision of drugs. The most expensive and ineffective way of treating STD was by not providing drugs. These findings confirm the fact that it is feasible to provide STD services to women at high risk in HIV high transmission areas. These women would utilise STD services provided in a manner that suits them if mobilised and encouraged by their peer educators.

PIP: Long-distance truck drivers and their sexual partners have a disproportionate effect on the transmission dynamics of sexually transmitted diseases (STDs), including HIV infections, in Tanzania. In 1993, the African Medical and Research Foundation added an STD component (peer education and condom distribution) to its HIV/AIDS prevention program along the Tanzania-Zambia highway. The present study of 1330 women (mean age, 27.3 years) recruited from 7 highway truckstops assessed the acceptability and feasibility of 4 approaches to the prevention of STDs: special STD services offered twice a week at a site and hours chosen by women, special clinic-based outreach services for women once every 3 months, integration of STD services into the nearest primary health care clinic, and provision of STD drugs. Most study participants were local brew sellers (47.2%), bar/guest house attendants (27%), and petty traders (21.1%). The overall HIV prevalence was 50%. Attendance per woman was higher when services were offered outside a health facility (1.23) or at times other than normal clinic hours (1.43) than when STD services were integrated with primary health care (1.0). The total cost per patient was US$11 when the clinic did not provide STD drugs, $12 for special clinic-based services for women, $11.50 for non-clinic-based services, and $11 for the integrated STD/primary health care approach. Women were equally satisfied with the 3 service delivery strategies, but highly dissatisfied when STD-specific drugs were not provided and their infection was not cured.

Factors influencing attendance to immunization sessions for children in a rural district of Ghana.

Improving immunization coverage is vital to promoting child health and reducing childhood diseases and deaths. In spite of being actively promoted as a major public health intervention for national development since the late 1970s, immunization coverage in Ghana remains low. We investigated factors that influence attendance to immunization sessions in the Komenda-Edina-Eguafo-Abrem District of Ghana. The major factors hindering attendance were poor knowledge about immunization, lack of suitable venues and furniture at outreach clinics, financial difficulties, long waiting times, transport difficulties, poorly motivated service providers and weak intersectoral collaboration. The timing of immunization sessions, length of prior notice to the community, attitude of service providers and fear of side-effects generally did not deter attendance.

PIP: Although childhood immunization has been a major national development goal in Ghana since the late 1970s, coverage rates remain low. In 1992, coverage for the third dose of diphtheria-pertussis-tetanus (DPT) was 43% for children under 12 months of age. The present study, conducted in August 1993, used focus group discussions and interviews with 469 mothers of children under 2 years of age, 17 service providers, and 10 heads of health-related sectors, to investigate factors influencing attendance to immunization sessions in Ghana's Komenda-Edina-Eguafo-Abrem District. 73% of mothers reported they attended child welfare clinics regularly. The main factors motivating mothers to attend were the perceived benefits of immunization for disease prevention, its impact on socioeconomic development, the relatively low cost of disease prevention, and the need for vaccination cards for school entry. The major factors hindering attendance were poor knowledge about immunization, lack of suitable venues and furniture at outreach clinics, financial difficulties, long waiting times, transportation problems, poorly motivated service providers, and weak intersectoral collaboration. The timing of immunization sessions, length of advance notice to the community, attitude of service providers, and fear of side effects generally did not deter attendance. Attention to the obstacles to compliance with childhood immunization schedules is essential if Ghana is to achieve the goal of 80% coverage by the year 2000.

Assessment of rational drug use and prescribing in primary health care facilities in north west Ethiopia.

A study on rational drug use was undertaken in nine health centres (HCs) and nine health stations (HSs) in Ethiopia. Prescribing, patient care and facility specific factors were measured using drug use indicators. Prescribing patterns of drugs were also assessed. With only few exceptions, the drug use indicators in HCs and HSs and between retrospective and prospective studies were similar despite differences in manpower and facilities. The average consultation time (in minutes) in HSs and HCs was 5.1 +/- 0.8 and 5.8 +/- 1.06, respectively. The dispensing time (in minutes) was 1.5 +/- 0.7 in HSs and 1.9 +/- 0.6 in HCs. Both patient care indicators seem to be adequate to influence patient satisfaction to the overall health service and patient knowledge of important dosage instructions. Most drugs (more than 89% in HCs and 71% in HSs) were actually dispensed from the health facilities and labelling was satisfactory. Prescribing by generic names (average: 75% in HCs and 83% in HSs) was encouraging. While the availability of key drugs was ensured, essential documents were missing in most facilities or they were unpopular for use, and those available required revision and updating. Polypharmacy in which the number of drugs/encounter was < 2.5 was minimal, but that a large proportion of the prescriptions contained two or more drugs could result in adverse drug-drug interactions. The most frequently prescribed drugs were anti-infectives and analgesics accounting for over 76% in HCs and 82% in HSs and in most cases they are probably prescribed with little justification. The exposure of patients to antibiotics (average: 60% in HCs and 65% in HSs) was unacceptably high to justify epidemiological trends. The high exposure of patients to injections, especially in the HSs (over 37%), should be seen from the health and economic points of view. The results revealed priority areas for intervention. They also provide standard references to compare drug use situations and their change over time in different settings, area and time in Ethiopia.

PIP: In a study on rational drug use in 9 health centers (HC) and 9 health stations (HS) in Ethiopia, prescribing, patient care, and facility-specific factors were observed and measured through drug use indicators during February-June 1995. With only few exceptions, the drug use indicators in HCs and HSs were similar despite differences in manpower and facilities. The average consultation times in minutes in HSs and HCs were 5.1 and 5.8, respectively, while the dispensing times were 1.5 and 1.9 minutes, respectively. More than 89% of drugs in HCs and 71% in HSs were dispensed from the health facilities, and labeling was satisfactory. On average, generic brands were prescribed 75% of the time in HCs and 83% of the time in HSs. Key drugs were available, but important documents were missing in most facilities or were unpopular for use. When documents were available, they needed to be revised and updated. The level of polypharmacy was low. The most often prescribed drugs were anti-infectives and analgesics, accounting for more than 76% in HCs and 82% in HSs, and probably often prescribed with little justification. 60% of patients in HCs and 65% in HSs were exposed to antibiotics, levels too high for the prevailing disease conditions. More than 37% of HS patients received injections.

Missed opportunities to vaccinate in Peru.

PIP: In October 1995, in Peru, the Ministry of Health (MOH) conducted a follow-up survey of missed opportunities to vaccinate children aged less than 2 years to evaluate the impact of recommendations made following the 1990 survey of missed opportunities. The follow-up survey also examined missed opportunities to vaccinate women of reproductive age with tetanus toxoid. 1784 persons accompanying children aged less than 2 years to a health facility and 4299 women of reproductive age were interviewed at 13 hospitals and 14 health centers in six departmental health units. Vaccination data for the children were collected from vaccination cards (21%) and verbally by the accompanying person (79%). Those for the women were collected from vaccination cards (11%) and verbal histories (89%). Between 1990 and 1995, missed opportunities decreased from 52% to 13%. The reduction was 75% for children aged less than 2 years and 84% for infants. The key causes of missed opportunities were different in 1995 than those in 1990. Between 1990 and 1995 false contraindications increased 60%. Negative attitudes of health workers were responsible for 32% of missed opportunities in 1990, while they were responsible for only 4% in 1995. Other important causes of missed opportunities were policy/logistics (19%) and family attitudes (17%). Missed opportunities were common in 47% of women of childbearing age. The first dose of tetanus toxoid was the most commonly missed dose (40%). Reasons for missed opportunities to vaccinate for tetanus toxoid were policy (31%), personal attitudes (30%), logistics (15%), false contraindications (20%), and health workers' attitude (4%). Based on these findings, MOH developed recommendations to further reduce missed opportunities to vaccinate children and women of childbearing age. For example, training of health workers needs to be improved to reduce the number of false contraindications. MOH must implement strategies to improve accessibility to vaccinations in hospitals.^ieng

Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe.

BACKGROUND: Many of the individual components of antenatal care have been studied in randomised controlled trials, but few studies have compared whole programmes of antenatal care. Our aim was to test the hypothesis that a new programme of antenatal care with fewer goal-oriented visits would give an equivalent or better result in the outcomes associated with pregnancy and delivery. METHODS: In a randomised clinical trial in Harare, Zimbabwe, we compared a new programme of antenatal care with the standard programme. The new programme consisted of fewer but more objectively oriented visits and fewer procedures per visit. Seven primary care clinics were randomly assigned to the two programmes-three to the standard programme and four to the new programme. FINDINGS: Over a 2-year period, 15,994 women were recruited into the study at the time they booked antenatal care. 97% of the women were followed up, 9,394 who had followed the new programme, and 6,138 from clinics with the standard one. Women allocated to the new programme made, as planned, fewer visits than those in the standard programme (median 4 vs 6 visits, respectively). The proportion of antenatal referrals was also lower (13.6 vs 15.3%; odds ratio 0.87 [95% CI 0.79-0.95]) because of significantly fewer referrals for pregnancy-induced hypertension (2.5 vs 3.8%; 0.66 [0.55-0.79]). Nevertheless, there were significantly fewer labour referrals for severe hypertension or eclampsia (2.1 vs 2.6%; 0.81 [0.66-1.00]). The risk for preterm (< 37 weeks) delivery was significantly lower for women on the new programme (10.1 vs 11.5%; 0.86 [0.78-0.96]). There were no other significant differences between the programmes in other major indices of pregnancy outcome, including antenatal referrals for other causes, labour referrals, obstetric interventions, low birthweight, and perinatal and maternal mortality and morbidity. INTERPRETATION: An antenatal care programme with fewer more objectively oriented visits can be introduced without adverse effects on the main intermediate outcome pregnancy variables.

PIP: Many of the individual components of prenatal care have been studied in randomized controlled trials, but few studies have compared whole programs of prenatal care. The objective of this study was to test the hypothesis that a new program of prenatal care with fewer goal-oriented visits would give an equivalent or better result in pregnancy and delivery outcomes. A new program of prenatal care was compared with the standard program in a randomized clinical trial in Harare, Zimbabwe. The new program consisted of fewer but more objectively oriented visits and fewer procedures per visit. Seven primary care clinics were randomly assigned to the two programs: three to the standard program and four to the new program. Over a two-year period between July, 1989, and July, 1991, 15,994 women were recruited into the study at the time they were booked for prenatal care. 97% of the women were followed up: 9394 followed the new program and 6138 were from clinics with the standard one. The median number of visits was reduced from 7 to 6 in the standard program and from 7 to 4 in the new program. The proportion of prenatal referrals was also lower (13.6% vs. 15.3%; odds ratio [OR] 0.87 [95% confidence interval [CI] 0.79-0.95]) because of significantly fewer referrals for pregnancy-induced hypertension (2.5% vs. 3.8%; OR 0.66 [CI 0.55-0.79]). Nevertheless, there were significantly fewer referrals in labor for severe hypertension or eclampsia (2.1% vs 2.6%; OR 0.81 [CI 0.66-1.00]). The risk for preterm ( 37 weeks) delivery was significantly lower for women in the new program (10.1% vs. 11.5%; OR 0.86 [CI 0.78-0.96]). There were no other significant differences between the programs in other major indices of pregnancy outcome, including prenatal referrals for other causes, labor referrals, obstetric interventions, low birth weight, and perinatal and maternal mortality and morbidity. A prenatal care program with fewer, more objectively oriented visits can be introduced without adverse effects on the main intermediate outcome pregnancy variables.

Arthritis associated with HIV infection in Zimbabwe.

OBJECTIVE: To document the clinical and immunogenetic features of arthritis associated with heterosexually acquired human immunodeficiency virus (HIV) infection. METHODS: All patients were assessed by a rheumatologist and standard laboratory tests were performed. RESULTS: There were 3 common clinical presentations. (1) Oligo/polyarticular arthritis (22 men, 4 women). HIV infection had not previously been diagnosed in 24 of these patients but persistent generalized lymphadenopathy (85%) and weight loss (42%) were present. Joints commonly involved were ankles (65%) and knees (54%), often with associated enthesitis (31%) and dactylitis (23%). Followup data in 18 patients showed that arthritis resolved completely in 9 patients (one subsequently recurred), improved by >50% in 5 patients, was unremitting in 3 patients, and recurred frequently in one patient. None of 7 patients tested were HLA-B27 or B7 positive. (2) Reiter's syndrome (RS) (21 men, 3 women; incomplete RS 18 patients,complete RS 6 patients). Lymphadenopathy was present in 19 patients (79%) and 4 patients were previously known to have HIV infection. Involvement of knees (80%) and ankles (58%) was common, as were enthesitis (29%) and dactylitis (13%). Followup data in 21 patients showed that 14 resolved (5 with recurrences), 2 improved by >50%, and 5 had continued arthritis. HLA-B27 was not found in 13 patients tested but a cross reacting antigen was found in 6 patients. (3) Symmetrical polyarthritis (4 men, 4 women). Symmetrical arthritis of the wrists (8 patients) and peripheral interphalangeal (PIP) and metacarpophalangeal (MCP) joints (7), as well as lymphadenopathy (5), nodules (4), rheumatoid factor (3), and erosive radiographic changes (one patient) were seen. (4) Miscellaneous. Other types of arthritis included 3 patients with psoriasis and arthritis and one patient each with Behcet's disease, Salmonella septic arthritis, and secondary syphilis. CONCLUSION: Arthritis associated with HIV in this population is most commonly characterized by oligoarticular, asymmetrical, large joint arthritis, with or without features of Reiter's syndrome, and is not associated with HLA-B27.

PIP: Patients with arthritis referred to the rheumatic disease clinic at the University of Zimbabwe or seen in consultation over a period of 4 years were studied. All 64 patients were assessed by a rheumatologist and standard laboratory tests were performed. There were three common clinical presentations. 1) Oligo- and polyarticular arthritis (22 men, 4 women). HIV infection had not previously been diagnosed in 24 of these patients, but persistent generalized lymphadenopathy (85%) and weight loss (42%) were present. Joints commonly involved were ankles (65%) and knees (54%), often with associated enthesitis (31%) and dactylitis (23%). Follow-up data in 18 patients showed that arthritis resolved completely in 9 patients (one subsequently recurred), improved by 50% in 5 patients, was unremitting in 3 patients, and recurred frequently in 1 patient. None of 7 patients tested possessed HLA-B27 or one of the B7 cross-reacting group (B7-CREG) of antigens. 2) Reiter's syndrome (RS) (21 men, 3 women: incomplete RS, 18 patients; complete RS, 6 patients). Lymphadenopathy was present in 19 patients (79%), and 4 patients were previously known to have HIV infection. Involvement of knees (80%) and ankles (58%) was common, as were enthesitis (29%) and dactylitis (13%). Follow-up data in 21 patients showed that 14 resolved (5 with recurrences), 2 improved by 50%, and 5 had continued arthritis. HL-B27 was not found 13 patients tested, but a cross-reacting antigen was found in 6 patients. 3) Symmetrical polyarthritis (4 men, 4 women). Symmetrical arthritis of the wrists (8 patients) and peripheral interphalangeal (PIP) and metacarpophalangeal (MCP) joints (7), as well as lymphadenopathy (5), nodules (4), rheumatoid factor (3), and erosive radiographic changes (1) were seen. Other types of arthritis included 3 patients with psoriasis and arthritis and 1 patient each with Beheet's disease, Salmonella septic arthritis, and secondary syphilis. All patients were treated with a nonsteroidal anti-inflammatory drug (NSAID), most commonly indomethacin, with the addition of low-dose prednisolone (5-10 mg for 4 patients) and/or chloroquine (150 mg base daily for 11 patients) if clinically indicated. In patients in whom arthritis improved, the effect was gradual over 3-6 months.

A school-linked health service for adolescents in Jerusalem.

This paper describes the Adolescent Health Service (AHS) and its multidisciplinary, school-linked, community-based adolescent health clinic located in a western neighborhood of Jerusalem. Files of the first 134 adolescents who completed or discontinued treatment in the clinic during the first two years of operation were reviewed for demographic data, referral source, number of visits, health concerns and clinical impressions. The clinic population included Jewish Jerusalem residents, ages 12-18, 75% of whom were female. Most referrals came from schools. The average number of visits per patient was five (range 1-20). The most frequent presenting concerns as well as the most frequent clinical impressions were in the psychosocial and nutritional domains. Concordance between presenting concern and clinical impression was 61% (k = 0.47). Health problems of Israeli high school students attending the clinic mainly were psychosocial and nutritional. The school-linked health service applied a comprehensive approach to the biopsychosocial needs of adolescents, not addressed at other health services.

PIP: In Jerusalem, Israel, a community-based comprehensive adolescent health center was established in 1989 to promote health among the students of 11 secondary and high schools; to provide multidisciplinary health care within a community-based, school-linked clinic; to serve as a professional training facility; and to establish a research database. The service is accessible during after-school hours, confidential, and free to adolescent residents of Jerusalem. To evaluate the service, data from the first 134 adolescents treated during the first 2 years of service were analyzed to determine demographic parameters, referral sources, presenting symptoms (nutritional, psychosocial, sexuality, somatic, or health maintenance), diagnoses, number of patient visits, management approach, duration of follow-up, and termination of contact. It was found that 75% of the patients were girls, and 75% were 14-17 years old. Referrals came from school professionals (60%), parents (11%), primary care physicians (4%), and the adolescents themselves (25%). The patients averaged 5 visits, with 35% being seen only once and 15% more than 10 times. The most frequent presenting complaints were psychosocial and nutritional problems (sexuality was named by only 4.5% of the patients), and concordance between presenting concern and clinical impression was only 61% (with most discordance among those who presented for health maintenance). Most of the youth who attended were from middle- and upper-class families despite the clinic location in a low-to-middle class neighborhood. It was concluded that the clinic had not yet had a major impact on access to health services for most of the teenagers in the city but that it provided a unique service with a multidisciplinary approach that has served as a model for adolescent "non-acute" health care in Israel. The clinic's high drop-out rate was attributed to ambivalent care-seeking behavior and accessibility of primary health care (which, however, fails to address many of the problems addressed by the adolescent clinic).

Knowledge about AIDS and follow-up compliance in patients attending a sexually transmitted disease clinic in the highlands of Papua New Guinea.

In a survey of 300 consecutive new attenders at the Porgera Health Centre Sexually Transmitted Disease Clinic information was obtained regarding knowledge about AIDS from male and female attenders. The differences between the sexes regarding a variety of socioeconomic variables, knowledge about AIDS and their compliance to follow-up appointments were studied as well as possible relationships between these social variables and the degrees of AIDS knowledge and compliance. Males tended to originate from further afield, be more educated, be either in salaried employment or not working at all, and be single as compared to females. They also admitted to more extramarital sexual contacts and received more adequate treatment. Knowledge about AIDS was also significantly higher amongst male attenders and in this group was correlated strongly with overall educational attainment and employment status but did not show any relationship with the number of extramarital contacts admitted to. Only 9% of the patients knew about condoms and their role in prevention. Follow-up compliance was generally poor, and not significantly higher in those with higher scores of knowledge about AIDS, but showed a relationship with the type of disease being treated and with the ultimate adequacy of treatment received.

PIP: Gender differences in knowledge about AIDS and compliance with follow-up appointments were investigated in 300 consecutive new patients (176 men and 124 women) at the Porgera Health Center Sexually Transmitted Disease (STD) Clinic in the highlands of Papua New Guinea in 1992-93. The most common STDs diagnosed among men and women, respectively, were: gonorrhea (28% and 12%), donovanosis (30% and 24%), and nongonorrheal urethritis/pelvic inflammatory disease (20% and 56%). Compared to females, men tended to be from outside the district, have some formal education, be either unemployed or in a salaried position, and be single. 60% of male clients, compared with 10% of female clients, reported an extramarital sexual contact in the previous 3 months. 46% of male and 68% of female STD patients had either never heard of AIDS or knew the name only. Knowledge about AIDS was significantly higher among males and was associated with overall educational attainment and employment status. Only 9% of patients (14% of men and 1% of women) were aware of condoms and their role in STD prevention. Of the 230 clients scheduled for follow up, only 19% of males and 35% of females were fully compliant. Follow-up compliance was not associated with AIDS knowledge scores, but was related to the type of disease being treated and inadequate treatment. These findings suggest an urgent need for AIDS education and promotion of condom use (despite opposition from some Christian groups) in this area.

Research note: does cost recovery for curative care affect preventive care utilization?

PIP: Findings are presented from cost recovery pilot tests implemented by the government of Niger, with technical assistance from USAID's Health Financing and Sustainability (HFS) Project, in the primary health care sector in Boboye and Say districts during 1993-94. The tests focused upon the use of free prenatal care for pregnant women. Two different payment methods were tested along with interventions to improve the quality of care. An annual adult tax plus a small fee-per-episode at the time of use were assessed in Boboye, while a straight fee-per-episode of illness was implemented in Say. The difference in the financial burden to the consumer between the two schemes depended upon the number of illnesses experienced. Preventive services remained free of charge in all public facilities. Together with the introduction of cost recovery, health facility staff in the two test districts were trained on diagnostic and treatment protocols, an initial stock of generic drugs was provided to the involved health facilities, and a drug inventory and financial management system were established. Far from suffering with the introduction of cost recovery and quality improvements, the use of preventive services actually increased. Additional research is needed on the effect of cost recovery upon the use of preventive services.^ieng