Spatial access to health care in Costa Rica and its equity: a GIS-based study

Primary health care as a tool to promote equity and sustainability; a review of Latin American and Caribbean literature

Primary health care (PHC) has increased in global relevance as it has been demonstrated to be a useful strategy to promote community access to health services. Multilateral organizations and national governments have reached a consensus regarding the basic principles of PHC, but the application of these varies from country to country due to the particularities of local health systems.This article aims to review and summarize PHC strategies and the configuration of health networks in Latin American and Caribbean countries.The review was carried out using keywords in at least 9 databases. Papers in languages other than English, Portuguese, and Spanish were excluded, while non-refereed articles and regional gray literature were incorporated. As a result, 1,146 papers were identified. After three instances of analysis, 142 articles were selected for this investigation. Data were analyzed according to an analysis by theme.The evidence collected on health reforms in the region reflects the need to intensify care strategies supported by PHC and care networks. These must be resilient to changes in the population's needs and must be able to adapt to contexts of epidemiological accumulation.

Comparison of the transportation network for public transit and private vehicles in Shanghai: An accessibility approach

This study examines the differences in service level and coverage of public transit (PT) and private vehicles (PV) with multi-source data in Shanghai. To construct computable networks and address visual results, the constrained shortest path algorithm and a spatial grid accessibility model are employed to seek the optimal path for travelers to city key points. Travel time ratio of PV and PT is applied to reflect the competitiveness of the two modes over different areas of Shanghai. Results show that for PV, although the average travel time meets the needs of car travel, 51 % of the population cannot get to graded city centers within 45 min. In addition, the PV accessibility gradually weakens from the central city to the outside, highways and expressways may be feasible solutions. For PT, half of the population can't reach any city key points within two transfers, and almost all of these people live in the suburbs. Less than 30 % of the population can reach the city key points within 1 h, of which rail transit contributes more than conventional buses. Furthermore, the travel accessibility of PV is much better than that of PT. The average travel time ratio in all comparable grids is 2.04 for hubs, and 2.10 for graded city centers. For travels to graded city centers, the travel time ratio of suburbs is 35 % higher than that of central city, indicating that the inequity distribution of public transportation resources is worse in the suburbs than in the central city. This study also measures equity performance of groups based on spatial location and income level, and we find out that more core locations and higher income lead to higher accessibility. The gap among groups is significant, with a Gini coefficient over 0.5.

Dynamic evolution and spatial difference of public health service supply in economically developed provinces of China: typical evidence from Guangdong Province

OBJECTIVE

The outbreak of the COVID-19 pandemic has drawn attention from all sectors of society to the level of public health services. This study aims to investigate the level of public health service supply in the four major regions of Guangdong Province, providing a basis for optimizing health resource allocation.

METHODS

This article uses the entropy method and panel data of 21 prefecture-level cities in Guangdong Province from 2005 to 2021 to construct the evaluation index system of public health service supply and calculate its supply index. On this basis, the standard deviation ellipse method, kernel density estimation, and Markov chain are used to analyze the spatiotemporal evolution trend of the public health service supply level in Guangdong Province. The Dagum Gini coefficient and panel regression model are further used to analyze the relative differences and the key influencing factors of difference formation. Finally, the threshold effect model is used to explore the action mechanism of the key factors.

RESULTS

Overall, the level of public health service supply in Guangdong Province is on an upward trend. Among them, polarization and gradient effects are observed in the Pearl River Delta and Eastern Guangdong regions; the balance of public health service supply in Western Guangdong and Northern Mountainous areas has improved. During the observation period, the level of public health services in Guangdong Province shifted towards a higher level with a smaller probability of leapfrogging transition, and regions with a high level of supply demonstrated a positive spillover effect. The overall difference, intra-regional difference and inter-regional difference in the level of public health service supply in Guangdong Province during the observation period showed different evolutionary trends, and spatial differences still exist. These differences are more significantly positively affected by factors such as the level of regional economic development, the degree of fiscal decentralization, and the urbanization rate. Under different economic development threshold values, the degree of fiscal decentralization and urbanization rate both have a double threshold effect on the role of public health service supply level.

CONCLUSION

The overall level of public health service supply in Guangdong Province has improved, but spatial differences still exist. Key factors influencing these differences include the level of regional economic development, the degree of fiscal decentralization, and the urbanization rate, all of which exhibit threshold effects. It is suggested that, in view of the actual situation of each region, efforts should be made to build and maintain their own advantages, enhance the spatial linkage of public health service supply, and consider the threshold effects of key factors in order to optimize the allocation of health resources.

The effect of primary healthcare on mortality: Evidence from Costa Rica

This paper uses the gradual implementation of a primary healthcare (PHC) intervention in Costa Rica to examine the long-term effect of PHC on mortality. Nine years after opening a primary care center, known as a Health Area, there was an associated 13% reduction in age-adjusted mortality rate in the assigned patient population. The effect was highest among adults over 65 years of age and for those with noncommunicable diseases, such as cardiovascular-related causes of death. We also show that as Health Areas opened, more individuals sought care at primary care clinics, while fewer sought care at emergency rooms; these changes may have partially mediated the effect of the intervention on mortality.

Under-5, infant, and neonatal mortality trends and causes of death, 1991-2022: Findings from death surveillance in Xicheng district of Beijing, China

Overall, China has made substantial progress in improving child survival over the past few decades, but a detailed understanding of child mortality trend at local level is limited. This study aimed to present a comprehensive analysis of under-5, infant, and neonatal mortality rates and its trend in Xicheng district of Beijing, China. We used the surveillance data of under-5 children reported by Preventive Health Department of Xicheng District Community Health Service Center from 1991 to 2022. The data was collected based on the Child Death Reporting Card of the Beijing Under-5 Mortality Rate Surveillance Network. Data check was performed by each community health service center and related medical institutions. We extracted data included maternal age, date of death, date of birth, gender, census register, classification of any causes of death, and utilization of healthcare services before death and doubly input it in the Excel 2016 program. Categorization of the causes of death was adapted by the International Categorization of Diseases (ICD-10). Mortality rates and distribution of the leading causes of death were analyzed with descriptive statistics and the Pearson's Chi-square test using SAS 14.0 software. The Chi-square trend test was used to explore the trends in mortality. Interrupted time series analysis (ITSA) was conducted to assess the impact of the two-child policy on mortality using STATA statistical packages. From 1991 to 2022, totally, there were 166,061 live births and 793 (4.78 ‰) under-5 deaths. The mortality rates of under-5 children, infants and neonates in Xicheng district decreased from 14.75 ‰, 11.25 ‰ and 8.00 ‰ to 1.03 ‰, 0.83 ‰ and 0.41 ‰ respectively. All mortality rates showed an overall significant decline trend (χ2 trend for neonatal = -15.8136, P trend for neonatal < 0.001; χ2 trend for infant = -17.6652, P trend for infant < 0.001; χ2 trend for under-5 = -18.9103, P trend for under-5 < 0.001). The leading causes of death among under-5 children were congenital heart disease (1.65 ‰), birth asphyxia (1.44 ‰), and other congenital abnormalities (except congenital heart disease and down's syndrome) (1.36 ‰). ITSA results showed that the two-child policy did not change the overall decreased trend of child mortality rates. Future preventive measures for child healthcare should give a priority for congenital heart disease, birth asphyxia, and other congenital abnormalities.

Health workers vaccination: Experience and lessons learned from Costa Rica

Objective

To describe the decision-making processes, enablers, challenges and lessons learned in Costa Rica for implementing a sustained and multi-pronged approach in health workers vaccination (HW).

Methods

A retrospective descriptive analysis was conducted by searching published and grey literature, including scientific publications, legislation, decrees, policies, manuals, technical reports, and platforms used for data register and coverage monitoring. Key informants from the Ministry of Health (MoH), the Costa Rican Social Security Fund (CCSS) were interviewed representing national, subnational and local levels; as well as members of the National Technical Advisory Group (NITAG) and the private sector. Collected data were transcribed and categorized by the following specific topics using a thematic content analysis approach: decision making process, pre-service screening, vaccination for current HWs and engagement with the private sector. Major findings were discussed and organized into enablers, challenges and lessons learned.

Results

Decision making processes to establish the vaccination strategies and schedules in Costa Rica were based on the epidemiological trends of vaccine-preventable diseases (VPDs) and cost analysis. Risk assessment and feasibility considerations determined that some vaccines such as hepatitis B, varicella and influenza, were first introduced in HWs and then were expanded to other target populations. These decisions were approved by the NITAG as the advisory technical advisory group of the MoH. Main enablers identified were: high level and sustained political will, decisions based on data analysis and feasibility considerations, HWs knowledge and high vaccine acceptance and demand. Challenges were related to effective coverage monitoring, and private sector engagement.

Conclusions

The Costa Rican experience provides lessons learned that can be leveraged by other countries to strengthen HWs vaccination strategies at regional and global levels.

Inequities in spatial access to health services in Ghanaian cities

Consideration of health equity is fundamental to enhancing the health of those who are economically/socially disadvantaged. A vital characteristic of health equity and therefore health disparity is the level of spatial access to health services and its distribution among populations. Adequate knowledge of health disparity is critical to enhancing the optimal allocation of resources, identification of underserved populations and improving the efficiency and performance of the health system. The provision of such insight for sub-Saharan African (SSA) cities is a challenge and is severely limited in the literature. Accordingly, this study examined the disparities in potential spatial access to health services for four selected urban areas in Ghana based on: (1) the number of physicians per population; (2) access score based on a weighted sum of access components; (3) travel time to health services and (4) the combined evaluation of linkages between travel distance, settlement area, population and economic status. The overall spatial access to health services is low across all selected cities varying between 3.02 and 1.78 physicians per 10 000 persons, whereas the access score is between 1.70 and 2.54. The current number of physicians needs to be increased by about five times to satisfy the World Health Organization's standard. The low spatial access is not equitable across and within the selected cities, where the economically disadvantaged populations were found to endure longer travel distances to access health services. Inequities were found to be embedded within the selected cities where economically poor populations are also disadvantaged in their physical access to healthcare. The health facilities in all cities have reasonable travel distances separating them but are inadequately resourced with physicians. Thus, increasing the physician numbers and related resources at spatially targeted existing facilities would considerably enhance spatial access to health services.

A genetic algorithm-based strategic planning framework for optimising accessibility and costs of general practices in Northland, New Zealand

Shortage of general practitioners (GP) is a challenge worldwide, not only in Europe, but also in countries like New Zealand. Providing primary care in rural areas is especially challenging. In order to support decision makers, it is necessary to first assess the current GP coverage and then to determine different scenarios and plans for the future. In this paper, we first present a thorough overview of related literature on locating GP practices. Second, we propose an approach for assessing the GP coverage and determining future GP locations based on a genetic algorithm framework. As a use case, we have chosen the rural New Zealand region of Northland. We also perform a sensitivity analysis for the main input parameters.

Dynamic geographical accessibility assessments to improve health equity: protocol for a test case in Cali, Colombia

This protocol proposes an approach to assessing the place of residence as a spatial determinant of health in cities where traffic congestion might impact health services accessibility. The study provides dynamic travel times presenting data in ways that help shape decisions and spur action by diverse stakeholders and sectors.  Equity assessments in geographical accessibility to health services typically rely on static metrics, such as distance or average travel times. This new approach uses dynamic spatial accessibility measures providing travel times from the place of residence to the health service with the shortest journey time. It will show the interplay between traffic congestion, accessibility, and health equity and should be used to inform urban and health services monitoring and planning. Available digitised data enable efficient and accurate accessibility measurements for urban areas using publicly available sources and provide disaggregated sociodemographic information and an equity perspective. Test cases are done for urgent and frequent care (i.e., repeated ambulatory care). Situational analyses will be done with cross-sectional urban assessments; estimated potential improvements will be made for one or two new services, and findings will inform recommendations and future studies. This study will use visualisations and descriptive statistics to allow non-specialized stakeholders to understand the effects of accessibility on populations and health equity. This includes "time-to-destination" metrics or the proportion of the people that can reach a service by car within a given travel time threshold from the place of residence. The study is part of the AMORE Collaborative Project, in which a diverse group of stakeholders seeks to address equity for accessibility to essential health services, including health service users and providers, authorities, and community members, including academia.

Preliminary assessment of antivenom availability and management in the public health system of Costa Rica: An analysis based on a survey to pharmacists in public health facilities

Availability and accessibility of safe and effective antivenoms are key elements for the successful treatment of snakebite envenoming (SBE). This study provides a preliminary analysis on the way antivenoms are managed by the public health system in Costa Rica and on the role played by pharmacists in the overall management of antivenoms. This was an observational, cross-sectional study based on an online survey sent to pharmacists working at Caja Costarricense de Seguro Social (Costa Rican Social Security System; CCSS) in different locations in Costa Rica. Characteristics and location of health facilities, as well as antivenom availability and management details, were analyzed. Responses from a total of 96 pharmacists, corresponding to 55 different healthcare facilities, were included in this study. Most respondents worked at pharmacies located in urban communities (69.0%) and in the secondary level of care, which includes clinics, and regional and peripheral hospitals (55.2%). Overall, participants reported antivenom availability at all levels of care and in centers having various operating schedules, although they were not available in some facilities in regions where SBE is uncommon or do not attend SBE cases because of the proximity of more complex health centers. On average, the stocks of anticoral and polyvalent antivenoms per health facility were compatible with the dose of antivenom required for treating a SBE case. More than half of participants reported knowing the availability of protocols for the management of SBE and the correct use of antivenom at their healthcare facilities. Of the total respondents, 49% agreed on possessing all the resources needed for the correct management of these medicines at their facilities, and 65.6% indicated that they know the procedures for antivenom storage and management. Our findings provide a first description of the availability of antivenoms in the public health system of Costa Rica, including the primary care level. Results also underscore the perceived role of participating pharmacists in the management of these life-saving drugs and the need to improve their knowledge on this topic.

Spatial distribution, regional differences, and dynamic evolution of the medical and health services supply in China

The imbalance of medical and health services supply (MHSS) is a significant public health concern as regional economic development disparities widen in China. Based on the provincial panel data of medical and health services, this paper constructed an evaluation index system and used the two-stage nested entropy method to measure the MHSS level of 31 provinces in China from 2005 to 2020. Then we used the standard deviation ellipse, Dagum Gini coefficient, β convergence model, kernel density estimation and Markov chain to investigate the spatial distribution, regional differences, and dynamic evolution of MHSS. According to the results of these analysis, the conclusions are drawn as follows: (1) In general, the MHSS level in China showed a significant up-ward trend from 2005 to 2020. However, the MHSS level among different provinces showed a non-equilibrium characteristic. (2) Regional comparison shows that the eastern region had the highest level, and the central region had the lowest level. The eastern and central regions presented polarization, while the western region showed unremarkable gradient effect. (3) During the period, the overall regional differences, intra-regional differences, and inter-regional differences of MHSS level all showed convergence. (4) The economic development, urbanization rate, fiscal self-sufficiency rate, and foreign direct investment had significant impacts on the convergence. (5) The provinces with high levels had the positive spillover effect. The findings of this paper provide theoretical supports for optimizing the allocation of health resources and improving the equity of MHSS.

Oral anticoagulant management of patients with mechanical heart valves at the Salam Centre of Khartoum: Observations on quality of anticoagulation and thrombotic risk

INTRODUCTION

Rheumatic heart disease with mechanical heart valve (MHV) replacement is common in Africa. However, MHV requires long-life anticoagulation and managing this can be challenging.

METHODS AND RESULTS

We report data of a prospective observational study conducted between August 2018 and September 2019 in MHV patients in the Salam Centre for Cardiac Surgery built in Khartoum, by Emergency, an Italian Non-Governmental Organization, to evaluate the quality of anticoagulation control and the risk of thrombotic complications.

RESULTS

We studied 3647 patients (median age 25.1 years; 53.9 % female). Median Time in Therapeutic Range (TTR) was 53 % (interquartile range 37 % to 67 %) and 70 thrombotic events (rate 1.8 × 100 pt-years [95 % CI 1.38-2.23]) were recorded. Among patients in the first quartile of TTR (≤37 %), we recorded 34/70 (48.6 %) of all thrombotic events (rate 3.7 × 100 pt-years [95 % CI 2.5-5.1]), with a high mortality rate (2.2 × 100 pt-years [95 % CI 1.3-3.3]). In patients with guideline-recommended TTR (≥65 %) the event rate was 0.8 × 100 pt-years for thrombotic events [95 % CI 0.3-1.5] and 0.4 × 100 pt-years for mortality [95 % CI 0.1-0.9]. Multivariable analysis showed that having a TTR in the lowest quartile (≤37 %) and being noncompliant are significantly associated with increased thrombotic risk. Aspirin use or different valve type did not influence the thrombotic risk. Almost 40 % of all thromboembolic complications could have been potentially prevented by further improving VKA management to obtain a TTR > 37 %.

CONCLUSION

The thrombotic risk of MHV patients on VKAs living in a low-income country like Sudan is associated with low quality of anticoagulation control. Efforts should be made to decrease the number of non-compliant patients and to reach a guideline-recommended TTR of ≥65 %.

Value of Geographical Information Systems in Analyzing Geographic Accessibility to Inform Radiotherapy Planning: A Systematic Review

PURPOSE

Vulnerable populations face geographical barriers in accessing radiotherapy (RT) facilities, resulting in heterogeneity of care received and cancer burden faced. We aimed to explore the current use of Geographical Information Systems (GIS) in access to RT and use these findings to create sustainable solutions against barriers for access in low- and middle-income countries.

MATERIALS AND METHODS

A systematic review using the PRISMA search strategy was done for studies using GIS to explore outcomes among patients with cancer. Included studies were reviewed and classified into three umbrella categories of how GIS has been used in studying access to RT.

RESULTS

Forty articles were included in the final review. Thirty-eight articles were set in high-income countries and two in upper-middle-income countries. Included studies were published from 2000 to 2020, and were comprised of patients with all-cancers combined, breast, colon, skin, lung, prostate, ovarian, and rectal carcinoma patients. Studies were categorized under three groups on the basis of how they used GIS in their analyses: to describe geographic access to RT, to associate geographic access to RT with outcomes, and for RT planning. Most studies fell under multiple categories.

CONCLUSION

Although this field is relative nascent, there is a wide array of functions possible through GIS for RT planning, including identifying high-risk populations, improving access in high-need areas, and providing valuable information for future resource allocation. GIS should be incorporated in future studies, especially set in low- and middle-income countries, which evaluate access to RT.

Evaluating the Inequality of Medical Resource Allocation Based on Spatial and Non-Spatial Accessibility: A Case Study of Wenzhou, China

Environmental and social factors influencing resource allocation in rural, developing regions are critical social determinants of health that necessitate cross-sector collaboration to improve health opportunities. Thus, we sought to evaluate the spatial distribution and accessibility of medical resources to assess existing disparities, identify best practices for resource allocation, and inform regional health planning policies. In this study, inequality in the frequency distribution of medical resources in Wenzhou, China, was measured using the Gini coefficient and agglomeration degree. We evaluated the spatial accessibility of medical institutions throughout the city using the modified hierarchical two-step floating catchment area (H2SFCA) method. Using the Spearman correlation analysis, we investigated the factors influencing accessibility differences. The results indicate that Wenzhou’s spatial distribution of medical resources is unbalanced and unequal. According to the population and geographic distribution, the distribution of medical resources in Wenzhou is unequal. Wenzhou’s overall spatial accessibility is poor. The east region is more accessible than the west region, and the accessibility of medical institutions at different levels varies greatly. The correlation between accessibility and the number of institutions, doctors, population density, road density, and GDP is positive. There is a need for policies and initiatives to enhance the geographical distribution of resources, construct interconnected road networks, and improve residents’ access to medical resources.

Health Care Accessibility Analysis Considering Behavioral Preferences for Hospital Choice

Research on the potential accessibility of medical services has made great progress, but there is a large gap between the analysis results and the actual feelings of residents. With the refinement of urban management, the need for actual accessibility calculations reflecting the current status of medical service levels is becoming stronger. In modern society, as people work and live at an increasingly fast pace, people increasingly focus on time saving. However, in addition to travel time and distance, personal perceptions of medical facilities and access habits also influence residents’ choice of specific hospitals for medical treatment. With the combined effect of these factors, the actual status of accessibility of medical facility services is formed. In order to improve estimates of the actual accessibility and narrow the gap with residents’ subjective perceptions, this study leverages realistic data, such as real-time navigation prediction data that approximates residents’ actual travel time to hospitals and information on residents’ subjective behaviors in choosing specific hospitals for medical treatment. Finally, a new approach is proposed to further improve the existing Gaussian two-step floating catchment area (Ga2SFCA) method by fully respecting the important effects of distance cost and time cost, and combining them by using a weighted mean.

Global health radiology planning using Geographic Information Systems to identify populations with decreased access to care

Background

Communities throughout northern Canada face significant health care disparities including decreased access to radiology. A medical hybrid airship is under development which aims to serve remote populations, requiring strategic outreach planning. This study aims to use geographic information systems (GIS) to identify (1) high risk and medically underserved patient populations in northern Canada and (2) potential landing sites for a medical airship to allow for mobile delivery of radiology services.

Methods

The northern region of Canada extending from the Rocky Mountains to the Atlantic Ocean was analyzed using multi-variable, multi-weighted GIS modeling. Based on population distance from hospitals (50% weight), health centers (eg, clinic; 30% weight), remote communities (not connected to electric grid; 10% weight), and roads (10% weight), individuals were stratified into one of five health care accessibility index (HAI) categories (ranging from very low to very high severity). HAI (80% weight) was combined with population density (20%) to create a health care access severity index (HASI). Topographic and land cover data were used to identify suitable landing sites for the medical airship. A coordinate data set was made from georeferenced health care facilities, and infrastructure data was obtained from OpenStreetMap.

Results

GIS analyzed 815 772 Canadians. Of this population, 522 094 (64%) were found to live ≥60 km from a hospital, 326 309 (40%) were ≥45 km from the nearest health center, 65 262 (8%) were within 30 km of a remote community, and 57 104 (7%) lived ≥1 km from the nearest road. Combined, the HASI identified 44% of the population as having decreased access to care (high or very high severity). Lastly, 27.5% of land analyzed was found to be suitable for airship operations.

Conclusions

GIS identified medically underserved populations in northern Canada who may benefit from mobile radiology services. These techniques may help to guide future global health outreach efforts.

Geographic accessibility to cancer treatment in Brazil: A network analysis

Background

Geographic accessibility to healthcare services is a fundamental component in achieving universal health coverage, the central commitment of the Brazilian Unified Health System (SUS). For cancer patients, poor accessibility has been associated with inadequate treatment, worse prognosis, and poorer quality of life.

Methods

We explored nationwide healthcare data from the SUS health information systems, and mapped the geographic accessibility to cancer treatment in two time-frames: 2009-2010 and 2017-2018. We applied social network analysis (SNA) to estimate the commuting route, flow, and distances travelled by cancer patients to undergo surgical, radiotherapy, and chemotherapy treatment.

Findings

A total of 12,751,728 treatment procedures were analyzed. Overall, more than half of the patients (49·2 to 60·7%) needed to travel beyond their municipality of residence for treatment, a fact that did not change over time. Marked regional differences were observed, as patients living in the northern and midwestern regions of the country had to travel longer distances (weighted average of 296 to 870 km). Cancer care hubs and attraction poles were mostly identified in the southeast and northeast regions, with Barretos being the main hub for all types of treatment throughout time.

Interpretation

Important regional disparities in the accessibility to cancer treatment in Brazil were revealed, suggesting the need to review the distribution of specialized care in the country. The data presented here contribute to ongoing research on improving access to cancer care and can provide reference to other countries, offering relevant data for oncological and healthcare service evaluation, monitoring, and strategic planning.

Funding

This work was funded by the Oswaldo Cruz Foundation - Fiocruz (Inova - no. 8451635123 to BPF) and the National Council for Scientific and Technological Development - CNPq (no. 407060/2018-9 to BPF); Coordination for the Improvement of Higher Education Personnel - CAPES (scholarship to PCA, Finance Code 001); and Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas (INCT-IDPN).

Resumo

A acessibilidade geográfica aos serviços de saúde é um componente fundamental para o alcance da cobertura universal de saúde, compromisso central do Sistema Único de Saúde (SUS). Para pacientes com câncer, a baixa acessibilidade aos serviços especializados tem sido associada ao tratamento inadequado, piora no prognóstico e na qualidade de vida.Neste estudo, dados de saúde dos sistemas de informação em saúde do SUS foram utilizados para mapear a acessibilidade geográfica ao tratamento do câncer em dois períodos: 2009-2010 e 2017-2018. Aplicamos a análise de redes sociais (ARS) para estimar os fluxos de deslocamento e as distâncias percorridas por pacientes com câncer para receberem tratamento cirúrgico, radioterápico e quimioterápico.Um total de 12.751.728 procedimentos de tratamento foram analisados. Em geral, mais da metade dos pacientes (49,2 a 60,7%) precisaram se deslocar de seus municípios de residência para receber tratamento, fato que não mudou comparando os dois períodos de tempo analisados. Foram observadas importantes diferenças regionais no acesso. Pacientes residentes das regiões norte e centro-oeste do país tiveram que percorrer maiores distâncias para alcançar os serviços (média ponderada = 296 a 870 km). A maioria dos hubs e polos de atração para atendimento oncológico foram identificados nas regiões Sudeste e Nordeste, sendo o município de Barretos o principal hub para todos os tipos de tratamento ao longo do tempo.As disparidades de acessibilidade para o tratamento de câncer, alertam para a necessidade de revisar a distribuição dos serviços de atenção especializada no país. A metodologia e os resultados apresentados neste estudo contribuem para as pesquisas sobre a melhoria do acesso ao tratamento do câncer e podem servir como referência para outros países, oferecendo dados relevantes para avaliação, monitoramento e planejamento estratégico de serviços oncológicos e de saúde em geral.

Geospatial Distribution of Family Planning Services in Kira Municipality, Wakiso District, Uganda

Introduction: Access to family planning (FP) services remains a challenge, particularly in informal urban settlements. The unmet need for FP in these settings is high, with a correspondingly high prevalence of unintended pregnancies that may lead to unsafe abortions. However, there is a paucity of quality data on the distribution of FP services in such settings in Uganda. This paper described the geospatial distribution of FP services in Kira Municipality, Wakiso District, Uganda.

Methods: This was a cross-sectional study in which we determined the availability and distribution of FP services in Kira Municipality. Community mapping and analysis were conducted using ArcGIS (version 10.1) and ArcGIS Online. Stata version 13.1 was used for data analysis. Chi-square test was used to compare the contraceptive provision and availability among facilities from informal and formal settlements.

Results: Of the 176 healthcare facilities surveyed, only 42% (n = 74) offered contraceptives in informal settlements. The majority of the facilities were privately owned small clinics (95%). At least 80% of the facilities provided three or more modern contraceptive methods, with no difference (p = 0.107) between facilities in informal and formal settlements. Only 30.7% (p = 0.001) of the facilities provided at least one long-acting contraceptive. Similarly, 20 and 12% (p = 0.001) of the facilities had implants and intrauterine devices (IUDs) on the day of the survey. Almost 25% of the facilities did not offer contraceptive services (counseling and commodities) to unmarried adolescents.

Conclusions: Most facilities were small privately-owned clinics, offering at least three modern contraceptive methods. The unavailability of long-acting reversible methods in the informal settings may affect the quality of FP services due to limited choice. The inequity in service provision that disfavors the unmarried adolescent may increase unwanted/unintended pregnancies. We recommend that local governments and partners work toward filling the existing commodities gap and addressing the discrimination against unmarried adolescents in such settings.

Geographic barriers to achieving universal health coverage: evidence from rural Madagascar

Poor geographic access can persist even when affordable and well-functioning health systems are in place, limiting efforts for universal health coverage (UHC). It is unclear how to balance support for health facilities and community health workers in UHC national strategies. The goal of this study was to evaluate how a health system strengthening (HSS) intervention aimed towards UHC affected the geographic access to primary care in a rural district of Madagascar. For this, we collected the fokontany of residence (lowest administrative unit) from nearly 300 000 outpatient consultations occurring in facilities of Ifanadiana district in 2014-2017 and in the subset of community sites supported by the HSS intervention. Distance from patients to facilities was accurately estimated following a full mapping of the district's footpaths and residential areas. We modelled per capita utilization for each fokontany through interrupted time-series analyses with control groups, accounting for non-linear relationships with distance and travel time among other factors, and we predicted facility utilization across the district under a scenario with and without HSS. Finally, we compared geographic trends in primary care when combining utilization at health facilities and community sites. We find that facility-based interventions similar to those in UHC strategies achieved high utilization rates of 1-3 consultations per person year only among populations living in close proximity to facilities. We predict that scaling only facility-based HSS programmes would result in large gaps in access, with over 75% of the population unable to reach one consultation per person year. Community health delivery, available only for children under 5 years, provided major improvements in service utilization regardless of their distance from facilities, contributing to 90% of primary care consultations in remote populations. Our results reveal the geographic limits of current UHC strategies and highlight the need to invest on professionalized community health programmes with larger scopes of service.

Snakebite envenoming in different national contexts: Costa Rica, Sri Lanka, and Nigeria

Snakebite envenoming is a neglected tropical disease that predominantly affects impoverished rural communities in sub-Saharan Africa, Asia, and Latin America. The global efforts to reduce the impact of this disease must consider the local national contexts and, therefore, comparative studies on envenomings in different countries are necessary to identify strengths, weaknesses and needs. This work presents a comparative analysis of snakebite envenomings in Costa Rica, Sri Lanka, and Nigeria. The comparison included the following aspects: (a) burden of envenomings, (b) historical background of national efforts to confront envenomings, (c) national health systems, (d) antivenom availability and accessibility including local production, (e) training of physicians and nurses in the diagnosis and management of envenomings, (f) prevention campaigns and community-based work, (g) scientific and technological platforms in these topics, and (h) international cooperation programs. Strengths and weaknesses were identified in the three contexts and several urgent tasks to improve the management of this disease in these countries are highlighted. This comparative analysis could be of benefit for similar studies in other national and regional contexts.

Implementing sustainable primary healthcare reforms: strategies from Costa Rica

As the world strives to achieve universal health coverage by 2030, countries must build robust healthcare systems founded on strong primary healthcare (PHC). In order to strengthen PHC, country governments need actionable guidance about how to implement health reform. Costa Rica is an example of a country that has taken concrete steps towards successfully improving PHC over the last two decades. In the 1990s, Costa Rica implemented three key reforms: governance restructuring, geographic empanelment, and multidisciplinary teams. To understand how Costa Rica implemented these reforms, we conducted a process evaluation based on a validated implementation science framework. We interviewed 39 key informants from across Costa Rica's healthcare system in order to understand how these reforms were implemented. Using the Exploration Preparation Implementation Sustainment (EPIS) framework, we coded the results to identify Costa Rica's key implementation strategies and explore underlying reasons for Costa Rica's success as well as ongoing challenges. We found that Costa Rica implemented PHC reforms through strong leadership, a compelling vision and deliberate implementation strategies such as building on existing knowledge, resources and infrastructure; bringing together key stakeholders and engaging deeply with communities. These reforms have led to dramatic improvements in health outcomes in the past 25 years. Our in-depth analysis of Costa Rica's specific implementation strategies offers tangible lessons and examples for other countries as they navigate the important but difficult work of strengthening PHC.

Advancing health equity and access using telemedicine: a geospatial assessment

INTRODUCTION

Health disparity affects both urban and rural residents, with evidence showing that rural residents have significantly lower health status than urban residents. Health equity is the commitment to reducing disparities in health and in its determinants, including social determinants.

OBJECTIVE

This article evaluates the reach and context of a virtual urgent care (VUC) program on health equity and accessibility with a focus on the rural underserved population.

MATERIALS AND METHODS

We studied a total of 5343 patient activation records and 2195 unique encounters collected from a VUC during the first 4 quarters of operation. Zip codes served as the analysis unit and geospatial analysis and informatics quantified the results.

RESULTS

The reach and context were assessed using a mean accumulated score based on 11 health equity and accessibility determinants calculated for each zip code. Results were compared among VUC users, North Carolina (NC), rural NC, and urban NC averages.

CONCLUSIONS

The study concluded that patients facing inequities from rural areas were enabled better healthcare access by utilizing the VUC. Through geospatial analysis, recommendations are outlined to help improve healthcare access to rural underserved populations.

Under-5 Mortality in Central America: 1990-2016

BACKGROUND AND OBJECTIVES

We aimed to calculate the change in under-5 mortality rates (U5MRs) (1990-2016), to assess countries' status regarding Sustainable Development Goal (SDG) 3.2.1 (reducing the U5MR to ≤25 deaths per 1000 live births by 2030), to list the most important causes of death (1990, 2016), and to examine the association between selected SDG indicators and U5MRs using a linear mixed-effects regression.

METHODS

Ecological study in which we used estimates from the Global Burden of Disease Study 2016 for Central American countries. Results were expressed as U5MRs (deaths per 1000 live births), cause-specific mortality rates (deaths per 100 000 population <5 years of age), and regression coefficients with 95% confidence intervals.

RESULTS

U5MRs decreased 65% (1990-2016), and in 2016, all countries but Guatemala had met SDG 3.2.1. The main causes of death were diarrheal diseases (1990; 311.1 per 100 000) and lower respiratory infections (LRIs) (2016; 78.1 per 100 000). When disaggregated by country (2016), congenital birth defects were the most important cause of death in all countries except for in Honduras (neonatal preterm birth) and Guatemala (LRIs). Nutritional status; availability of water, sanitation, and hygiene services; coverage of vaccines; and coverage of contraception were associated with a reduction in U5MRs.

CONCLUSIONS

Central America has achieved a large reduction in U5MRs. Countries must address both the high mortality caused by LRIs and the rising mortality caused by noncommunicable causes of death through an improvement of SDG indicators that guarantees equitable progress in child survival in the region.

Disparities in Geographical Access to Hospitals in Portugal

Geographical accessibility to health care services is widely accepted as relevant to improve population health. However, measuring it is very complex, mainly when applied at administrative levels that go beyond the small-area level. This is the case in Portugal, where the municipality is the administrative level that is most appropriate for implementing policies to improve the access to those services. The aim of this paper is to assess whether inequalities in terms of access to a hospital in Portugal have improved over the last 20 years. A population-weighted driving time was applied using the census tract population, the roads network, the reference hospitals’ catchment area and the municipality boundaries. The results show that municipalities are 25 min away from the hospital—3 min less than in 1991—and that there is an association with premature mortality, elderly population and population density. However, disparities between municipalities are still huge. Municipalities with higher rates of older populations, isolated communities or those located closer to the border with Spain face harder challenges and require greater attention from local administration. Since municipalities now have responsibilities for health, it is important they implement interventions at the local level to tackle disparities impacting access to healthcare.

New insights into snakebite epidemiology in Costa Rica: A retrospective evaluation of medical records

Continuous monitoring of the snakebite envenoming allows elucidating factors that affect its incidence at spatial and temporal scales, and is a great tool to evaluate the proper management of snakebite in health centers. To determine if there have been changes over time in snakebite epidemiology in Costa Rica, we conducted a retrospective study using medical records from six hospitals for the years 2012-2013. A total of 475 snakebite patients were treated at the selected hospital during this period. Most bites occurred during the rainy season and primarily affected young men, mainly farm workers and schoolchildren. About 55% of bites occur in peri-domiciliary environments, although its prevalence varies geographically. Bothrops asper generates the vast majority of envenoming in the country, which is why the main local symptoms registered are edema, pain, and bleeding disorders. The time elapsed until treatment did not explain the degree of severity at admission. However, complications were observed more frequently in patients who took longer to receive treatment. The primary complications were bacterial infections, whereas kidney failure and compartment syndrome documented at very low frequencies. Only one death was recorded, reflecting the low fatality rate exhibited in the country. Hospital treatment included the rapid administration of antivenom and complementary treatment of antibiotics, analgesics, and antihistamines. The application of the latter as prophylactic does not seem to prevent the appearance of mild early adverse reactions, registered in 22.5% of the cases. Morbidity and mortality rates from snakebite have continued to decrease in the country, as a result of the efforts that Costa Rica has made to improve its public health system. Among those efforts, the creation of primary care centers (EBAIS) has reduced the time to treatment in many regions of the country. The Costa Rican experience of using antivenom in primary health care centers and maintaining good medical records could be considered for application in other countries where snakebite is a major health problem.

Improving geographical accessibility modeling for operational use by local health actors

BACKGROUND

Geographical accessibility to health facilities remains one of the main barriers to access care in rural areas of the developing world. Although methods and tools exist to model geographic accessibility, the lack of basic geographic information prevents their widespread use at the local level for targeted program implementation. The aim of this study was to develop very precise, context-specific estimates of geographic accessibility to care in a rural district of Madagascar to help with the design and implementation of interventions that improve access for remote populations.

METHODS

We used a participatory approach to map all the paths, residential areas, buildings and rice fields on OpenStreetMap (OSM). We estimated shortest routes from every household in the District to the nearest primary health care center (PHC) and community health site (CHS) with the Open Source Routing Machine (OSMR) tool. Then, we used remote sensing methods to obtain a high resolution land cover map, a digital elevation model and rainfall data to model travel speed. Travel speed models were calibrated with field data obtained by GPS tracking in a sample of 168 walking routes. Model results were used to predict travel time to seek care at PHCs and CHSs for all the shortest routes estimated earlier. Finally, we integrated geographical accessibility results into an e-health platform developed with R Shiny.

RESULTS

We mapped over 100,000 buildings, 23,000 km of footpaths, and 4925 residential areas throughout Ifanadiana district; these data are freely available on OSM. We found that over three quarters of the population lived more than one hour away from a PHC, and 10-15% lived more than 1 h away from a CHS. Moreover, we identified areas in the North and East of the district where the nearest PHC was further than 5 h away, and vulnerable populations across the district with poor geographical access (> 1 h) to both PHCs and CHSs.

CONCLUSION

Our study demonstrates how to improve geographical accessibility modeling so that results can be context-specific and operationally actionable by local health actors. The importance of such approaches is paramount for achieving universal health coverage (UHC) in rural areas throughout the world.

Spatiotemporal matching between medical resources and population ageing in China from 2008 to 2017

Background

Globally, the increasingly severe population ageing issue has been creating challenges in terms of medical resource allocation and public health policies. The aim of this study is to address the space-time trends of the population-ageing rate (PAR), the number of medical resources per thousand residents (NMRTR) in mainland China in the past 10 years, and to investigate the spatial and temporal matching between the PAR and NMRTR in mainland China.

Methods

The Bayesian space-time hierarchy model was employed to investigate the spatiotemporal variation of PAR and NMRTR in mainland China over the past 10 years. Subsequently, a Bayesian Geo-Detector model was developed to evaluate the spatial and temporal matching levels between PAR and NMRTR at national level. The matching odds ratio (OR) index proposed in this paper was applied to measure the matching levels between the two terms in each provincial area.

Results

The Chinese spatial and temporal matching q-statistic values between the PAR and three vital types of NMRTR were all less than 0.45. Only the spatial matching Bayesian q-statistic values between the PAR and the number of beds in hospital reached 0.42 (95% credible interval: 0.37, 0.48) nationwide. Chongqing and Guizhou located in southwest China had the highest spatial and temporal matching ORs, respectively, between the PAR and the three types of NMRTR. The spatial pattern of the spatial and temporal matching ORs between the PAR and NMRTR in mainland China exhibited distinct geographical features, but the geographical structure of the spatial matching differed from that of the temporal matching between the PAR and NMRTR.

Conclusion

The spatial and temporal matching degrees between the PAR and NMRTR in mainland China were generally very low. The provincial regions with high PAR largely experienced relatively low spatial matching levels between the PAR and NMRTR, and vice versa. The geographical pattern of the temporal matching between the PAR and NMRTR exhibited the feature of north-south differentiation.

A method for measuring spatial effects on socioeconomic inequalities using the concentration index

BACKGROUND

Although spatial effects contribute to inequalities in health care service utilisation and other health outcomes in low and middle income countries, there have been no attempts to incorporate the impact of neighbourhood effects into equity analyses based on concentration indices. This study aimed to decompose and estimate the contribution of spatial effects on inequalities in uptake of HIV tests in Malawi.

METHODS

We developed a new method of reflecting spatial effects within the concentration index using a spatial weight matrix. Spatial autocorrelation is presented using a spatial lag model. We use data from the Malawi Demographic Health Survey (n = 24,562) to illustrate the new methodology. Need variables such as 'Any STI last 12 month', 'Genital sore/ulcer', 'Genital discharge' and non need variables such as Education, Literacy, Wealth, Marriage, and education were used in the concentration index. Using our modified concentration index that incorporates spatial effects, we estimate inequalities in uptake of HIV testing amongst both women and men living in Malawi in 2015-2016, controlling for need and non-need variables.

RESULTS

For women, inequalities due to need variables were estimated at - 0.001 and - 0.0009 (pro-poor) using the probit and new spatial probit estimators, respectively, whereas inequalities due to non-need variables were estimated at 0.01 and 0.0068 (pro-rich) using the probit and new spatial probit estimators. The results suggest that spatial effects increase estimated inequalities in HIV uptake amongst women. Horizontal inequity was almost identical (0.0103 vs 0.0102) after applying the spatial lag model. For men, inequalities due to need variables were estimated at - 0.0002 using both the probit and new spatial probit estimators; however, inequalities due to non-need variables were estimated at - 0.006 and - 0.0074 for the probit and new spatial probit models. Horizontal inequity was the same for both models (- 0.0057).

CONCLUSION

Our findings suggest that men from lower socioeconomic groups are more likely to receive an HIV test after adjustment for spatial effects. This study develops a novel methodological approach that incorporates estimation of spatial effects into a common approach to equity analysis. We find that a significant component of inequalities in HIV uptake in Malawi driven by non-need factors can be explained by spatial effects. When the spatial model was applied, the inequality due to non need in Lilongwe for men and horizontal inequity in Salima for women changed the sign. This approach can be used to explore inequalities in other contexts and settings to better understand the impact of spatial effects on health service use or other health outcomes, impacting on recommendations for service delivery.

Utilizing geospatial information to implement SDGs and monitor their Progress

It is more than 4 years since the 2030 agenda for sustainable development was adopted by the United Nations and its member states in September 2015. Several efforts are being made by member countries to contribute towards achieving the 17 Sustainable Development Goals (SDGs). The progress which had been made over time in achieving SDGs can be monitored by measuring a set of quantifiable indicators for each of the goals. It has been seen that geospatial information plays a significant role in measuring some of the targets, hence it is relevant in the implementation of SDGs and monitoring of their progress. Synoptic view and repetitive coverage of the Earth's features and phenomenon by different satellites is a powerful and propitious technological advancement. The paper reviews robustness of Earth Observation data for continuous planning, monitoring, and evaluation of SDGs. The scientific world has made commendable progress by providing geospatial data at various spatial, spectral, radiometric, and temporal resolutions enabling usage of the data for various applications. This paper also reviews the application of big data from earth observation and citizen science data to implement SDGs with a multi-disciplinary approach. It covers literature from various academic landscapes utilizing geospatial data for mapping, monitoring, and evaluating the earth's features and phenomena as it establishes the basis of its utilization for the achievement of the SDGs.

Spatial Accessibility and Social Inclusion: The Impact of Portugal's Last Health Reform

Health policies seek to promote access to health care and should provide appropriate geographical accessibility to each demographical functional group. The dispersal demand of health-care services and the provision for such services at fixed locations contribute to the growth of inequality in their access. Therefore, the optimal distribution of health facilities over the space/area can lead to accessibility improvements and to the mitigation of the social exclusion of the groups considered most vulnerable. Requiring for such, the use of planning practices joined with accessibility measures. However, the capacities of Geographic Information Systems in determining and evaluating spatial accessibility in health system planning have not yet been fully exploited. This paper focuses on health-care services planning based on accessibility measures grounded on the network analysis. The case study hinges on mainland Portugal. Different scenarios were developed to measure and compare impact on the population's accessibility. It distinguishes itself from other studies of accessibility measures by integrating network data in a spatial accessibility measure: the enhanced two-step floating catchment area. The convenient location for health-care facilities can increase the accessibility standards of the population and consequently reduce the economic and social costs incurred. Recently, the Portuguese government implemented a reform that aimed to improve, namely, the access and equity in meeting with the most urgent patients. It envisaged, in terms of equity, the allocation of 89 emergency network points that ensured more than 90% of the population be within 30 min from any one point in the network. Consequently, several emergency services were closed, namely, in rural areas. This reform highlighted the need to improve the quality of the emergency care, accessibility to each care facility, and equity in their access. Hence, accessibility measures become an efficient decision-making tool, despite its absence in effective practice planning. According to an application of this type of measure, it was possible to verify which levels of accessibility were decreased, including the most disadvantaged people, with a larger time of dislocation of 12 min between 2001 and 2011.

Geospatial attributes in psychogeriatric service delivery in the district of Colombo, Sri Lanka

BACKGROUND

Mental health is a neglected area within the healthcare systems in developing nations, including Sri Lanka. However, the rapid population aging and the resulting rise in psychological issues among the elderly are becoming major concerns within the country. Therefore, a proper assessment of distribution of mental healthcare facilities within the country is much needed in reducing the unmet need among people with psychological symptoms. In this study, the distribution of mental health services within the district of Colombo, which is the capital of the country, was assessed.

METHODS

With this view, mapping of mental healthcare services within the district of Colombo was carried out using the Geographic Information System to assess service and human resource availability and physical accessibility to the elderly within the district.

RESULTS

Certain deficiencies in availability and accessibility of the services were identified which were more significant toward eastern parts of the district.

CONCLUSIONS

Establishment of new mental healthcare facilities as well as upgrading of already available centres while ensuring availability of professional human resources to these centres is a timely need.

How can the spatial equity of health services be defined and measured? A systematic review of spatial equity definitions and methods

Background

Spatial equity analysis has been carried out in a variety of contexts and on a range of health services. However, there is no clear consensus on spatial equity definitions or measures. This review seeks to summarize spatial equity definitions and methods of analysis.

Methods

We systematically searched two electronic databases and six journals for papers providing a definition of spatial equity or performing a spatial equity analysis on health services. Studies were classified according to four definition themes: (1) distributional fairness; (2) needs-based distribution; (3) focus on outcomes or causes and (4) none provided.

Results

Seventy-five studies met our inclusion criteria. Sixty-one papers provided a definition of spatial equity, while a further 14 papers analysed the spatial equity of health services without providing a definition. Most authors used a needs-based definition of spatial equity, while the Gini coefficient was the most commonly used equity measure. However, analysis approaches varied according to the definition provided by each paper. Among the needs-based definitions, spatial autocorrelation was the most common spatial equity measure.

Conclusions

To our knowledge, this is the first systematic review summarizing spatial equity definitions and analysis methods. A lack of consensus on definitions and measures persists. The classification of measures according to definition themes makes this review a useful tool for planning and interpreting spatial equity investigations. Future research should examine the impact different measures of accessibility and need have on the results of spatial equity research.

Elderly Health Inequality in China and its Determinants: A Geographical Perspective

Inter-regional health differences and apparent inequalities in China have recently received significant attention. By collecting health status data and individual socio-economic information from the 2015 fourth sampling survey of the elderly population in China (4th SSEP), this paper uses the geographical differentiation index to reveal the spatial differentiation of health inequality among Chinese provinces. We test the determinants of inequalities by multilevel regression models at the provincial and individual levels, and find three main conclusions: 1) There were significant health differences on an inter-provincial level. For example, provinces with a very good or good health rating formed a good health hot-spot region in the Yangtze River Delta, versus elderly people living in Gansu and Hainan provinces, who had a poor health status. 2) Nearly 2.4% of the health differences in the elderly population were caused by inter-provincial inequalities; access (or lack of access) to economic, medical and educational resources was the main reason for health inequalities. 3) At the individual level, inequalities in annual income served to deepen elderly health differences, and elderly living in less developed areas were more vulnerable to urban vs. rural-related health inequalities.

Service environment link and false discovery rate correction: Methodological considerations in population and health facility surveys

Background

Geospatial data are important in monitoring many aspects of healthcare development. Geographically linking health facility data with population data is an important area of public health research. Examining healthcare problems spatially and hierarchically assists with efficient resource allocation and the monitoring and evaluation of service efficacy at different levels. This paper explored methodological issues associated with geographic data linkage, and the spatial and multilevel analyses that could be considered in analysing maternal health service data.

Methods

The 2016 Ethiopia Demographic and Health Survey and the 2014 Ethiopia Service Provision Assessment data were used. Two geographic data linking methods were used to link these two datasets. Administrative boundary link was used to link a sample of health facilities data with population survey data for analysing three areas of maternal health service use. Euclidean buffer link was used for a census of hospitals to analyse caesarean delivery use in Ethiopia. The Global Moran’s I and the Getis-Ord Gi* statistics need to be carried out for identifying hot spots of maternal health service use in ArcGIS software. In addition to this, since the two datasets contain hierarchical data, a multilevel analysis was carried out to identify key determinants of maternal health service use in Ethiopia.

Results

Administrative boundary link gave more types of health facilities and more maternal health services as compared to the Euclidean buffer link. Administrative boundary link is the method of choice in case of sampled health facilities. However, for a census of health facilities, the Euclidean buffer link is the appropriate choice as this provides cluster level service environment estimates, which the administrative boundary link does not. Applying a False Discovery Rate correction enables the identification of true spatial clusters of maternal health service use.

Conclusions

A service environment link minimizes the methodological issues associated with geographic data linkage. A False Discovery Rate correction needs to be used to account for multiple and dependent testing while carrying out local spatial statistics. Examining maternal health service use both spatially and hierarchically has tremendous importance for identifying geographic areas that need special emphasis and for intervention purposes.

Testing the Usability of a Software for Geospatial and Transport Modeling in Acute Stroke Service Planning

Introduction: Geographic visualizations have been used to understand disease since the nineteenth century. We developed a software that creates simple visualizations which can be used as a decision support tool for pre-hospital acute stroke transportation planning. In this study, we test the usability of this software to improve user experience and assess the interpretability of the visualizations it produces as it relates to planning and optimizing stroke systems of care. Materials and Methods: Healthcare practitioners and administrators working within the acute stroke system in Alberta, Canada were invited to participate. Participants were randomized to either the geographic visualization or 2-D temporospatial diagrams. Using a standardized script participants were asked to complete tasks and interpret the visualizations produced by the software. The computer screen and audio were recorded. Recordings were transcribed verbatim and analyzed using inductive thematic analyses. The number of errors made and time to task completion were also analyzed. Results: Eighteen participants (8 physicians, 5 healthcare administrators, 3 paramedics, and 2 nurses) were enrolled. Mean age was 41.22 years (SD: 10.55) and 8 participants were female. It took users a mean of 1.59 min (SD: 0.71) to complete all 10 tasks for the geographic visualizations and a mean of 1.08 min (SD: 0.33) to complete all 15 tasks for the 2-D temporospatial diagrams. Map users made a median of 2 errors (IQR: 4), 2-D temporospatial diagram users also made a median of 2 errors (IQR: 1.5). All but one map user correctly interpreted all maps, only three of the eight 2-D temporospatial diagram correctly interpreted all diagrams. In the qualitative analysis three common themes were identified: comments on the user interface, comments on the visualization tool(s), and suggestions for improvement. Most study participants mentioned that the software would be useful in their work. Conclusions: Healthcare professional from several different aspects of stroke care see geographic visualizations in transport decision making to be a useful tool. The software demonstrated high usability. However, several suggestions were made to improve user experience as well as additional features which could be developed and become the subject of future studies.

Impact of China's referral reform on the equity and spatial accessibility of healthcare resources: A case study of Beijing

In 2015, the Chinese government implemented referral reform in its hierarchical medical system by adjusting the reimbursement rules of medical insurance, in order to guide patients' hospital preference. This reform has impacted the equity and spatial accessibility of healthcare resources in different regions. Taking Beijing as a case study, we calculated and compared the equity and accessibility of healthcare resources before and after referral reform with a three-stage two-step floating catchment area method. We set different referral rates and explored their effects on medical service accessibility and equity. The results showed that the referral reform improved total accessibility of public hospitals in Beijing, but at the same time aggravated the inequality of healthcare resource accessibility among towns and streets. Healthcare accessibility demonstrated a U shape with an increase in referral rates. After testing five scenarios, we conclude that a 90% referral rate from the secondary hospitals to tertiary hospitals could be a trade-off when the government strikes a balance between equal chance of access to health services and high accessibility.

Aging in the Americas: Disability-free Life Expectancy Among Adults Aged 65 and Older in the United States, Costa Rica, Mexico, and Puerto Rico

Objectives

To estimate and compare disability-free life expectancy (DFLE) and current age patterns of disability onset and recovery from disability between the United States and countries in Latin America and the Caribbean.

Method

Disability is measured using the activities of daily living scale. Data come from longitudinal surveys of older adult populations in Costa Rica, Mexico, Puerto Rico, and the United States. Age patterns of transitions in and out of disability are modeled with a discrete-time logistic hazard model, and a microsimulation approach is used to estimate DFLE.

Results

Overall life expectancy for women aged 65 is 20.11 years in Costa Rica, 19.2 years in Mexico, 20.4 years in Puerto Rico, and 20.5 years in the United States. For men, these figures are 19.0 years in Costa Rica, 18.4 years in Mexico, 18.1 years in Puerto Rico, and 18.1 years in the United States. Proportion of remaining life spent free of disability for women at age 65 is comparable between Mexico, Puerto Rico, and the United States, with Costa Rica trailing slightly. Male estimates of DFLE are similar across the four populations.

Discussion

Though the older adult population of Latin America and the Caribbean lived many years exposed to poor epidemiological and public health conditions, their functional health in later life is comparable with the older adult population of the United States.

Inequality in the Incidence of Cervical Cancer: Costa Rica 1980-2010

Introduction: Cervical cancer is the third most incident and the fourth most lethal cancer among Costa Rican women. The purpose of this study was to quantify incidence inequality along three decades and to explore its determinants. Materials and Methods: This is a population-based study. Main data sources were the National Tumor Registry (1980-2010), CRELES (Costa Rican Longevity and Healthy Aging Study) longitudinal survey (2013), and published indices of economic condition (2007) and access to healthcare (2000). Cartography was made with QGIS software. Inequality was quantified using the Theil-T index. With the purpose of detecting differences by tumor's behavior, inequality was estimated for "in situ" and invasive incidence. In Situ/Invasive Ratios were estimated as an additional marker of inequality. Poisson and spatial regression analyses were conducted with Stata and ArcMap software, respectively, to assess the association between incidence and social determinants such as economic condition, access to healthcare and sub-utilization of Papanicolaou screening. Results: As measured by Theil-T index, incidence inequality has reached high (83 to 87%) levels during the last three decades. For invasive cervical cancer, inequality has been rising especially in women aged 50-59; increasing from 58% in the 1980's to 66% in 2000's. Poisson regression models showed that sub-utilization of Papanicolaou smear was associated with a significant decrease in the probability of early diagnosis. Costa Rican guidelines establish a Pap smear every 2 years; having a Pap smear every 3 years or longer was associated with a 36% decrease in the probability of early "in situ" diagnosis (IRR = 0.64, p = 0.003) in the last decade. Spatial regression models allowed for the detection of specific areas where incidence of invasive cervical cancer was higher than expected. Conclusion: Results from this study provide evidence of inequality in the incidence of cervical cancer, which has been high over three decades, and may be explained by sub-utilization of Papanicolaou smear screening in certain regions. The reasons why women do not adequately use screening must be addressed in future research. Interventions should be developed to stimulate the utilization of screening especially among women aged 50 to 59 where inequality has been rising.

Spatial dynamics of access to primary care for the medicaid population

Primary care (PC) has always been underestimated and underinvested by the United States health system. Our goal was to investigate the effect of Medicaid expansion and the Affordable Care Act (ACA) provisions on PC access in Broome County, NY, a county that includes both rural and urban areas, and can serve as a benchmark for other regions. We developed a spatial system dynamics model to capture different stages of PC access for the Medicaid population by using the health belief model constructs and simulate the effect of several hypothetical interventions on PC utilisation. The government data portals used as data sources for calibrating our model include the New York State Department of Health, the Medicaid Delivery System Reform Incentive Payment (DSRIP) dashboards, and the US census. In our unique approach, we integrated the simulation results within Geographical Information System (GIS) maps, to assess the influence of geospatial factors on PC access. Our results identify hot spot demographic areas that have poor access to PC service facilities due to transportation constraints and a shortage in PC providers. Our decision support tool informs policymakers about programmes with the strongest impact on improving access to care, considering spatial and temporal characteristics of a region.

Cross-border spatial accessibility of health care in the North-East Department of Haiti

BACKGROUND

The geographical accessibility of health services is an important issue especially in developing countries and even more for those sharing a border as for Haiti and the Dominican Republic. During the last 2 decades, numerous studies have explored the potential spatial access to health services within a whole country or metropolitan area. However, the impacts of the border on the access to health resources between two countries have been less explored. The aim of this paper is to measure the impact of the border on the accessibility to health services for Haitian people living close to the Haitian-Dominican border.

METHODS

To do this, the widely employed enhanced two-step floating catchment area (E2SFCA) method is applied. Four scenarios simulate different levels of openness of the border. Statistical analysis are conducted to assess the differences and variation in the E2SFCA results. A linear regression model is also used to predict the accessibility to health care services according to the mentioned scenarios.

RESULTS

The results show that the health professional-to-population accessibility ratio is higher for the Haitian side when the border is open than when it is closed, suggesting an important border impact on Haitians' access to health care resources. On the other hand, when the border is closed, the potential accessibility for health services is higher for the Dominicans.

CONCLUSION

The openness of the border has a great impact on the spatial accessibility to health care for the population living next to the border and those living nearby a road network in good conditions. Those findings therefore point to the need for effective and efficient trans-border cooperation between health authorities and health facilities. Future research is necessary to explore the determinants of cross-border health care and offers an insight on the spatial revealed access which could lead to a better understanding of the patients' behavior.

Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?

The Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of primary health care, reflecting the disappointing implementation of the Alma-Ata declaration of 1978 over the past four decades. The draft Astana declaration (Alma-Ata 2·0), released in June, 2018, restates the key principles of primary health care and renews these as driving forces for achieving the SDGs, emphasising universal health coverage. We use accumulating evidence to show that countries that reoriente their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or low investment in health. We then argue that an even bolder approach, which fully embraces the Alma-Ata vision of primary health care, could deliver substantially greater SDG progress, by addressing the wider determinants of health, promoting equity and social justice throughout society, empowering communities, and being a catalyst for advancing and amplifying universal health coverage and synergies among SDGs.

Using geographical analysis to identify child health inequality in sub-Saharan Africa

One challenge to achieving Millennium Development Goals was inequitable access to quality health services. In order to achieve the Sustainable Development Goals, interventions need to reach underserved populations. Analyzing health indicators in small geographic units aids the identification of hotspots where coverage lags behind neighboring areas. The purpose of these analyses is to identify areas of low coverage or high need in order to inform effective resource allocation to reduce child health inequity between and within countries. Using data from The Demographic and Health Survey Program surveys conducted in 27 selected African countries between 2010 and 2014, we computed estimates for six child health indicators for subnational regions. We calculated Global Moran's I statistics and used Local Indicator of Spatial Association analysis to produce a spatial layer showing spatial associations. We created maps to visualize sub-national autocorrelation and spatial clusters. The Global Moran's I statistic was positive for each indicator (range: 0.41 to 0.68), and statistically significant (p <0.05), suggesting spatial autocorrelation across national borders, and highlighting the need to examine health indicators both across countries and within them. Patterns of substantial differences among contiguous subareas were apparent; the average intra-country difference for each indicator exceeded 20 percentage points. Clusters of cross-border associations were also apparent, facilitating the identification of hotspots and informing the allocation of resources to reduce child health inequity between and within countries. This study exposes differences in health indicators in contiguous geographic areas, indicating that specific regional and subnational, in addition to national, strategies to improve health and reduce health inequalities are warranted.

Population characteristics and geographic coverage of primary care facilities

BACKGROUND

The location of General Practitioner (GP) facilities is an important aspect in the design of healthcare systems to ensure they are accessible by populations with healthcare needs. A key consideration in the facility location decision involves matching the population need for the services with the supply of healthcare resources. The literature points to several factors which may be important in the decision making process, such as deprivation, transportation, rurality, and population age.

METHODS

This study uses two approaches to examine the factors associated with GP accessibility in Northern Ireland. The first uses multinomial regression to examine the factors associated with GP coverage, measured as the proportion of people who live within 1.5 km road network distance from the nearest GP practice. The second focuses on the factors associated with the average travel distance to the nearest GP practice, again measured using network distance. The empirical research is carried out using population and geospatial data from Northern Ireland, across 890 Super Output Areas and 343 GP practices.

RESULTS

In 19% of Super Output Areas, all of the population live within 1.5 km of a GP practice, whilst in 24% none of the population live within 1.5 km. The regression results show that there are higher levels of population coverage in more deprived areas, smaller areas, and areas that have more elderly populations. Similarly, the average travel distance is related to deprivation, population age, and area size.

CONCLUSIONS

The results indicate that GP practices are located in areas with higher levels of service need, but also that care needs to be taken to ensure rural populations have sufficient access to services, whether delivered through GP practices or through alternative services where GP practices are less accessible. The methodology and results should be considered by policy makers and healthcare managers when making decisions about GP facility location and service provision.

Prevention Efforts for Malaria

PURPOSE OF REVIEW

Malaria remains a global burden contributing to morbidity and mortality especially in children under 5 years of age. Despite the progress achieved towards malaria burden reduction, achieving elimination in more countries remains a challenge. This article aims to review the prevention and control strategies for malaria, to assess their impact towards reducing the disease burden and to highlight the best practices observed.

RECENT FINDINGS

Use of long-lasting insecticide-treated nets and indoor residual spraying has resulted a decline in the incidence and prevalence of malaria in Sub-Saharan Africa. Other strategies such as larval source management have been shown to reduce mosquito density but require further evaluation. New methods under development such as house improvement have demonstrated to minimize disease burden but require further evidence on efficacy. Development of the RTS,S/AS01 malaria vaccine that provides protection in under-five children has provided further progress in efforts of malaria control.

SUMMARY

There has been a tremendous reduction in malaria burden in the past decade; however, more work is required to fill the necessary gaps to eliminate malaria.

Breastfeeding Support: A Geographic Perspective on Access and Equity

BACKGROUND

Clinical lactation professionals, breastfeeding peer counseling, and mother-to-mother support are important sources of information and guidance for helping mothers initiate and maintain breastfeeding in the early weeks, months, and years postpartum. However, there is limited information concerning the geographic barriers that mothers face when seeking this support. Research aim: This study aimed to identify the geographic barriers to breastfeeding support, delineate gaps in access, assess inequities in the distribution of local support, and highlight the underlying differences in access and equity for different demographic and socioeconomic groups.

METHODS

The locations of formal breastfeeding support resources were collected for the state of Ohio for 2016 and were combined with demographic and socioeconomic estimates and derived transportation catchment areas to conduct an analysis of spatial access and equity.

RESULTS

Significant geographic gaps in formal breastfeeding support exist within the state of Ohio. Although urban areas benefit from a higher density of support options, including a wide variety of clinical experts and mother-to-mother support groups, inequities in exurban and rural areas were more strongly aligned with socioeconomic status than geography. In particular, the Special Supplemental Nutrition Program for Women, Infants, and Children offices in rural Ohio offer breastfeeding support to income-qualifying mothers but cannot address the needs of mothers who do not qualify.

CONCLUSION

Spatial analytical approaches facilitate a more nuanced view of access and equity to breastfeeding support options, helping to both decompose important structural differences in the state of Ohio and identify locations that could benefit from additional breastfeeding support resources.

Parental Action and Referral Patterns in Spatial Clusters of Childhood Autism Spectrum Disorder

Sociodemographic factors have long been associated with disparities in autism spectrum disorder (ASD) diagnosis. Studies that identified spatial clustering of cases have suggested the importance of information about ASD moving through social networks of parents. Yet there is no direct evidence of this mechanism. This study explores the help-seeking behaviors and referral pathways of parents of diagnosed children in Costa Rica, one of two countries in which spatial clusters of cases have been identified. We interviewed the parents of 54 diagnosed children and focused on social network connections that influenced parents' help seeking and referral pathways that led to assessment. Spatial clusters of cases appear to be a result of seeking private rather than public care, and private clinics are more likely to refer cases to the diagnosing hospital. The referring clinic rather than information spread appears to explain the disparities.