Psychiatric disorders in childhood cancer survivors: A retrospective matched cohort study of inpatient hospitalisations and community-based mental health services utilisation in Western Australia

OBJECTIVE

We examined the impact of long-term mental health outcomes on healthcare services utilisation among childhood cancer survivors in Western Australia using linked hospitalisations and community-based mental healthcare records from 1987 to 2019.

METHOD

The study cohort included 2977 childhood cancer survivors diagnosed with cancer at age < 18 years in Western Australia from 1982 to 2014 and a matched non-cancer control group of 24,994 individuals. Adjusted hazard ratios of recurrent events were estimated using the Andersen-Gill model. The cumulative burden of events over time was assessed using the method of mean cumulative count. The annual percentage change in events was estimated using the negative binomial regression model.

RESULTS

The results showed higher community-based service contacts (rate/100 person-years: 30.2, 95% confidence interval = [29.7-30.7] vs 22.8, 95% confidence interval = [22.6-22.9]) and hospitalisations (rate/1000 person-years: 14.8, 95% confidence interval = [13.6-16.0] vs 12.7, 95% confidence interval = [12.3-13.1]) in childhood cancer survivors compared to the control group. Childhood cancer survivors had a significantly higher risk of any event (adjusted hazard ratio = 1.5, 95% confidence interval = [1.1-2.0]). The cumulative burden of events increased with time since diagnosis and across age groups. The annual percentage change for hospitalisations and service contacts significantly increased over time (p < 0.05). Substance abuse was the leading cause of hospitalisations, while mood/affective and anxiety disorders were common causes of service contacts. Risk factors associated with increased service events included cancer diagnosis at age < 5 years, leukaemia diagnosis, high socioeconomic deprivation, and an attained age of < 18 years.

CONCLUSIONS

The elevated utilisation of healthcare services observed among childhood cancer survivors emphasises the need for periodic assessment of psychiatric disorders, particularly in high-risk survivors, to facilitate early management and optimise healthcare resources.

Delphi Plus: A novel methodology for identifying evidence-based data standards for health service decision-making

The underlying tenet of evidence-based decision-making in health services is assessing all the relevant evidence. Using the traditional qualitative and quantitative approaches to identifying evidence may not capture the full spectrum of factors that need to be addressed. A selective mixed-method approach may provide a comprehensive assessment of the relevant knowledge. This paper adds to the methodological literature by outlining a novel sequential, mixed-method, exploratory process for identifying evidence-based data standards that may be used for health service decision-making. The three-phase process, entitled Delphi Plus, engages peer-nominated topic-specific experts to assess all publicly available and practice-based items and, through a series of reviews, reach an evidence-based consensus on standards for decision-making. Each process phase is outlined in-depth and supplemented by practical learnings gained through its implementation. The Delphi Plus methodology provides the first comprehensive process for combining the published and practised data to develop evidence-based data standards. The routine use of Delphi Plus would provide a framework for benchmarking in health services, enabling greater monitoring and evaluation of client outcomes and improving quality care. This manuscript describes the process of implementing Delphi Plus and provides an example of data standards generated from its use, which directly inform the Australian Government's Primary Health Care 10 Year Plan.

Discovering risk patterns in people with affective disorder-induced disabilities associated with their healthcare delay

BACKGROUND

People with affective disorder-induced disabilities (ADIDs) often experience complex needs that delay their healthcare. Discovering hidden patterns in these people for real-world use of health services is essential to improve healthcare delivery.

METHODS

A cross-sectional study population (2501 adults with ADIDs) was obtained from the Australian national representative survey of disability in 2015, including 21 demographic, health and social characteristics and healthcare delay information in general practice, specialist and hospital services. The Self-Organising Map Network was used to identify hidden risk patterns associated with healthcare delay and investigate potential predictors of class memberships by means of simple visualisations.

RESULTS

While experiencing disability avoidance showed across different healthcare delays, labour force appeared not to have any influence. Approximately 30% delayed their healthcare to general practice services; these were young, single females in great need of psychosocial support and aids for personal activities. Those who delayed their healthcare commonly presented a lack of social connections and a need for contact with family or friends not living in the same household.

CONCLUSIONS

The pattern evidence provides an avenue to further develop integrated care strategies with better targeting of people with ADIDs, considering social participation challenges facing them, to improve health service utilisation.

Understanding the uptake of HIV testing among women in Liberia: the role of female genital mutilation/cutting

Past studies show that the processes of female genital mutilation/cutting (FGM/C) on women can increase their susceptibility to HIV infection. This is because genital tears or ruptures, scars and wounds from FGM/C may expose survivors to heightened risks of contracting sexually transmitted infections, including HIV, if they engage in unsafe sexual practices. Hence, there is the need to promote HIV screening and testing among this population. Yet, in Liberia, there is a dearth of studies exploring the uptake of HIV testing among women who have experienced FGM/C. To understand this relationship, we used the 2019-2020 Liberia Demographic and Health Survey (LDHS) and employed logistic regression analysis to answer the following questions: (1) Are FGM/C survivors less likely to have been tested for HIV compared to non-FGM/C women; and (2) How does this disparity in the uptake of HIV testing differ by women's marital status? We found that survivors of FGM/C were less likely to have been tested for HIV than non-FGM/C women, even after accounting for theoretically relevant variables (OR = 0.83, p < 0.01). In response to our second question, we found that survivors of FGM/C who were formerly married were less likely to have been tested for HIV compared to their non-FGM/C counterparts (OR = 0.48, p < 0.01). These findings highlight the importance of trauma-informed HIV prevention strategies in Liberia, and the need for policymakers to take a holistic approach to addressing the challenges that FGM/C survivors, especially formerly married women, may face in accessing HIV prevention and testing services, and to work towards creating a more inclusive and supportive environment for all at-risk groups.

Voices From the Community: Maternal Healthcare Experiences During the COVID-19 Pandemic

Introduction The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on health services around the world. Many hospitals and clinics were overwhelmed by the influx of patients, leading to delays and disruptions in care. The fear of contracting the virus also led to a decrease in the number of people seeking medical care, even for urgent or life-threatening conditions. Various studies have reported a decrease in overall utilization of maternal health services. However, it remains vital to find the reasons for reduced utilization along with the experiences of the women as well as healthcare workers during the pandemic. Objective The objective of this study was to identify the facilitators and barriers to maternal healthcare services utilization during the COVID-19 pandemic. Methods It was a qualitative study conducted in a rural area of Haryana, India. Twelve in-depth interviews (IDIs) were conducted with health workers and four focused group discussions (FGDs) were conducted with pregnant women. Textual analysis was done for both IDIs as well as FGDs. Qualitative analysis was done manually. Results The identified themes were complete cessation of services, no outpatient department (OPD) services for many months, no antenatal care (ANC) services for two months, disruption of supply of medicines, unavailability of drugs, fear of getting COVID-19 infection, mandatory COVID-19 negative report for admission in hospital, and increased referral from government health facilities during the pandemic and lockdown. Conclusion Maternal healthcare services suffered during COVID-19 for various reasons including the closure of health facilities, limited supply of stocks, or fear of the disease among pregnant women. This evidence can be used to prepare as well as manage healthcare services in future.

Collaborative Ambulatory Orthopaedic Care in Patients with Hip and Knee Osteoarthritis: A Retrospective Comparative Cohort Study on Health Utilisation and Economic Outcomes

Objective

To evaluate a novel healthcare programme for the treatment of patients with hip and knee osteoarthritis in southern Germany in terms of clinical and health economic outcomes. The study is based on claims data from 2014 to 2017.

Methods

We conducted a retrospective comparative cohort study of 9768 patients with hip and knee osteoarthritis, of whom 9231 were enrolled in a collaborative ambulatory orthopaedic care programme (intervention group), and 537 patients received usual orthopaedic care (control group). Key features of the programme are coordinated care, morbidity-adapted reimbursement and extended consultation times. Multivariable analysis was performed to determine effects on health utilisation outcomes. The economic analysis considered annual costs per patient from a healthcare payer perspective, stratified by healthcare service sector. Besides multivariable regression analyses, bootstrapping was used to estimate confidence intervals for predicted mean costs by group.

Results

Musculoskeletal-disease-related hospitalisation was much less likely among intervention group patients than control group patients [odds ratio (OR): 0.079; 95% CI: 0.062-0.099]. The number of physiotherapy prescriptions per patient was significantly lower in the intervention group (RR: 0.814; 95% CI: 0.721-0.919), while the likelihood of participation in exercise programmes over one year was significantly higher (OR: 3.126; 95% CI: 1.604-6.094). Enrolment in the programme was associated with significantly higher ambulatory costs (€1048 vs. €925), but costs for inpatient care, including hospital stays, were significantly lower (€1003 vs. €1497 and €928 vs. €1300 respectively). Overall annual cost-savings were €195 per patient.

Conclusions

Collaborative ambulatory orthopaedic care was associated with reduced hospitalisation in patients with hip and knee osteoarthritis. Health costs for programme participants were lower overall, despite higher costs for ambulatory care.

Fall-related health service use in Stepping On programme participants and matched controls: a non-randomised observational trial within the 45 and Up Study

BACKGROUND

Falls and fall-related health service use among older adults continue to increase. The New South Wales Health Department, Australia, is delivering the Stepping On fall prevention programme at scale. We compared fall-related health service use in Stepping On participants and matched controls.

METHODS

A non-randomised observational trial was undertaken using 45 and Up Study data. 45 and Up Study participants who did and did not participate in Stepping On were extracted in a 1:4 ratio. Rates of fall-related health service use from linked routinely collected data were compared between participants and controls over time using multilevel Poisson regression models with adjustment for the minimally sufficient set of confounders identified from a directed acyclic graph.

RESULTS

Data from 1,452 Stepping On participants and 5,799 controls were analysed. Health service use increased over time and was greater in Stepping On participants (rate ratios (RRs) 1.47-1.82) with a spike in use in the 6 months prior to programme participation. Significant interactions indicated differential patterns of health service use in participants and controls: stratified analyses revealed less fall-related health service use in participants post-programme compared to pre-programme (RRs 0.32-0.48), but no change in controls' health service use (RRs 1.00-1.25). Gender was identified to be a significant effect modifier for health service use (P < 0.05 for interaction).

DISCUSSION

Stepping On appeared to mitigate participants' rising fall-related health service use. Best practice methods were used to maximise this study's validity, but cautious interpretation of results is required given its non-randomised nature.

The health service contact patterns of people with psychotic and non-psychotic forms of severe mental illness in New South Wales, Australia: A record-linkage study

OBJECTIVE

To describe and compare the health profiles and health service use of people hospitalised with severe mental illness, with and without psychotic symptoms.

METHODS

We conducted a historical cohort study using linked administrative datasets, including data on public hospital admissions, emergency department presentations and ambulatory mental health service contacts in New South Wales, Australia. The study cohort comprised 169,306 individuals aged 12 years and over who were hospitalised at least once with a mental health diagnosis between 1 July 2002 and 31 December 2014. Of these, 63,110 had a recorded psychotic illness and 106,196 did not. Outcome measures were rates of hospital, emergency department and mental health ambulatory service utilisation, analysed using Poisson regression.

RESULTS

People with psychotic illnesses had higher rates of hospital admission (adjusted incidence rate ratio (IRR) 1.26; 95% confidence interval [1.23, 1.30]), emergency department presentation (adjusted IRR 1.17; 95% confidence interval [1.13, 1.20]) and ambulatory mental health treatment days (adjusted IRR 2.90; 95% confidence interval [2.82, 2.98]) than people without psychotic illnesses. The higher rate of hospitalisation among people with psychotic illnesses was driven by mental health admissions; while people with psychosis had over twice the rate of mental health admissions, people with other severe mental illnesses without psychosis (e.g. mood/affective, anxiety and personality disorders) had higher rates of physical health admissions, including for circulatory, musculoskeletal, genitourinary and respiratory disorders. Factors that predicted greater health service utilisation included psychosis, intellectual disability, greater medical comorbidity and previous hospitalisation.

CONCLUSION

Findings from this study support the need for (a) the development of processes to support the physical health of people with severe mental illness, including those without psychosis; (b) a focus in mental health policy and service provision on people with complex support needs, and (c) improved implementation and testing of integrated models of care to improve health outcomes for all people experiencing severe mental illness.

Uncovering healthcare staff attitudes to the rapid deployment of telehealth in Victoria, 2020-2021: a 12-month telehealth experience

BACKGROUND

Telehealth was widely adopted in health services during the Covid-19 pandemic. It is unknown what the attitudes and ongoing needs of healthcare staff are after a rapid implementation of telehealth.

AIMS

To evaluate staff attitudes to telehealth utilisation after a rapid implementation.

METHODS

A health service-wide bespoke survey was sent to all clinicians, managers, and administration staff in June-July 2021. We evaluated attitudes to (i) telehealth application in the model of care and (ii) the barriers and enablers to use of telehealth. Descriptive statistics were used for quantitative data, and content analysis for the textual data.

RESULTS

A hundred and thirty-four respondents completed the survey (response rate = 22.5% of healthdirect users (71/315), and = 3.2% of total healthcare staff population). Most commonly, telehealth was identified as being important (78%) and safe (79%) by clinicians; important (100%) and encouraged (88%) by managers. In contrast, telehealth was identified as not the same as face-to-face (56%, 50%); but easy to add to usual work arrangements (43%, 44%) by clinicians and managers, respectively. The most common enablers of telehealth were: (i) having others use the same telehealth platform (74.3%, 100%), and (ii) completing training (68.9%, 72.7%) by clinicians and managers, respectively. The most common barriers were having (i) reliable internet connectivity (39.2%, 45.5%) by clinicians and managers respectively, (ii) the right equipment (clinician 37.8%), and (iii) a private area (managers 36.3%).

CONCLUSIONS

Despite training and having support from colleagues to implement telehealth, ongoing needs were identified that may promote uptake in specific health settings. This article is protected by copyright. All rights reserved.

Systematic Review on the Impact of Conditional Cash Transfers on Child Health Service Utilisation and Child Health in Sub-Saharan Africa

Background: Conditional cash transfers (CCTs) are interventions which provide assistance in the form of cash to specific vulnerable groups on the condition that they meet pre-defined requirements. The impact of conditional cash transfers on children's access to health services and on their overall health has not been established in sub-Saharan Africa.

Method: We conducted a systematic review aimed at summarising the available information on the impact of conditional cash transfers on health service utilisation and child health in sub-Saharan Africa. We searched databases for peer-reviewed articles, websites of organisations involved in implementing conditional cash transfer programmes, and Google scholar to identify grey literature. Records were selected based on predefined eligibility criteria which were drawn from a programme impact framework. Records were eligible if one of the following outcomes was evaluated: health services utilisation, immunisation coverage, growth monitoring, anthropometry, illness reported, and mortality. Other records which reported on important intermediate outcomes or described mechanisms significantly contributing to impact were also included in the review. Data items were extracted from eligible records into an extraction form based on predefined data items. Study quality indicators were also extracted into a quality assessment form.

Results: Thematic narrative synthesis was conducted using data from nine included records. The review included five cluster randomised evaluations, one quasi-experimental clustered study, one randomised trial at the individual level, one mixed-method study and one purely qualitative study. There was insufficient evidence of an impact of conditional cash transfers on health service utilisation. There was also not enough evidence of an impact on nutritional status. No impact was observed on health status based on illness reports, nor on immunisation rates. None of the included records evaluated the impact on childhood mortality.

Conclusions: The findings of this review suggest that a positive impact may be observed in health service utilisation and nutrition, however, this may not translate into improved child health. Further research is needed to understand the mechanisms and pathways by which these interventions work, explore the effect of contextual factors on their impact, and assess their cost implication especially within resource-constrained settings.

Functioning profiles in a nationally representative cohort of Spanish older adults: A latent class study

Ageing well involves individuals continuing participating in personal, social and civic affairs even in older age. From this standpoint, limitations in individual's functioning (beyond the mere absence of disease) may drastically impact on how well people becoming older. This study aimed to identify functional status profiles in a nationally representative sample of older adults, using latent class analysis methods. Moreover, it intended to study the how identified classes would be related to health-related outcomes later in life, as a way to provide some evidence on predictive validity. Data from a nationally representative sample of Spanish older adults (N = 2,118; 56.18% women; M = 71.50 years, SD = 7.76), were used. Profiles were identified according to a large set of functioning indicators from multiple domains using latent class analysis. Outcomes were studied over a 3-year follow-up, considering both the individual (quality of life, well-being and mortality) and institutional level (health service utilisation). As a result, seven profiles were identified: normative profile (showed by most participants), limited cognitive functioning class, limited global functioning class, limited mental and mobility functioning class, poor self-reported health class, limited sensory functioning class and limited objective functioning class. All the profiles with limitations across domains showed poor outcomes. Multidimensional limitations were related to the worst outcomes, especially when psychosomatic complaints and high feelings of loneliness were reported. To sum up, latent class analysis constitutes a suitable alternative to study population heterogeneity, providing relevant evidence to help making decision in public and community health.

Do Targeted User Fee Exemptions Reach the Ultra-Poor and Increase their Healthcare Utilisation? A Panel Study from Burkina Faso

Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of user fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of user fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of user fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = −0.07; 95% CI = −0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.

Australian Suicide Prevention using Health-Linked Data (ASHLi): Protocol for a population-based case series study

INTRODUCTION

In Australia, suicide is the leading cause of death for people aged 15-44 years. Health professionals deliver most of our key suicide prevention strategies via health services, but other efficacious population-level strategies include means restriction and public awareness campaigns. Currently, we have no population-level data allowing us to determine which individuals, in what parts of Australia, are likely to use our most promising interventions delivered by health services. The aims of this study are to describe: (1) health service utilisation rates in the year prior to death by suicide, and how this varies by individual case characteristics; (2) prescribed medicines use in the year prior to death by suicide, medicines used in suicide by poisoning and how this varies by individual case characteristics.

METHODS AND ANALYSIS

This is a population-based case series study of all suicide cases in Australia identified through the National Coronial Information System (NCIS) from 2013 to 2019. Cases will be linked to administrative claims data detailing health service use and medicines dispensed in the year before death. We will also obtain findings from the coronial enquiry, including toxicology. Descriptive statistics will be produced to characterise health service and prescribed medicine use and how utilisation varies by age, sex, method of death and socioeconomic status. We will explore the geographical variability of health service and medicine use, highlighting regions in Australia associated with more limited access.

ETHICS AND DISSEMINATION

This project involves the use of sensitive and confidential data. Data will be linked using a third-party privacy-preserving protocol meaning that investigators will not have access to identifiable information once the data have been linked. Statistical analyses will be carried out in a secure environment. This study has been approved by the following ethics committees: (1) the Justice Department Human Research Ethics Committee (REF: CF/17/23250), (2) the Western Australian Coroners Court (REF: EC 14/18 M0400), (3) the Australian Institute of Health and Welfare (REF: EO2017/4/366) and (4) NSW Population & Health Services Research Ethics Committee (REF: 2017/HRE1204). Findings will be published in peer-reviewed journals, presented at conferences and communicated to regulatory authorities, clinicians and policy-makers.

The Mixed Effect of China's New Health Care Reform on Health Insurance Coverage and the Efficiency of Health Service Utilisation: A Longitudinal Approach

In 2009, China launched a new health care reform as it endeavoured to develop a tiered system of disease diagnosis and treatment to promote the integration of medical resources. This was important for improving service capacity and building medical alliances that would eventually lead to improved health service utilisation efficiency. However, while the 2009 reform aimed to provide universal health insurance coverage to all citizens, its overall effect on health service utilisation efficiency remains unclear. We aimed to examine the new health care reform's mixed effect by applying a longitudinal study using China Health and Nutrition Survey (CHNS) data and the difference-in-difference (DID) method to estimate the health reform's impact on health insurance coverage rate. Then, we studied whether the increase in health insurance coverage rate affected health service utilisation efficiency in China. Our results showed that the increase in insurance coverage rate has indeed made expensive medical services available to low-income individuals. However, it also increased the likelihood of use of hospitals rather than primary care facilities, since there is more insurance cover for outpatient visits, which has led to an increased demand for quality services. This effect has generated a negative impact on health care utilisation which directly pertains to systemic inefficiency. This study thus indicates that China's latest health reform requires further policies to improve its overall efficiency.

Barriers and Enablers of Health Service Utilisation for Childhood Skin Infections in Remote Aboriginal Communities of Western Australia

In Australia, children living in remote Aboriginal communities experience high rates of skin infections and associated complications. Prompt presentation to primary care health services is crucial for early diagnosis and treatment. We performed a qualitative study in four remote Aboriginal communities in the Pilbara region of Western Australia to explore factors that affected health service utilisation for childhood skin infections in this setting. The study consisted of semistructured interviews and focus group discussions with parents and carers (n = 16), healthcare practitioners (n = 15) and other community service providers (n = 25). We used Andersen's health service utilisation model as an analytical framework. Our analysis captured a wide range of barriers that may undermine timely use of health services for childhood skin infections. These included general factors that illustrate the importance of cultural competency amongst healthcare providers, patient-centred care and community engagement. Relating specifically to health service utilisation for childhood skin infections, we identified their apparent normalisation and the common use of painful benzathine penicillin G injections for their treatment as important barriers. Health service utilisation in this setting may be enhanced by improving general awareness of the significance of childhood skin infections, actively engaging parents and carers in consultation and treatment processes and strengthening community involvement in health service activities.

Chronic ill health in a regional Victoria setting: A 13-year comparison

OBJECTIVE

High-quality data regarding the prevalence of chronic disease in rural areas are essential in understanding the challenges faced by rural populations and for informing strategies to address health care needs. This study compared the prevalence of a range of self-reported chronic conditions and utilisation of GP services and emergency department in a regional Victorian setting between two studies conducted in the same region in 2001-2003 and 2014.

DESIGN

Repeat cross-sectional studies conducted over a decade apart.

SETTING

The projects were conducted in the Goulburn Valley in regional Victoria.

PARTICIPANTS

The earlier study randomly selected households from local government lists. The later study randomly selected householders from the telephone directory.

MAIN OUTCOME MEASURES

Participants were asked whether they had been diagnosed with a range of chronic health conditions and how often they had visited a general practitioner or emergency department in the past 12 months.

RESULTS

The age-standardised prevalence of depression was higher in the 2014 study than the 2001-2003 study in men (increased by 8.0% (95% CI 4.5, 11.5%)) and women (increased by 13.7% (95% CI 8.4, 19.0%)). Similarly, the prevalence of age-standardised diabetes and hypertension was higher in 2014 than 2001-2003 (men increased by 3.6% (95% CI 0.7, 6.5% (diabetes)) and 13.6% (95% CI 8.6, 18.6% (hypertension)), women increased by 3.1% (95% CI 0.3, 6.5% (diabetes)) and 8.4% (95% CI 2.3, 14.5% (hypertension))).

CONCLUSION

The results of this study indicate that the prevalence of self-reported depression, diabetes and hypertension has increased in this regional Victorian area over the past 13 years. The reasons for these observed increases and the subsequent impact on the health care needs of regional communities warrants further investigation.

Comorbidity and healthcare use for individuals with CVD in the Ireland: a cross-sectional, population-based study

OBJECTIVE

This study explores the factors associated with health service use for individuals with cardiovascular disease (CVD) and comorbidity in the Ireland.

DESIGN

Population-based cross-sectional survey.

SETTING

Nationally representative health and health service use survey from the 2010 Quarterly National Household Survey was analysed.

PRIMARY OUTCOME MEASURES

Four outcome variables were examined: no CVD, CVD only, CVD with CVD-related comorbidities and CVD with non-CVD-related comorbidity.

RESULTS

Of the 791 individuals reporting doctor-diagnosed CVD, 77% had a second morbidity. Using type of healthcare coverage as a proxy for socioeconomic status, both CVD-related and non CVD-related comorbidity increases the use of health service usage substantially for individuals with CVD, particularly general practitioner services (8.47, CI 4.49 to 15.96 and 5.20, CI 2.10 to 12.84) and inpatient public hospital care (3.64, CI 2.93 to 4.51 and 3.00, CI 2.11 to 4.26).

CONCLUSION

This study indicated that even when demographic and socioeconomic factors are controlled for, comorbidity significantly increases the risk of accessing health services for individuals with CVD.

The perceptions, health-seeking behaviours and access of Scheduled Caste women to maternal health services in Bihar, India

The caste system is a complex social stratification system which has been abolished, but remains deeply ingrained in India. Scheduled Caste (SC) women are one of the historically deprived groups, as reflected in poor maternal health outcomes and low utilisation of maternal healthcare services. Key government schemes introduced in 2005 mean healthcare-associated costs should now be far less of a deterrent. This paper examines the factors contributing to this low use of maternal health services by investigating the perceptions, health-seeking behaviours and access of SC women to maternal healthcare services in Bihar, India. Eighteen in-depth, semi-structured interviews were conducted with SC women in Bihar. Data were analysed using Framework Analysis and presented using the AAAQ Toolbox. Main facilitating factors included the introduction of accredited social health activists (ASHAs), free maternal health services, the Janani Shishu Suraksha Karyakram (JSSK), and changes in the cultural acceptability of institutional delivery. Main barriers included inadequate ASHA coverage, poor information access, transport costs and unauthorised charges to SC women from healthcare staff. SC women in Bihar may be inequitably served by maternal health services, and in some cases may face specific discrimination. Recommendations to improve SC service utilisation include research into the improvement of postnatal care, reducing unauthorised payments to healthcare staff and improvements to the ASHA programme.

Cost-utility analysis of low-intensity case management to increase contact with health services among ex-prisoners in Australia

OBJECTIVES

The economic burden of incarceration is substantial in Australia. People released from prison are at high risk of poor health and this is an important predictor of recidivism. The 'Passports Study' was a randomised controlled trial of an intervention designed to increase health service utilisation after release from prison. The aim of this study is to conduct a cost-utility analysis of this transitional programme.

SETTING

Australia DESIGN: A hybrid simulation model was developed to estimate the changes to total economic costs and effectiveness expressed as quality-adjusted life-years (QALYs) from the adoption of the 'Passports' intervention compared with the control group. Model parameters were informed by linked data from Queensland Corrective Services, Medicare, Pharmaceutical Benefits Scheme, Queensland Hospital Admission Patient Data Collection, Emergency Department Information System and National Death Index. Health-related quality of life was measured using the Short-Form 8 Health Survey (SF-8). The primary outcomes were the costs and estimated QALYs associated with the intervention group and the control group. Probabilistic sensitivity analysis was conducted to test parameter uncertainties.

RESULTS

Compared with the control group where no attempt was made to encourage health service utilisation, an average participant in the intervention group incurred an extra cost of AUD 1790 and experienced slightly reduced QALYs, which indicated that the intervention was dominated in the baseline analysis. Probabilistic sensitivity analysis revealed that the transitional programme had a low probability of being cost-effective with the outcome measures selected.

CONCLUSION

The findings of this study do not provide economic evidence to support the widespread adoption of the Passports intervention. Due to the reductionist nature of the cost-utility approach, it may be that important health-related benefits have been omitted. Another research approach using a wider range of health-related measures might generate different conclusions.

Health service utilisation amongst urban Aboriginal and Torres Strait Islander children aged younger than 5 years registered with a primary health-care service in South-East Queensland

AIM

The majority of Australia's Aboriginal and/or Torres Strait Islander children live in urban areas; however, little is known about their health service use. We aimed to describe health service utilisation amongst a cohort of urban Aboriginal and/or Torres Strait Islander children aged <5 years.

METHODS

We analysed health service utilisation data collected in an ongoing prospective cohort study of children aged <5 years registered with an Aboriginal-owned and operated primary health-care service. Enrolled children were followed monthly for 12 months, with data on health service utilisation collected at baseline and at each monthly follow-up. Health service utilisation rates, overall and by service provider and reason for presentation, were calculated and reported as incidence rates per 100 child-months with the corresponding 95% confidence intervals (CIs).

RESULTS

Between February 2013 and November 2015, 180 children were enrolled, and 1541 child-months of observation were available for analysis. The overall incidence of health service utilisation was 52.5 per 100 child-months (95% CI 48.7-56.5); 81% of encounters were with general practitioners. Presentation rates were the highest for acute respiratory illnesses (30.7/100 child-months, 95% CI 27.8-33.9).

CONCLUSIONS

In this community, acute respiratory illnesses are predominant causes of health service utilisation in young children. The health-care utilisation profile of these children presents important opportunities for health promotion and intervention.

The epidemiology of multimorbidity in primary care: a retrospective cohort study

BACKGROUND

Multimorbidity places a substantial burden on patients and the healthcare system, but few contemporary epidemiological data are available.

AIM

To describe the epidemiology of multimorbidity in adults in England, and quantify associations between multimorbidity and health service utilisation.

DESIGN AND SETTING

Retrospective cohort study, undertaken in England.

METHOD

The study used a random sample of 403 985 adult patients (aged ≥18 years), who were registered with a general practice on 1 January 2012 and included in the Clinical Practice Research Datalink. Multimorbidity was defined as having two or more of 36 long-term conditions recorded in patients' medical records, and associations between multimorbidity and health service utilisation (GP consultations, prescriptions, and hospitalisations) over 4 years were quantified.

RESULTS

In total, 27.2% of the patients involved in the study had multimorbidity. The most prevalent conditions were hypertension (18.2%), depression or anxiety (10.3%), and chronic pain (10.1%). The prevalence of multimorbidity was higher in females than males (30.0% versus 24.4% respectively) and among those with lower socioeconomic status (30.0% in the quintile with the greatest levels of deprivation versus 25.8% in that with the lowest). Physical-mental comorbidity constituted a much greater proportion of overall morbidity in both younger patients (18-44 years) and those patients with a lower socioeconomic status. Multimorbidity was strongly associated with health service utilisation. Patients with multimorbidity accounted for 52.9% of GP consultations, 78.7% of prescriptions, and 56.1% of hospital admissions.

CONCLUSION

Multimorbidity is common, socially patterned, and associated with increased health service utilisation. These findings support the need to improve the quality and efficiency of health services providing care to patients with multimorbidity at both practice and national level.

Association between health service utilisation of internal migrant children and parents' acculturation in Guangdong, China: a cross-sectional study

OBJECTIVES

To assess the health service utilisation of internal migrant children in Guangdong, China, and to explore the association between children's health service utilisation and their parents' acculturation.

DESIGN

Cross-sectional survey between April and May 2016.

SETTING

Six society-run schools of Tianhe and Baiyun districts in Guangzhou City of China.

PARTICIPANTS

We recruited all students at grade 7 or 8 and one of their parents who resided in Guangzhou over 6 months without permanent registered residence (hukou) in Guangzhou (1161 pairs completed this survey). 258 children were ill within the past 2 weeks or during the last year.

MAIN OUTCOME MEASURES

The main outcome was self-reported health service utilisation. Logistic regression analysis was conducted to explore the association between children's unmet needs for outpatient or inpatient service and their parents' acculturation (categorised into high, middle and low groups).

RESULTS

In total, 216 children, or 18.6% of the total subjects, were ill within the past 2 weeks and were in need of outpatient service; 94 children, or 8.1% of the total subjects, were in need of inpatient service. Among them, 17.6% and 46.8% of the migrant children had unmet needs for outpatient and inpatient services, respectively. After controlling for enabling resources and predisposing characteristics, migrant children with parents in the middle-acculturation group (adjusted OR=3.17, 95% CIs 1.2 to 8.3, P<0.05) were more likely to have an unmet outpatient need than high-acculturation or low-acculturation groups, although only statistically significant when comparing with the high-acculturation group. Stratified analysis suggested that this association could be moderated by their family economic status.

CONCLUSIONS

Our study suggested that the association between migrant children's health service utilisation and their parents' acculturation was complex and could be moderated by family economic status. Increasing the service utilisation among migrant children requires improving the acculturation and economic status of the parents of internal migrants.

Influence of the 2014-2015 Ebola outbreak on the vaccination of children in a rural district of Guinea

Setting: All health centres in Macenta District, rural Guinea. Objective: To compare stock-outs of vaccines, vaccine stock cards and the administration of various childhood vaccines across the pre-Ebola, Ebola and post-Ebola virus disease periods. Design: This was an ecological study. Results: Similar levels of stock-outs were observed for all vaccines (bacille Calmette-Guérin [BCG], pentavalent, polio, measles, yellow fever) in the pre-Ebola and Ebola periods (respectively 2760 and 2706 facility days of stock-outs), with some variation by vaccine. Post-Ebola, there was a 65-fold reduction in stock-outs compared to pre-Ebola. Overall, 24 facility-months of vaccine stock card stock-outs were observed during the pre-Ebola period, which increased to 65 facility-months of stock-outs during the Ebola outbreak period; no such stock-out occurred in the post-Ebola period. Apart from yellow fever and measles, vaccine administration declined universally during the peak outbreak period (August-November 2014). Complete cessation of vaccine administration for BCG and a prominent low for polio (86% decrease) were observed in April 2014, corresponding to vaccine stock-outs. Post-Ebola, overall vaccine administration did not recover to pre-Ebola levels, with the highest gaps seen in polio and pentavalent vaccines, which had shortages of respectively 40% and 38%. Conclusion: These findings highlight the need to sustain vaccination activities in Guinea so that they remain resilient and responsive, irrespective of disease outbreaks.

Hospital admissions for respiratory system diseases in adults with intellectual disabilities in Southeast London: a register-based cohort study

BACKGROUND

Intellectual disability (ID) carries a high impact on need for care, health status and premature mortality. Respiratory system diseases contribute a major part of mortality among people with ID, but remain underinvestigated as consequent morbidities.

METHODS

Anonymised electronic mental health records from the South London and Maudsley Trust (SLaM) were linked to national acute medical care data. Using retrospective cohort and matched case-control study designs, adults with ID receiving SLaM care between 1 January 2008 and 31 March 2013 were identified and compared with local catchment residents for respiratory system disease admissions. Standardised admission ratios (SARs) were first calculated, followed by a comparison of duration of hospitalisation with respiratory system disease between people with ID and age-matched and gender-matched random counterparts modelled using linear regression. Finally, the risk of readmission for respiratory system disease was analysed using the Cox models.

RESULTS

For the 3138 adults with ID identified in SLaM, the SAR for respiratory system disease admissions was 4.02 (95% CI 3.79 to 4.26). Compared with adults without ID, duration of hospitalisation was significantly longer by 2.34 days (95% CI 0.03 to 4.64) and respiratory system disease readmission was significantly elevated (HR=1.35; 95% CI 1.17 to 1.56) after confounding adjustment.

CONCLUSIONS

Respiratory system disease admissions in adults with ID are more frequent, of longer duration and have a higher likelihood of recurring. Development and evaluation of potential interventions to the preventable causes of respiratory diseases should be prioritised.

Preventive dental visiting: a critical interpretive synthesis of theory explaining how inequalities arise

BACKGROUND

In many countries, those with lower socioeconomic status are disproportionately affected by poor oral health. This can be attributed, at least in part, to differences in preventive dental visiting. While several theories have been applied to the area, they generally fail to capture the recursive nature of dental visiting behaviour, and fall short of informing the design of complex interventions to tackle inequalities.

OBJECTIVE

To undertake a systematic review and synthesis of theory in order to provide an overview of the pathways which bring about socioeconomic inequalities in early dental visiting, and identify possible intervention points.

METHODS

Electronic searching identified 8947 titles and abstracts. Paper screening and citation snowballing left 77 included papers. Drawing on the tenets of Critical Interpretive Synthesis, data extraction involved capturing concepts and relationships and translating these sometimes into synthetic constructs.

RESULTS

We theorize that at the individual (micro-level), dental visiting behaviour is influenced by: the 'Importance of obtaining care', 'Emotional response' and 'Perceived control', which feed into a balancing of 'Competing Demands' against 'Internal resources' (coping, self-identity), although attendance is tempered by the effective 'Affordability and Availability of services'. Positive Care experiences are theorized to lower the demands and increase internal resources associated with dental visiting. We also outline meso-level factors 'Social norms and sanctions', 'Obligations, expectations and trust', 'Information channels', 'Social structures' and theorize how these can exert an overwhelming influence in deprived areas.

CONCLUSIONS

Socioeconomic inequalities in early dental visiting emerge from several stages in the care-seeking process. Dental visiting behaviour should be viewed not just as a one-off event, but extending over time and social space. Since there is recursivity in peoples' most recent dental experience any future visits we identify that interventions which make care a positive experience for low socioeconomic patients may be particularly beneficial in reducing inequalities.

Allied health management of technology-related musculoskeletal complaints among children and adolescents

BACKGROUND/AIM

Children and adolescents are prolific users of information and communication technologies (ICT) in learning, leisure, and social communication activities. High exposure to ICT is associated with musculoskeletal injuries in adults; however, the management of ICT physical complaints in children is not well-understood.

METHODS

An online survey of allied health professionals (occupational therapists, physiotherapists, and chiropractors) was undertaken to determine (i) the number of children and adolescents in Perth, Western Australia who accessed treatment for musculoskeletal complaints related to use of technology; (ii) the typical frequency and duration of service provision; and (iii) the nature of treatment provided. Costs associated with service provision were estimated.

RESULTS

Data from 101 identified the most commonly treated musculoskeletal complaints among children and adolescents included: non-specific neck pain; thoracic postural pain disorder; non-specific low back pain; and lumbar postural pain disorder. Approximately 1445 children were treated in the previous 12 months; with one-third of chiropractors each reported treating 31+ children. Most common treatments were soft tissue release, mobilisation, flexibility and conditioning exercises, soft tissue massage and kinesio-taping. Verbal education about healthy use of technology was provided by most clinicians (88%), with some inconsistent recommendations. The estimated cost of treatment was AUD$1,057,715; of which AUD$544,886 was health system funded.

CONCLUSIONS

Children and adolescents received allied health treatment for a range of musculoskeletal complaints associated with ICT use. The potential long-term impacts on their health and wellbeing, and the economic burden associated with this health issue warrant the development of systematic risk reduction strategies.

The relation of HIV testing and treatment to identity formation in Zambia

Why would many Zambians be reluctant to access lifesaving antiretroviral treatment? Does the process of accessing an HIV test in Zambia promote an identity that can change individuals' livelihood strategies? What happens to individuals when people access treatment? Voluntary testing and treatment centres and the HIV-prevention programmes that support them have come to embody explicit messages about 'health,' 'progress,' 'civilisation' and 'modernity,' and through this they compel individuals to take on a particular identity. In Zambia the pursuit of HIV testing and biomedical treatment forces individuals to locate themselves somewhat differently in relation to community support structures, placing their faith in the future on an uneasy foundation of a 'modern' identity. This is embodied in the deep-rooted suspicion that many Zambians have toward the international HIV/AIDS-response sector from which HIV and AIDS treatment programmes are derived. Drawing upon the notion of 'therapeutic citizenship' I examine why the 'AIDS industry' continues to symbolise such tension. I explore how individuals believe their identity will shift through participation in HIV testing and treatment options and how that might impact long-term and short-term livelihood strategies.

Integrating community outreach into a quality improvement project to promote maternal and child health in Ghana

Quality improvement (QI) is used to promote and strengthen maternal and child health services in middle- and low-income countries. Very little research has examined community-level factors beyond the confines of health facilities that create demand for health services and influence health outcomes. We examined the role of community outreach in the context of Project Fives Alive!, a QI project aimed at improving maternal and under-5 outcomes in Ghana. Qualitative case studies of QI teams across six regions of Ghana were conducted. We analysed the data using narrative and thematic techniques. QI team members used two distinct outreach approaches: community-level outreach, including health promotion and education efforts through group activities and mass media communication; and direct outreach, including one-on-one interpersonal activities between health workers, pregnant women and mothers of children under-5. Specific barriers to community outreach included structural, cultural, and QI team-level factors. QI efforts in both rural and urban settings should consider including context-specific community outreach activities to develop ties with communities and address barriers to health services. Sustaining community outreach as part of QI efforts will require improving infrastructure, strengthening QI teams, and ongoing collaboration with community members.

African American women's preventative care usage: the role of social support and racial experiences and attitudes

Research suggests that African Americans are less likely to utilise preventative care services than Americans of European descent, and that these patterns may contribute to racial health disparities in the United States. Despite the persistence of inequalities in preventative care utilisation, culturally relevant factors influencing the use of these gateway health services have been understudied among marginalised groups. Using a stratified sample of 205 low-income African American women, this research examines the predictors of receiving a physical exam, with a particular emphasis on how differing levels of social support from friend and family networks and experiences of racial discrimination and cultural mistrust shape utilisation. The findings underscore the importance of traditional predictors of utilisation, including insurance status and having a usual physician. However, they also indicate that supportive ties to friendship networks are associated with higher predicted rates of having an annual physical exam, while social support from family and sentiments of cultural mistrust are associated with lower rates of utilisation. Broadly, the findings indicate that even as traditional predictors of help-seeking become less relevant, it will be critical to explore how variations in discrimination experiences and social relationships across marginalised groups drive patterns of preventative care utilisation.

Factors associated with reported service use for mental health problems by residents of rural and remote communities: cross-sectional findings from a baseline survey

BACKGROUND

The patterns of health service use by rural and remote residents are poorly understood and under-represented in national surveys. This paper examines professional and non-professional service use for mental health problems in rural and remote communities in Australia.

METHODS

A stratified random sample of adults was drawn from non-metropolitan regions of New South Wales, Australia as part of a longitudinal population-based cohort. One-quarter (27.7%) of the respondents were from remote or very remote regions. The socio-demographic, health status and service utilization (professional and non-professional) characteristics of 2150 community dwelling residents are described. Hierarchical logistic regressions were used to identify cross-sectional associations between socio-demographic, health status and professional and non-professional health service utilization variables.

RESULTS

The overall rate of professional contacts for mental health problems during the previous 12 months (17%) in this rural population exceeded the national rate (11.9%). Rates for psychologists and psychiatrists were similar but rates for GPs were higher (12% vs. 8.1%). Non-professional contact rates were 12%. Higher levels of help seeking were associated with the absence of a partner, poorer finances, severity of mental health problems, and higher levels of adversity. Remoteness was associated with lower utilization of non-professional support. A Provisional Service Need Index was devised, and it demonstrated a broad dose-response relationship between severity of mental health problems and the likelihood of seeking any professional or non-professional help. Nevertheless, 47% of those with estimated high service need had no contact with professional services.

CONCLUSIONS

An examination of self-reported patterns of professional and non-professional service use for mental health problems in a rural community cohort revealed relatively higher rates of general practitioner attendance for such problems compared with data from metropolitan centres. Using a measure of Provisional Service Need those with greater needs were more likely to access specialist services, even in remote regions, although a substantial proportion of those with the highest service need sought no professional help. Geographic and financial barriers to service use were identified and perception of service adequacy was relatively low, especially among those with the highest levels of distress and greatest adversity.

Utilisation of eye care services by urban and rural Australians

AIM

To investigate factors related to the use of eye care services in Australia.

METHODS

Health, eye care service use, and sociodemographic data were collected in a structured interview of participants in a population based study. All participants had a standard eye examination.

RESULTS

Men (OR 1.3 CL 1.02, 1.7), those who spoke Greek (OR 2.1 CL 1.1, 3.8) or Italian (OR 1.9 CL 1.0, 3.3), and those without private health insurance (OR 1.59 CL 1.22, 2.04) were more likely to have not used eye care services. Ophthalmology services were utilised at lower rates in rural areas (OR 0.14 CL 0.09, 0.2). Approximately 40% of participants with undercorrected refractive error, cataract, and undiagnosed glaucoma had seen either an ophthalmologist, optometrist, or both within the last year.

CONCLUSION

Despite the similarity in prevalence of eye disease in urban and rural areas, significant differences exist in the utilisation of eye care services. Sex, private health insurance, urban residence, and the ability to converse in English were significant factors associated with eye healthcare service use. Many participants had undiagnosed eye disease despite having seen an eye care provider in the last year.