Physical access to primary health care in Andean Bolivia

Evaluating the spatial accessibility and spatial layout optimization of HIV/AIDS healthcare services in Shandong Province, China

Improving access to HIV/AIDS healthcare services is of great concern to government and policymakers striving to strengthen overall public health. How to reasonably allocate HIV/AIDS healthcare resources and maximize the equality of access to healthcare services across subdistrict areas has become an urgent problem to be solved. However, there is limited research on this topic in China. It is necessary to evaluate spatial accessibility to improve the accessibility and equity of HIV/AIDS healthcare services. In this study, the improved multi-modal two-step floating catchment area (2SFCA) and inverted 2SFCA (i2SFCA) methods are used to measure the spatial accessibility of HIV/AIDS healthcare services and the crowdedness of the healthcare sites in Shandong Province, China. Then, the theoretical supply and the optimal spatial distribution of resources are calculated and visualized by minimizing the accessibility gaps between demand locations. This study showed that the spatial accessibility of HIV/AIDS service resources in Shandong Province was concentrated and unevenly distributed, and the accessibility scores in the marginal areas of prefecture-level cities were significantly lower than those in other areas. Regions with a large number of doctors had significantly higher levels of spatial accessibility. The ART accessibility scores in the southwest of Shandong Province were higher than those in other regions. As the travel friction coefficient increased, the accessibility scores formed an approximately circular cluster distribution centered on the healthcare sites in geographical distribution. More ART drugs needed to be supplied in marginal areas and more doctors were needed to work on HIV/AIDS in urban areas to address the spatial distribution imbalance of HIV/AIDS healthcare services. This study profoundly analyzed the spatial accessibility of HIV/AIDS healthcare services and provided essential references for decision-makers. In addition, it gives a significant exploration for achieving the goal of equal access to HIV/AIDS healthcare services in the future.

Evaluation of healthcare facilities and personnel distribution in Lagos State: implications on universal health coverage

BACKGROUND

Nigeria is considering making Universal Health Coverage (UHC) a common policy goal to ensure that citizens have access to high-quality healthcare services without crippling debt. Globally, there is an acute shortage of human resources for Health (HRH), and the most significant burden is borne by low-income countries, especially in sub-Saharan Africa. This shortage has considerably constrained the achievement of health-related development goals and impeded accelerated progress toward universal health coverage. We examine the existing human resource capacity and the distribution of health facilities in Lagos state in this study, discussing the implications of our findings.

METHODS

The study is descriptive using secondary data analysis. We leverage census-based primary data collected by NOIPoll on health facility assessments in Lagos state. The collected data was analyzed using counts, ratios, rates, and percentages.

RESULTS

We observe a ratio of 5,014 people to 1 general medical doctor, 2,942 people to 1 specialist, 2,165 people to 1 nurse, and 5,117 people to 1 midwife, which are far higher than the WHO recommendation. We also observe that the ratio of nurses to general medical practitioners is 2.2:1 in urban areas and 2.7:1 in rural. In contrast, the ratio of nurses to specialist medical doctors is 1.3:1 in the urban area and 1.5:1 in the rural areas of Lagos state. The overall nurse per general medical practitioner ratio is 2.3:1 and 1.4:1 for specialist medical doctors. 77.2% of the health facilities surveyed were in the urban areas, with private-for-profit facilities accounting for 82.9%, government facilities accounting for 15.4%, and NGOs/faith clinics accounting for 1.7%. Primary healthcare facilities account for 75.3% of the facilities surveyed, secondary and tertiary facilities account for 24.6% and 0.08%, respectively. Alimosho LGA has the most health facilities (77.38% PHCs, and 22.62% SHCs) and staff strength specifically for general medical practitioners, specialists, nurses, and midwives (16.9%, 19.9%, 16.7%, 17.1%, respectively). Eti-Osa LGA has the best density ratio for generalist doctors, specialist doctors, and nurses per 10,000 (4.42, 12.96, and 11.34 respectively), while Ikeja has the best midwife population density ratio 5.46 per 10,000 population.

CONCLUSION

The distribution of health personnel and facilities in Lagos State is not equitable, with evident variation between rural and urban areas. This inequitable distribution could affect the physical distance of health facilities to residents, leading to decreased utilization, ultimately poor health outcomes, and impaired access. Much like child mortality, maternal mortality also exhibits a correlation with healthcare worker density. As the physician density increases linearly, the maternal mortality rate decreases exponentially. However, due to the low number of healthcare workers in Lagos state, doctors, nurses, and midwives are frequently unavailable during childbirth, resulting in increasing infant, neonatal, and maternal death. As such, the government should adopt the UHC strategy in its distribution of facilities and personnel in the state for adequate coverage and optimal performance of the facilities. Also, additional investments are needed in some parts of the state to improve access to tertiary health facilities and leverage private sector capacity.

Measuring spatial accessibility and supply-demand deviation of urban green space: A mobile phone signaling data perspective

The reasonable distribution of urban green space (UGS) is a topic that urban researchers have been exploring for a long time. Solving the imbalance between the supply and demand of UGS plays an important role in improving the health level of a city. This study examines the central urban area of Hefei as an example. We developed a modified Gaussian two-step floating catchment area method and used the path planning model of Gaode Map to evaluate the accessibility of UGS under different transportation modes and different time thresholds while integrating mobile phone signaling data. Additionally, a fine-scale analysis of the actual supply and demand relationship of UGS was conducted by integrating the accessibility evaluation results with the recreational situation of UGS to analyze the deviation of supply and demand to further discuss the spatial distribution equilibrium of UGS. The main conclusions are as follows. (1) The spatial distribution of UGSs in the central urban area of Hefei is uneven. Different time thresholds and different transportation modes have a significant impact on the UGS accessibility evaluation results. (2) With the increase in the time threshold or travel distance, the number of grids above the moderate accessibility level generally increases. The spatial distribution of the grids with moderate, high and highest accessibility level present different patterns of contiguous, clusters, and spots distribution. (3) After combining these results with the actual recreational situation of UGS, we found that the overall demand in the central urban area exceeds the supply at the 15-min threshold, while the overall supply exceeds the demand at the 30-min threshold. The grids with balanced supply and demand or more supply than demand have comprehensive parks with a moderate population density and strong road connectivity in the neighborhood. This study strengthens the data granularity and improves the accuracy of accessibility evaluation by integrating mobile phone signaling data with the path planning model of Gaode Map. Also, we evaluate the accessibility with multi-transport modes and different time thresholds, which can bring more practical guidance for optimizing the distribution of UGS.

Intralesional Meglumine Antimoniate: Safe, Feasible and Effective Therapy for Cutaneous Leishmaniasis in Bolivia

The standard of care for cutaneous leishmaniasis includes the intramuscular/intravenous administration of pentavalent antimonials that are toxic and poorly tolerated. Primary health care usually lacks trained health staff for the diagnosis and treatment of leishmaniasis in Cochabamba Bolivia. Taking these aspects into account, a Bolivian consortium set out to explore the intralesional administration of meglumine antimoniate to treat cutaneous leishmaniasis during primary care under programmatic conditions. A four-step strategy consisting of clinical training for intralesional treatment and the promotion and periodic follow-up of health staff was carried out. The training process was applied in situ to personnel of nine primary health care centres. The intralesional treatment was applied five times every other day. Clinical follow-up after six-months of treatment showed a 77% healing proportion and 5% of therapeutic failure among 152 enrolled patients. The drug volume used in the intralesional procedure was on average 1.7 mL/ulcer treated. In conclusion, the strategy used was successful and effective, accomplishing a healing proportion similar to the long standardized treatment with a reduced time of administration, no severe side effects, and it is feasible to conduct by trained health staff. Our study supports the current PAHO/WHO recommendation for the intralesional administration of pentavalent antimonials for the treatment of cutaneous leishmaniasis.

Geographical accessibility of emergency neonatal care services in Ethiopia: analysis using the 2016 Ethiopian Emergency Obstetric and Neonatal Care Survey

INTRODUCTION

Access to emergency neonatal health services has not been explored widely in the Ethiopian context. Accessibility to health services is a function of the distribution and location of services, including distance, travel time, cost and convenience. Measuring the physical accessibility of health services contributes to understanding the performance of health systems, thereby enabling evidence-based health planning and policies. The physical accessibility of Ethiopian health services, particularly emergency neonatal care (EmNeC) services, is unknown.

OBJECTIVE

To analyse the physical accessibility of EmNeC services at the national and subnational levels in Ethiopia.

METHODS

We analysed the physical accessibility of EmNeC services within 30, 60 and 120 min of travel time in Ethiopia at a national and subnational level. We used the 2016 Ethiopian Emergency Obstetric and Neonatal Care survey in addition to several geospatial data sources.

RESULTS

We estimated that 21.4%, 35.9% and 46.4% of live births in 2016 were within 30, 60 and 120 min of travel time of fully EmNeC services, but there was considerable variation across regions. Addis Ababa and the Hareri regional state had full access (100% coverage) to EmNeC services within 2 hours travel time, while the Afar (15.3%) and Somali (16.3%) regional states had the lowest access.

CONCLUSIONS

The physical access to EmNeC services in Ethiopia is well below the universal health coverage expectations stated by the United Nations. Increasing the availability of EmNeC to health facilities where routine delivery services currently are taking place would significantly increase physical access. Our results reinforce the need to revise service allocations across administrative regions and consider improving disadvantaged areas in future health service planning.

Using open-source data to construct 20 metre resolution maps of children's travel time to the nearest health facility

Physical access to health facilities is an important factor in determining treatment seeking behaviour and has implications for targets within the Sustainable Development Goals, including the right to health. The increased availability of high-resolution land cover and road data from satellite imagery offers opportunities for fine-grained estimations of physical access which can support delivery planning through the provision of more realistic estimates of travel times. The data presented here is of travel time to health facilities in Uganda, Zimbabwe, Tanzania, and Mozambique. Travel times have been calculated for different facility types in each country such as Dispensaries, Health Centres, Clinics and Hospitals. Cost allocation surfaces and travel times are provided for child walking speeds but can be altered easily to account for adult walking speeds and motorised transport. With a focus on Uganda, we describe the data and method and provide the travel maps, software and intermediate datasets for Uganda, Tanzania, Zimbabwe and Mozambique.

Measurement(s)	Walking travel time • Walking travel friction
Technology Type(s)	Cost surface of travel speeds andhealth centre locations as destination points • land cover, digital elevation and road data to estimate the effort or friction of travel
Sample Characteristic - Location	Uganda • Mozambique • Tanzania • Zimbabwe

Classification of Public Health Centres in Accra through a Web-Based Portal Integrated with Geographical Information System (GIS)

A health system is described as a logically organized collection of resources, agents, and institutions that offer healthcare to a specific population based on the finance, regulation, and delivery of health services. Many health centres have been established in Accra, the capital city of Ghana, due to the importance of good health. People in other developed nations can seek adequate healthcare, since information about relevant health centres is readily available. However, there is a paucity of information about the services provided by existing health institutions in Ghana, particularly in Accra. The majority of patients commute to either Korle-Bu Teaching Hospital or Greater Accra Regional Hospital, putting a considerable medical strain on these facilities. In this study, we use a Geographic Information System (GIS) to establish a database for all of Accra's health centres and categorize them according to the services they provide. This research tackled the previously mentioned problem by proposing and developing a web-based map called Geohealth for the classification of public health centres in Accra using GIS to assist users in accessing information and locating health centres. We utilized a mixed-method approach consisting of quantitative as well as Build Computer Science Research Methods. Results of our study show that the majority of the participants and stakeholders in our research are eager to embrace Geohealth. Furthermore, in comparison with existing techniques such as Google Maps, our proposed approach, Geohealth, takes less time to obtain information and locate public health centres in Accra, Ghana.

Exploring Equity in Healthcare Services: Spatial Accessibility Changes during Subway Expansion

The unequal allocation of healthcare resources raises many fundamental problems, one of which is how to address inequity in population health. This paper focuses on disparities in public transport healthcare accessibility, with a special focus on an expanding subway system. Based on a vulnerability index, including factors that are likely to limit healthcare opportunities, a two-step floating catchment area method was used to assess the distribution of supply and demand for healthcare. Quantity, quality, and walking distance accessibility were aggregated into hexagonal grids. The Theil index was used to measure inequity and understand the influence of subways on spatial disparities in healthcare accessibility. The ongoing construction of the subway has heterogeneous impacts on healthcare accessibility for different parts of the city and exacerbates spatial inequity in many areas. In an environment where people in peri-urban areas are excluded from healthcare access because of low subway coverage, the results suggest that the potential for subways to address inaccessibility is limited. The findings highlight the requirement of efficient public transport services and are relevant to researchers, planners, and policymakers aiming to improve accessibility to healthcare, especially for populations who dwell in winter cities.

Travel Time to Health Facilities as a Marker of Geographical Accessibility Across Heterogeneous Land Coverage in Peru

To better estimate the travel time to the most proximate health care facility (HCF) and determine differences across heterogeneous land coverage types, this study explored the use of a novel cloud-based geospatial modeling approach. Geospatial data of 145,134 cities and villages and 8,067 HCF were gathered with land coverage types, roads and river networks, and digital elevation data to produce high-resolution (30 m) estimates of travel time to HCFs across Peru. This study estimated important variations in travel time to HCFs between urban and rural settings and major land coverage types in Peru. The median travel time to primary, secondary, and tertiary HCFs was 1.9-, 2.3-, and 2.2-fold higher in rural than urban settings, respectively. This study provides a new methodology to estimate the travel time to HCFs as a tool to enhance the understanding and characterization of the profiles of accessibility to HCFs in low- and middle-income countries.

Maternal education and the multidimensionality of child health outcomes in India

Maternal education plays a central role in children's health, but there has been little research comparing the role of maternal education across health outcomes. It is important to distinguish child health outcomes from medical care outcomes. Health outcomes such as short-term morbidity and stunting are multifactorial in origin and determined by a range of factors not necessarily under a mother's control. Mother's education, given the necessary structural factors such as medical centres, is likely to lead to increased access to, and uptake of, medical services. Using data from the 2004-05 India Human Development Survey, eight separate logistic regressions were carried out on 11,026 women of reproductive age and their last-born child under five years of age. The results showed that maternal education had the strongest association with medical care, immunization (except polio) and iron supplementation for pregnant mothers, moderate association with underweight and weak association with short-term diseases and stunting. In addition, the study investigated whether maternal education impacts child health and medical care outcomes through the intervening roles of empowerment and human, social and cultural capital. These intervening linkages were found to be missing for short-term diseases and stunting, bolstering the argument that the influence of maternal education is limited for these outcomes.

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.

Different patterns in medicinal plant use along an elevational gradient in northern Peruvian Andes

ETHNOPHARMACOLOGICAL RELEVANCE

Through the study of mestizo people that share a common culture in a large geographic region and where traditional knowledge (TK) is still poorly documented, we compared medicinal plant use in the northern Andes of Peru.

AIMS OF THE STUDY

(1) To compare patterns of the distribution of TK for a human group living between two ecoregions: high tropical montane forests vs. low tropical montane forests; (2) to understand the TK at the gender level; and (3) to analyse TK transmission over five generations.

MATERIAL AND METHODS

The study was conducted in two ecoregions, four areas and 12 localities. We gathered information with 600 participants through semi-structured interviews. We worked with 3-7 expert informants per locality using the "walk in the woods" methodology for gathering ethnomedicinal information in the field. We annotated local vernacular names, medicinal indications, and collected the plants in their habitats. Then we interviewed the rest of the participants in their homes. To evaluate significant differences between highlands and lowlands, we use general mixed linear models test and its corresponding post hoc LSD Fisher test of multiple comparisons (p < 0.05) at ecoregion, gender and generation level.

RESULTS

A total of 416 species belonging to 107 plant families and 13,898 use-reports were found in both ecoregions. Overall, significant differences indicated that people in the highlands had higher TK than people in the lowlands for most of the medicinal categories. Women showed higher knowledge on medicinal plants in all medicinal categories and areas in both ecoregions. However, transmission of TK showed different patterns between ecoregions. In the highlands, the TK increased from the youngest to the senior group (51-60 years), with a slight decreasing for those over 60 years, whereas in the lowlands the findings were less clear and generations with highest TK were divergent across localities.

CONCLUSION

TK on medicinal plants is still widely applied in the tropical montane forests of northern Peru. The localities with less prosperous socioeconomic development (highlands) were the areas with higher TK on medicinal plants. Women are mainly the depositories of the traditional medicine. The older generations maintain most of the TK in the highlands, whereas in the lowlands the TK is more widespread across generations. Future conservation programs on medicinal plants should understand who are the generations depositaries of the TK before dedicate any effort.

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.

The rise of medicalization of plants in Brazil: A temporal perspective on vernacular names

ETHNOPHARMACOLOGICAL RELEVANCE

Brazilian plant species used in folk medicine have acquired several popular names related to commercial medicines in recent decades. This fact has directly effect to the medicalization process.

AIM OF THE STUDY

Evaluate the rise of medicalized popular names of medicinal plants in Brazil.

MATERIALS AND METHODS

Medicalized popular names of medicinal plants were recorded from 314 ethnobotanical articles in eleven scientific journals published between 1980 and 2017.

RESULTS

The review included 141 ethnobotanical articles containing medicalized names from 314 articles consulted. The presence of medicalized names in Brazilian ethnobotanical studies has increased significantly since the 2000s. A total of 85 medicalized popular names were recorded according with phonetic and graphical similarity. The most cited medicalized names were Anador, Insulin, Terramycin, Vick, Novalgin and Penicillin. The prevalence of medicalized name citations in ethnobotanical surveys over non-medicalized names for several species indicates the existence of medicalized plant species.

CONCLUSION

Since the 2000s, an increasing number of ethnobotanical studies revealed the appropriation of drug names by folk medicine through the changes of vernacular names of medicinal plants. This medicalization process is mostly related to the expansion of the Brazilian Unified Health System, pharmaceutical industry marketing and Non-Governmental Organizations in the last decades.

[Experiences, benefits and challenges of the use of geoprocessing for the development of primary health careExperiências, benefícios e desafios do uso de geoprocessamento para o desenvolvimento da atenção primária à saúde]

Objective

To review the empirical consequences of the use of geoprocessing in the management of primary health care (PHC) services, in order to disseminate the benefits of this technology and analyze the challenges that must be overcome for its contribution to the development of PHC.

Methods

A systematic review of primary studies published in Spanish, English or Portuguese between 2000 and 2017 was carried out. First, a review of the academic production was carried out by continent and type of objective. In a second stage, the studies that experimented with and evaluated the use of geoprocessing in empirical form were selected. Specific and generic benefits, as well as limitations, were reviewed.

Results

134 articles were identified in the first stage of selection, half of them from the Region of the Americas. Only nine studies met the criteria and were reviewed in the second stage. These studies showed that the use of geoprocessing generates benefits that go beyond the technical benefits, with limitations that can be overcome.

Conclusions

Although the benefits of using geoprocessing have been widely discussed, few studies have evaluated its implementation in PHC empirically. Practical experiences, which could easily be reproduced in different communities, show that its continued use could increase the capacity to respond to the goals of PHC, as well as to the goals of sustainable development.

Applications of Space Technologies to Global Health: Scoping Review

Background

Space technology has an impact on many domains of activity on earth, including in the field of global health. With the recent adoption of the United Nations’ Sustainable Development Goals that highlight the need for strengthening partnerships in different domains, it is useful to better characterize the relationship between space technology and global health.

Objective

The aim of this study was to identify the applications of space technologies to global health, the key stakeholders in the field, as well as gaps and challenges.

Methods

We used a scoping review methodology, including a literature review and the involvement of stakeholders, via a brief self-administered, open-response questionnaire. A distinct search on several search engines was conducted for each of the four key technological domains that were previously identified by the UN Office for Outer Space Affairs’ Expert Group on Space and Global Health (Domain A: remote sensing; Domain B: global navigation satellite systems; Domain C: satellite communication; and Domain D: human space flight). Themes in which space technologies are of benefit to global health were extracted. Key stakeholders, as well as gaps, challenges, and perspectives were identified.

Results

A total of 222 sources were included for Domain A, 82 sources for Domain B, 144 sources for Domain C, and 31 sources for Domain D. A total of 3 questionnaires out of 16 sent were answered. Global navigation satellite systems and geographic information systems are used for the study and forecasting of communicable and noncommunicable diseases; satellite communication and global navigation satellite systems for disaster response; satellite communication for telemedicine and tele-education; and global navigation satellite systems for autonomy improvement, access to health care, as well as for safe and efficient transportation. Various health research and technologies developed for inhabited space flights have been adapted for terrestrial use.

Conclusions

Although numerous examples of space technology applications to global health exist, improved awareness, training, and collaboration of the research community is needed.

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.

How do administrative borders affect accessibility to hospitals? The case of Sweden

An administrative border might hinder the optimal allocation of a given set of resources by restricting the flow of goods, services, and people. In this paper, we address the question: Do administrative borders lead to poor accessibility to public service? In answering the question, we have examined the case of Sweden and its regional administrative borders and hospital accessibility. We have used detailed data on the Swedish road network, its hospitals, and its geo-coded population. We have assessed the population's spatial accessibility to Swedish hospitals by computing the inhabitants' distance to the nearest hospital. We have also elaborated several scenarios ranging from strongly confining regional borders to no confinements of borders and recomputed the accessibility. Our findings imply that administrative borders are only marginally worsening the accessibility.

'Seeking affluent neighbourhoods?' a time-trend analysis of geographical distribution of hospitals in the Megacity of Tehran

OBJECTIVE

Access to hospitals in megacities in low and middle income countries might be hampered by travel barriers and distance. We assessed the 'inverse care law' hypothesis: whether hospitals tended to be built in the relatively better-off areas through the time.

METHODS

A longitudinal time-series study (1966 to 2011) in Tehran to measure inequality in the distribution of hospital beds. We assessed correlations between the district socioeconomic status and availability of hospital beds via regression analyses, estimated correlation, Gini and concentration indices, and used GIS models to map hospital distributions through time.

FINDING

We found a clear relationship between socioeconomic status and number of hospital beds per capita ( P -values <0.05). Gini coefficients were about 0.6 and 0.8 for public and private beds, respectively. A third of the variations in hospital bed distribution was explained by the welfare status of the district. For every extra residential room per capita, 130 to 280 extra beds were observed per ten thousand population at the district level. In 2011, out of 162 hospitals, 110 were located in six districts around the centre and northern part of the city. During the time period only two private hospitals were built in relatively disadvantaged districts.

CONCLUSION

Over a period of about fifty years new hospitals had been established in the relatively affluent areas of the city and the relationship between socioeconomic status of district with total, private and public beds were direct and intensive. Results indicate the problem of inequality may remain over time and be resistant to policy initiatives and major political changes.

Treating infants with frigg: linking disease aetiologies, medicinal plant use and care-seeking behaviour in southern Morocco

BACKGROUND

Although most Moroccans rely to some extent on traditional medicine, the practice of frigg to treat paediatric ailments by elderly women traditional healers known as ferraggat, has not yet been documented. We describe the role of these specialist healers, document the medicinal plants they use, and evaluate how and why their practice is changing.

METHODS

Ethnomedicinal and ethnobotanical data were collected using semi-structured interviews and observations of medical encounters. Information was collected from traditional healers, namely ferraggat, patients, herbalists and public health professionals. Patients' and healers' narratives about traditional medicine were analysed and medicinal plant lists were compiled from healers and herbalists. Plants used were collected, vouchered and deposited in herbaria.

RESULTS

Ferragat remain a key health resource to treat infant ailments in the rural High Atlas, because mothers believe only they can treat what are perceived to be illnesses with a supernatural cause. Ferragat possess baraka, or the gift of healing, and treat mainly three folk ailments, taqait, taumist and iqdi, which present symptoms similar to those of ear infections, tonsillitis and gastroenteritis. Seventy plant species were used to treat these ailments, but the emphasis on plants may be a recent substitute for treatments that used primarily wool and blood. This change in materia medica is a shift in the objects of cultural meaningfulness in response to the increasing influence of orthodox Islam and state-sponsored modernisation, including public healthcare and schooling.

CONCLUSIONS

Religious and other sociocultural changes are impacting the ways in which ferraggat practice. Treatments based on no-longer accepted symbolic elements have been readily abandoned and substituted by licit remedies, namely medicinal plants, which play a legitimisation role for the practice of frigg. However, beliefs in supernatural ailment aetiologies, as well as lack or difficult access to biomedical alternatives, still underlie the need for specialist traditional healers.

Role of acceptability barriers in delayed diagnosis of Tuberculosis: Literature review from high burden countries

PURPOSE

Direct transmission of mutated tuberculosis (TB) strains is among major contributors to the worldwide epidemic of Drug-Resistant Tuberculosis. Expanding access to TB-services and decreasing diagnostic delays are acknowledged as potential solutions. We aimed to summarize evidence about links between health care acceptability barriers and TB diagnostic delays. Scoping and systematic review approaches were combined to determine the depth/breadth of the literature, identify gaps, and synthesize findings.

METHODS

Electronic data-bases, key journals, other relevant electronic sources, and references of relevant articles were selected as potential sources through a preliminary search and expertś advice. Titles and abstracts of 4046 initial records and 1796 references were screened against preliminarily developed and post-hoc inclusion/exclusion criteria. Author, year of publication, study location, study aims, overview of methods, study population, intervention type, outcomes measures and results of each included paper were extracted. Methodological quality of studies was assessed. Narrative synthesis of the study results was conducted through the thematic analysis approach.

RESULTS

Patients' negative expectations, doubts about quality of services/medications and burden of stigma, as well as providers' discriminative attitudes towards patients' characteristics (age, gender, ethnicity) were reported as major barriers. Scarcity and unequal distribution of the literature and lack of attention to all potential acceptability barriers were found as major gaps in the current research.

CONCLUSION

Overall, study findings indicate the significance of acceptability barriers' role in TB diagnostic delays. Emerging character of the field is demonstrated. Recommendations about further research directions are outlined.

Primary Healthcare Workers' Perceptions about Barriers to Health Services in Zambia

In Zambia, health policy reforms have recently focused upon decentralization of care with an emphasis upon community-based services. The perspective of primary healthcare workers (PHCWs), who provide these services, may offer valuable insight into this changing health system. To explore the perspective of PHCWs in Zambia, we conducted a written survey of 80 PHCWs. Several barriers to care, many surrounding issues of access to care, were consistently and independently reported by the PHCWs surveyed.

Shifting care into the community will only be beneficial if primary care clinics can offer a reasonable minimal standard of care. From the perspective of healthcare workers on the frontline of primary care delivery in Zambia, expanded training of providers and an increased number of providers is needed. Improving access to drugs and supplies is also necessary. User fees that might increase financial resources for the healthcare system may also deter needed care among vulnerable patient populations.

Hospital survival upon discharge of ill-neonates transported by ground or air ambulance to a tertiary center

OBJECTIVE

To evaluate the differences in hospital survival between modes of transport to a tertiary center in Colombia for critically ill neonates.

METHODS

Observational study of seriously ill neonates transported via air or ground, who required medical care at a center providing highly complex services. Data on sociodemographic, clinical, the Transport Risk Index of Physiologic Stability (TRIPS), and mode of transport were collected. Patients were described, followed by a bivariate analysis with condition (live or dead) at time of discharge as the dependent variable. A multiple Poisson regression with robust variance model was used to adjust associations.

RESULTS

A total of 176 neonates were transported by ambulance (10.22% by air) over six months. The transport distances were longer by air (median: 237.5km) than by ground (median: 11.3km). Mortality was higher among neonates transported by air (33.33%) than by ground (7.79%). No differences in survival were found between the two groups when adjusted by the multiple model. An interaction between mode of transport and distance was observed. Live hospital discharge was found to be associated with clinical severity upon admittance, birth weight, hemorrhaging during the third trimester, and serum potassium levels when admitted.

CONCLUSIONS

Mode of transport was not associated with the outcome. In Colombia, access to medical services through air transport is a good option for neonates in critical condition. Further studies would determine the optimum distance (time of transportation) to obtain good clinical outcomes according type of ambulance.

Defining Remoteness from Health Care: Integrated Research on Accessing Emergency Maternal Care in Indonesia

The causes of maternal death are well known, and are largely preventable if skilled health care is received promptly. Complex interactions between geographic and socio-cultural factors affect access to, and remoteness from, health care but research on this topic rarely integrates spatial and social sciences. In this study, modeling of travel time was integrated with social science research to refine our understanding of remoteness from health care. Travel time to health facilities offering emergency obstetric care (EmOC) and population distribution were modelled for a district in eastern Indonesia. As an index of remoteness, the proportion of the population more than two hours estimated travel time from EmOC was calculated. For the best case scenario (transport by ambulance in the dry season), modelling estimated more than 10,000 fertile aged women were more than two hours from EmOC. Maternal mortality ratios were positively correlated with the remoteness index, however there was considerable variation around this relationship. In a companion study, ethnographic research in a subdistrict with relatively good access to health care and high maternal mortality identified factors influencing access to EmOC, including some that had not been incorporated into the travel time model. Ethnographic research provided information about actual travel involved in requesting and reaching EmOC. Modeled travel time could be improved by incorporating time to deliver request for care. Further integration of social and spatial methods and the development of more dynamic travel time models are needed to develop programs and policies to address these multiple factors to improve maternal health outcomes.

Primary health care research in Bolivia: systematic review and analysis

Bolivia is currently undergoing a series of healthcare reforms centred around the Unified Family, Community and Intercultural Health System (SAFCI), established in 2008 and Law 475 for Provision of Comprehensive Health Services enacted in 2014 as a first step towards universal health coverage. The SAFCI model aims to establish an intercultural, intersectoral and integrated primary health care (PHC) system, but there has not been a comprehensive analysis of effective strategies towards such an end. In this systematic review, we analyse research into developing PHC in Bolivia utilizing MEDLINE, the Virtual Health Library and grey literature from Pan American Health Organization/World Health Organization's internal database. We find that although progress has been made towards implementation of a healthcare system incorporating principles of PHC, further refining the system and targeting improvements effectively will require increased research and evaluation. Particularly in the 7 years since establishment of SAFCI, there has been a dearth of PHC research that makes evaluation of such key national policies impossible. The quantity and quality of PHC research must be improved, especially quasi-experimental studies with adequate control groups. The infrastructure for such studies must be strengthened through improved financing mechanisms, expanded institutional capacity and setting national research priorities. Important for future progress are improved tracking of health indicators, which in Bolivia are often out-of-date or incomplete, and prioritization of focused national research priorities on relevant policy issues. This study aims to serve as an aid towards PHC development efforts at the national level, as well as provide lessons for countries globally attempting to build effective health systems accommodating of a multi-national population in the midst of development.

Spatial analysis of the home addresses of hospital patients with hepatitis B infection or hepatoma in Shenzhen, China from 2010 to 2012

Background: Hepatoma associated with hepatitis B infection is a major public health problem in Shenzhen (China) and worldwide. China has the largest number of people infected with the hepatitis B virus (HBV), and many studies have demonstrated that HBV infection is associated with hepatoma development. Shenzhen officials have been attempting to monitor and control these diseases for many years. The methodology and the results of this study may be useful in developing a system to monitor, prevent and control these diseases. Methods: The aim of the study was to analyze HBV infection and hepatoma distribution characteristics and patterns in Shenzhen by combining geographic information system (GIS) technology and spatial analysis. The study used data from patients at the district level from the 2010–2012 population censuses. Results: Only one-third of the patients were female, and 70.7% of all cases were 20–50 years of age. There was no global spatial correlation of the distribution of hepatitis B infections and hepatomas; however, there was a local spatial correlation, and certain sub-districts of the Nanshan district had significant agglomeration effects. Based on incidence density and rate maps, we can conclude that the Shenzhen special zone had a higher incidence density and rate of hepatitis B infections and hepatomas compared with the area outside of the Shenzhen special zone during 2010–2012. Conclusions: This study demonstrated substantial geographic variation in the incidence of hepatitis B infection and hepatoma in Shenzhen. The prediction and control of hepatitis B infections and hepatoma development and interventions for these diseases should focus on disadvantaged areas to reduce disparities. GIS and spatial analysis play an important role in public health risk-reduction programs and may become integral components in the epidemiologic description, analysis and risk assessment of hepatitis B and hepatoma.

A geographical perspective on access to sexual and reproductive health care for women in rural Africa

Utilization of sexual and reproductive health (SRH) services can significantly impact health outcomes, such as pregnancy and birth, prenatal and neonatal mortality, maternal morbidity and mortality, and vertical transmission of infectious diseases like HIV/AIDS. It has long been recognized that access to SRH services is essential to positive health outcomes, especially in rural areas of developing countries, where long distances as well as poor transportation conditions, can be potential barriers to health care acquisition. Improving accessibility of health services for target populations is therefore critical for specialized healthcare programs. Thus, understanding and evaluation of current access to health care is crucial. Combining spatial information using geographical information system (GIS) with population survey data, this study details a gravity model-based method to measure and evaluate access to SRH services in rural Mozambique, and analyzes potential geographic access to such services, using family planning as an example. Access is found to be a significant factor in reported behavior, superior to traditional distance-based indicators. Spatial disparities in geographic access among different population groups also appear to exist, likely affecting overall program success.

A geographic analysis of access to health services in rural Guatemala

This paper uses road network analysis to quantify access to health care services in Alta Verapaz, a rural district in Guatemala with a majority Mayan population. Population data from the 2002 Guatemalan census, the location of health care facilities from the Ministry of Public Health and Social Assistance, and road and trail locations from the National Geographic Institute were included in a geographic information system (GIS). We computed the shortest path from each populated place to the nearest health care facility and then estimated the approximate travel time to the health facility based on road surface type. Road network analysis found that approximately 38.1% of residents of Alta Verapaz live within one hour of a hospital and 76.8% live within one hour of a basic care facility. In comparison, a circular buffer method found that 27.5% had access to a hospital and 94.5% had access to a primary care facility. Poverty was correlated with reduced access to care. The use of models that adjust for road types and allow for accurate estimation of travel times are helpful tools to identifying populations with limited access to health care services.

Horizontal equity and efficiency at primary health care facilities in rural Afghanistan: a seemingly unrelated regression approach

Producing services efficiently and equitably are important goals for health systems. Many countries pursue horizontal equity - providing people with the same illnesses equal access to health services - by locating facilities in remote areas. Staff are often paid incentives to work at such facilities. However, there is little evidence on how many fewer people are treated at remote facilities than facilities in more densely settled areas. This research explores if there is an association between the efficiency of health centers in Afghanistan and the remoteness of their location. Survey teams collected data on facility level inputs and outputs at a stratified random sample of 579 health centers in 2005. Quality of care was measured by observing staff interact with patients and determining if staff completed a set of normative patient care tasks. We used seemingly unrelated regression to determine if facilities in remote areas have fewer outpatient visits than other rural facilities. In this analysis, one equation compares the number of outpatient visits to facility inputs, while another compares quality of care to determinants of quality. The results indicate remote facilities have about 13% fewer outpatient visits than non-remote facilities, holding inputs constant. Our analysis suggests that facilities in remote areas are realizing horizontal equity since their clients are receiving comparable quality of care to those at non-remote facilities. However, we find the average labor cost for a visit at a remote facility is $1.44, but only $0.97 at other rural facilities, indicating that a visit in a remote facility would have to be 'worth' 1.49 times a visit at a rural facility for there to be no equity - efficiency trade-off. In determining where to build or staff health centers, this loss of efficiency may be offset by progress toward a social policy objective of providing services to disadvantaged rural populations.

Assessing dementia in resource-poor regions

The numbers and proportions of elderly are increasing rapidly in developing countries, where prevalence of dementia is often high. Providing cost-effective services for dementia sufferers and their caregivers in these resource-poor regions poses numerous challenges; developing resources for diagnosis must be the first step. Capacity building for diagnosis involves training and education of healthcare providers, as well as the general public, development of infrastructure, and resolution of economic and ethical issues. Recent progress in some low-to-middle-income countries (LMICs) provides evidence that partnerships between wealthy and resource-poor countries, and between developing countries, can improve diagnostic capabilities. Without the involvement of the mental health community of developed countries in such capacity-building programs, dementia in the developing world is a disaster waiting to happen.

Planning toward Equal Accessibility to Services: A Quadratic Programming Approach

In the literature various accessibility indices have been developed to assess the relative ease by which the locations of services (supply) can be reached from a residential (demand) location. In this paper we address the planning problem: how the resources can be redistributed to achieve the highest equality of accessibility to the service providers. In particular, a quadratic programming approach is used to minimize the variance of accessibility scores across demand locations by readjusting the amounts of service supplies. Two case studies—job access in Columbus, OH and primary healthcare access in Chicago, IL—are used to illustrate the method. The result suggests that in order to achieve better equality of accessibility, peripheral areas, in general, need additional supplies to compensate for their less-central locations, and some central city areas also need to add supplies to accommodate high demands by the high population density there.

Geographical access to care at birth in Ghana: a barrier to safe motherhood

BACKGROUND

Appropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning. In this study, we develop a uniquely detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana, a high-burden country typical of many in sub-Saharan Africa.

METHODS

We assembled detailed spatial data on the population, health facilities, and landscape features influencing journeys. These were used in a geospatial model to estimate journey-time for all women of childbearing age (WoCBA) to their nearest health facility offering differing levels of care at birth, taking into account different transport types and availability. We calibrated the model using data on actual journeys made by women seeking care.

RESULTS

We found that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the 'partial' standard or better. Nearly half (45%) live that distance or further from 'comprehensive' EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. Poor levels of access were found in many regions that meet international targets based on facilities-per-capita ratios.

CONCLUSIONS

Detailed data assembly combined with geospatial modelling can provide nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes because they fail to take account of the location and accessibility of services relative to the women they serve.

People, plants and health: a conceptual framework for assessing changes in medicinal plant consumption

BACKGROUND

A large number of people in both developing and developed countries rely on medicinal plant products to maintain their health or treat illnesses. Available evidence suggests that medicinal plant consumption will remain stable or increase in the short to medium term. Knowledge on what factors determine medicinal plant consumption is, however, scattered across many disciplines, impeding, for example, systematic consideration of plant-based traditional medicine in national health care systems. The aim of the paper is to develop a conceptual framework for understanding medicinal plant consumption dynamics. Consumption is employed in the economic sense: use of medicinal plants by consumers or in the production of other goods.

METHODS

PubMed and Web of Knowledge (formerly Web of Science) were searched using a set of medicinal plant key terms (folk/peasant/rural/traditional/ethno/indigenous/CAM/herbal/botanical/phytotherapy); each search terms was combined with terms related to medicinal plant consumption dynamics (medicinal plants/health care/preference/trade/treatment seeking behavior/domestication/sustainability/conservation/urban/migration/climate change/policy/production systems). To eliminate studies not directly focused on medicinal plant consumption, searches were limited by a number of terms (chemistry/clinical/in vitro/antibacterial/dose/molecular/trial/efficacy/antimicrobial/alkaloid/bioactive/inhibit/antibody/purification/antioxidant/DNA/rat/aqueous). A total of 1940 references were identified; manual screening for relevance reduced this to 645 relevant documents. As the conceptual framework emerged inductively, additional targeted literature searches were undertaken on specific factors and link, bringing the final number of references to 737.

RESULTS

The paper first defines the four main groups of medicinal plant users (1. Hunter-gatherers, 2. Farmers and pastoralists, 3. Urban and peri-urban people, 4. Entrepreneurs) and the three main types of benefits (consumer, producer, society-wide) derived from medicinal plants usage. Then a single unified conceptual framework for understanding the factors influencing medicinal plant consumption in the economic sense is proposed; the framework distinguishes four spatial levels of analysis (international, national, local, household) and identifies and describes 15 factors and their relationships.

CONCLUSIONS

The framework provides a basis for increasing our conceptual understanding of medicinal plant consumption dynamics, allows a positioning of existing studies, and can serve to guide future research in the area. This would inform the formation of future health and natural resource management policies.

Care of dogs and attitudes of dog owners in Port-au-Prince, the Republic of Haiti

This article reports the first known study on dogs in Port-au-Prince. Interviews with 1,290 residents provided information on 1,804 dogs. More than 57.7% of homes kept dogs. Not all the dogs received vaccinations for rabies (41.6%), even though 28.2% of households had had a household member bitten by a dog. Although the "owned" dog population had decreased as a result of the earthquake in January 2010, the number of roaming dogs appeared to have been uninfluenced by the disaster. Given that 64.8% of dogs probably had access to the street and only 6.0% of the females were spayed, to humanely contain the dog population will require both confinement and neutering. Although roaming dogs were considered a nuisance by 63.3% of respondents, 42.6% of households fed dogs they did not own.

Variables associated with utilization of a centralized medical post in the Andean community of Pampas Grande, Peru

CONTEXT

Integral to the location of health resources is the distance decay of utilization observed in a population. In rural Peru, a nongovernmental organization planning to increase the availability of health services needed this information.

PURPOSE

To determine variables associated with utilization of a central medical clinic and determine whether, because of the mountainous topography, travel time (TT) would be a better predictor of utilization than distance.

METHODS

A door-to-door survey of all available households (81% of total), using a Spanish translation of questions excerpted from the Behavioral Risk Factor Surveillance System Survey, was conducted in the summer of 2008 to determine variables associated with self-reported history of clinic utilization.

RESULTS

Utilization was inversely related to TT and distance. Of those living within 5 minutes of the clinic, 61% had been to the clinic whereas only 25% of those living 30 or more minutes away had sought care. Female gender and fever predicted increased odds of clinic utilization. Having a disability reduced one's odds (OR 0.55) of visiting the clinic, after adjusting for gender, TT, and fever. The inverse correlation of utilization with travel distance and TT was not significantly different, thus failing to demonstrate that TT is a better predictor of utilization than distance.

CONCLUSION

In health service planning, care for common conditions should be available within 5 minutes' TT or a few kilometers' distance from each person's home in order to improve health care access and reduce health care disparities worsened by disability.

Measurement, Optimization, and Impact of Health Care Accessibility: A Methodological Review

Despite spending more than any other nation on medical care per person, the United States ranks behind other industrialized nations in key health performance measures. A main cause is the deep disparities in access to care and health outcomes. Federal programs such as the designations of Medically Underserved Areas/Populations and Health Professional Shortage Areas are designed to boost the number of health professionals serving these areas and to help alleviate the access problem. Their effectiveness relies first and foremost on an accurate measure of accessibility so that resources can be allocated to truly needy areas. Various measures of accessibility need to be integrated into one framework for comparison and evaluation. Optimization methods can be used to improve the distribution and supply of health care providers to maximize service coverage, minimize travel needs of patients, limit the number of facilities, and maximize health or access equality. Inequality in health care access comes at a personal and societal price, evidenced in disparities in health outcomes, including late-stage cancer diagnosis. This review surveys recent literature on the three named issues with emphasis on methodological advancements and implications for public policy.

The assessment of dermatological needs in resource-poor regions

The assessment of health needs is a key step in determining the nature and level of health service provision required in any global region. In dermatology, information on needs has provided information on the scale and impact of skin conditions in poor rural and urban populations. In such areas, additional problems in providing adequate services are access to trained health care professionals and cost to families and individuals, set against the background of a village-mixed economy. A further problem is health literacy, which may limit the use of services. However, some of the most comprehensive surveys of the prevalence of skin disease have been carried out in resource-poor countries, and attempts have been made to assess these along with their impact on individual disability. These studies and their outcomes are described in this article.

Quantitative measurements of inequality in geographic accessibility to pediatric care in Oita Prefecture, Japan: standardization with complete spatial randomness

BACKGROUND

A quantitative measurement of inequality in geographic accessibility to pediatric care as well as that of mean distance or travel time is very important for priority setting to ensure fair access to pediatric facilities. However, conventional techniques for measuring inequality is inappropriate in geographic settings. Since inequality measures of access distance or travel time is strongly influenced by the background geographic distribution patterns, they cannot be directly used for regional comparisons of geographic accessibility. The objective of this study is to resolve this issue by using a standardization approach.

METHODS

Travel times to the nearest pediatric care were calculated for all children in Oita Prefecture, Japan. Relative mean differences were considered as the inequality measure for secondary medical service areas, and were standardized with an expected value estimated from a Monte Carlo simulation based on complete spatial randomness.

RESULTS

The observed mean travel times in the area considered averaged 4.50 minutes, ranging from 1.83 to 7.02 minutes. The mean of the observed inequality measure was 1.1, ranging from 0.9 to 1.3. The expected values of the inequality measure varied according to the background geographic distribution pattern of children, which ranged from 0.3 to 0.7. After standardizing the observed inequality measure with the expected one, we found that the ranks of the inequality measure were reversed for the observed areas.

CONCLUSIONS

Using the indicator proposed in this paper, it is possible to compare the inequality in geographic accessibility among regions. Such a comparison may facilitate priority setting in health policy and planning.

Social factors affecting ART adherence in rural settings in Zambia

The purpose of this study was to assess the factors that influence ART adherence arising in rural settings in Zambia. A survey was conducted with face-to-face interviews using a semi-structured questionnaire and written informed consent was obtained at ART sites in Mumbwa District in rural Zambia. The questionnaire included items such as the socio-demographic characteristics of respondents, support for adherence, ways to remember when to take ARVs at scheduled times, and the current status of adherence. Valid responses were obtained from 518 research participants. The mean age of the respondents was 38.3 years and the average treatment period was 12.5 months. More than half of the respondents (51%) were farmers, about half (49%) did not own a watch, and 10% of them used the position of the sun to remember when to take ARVs. Sixteen percent of respondents experienced fear of stigma resulting from taking ARVs at work or home, and 10% felt pressured to share ARVs with someone. Eighty-eight percent of the participants reported that they had never missed ARVs in the past four days. Multivariable logistic regression analysis identified age (38 years old or less, odds ratio (OR) = 2.5, 95% confidence interval (CI): 1.3–4.8, p = 0.005), “remembering when to take ARVs based on the position of the sun” (OR = 3.3, 95% CI: 1.3–8.8, p = 0.016), and “feeling pressured to share ARVs with someone” (OR = 4.4, 95% CI: 1.6–12.0, p = 0.004) as independent factors for low adherence. As ART services expand to rural areas, program implementers should pay more attention to more specific factors arising in rural settings since they may differ from those in urban settings.

Free and simple GIS as appropriate for health mapping in a low resource setting: a case study in eastern Indonesia

BACKGROUND

Despite the demonstrated utility of GIS for health applications, there are perceived problems in low resource settings: GIS software can be expensive and complex; input data are often of low quality. This study aimed to test the appropriateness of new, inexpensive and simple GIS tools in poorly resourced areas of a developing country. GIS applications were trialled in pilot studies based on mapping of health resources and health indicators at the clinic and district level in the predominantly rural province of Nusa Tenggara Timur in eastern Indonesia. The pilot applications were (i) rapid field collection of health infrastructure data using a GPS enabled PDA, (ii) mapping health indicator data using open source GIS software, and (iii) service availability mapping using a free modelling tool.

RESULTS

Through contextualised training, district and clinic staff acquired skills in spatial analysis and visualisation and, six months after the pilot studies, they were using these skills for advocacy in the planning process, to inform the allocation of some health resources, and to evaluate some public health initiatives.

CONCLUSIONS

We demonstrated that GIS can be a useful and inexpensive tool for the decentralisation of health data analysis to low resource settings through the use of free and simple software, locally relevant training materials and by providing data collection tools to ensure data reliability.

Physical accessibility and utilization of health services in Yemen

Background

Assessment of physical access to health services is extremely important for planning. Complex methods that incorporate data inputs from road networks and transport systems are used to assess physical access to healthcare in industrialised countries. However, such data inputs hardly exist in many developing countries. Straight-line distances between the service provider and resident population are easily obtained but their relationship with driving distance and travel time is unclear. This study aimed to investigate the relationship between different measures of physical access, including straight-line distances, road distances and travel time and the impact of these measures on the vaccination of children in Yemen.

Methods

Coordinates of houses and health facilities were determined by GPS machine in Urban and rural areas in Taiz province, Yemen. Road distances were measured by an odometer of a vehicle driven from participants' houses to the nearest health centre. Driving time was measured using a stop-watch. Data on children's vaccination were collected by personal interview and verified by inspecting vaccination cards.

Results

There was a strong correlation between straight-line distances, driving distances and driving time (straight line distances vs. driving distance r = 0.92, p < 0.001, straight line distances vs. driving time r = 0.75; p < 0.001, driving distance vs. driving time r = 0.83, p < 0.001). Each measure of physical accessibility showed strong association with vaccination of children after adjusting for socio-economic status.

Conclusion

Straight-line distances, driving distances and driving time are strongly linked and associated with vaccination uptake. Straight-line distances can be used to assess physical access to health services where data inputs on road networks and transport are lacking. Impact of physical access is clear in Yemen, highlighting the need for efforts to target vaccination and other preventive healthcare measures to children who live away from health facilities.

Geographic access to care is not a determinant of child mortality in a rural Kenyan setting with high health facility density

BACKGROUND

Policy-makers evaluating country progress towards the Millennium Development Goals also examine trends in health inequities. Distance to health facilities is a known determinant of health care utilization and may drive inequalities in health outcomes; we aimed to investigate its effects on childhood mortality.

METHODS

The Epidemiological and Demographic Surveillance System in Kilifi District, Kenya, collects data on vital events and migrations in a population of 220,000 people. We used Geographic Information Systems to estimate pedestrian and vehicular travel times to hospitals and vaccine clinics and developed proportional-hazards models to evaluate the effects of travel time on mortality hazard in children less than 5 years of age, accounting for sex, ethnic group, maternal education, migrant status, rainfall and calendar time.

RESULTS

In 2004-6, under-5 and under-1 mortality ratios were 65 and 46 per 1,000 live-births, respectively. Median pedestrian and vehicular travel times to hospital were 193 min (inter-quartile range: 125-267) and 49 min (32-72); analogous values for vaccine clinics were 47 (25-73) and 26 min (13-40). Infant and under-5 mortality varied two-fold across geographic locations, ranging from 34.5 to 61.9 per 1000 child-years and 8.8 to 18.1 per 1000, respectively. However, distance to health facilities was not associated with mortality. Hazard Ratios (HR) were 0.99 (95% CI 0.95-1.04) per hour and 1.01 (95% CI 0.95-1.08) per half-hour of pedestrian and vehicular travel to hospital, respectively, and 1.00 (95% CI 0.99-1.04) and 0.97 (95% CI 0.92-1.05) per quarter-hour of pedestrian and vehicular travel to vaccine clinics in children <5 years of age.

CONCLUSIONS

Significant spatial variations in mortality were observed across the area, but were not correlated with distance to health facilities. We conclude that given the present density of health facilities in Kenya, geographic access to curative services does not influence population-level mortality.