Impact of interpreter services on delivery of health care to limited-English-proficient patients

OBJECTIVE

To determine whether professional interpreter services increase the delivery of health care to limited-English-proficient patients.

DESIGN

Two-year retrospective cohort study during which professional interpreter services for Portuguese and Spanish-speaking patients were instituted between years one and two. Preventive and clinical service information was extracted from computerized medical records.

SETTING

A large HMO in New England.

PARTICIPANTS

A total of 4,380 adults continuously enrolled in a staff model health maintenance organization for the two years of the study, who either used the comprehensive interpreter services (interpreter service group [ISG]; N = 327) or were randomly selected into a 10% comparison group of all other eligible adults (comparison group [CG]; N = 4,053).

MEASUREMENTS AND MAIN RESULTS

The measures were change in receipt of clinical services and preventive service use. Clinical service use and receipt of preventive services increased in both groups from year one to year two. Clinical service use increased significantly in the ISG compared to the CG for office visits (1.80 vs. 0.70; P <.01), prescriptions written (1.76 vs 0.53; P <.01), and prescriptions filled (2.33 vs. 0.86; P<.01). Rectal examinations increased significantly more in the ISG compared to the CG (0.26 vs. 0.02; P =.05) and disparities in rates of fecal occult blood testing, rectal exams, and flu immunization between Portuguese and Spanish-speaking patients and a comparison group were significantly reduced after the implementation of professional interpreter services.

CONCLUSION

Professional interpreter services can increase delivery of health care to limited-English-speaking patients.

Barriers to Access to Palliative Care

Despite significant advances in understanding the benefits of early integration of palliative care with disease management, many people living with a chronic life-threatening illness either do not receive any palliative care service or receive services only in the last phase of their illness. In this article, I explore some of the reasons for failure to provide palliative care services and recommend some strategies to overcome these barriers, emphasizing the importance of describing palliative care accurately. I provide language which I hope will help health care professionals of all disciplines explain what palliative care has to offer and ensure wider access to palliative care, early in the course of their illness.

Evaluation of the 'healthy start to pregnancy' early antenatal health promotion workshop: a randomized controlled trial

BACKGROUND

Pregnancy is an ideal time to encourage healthy lifestyles as most women access health services and are more receptive to health messages; however few effective interventions exist. The aim of this research was to deliver a low-intensity, dietitian-led behavior change workshop at a Maternity Hospital to influence behaviors with demonstrated health outcomes.

METHODS

Workshop effectiveness was evaluated using an RCT; 'usual care' women (n = 182) received a nutrition resource at their first antenatal visit and 'intervention' women also attended a one-hour 'Healthy Start to Pregnancy' workshop (n = 178). Dietary intake, physical activity levels, gestational weight gain knowledge, smoking cessation, and intention to breastfeed were assessed at service-entry and 12 weeks later. Intention-to-treat (ITT) and per-protocol (PP) analyses examined change over time between groups.

RESULTS

Approximately half (48.3%) the intervention women attended the workshop and overall response rate at time 2 was 67.2%. Significantly more women in the intervention met pregnancy fruit guidelines at time 2 (+4.3%, p = 0.011) and had a clinically-relevant increase in physical activity (+27 minutes/week) compared with women who only received the resource (ITT). Women who attended the workshop increased their consumption of serves of fruit (+0.4 serves/day, p = 0.004), vegetables (+0.4 serves/day, p = 0.006), met fruit guidelines (+11.9%, p < 0.001), had a higher diet quality score (p = 0.027) and clinically-relevant increases in physical activity (+21.3 minutes/week) compared with those who only received the resource (PP).

CONCLUSIONS

The Healthy Start to Pregnancy workshop attendance facilitates improvements in important health behaviors. Service changes and accessibility issues are required to assist women's workshop attendance to allow more women to benefit from the workshop's effects.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611000867998.

Factors contributing to delayed diagnosis of cancer among Aboriginal people in Australia: a qualitative study

BACKGROUND/OBJECTIVES

Delayed presentation of symptomatic cancer is associated with poorer survival. Aboriginal patients with cancer have higher rates of distant metastases at diagnosis compared with non-Aboriginal Australians. This paper examined factors contributing to delayed diagnosis of cancer among Aboriginal Australians from patient and service providers' perspectives.

METHODS

In-depth, open-ended interviews were conducted in two stages (2006-2007 and 2011). Inductive thematic analysis was assisted by use of NVivo looking around delays in presentation, diagnosis and referral for cancer.

PARTICIPANTS

Aboriginal patients with cancer/family members (n=30) and health service providers (n=62) were recruited from metropolitan Perth and six rural/remote regions of Western Australia.

RESULTS

Three broad themes of factors were identified: (1) Contextual factors such as intergenerational impact of colonisation and racism and socioeconomic deprivation have negatively impacted on Aboriginal Australians' trust of the healthcare professionals; (2) health service-related factors included low accessibility to health services, long waiting periods, inadequate numbers of Aboriginal professionals and high staff turnover; (3) patient appraisal of symptoms and decision-making, fear of cancer and denial of symptoms were key reasons patients procrastinated in seeking help. Elements of shame, embarrassment, shyness of seeing the doctor, psychological 'fear of the whole health system', attachment to the land and 'fear of leaving home' for cancer treatment in metropolitan cities were other deterrents for Aboriginal people. Manifestation of masculinity and the belief that 'health is women's domain' emerged as a reason why Aboriginal men were reluctant to receive health checks.

CONCLUSIONS

Solutions to improved Aboriginal cancer outcomes include focusing on the primary care sector encouraging general practitioners to be proactive to suspicion of symptoms with appropriate investigations to facilitate earlier diagnosis and the need to improve Aboriginal health literacy regarding cancer. Access to health services remains a critical problem affecting timely diagnosis.

A realist synthesis of the effect of social accountability interventions on health service providers' and policymakers' responsiveness

BACKGROUND

Accountability has center stage in the current post-Millennium Development Goals (MDG) debate. One of the effective strategies for building equitable health systems and providing quality health services is the strengthening of citizen-driven or social accountability processes. The monitoring of actions and decisions of policymakers and providers by citizens is regarded as a right in itself but also as an alternative to weak administrative accountability mechanisms, in particular in settings with poor governance. The effects of social accountability interventions are often based on assumptions and are difficult to evaluate because of their complex nature and context sensitivity. This study aims to review and assess the available evidence for the effect of social accountability interventions on policymakers' and providers' responsiveness in countries with medium to low levels of governance capacity and quality. For policymakers and practitioners engaged in health system strengthening, social accountability initiatives and rights-based approaches to health, the findings of this review may help when reflecting on the assumptions and theories of change behind their policies and interventions.

METHODS/DESIGN

Little is known about social accountability interventions, their outcomes and the circumstances under which they produce outcomes for particular groups or issues. In this study, social accountability interventions are conceptualized as complex social interventions for which a realist synthesis is considered the most appropriate method of systematic review. The synthesis is based on a preliminary program theory of social accountability that will be tested through an iterative process of primary study searches, data extraction, analysis and synthesis. Published and non-published (grey) quantitative and qualitative studies in English, French and Spanish will be included. Quality and validity will be enhanced by continuous peer review and team reflection among the reviewers.

DISCUSSION

The authors believe the advantages of a realist synthesis for social accountability lie in the possibility of overcoming disciplinary or paradigmatic boundaries often found in public health and development. In addition, they argue that this approach fills the knowledge gap left by conventional synthesis or evaluation exercises of participatory programs. Finally, the authors describe the practical strategies adopted to address methodological challenges and validity.

Trial for Reducing Weight Retention in New Mums: a randomised controlled trial evaluating a low intensity, postpartum weight management programme

BACKGROUND

Failure to return to pregnancy weight by 6 months postpartum is associated with long-term obesity, as well as adverse health outcomes. This research evaluated a postpartum weight management programme for women with a body mass index (BMI) > 25 kg m(-2) that combined behaviour change principles and a low-intensity delivery format with postpartum nutrition information.

METHODS

Women were randomised at 24-28 weeks to control (supported care; SC) or intervention (enhanced care; EC) groups, stratified by BMI cohort. At 36 weeks of gestation, SC women received a 'nutrition for breastfeeding' resource and EC women received a nutrition assessment and goal-setting session about post-natal nutrition, plus a 6-month correspondence intervention requiring return of self-monitoring sheets. Weight change, anthropometry, diet, physical activity, breastfeeding, fasting glucose and insulin measures were assessed at 6 weeks and 6 months postpartum.

RESULTS

Seventy-seven percent (40 EC and 41 SC) of the 105 women approached were recruited; 36 EC and 35 SC women received a programme and 66.7% and 48.6% completed the study, respectively. No significant differences were observed between any outcomes. Median [interquartile range (IQR)] weight change was EC: -1.1 (9.5) kg versus SC: -1.1 (7.5) kg (6 weeks to 6 months) and EC: +1.0 (8.7) kg versus SC: +2.3 (9) kg (prepregnancy to 6 months). Intervention women breastfed for half a month longer than control women (180 versus 164 days; P = 0.10). An average of 2.3 out of six activity sheets per participant was returned.

CONCLUSIONS

Despite low intervention engagement, the high retention rate suggests this remains an area of interest to women. Future strategies must facilitate women's engagement, be individually tailored, and include features that support behaviour change to decrease women's risk of chronic health issues.

Modelling successful primary care for multimorbidity: a realist synthesis of successes and failures in concurrent learning and healthcare delivery

BACKGROUND

People are increasingly living for longer with multimorbidity. Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. The impact of multimorbidity on the educational needs of doctors is little understood. There has been little critique of how learning alongside healthcare provision is negotiated by patients, general practitioners and trainee doctors. This study asked 'what is known about how and why concurrent healthcare delivery and professional experiential learning interact to generate outcomes, valued by patients, general practitioners and trainees, for patients with multimorbidity in primary care?'

METHODS

This realist synthesis is reported using RAMESES standards. Relationship-centred negotiation of needs-based learning and care was the primary outcome of interest. Healthcare, social science and educational literature were sought as evidence. Data extraction focused on context, mechanism and outcome configurations within studies and on data which might assist understanding and explain; i) these configurations; ii) the relationships between them and; iii) their role and place in evolving programme theories arising from data synthesis. Mind-mapping software and team meetings were used to aid interpretative analysis.

RESULTS

The final synthesis included 141 papers of which 34 contained models for workplace-based experiential learning and/or patient care. Models of experiential learning for practitioners and for patient engagement were congruent, frequently referencing theories of transformation and socio-cultural processes as mechanisms for improving clinical care. Key issues included the perceived impossibility of reconciling personalised concepts of success with measurability of clinical markers or adherence to guidelines, and the need for greater recognition of social dynamics between patients, GPs and trainees including the complexities of shared responsibilities. A model for considering the implications of concurrency for learning and healthcare delivery in the context of multimorbidity in primary care is proposed and supporting evidence is presented.

CONCLUSIONS

This study is novel in considering empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery. The findings should inform future interventions designed to produce a medical workforce equipped to provide multimorbidity care.

TRIAL REGISTRATION

PROSPERO International prospective register of systematic reviews CRD42013003862.

Women's Contraceptive Preference-Use Mismatch

BACKGROUND

Family planning research has not adequately addressed women's preferences for different contraceptive methods and whether women's contraceptive experiences match their preferences.

METHODS

Data were drawn from the Women's Healthcare Experiences and Preferences Study, an Internet survey of 1,078 women aged 18-55 randomly sampled from a national probability panel. Survey items assessed women's preferences for contraceptive methods, match between methods preferred and used, and perceived reasons for mismatch. We estimated predictors of contraceptive preference with multinomial logistic regression models.

RESULTS

Among women at risk for pregnancy who responded with their preferred method (n = 363), hormonal methods (non-LARC [long-acting reversible contraception]) were the most preferred method (34%), followed by no method (23%) and LARC (18%). Sociodemographic differences in contraception method preferences were noted (p-values <0.05), generally with minority, married, and older women having higher rates of preferring less effective methods, compared to their counterparts. Thirty-six percent of women reported preference-use mismatch, with the majority preferring more effective methods than those they were using. Rates of match between preferred and usual methods were highest for LARC (76%), hormonal (non-LARC) (65%), and no method (65%). The most common reasons for mismatch were cost/insurance (41%), lack of perceived/actual need (34%), and method-specific preference concerns (19%).

CONCLUSION

While preference for effective contraception was common among this sample of women, we found substantial mismatch between preferred and usual methods, notably among women of lower socioeconomic status and women using less effective methods. Findings may have implications for patient-centered contraceptive interventions.

Optimizing an HIV testing program using a system dynamics model of the continuum of care

Realizing the full individual and population-wide benefits of antiretroviral therapy for human immunodeficiency virus (HIV) infection requires an efficient mechanism of HIV-related health service delivery. We developed a system dynamics model of the continuum of HIV care in Vancouver, Canada, which reflects key activities and decisions in the delivery of antiretroviral therapy, including HIV testing, linkage to care, and long-term retention in care and treatment. To measure the influence of operational interventions on population health outcomes, we incorporated an HIV transmission component into the model. We determined optimal resource allocations among targeted and routine testing programs to minimize new HIV infections over five years in Vancouver. Simulation scenarios assumed various constraints informed by the local health policy. The project was conducted in close collaboration with the local health care providers, Vancouver Coastal Health Authority and Providence Health Care.

'How to know what you need to do': a cross-country comparison of maternal health guidelines in Burkina Faso, Ghana and Tanzania

BACKGROUND

Initiatives to raise the quality of care provided to mothers need to be given priority in Sub Saharan Africa (SSA). The promotion of clinical practice guidelines (CPGs) is a common strategy, but their implementation is often challenging, limiting their potential impact. Through a cross-country perspective, this study explored CPGs for maternal health in Burkina Faso, Ghana, and Tanzania. The objectives were to compare factors related to CPG use including their content compared with World Health Organization (WHO) guidelines, their format, and their development processes. Perceptions of their availability and use in practice were also explored. The overall purpose was to further the understanding of how to increase CPGs' potential to improve quality of care for mothers in SSA.

METHODS

The study was a multiple case study design consisting of cross-country comparisons using document review and key informant interviews. A conceptual framework to aid analysis and discussion of results was developed, including selected domains related to guidelines' implementability and use by health workers in practice in terms of usability, applicability, and adaptability.

RESULTS

The study revealed few significant differences in content between the national guidelines for maternal health and WHO recommendations. There were, however, marked variations in the format of CPGs between the three countries. Apart from the Ghanaian and one of the Tanzanian CPGs, the levels of both usability and applicability were assessed as low or medium. In all three countries, the use of CPGs by health workers in practice was perceived to be limited.

CONCLUSION

Our cross-country study suggests that it is not poor quality of content or lack of evidence base that constitute the major barrier for CPGs to positively impact on quality improvement in maternal care in SSA. It rather emphasises the need to prioritise the format of guidelines to increase their usability and applicability and to consider these attributes together with implementation strategies as integral to their development processes.

Low-dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar

The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready-to-use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low-dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiary's body weight, until the child reached a Weight-for-Height z-score of ≥-3 and mid-upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low-dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non-responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg(-1) day(-1) [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non-response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67-7.42). Our results indicate that a low-dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here.

Health Service Accessibility and Risk in Cervical Cancer Prevention: Comparing Rural Versus Nonrural Residence in New Mexico

PURPOSE

Multiple intrapersonal and structural barriers, including geography, may prevent women from engaging in cervical cancer preventive care such as screening, diagnostic colposcopy, and excisional precancer treatment procedures. Geographic accessibility, stratified by rural and nonrural areas, to necessary services across the cervical cancer continuum of preventive care is largely unknown.

METHODS

Health care facility data for New Mexico (2010-2012) was provided by the New Mexico Human Papillomavirus Pap Registry (NMHPVPR), the first population-based statewide cervical cancer screening registry in the United States. Travel distance and time between the population-weighted census tract centroid to the nearest facility providing screening, diagnostic, and excisional treatment services were examined using proximity analysis by rural and nonrural census tracts. Mann-Whitney test (P < .05) was used to determine if differences were significant and Cohen's r to measure effect.

FINDINGS

Across all cervical cancer preventive health care services and years, women who resided in rural areas had a significantly greater geographic accessibility burden when compared to nonrural areas (4.4 km vs 2.5 km and 4.9 minutes vs 3.0 minutes for screening; 9.9 km vs 4.2 km and 10.4 minutes vs 4.9 minutes for colposcopy; and 14.8 km vs 6.6 km and 14.4 minutes vs 7.4 minutes for precancer treatment services, all P < .001).

CONCLUSION

Improvements in cervical cancer prevention should address the potential benefits of providing the full spectrum of screening, diagnostic and precancer treatment services within individual facilities. Accessibility, assessments distinguishing rural and nonrural areas are essential when monitoring and recommending changes to service infrastructures (eg, mobile versus brick and mortar).

Psychosis, Socioeconomic Disadvantage, and Health Service Use in South Australia: Findings from the Second Australian National Survey of Psychosis

The association between mental illness and poor physical health and socioeconomic outcomes has been well established. In the twenty-first century, the challenge of how mental illnesses, such as psychosis, are managed in the provision of public health services remains complex. Developing effective clinical mental health support and interventions for individuals requires a coordinated and robust mental health system supported by social as well as health policy that places a priority on addressing socioeconomic disadvantage in mental health cohorts. This paper, thus, examines the complex relationship between socioeconomic disadvantage, family/social supports, physical health, and health service utilization in a community sample of 402 participants diagnosed with psychosis. The paper utilizes quantitative data collected from the 2010 Survey of High Impact Psychosis research project conducted in a socioeconomically disadvantaged region of Adelaide, SA, Australia. Participants (42% female) provided information about socioeconomic status, education, employment, physical health, contact with family and friends, and health service utilization. The paper highlights that socioeconomic disadvantage is related to increased self-reported use of emergency departments, decreased use of general practitioners for mental health reasons, higher body mass index, less family contact, and less social support. In particular, the paper explores the multifaceted relationship between socioeconomic disadvantage and poor health confronting individuals with psychosis, highlighting the complex link between socioeconomic disadvantage and poor health. It emphasizes that mental health service usage for those with higher levels of socioeconomic disadvantage differs from those experiencing lower levels of socioeconomic disadvantage. The paper also stresses that the development of health policy and practice that seeks to redress the socioeconomic and health inequalities created by this disadvantage be an important focus for mental health services. Such health policy would provide accessible treatment programs and linked pathways to illness recovery and diminish the pressure on the delivery of health services. Consequently, the development of policy and practice that seeks to redress the socioeconomic and health inequalities created by disadvantage should be an important focus for the improvement of mental health services.

Teleaudiology hearing aid fitting follow-up consultations for adults: single blinded crossover randomised control trial and cohort studies

OBJECTIVE

To evaluate and compare the effectiveness and quality of standard face-to-face and teleaudiology hearing aid fitting follow-up consultations and blended services for adult hearing aid users.

DESIGN AND STUDY SAMPLE

Fifty-six participants were randomly allocated to two equal groups, with equal numbers of new and experienced users. One standard and one teleaudiology follow-up consultation were delivered by an audiologist, the latter assisted by a facilitator. The order was reversed for the second group. Outcome measurement tools were applied to assess aspects of participants' communication, fitting (physical, sensorial), quality of life, and service. Cross-sectional and longitudinal outcomes were analysed.

RESULTS

Most participants presented with moderate, sloping, and symmetrical sensorineural hearing loss. The duration of teleaudiology (42.96 ± 2.73 min) was equivalent to face-to-face consultations (41.25 ± 2.61 min). All modes of service delivery significantly improved outcomes for communication, fitting, and quality of life (p > 0.05). Satisfaction for both consultation modes was high, although significantly greater with standard consultations. The mode and order of delivery of the consultations did not influence the outcomes.

CONCLUSION

Teleaudiology hearing aid follow-up consultations can deliver significant improvements, and do not differ from standard consultations. Blended services also deliver significant improvements. Satisfaction can be negatively impacted by technical or human-related issues.

Integrated care in cancer: What is it, how is it used and where are the gaps? A textual narrative literature synthesis

Integrated care is an underpinning concept of contemporary health care policy proffered as a strategy to overcome the fragmentations in care encountered by people with complex care needs (Shaw et al. [2011] What is Integrated Care? An Overview of Integrated Care in the NHS). Cancer patients have potential to benefit from such policy, often having needs that extend beyond cancer. This paper seeks to understand how the concept of integrated care is used in the cancer literature. A search of leading databases was conducted for original research relating to integrated care or an integration intervention aiming to improve outcomes of cancer patients, and analysed using textual narrative synthesis. 38 papers were included, each with a focus on improving cancer-specific aspects of care enhancing the capabilities of the cancer multidisciplinary team. Of the eight studies involving integration between the cancer service and other care providers, all focused on utilising the external provider to deliver aspects of cancer care or placed them in a passive role, as survey participant, a recipient of cancer-related clinical information or as the comparator "usual care" arm. Within the cancer literature, integration is predominantly used to describe initiatives to improve cancer-related aspects of care. Less attention is given to integration initiatives that enhance coordination across levels of the healthcare system or service providers.

Patients' valuation of the prescribing nurse in primary care: a discrete choice experiment

BACKGROUND

Recently, primary care in the United Kingdom has undergone substantial changes in skill mix. Non-medical prescribing was introduced to improve patient access to medicines, make better use of different health practitioners' skills and increase patient choice. There is little evidence about value-based patient preferences for 'prescribing nurse' in a general practice setting.

OBJECTIVE

To quantify value-based patient preferences for the profession of prescriber and other factors that influence choice of consultation for managing a minor illness.

DESIGN

Discrete choice experiment patient survey.

SETTING AND PARTICIPANTS

Five general practices in England with non-medical prescribing services, questionnaires completed by 451 patients.

MAIN OUTCOME MEASURE

Stated choice of consultation.

MAIN RESULTS

There was a strong general preference for consulting 'own doctor' for minor illness. However, a consultation with a nurse prescriber with positive patient-focused attributes can be more acceptable to patients than a consultation provided by a doctor. Attributes 'professional's attention to Patients' views' and extent of 'help offered' were pivotal. Past experience influenced preference.

DISCUSSION AND CONCLUSION

Respondents demonstrated valid preferences. Preferences for consulting a doctor remained strong, but many were happy to consult with a nurse if other aspects of the consultation were improved. Findings show who to consult is not the only valued factor in choice of consultation for minor illness. The 'prescribing nurse' role has potential to offer consultation styles that patients value. Within the study's limitations, these findings can inform delivery of primary care to enhance patient experience and substitute appropriate nurse prescribing consultations for medical prescribing consultations.

Optimizing health system response to patient's needs: an argument for the importance of functioning information

BACKGROUND

Current health systems are increasingly challenged to meet the needs of a growing number of patients living with chronic and often multiple health conditions. The primary outcome of care, it is argued, is not merely curing disease but also optimizing functioning over a person's life span. According to the World Health Organization, functioning can serve as foundation for a comprehensive picture of health and augment the biomedical perspective with a broader and more comprehensive picture of health as it plays out in people's lives. The crucial importance of information about patient's functioning for a well-performing health system, however, has yet to be sufficiently appreciated.

METHODS

This paper argues that functioning information is fundamental in all components of health systems and enhances the capacity of health systems to optimize patients' health and health-related needs.

RESULTS AND CONCLUSION

Beyond making sense of biomedical disease patterns, health systems can profit from using functioning information to improve interprofessional collaboration and achieve cross-cutting disease treatment outcomes. Implications for rehabilitation Functioning is a key health outcome for rehabilitation within health systems. Information on restoring, maintaining, and optimizing human functioning can strengthen health system response to patients' health and rehabilitative needs. Functioning information guides health systems to achieve cross-cutting health outcomes that respond to the needs of the growing number of individuals living with chronic and multiple health conditions. Accounting for individuals functioning helps to overcome fragmentation of care and to improve interprofessional collaboration across settings.

"You only have time for so much in 12 hours" unmet social needs of hospitalised patients: A qualitative study of acute care nurses

AIMS AND OBJECTIVES

To explore the experiences of nurses caring for socially at-risk patients and gain an understanding of the challenges nurses face when providing care.

BACKGROUND

Nurses play a pivotal role in caring for hospitalised patients with social risk factors and preparing them for discharge. Few studies have explored whether acute care nurses are adequately supported in their practice environments to address the unique needs of socially at-risk patients as they transition back into community settings.

DESIGN

A qualitative descriptive study of nurses working in a large urban academic medical centre.

METHODS

We conducted six semi-structured focus groups of nurses (n = 21). Thematic content analysis was performed to analyse the transcripts from the focus groups. We adhered to COREQ guidelines for reporting this qualitative study.

RESULTS

Six key themes emerged: (a) nurses' assessments of social risk factors, (b) experiences providing care, (c) barriers to care, (d) fear of "labelling" socially at-risk patients, (e) unmet social care needs and (f) recommendations to improve care.

CONCLUSIONS

Our findings suggest that nurses are able to identify social risk factors. However, prioritisation of medical needs during acute care hospitalisation and lack of organisational supports may deter nurses from fully addressing social concerns.

RELEVANCE TO CLINICAL PRACTICE

Acute care nurses should be involved in the development of future efforts to address the needs of socially at-risk patients and be provided with additional supports in their practice environments. This could include continuing education to build nursing competencies in community-based care and social vulnerability.

Differences in primary health care delivery to Australia's Indigenous population: a template for use in economic evaluations

BACKGROUND

Health economics is increasingly used to inform resource allocation decision-making, however, there is comparatively little evidence relevant to minority groups. In part, this is due to lack of cost and effectiveness data specific to these groups upon which economic evaluations can be based. Consequently, resource allocation decisions often rely on mainstream evidence which may not be representative, resulting in inequitable funding decisions. This paper describes a method to overcome this deficiency for Australia's Indigenous population. A template has been developed which can adapt mainstream health intervention data to the Indigenous setting.

METHODS

The 'Indigenous Health Service Delivery Template' has been constructed using mixed methods, which include literature review, stakeholder discussions and key informant interviews. The template quantifies the differences in intervention delivery between best practice primary health care for the Indigenous population via Aboriginal Community Controlled Health Services (ACCHSs), and mainstream general practitioner (GP) practices. Differences in costs and outcomes have been identified, measured and valued. This template can then be used to adapt mainstream health intervention data to allow its economic evaluation as if delivered from an ACCHS.

RESULTS

The template indicates that more resources are required in the delivery of health interventions via ACCHSs, due to their comprehensive nature. As a result, the costs of such interventions are greater, however this is accompanied by greater benefits due to improved health service access. In the example case of the polypill intervention, 58% more costs were involved in delivery via ACCHSs, with 50% more benefits. Cost-effectiveness ratios were also altered accordingly.

CONCLUSIONS

The Indigenous Health Service Delivery Template reveals significant differences in the way health interventions are delivered from ACCHSs compared to mainstream GP practices. It is important that these differences are included in the conduct of economic evaluations to ensure results are relevant to Indigenous Australians. Similar techniques would be generalisable to other disadvantaged minority populations. This will allow resource allocation decision-makers access to economic evidence that more accurately represents the needs and context of disadvantaged groups, which is particularly important if addressing health inequities is a stated goal.

Targets and teamwork: Understanding differences in pediatric diabetes centers treatment outcomes

OBJECTIVE

The reason for center differences in metabolic control of childhood diabetes is still unknown. We sought to determine to what extent the targets, expectations, and goals that diabetes care professionals have for their patients is a determinant of center differences in metabolic outcomes.

RESEARCH DESIGN AND METHODS

Children, under the age of 11 with type 1 diabetes and their parents treated at the study centers participated. Clinical, medical, and demographic data were obtained, along with blood sample for centralized assay. Parents and all members of the diabetes care team completed questionnaires on treatment targets for hemoglobin A1c (HbA1c) and recommended frequency of blood glucose monitoring.

RESULTS

Totally 1113 (53% male) children (mean age 8.0 ± 2.1 years) from 18 centers in 17 countries, along with parents and 113 health-care professionals, participated. There were substantial differences in mean HbA1c between centers ranging from 7.3 ± 0.8% (53 mmol/mol ± 8.7) to 8.9 ± 1.1% (74 mmol/mol ± 12.0). Centers with lower mean HbA1c had (1) parents who reported lower targets for their children, (2) health-care professionals that reported lower targets and more frequent testing, and (3) teams with less disagreement about recommended targets. Multiple regression analysis indicated that teams reporting higher HbA1c targets and more target disagreement had parents reporting higher treatment targets. This seemed to partially account for center differences in Hb1Ac.

CONCLUSIONS

The diabetes care teams' cohesiveness and perspectives on treatment targets, expectations, and recommendations have an influence on parental targets, contributing to the differences in pediatric diabetes center outcomes.

Task Shifting and Task Sharing Implementation in Africa: A Scoping Review on Rationale and Scope

Numerous studies have reported task shifting and task sharing due to various reasons and with varied scopes of health services, either task-shifted or -shared. However, very few studies have mapped the evidence on task shifting and task sharing. We conducted a scoping review to synthesize evidence on the rationale and scope of task shifting and task sharing in Africa. We identified peer-reviewed papers from PubMed, Scopus, and CINAHL bibliographic databases. Studies that met the eligibility criteria were charted to document data on the rationale for task shifting and task sharing, and the scope of tasks shifted or shared in Africa. The charted data were thematically analyzed. Sixty-one studies met the eligibility criteria, with fifty-three providing insights on the rationale and scope of task shifting and task sharing, and seven on the scope and one on rationale, respectively. The rationales for task shifting and task sharing were health worker shortages, to optimally utilize existing health workers, and to expand access to health services. The scope of health services shifted or shared in 23 countries were HIV/AIDS, tuberculosis, hypertension, diabetes, mental health, eyecare, maternal and child health, sexual and reproductive health, surgical care, medicines' management, and emergency care. Task shifting and task sharing are widely implemented in Africa across various health services contexts towards ensuring access to health services.

Factors determining eligibility and access to subacute rehabilitation for elderly people with dementia and hip fracture

With hip fracture and dementia increasing in incidence in the global ageing population, there is a need for the development of specific procedures targeting optimal treatment outcomes for these patients. This paper looks primarily at the factors that limit access to subacute rehabilitation services as a growing body of evidence suggests that access to timely inpatient rehabilitation increases functional outcomes for patients both with dementia and without. Information was gathered by searching electronic data bases (SCOPUS, Medline, CINAHL, Health Source Nursing/Academic Addition, Psychinfo and the Cochrane Library) for relevant articles using the search terms dementia OR Alzheimer* AND hip fracture AND subacute rehabilitation OR convalescence for the period 2005–2015. Abstracts were scanned to identify articles discussing eligibility and access. A total of nine papers were identified that directly addressed this topic. Other papers discussing success or failure of rehabilitation and improved models of care were also reviewed. Barriers to access discussed in the literature include information management, management of comorbidities, attitudes, resource availability, and the quality of evidence and education. By identifying these factors we can identify strategic points of intervention across the trajectory of prevention, treatment and rehabilitation that may improve outcomes for this growing group of vulnerable patients. Emerging best practice for these patients is also discussed.

Improving Primary Health Care in Chronic Musculoskeletal Conditions through Digital Media: The PEOPLE Meeting

BACKGROUND

Musculoskeletal (MSK) conditions are the most common cause of severe chronic pain and disability worldwide. Despite the impact of these conditions, disparity exists in accessing high quality basic care. As a result, effective treatments do not always reach people who need services. The situation is further hampered by the current models of care that target resources to a limited area of health services (eg, joint replacement surgery), rather than the entire continuum of MSK health, which includes services provided by primary care physicians and health professionals. The use of digital media offers promising solutions to improve access to services. However, our knowledge in this field is limited. To advance the use of digital media in improving MSK care, we held a research planning meeting entitled "PEOPLE: Partnership to Enable Optimal Primary Health Care by Leveraging Digital Media in Musculoskeletal Health". This paper reports the discussion during the meeting.

OBJECTIVE

The objective of this study was to: (1) identify research priorities relevant to using digital media in primary health care for enhancing MSK health, and (2) develop research collaboration among researchers, clinicians, and patient/consumer communities.

METHODS

The PEOPLE meeting included 26 participants from health research, computer science/digital media, clinical communities, and patient/consumer groups. Based on consultations with each participant prior to the meeting, we chose to focus on 3 topics: (1) gaps and issues in primary health care for MSK health, (2) current application of digital media in health care, and (3) challenges to using digital media to improve MSK health in underserviced populations.

RESULTS

The 2-day discussion led to emergence of 1 overarching question and 4 research priorities. A main research priority was to understand the characteristics of those who are not able to access preventive measures and treatment for early MSK diseases. Participants indicated that this information is necessary for tailoring digital media interventions. Other priorities included: (1) studying barriers and ethical issues associated with the use of digital media to optimize MSK health and self-management, (2) improving the design of digital media tools for providing "just-in-time" health information to patients and health professionals, and (3) advancing knowledge on the effectiveness of new and existing digital media interventions.

CONCLUSIONS

We anticipate that the results of this meeting will be a catalyst for future research projects and new cross-sector research partnerships. Our next step will be to seek feedback on the research priorities from our collaborators and other potential partners in primary health care.

Ageing, Chronic Disease and Injury: A Study in Western Victoria (Australia)

Background: An increasing burden of chronic disease and associated health service delivery is expected due to the ageing Australian population. Injuries also affect health and wellbeing and have a long-term impact on health service utilisation. There is a lack of comprehensive data on disease and injury in rural and regional areas of Australia. The aim of the Ageing, Chronic Disease and Injury study is to compile data from various sources to better describe the patterns of chronic disease and injury across western Victoria.

Design: Ecological study.

Methods: Information on demographics, socioeconomic indicators and lifestyle factors are obtained from health surveys and government departments. Data concerning chronic diseases and injuries will be sourced from various registers, health and emergency services, local community health centres and administrative databases and compiled to generate profiles for the study region and for sub-populations within the region.

Expected impact for public health: This information is vital to establish current and projected population needs to inform policy and improve targeted health services delivery, care transition needs and infrastructure development. This study provides a model that can be replicated in other geographical settings.

HIV and STI Testing Preferences for Men Who Have Sex with Men in High-Income Countries: A Scoping Review

Background: Regular testing for HIV and other sexually transmitted infections (STI) is recommended at least annually for sexually active men who have sex with men (MSM) in most high-income countries. To encourage regular use of HIV and STI testing and treatment services for MSM, we reviewed the literature to summarise the attributes of an HIV/STI testing service that MSM prefer. Method: We conducted a scoping review, searching PubMed, EMBASE, PsycINFO and CINAHL in January 2020 for articles reporting primary data on the preferences of MSM (living in high-income countries) for HIV/STI testing services. Two reviewers independently screened titles and abstracts and any discrepancies were resolved by a third reviewer. We extracted data on the service attributes that MSM preferred and summarised these thematically using a socioecological framework. Results: In total, 1464 publications were identified, 220 full texts were read and 57 were included in the final analysis. We found 21 articles addressing 'individual' attributes, 50 articles addressing 'service' attributes and 17 articles addressing 'societal' attributes. The key themes of preferences for HIV/STI testing services were: (1) the appeal of self-testing due to convenience and privacy; (2) the need to provide a variety of testing options; and (3) the influence of the testing experience, including confidentiality and privacy, tester characteristics and stigma. There were distinct patterns of preferences for subpopulations of MSM across studies, such as the preference of self-testing for young MSM, and of in-clinic testing for those who perceived themselves as high risk (i.e., with symptoms of STIs or exposed to a partner living with HIV). Conclusion: To make HIV/STI testing more accessible for MSM and encourage regular screening, it is important to address 'individual', 'service' and 'societal' attributes, such as enhancing the convenience of testing through self-testing, and providing a service that men feel comfortable and safe accessing. Furthermore, services should accommodate the preferences of diverse sub-populations within the MSM community.