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Background: This study involved a scoping review to explore factors influencing dental hygienist demand and supply in high-income countries. Methods: A six-stage scoping review was conducted with separate search strategies tailored to four databases (MEDLINE, CINAHL, Google Scholar, and Google) plus a targeted scan of dental hygienist organization websites. This yielded 2,117 unique citations, leading to 148 articles included in the review. Results: Nearly half of the articles (47%) focused on the United States, with 11% on Canada. Most articles (91%) were in English, alongside 13 in Korean and one in French. Journal articles comprised 62% of the publications, followed by reports/working papers (11%) and websites (11%). Other types included conference abstracts, policy briefs, and presentation slides. Content-wise, 47% were original research, with analysis articles (14%), commentaries (11%), and reviews (8%) also present. The articles were coded into three main categories: workforce characteristics/projections, factor-specific analyses, and workforce opportunities. The articles on workforce characteristics covered demographic, geographic, and employment aspects of dental hygienists, along with projections for supply and demand using simulation modelling and geospatial analyses. Factor-specific articles investigated the (1) working environment, (2) policy/regulatory/training environment, (3) job/career satisfaction and related human resource issues, and (4) scope of practice. The third key category of articles highlighted opportunities for expanding the workforce through alternative models in different sectors/settings (e.g., public health, primary care, long-term care, hospitals, mobile outreach, and non-clinical roles including research, education and leadership) and for a range of vulnerable or underserved populations (e.g., geriatric and pediatric populations, persons with disabilities, those living in rural/remote areas, Indigenous peoples, and incarcerated people). Conclusions: This review provides a comprehensive documentation of the current state of the dental hygienist workforce, compiling factors affecting demand and supply, and highlighting opportunities for the dental hygienist workforce in Canada and other high-income countries. The findings offer a foundation for future research, highlighting the need for more focused and rigorous reviews and underscoring the necessity of high-quality studies to verify the effectiveness of various interventions and policies. This is crucial to address dental hygienist workforce challenges and ensure the sustainability and effectiveness of oral health care delivery. [ABSTRACT FROM AUTHOR]

Object: To analyze the trend of the coupling and coordination of the supply and demand of healthcare resources between the elderly population and healthcare resources in China during the period of 2012–2022, to reveal the impact of the growth of the elderly population on the relationship between the supply and demand of healthcare resources, and to put forward suggestions to improve the coupling and coordination between the supply and demand of healthcare resources and the elderly population, in order to cope with the challenges of an aging society. Methods: By obtaining relevant data from authoritative data sources such as China Statistical Yearbook, Health and Health Statistics Yearbook, and the Chinese government website from 2012 to 2022, we constructed a comprehensive measurement index for the three systems of elderly population, healthcare resource supply, and healthcare resource demand; Using the entropy value method to assign weights to the indicators, combined with the coupling coordination degree model, to reveal the changes of the elderly population change and the supply and demand of medical and health resources; using ArcGIS technology, to study the spatial characteristics of the elderly population change and the supply and demand of medical and health resources. Results: From 2012 to 2022, the supply and demand of healthcare resources and the variation of the elderly population in China show a continuous growth trend, and the comprehensive development level of the system gradually climbs from a low level to a high level. The fluctuation of coupling degree and coordination degree rises, although the coordination degree has always been lower than the coupling degree, but the distance between the coordination degree and the coupling degree gradually narrows with the passage of time. The coordination degree between population aging and medical and health resources development shows spatial heterogeneity in China, with the eastern region significantly higher than the western region/. Conclusions: The coupling degree between population aging and healthcare resource supply and demand in China from 2012 to 2022 shows a general upward trend from low coupling to medium-high coupling, but it is worth noting that even though the degree of coupling increases, the degree of coordination is still relatively lagging behind, suggesting that the government and relevant departments need to pay more attention to coordinated allocation and management of healthcare resources. At the same time, the spatial differences in the degree of coordination among provinces suggest that future policymakers should take regional differences into full consideration in policymaking and sustainable development. [ABSTRACT FROM AUTHOR]

Over the last decades, the face of health care has changed dramatically, with big improvements in what is technically feasible. However, there are indicators that the current approach to evaluating evidence in health care is not holistic and hence in the long run, health care will not be sustainable. New conceptual and normative frameworks for the evaluation of health care need to be developed and investigated. The current paper presents a novel framework of justifiable health care and explores how the use of artificial intelligence and big data can contribute to achieving the goals of this framework. [ABSTRACT FROM AUTHOR]

Background: While there is an extensive literature on Health System (HS) strengthening and on the performance of specific HSs, there are few exhaustive syntheses of the challenges HSs are facing worldwide. This paper reports the findings of a scoping review aiming to classify the challenges of HSs investigated in the scientific literature. Specifically, it determines the kind of research conducted on HS challenges, where it was performed, in which health sectors and on which populations. It also identifies the types of challenge described the most and how they varied across countries.Methods: We searched 8 databases to identify scientific papers published in English, French and Italian between January 2000 and April 2016 that addressed HS needs and challenges. The challenges reported in the articles were classified using van Olmen et al.'s dynamic HS framework. Countries were classified using the Human Development Index (HDI). Our analyses relied on descriptive statistics and qualitative content analysis.Results: 292 articles were included in our scoping review. 33.6% of these articles were empirical studies and 60.1% were specific to countries falling within the very high HDI category, in particular the United States. The most frequently researched sectors were mental health (41%), infectious diseases (12%) and primary care (11%). The most frequently studied target populations included elderly people (23%), people living in remote or poor areas (21%), visible or ethnic minorities (15%), and children and adolescents (15%). The most frequently reported challenges related to human resources (22%), leadership and governance (21%) and health service delivery (24%). While health service delivery challenges were more often examined in countries within the very high HDI category, human resources challenges attracted more attention within the low HDI category.Conclusions: This scoping review provides a quantitative description of the available evidence on HS challenges and a qualitative exploration of the dynamic relationships that HS components entertain. While health services research is increasingly concerned about the way HSs can adopt innovations, little is known about the system-level challenges that innovations should address in the first place. Within this perspective, four key lessons are drawn as well as three knowledge gaps. [ABSTRACT FROM AUTHOR]

Background: Despite efforts to extend Universal Health Coverage in Colombia, rural and remote populations still face significant challenges in accessing equitable health services. Social innovation has been growing in Colombia as a creative response to the country's social problems including access to healthcare. This paper presents the findings of a social innovation case study, which was implemented in the rural area of Sumapaz in Colombia, with the purpose of holistically addressing the health needs of the local population and enhancing health service access. Methods: A case study methodology was used to investigate and understand the process by which the Model of Integral Health Care for Rural Areas was developed and how the various strategies were defined and implemented. Qualitative methods were used in the data collection and all data was analysed using Farmer et al. staged framework on grassroots social innovation which includes growing the idea; implementing the idea; sustainability and diffusion. Results: The social innovation model was designed as a co-learning process based on community participation. The model was implemented adopting a holistic health approach and considerate of the conditions of a rural context. As a result of this process, access to quality health services were enhanced for the vulnerable rural community. The model has also provided outcomes that transcend health and contribute to individual and community development in different areas eg. agriculture. Conclusion: The Model of Integral Health Care for Rural Areas is a social innovation in health that demonstrates how Universal Health Coverage can be achieved for vulnerable populations through a series of creative strategies which fill systemic voids in access and co-ordination of care, as well as in addresings upstream environmental factors responsible for ill-health. [ABSTRACT FROM AUTHOR]

Background: Despite tremendous health workforce efforts which have resulted in increases in the density of physicians, nurses and midwives from 1.07 per 1000 population in 2005 to 2.65 per 1000 population in 2017, Ghana continues to face shortages of health workforce alongside inefficient distribution. The Ministry of Health and its agencies in Ghana used the Workload Indicators of Staffing Needs (WISN) approach to develop staffing norms and standards for all health facilities, which is being used as an operational planning tool for equitable health workforce distribution. Using the nationally agreed staffing norms and standards, the aim of this paper is to quantify the inequitable distribution of health workforce and the associated cost implications. It also reports on how the findings are being used to shape health workforce policy, planning and management.Methods: We conducted a health workforce gap analysis for all health facilities of the Ghana Health Service in 2018 in which we compared a nationally agreed evidence-based staffing standard with the prevailing staffing situation to identify need-based gaps and inequitable distribution. The cost of the prevailing staffing levels was also compared with the stipulated standard, and the staffing cost related to inequitable distribution was estimated.Results: It was found that the Ghana Health Service needed 105,440 health workers to meet its minimum staffing requirements as at May 2018 vis-à-vis its prevailing staff at post of 61,756 thereby leaving unfilled vacancies of 47,758 (a vacancy rate of 41%) albeit significant variations across geographical regions, levels of service and occupational groups. Of note, the crude equity index showed that in aggregate, the best-staffed region was 2.17 times better off than the worst-staffed region. The estimated cost (comprising basic salaries, market premium and other allowances paid from central government) of meeting the minimum staffing requirements was estimated to be GH¢2,358,346,472 (US$521,758,069) while the current cost of staff at post was GH¢1,424,331,400 (US$315,117,566.37), resulting in a net budgetary deficit of 57% (~ US$295.4 million) to meet the minimum requirement of staffing for primary and secondary health services. Whilst the prevailing staffing expenditure was generally below the required levels, an average of 28% (range 14-50%) across the levels of primary and secondary healthcare was spent on staff deemed to have been inequitably distributed, thus providing scope for rationalisation. We estimate that the net budgetary deficit of meeting the minimum staffing requirement could be drastically reduced by some 30% just by redistributing the inequitably distributed staff.Policy Implications: Efficiency gains could be made by redistributing the 14,142 staff deemed to be inequitably distributed, thereby narrowing the existing staffing gaps by 30% to 33,616, which could, in turn, be filled by leveraging synergistic strategy of task-sharing and/or new recruitments. The results of the analysis provided insights that have shaped and continue to influence important policy decisions in health workforce planning and management in the Ghana Health Service. [ABSTRACT FROM AUTHOR]

Background: Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015.Methods: Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies.Results: There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed.Conclusions: There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning. [ABSTRACT FROM AUTHOR]

Background: Achievement of improved maternal and child health (MCH) outcomes continues to be an issue of international priority, particularly for sub-Saharan African countries such as Nigeria. Evidence suggests that the use of Community Health Workers (CHWs) can be effective in broadening access to, and coverage of, health services and improving MCH outcomes in such countries.Methods/design: In this paper, we report the methodology for a 5-year study which aims to evaluate the context, processes, outcomes and longer-term sustainability of a Nigerian CHW scheme. Evaluation of complex interventions requires a comprehensive understanding of intervention context, mechanisms and outcomes. The multidisciplinary and mixed-method realist approach will facilitate such evaluation. A favourable policy environment within which the study is conducted will ensure the successful uptake of results into policy and practice. A realist evaluation provides an overall methodological framework for this multidisciplinary and mixed methods research, which will be undertaken in Anambra state. The study will draw upon health economics, social sciences and statistics. The study comprises three steps: (1) initial theory development; (2) theory validation and (3) theory refinement and development of lessons learned. Specific methods for data collection will include in-depth interviews and focus group discussions with purposefully identified key stakeholders (managers, service providers and service users), document reviews, analyses of quantitative data from the CHW programme and health information system, and a small-scale survey. The impact of the programme on key output and outcome indicators will be assessed through an interrupted time-series analysis (ITS) of monthly quantitative data from health information system and programme reports. Ethics approvals for this study were obtained from the University of Leeds and the University of Nigeria.Discussion: This study will provide a timely and important contribution to health systems strengthening specifically within Anambra state in southeast Nigeria but also more widely across Nigeria. This paper should be of interest to researchers who are interested in adapting and applying robust methodologies for assessing complex health system interventions. The paper will also be useful to policymakers and practitioners who are interested in commissioning and engaging in such complex evaluations to inform policies and practices. [ABSTRACT FROM AUTHOR]

Background: A Learning Health Care Community (LHCC) is a framework to enhance health care through mutual accountability between the health care system and the community. LHCC components include infrastructure for health-related data capture, care improvement targets, a supportive policy environment, and community engagement. The LHCC involves health care providers, researchers, decision-makers, and community members who work to identify health care needs and address them with evidence-based solutions. The objective of this study was to summarize the barriers and enablers to building an LHCC in rural areas. Methods: A systematic review was conducted by searching electronic databases. Eligibility criteria was determined by the research team. Published literature on LHCCs in rural areas was systematically collected and organized. Screening was completed independently by two authors. Detailed information about rural health care, activities, and barriers and enablers to building an LHCC in rural areas was extracted. Qualitative analysis was used to identify core themes. Results: Among 8169 identified articles, 25 were eligible. LHCCs aimed to increase collaboration and co-learning between community members and health care providers, integrate community feedback in health care services, and to share information. Main barriers included obtaining adequate funding and participant recruitment. Enablers included meaningful engagement of stakeholders and stakeholder collaboration. Conclusions: The LHCC is built on a foundation of meaningful use of health data and empowers health care practitioners and community members in informed decision-making. By reducing the gap between knowledge generation and its application to practice, the LHCC has the potential to transform health care delivery in rural areas. [ABSTRACT FROM AUTHOR]

Background: Older persons report poor health status and greater need for healthcare. However, there is limited research on older persons' healthcare disparities in Uganda. Therefore, this paper aimed at investigating factors associated with older persons' healthcare access in Uganda, using a nationally representative sample. Methods: We conducted secondary analysis of data from a sample of 1602 older persons who reported being sick in the last 30 days preceding the Uganda National Household Survey. We used frequency distributions for descriptive data analysis and chi-square tests to identify initial associations. We fit generalized linear models (GLM) with the poisson family and the log link function, to obtain incidence risk ratios (RR) of accessing healthcare in the last 30 days, by older persons in Uganda. Results: More than three quarters (76%) of the older persons accessed healthcare in the last 30 days. Access to healthcare in the last 30 days was reduced for older persons from poor households (RR = 0.91, 95% CI: 0.83-0.99); with some walking difficulty (RR = 0.90, 95% CI: 0.83-0.97); or with a lot of walking difficulty (RR = 0.84, 95% CI: 0.75-0.95). Conversely, accessing healthcare in the last 30 days for older persons increased for those who earned wages (RR = 1.08, 95% CI: 1.00-1.15) and missed work due to illness for 1-7 days (RR =1.19, 95% CI: 1.10-1.30); and 8-14 days (RR = 1.19, 95% CI: 1.07-1.31). In addition, those who reported non-communicable diseases (NCDs) such as heart disease, hypertension or diabetes (RR= 1.09, 95% CI: 1.01-1.16); were more likely to access healthcare during the last 30 days. Conclusion: In the Ugandan context, health need factors (self-reported NCDs, severity of illness and mobility imitations) and enabling factors (household wealth status and earning wages in particular) were the most important determinants of accessing healthcare in the last 30 days among older persons. [ABSTRACT FROM AUTHOR]

Background: Treatment burden is the workload of healthcare experienced by those with long-term conditions and the impact that this has on well-being. Treatment burden can negatively impact on quality of life and adherence to treatments. Individuals are likely to differ in their ability to manage health problems and follow treatments, defined as patient capacity. This has been under investigated in stroke. The aim of this paper is to create a conceptual model of treatment burden and patient capacity for people who have had a stroke through exploration of their experiences of healthcare. Methods: Interviews were conducted at home with 29 individuals who have had a stroke. These were recorded and transcribed verbatim. Fifteen explored treatment burden and were analysed by framework analysis underpinned by Normalisation Process Theory (NPT). Fourteen explored patient capacity and were analysed by thematic analysis. Taxonomies of treatment burden and patient capacity were created and a conceptual model produced. Results: Mean age was 68 years. Sixteen were men and 13 women. The following broad areas of treatment burden were identified: making sense of stroke management and planning care; interacting with others including health professionals, family and other stroke patients; enacting management strategies; and reflecting on management. Treatment burdens were identified as arising from either: the workload of healthcare; or the endurance of care deficiencies. Six factors were identified that influence patient capacity: personal attributes and skills; physical and cognitive abilities; support network; financial status; life workload, and environment. Conclusions: Healthcare workload and the presence of care deficiencies can influence and be influenced by patient capacity. The quality and configuration of health and social care services has considerable influence on treatment burden and patient capacity. Findings have important implications for the design of clinical guidelines and healthcare delivery, highlighting issues such as the importance of good care co-ordination. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests that transgender (trans) individuals in Canada are a medically underserved population; barriers range from lack of provider knowledge on trans issues to refusal of care. This paper provides the first formal estimation of health care inequalities between trans and cisgender individuals in Ontario, Canada.Methods: Weighted statistics from the Ontario-wide Trans PULSE Project (n = 433) were compared with age-standardized Ontario data from the Canadian Community Health Survey (n = 39,980) to produce standardized prevalence differences (SPDs). Analysis was also conducted separately for trans men and trans women, each compared to the age-standardized Ontario population.Results: An estimated 33.2% (26.4,40.9) of trans Ontarians reported a past-year unmet health care need in excess of the 10.7% expected based on the age-standardized Ontario population. Inequality was greatest comparing trans with cisgender men (SPD = 34.4% (23.0, 46.1). While trans Ontarians evaluated health care availability in Ontario similarly to the broader population, they were significantly more likely to evaluate availability in their community as fair or poor.Conclusions: Trans Ontarians experience inequalities in perception and reported experiences of health care access, with 43.9% reporting a past-year unmet health care need. [ABSTRACT FROM AUTHOR]

Background: Healthcare systems are operating under substantial pressures, and often simply cannot provide the standard of care they aspire to within the available resources. Organisations, managers, and individual clinicians make constant adaptations in response to these pressures, which are typically improvised, highly variable and not coordinated across clinical teams. The purpose of this study was to identify and describe the types of everyday pressures experienced by surgical teams and the adaptive strategies they use to respond to these pressures. Methods: We conducted interviews with 20 senior multidisciplinary healthcare professionals from surgical teams in four major hospitals in the United Kingdom. The interviews explored the types of everyday pressures staff were experiencing, the strategies they use to adapt, and how these strategies might be taught to others. Results: The primary pressures described by senior clinicians in surgery were increased numbers and complexity of patients alongside shortages in staff, theatre space and post-surgical beds. These pressures led to more difficult working conditions (e.g. high workloads) and problems with system functioning such as patient flow and cancellation of lists. Strategies for responding to these pressures were categorised into increasing or flexing resources, controlling and prioritising patient demand and strategies for managing the workload (scheduling for efficiency, communication and coordination, leadership, and teamwork strategies). Conclusions: Teams are deploying a range of strategies and making adaptations to the way care is delivered. These findings could be used as the basis for training programmes for surgical teams to develop coordinated strategies for adapting under pressure and to assess the impact of different combinations of strategies on patient safety and surgical outcomes. [ABSTRACT FROM AUTHOR]

Background: Registered nurses working in the mobile health clinics (MHCs) play an important role in enabling HIV care access to populations in remote areas through Nurse Initiated Antiretroviral Therapy program (NIMART). Aim: To explore and describe the nurses' experiences regarding operational factors influencing the implementation of HIV care services in the mobile health clinics (MHCs) of eThekwini Municipality in KwaZulu Natal. Methods: Qualitative Exploratory Descriptive (QED) method was used after permission was granted from North-West University Human Research Ethics Committee provincial and local health authorities. Data saturation informed sample size of thirteen MHCs nurses were purposefully sampled to participate. Audio-recorded, semi-structured, online, one-on-one interviews guided by open-ended questions were done for data collection, and including demographic profile. The interview transcripts were analysed using Atlas-TI and SPSS descriptive statistics was used for demographics. Results: Eleven subthemes emerged under patient-related, nurse-related, and organisational-related themes which influence the operational factors in the MHCs, namely: patient defaulting treatment, lack of privacy, unavailability of phones, stressful and demotivating MHCs, nurses feel unsafe, lack of support from management, lack of budget, unavailability of computers, shortage of medical equipment, shortage of nursing staff and absence of data capturers. Conclusion: Structured contextual coaching and support program for nurses is imperative to ensure effective and strengthened operations in MHCs, further supported by improvement in human resource for health allocation for MHCs in light of expanding health care programs Contributions: Evaluation of health care programmes, and human resource for health quality improvement needs in the clinical practice of HIV care of MHCs nurses which advocate for specific policy formulations. [ABSTRACT FROM AUTHOR]

Background: Effectively addressing health disparities between Aboriginal and non-Aboriginal Australians is long overdue. Health services engaging Aboriginal communities in designing and delivering healthcare is one way to tackle the issue. This paper presents findings from evaluating a unique strategy of community engagement between local Aboriginal people and health providers across five districts in Perth, Western Australia. Local Aboriginal community members formed District Aboriginal Health Action Groups (DAHAGs) to collaborate with health providers in designing culturally-responsive healthcare. The purpose of the strategy was to improve local health service delivery for Aboriginal Australians.Methods: The evaluation aimed to identify whether the Aboriginal community considered the community engagement strategy effective in identifying their health service needs, translating them to action by local health services and increasing their trust in these health services. Participants were recruited using purposive sampling. Qualitative data was collected from Aboriginal participants and health service providers using semi-structured interviews or yarning circles that were recorded, transcribed and independently analysed by two senior non-Aboriginal researchers. Responses were coded for key themes, further analysed for similarities and differences between districts and cross-checked by the senior lead Aboriginal researcher to avoid bias and establish reliability in interpreting the data. Three ethics committees approved conducting the evaluation.Results: Findings from 60 participants suggested the engagement process was effective: it was driven and owned by the Aboriginal community, captured a broad range of views and increased Aboriginal community participation in decisions about their healthcare. It built community capacity through regular community forums and established DAHAGs comprising local Aboriginal community members and health service representatives who met quarterly and were supported by the Aboriginal Health Team at the local Population Health Unit. Participants reported health services improved in community and hospital settings, leading to increased access and trust in local health services.Conclusion: The evaluation concluded that this process of actively engaging the Aboriginal community in decisions about their health care was a key element in improving local health services, increasing Aboriginal people's trust and access to care. [ABSTRACT FROM AUTHOR]

Background: Increased numbers of children with chronic illnesses and/or disabilities who have complex care needs are living at home. Along with the transfer of care to the home setting, parents assume the primary responsibility of their child's complex care needs. Accordingly, it becomes even more important to understand the evolving roles and challenges faced by parents of children with complex care needs in order to better support them. The aim of this paper is to present research findings that add to our understanding of the roles parents assume in parenting their children with complex care needs.Methods: To arrive at a detailed and accurate understanding of families' perspectives and experiences, the qualitative research design of ethnography was used. In total, 68 parents from 40 families were recruited. Data collection strategies included ethnographic methods of interviewing and photovoice. Several levels of analysis generated a sociocultural theme with subthemes representing how parents experienced raising children with complex care needs within the context of their life situations.Results: Intense parenting as the overarching theme refers to the extra efforts parents had to commit to in raising their children with complex care needs. Parenting was described as labour-intensive, requiring a readiness to provide care at any time. This left parents with minimal time for addressing any needs and tasks not associated with caring for their child. The main theme is supported by four sub-themes: 1) the good parent; 2) more than a nurse; 3) there's just not enough; 4) it takes a toll on the health of parents.Conclusions: Overall, parents of children with complex care needs take on more roles as well as work more intensely at these roles than parents of healthy children. This, in turn, has led to the need for additional supports and resources for parents. However, to date, parents of children with complex care needs are still lacking adequate services and supports necessary to help them in their role of intense parenting. The findings sensitize professionals to the issues confronted by parents caring for children with complex care needs. Implications for further research and clinical practice are discussed. [ABSTRACT FROM AUTHOR]

Background: Health care organizations need to be responsive to the needs of increasingly diverse patient populations. We compared the contents of six publicly available approaches to organizational responsiveness to diversity. The central questions addressed in this paper are: what are the most consistently recommended issues for health care organizations to address in order to be responsive to the needs of diverse groups that differ from the majority population? How much consensus is there between various approaches?Methods: We purposively sampled six approaches from the US, Australia and Europe and used qualitative textual analysis to categorize the content of each approach into domains (conceptually distinct topic areas) and, within each domain, into dimensions (operationalizations). The resulting classification framework was used for comparative analysis of the content of the six approaches.Results: We identified seven domains that were represented in most or all approaches: organizational commitment, empirical evidence on inequalities and needs, a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and actively promoting responsiveness. Variations in the operationalization of these domains related to different scopes, contexts and types of diversity. For example, approaches that focus on ethnic diversity mostly provide recommendations to handle cultural and language differences; approaches that take an intersectional approach and broaden their target population to vulnerable groups in a more general sense also pay attention to factors such as socio-economic status and gender.Conclusions: Despite differences in labeling, there is a broad consensus about what health care organizations need to do in order to be responsive to patient diversity. This opens the way to full scale implementation of organizational responsiveness in healthcare and structured evaluation of its effectiveness in improving patient outcomes. [ABSTRACT FROM AUTHOR]

Background: In spite of the investments made by the Ugandan Government, the utilisation of maternal health services has remained low, resulting in a high maternal mortality (438 maternal deaths per 100,000 live births). Aiming to reduce poor women's constraints to the utilisation of services, an intervention consisting of a voucher scheme and health system strengthening was implemented. This paper presents the lessons learnt during the setup and implementation of the intervention in Eastern Uganda, in order to inform the design and scale up of similar future interventions.Methods: The key lessons were synthesised from a variety of project reports, as well as qualitative data drawn from six focus group discussions and four in-depth interviews conducted in the Buyende and Pallisa districts during the implementation phase of the voucher scheme.Results and Conclusions: To promote the successful implementation of interventions with demand and supply side initiatives, such as voucher schemes, the health system should be able to respond to the demand created by providing the additional required resources such as health workers, essential supplies and equipment. Involving a diverse, multi-sectoral group of stakeholders is important for addressing the different barriers experienced by women when seeking maternal health services. Voucher schemes should have a mechanism of detecting unintended consequences and mitigating them. Sustainability plans should be built into such interventions to maintain the gains achieved. Lastly, health policy planners can use this information to develop follow-up programmes to test modified versions that are more sustainable. Such programmes could use locally existing community structures for management and resource mobilisation for self-sustainment. [ABSTRACT FROM AUTHOR]

Background: Chronic disease management presents enormous challenges to the primary care workforce because of the rising epidemic of cardiovascular risk factors. The chronic care model was proven effective in improving chronic disease outcomes in developed countries, but there is little evidence of its effectiveness in developing countries. The aim of this study was to evaluate the effectiveness of the EMPOWER-PAR intervention (multifaceted chronic disease management strategies based on the chronic care model) in improving outcomes for type 2 diabetes mellitus and hypertension using readily available resources in the Malaysian public primary care setting. This paper presents the study protocol. Methods/Design: A pragmatic cluster randomised controlled trial using participatory action research is underway in 10 public primary care clinics in Selangor and Kuala Lumpur, Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Each clinic consecutively recruits type 2 diabetes mellitus and hypertension patients fulfilling the inclusion and exclusion criteria over a 2-week period. The EMPOWER-PAR intervention consists of creating/strengthening a multidisciplinary chronic disease management team, training the team to use the Global Cardiovascular Risks Self-Management Booklet to support patient care and reinforcing the use of relevant clinical practice guidelines for management and prescribing. For type 2 diabetes mellitus, the primary outcome is the change in the proportion of patients achieving HbA1c < 6.5%. For hypertension without type 2 diabetes mellitus, the primary outcome is the change in the proportion of patients achieving blood pressure < 140/90 mmHg. Secondary outcomes include the proportion of patients achieving targets for serum lipid profile, body mass index and waist circumference. Other outcome measures include medication adherence levels, process of care and prescribing patterns. Patients' assessment of their chronic disease care and providers' perceptions, attitudes and perceived barriers in care delivery and cost-effectiveness of the intervention are also evaluated. Discussion: Results from this study will provide objective evidence of the effectiveness and cost-effectiveness of a multifaceted intervention based on the chronic care model in resource-constrained public primary care settings. The evidence should instigate crucial primary care system change in Malaysia. Trial Registration: ClinicalTrials.gov NCT01545401 [ABSTRACT FROM AUTHOR]

Purpose: As the older adult population in Taiwan continues to increase, primary health centers (PHCs) play a crucial role in geriatric care. This study explored the differences in the PHC experiences and usage needs of older adults in urban versus rural areas. Methods: A qualitative study was conducted. Twenty-one older adults were recruited from PHCs in northern, central, southern, and eastern Taiwan. Semistructured interviews were used to collect data, and the interview guidelines included their reasons for visiting PHCs, the health-care services they received, their evaluation of the services, and the advantages and disadvantages of these centers. The data were analyzed using thematic content analysis. Results: The PHC usage needs of older adults in urban areas differ from those of older adults in rural areas in the following 3 aspects: (1) Medical services: older adults in rural areas demand clinics specializing in various medical domains, mobile and home medical care, and case management, whereas those in urban areas demand mobile health examinations. (2) Environment and transportation: older adults in rural areas demand diverse medical equipment, shuttle services, and accessible facilities, whereas those in urban areas demand recreational facilities. (3) Active aging: older adults in rural areas demand health education courses, and those in urban areas demand diverse senior citizen courses as well as opportunities to volunteer and build interpersonal relationships. Conclusion: The older adults in urban and rural areas had different PHC usage needs. The older adults in rural areas generally focused on medical care and transportation services in PHCs, whereas those in urban areas generally focused on health promotion as a means of social participation and active aging. [ABSTRACT FROM AUTHOR]

Chinese health system remains the crucial one for understanding the wider healthcare landscape across the Global South and in particular the leading Emerging Markets. Purpose of our observation was to understand the inner dynamics of mainland Chinese health reforms adopting a lengthy time horizon. We have analysed the public reports and seminal evidence on Chinese of multiple waves of national health reforms taking place since 1980s in terms of medical care and pharmaceuticals provision and financing. Chinese international trade with ASEAN nations and wider South-East Asia is accelerating its growth after the recovery of trade routes. In terms of health sector this means that global demand and supply of medical goods, services and pharmaceuticals remains largely driven by Chinese domestic developments. Furthermore, Chinese domestic manufacturing and sales of decent quality medical devices and services have grown exponentially. Some temporary pitfalls and increasing in rural–urban inequalities in equity of access and affordability of medical care and pharmaceuticals did take place. Despite these difficulties to generate a balanced development strategy for the largest global market, this is a clear path upwards. Further upcoming improvements expanding health insurance coverage are in strong demand for certain layers of the society. Domestic bottleneck weaknesses yet remain manufacturing, import and market penetration of cutting-edge pharmaceuticals such as monoclonal antibodies and targeted oncology agents. Yet some of these obstacles are likely to be overcome in foreseeable future with the adoption of responsible strategies by governmental agencies in health care arena. [ABSTRACT FROM AUTHOR]

Background: Community engagement is increasingly seen as crucial to achieving high quality, efficient and collaborative care. However, organisations are still searching for the best and most effective ways to engage citizens in the shaping of health and care services. This review highlights the barriers and enablers for engaging communities in the planning, designing, governing, and/or delivering of health and care services on the macro or meso level. It provides policymakers and professionals with evidence-based guiding principles to implement their own effective community engagement (CE) strategies.Methods: A Rapid Realist Review was conducted to investigate how interventions interact with contexts and mechanisms to influence the effectiveness of CE. A local reference panel, consisting of health and care professionals and experts, assisted in the development of the research questions and search strategy. The panel's input helped to refine the review's findings. A systematic search of the peer-reviewed literature was conducted.Results: Eight action-oriented guiding principles were identified: Ensure staff provide supportive and facilitative leadership to citizens based on transparency; foster a safe and trusting environment enabling citizens to provide input; ensure citizens' early involvement; share decision-making and governance control with citizens; acknowledge and address citizens' experiences of power imbalances between citizens and professionals; invest in citizens who feel they lack the skills and confidence to engage; create quick and tangible wins; take into account both citizens' and organisations' motivations.Conclusions: An especially important thread throughout the CE literature is the influence of power imbalances and organisations' willingness, or not, to address such imbalances. The literature suggests that 'meaningful participation' of citizens can only be achieved if organisational processes are adapted to ensure that they are inclusive, accessible and supportive of citizens. [ABSTRACT FROM AUTHOR]

Background: This is the eighth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was a systematic, integrated, evidence-based program for disinvestment within a large Australian health service. One of the aims was to explore methods to deliver existing high quality synthesised evidence directly to decision-makers to drive decision-making proactively. An Evidence Dissemination Service (EDS) was proposed. While this was conceived as a method to identify disinvestment opportunities, it became clear that it could also be a way to review all practices for consistency with current evidence. This paper reports the development, implementation and evaluation of two models of an in-house EDS.Methods: Frameworks for development of complex interventions, implementation of evidence-based change, and evaluation and explication of processes and outcomes were adapted and/or applied. Mixed methods including a literature review, surveys, interviews, workshops, audits, document analysis and action research were used to capture barriers, enablers and local needs; identify effective strategies; develop and refine proposals; ascertain feedback and measure outcomes.Results: Methods to identify, capture, classify, store, repackage, disseminate and facilitate use of synthesised research evidence were investigated. In Model 1, emails containing links to multiple publications were sent to all self-selected participants who were asked to determine whether they were the relevant decision-maker for any of the topics presented, whether change was required, and to take the relevant action. This voluntary framework did not achieve the aim of ensuring practice was consistent with current evidence. In Model 2, the need for change was established prior to dissemination, then a summary of the evidence was sent to the decision-maker responsible for practice in the relevant area who was required to take appropriate action and report the outcome. This mandatory governance framework was successful. The factors influencing decisions, processes and outcomes were identified.Conclusion: An in-house EDS holds promise as a method of identifying disinvestment opportunities and/or reviewing local practice for consistency with current evidence. The resource-intensive nature of delivery of the EDS is a potential barrier. The findings from this study will inform further exploration. [ABSTRACT FROM AUTHOR]

Background: People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. Methods: We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. Results: Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. Conclusions: The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care. Trial registration: This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687. [ABSTRACT FROM AUTHOR]

Background: Maternal healthcare service is the care given for the woman during her gestation, delivery and postpartum period. The Maternal Mortality Ratio (MMR) was remains high and a public health problem in Ethiopia. Sub-Saharan African (SSA) countries account two-thirds of the global total maternal deaths. To curb such high burden related with child births, comprehensive emergency obstetric care is designed as one of the strategies for maternal healthcare services. However, its implementation status was not well investigated. This study aims to evaluate the implementation of comprehensive emergency obstetric and new born care program in terms of Availability, compliance and acceptability dimensions at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. Methods: A single case study design was employed from 01 to 30 April 2021. A total of 265 mothers who gave birth at University of Gondar Comprehensive Specialized Hospital (UoGCSH) during the data collection period for acceptability, 13 key informant interviews (KIIs), 49 non-participatory observations (25 observations during C/S performance and 24 assisted spontaneous vaginal deliver) and 320 retrospective document review were conducted. Availability, compliance and acceptability dimensions were evaluated using 32 indicators. Binary logistic regression model was fitted to identify factors associated with acceptability of the services. Adjusted Odds Ratio (AOR) with 95% confidence interval (CI) and p-value < 0.05 were also used to identify associated variables with acceptability. The qualitative data were recorded using tape recorder, transcribed in Amharic and translated to English language. Thematic analysis was done to supplement the quantitative findings. Results: The overall implementation of comprehensive emergency obstetric and newborn care (CEmONC) was 81.6%. Moreover, acceptability, availability and care provider's compliance with the guideline accounted 81, 88.9 and 74.8%, respectively. There were stocked-out of some essential drugs, such as methyldopa, nifidipine, gentamycin and vitamin K injection. CEmONC training gaps, inadequate number of autoclaves, shortage of water supply and long-distance delivery ward to laboratory unit were also the barriers for the CEmONC service. Short waiting time of clients (AOR = 2.40; 95%CI: 1.16, 4.90) and maternal educational level (AOR = 5.50, 95%CI: 1.95, 15.60) were positively associated with acceptability of CEmONC services. Conclusion: The implementation status of CEmONC program was good as per our judgment parameter. Compliance of healthcare providers with the guideline was fair and needed improvement. Essential emergency drugs, equipment and supplies were stocked-out. The University of Gondar Comprehensive Specialized Hospital was therefore had better to give great emphasis to expand maternity rooms/ units. The hospital had better to avail the resources and provide continuous capacity building for healthcare providers to enhance the program implementation. Plain Language Summary: Maternal healthcare service is the care given for the woman during her gestation, delivery and postpartum period. The Maternal Mortality Ratio (MMR) was remains high and a public health problem in Ethiopia. Sub-Saharan African (SSA) countries account two-thirds of the total global maternal deaths. To curb such high burden related with child births, comprehensive emergency management obstetric and newborn care is designed as one of the strategies for maternal healthcare services. The implementation status of CEmONC program service at University of Gondar comprehensive specialized hospital was good as per the preset judgment parameter. Unavailability of resources such as delivery couch, operational table, maternity and labor ward beds, glove, gauze, blood, vital sign instruments, and essential drugs including methyldopa, nifidipine, gentamycin, and vitamin K were stocked out and the challenges to provide CEmONC services. Healthcare providers' compliance with the implementation protocol were also fairly affected. Moreover, acceptability CEmONC service was also judged as good as per the judgmental evaluation parameter. Hospital had better to fulfil the necessary equipment and drugs to enhance the implementation status of the hospitals. Capacity building of healthcare providers might also a better strategy to improve the compliance. Strengthening awareness creation for women and their husbands had a paramount importance to enhance the acceptability of the services. [ABSTRACT FROM AUTHOR]

Background: Primary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Māori and non-Māori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Māori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care. Methods: We conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes. Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response. Results: The study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Māori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Māori, Pacific and Trust/NGO practices. There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Māori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes. Conclusions: Model-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care. [ABSTRACT FROM AUTHOR]

Background: Meeting the demands of older adults for health promotion services (DOAHPS) is essential for maintaining their health and enhancing their quality of life. The purpose of this study was to construct a model for evaluating DOAHPS to quantitatively evaluate the current state and equity level of DOAHPS in China, as well as to explore the main factors affecting DOAHPS' current state and equity level. Methods: This study analyzed the DOAHPS data from the "Survey on Chinese Residents' Health Service Demands in the New Era", which included 1542 older adults aged 65 and older. Relationships between evaluation indicators of DOAHPS were explored using Structural Equation Modeling (SEM). The Weighted TOPSIS method and Logistic regression (LR) were used to analyze the current state and factors impacting DOAHPS. The equity level of DOAHPS' allocation among different older adult groups and its influencing factors were determined using the Rank Sum Ratio (RSR) method and T Theil index. Results: The evaluation score for DOAHPS was 42.57 ± 1.51. Health status, health literacy and behavior were positively correlated with DOAHPS (r = 0.40, 0.38; P < 0.05). The LR results revealed that the most significant determinants of DOAHPS were sex, residence, education level and pre-retirement occupation (all P < 0.05). The number of older adults with very poor, poor, general, high and very high level health promotion service demands accounted for 2.27%, 28.60%, 53.05%, 15.43% and 0.65%, respectively. The total T Theil index of DOAHPS was 2.7433*10–4, and the intra-group difference contribution rate exceeded 72%. Conclusions: Compared to the maximum level, the total DOAHPS level was found to be moderate, although the demands of urban seniors with higher levels of education may be substantially greater. The observed inequities in the allocation of DOAHPS were primarily related to differences in education level and pre-retirement occupation within group. To better address health promotion services for older adults, policymakers could target older males with low education who reside in rural regions. [ABSTRACT FROM AUTHOR]

Background: Traumatic events are associated with psychological and physical health problems for women in the perinatal period (i.e., pregnancy-12-months after childbirth). Despite the negative impact of trauma on perinatal women, the long-term impact of such diverse trauma and women's experience during the perinatal period remains understudied. Methods: This study explored two research questions: 1) What are the psychological experiences of perinatal women who have experienced interpersonal traumatic events? And 2) What are the service needs and gaps expressed by women relating to perinatal medical protocols and psychological services? These questions were addressed via in-depth semi-structured qualitative interviews with nine perinatal women (one pregnant and eight postpartum) residing in central Canada who reported experiencing interpersonal traumatic events occurring from adolescence to the perinatal period. Recruitment and data collection occurred from October 2020 to June 2021. Interviews were audio-recorded, transcribed, and analyzed according to constructivist grounded theory. Results: The emergent grounded theory model revealed the central theme of the role of prior trauma in shaping women's perinatal experiences, with four related main themes including perinatal experiences during the COVID-19 pandemic, the role of social support in women's perinatal experiences, the barriers that women experienced while seeking psychological and medical services prior to the perinatal period and during the perinatal period, and the specific needs of perinatal women with a history of interpersonal trauma. Conclusions: Findings of this research highlight the negative and long-lasting impact of traumatic events experienced on women's psychological health and psychosocial functioning during the perinatal period, as well as perinatal women's unmet psychological and medical service needs. A call to action for perinatal researchers and clinicians is imperative in furthering this important area of research and practicing person-centered and trauma-informed care with this population. [ABSTRACT FROM AUTHOR]

Background: Up to half of adults with advanced cancer report anxiety or depression symptoms, which can cause avoidance of future planning. We present a study protocol for an innovative, remotely-delivered, acceptance-based, multi-modal palliative care intervention that addresses advance care planning (ACP) and unmet psychological needs commonly experienced by adults with metastatic cancer. Methods: A two-armed, prospective randomized controlled trial (RCT) randomizes 240 adults with Stage IV (and select Stage III) solid tumor cancer who report moderate to high anxiety or depression symptoms to either the multi-modal intervention or usual care. The intervention comprises five weekly two-hour group sessions (plus a booster session one month later) delivered via video conferencing, with online self-paced modules and check-ins completed between the group sessions. Intervention content is based on Acceptance and Commitment Therapy (ACT), an acceptance, mindfulness, and values-based model. Participants are recruited from a network of community cancer care clinics, with group sessions led by the network's oncology clinical social workers. Participants are assessed at baseline, mid-intervention, post-intervention, and 2-month follow-up. The primary outcome is ACP completion; secondary outcomes include anxiety and depression symptoms, fear of dying, and sense of life meaning. Relationships between anxiety/depression symptoms and ACP will be evaluated cross-sectionally and longitudinally and theory-based putative mediators will be examined. Discussion: Among adults with advanced cancer in community oncology settings, this RCT will provide evidence regarding the efficacy of the group ACT intervention on ACP and psychosocial outcomes as well as examine the relationship between ACP and anxiety/ depression symptoms. This trial aims to advance palliative care science and inform clinical practice. Trial Registration: Clinicaltrials.gov NCT04773639 on February 26, 2021. [ABSTRACT FROM AUTHOR]

Background: Studies show that sexual and gender minorities have unique health care needs and encounter complicated problems to access health services. Drawing on the intersectionality approach, this paper examines the intersecting factors that determine health care seeking behaviour and utilization of health care services among Lesbians, Gays and Bisexuals (LGB) in Ethiopia including the diversity in experiences of these determinants and differences in the coping mechanisms to navigate these challenges within the LGB group. Despite the importance, there remains a paucity of evidence on the topic in Ethiopia. Methods: A concurrent mixed method design was used including survey of 100 LGB, and in-depth interviews and an FGD with 10 and 8 participants, each respectively. The quantitative data was analysed using descriptive statistics. Qualitative data was analysed thematically and triangulated with quantitative data. Results: The results show that heteronormativity intersects with LGB's social position (sexual identity, social network and class) to influence health care need, health seeking behaviour or access to health services. Sexual health and mental health problems are main concerns of LGB, who reported to live under acute anxiety and fear of being exposed, or bringing shame and humiliation to themselves or their families. One of the main emerging themes from the research is the link between mental health and risky sexual practices. Risk perception to HIV was high among LGB, with two-thirds reporting high risk. Only 37.5% (33/88) stated being always motivated to seek care when sick and the rest cited the following barriers that stifled their health seeking behaviour and utilization of health care services: Stigma and discrimination (83%), shame and embarrassment (83%), fear of being discovered (78%), lack of LGB friendly services (45%), affordability (18%), distance (17%), and health care professional refusal (10%). Conclusion: Homophobia and criminalization of homosexuality, and heteronormativity of health care services intersect with LGB's social position resulting in heterogeneity of risk, diversity of sexual and mental health needs, and difference in coping mechanisms (disadvantages and privilege). The main implication of the study is the need to recognize the existence of LGB and their diverse sexual and mental health needs, and link them to appropriate health care and pyscho-social services including HIV/AIDS prevention and treatment. [ABSTRACT FROM AUTHOR]

Value Based competition in Health Care (VBHC) has become a guiding principle in the quest for high quality health care for acceptable costs. Current literature lacks substantial ethical evaluation of VBHC.In this paper we describe how a single-minded focus on VBHC may cause serious infringements upon at least four medical ethical principles: 1) it tends to neglect patients' personal values; 2) it ignores the intrinsic value of the caring act; 3) it disproportionately replaces trust in professionals with accountability, and 4) it undermines solidarity.Health care needs a next step in VBHC. We suggest a 'Values-Driven Health Care' (VDHC) approach that a) takes patients' personal values as prescriptive and guiding; b) holds a value account that encompasses health care's intrinsic (gift) values; c) is based upon intelligent accountability that supports trust in trustworthy professionals, and d) encourages patients to raise their voices for the shared good of health care. [ABSTRACT FROM AUTHOR]

Background: In Ghana, prostate cancer is more prevalent than all other cancers, with a mortality rate of 75% partly due to late presentation to the health care facilities. Limited health services provision across the country and shortages of skilled nurses place a significant demand on family caregivers who are often ill-equipped for the caring role, resulting in many challenges. As they are expected to provide complex care at home with little resources, information, and support, the healthcare system rarely addresses the challenging needs of these family caregivers. This study explored the challenges encountered by family caregivers of people with prostate cancer. Methods: We conducted interviews using a descriptive phenomenological approach. Twelve family caregivers of prostate cancer patients were selected through a purposive sampling technique at the Cape Coast Teaching Hospital. All interviews were recorded, transcribed, and analysed using Colaizzi's (1978) data analysis approach. Results: Three main themes were identified as critical challenges: education and training needs, resources and caregiver-nurse relationship issues. Under the three main themes emerged seven sub-themes that collectively hindered the family caregiver's ability to meet the care demands. Sub-themes that emerged were; lack of preparedness towards the caring role, lack of knowledge about condition/ treatment, misconception about the condition, lack of accommodation facilities, financial constraints, poor communication, and poor staff attitude. Conclusion: Caregiving is associated with significant challenges that hinder the family caregiver's ability to care for the patient effectively, further diminishing the caregiver's quality of life and patient care. Therefore, healthcare professionals, especially nurses, should consider these challenges family caregivers face and take measures to obviate them through education, preparation and support. [ABSTRACT FROM AUTHOR]

Background: Government health subsidy (GHS) is an effective tool to improve population health in China. Ensuring an equitable allocation of GHS, particularly among the poorer socio-economic groups, is a major goal of China's healthcare reform. The paper aims to explore how GHS was allocated across different socioeconomic groups, and how well the overall health system was performing in terms of the allocation of subsidy for different types of health services. Methods: Data from China's National Health Services Survey (NHSS) in 2013 were used. Benefit incidence analysis (BIA) was applied to examine if GHS was equally distributed across income quintile. Benefit incidence was presented as each quintile's percentage share of total benefits, and the concentration index (CI) and Kakwani index (KI) were calculated. Health benefits from three types of healthcare services (primary health care, outpatient and inpatient services) were analyzed, separated into urban and rural populations. In addition, the distribution of benefits was compared to the distribution of healthcare need (measured by self-reported illness and chronic disease) across income quintiles. Results: In urban populations, the CI value of GHS for primary care was negative. (− 0.14), implying an allocation tendency toward poor region; the CI values of outpatient and inpatient services were both positive (0.174 and 0.194), indicating allocation tendencies toward rich region. Similar allocation pattern was observed in rural population, with pro-poor tendency of primary care service (CI = − 0.082), and pro-rich tendencies of outpatient (CI = 0.153) and inpatient services (CI = 0.203). All the KI values of three health services in urban and rural populations were negative (− 0.4991,-0.1851 and − 0.1651; − 0.482, − 0.247and − 0.197), indicating that government health subsidy was progressive and contributed to the narrowing of economic gap between the poor and rich. Conclusions: The inequitable distribution of GHS in China exited in different healthcare services; however, the GHS benefit is generally progressive. Future healthcare reforms in China should not only focus on expanding the coverage, but also on improving the equity of distribution of healthcare benefits. [ABSTRACT FROM AUTHOR]

Background: Indigenous peoples in developed countries have reduced life expectancies, particularly from chronic diseases. The lack of access to and take up of palliative care services of Indigenous peoples is an ongoing concern. Objectives: To examine and learn from published studies on provision of culturally safe palliative care service delivery to Indigenous people in Australia, New Zealand (NZ), Canada and the United States of America (USA); and to compare Indigenous peoples' preferences, needs, opportunities and barriers to palliative care. Methods: A comprehensive search of multiple databases was undertaken. Articles were included if they were published in English from 2000 onwards and related to palliative care service delivery for Indigenous populations; papers could use quantitative or qualitative approaches. Common themes were identified using thematic synthesis. Studies were evaluated using Daly's hierarchy of evidence-for-practice in qualitative research. Results: Of 522 articles screened, 39 were eligible for inclusion. Despite diversity in Indigenous peoples' experiences across countries, some commonalities were noted in the preferences for palliative care of Indigenous people: to die close to or at home; involvement of family; and the integration of cultural practices. Barriers identified included inaccessibility, affordability, lack of awareness of services, perceptions of palliative care, and inappropriate services. Identified models attempted to address these gaps by adopting the following strategies: community engagement and ownership; flexibility in approach; continuing education and training; a whole-of-service approach; and local partnerships among multiple agencies. Better engagement with Indigenous clients, an increase in number of palliative care patients, improved outcomes, and understanding about palliative care by patients and their families were identified as positive achievements. Conclusions: The results provide a comprehensive overview of identified effective practices with regards to palliative care delivered to Indigenous populations to guide future program developments in this field. Further research is required to explore the palliative care needs and experiences of Indigenous people living in urban areas. [ABSTRACT FROM AUTHOR]

Introduction: Refugees have many complex health care needs which should be addressed by the primary health care services, both on their arrival in resettlement countries and in their transition to long-term care. The aim of this narrative synthesis is to identify the components of primary health care service delivery models for such populations which have been effective in improving access, quality and coordination of care. Methods: A systematic review of the literature, including published systematic reviews, was undertaken. Studies between 1990 and 2011 were identified by searching Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service -- Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar. A limited snowballing search of the reference lists of all included studies was also undertaken. A stakeholder advisory committee and international advisers provided papers from grey literature. Only English language studies of evaluated primary health care models of care for refugees in developed countries of resettlement were included. Results: Twenty-five studies met the inclusion criteria for this review of which 15 were Australian and 10 overseas models. These could be categorised into six themes: service context, clinical model, workforce capacity, cost to clients, health and non-health services. Access was improved by multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers. These services were affordable, appropriate and acceptable to the target groups. Coordination between the different health care services and services responding to the social needs of clients was improved through case management by specialist workers. Quality of care was improved by training in cultural sensitivity and appropriate use of interpreters. Conclusion: The elements of models most frequently associated with improved access, coordination and quality of care were case management, use of specialist refugee health workers, interpreters and bilingual staff. These findings have implications for workforce planning and training. [ABSTRACT FROM AUTHOR]

Background: Failures in care for people with learning disabilities have been repeatedly highlighted and remain an international issue, exemplified by a disparity in premature death due to poor quality and unsafe care. This needs urgent attention. Therefore, the aim of the study was to understand the care experiences of people with learning disabilities, and explore the potential patient safety issues they, their carers and families raised. Methods: Two data sources exploring the lived experience of care for people with learning disabilities were synthesised using an integrative approach, and explored using reflexive thematic analysis. This comprised two focus groups with a total of 13 people with learning disabilities and supportive staff, and 377 narratives posted publicly via the feedback platform Care Opinion. Results: The qualitative exploration highlighted three key themes. Firstly, health and social care systems operated with varying levels of rigidity. This contributed to an inability to effectively cater to; complex and individualised care needs, written and verbal communication needs and needs for adequate time and space. Secondly, there were various gaps and traps within systems for this population. This highlighted the importance of care continuity, interoperability and attending to the variation in support provision from professionals. Finally, essential 'dependency work' was reliant upon social capital and fulfilled by paid and unpaid caring roles to divergent extents, however, advocacy provided an additional supportive safety net. Conclusions: A series of safety inequities have been identified for people with learning disabilities, alongside potential protective buffers. These include; access to social support and advocacy, a malleable system able to accommodate for individualised care and communication needs, adequate staffing levels, sufficient learning disabilities expertise within and between care settings, and the interoperability of safety initiatives. In order to attend to the safety inequities for this population, these factors need to be considered at a policy and organisational level, spanning across health and social care systems. Findings have wide ranging implications for those with learning disabilities, their carers and families and health and social care providers, with the potential for international learning more widely. [ABSTRACT FROM AUTHOR]

Background: Singapore faces an ageing population with increasingly complex healthcare needs, a problem which could be addressed by high quality primary care. Many patients with complex needs are not managed by private general practitioners (GPs) who form the majority of the primary care workforce. Currently, there is paucity of literature describing the needs of these private GPs in providing such care. Aim: Understand the challenges, enablers and possible solutions from the perspective of private GPs in providing primary care of patients with complex needs. Method: We conducted a qualitative study using an inductive approach. Private GPs were interviewed using a semi-structured question guide with convenience sampling until thematic saturation was reached. These 12 interviewees were part of a network of clinics that provide primary care for complex patients who were recently discharged from a community hospital providing post-acute care. Data was transcribed prior to a process of familiarisation, coded and analysed using thematic analysis by three independent investigators. Results: Three themes emerged in the analysis. From a micro-organizational standpoint, private GPs and patients with complex needs must be willing to accept each other to have a therapeutic encounter (e.g., patients' multidimensional needs, GP clinic set-up is simple yet busy). Next, from a meso-organizational view, trust and good communication channels between the referring doctors and private GPs must exist for effective collaboration in managing complex care. Lastly, macro-organizationally, external stakeholders (e.g., policy-makers) should fund care models, which are financially viable to both patients, and private GPs (e.g., via adequate subsidies and renumeration respectively) as such complex care require many resources. Conclusion: Multiple factors exist which influence the ability of private GPs in Singapore to care for patients with complex needs. Addressing these factors may reduce the over dependence on high-cost hospitals for care delivery in similar healthcare systems. [ABSTRACT FROM AUTHOR]

Background: The population of incarcerated older adults is the fastest growing demographic in prisons. Older persons in custody have poorer health as compared with those in the community. The unmet and complex health care needs of incarcerated older adults with mental illness raise justice, safety, dignity and fairness in care as ethical concerns. As there exists research gap to better understand these concerns, the current study aimed at exploring the perspectives of mental health professionals on challenges in delivering ethically competent care to mentally ill incarcerated older adults in Canada.Methods: Thirty-four semi-structured interviews were conducted between August 2017 and November 2018 with prison mental health professionals in Canada who were selected using purposive and convenience sampling techniques. The audio recorded interviews were transcribed verbatim and analysed inductively to generate themes.Results: The results were distilled into three main categories and seven subcategories that related to ethical issues in the provision of health care for mentally ill incarcerated older adults. The main categories included imprisoned older persons with special care needs, lack of resources, and the peer-support program.Conclusions: Results of this study showed that existing practices of care of mentally ill incarcerated older adults are characterised by challenges that increase their vulnerability to worse health conditions. It is imperative for local authorities, policy makers and representatives to prepare for and respond to the challenges that compromise ethically competent health care for, and healthy ageing of, mentally ill incarcerated older adults. [ABSTRACT FROM AUTHOR]

Persisting evidence suggests significant socioeconomic and sociodemographic inequalities in access to medical treatment in the UK. Consequently, a systematic review was undertaken to examine these access inequalities in relation to hip replacement surgery. Database searches were performed using MEDLINE, PubMed and Web of Science. Studies with a focus on surgical need, access, provision and outcome were of interest. Inequalities were explored in the context of sociodemographic characteristics, socioeconomic status (SES), geographical location and hospital-related variables. Only studies in the context of the UK were included. Screening of search and extraction of data were performed and 482 articles were identified in the database search, of which 16 were eligible. Eligible studies consisted of eight cross-sectional studies, seven ecological studies and one longitudinal study. Although socioeconomic inequality has somewhat decreased, lower SES patients and ethnic minority patients demonstrate increased surgical needs, reduced access and poor outcomes. Lower SES and Black minority patients were younger and had more comorbidities. Surgical need increased with age. Women had greater surgical need and provision than men. Geographical inequality had reduced in Scotland, but a north-south divide persists in England. Rural areas received greater provision relative to need, despite increased travel for care. In all, access inequalities remain widespread and policy change driven by research is needed. [ABSTRACT FROM AUTHOR]

Background: It is necessary to invest in married adolescent girls' health because of their roles in promoting the community and health of the next generation. Meanwhile, there are many concerns about their sexual and reproductive health. The International Conference on Population and Development emphasized the importance of access to adolescent girls to reproductive health services and counseling. In Iran, about 24% of registered marriages are to girls under 19, while their sexual and reproductive health needs have neglected. Therefore, this study aimed to identify married adolescent girls' reproductive and sexual needs. Methods/design: Data were obtained through in-depth, semi-structured individual interviews with 36 participants, including 11 women who got married at 10 to 21 years of age, two mothers whose daughters were married in adolescence, and 23 healthcare providers and policymakers. The participants were selected through purposive sampling with maximum variation. Data collection continued until data saturation. The interviews were analyzed by qualitative content analysis. Similar codes were merged, and sub-categorization was performed, whereby similar categories were combined until the main categories that emerged. Results: The results revealed five main categories: preparing for marriage, enhancing awareness and decision—making power on sexual and reproductive health issues, developing adolescent-friendly sexual and reproductive services, providing tailored pregnancy and childbirth services, and preparing adolescents for motherhood. Conclusion: Adolescents step into marital life without the required life skills or physical and mental preparedness. They often become pregnant due to social pressures and lack of access to contraception. Therefore, in countries like Iran, where there is a high frequency of early marriage, families, education, and the health system should prepare the necessary foundation to support these adolescents and provide tailored and comprehensive sexual and reproductive health services. Plain English summary: Married adolescent girls have unique sexual and reproductive health needs; however, the appropriate services have not always been provided. This was a qualitative study conducted in Iran to explore married adolescent girls' reproductive and sexual needs. We found that married adolescent girls were not prepared for marriage and had limited awareness and decision-making power on sexual and reproductive issues. There is a need to develop adolescent-friendly sexual and reproductive services. It is essential to give tailored pregnancy and childbirth services and prepare adolescents for motherhood. Adolescents step into marital life without the required life skills and physical and mental preparedness. They do not have the proper knowledge and ability to decide on sexuality and reproductive issues. Therefore, families, education, and health system should prepare the necessary foundation to support and empower these adolescents, and provide tailored and comprehensive sexual and reproductive health services. [ABSTRACT FROM AUTHOR]

Background: Optimal, need-based, and equitable allocation of financial resources is one of the most important concerns of health systems worldwide. Fulfilling this goal requires considering various criteria when allocating resources. The present study was conducted to identify the need indicators used to allocate health resources in different countries worldwide.Methods: A systematic review conducted on all published articles and reports on the need-based allocation of health financial resources in the English language from 1990 to 2020 in databases, including PubMed, Cochrane, and Scopus as well as those in Persian language databases, including magiran, SID, and Google and Google scholar search engines. After performing different stages of screening, appropriate studies were identified and their information were extracted independently by two people, which were then controlled by a third person. The extracted data were finally analyzed by content analysis method using MAXQDA 10 software.Result: This search yielded 823 studies, of which 29 were included for the final review. The findings indicated that many need-based resource allocation formulas attempt to deal with health care needs using some weighting methods for individuals. In this regard, the most commonly used indicators were found as follows: age, gender, socio-economic status or deprivation, ethnicity, standardized mortality ratio (SMR), the modified health indicators (disease consequences, self-assessed health, and disability), geographical area / place of residence (geographical) (rural versus urban), cross-boundary flows, cost of services, and donations.Conclusion: The indicators used in allocating the health systems' financial resources in each country should be designed in order to be simple and transparent and in accordance with the moral norms of that society. Moreover, these should be a good representative of the health needs of people in different geographical areas of that country. In addition, their related data should be available to an acceptable extent. [ABSTRACT FROM AUTHOR]

Background: Integrated primary care teams are ideally positioned to support the mental health care needs arising during the COVID-19 pandemic. Understanding how COVID-19 has affected mental health care delivery within primary care settings will be critical to inform future policy and practice decisions during the later phases of the pandemic and beyond. The objective of our study was to describe the impact of the COVID-19 pandemic on primary care teams' delivery of mental health care. Methods: A qualitative study using focus groups conducted with primary care teams in Ontario, Canada. Focus group data was analysed using thematic analysis. Results: We conducted 11 focus groups with 10 primary care teams and a total of 48 participants. With respect to the impact of the COVID-19 pandemic on mental health care in primary care teams, we identified three key themes: i) the high demand for mental health care, ii) the rapid transformation to virtual care, and iii) the impact on providers. Conclusions: From the outset of the COVID-19 pandemic, primary care quickly responded to the rising mental health care demands of their patients. Despite the numerous challenges they faced with the rapid transition to virtual care, primary care teams have persevered. It is essential that policy and decision-makers take note of the toll that these demands have placed on providers. There is an immediate need to enhance primary care's capacity for mental health care for the duration of the pandemic and beyond. [ABSTRACT FROM AUTHOR]

Background: The postpartum period is redefined as 12 weeks following childbirth. Primary care physicians (PCP) often manage postpartum women in the community after uneventful childbirths. Postpartum care significantly impacts on the maternal and neonatal physical and mental health. However, evidence has revealed unmet needs in postpartum maternal care. Aim: The study aimed to explore the experiences of PCPs in managing postpartum mothers. Methods: Four focus group discussions and eleven in-depth interviews with twenty-nine PCPs were conducted in this qualitative research study in urban Singapore. PCPs of both gender and variable postgraduate training background were purposively enrolled. Audited transcripts were independently coded by two investigators. Thematic content analysis was performed using the codes to identify issues in the "clinician", "mother", "postpartum care" and "healthcare system & policy" domains stipulated in "The Generalists' Wheel of Knowledge, Understanding and Inquiry" framework. Findings: PCPs' personal attributes such as gender and knowledge influenced their postpartum care delivery. Prior training, child caring experience and access to resource materials contributed to their information mastery of postpartum care. Their professional relationship with local multi-ethic and multi-lingual Asian mothers was impacted by their mutual communication, language compatibility and understanding of local confinement practices. Consultation time constraint, awareness of community postnatal services and inadequate handover of care from the specialists hindered PCPs in the healthcare system. Discussion: Personal, maternal and healthcare system barriers currently prevent PCPs from delivering optimal postpartum care. Conclusion: Interventions to overcome the barriers to improve postpartum care will likely be multi-faceted across domains discussed. [ABSTRACT FROM AUTHOR]

Background: Medical Assessment Units (MAUs) have become a popular model of acute medical care to improve patient flow through timely clinical assessment and patient management. The purpose of this study was to determine the effectiveness of a consensus-derived set of clinical criteria for patient streaming from the Emergency Department (ED) to a 15-bed MAU within the highly capacity-constrained environment of a large quaternary hospital in Queensland, Australia.Methods: Clinically coded data routinely submitted for inter-hospital benchmarking purposes was used to identify the cohort of medical admission patients presenting to the ED in February 2016 (summer) and June 2016 (winter). A retrospective review of patient medical records for this cohort was then conducted to extract MAU admission data, de-identified patient demographic data, and clinical criteria. The primary outcome was the proportion of admissions that adhered to the MAU admission criteria.Results: Of the total of 540 included patients, 386 (71 %) patients were deemed to meet the MAU eligibility admission criteria. Among patients with MAU indications, 66 % were correctly transferred (95 % CI: 61 to 71) to the MAU; this estimated sensitivity was statistically significant when compared with random allocation (p-value < 0.001). Transfer outcomes for patients with contraindications were subject to higher uncertainty, with a high proportion of these patients incorrectly transferred to the MAU (73 % transferred; 95 % CI: 50 to 89 %; p-value = 0.052).Conclusions: Based on clinical criteria, approximately two-thirds of patients were appropriately transferred to the MAU; however, a larger proportion of patients were inappropriately transferred to the MAU. While clinical criteria and judgement are generally established as the process in making decisions to transfer patients to a limited-capacity MAU, our findings suggest that other contextual factors such as bed availability, time of day, and staffing mix, including discipline profile of decision-making staff during ordinary hours and after hours, may influence decisions in directing patient flow. Further research is needed to better understand the interplay of other determinants of clinician decision making behaviour to inform strategies for improving more efficient use of MAUs, and the impact this has on clinical outcomes, length of stay, and patient flow measures in MAUs. [ABSTRACT FROM AUTHOR]

Background: Elderly patients with multiple health problems often experience disease complications and functional failure, resulting in a need for health care across different health care systems during care trajectory. The patients' perspective of the care trajectory has been insufficiently described, and thus there is a need for new insights and understanding. The study aims to explore how elderly patients with complex health problems engage in and interact with their care trajectory across different health care systems where several health care personnel are involved.Methods: The study had an explorative design with a qualitative multi-case approach. Eleven patients (n = 11) aged 65-91 years participated. Patients were recruited from two hospitals in Norway. Observations and repeated interviews were conducted during patients' hospital stays, discharge and after they returned to their homes. A thematic analysis method was undertaken.Results: Patients engaged and positioned themselves in the care trajectory according to three identified themes: 1) the patients constantly considered opportunities and alternatives for handling the different challenges and situations they faced; 2) patients searched for appropriate alliance partners to support them and 3) patients sometimes circumvented the health care initiation of planned steps and took different directions in their care trajectory.Conclusions: The patients' considerations of their health care needs and adjustments to living arrangements are constant throughout care trajectories. These considerations are often long term, and the patient engagement in and management of their care trajectory is not associated with particular times or situations. Achieving consistency between the health care system and the patient's pace in the decision-making process may lead to a more appropriate level of health care in line with the patient's preferences and goals. [ABSTRACT FROM AUTHOR]

Background: All adults over 17 years of age have access to the Public Dental Service after the Finnish Dental Care Reform in 2001–2002. This study aimed to survey the treatment needs and treatment measures provided for adult patients and changes in these during the period 2001–2013. Methods: Sing each person's unique identifier, demographic data on dental visits during the period 2001–2013 were collected from municipal databases in five PDS-units covering 320,000 inhabitants. The numbers of visitors, those in need of basic periodontal or caries treatment (CPI > 2 and D + d > 0) were calculated for three age groups. Treatment provided was also calculated in 13 treatment categories. Trend analyses were performed to study changes during the study period. Results: Restorative treatments (968,772; 23.6%), examinations (658,394; 16.1%), radiographs taken (529,875; 12.9%) anaesthesia used (521,169; 12.7%) and emergency treatments (348,229; 8.5%) made up 73.8% of all treatment measures during the entire study period. Periodontal treatment (7.8%) and caries prevention (3.9%) made up a small part of the care provided and prosthetics and treatment of TMJ disorders were extremely uncommon (fewer than 1%). Treatments related to caries (restorative treatment, examinations, endodontics, emergencies, anaesthesia and radiographs) made up 60.4% of the dental personnel's treatment time. During the study period, statistically significant increasing trends were found for radiographs (p < 0.001***), anaesthesia (p = 0.003**) and total number of treatments (p = 0.009**). There was a slight decreasing trend in treatment need among the youngest adults (18–39 years; p = 0.033*). Conclusion: Compared with the results of national epidemiological studies, insufficient periodontal treatment is provided and prosthetic treatment is almost totally neglected in the PDS. Rather, adults' dental treatment concentrates on treatment of caries. The unmet needs may be due to tradition, inadequate treatment processes or a lack of resources or failed salary incentives. [ABSTRACT FROM AUTHOR]

Background: Elderly in need of long-term care tend to have worse health and have higher need of medical care than elderly without need for long-term care. Yet, characteristics associated with long-term care need can impede health care access: Higher levels of long-term care need come with physical and cognitive decline such as frailty and memory loss. Yet, it has not been investigated whether level of long-term care need is related to medical care utilization. Methods: We investigated the association between the level of long-term care and medical specialist utilization among nursing home residents and home care recipients. We applied zero-inflated Poisson regression with robust standard errors based on a sample of statutory health insurance members. The sample consisted of 100.000 elderly over age 60. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner utilization. Results: We found a strong gradient effect of the level of long-term care for 9 out of 12 medical specialties: A higher level of long-term care need was associated with a lower probability of having a medical specialist visit. Yet, we did not find clear effects of the level of long-term care need on the intensity of medical specialist care. These findings were similar for both the nursing home and home care setting. Conclusion: The findings indicate that inequalities in medical specialist utilization exist between elderly with differing levels of long-term care need because differences in morbidity were controlled for. Elderly with higher need of long-term care might face more access barriers to specialist medical care. [ABSTRACT FROM AUTHOR]

Background: Depression is a major public health concern. E-health interventions for preventing and reducing depressive complaints have proven to be effective, and have the potential to make (mental) health care more accessible and efficient. However, the reach of these interventions needs to be improved, especially among people with a lower socioeconomic status (SES). Stimulating and supporting implementation of e-health in primary care, and offering guidance from general practice nurses (GP nurses) may be important strategies to achieve this.Methods/design: The online 'Complaint Directed Mini-Interventions' (CDMIs) for stress, sleep and worry complaints, which were found to be (cost-)effective in a self-guided format, will be implemented in the primary care setting using a blended care format (i.e. combining e-health with face-to-face sessions) with minimal guidance provided by the GP nurse. The main aim is to evaluate whether a SES-sensitive implementation strategy improves the participation rate (i.e. reach) of lower-SES patients in the blended online CDMIs as compared to a regular implementation strategy in a cluster randomised controlled trial. Randomisation will occur at the level of the GP nurse, and 228 patients will be included in the study. The primary outcome is the participation rate (completing at least one face-to-face session and two online exercises) of the lower-SES target group. It is hypothesised that this percentage will be higher in the SES-sensitive group as compared to the regular group. Secondary objectives are to evaluate the implementation process, to monitor and evaluate psychological complaints (depression, sleep, stress, worry and anxiety) and well-being over time. Patient assessments will take place at baseline, 3 and 12 months post baseline.Discussion: This study should contribute to our knowledge of reaching the lower-SES groups with a brief and complaint-specific blended approach for depressive complaints in primary care. It should also further our knowledge on successful strategies to implement depression prevention in primary care.Trial Registration: Netherlands Trial Register, ID: NL6595. Registered on 12 November 2017. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a serious heart arrhythmia associated with devastating outcomes such as stroke. Inequitable rural AF care may put patients at risk. Virtually delivered specialty AF care offers a viable option, but stakeholder perceptions of this option within the context of rural AF care is unknown. The study purpose was to obtain patient and primary care physician perspectives of rural AF care and virtually delivered AF care as a potential option. Methods: Using a mixed methods design, AF patients (n = 101) and physicians (n = 15) from three rural communities participated in focus groups and/or surveys. Focus group data were thematically analyzed, survey data were descriptively analyzed, and data were triangulated. Results: Findings captured patients' and physicians' perceptions of prioritized, needs, concerns and problems in AF management, available/unavailable services, and their ideas about virtual AF care. Patients and physicians identified eclectic problems in managing AF. Overall, patients felt ill informed about managing their AF and their most salient problems related to fatigue, exercise intolerance, weight maintenance, sleep apnea, and worry about stroke and bleeding. Physicians found treating patients with co-morbidities and cognitive decline problematic and balancing risks related to anticoagulation challenging. Patients and physicians identified education as a pressing need, which physicians lacked time and resources to meet. Despite available rural services, access to primary and cardiology care was a recurring challenge, and emergency department (ED) use highly contentious but often the only option for accessing care. Physicians' managed AF care and varied in the referrals they made, often reserving them for complex situations to avoid patient travel. Patients and providers supported a broad approach to virtual AF care, tailored to an inclusive rural patient demographic. Conclusions: The study offered valuable physician and patient perspectives on AF care in rural communities including diverse management challenges, gaps in access to primary and specialty services that made ED an often used but contentious option. Findings point to the potential value of virtual care designed to reach patients with AF across the spectrum and geared to local contexts that preserve the vital role of primary care physicians in AF care in their communities. [ABSTRACT FROM AUTHOR]

Background: Homeless people often suffer from complex and chronic comorbidities, have high rates of morbidity and die at much younger ages than the general population. Due to a complex combination of physical, psychosocial and addiction problems at the end of life, they often have limited access to palliative care. Both the homeless and healthcare providers experience a lot of barriers. Therefore, providing palliative care that fits the needs and concerns of the homeless is a challenge to healthcare providers. This systematic review aims to summarize evidence about the concerns, palliative care needs and preferences of homeless people, as well as barriers and facilitators for delivering high quality palliative care. Methods: PubMed, Embase, PsycINFO, CINAHL and Web of Science were searched up to 10 May 2016. Included were studies about homeless people with a short life expectancy, their palliative care needs and the palliative care provided, that were conducted in Western countries. Data were independently extracted by two researchers using a predefined extraction form. Quality was assessed using a Critical Appraisal instrument. The systematic literature review was based on the PRISMA statement. Results: Twenty-seven publications from 23 different studies met the inclusion criteria; 15 studies were qualitative and eight were quantitative. Concerns of the homeless often related to end-of-life care not being a priority, drug dependence hindering adequate care, limited insight into their condition and little support from family and relatives. Barriers and facilitators often concerned the attitude of healthcare professionals towards homeless people. A respectful approach and respect for dignity proved to be important in good quality palliative care. Conclusions: A patient-centred, flexible and low-threshold approach embodying awareness of the concerns of homeless people is needed so that appropriate palliative care can be provided timely. Training, education and experience of professionals can help to accomplish this. [ABSTRACT FROM AUTHOR]