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In this paper, we aim to establish a mathematical model to design a maximizing social welfare intervention mechanism of healthcare service goods in China. The intervention mechanism is helpful to facilitate the adoption of the healthcare service goods. We consider a research problem that regulates the supply chain system for healthcare service goods by an intervention mechanism, and two intervention strategies composed of demand-growth strategy and subsidy strategy are used to the combination of intervention mechanism. Then this paper presents a new method based on fuzzy set and bilevel programming to design the intervention mechanism. To demonstrate the effectiveness of the proposed model, we conduct a case study for Wudang personalized health package and verify our model by the specific result analysis, the result indicates that our joint intervention mechanism is helpful to achieve the target and increase social welfare. [ABSTRACT FROM AUTHOR]

Objective: This paper reflected on the prevalence of hypertension and diabetes in Bangladesh, which is spreading rapidly in low-income countries. The rationale of constructing more health centers for addressing NCDs was assessed in this paper by determining the relationship between prevalence of NCDs, particularly hypertension and diabetes, and distance to health facilities. Methods: From BDHS (Bangladesh Health and Demographic Survey) 2011 data set, 7544 samples were analyzed to demonstrate association between Non-communicable diseases (NCD) and distance from respondents’ home to health facilities like hospitals, community clinics, pharmacies or doctors’ chambers, and community facilities like market, post office or cinema hall. Bivariate analysis was conducted between accessibility to health facilities and prevalence of the diseases. The causal relationship between the spatial effects and the prevalence of the diseases were analyzed by applying Generalized Linear Mixed Model (GLMM) was fitted. Results: Fitting linear mixed effect models, we found that hypertension and diabetes react differently with various spatial effects. Distance from home to hospital had significant effect (P < 0.001) on hypertension showing people living further from the facilities or town centers seemed to be less hypertensive, whereas diabetes showed no such affiliation. Conclusion: Higher prevalence of diabetes (40.9%) over hypertension (26.5%) in people aging 35 or higher, have appeared to have caused the difference, which concluded that each non-communicable disease should be dealt to its own merit for policy making instead considering as a group of diseases. [ABSTRACT FROM AUTHOR]

Telemedicine has become an increasingly popular option for long-distance health care and continuing education. As information and communication technology is underdeveloped in China, telemedicine develops slowly. At present, telemedicine consultation centers are situated mainly in developed cities, such as Beijing, Shanghai, and Guangzhou. In many less developed regions, such as northwest China, the conditions or related facilities are not available for the application of a better medical service. Accordingly, the aim of this paper was to introduce the construction and application of a telemedicine consultation center in Gansu Province in the northwest of China. In addition, the function of Gansu Provincial Telemedicine Consultation Center on emergency public events was introduced. As a whole, there was a great demand for telemedicine service in the local medical institutions. In the telemedicine consultation center, the telemedicine equipments and regulations were needed to be improved. The function of telemedicine service was not fully used, there was a large space to be applied and the publicity of telemedicine service was important. What is important was that telemedicine played a significance role in promoting the medical policy reform, improving the medical environment and launching the remote rescue in the emergency public events. This paper emphasizes the health care challenges of poor regions, and indicates how to share the high-quality medical service of provincial hospitals effectively and how to help residents in resource-poor environments. [ABSTRACT FROM AUTHOR]

Background: Leprosy remains a disease of concern in many countries including Nepal. To achieve the target of elimination, the WHO strategy promotes comprehensive education of patients, healthcare workers (HCWs), and the public on leprosy-related issues. However most educational programs are based on the concerns of HCWs and not on patients’ needs. The objective of this paper is to explore the educational needs of leprosy affected patients in Nepal and compare them to the needs perceived by HCWs. Methodology/principal findings: Semi directive interviews were conducted with patients and HCWs. The data was analyzed using the basic interpretative qualitative framework. The study was conducted in two leprosy referral centers, one university hospital and one primary health care center: Lalgadh Leprosy Hospital and Services Centre, Anandaban Hospital and its satellite clinic in Patan, B. P. Koirala Institute of Health Sciences in Dharan, and the Itahari primary health care centre. The results show that there remains a lack of knowledge regarding the disease (origins, manifestations, prevention and treatment) contributing to late care seeking behavior and high levels of stigma, with an important psychological and financial stress for patients. All of the HCWs displayed a good understanding of patients’ difficulties and needs and acknowledged the key role of patient education. However, they expressed several challenges in managing patients due to lack of time, human resources and training in patient education. Conclusions/significance: Further efforts need to be made to increase patients’ general knowledge of the disease in order to motivate them to seek healthcare earlier and change their perception of the disease to reduce stigma. HCWs need proper training in patient education and counseling for them to acquire the necessary skills required to address the different educational needs of their patients. The use of lay and peer counselors would be an option to address the workload and lack of time expressed by HCWs. [ABSTRACT FROM AUTHOR]

Objective: Recognizing what physicians know and do not know about a particular disease is one of the keys to designing clinical decision support systems, since these systems can fulfill complementary role by recognizing this boundary. To our knowledge, however, no study has attempted to quantify how many diseases physicians actually know and thus the boundary is unclear. This study explores a method to solve this problem by investigating whether the vocabulary assessment techniques developed in the linguistics field can be applied to assess physicians’ knowledge. Methods: The test design required us to pay special attention to disease knowledge assessment. First, to avoid imposing unnecessary burdens on the physicians, we chose a self-assessment questionnaire that was straightforward to fill out. Second, to prevent overestimation, we used a “pseudo-word” approach: fictitious diseases were included in the questionnaire, and positive responses to them were penalized. Third, we used paper-based tests, rather than computer-based ones, to further prevent participants from cheating by using a search engine. Fourth, we selectively used borderline diseases, i.e., diseases that physicians might or might not know about, rather than well-known or little-known diseases, in the questionnaire. Results: We collected 102 valid answers from 109 physicians who attended the seminars we conducted. On the basis of these answers, we estimated that the average physician knew of 2008 diseases (95% confidence interval: (1939, 2071)). This preliminary estimation agrees with the guideline for the national license examination in Japan, suggesting that this vocabulary assessment was able to evaluate physicians’ knowledge. The survey included physicians with various backgrounds, but there were no significant differences between subgroups. Other implication for researches on clinical decision support and limitation of the sampling method adopted in this study are also discussed, toward more rigorous estimation in future surveys. [ABSTRACT FROM AUTHOR]

Introduction: Public health spending in India has been traditionally one of the lowest globally. Punjab is one of the states with highest proportion of out-of-pocket expenditures for healthcare in India. We undertook this study to produce the sub-national health accounts (SNHA) for Punjab state in India. Methodology: We used System of Health Accounts (SHA) 2011 framework for preparing health accounts for Punjab state. Data on health spending by government was obtained from concerned public sector departments both at state and central level. Estimates on Out-of-Pocket Expenditures (OOPE) expenditure were derived from National Sample Survey (NSS) 71st round data, Consumer Expenditure Survey (CES) data and Pharmatrac. Primary surveys were done for assessing health expenditure data by firms and non-governmental organizations. All estimates of healthcare expenditures reported in our paper pertain to 2013–14, and are reported in both Indian National Rupee (INR) and United States Dollar (US $),using average conversion rate of INR 60.50 per US $. Results: In 2013–14, the current health expenditures (CE) in Punjab was INR 134,680million (US $ 2245 million) which was 4.02% of its gross state domestic product (GSDP).However, public spending on health was 0.95% of GSDP i.e. 21% of the total health expenditure (THE), while 79% was private expenditure. In per capita terms, THE in Punjab was INR 4963 (US $ 82.03). In terms of functions, medical goods (41.6%) and curative care (37%) consumed larger share of expenditure in the Punjab state. Households spent 52% of expenditures for medicines and other pharmaceutical goods. Risk pooling mechanisms are being adopted to a lesser extent in the state. Conclusion: The healthcare in Punjab is largely financed through private OOPE. Currently, public health spending in Punjab is inadequate to meet the healthcare demands of population, which is less than 1% of state’s GSDP. Monitoring public resources is very important for better resource allocations. Health Accounts production is useful in order to assess future trends and impact of health financing policies on goals of universal health coverage and should be made a part of routine monitoring system both at national and sub-national level. [ABSTRACT FROM AUTHOR]

Background: This paper describes the association between workplace violence and job satisfaction among physicians and nurses in Macau. Convenience sampling was sourced from six health centers under the Macau Health Bureau. Methods: This study uses a cross-sectional self-administrative survey. The study used case studies research instruments for workplace violence in the health sector by country (from the ILO, ICN, WHO, PSI), the Minnesota Satisfaction Questionnaire and Perceived Stress Scale. The data collection period spanned from August to December, 2014. Data analysis: Multiple logistic regression examines levels of intrinsic and extrinsic satisfaction in physicians and nurses and significant correlates affecting their job satisfaction. Results: A total of 720 (14.9% physicians) participants were recruited. 57.2% of participants reported physical and psychological workplace violence in the preceding year. The most common forms of workplace violence were verbal abuse (53.4%), physical assault (16.1%), bullying / harassment (14.2%), sexual harassment (4.6%) and racial harassment (2.6%). Nurses were at a significantly higher risk of physical assault and verbal abuse compared to physicians. Patients, patients’ relatives, and colleagues were the main perpetrators. Worry about WPV, on-call duty and shift work, experience of bullying and verbal abuse and employment sector emerged as significant correlates affecting the intrinsic and extrinsic job satisfaction of physicians and nurses. Frontline staff, aged 30 and 39, coming from an ethnic minority, and perceived stress were significant correlates affecting nurses’ job satisfaction. Conclusions: WPV remains a significant concern in healthcare settings in Macau. Stakeholders should legally enforce a zero-tolerance policy towards WPV within healthcare workplaces. WPV is detrimental to healthcare professionals’ mental wellbeing, risking irreversible physical and psychological harm for its victims. [ABSTRACT FROM AUTHOR]

Waiting time for non-emergency medical care in developing countries is rarely of immediate concern to policy makers that prioritize provision of basic health services. However, waiting time as a measure of health system responsiveness is important because longer waiting times worsen health outcomes and affect utilization of services. Studies that assess socio-economic inequalities in waiting time provide evidence from developed countries such as England and the United States; evidence from developing countries is lacking. In this paper, we assess the relationship between social class i.e. caste of an individual and waiting time at health facilities—a client orientation dimension of responsiveness. We use household level data from two rounds of the Indian Human Development Survey with a sample size of 27,251 households in each wave (2005 and 2012) and find that lower social class is associated with higher waiting time. This relationship is significant for individuals that visited a male provider but not so for those that visited a female provider. Further, caste is positively related to higher waiting time only if visiting a private facility; for individuals visiting a government facility the relationship between waiting time and caste is not significant. In general, caste related inequality in waiting time has worsened over time. The results are robust to different specifications and the inclusion of several confounders. [ABSTRACT FROM AUTHOR]

This paper uses two nationally representative sets of medical claims data from medical assistance and universal public health insurance systems to examine how medical assistance system assignment affects short-term inpatient health care provision. In Japan, the medical assistance system, which is part of a public assistance system, provides medical care services for its beneficiaries without imposing any financial burdens, such as copayments or advance premium payments. These circumstances can lead to inpatient costs, as physicians may provide more treatments because there is a financial incentive. Because the assignment of public assistance in Japan is not random but is subject to means testing by the local government, I employ the instrumental variable model to control the potential correlation. I find that medical expenditure is significantly higher for medical assistance patients than for universal public health insurance patients, with an arc elasticity of approximately 0.20. This elasticity is slightly greater than that found for inpatient care in the randomized RAND Health Insurance Experiment and recent empirical studies on low-income populations. In addition, the elasticities for patients who receive medication, treatment and surgery are greater. [ABSTRACT FROM AUTHOR]

Background: The Philippine government has an extensive network of 513 Animal Bite Treatment Centers (ABTCs) to supply rabies post exposure prophylaxis (PEP), reaching over 1 million bite victims in 2016. The network was evaluated using a review of existing national and provincial data, key informant interviews and surveys in sample ABTCs to determine the cost-effectiveness of this network in preventing human rabies deaths. Methodology and principal findings: One urban and one rural ABTC in each of three selected provinces were studied in more detail. PEP delivery generally followed national guidance based on best practices, but there was evidence of operational challenges in supplying all ABTCs with adequate biologics and recently trained staff. Funding was contributed by different levels of government and in some clinics, patients paid for a significant fraction of the total cost. From a health provider perspective including both fixed and variable costs, the average PEP course delivered cost USD 32.91 /patient across urban ABTCs (with higher patient throughput) and USD 57.21 /patient across rural ABTCs. These costs suggests that PEP provision in the Philippines cost USD 37.6 million in 2016, with a cost per life saved of USD 8,290. An analysis of the 2,239 suspected rabies deaths from 2008 to 2016 showed no significant decline, and from 2014–16 an average of 8,534 years of life were lost annually. The incidence of rabies deaths from 2014–16 was not clearly related to the provision of ABTCs (per 100,000 population) or human population density, but deaths were more common in higher income provinces. Conclusions/Significance: In the context of comprehensive rabies control (including dog vaccination and public awareness) ways to reduce this high expenditure on PEP should be explored, to most cost-effectively reach the elimination of human rabies deaths. This paper is accompanied by another containing data on the operation of ABTCs network from a patient perspective. [ABSTRACT FROM AUTHOR]

Background: Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship. Objective: The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh. Methods: A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted. Results: A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household’s monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing. Conclusion and policy implications: Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs. [ABSTRACT FROM AUTHOR]

Background: Around the world, regulatory bodies have taken the lead in determining the competencies required to become a physician. As a first step in addressing this project, it was decided to develop a set of core competencies that were unique to China and that might serve as a basis for medical education. The purpose of this paper was to construct a competency model for clinical physicians in China. Methods: Data was collected using a cross-sectional survey of 6247 clinicians from seven administrative regions (31 provinces, autonomous regions and municipalities directly under the central government) in China. The total sample was randomly divided into two sub-samples, an initial sample (Sample 1) and a replication sample (Sample 2). Independent exploratory factor analysis was conducted in each sample and the results were compared to determine the stability. After that the confirmatory factor analysis was used to ascertain the competency model for physicians. The reliability, convergent and discriminant validity of competency-based instrument were also examined. Results: 76 items with 8 dimensions were identified, accounting for 68.41% of the construct’s total variance in the initial sample and 67.47% in the replication sample. For the two samples, the overall scale reliability (Cronbach’s alpha) was both 0.985 with dimensions from 0.905 to 0.954 for the initial sample and from 0.902 to 0.955 for the replication sample after deleting the items. In confirmatory factor analysis, the result showed that all items had acceptable goodness of fit index. RMSEA and SRMR were less than 0.08 (RMSEA = 0.046, SRMR = 0.040), while GFI, NFI, IFI, and CFI were higher than 0.9 (GFI = 0.905, NFI = 0.903, IFI = 0.909, CFI = 0.909), leading to acceptable construct validity. All construct reliability values of the factors were higher than 0.70, and all average variance extracted values exceeded 0.50. Thus, we considered the reliability and validity of the 8 dimensions were acceptable. Conclusions: The instrument was shown to be both valid and reliable for measuring clinical physicians’ competency in China. The results of the competency-based instrument can be used by ministry of health and administrators of hospitals to assess physicians’ competencies, encourage and guide them to modify their behaviors according to the evaluation criteria, and also cultivate physicians with strong clinical practice, innovation and independent scientific research ability. Through these measurements and understandings, the overall level of clinical physicians will be increased in China. [ABSTRACT FROM AUTHOR]

Introduction: Common mental disorders (CMD) such as depression, suicidal risk and emotional/medically unexplained complaints affect a large number of people in India, but few receive appropriate care. Key reasons for this include few trained mental health professionals and stigma associated with mental health. A potential approach to address poor access to care is by training village healthcare workers in providing basic mental health care, and harnessing India’s vast mobile network to support such workers using mobile-based applications. We propose an intervention to implement such an approach that incorporates the use of mobile-based electronic decision support systems (EDSS) to provide mental health services for CMD, combined with a community-based anti-stigma campaign. This will be implemented and evaluated across 42 villages in Andhra Pradesh, a south Indian state. This paper discusses the development and testing of the EDSS, and the formative research that informed the anti-stigma campaign. Materials and Methods: The development of the EDSS used an iterative process that was validated against clinical diagnosis. A mixed methods approach tested the user acceptability of the EDSS. Focus group discussions and in-depth interviews provided community-level perceptions about mental health. This study involved 3 villages and one primary health centre. Results: The EDSS application was found to be acceptable, but some modifications were needed. The community lacked adequate knowledge about CMD and its treatment and there was stigma associated with mental illness. Faith and traditional healers were considered to be important mental health service providers. Discussion: A number of barriers and facilitators were identified in implementing the intervention analysed in a framework using Andersen’s behavioural model of health services use. Conclusion: The findings assisted with refining the intervention prior to large-scale implementation and evaluation. [ABSTRACT FROM AUTHOR]

Background: In this paper, we report findings regarding the prevalence of expressed distress and depressive conditions among women living in a rural region of Sichuan Province. As well, we know of no data among women in rural China that examine whether “depression,” as categorically defined in classifications such as the DSM, adequately captures the expressed distress and symptomatic complaints of women in rural China. Methods: A multistage sampling method was employed to recruit the target population. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure distress symptoms, and MINI International Neuropsychiatric Interview (MINI) was employed to determine the prevalence of diagnosable depression and other disorders. Results: Among 1898 rural women, 12.4% (236) scored ≥16 on the CES-D, indicative of distress, and a subset of 7.7% (146) had scores ≥21, highly suggestive of a clinically significant disorder. We found that 49.8% women with ≥16 CES-D score were identified as showing features consistent with a current major depressive episode (MDE) vs. 1.9% in a sample of randomly selected women with <16 CES-D score. Among respondents, 30 of 84 (35.7%) scoring 16–20 and 83 of 143 (58.0%) scoring ≥21 reported symptoms consistent with MDE. 25.1% of women with a positive CES-D score did not describe symptoms consistent with any DSM-IV disorder. Conclusions: We found a higher portion of women reporting significant distress than previously described. Among them, there was a clear gradient, such that 41.7% of women with moderate distress did not have a psychiatric diagnosis, and even among those with more severe symptoms, 15.4% did not manifest a DSM-specific psychiatric condition. [ABSTRACT FROM AUTHOR]

The aim of this research is to explore factors influencing the management decisions to adopt human resource information system (HRIS) in the hospital industry of Bangladesh—an emerging developing country. To understand this issue, this paper integrates two prominent adoption theories—Human-Organization-Technology fit (HOT-fit) model and Technology-Organization-Environment (TOE) framework. Thirteen factors under four dimensions were investigated to explore their influence on HRIS adoption decisions in hospitals. Employing non-probability sampling method, a total of 550 copies of structured questionnaires were distributed among HR executives of 92 private hospitals in Bangladesh. Among the respondents, usable questionnaires were 383 that suggesting a valid response rate of 69.63%. We classify the sample into 3 core groups based on the HRIS initial implementation, namely adopters, prospectors, and laggards. The obtained results specify 5 most critical factors i.e. IT infrastructure, top management support, IT capabilities of staff, perceived cost, and competitive pressure. Moreover, the most significant dimension is technological dimension followed by organisational, human, and environmental among the proposed 4 dimensions. Lastly, the study found existence of significant differences in all factors across different adopting groups. The study results also expose constructive proposals to researchers, hospitals, and the government to enhance the likelihood of adopting HRIS. The present study has important implications in understanding HRIS implementation in developing countries. [ABSTRACT FROM AUTHOR]

Objectives: It can be argued that with several players marketing a large number of brands, the pharmaceutical market in India is competitive. However, the pharmaceutical market should not be studied as a single market but, as a sum total of a large number of individual sub-markets. This paper examines the methodological issues with respect to defining the relevant market involved in studying concentration in the pharmaceutical market in India. Further, we have examined whether the Indian pharmaceutical market is competitive. Methods: Indian pharmaceutical market was studied using PharmaTrac, the sales audit data from AIOCD-AWACS, that organises formulations into 5 levels of therapeutic classification based on the EphMRA system. The Herfindahl-Hirschman Index (HHI) was used as the indicator of market concentration. We calculated HHI for the entire pharmaceutical market studied as a single market as well as at the five different levels of therapeutic classification. Results and Discussion: Whereas the entire pharmaceutical market taken together as a single market displayed low concentration (HHI = 226.63), it was observed that if each formulation is defined as an individual sub-market, about 69 percent of the total market in terms of market value displayed at least moderate concentration. Market should be defined taking into account the ease of substitutability. Since, patients cannot themselves substitute the formulation prescribed by the doctor with another formulation with the same indication and therapeutic effect, owing to information asymmetry, it is appropriate to study market concentration at the narrower levels of therapeutic classification. [ABSTRACT FROM AUTHOR]

Background: The aging of populations is rapidly accelerating worldwide. Especially, Japan has maintained the highest rate of population aging worldwide. As countermeasures, the Japanese government prioritized the promotion of local comprehensive care systems and collaboration in medical care and social (long-term) care. Development of a system to connect medical and social services in the community is necessary for the increasing older people, especially for the people in the stage of end of life. Objective: This study aimed to assess the effect of a multidisciplinary end-of-life educational intervention program on confidence in inter-professional collaboration and job satisfaction among health and social care professionals. Design: a cluster-randomized controlled trial Setting/Participants: Three professional groups (home care nurses, care managers, and heads of care workers) in an urban area participated in this trial. Intervention: We implemented a multidisciplinary end-of-life educational intervention program comprising two educational workshops and an educational booklet to support multidisciplinary care for end-of-life patients during the 7-month study period. Main outcome measure: Confidence in improved interactions among professionals and job satisfaction were assessed with the Face-to-Face Cooperative Confidence Questionnaire and the Minnesota Satisfaction Questionnaire at T1 (before intervention) and T2 (7 months after the intervention). Results: In total, 291 professionals participated in this study (experimental group n = 156; control group n = 135). Multivariate regression analyses showed significant between-group increases on all of seven subscales in participants’ face-to-face cooperative confidence over the study period; no effect was evident regarding job satisfaction. Conclusions: A multidisciplinary end-of-life educational intervention program increased confidence in multidisciplinary collaboration among health and social care professionals. Trial number: UMIN Clinical Trial Registry, Japan . [ABSTRACT FROM AUTHOR]

Adolescent-friendly health programs have been in place in Nepal since 2008, yet uptake of the services for sexual and reproductive health remains suboptimal. For uptake of these services to improve, a rich understanding is needed of the factors impacting their acceptance and utilization from the perspectives of adolescents, health care staff, and key community informants. This study applied a qualitative research design involving six focus groups with 52 adolescents and in-depth interviews with 16 adolescents, 13 key informants, and 9 health care providers from six adolescent-friendly health facilities in Nepal. Thematic analysis was conducted for data analysis. The key themes identified as barriers include access issues due to travel, institutional health care barriers, perceived lack of privacy and confidentiality, and the unprofessional attitudes of staff towards the sexual health needs of adolescents. These themes are underpinned by gendered ideology and a moral framework around the sexual behavior of adolescents. Interview responses suggested that health care providers take a policing role in prescribing adolescents’ conformity to this moral framework in their delivery of reproductive health care and services. While physical access to health services may be problematic for some adolescents, this is not the priority issue. Attention needs to be given to increasing the capacity of health care providers to deliver services without imposing their own and socially sanctioned moral frameworks around adolescent sexual behavior. Such capacity building should include training that is experiential and emphasizes the importance of confidentiality and non-judgmental attitudes. [ABSTRACT FROM AUTHOR]

Introduction: The National Rural Health Mission (NRHM) was launched in India in 2005 to address the health needs of under-served populations in rural areas, and to support universal access to care. Despite this initiative, unaccredited informal providers (IPs) often remain patients’ first point of contact, which has led to inconsistencies in treatment, and has compromised the quality of care. Aim: To explore the factors that influence patients’ decisions about healthcare providers in rural areas of central India. Methods: Nine focus group discussions (FGDs) were held in nine villages in central India. Framework analysis using an inductive approach was used to analyse the data. Results: The crosscutting theme across the discussions was not choice but need—the need for affordable and accessible health care regardless of the provider’s qualification. Results highlighted that IPs play a pivotal role in villagers’ lives. Formal healthcare services were accessed infrequently, and mainly when a condition was judged severe or possibly even fatal. Even then, affordability was carefully weighed. Villagers’ distance from formal providers contributed to high cost and low preference of formal providers. When opting for IPs, familiarity and trust were more important to villagers than qualifications. IPs have operated in rural communities in India for a long time and have adapted their services to meet the needs, preferences, social norms, and economic conditions of villagers. Conclusion: IPs have captured a niche and are often the first contact point in rural settings even when patients ultimately are diagnosed and treated by trained doctors. Merely tackling the undersupply of qualified doctors is not effective or sufficient to impact on the rural healthcare system: the strong and prevalent influence of IPs needs to be addressed also. [ABSTRACT FROM AUTHOR]

Background: Malaysia is widely credited to have achieved universal health coverage for citizens. However, the accessibility of healthcare services to migrant workers is questionable. Recently, medical fees for foreigners at public facilities were substantially increased. Mandatory health insurance only covers public hospital admissions and excludes undocumented migrants. This study explores barriers to healthcare access faced by documented and undocumented migrant workers in Malaysia. Methods: We use qualitative data from 17 in-depth interviews conducted with key informants from civil society organisations, trade unions, academia, medical professionals, as well as migrant workers and their representatives. We interviewed doctors working in public hospitals and private clinics frequented by migrants. Data were analysed using thematic analysis. Results: We found that healthcare services in Malaysia are often inaccessible to migrant workers. Complex access barriers were identified, many beyond the control of the health sector. Major themes include affordability and financial constraints, the need for legal documents like valid passports and work permits, language barriers, discrimination and xenophobia, physical inaccessibility and employer-related barriers. Our study suggests that government mandated insurance for migrant workers is insufficient in view of the recent increase in medical fees. The perceived close working relationship between the ministries of health and immigration effectively excludes undocumented migrants from access to public healthcare facilities. Language barriers may affect the quality of care received by migrant workers, by inadvertently resulting in medical errors, while preventing them from giving truly informed consent. Conclusions: We propose instituting migrant-friendly health services at public facilities. We also suggest implementing a comprehensive health insurance to enable healthcare access and financial risk protection for all migrant workers. Non-health sector solutions include the formation of a multi-stakeholder migration management body towards a comprehensive national policy on labour migration which includes health. [ABSTRACT FROM AUTHOR]

Despite the efforts of community health workers to increase access to healthcare among ethnic minority groups in low- and -middle income countries, members of ethnic minorities are less likely than women from other ethnic groups to use maternal and child healthcare services. However, much less is known about the factors that limit access of ethnic minorities to healthcare services, including the services of community health workers in Nepal, who are known as Female Community Health Volunteers (FCHVs). To address this issue, we conducted a qualitative study to explore perceived barriers to accessing maternal and child healthcare services among ethnic minority groups in two different geographical locations (the hill and Terai regions- flatland bordering south India) with varying degrees of access to local healthcare centres. Between April 2014 and September 2014, semi-structured interviews were conducted with twenty FCHVs, 26 women service users and 11 paid local health workers. In addition, 15 FCHVs participated in four focus group discussions. A thematic analysis of the data identified five major themes underlying barriers to accessing available maternal and child healthcare services by ethnic minority groups such as Dalits, Madhesi, Muslim, Chepang and Tamang. These themes include: a) lack of knowledge among service users; b) lack of trust in volunteers; c) traditional beliefs and healthcare practices; d) low decision-making power of women; and e) perceived indignities experienced when using health centres. We conclude that community health programmes should focus on increasing awareness of healthcare services among ethnic minority groups, and the programmes should involve family members (husband and mothers-in-law) and traditional health practitioners. Both the FCHVs and local healthcare providers should be trained to communicate effectively in order to deliver respectful care among ethnic minorities if we want to achieve universal healthcare coverage for maternal and child health in low- and -middle income countries. [ABSTRACT FROM AUTHOR]

Objectives: This study investigated how the essential elements of informed consent are realised during the consent process and examined the challenges in obtaining genuine informed consent in Korea. Methods: Through purposive sampling, we recruited 21 subjects from those participating in anticancer drug research since 2013. We undertook 1:1 in-depth interviews and analysed the data by framework analysis. Results: Themes raised throughout the interviews were categorised into ‘disclosure’ and ‘understanding’ of clinical information and ‘decision’. Provider-centred information, both verbal and written, was delivered to each participant. There were few tools that the research staff might evaluate study participants’ level of understanding of the provided information during the clinical trial. Although participants did not understand basic clinical trial concepts as much as desired, they may not seek to solve difficulties through communication with trial researchers. Doubts were raised about whether participants had sufficient capacity and free will to provide informed consent. Conclusion: There is a concern that informed consent can fall short of genuine in Korea. To ensure informed consent meets the international standard, greater efforts should be made to establish an explicit standard operational protocol for obtaining informed consent. [ABSTRACT FROM AUTHOR]

Background: Disclosure of HIV status is a critical gateway to HIV prevention. Despite many studies on this topic, there is a gap in knowledge regarding HIV status disclosure and risky sexual behavior in HIV-infected female migrant workers. The current study addressed this research gap, and focused on HIV-infected Shan female migrant workers in Northern Thailand. Methods: This study conducted in-depth interviews with 18 HIV-infected Shan female migrants (aged between 23–54 years old) and 29 healthcare workers in district hospitals in Chiang Mai. Content analysis was employed to identify particular themes related to HIV status disclosure, sexual risk behavior, and ART adherence. Results: We found that non-disclosure to husbands/partners was mostly related to fear of marital conflict and of losing social and financial support. Non-disclosure prevented Shan female migrant workers from negotiating condom use with their partners. Reasons for not disclosing to friends, family and other community members were mostly related to feared rejection and discrimination due to HIV-related stigma. Accounts of condomless sex in the context of HIV status disclosure suggest that gender norms and male dominance over women influenced decision-making for safe sex. Lastly, some female migrant workers perceived low risk of HIV transmission with good adherence to the ART. Conclusions: This study highlighted the complex challenges of HIV status disclosure among HIV-positive Shan female migrant workers and the link between disclosure/non-disclosure and condom use. There is a pressing need to create realistic disclosure mechanisms that take into account the socio-cultural barriers to disclosure including marital conflicts, stigma, and gender norms. Messages to encourage condom use should be delivered carefully so that knowledge of the HIV transmission reduction qualities of good ART adherence does not serve as a barrier to condom use. [ABSTRACT FROM AUTHOR]

Introduction: Safety climate, which provides a snapshot of safety culture, is rarely measured in Indonesian healthcare organisations because there are no validated surveys that can be administered in its native language, Bahasa Indonesia. The objectives of this study were to translate and linguistically adapt the Safety Attitudes Questionnaire into Bahasa Indonesia, and investigate the internal construct validity and reliability of the translated survey. Methods: The Safety Attitudes Questionnaire was translated into Indonesian language through forward and backward translation. The internal construct validity and reliability of the translated survey was assessed using Rasch analysis which examines overall model fit, unidimensionality, response format, targeting, internal consistency reliability and item bias. Results: A total of 279 nurses (response rate 82%) completed the Indonesian version of the Safety Attitudes Questionnaire. Most respondents were Division 2 registered nurses (n = 209; 75%), female (n = 174; 62%), and aged less than 30 years (n = 187; 67%). All six domains of the Indonesian version of the Safety Attitudes Questionnaire demonstrated unidimensionality (t-test less than 0.05 threshold value). However, suboptimal targeting (ceiling effect) was observed in all domains, and had at least one misfitting item (item fit residual beyond ±2.5) Item bias was also evident in most domains. Conclusion: This study has translated and validated an Indonesian version of the Safety Attitudes Questionnaire for the first time. Whilst there was general support to sum items to obtain domain scores, further work is required to refine the response options as well as the wording and number of items in this survey to improve its overall measurement properties. [ABSTRACT FROM AUTHOR]

Background: Migration of physicians has been a cause for global concern. In China, reforms of the higher education and healthcare systems have led to a shortage of postgraduate training positions relative to the number of medical graduates. Medical graduates opt for non-clinical roles or move abroad to pursue further training and practice opportunities. The impact of this physician migration is not known. This study quantifies where Chinese migrant physicians to the U.S. were educated, where they went to practice, and how these trends have changed over time. Methods: We combined data on physician characteristics from the 2008 and 2017 American Medical Association Physician Masterfiles with demographic information from the Educational Commission for Foreign Medical Graduates. Using a repeated cross-sectional approach, we reviewed the available data, including citizenship at entry to medical school, medical school attended, practice specialty, and practice location. Results: The number of Chinese-educated physicians (CEPs) to the United States (US) has increased over the past 10 years, from 3,878 in 2008 to 5,355 in 2017 (+38.1%). The majority held Chinese citizenship at entry to medical school (98.4% vs 97.1%) with the remainder being citizens of other East Asian nations. Of the Chinese citizens identified in 2008, 913 (19.3%) attended medical school outside of China; in 2017, 376 (6.7%) attended medical school outside of China, representing a decrease of 58.8%. Overall, in 2017, four Chinese medical schools provided 32.1% of all Chinese-educated physicians in the US. Over 50% of the CEPs were practicing in Internal Medicine, Anatomic/ Clinical Pathology, Anesthesiology, Family Medicine or Neurology. Compared with all IMGs, CEPs are more likely to be Anatomic/ Clinical Pathologists and Anesthesiologists. CEPs were concentrated in several states, including New York, California and Massachusetts. In 2017, a lower proportion of CEPs in the US healthcare workforce were in residency training, compared to 2008 (13.2% vs 22.8%). Conclusions: Unlike trends from some other South Asian countries, the number of CEPs in the US has increased over the past 10 years. Migration trends may vary depending on citizenship and country of medical school training. The majority of Chinese-educated graduates come to the US from relatively few medical schools. Fewer CEPs currently in residency training might indicate lower success rates in securing GME training in the US. [ABSTRACT FROM AUTHOR]

Commercial surrogacy in emerging countries such as India is often associated with exploitation of vulnerable women, the assumption being that it is performed by poor and uneducated women for rich intended parents. However, the hypothesis that surrogates are poor women has rarely been confronted with field data. The objective was to compare the socioeconomic characteristics of Indian surrogates interviewed in social studies with those of Indian women in the general population in order to provide preliminary data on whether surrogates have a specific profile and are indeed disadvantaged compared with their counterparts. The study analyzes the data from four cross-sectional studies carried out in India among surrogates between 2006 and 2014. Surrogates were recruited through clinics, agencies and agents. Data were collected during face-to-face interviews. The resulting convenience sample included 96 Indian surrogates. Their sociodemographic characteristics were compared with those of the general population extracted from Indian national surveys. The surrogates interviewed had their first child at a younger age than women in the general population, but they tended to have a smaller family. Their social situation tended to be better than that of the general population in terms of education, employment and family income. These results provide first empirical evidence moderating the common assumption that Indian surrogates are the poorest and least educated women. This does not mean, however, that exploitation does not exist. More studies are needed to confirm these results and to explore the issue in new international destinations for surrogacy. [ABSTRACT FROM AUTHOR]

Background: Diabetes education has been found to impact positively on self-management by people with diabetes although little is known about the process by which they assimilate information. The aim of this study was to generate a theory explaining the process by which people with diabetes learn about their disease in Indonesia. Methods: This study employed a grounded theory methodology influenced by constructivism and symbolic interactionism. A total of twenty-eight face-to-face or telephone interviews with participants from Indonesia that included people with diabetes, healthcare professionals, health service providers and families of people with diabetes were conducted in both Indonesia and Australia. Results: This study discloses a core category of Learning, choosing, and acting: self-management of diabetes in Indonesia as the basic social process of how people learn about their diabetes. The process includes five distinctive major categories. People with diabetes acted after they had received recommendations that they considered to be trustworthy. Factors that influenced their choice of recommendations to adopt are also identified. Conclusions: Awareness of the complexity involved in their decision making will assist healthcare professionals to engage effectively with people living with diabetes. [ABSTRACT FROM AUTHOR]

Informed consent is an essential part of an ethical clinical trial; to this end, researchers have developed several interventions to promote participants’ full understanding of trials and thereby improve the consent process. However, few empirical studies have examined how patients make the decision of whether to give consent. The objective of this study, therefore, is to analyze patients’ decision-making process when participating in clinical trials. We conduct an internet survey (n = 2,045) and interview data analysis (n = 40) with patients and categorize respondents into three types of participants: active, passive, and non-participation. Our results show that patients often make informal and quick decisions before medical staff provide them with relevant information during the informed consent process. For example, 55.9% of patients received initial information on clinical trials from an online article or web advertising, and 54.5% consulted no one about whether to participate in the clinical trial before making a decision. Only 20.7% of respondents subjectively spent time making the decision whether to participate; 43.0% of patients who said that they “spent time” coming to a decision took four or more days to reach a decision, while 8.3% of people who “did not spend time” making a decision took this among of time. Based on these results, we were able to break patients’ decision-making process into four steps: first contact, informal decision making, relevant information, and formal decision making. Our results show that patients are most likely to make a decision based on the first information they receive on the clinical trial, whatever the source. To this end, having a list of questions for potential participants to ask researchers would be useful in helping better collecting information of clinical trials. In addition, research teams should give patients more than four days to decide between providing them with relevant information and obtaining written consent, even if the patient seems to make a quick decision. [ABSTRACT FROM AUTHOR]

Background: It has been widely understood that well-trained doctors are crucial for a high-quality public health system and safe patient care. Thus, in 2011, China initiated its first national residency training program, called the China Standardized Training for Resident Doctor (C-STRD), for medical graduates to prepare qualified doctors for the medical care system with increasing demands. So far, no studies have specifically address the prevalence of stress and its determinants among residents enrolled in the C-STRD. Participants and methods: The research is performed in two stages. In stage I, the authors conducted a pilot study and met 112 C-STRD residents in person. Based on the preliminary data, a revised questionnaire was adopted in stage II, during which the authors conducted a multi-institutional, cross-sectional survey of 340 participants from 11 hospitals in Shanghai in a self-administered manner. Results: The results showed that C-STRD residents were overall under severe stress as their mean PSS score was 27.5 ± 4.9, which was higher than the threshold of high stress (PSS = 20). Specifically, the PSS score for the residents with Bachelor (MB), Master (MM) and Doctoral of Medicine (MD) educational degree were 26.6 ± 4.1, 27.8 ± 3.5 and 27.1 ± 5.2, respectively (P>0.05). Their stress was mainly associated with their financial income status and workload, as these two factors caused more severe burden than other listed stressors (P<0.05). Specially, the residents indicated that their montly payroll amout were as low as $590.2 ± 127 while no benefit package and allowance were given. Surprisingly, wage arrears up to 5.3 month were reported by 36 (10%) participants. Workload survey showed the residents has high work intensity and inadequate rest. Since no stress management program was provided, the majority of residents tended to cope their stress with unhealthy strategies, such as mesmerizing in TV/computer (88.2%) and overeating (59.7%). Conclusion: The C-STRD residents are at high risk of perceived stress. Although there was a difference in perception of stress for workload and career future among different educational degree owners, low financial income is the major stressor among all C-STRD residents. Unhealthy stress management strategies were adopted by all residents due to lack of appropriate stress-relieving intervention. [ABSTRACT FROM AUTHOR]

Background: Workplace violence is a widely-reported phenomenon among healthcare providers and negatively affects quality of care and treatment. This study aims to understand the potential factors related to HCV through the experiences of women who have undergone a pregnancy termination due to fetal anomaly. Methods: Qualitative interview was used to collect data in this case study. Forty-one pregnant women who decided to terminate their pregnancy due to fetal anomaly were recruited from four Chinese hospital facilities, including three general hospitals and one specialty hospital in Changsha, Hunan, China. In-depth interviews were conducted from May to September 2017. Content analysis was used to analyze the data. Results: Several potential factors related to violence in healthcare facilities were identified, including preventive factors, which possibly relieve healthcare violence; and negative experiences, which potentially related to healthcare violence. Preventive factors include healthcare providers gaining patient trust with detailed observation, expressing patient-centered care through discreet behavior, and showing patience and professionalism. Factors related to violence include busy work schedules, hurried visits, mechanized process, patients’ scant medical knowledge and mental distress. Conclusions: This study highlights potential factors related to healthcare violence. The results will be submitted to the Chinese government’s policy making department in order to improve the healthcare system. We also suggest several important strategies to prevent HCV in a healthcare setting, both in China and globally. [ABSTRACT FROM AUTHOR]

Interaction of medical students with the pharmaceutical industry is common. However, students are thought to be vulnerable to the influence of this interaction, and regulations to limit such interactions are required. The Japan Pharmaceutical Manufacturers Association revised its promotion code in 2013 and specified upper limits for promotional aids. We aimed to investigate whether Japanese medical students’ interactions with the pharmaceutical industry changed from 2012 to 2016. This study solicited the participation of all medical schools in Japan. An anonymous cross-sectional survey was administered to medical students from May 2016 to March 2017 to investigate their interactions with the pharmaceutical industry. The results were compared with those of a previous study conducted in 2012. Forty of the 80 medical schools in Japan participated. The student response rate was 74.1%, with 6771 (3395 preclinical, 3376 clinical) evaluable responses. More than 98% of clinical students had previously accepted stationery, a brochure, or a lunch, and significantly higher percentages of clinical students had accepted these items in 2016 than in 2012 (p < .001). The interactions between clinical students and pharmaceutical companies increased slightly between 2012 and 2016. This study will hopefully promote discussion regarding the regulation of student–industry interactions. [ABSTRACT FROM AUTHOR]

Background: There is a need for theory informed interventions to optimise medication reporting. This study aimed to quantify and explain behavioural determinants relating to error reporting of healthcare professionals in Qatar as a basis of developing interventions to optimise the effectiveness and efficiency of error reporting. Methods: A sequential explanatory mixed methods design comprising a cross-sectional survey followed by focus groups in Hamad Medical Corporation, Qatar. All doctors, nurses and pharmacists were invited to complete a questionnaire that included items of behavioural determinants derived from the Theoretical Domains Framework (TDF), an integrative framework of 33 theories of behaviour change. Principal component analysis (PCA) was used to identify components, with total component scores computed. Differences in total scores among demographic groupings were tested using Mann-Whitney U test (2 groups) or Kruskal-Wallis (>2 groups). Respondents expressing interest in focus group participation were sampled purposively, and discussions based on survey findings using the TDF to provide further insight to survey findings. Ethical approval was received from Hamad Medical Corporation, Robert Gordon University, and Qatar University. Results: One thousand, six hundred and four questionnaires were received (67.9% nurses, 13.3% doctors, 12.9% pharmacists). Questionnaire items clustered into six components of: knowledge and skills related to error reporting; feedback and support; action and impact; motivation; effort; and emotions. There were statistically significant higher scores in relation to age (older more positive, p<0.001), experience as a healthcare professional (more experienced most positive apart from those with the highest level of experience, p<0.001), and profession (pharmacists most positive, p<0.05). Fifty-four healthcare professionals from different disciplines participated in the focus groups. Themes mapped to nine of fourteen TDF domains. In terms of emotions, the themes that emerged as barriers to error reporting were: fear and worry on submitting a report; that submitting was likely to lead to further investigation that could impact performance evaluation and career progression; concerns over the impact on working relationships; and the potential lack of confidentiality. Conclusions: This study has quantified and explained key facilitators and barriers of medication error reporting. Barriers appeared to be largely centred on issues relating to emotions and related beliefs of consequences. Quantitative results demonstrated that while these were issues for all healthcare professionals, those younger and less experienced were most concerned. Qualitative findings highlighted particular concerns relating to these emotional aspects. These results can be used to develop theoretically informed interventions with the aims of improving the effectiveness and efficiency of the medication reporting systems impacting patient safety. [ABSTRACT FROM AUTHOR]

Background: Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality. Methods: Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care. Results: Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments. Conclusions: The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care. [ABSTRACT FROM AUTHOR]

Background: Mobile application based delivery of psycho-social interventions may help reduce the treatment gap for severe mental illnesses (SMIs) and decrease the burden on caregivers. Apps developed in high income settings show effectiveness, but they suffer from lack of applicability in low resource scenarios due to the difference in technology penetration, affordability, and acceptance. Objective: This study aimed to understand health technology usage, perceived needs, and acceptability of app based interventions in patients with SMIs to improve illness management and reduce caregiver burden. Methods: The study was conducted in inpatient and outpatient settings of a tertiary care center in North India. A cross-sectional survey assessed smartphone and health app usage. Further, three focus group discussions evaluated the needs and apprehensions in using apps in management of SMIs. Results: A total of 176 participants including 88 patients and 88 caregivers completed the survey. Smartphone ownership was similar to the national average (30%) in both caregivers (38.6%) and in patients (31.8%). Although subjects regularly used a third party app, health app usage was very low. Cost, unfamiliarity, and language were significant barriers to adoption. The focus group discussions provided insight into the various apprehensions of caregivers in using and in allowing patients to use smartphones and such apps. Caregivers wanted mobile apps for accessing information regarding services and resources available for people with SMI, and they felt such apps can be helpful if they could automate some of their routine caregiving activities. However, the significant difficulty was perceived in regards to the cost of the device, language of the medium, and unfamiliarity in using technology. Apprehensions that SMI patients might misuse technology, or damage the device were also prevalent. Conclusions: The study systematically looks into the scope, design considerations and limitations of implementing a mobile technology based intervention for low resource settings. With only one-third of the patients and caregivers having access to smartphones and internet, parallel outreach strategies like IVRS should be actively considered while designing interventions. The difficulty of understanding and searching in a non-native language needs to be addressed. Hand holding of caregivers and frequent encouragement from treating doctors might significantly help in technology adoption and in surmounting the apprehensions related to using technology. To make the solution acceptable and useful to the already over-burdened caregivers, developers need to work closely with patients’ family members and follow a ground-up collaborative approach to app development. The scope of delivering mental health services through technology is immense in resource constrained settings like India, provided we, researchers, appreciate and accept the fact that in the varied landscape of a divergent economic, educational, and cultural milieu, a single solution will never suffice for all, and intervention modality matching with end user capacity will be of paramount importance in determining the success of the endeavor. [ABSTRACT FROM AUTHOR]

We aimed to estimate the impact of a Community-Based Health Insurance (CBHI) scheme on utilization of healthcare from medically trained providers (MTP) by informal workers. A quasi-experimental study was conducted where insured households were included in the intervention group and uninsured households in comparison group. In total 1,292 (646 insured and 646 uninsured) households were surveyed from Chandpur district comprising urban and rural areas after 1 year period of CBHI introduction. Matching of the characteristics of insured and uninsured groups was performed using a propensity score matching approach to minimize the observed baseline differences among the groups. Multilevel logistic regression model, with adjustment for individual and household characteristics was used for estimating association between healthcare utilization from the MTP and insurance enrolment. The utilization of healthcare from MTP was significantly higher in the insured group (50.7%) compared to the uninsured group (39.4%). The regression analysis demonstrated that the CBHI beneficiaries were 2.111 (95% CI: 1.458–3.079) times more likely to utilize healthcare from MTP.CBHI scheme increases the utilization of MTP among informal workers. Ensuring such healthcare for these workers and their dependents is a challenge in many low and middle income countries. The implementation and scale-up of CBHI schemes have the potential to address this challenge of universal health coverage. [ABSTRACT FROM AUTHOR]

Objective: Medical students in China are currently facing a dilemma of whether to clarify their identity as students to patients. Further investigation is needed to support policy-making. The aim was to identify factors influencing medical students’ decision on whether or not to clarify their identity to patients and to examine the effects of their decision. Methods: The study was a cross-sectional nationwide multicenter survey consisting of 947 medical students. A self-designed questionnaire was composed of 19 structured questions investigating the present situation and participants’ perception of the ethical dilemma surrounding medical student identity. The questionnaires were distributed randomly in teaching hospitals affiliated with 13 medical schools across China from June 2015 to January 2016. Results: A total of 947 valid questionnaires were retrieved with a valid response rate of 83.7%. Most medical students (71.4%) tended to be ambiguous about their student identity in front of patients. The frequency of encountering distrust and patients’ or patient relatives’ refusal to allow students to perform procedures was significantly lower for students who explicitly stated their identity than for those who were ambiguous about their identity (p<0.001). Less experience in clinical rotations (<0.5 y/0.5–1 y, OR 2.7, 95% CI 1.7–4.3; <0.5 y/>1 y, OR 3.6, 95% CI 2.0–6.5), preceptors’ straightforward introduction of the students (OR 8.7, 95% CI 5.4–13.8) and students’ acknowledgment of patients’ right to know (OR 2.3, 95% CI 1.2–4.5) were related to students’ clear self-introduction to patients. Conclusion: It is beneficial for medical students to clearly explain their identity to patients in order to decrease patient distrust and prevent the refusal to have certain appropriate procedures performed. Several methods, including emphasizing the role of mentors, developing curriculum for medical students, and creating clear regulations and guidelines for revealing the identity of medical students on the healthcare team can help address and ideally resolve this ethical dilemma of identity disclosure. [ABSTRACT FROM AUTHOR]

The interrelationship between the public and private sectors, and formal and informal healthcare sectors effects market-level service quality, pricing behaviour and referral networks. However, health utilisation analysis of national survey data from many low and middle income countries is constrained by the lack of disaggregated health provider data. This study is concerned with the pattern of repeat outpatient consultations for a single episode of fever from public and private qualified providers and private unqualified providers. Cross-sectional survey data from 1173 adult respondents sampled from three districts within India’s most populous state—Uttar Pradesh is analysed. Data was collected during the monsoon season—September to October—in 2012. Regression analysis focuses on the pattern of repeats visits for a single episode of mild-sever fever as the dependent variable. Results show that Women and Muslims in rural north India are more likely to not access healthcare, and if they do, consult with low quality unqualified outpatient healthcare providers. For fever durations of four or more days, men are more likely to access unqualified providers compared to women. Results of the current study supports the literature that women’s utilisation of outpatient healthcare for communicable illnesses in LMICs is often less than men. A relative lack of access to household resources explains why fever duration parameter estimates for women and men differ. [ABSTRACT FROM AUTHOR]

The increasing focus of healthcare systems worldwide on long-term care highlights the need for culturally sensitive Health-Related Quality of Life instruments to accurately capture perceived health of various populations. Such instruments require a contextualized conceptual framework of health domains, which is lacking in some socio-cultural contexts. We developed a comprehensive and culturally sensitive conceptual framework of health domains relevant to the Singaporean population. We recruited Singaporeans/ permanent residents, English/ Chinese-speaking, with/ without chronic illnesses to participate in focus group discussions (FGDs) and in-depth interviews (IDIs). We elicited health areas participants perceived to be important for them to be happy and satisfied with life. To encourage spontaneous emergence of themes, we did not specify any aspect beyond the broad domains of Physical, Mental, and Social health so as not to limit the emergence of new themes. Themes from the transcripts were distilled through open coding (two independent coders), then classified into more abstract domains (each transcript coded independently by two coders from a pool of six coders). From October 2013 to August 2014, 121 members of the general public participated in 18 FGDs and 13 IDIs (44.6% males, mean age: 53.3 years 77% Chinese, 9% Malay, 12% Indian, 63% with chronic illness) while 13 healthcare workers participated as patient-proxies in three FGDs. Thematic analysis identified 27 domains. The 15 physical domains included physical appearance, energy, physical fitness, and health and resistance to illness. The nine mental domains included emotions, self-esteem, and personal freedom. The three social domains were social contact, social relationships, and social roles. This conceptual framework reflected physical, mental, and social dimensions of well-being, suggesting that the Singapore population’s views on health support the World Health Organization’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. [ABSTRACT FROM AUTHOR]

Introduction: A required step for presenting results of clinical studies is the declaration of participants demographic and baseline characteristics as claimed by the FDAAA 801. The common workflow to accomplish this task is to export the clinical data from the used electronic data capture system and import it into statistical software like SAS software or IBM SPSS. This software requires trained users, who have to implement the analysis individually for each item. These expenditures may become an obstacle for small studies. Objective of this work is to design, implement and evaluate an open source application, called ODM Data Analysis, for the semi-automatic analysis of clinical study data. Methods: The system requires clinical data in the CDISC Operational Data Model format. After uploading the file, its syntax and data type conformity of the collected data is validated. The completeness of the study data is determined and basic statistics, including illustrative charts for each item, are generated. Datasets from four clinical studies have been used to evaluate the application’s performance and functionality. Results: The system is implemented as an open source web application (available at ) and also provided as Docker image which enables an easy distribution and installation on local systems. Study data is only stored in the application as long as the calculations are performed which is compliant with data protection endeavors. Analysis times are below half an hour, even for larger studies with over 6000 subjects. Discussion: Medical experts have ensured the usefulness of this application to grant an overview of their collected study data for monitoring purposes and to generate descriptive statistics without further user interaction. The semi-automatic analysis has its limitations and cannot replace the complex analysis of statisticians, but it can be used as a starting point for their examination and reporting. [ABSTRACT FROM AUTHOR]

Background: China’s universal medical insurance system (UMIS) is designed to promote social fairness through improving access to medical services and reducing out-of-pocket (OOP) costs for all Chinese. However, it is still not known whether UMIS has a significant impact on the accessibility of medical service supply and the affordability, as well as the seeking-care choice, of patients in China. Methods: Segmented time-series regression analysis, as a powerful statistical method of interrupted time series design, was used to estimate the changes in the quantity and quality of medical service supply before and after the implementation of UMIS. The rates of catastrophic payments and seeking-care choices for UMIS beneficiaries were selected to measure the affordability and medical service flow of patients after the implementation of UMIS. Results: China’s UMIS was established in 2008. After that, the trending increase of the expenditure of the UMIS was higher than that of increase in revenue compared to previous years. Up to 2014, the UMIS had covered 97.5% of the entire population in China. After introduction of the UMIS, there were significant increases in licensed physicians, nurses, and hospital beds per 1000 individuals. In addition, hospital outpatient visits and inpatient visits per year increased compared to the pre-UMIS period. The average fatality rate of inpatients in the overall hospital and general hospital and the average fatality rate due to acute myocardial infarction (AMI) in general hospitals was significantly decreased. In contrast, no significant and prospective changes were observed in rural physicians per 1000 individuals, inpatient visits and inpatient fatality rate in the community centers and township hospitals compared to the pre-UMIS period. After 2008, the rates of catastrophic payments for UMIS inpatients at different income levels were declining at three levels of hospitals. Whichever income level, the rate of catastrophic payments for inpatients of Urban Employee’s Basic Medical Insurance was the lowest. For the low-income patients, a single hospitalization at a tertiary hospital can lead to catastrophic payments. It is needless to say what the economic burden could be if patients required multiple hospitalizations within a year. UMIS beneficiaries showed the intention of growth to seek hospitalization services in tertiary hospitals. Conclusions: Introduction of the UMIS contributed to an increase in available medical services and the use thereof, and a decrease in fatality rate. The affordability of UMIS beneficiaries for medical expenses was successfully ameliorated. The differences in patients’ affordability are mainly manifested in different medical insurance schemes and different seeking-care choices. The ability of the poor patients covered by UMIS to resist catastrophic medical payments is still relatively weak. Therefore, the current UMIS should reform the insurance payment model to promote the integration of medical services and the formation of a tiered treatment system. UMIS also should establish supplementary medical insurance packages for the poor. [ABSTRACT FROM AUTHOR]

Responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. It plays a critical role in ensuring continuity and effectiveness of care within people centered health systems. Given the lack of contextualized research on responsiveness, we qualitatively explored the perceptions of outpatient users and providers regarding what constitute responsiveness in rural Bangladesh. An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews of physicians (n = 17) and users (n = 7), focus group discussions with users (n = 4), and observations of patient provider interactions (three weeks). Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust and optimizing benefits. In terms of friendliness, patients expected physicians to greet them before starting consultations; even though physicians considered this unusual. Patients also expected physicians to hold social talks during consultations, which was uncommon. With regards to respect patients expected physicians to refrain from disrespecting them in various ways; but also by showing respect explicitly. Patients also had expectations related to informing and guiding: they desired explanation on at least the diagnosis, seriousness of illness, treatment and preventive steps. In gaining trust, patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centers, accepting gifts from pharmaceutical representatives. In terms of optimizing benefits: patients expected that physicians should be financially sensitive and consider individual need of patients. There were multiple dimensions of responsiveness- for some, stakeholders had a consensus; context was an important factor to understand them. This being an exploratory study, further research is recommended to validate the nuances of the findings. It can be a guideline for responsiveness practices, and a tipping point for future research. [ABSTRACT FROM AUTHOR]

Background: Integrated care has been well-recognized as a solution to improve quality of care for patients with complex needs. As Singapore increasingly develops and promotes integrated models of care, it is unclear if providers, patients, and caregivers share similar understanding of changes in the healthcare system. Objectives: This study aims at exploring three dimensions of care integration: a) understanding of integration; b) challenges and c) changes perceived as essential among three distinct stakeholder groups: providers, patients and caregivers. Methods: This qualitative study was conducted among 41 care providers (clinicians and administrators) and care consumers (patients and caregivers) in Singapore utilizing 29 semi-structured interviews and 2 focus group discussions. Study participants were selected by purposive, snowball sampling from various clinical settings. Data were transcribed, familiarized, coded and analyzed using a conceptual framework. Results: Understanding of care integration was generally lacking among patient and caregivers. Most of them focused on healthcare costs and accessibility of services. Providers characterized care integration in clinical process terms and had a more systems view of the concept. Most participants viewed resource constraints as a key challenge in integrating care. Additionally, providers expressed the need for patients and their families to play a greater role in managing their health. Individuals and the community are key components of an integrated care system in the future. Reliance on the healthcare system alone is not sustainable. Conclusions: Patients, caregivers and providers have varying degrees of understanding towards care integration. The success of engaging stakeholders on the ground to be active participants in the healthcare system integration process requires policymakers and healthcare leaders to increase patient engagement efforts and to better appreciate the challenges faced by the healthcare workers in the rapidly changing national and global healthcare landscape. [ABSTRACT FROM AUTHOR]

Citizen report cards on health care providers have been identified as a potential means to increase citizen engagement, provider accountability and health systems performance. Research in high-income settings indicates that the wording, presentation and display of performance information are critical to achieve these goals. However, there are limited insights on developing effective report card designs for middle- and low-income settings. We conducted cognitive interviews to assess consumers’ understanding, interpretation of and preferences for displaying information for a health care report card in rural Tajikistan. We recruited a convenience sample of 40 citizens (20 women and 20 men aged 18–45) from rural areas of two provinces of Tajikistan (Soghd and Khatlon oblasts). The interview protocol was adapted from the model of cognitive interviews used in social science research to improve survey questionnaires. We used multivariate regression to assess understanding and interpretation of the report card; chi2 tests to assess differences in preferences for displaying information; and tests of proportions to assess the preferred comparison group. Respondents understood the main idea of the report card and are not confused by the indicators or display. However, many respondents had difficulties making comparisons, and when asked to identify worst-performing services. Respondents preferred detailed rankings using school grades, comparisons of their local clinic with the regional or national average performance, and the use of color in the report card. We found some heterogeneity across the two provinces. Overall, our findings are promising regarding the citizens’ comprehension of health care report cards in rural Tajikistan, while underscoring the challenges of effectively providing health care performance information to communities. Cognitive interviews and iterative testing can support an effective implementation of reporting initiatives. [ABSTRACT FROM AUTHOR]

Background: Studies around the world have shown that interactions between pharmaceutical companies, pharmacists and physicians have a great influence on prescribing and drug dispensing practices. In middle-income countries, the nature and extent of these interactions have not been well researched. Our objectives were to qualitatively explore the nature of the interactions between pharmaceutical companies, physicians and pharmacists, their impact on drug prescription and dispensing practices in Lebanon. Methods and findings: We used grounded theory approach as well as the known sponsor, purposive, and snowballing sampling strategies to identify interviewees from the three respective groups: physicians, pharmacists, and pharmaceutical representatives. We conducted semi-structured and analyzed transcripts thematically. This study encompassed 6 pharmaceutical representatives, 13 physicians and 13 pharmacists. The following themes emerged: purpose and driver for the interactions, nature of the interactions, incentives, impact on prescription practices, ethical considerations, and suggestions for managing the interactions. The main purposes for the interaction were educational, promotional, and monitoring prescription practices and dispensing, while the main drivers for these interactions were market potential and neighborhood socio-economic status. Physicians, pharmacists and pharmaceutical representatives who engage in these interactions benefit from a variety of incentives, some of which were characterized as unethical. It appears that pharmaceutical companies give prominence to selected physicians within their communities. Although members of the three interviewed groups refer to some of the interactions as being problematic, they described a culture of acceptance of gift giving. We developed a framework that depicts the prevailing politico-cultural environment, the interactions between the three professional groups, and their impact on drug prescription. Underreporting is the main limitation of this study. Conclusion: Interactions between physicians, pharmacists and pharmaceutical representatives are frequent. Although these interactions can be beneficial, they still have a substantial effect on drug prescription and dispensing practices. Hence, the need for new policies that regulate these interactions and penalize any misconduct. [ABSTRACT FROM AUTHOR]

Objective: To determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman’s eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers. Study design: We conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman’s eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care. Results: Both women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women’s assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers’ (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women’s difficulty using the checklist. PPV of FCHVs’ determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively. Conclusion: Although a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use. [ABSTRACT FROM AUTHOR]

Background: In Myanmar, over five million people are infected with hepatitis B virus (HBV) and hepatitis C virus (HCV). Hepatitis has been a recent focus with the development of a National Strategic Plan on Hepatitis and plans to subsidize HCV treatment. Methods: During a two-day national liver disease symposium covering HCV, HBV, hepatocellular (HCC), and end-stage liver disease (ESLD), physician surveys were administered using the automated response system (ARS) to assess physician knowledge, perceptions of barriers to screening and treatment, and proposed solutions. Multivariate logistic regression was used to estimate odds ratio (OR) relating demography and practice factors with higher provider knowledge and improvement. Results: One hundred two physicians attending from various specialty areas (31.0% specializing in gastroenterology/hepatology and/or infectious disease) were of mixed gender (46.8% male), were younger than or equal to 40 years old (51.1% 20 to 40 years), had less experience (61.6% with ≤10 years of medical practice), were from the metropolitan area of Yangon (72.1%), and saw <10 liver disease patients per week (74.3%). The majority of physicians were not comfortable with treating or managing patients with liver disease. The post-test scores demonstrated an improvement in liver disease knowledge (9.0% ± 27.0) compared to the baseline pre-test scores; no variables were associated with significant improvement in hepatitis knowledge. Physicians identified the cost of diagnostic blood tests and treatment as the most significant barrier to treatment. Top solutions proposed were universal screening policies (46%), removal of financial barriers for treatment (29%), patient education (14%) and provider education (11%). Conclusions: Physician knowledge improved after this symposium, and many other needs were revealed by the physician input on barriers to care and their solutions. These survey results are important in guiding the next steps to improve liver disease management and future medical education efforts in Myanmar. [ABSTRACT FROM AUTHOR]