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Objectives This study aimed to understand the impact of a previous adverse infant outcome (AIO) on use of preconception care prior to a subsequent pregnancy. Methods Responses from the 2010 and 2012 Los Angeles Mommy and Baby Surveys were analyzed. Weighted multivariate logistic regression was employed to identify significant associations between having had a previous AIO (preterm delivery, low birth weight infant, stillbirth, or major birth defect) and receipt of preconception care prior to the most recent pregnancy. Select patient-level covariates were included: chronic disease, age, education level, race/ethnicity, country of birth, insurance status prior to pregnancy and pregnancy intent. Adjustment for missing responses was performed using multiple chained imputation. Results After controlling for covariates, having had a previous AIO was associated with an increased odds of having utilized preconception care in the most recent pregnancy (OR 1.237, p = 0.040). Per the final regression model, a woman reporting a previous AIO and an intended subsequent pregnancy had a 42.4 % likelihood of having used preconception care. Of these women, only 28.8 % reported doing so because of concern regarding a previous birth complication. Discussion Women reporting a previous AIO were more likely to have used preconception care in a subsequent pregnancy. The prevalence of preconception care utilization remained low overall. Pregnancy intent emerged as a strong secondary predictor; any concerted strategy to improve access to preconception care must include initiatives to help ensure that pregnancies are planned., Author(s): Priya Batra[sup.1] , Chandra Higgins[sup.2] , Shin M. Chao[sup.2] Author Affiliations: (1) Robert Wood Johnson Foundation Clinical Scholars Program, University of California, Los Angeles, Los Angeles, CAUSA (2) Los [...]

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1468-0009.2010.00611.x Keywords: Total quality management; quality assurance; health care; quality improvement; context Abstract: Context: The mixed results of success among QI initiatives may be due to differences in the context of these initiatives. Methods: The business and health care literature was systematically reviewed to identify contextual factors that might influence QI success; to categorize, summarize, and synthesize these factors; and to understand the current stage of development of this research field. Findings: Forty-seven articles were included in the final review. Consistent with current theories of implementation and organization change, leadership from top management, organizational culture, data infrastructure and information systems, and years involved in QI were suggested as important to QI success. Other potentially important factors identified in this review included: physician involvement in QI, microsystem motivation to change, resources for QI, and QI team leadership. Key limitations in the existing literature were the lack of a practical conceptual model, the lack of clear definitions of contextual factors, and the lack of well-specified measures. Conclusions: Several contextual factors were shown to be important to QI success, although the current body of literature lacks adequate definitions and is characterized by considerable variability in how contextual factors are measured across studies. Future research should focus on identifying and developing measures of context tied to a conceptual model that examines context across all levels of the health care system and explores the relationships among various aspects of context. Author Affiliation: (1)Cincinnati Children's Hospital Medical Center; University of Cincinnati; University of Arkansas for Medical Sciences; Arkansas Children's Hospital Article note: Address correspondence to: Heather Kaplan, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7009, Cincinnati, OH 45229 (email: heather.kaplan@cchmc.org).

News, Views and Reviews provides focused updates, topic reviews and editorials the latest developments in dermatologic therapy. Introduction Dermatologic emergencies are associated with significant morbidity and mortality and must be [...]

Global scale-up of antiretroviral therapy (ART) has focused on clinical outcomes with little attention on its impact on existing health systems. In June-August 2008, we conducted a formative evaluation on ART scale-up and clinic operations at three clinics in Uganda to generate lessons for informing policy and larger public health care systems. Site visits and semistructured interviews with 10 ART clients and 6 providers at each clinic were used to examine efficiency of clinic operations (patient flow, staff allocation to appropriate duties, scheduling of clinic visits, record management) and quality of care (attending to both client and provider needs, and providing support for treatment adherence and retention). Clients reported long waiting times but otherwise general satisfaction with the quality of care. Providers reported good patient adherence and retention, and support mechanisms for clients. Like clients, providers mentioned long waiting times and high workload as major challenges to clinic expansion. Providers called for more human resources and stress-release mechanisms to prevent staff burnout. Both providers and clients perceive these clinics to be delivering good quality care, despite the recognition of congested clinics and long waiting times. These findings highlight the need to address clinic efficiency as well as support for providers in the context of rapid scale-up. DOI: 10.1089/apc.2010.0108

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2010.08.001 Byline: Emma Pitchforth (a), Richard J. Lilford (b), Yigzaw Kebede (c), Getahun Asres (c), Charlotte Stanford (d), Jodie Frost (e) Abstract: Ensuring high quality intrapartum care in developing countries is a crucial component of efforts to reduce maternal and neonatal mortality and morbidity. Conceptual frameworks for understanding quality of care have broadened to reflect the complexity of factors affecting quality of health care provision. Yet, the role of social sciences within the assessment and understanding of quality of care in this field has focused primarily on seeking to understand the views and experiences of service users and providers. In this pilot study we aimed to combine clinical and social science perspectives and methods to best assess and understand issues affecting quality of clinical care and to identify priorities for change. Based in one referral hospital in Ethiopia, data collection took place in three phases using a combination of structured and unstructured observations, interviews and a modified nominal group process. This resulted in a thorough and pragmatic methodology. Our results showed high levels of knowledge and compliance with most aspects of good clinical practice, and non-compliance was affected by different, inter-linked, resource constraints. Considering possible changes in terms of resource implications, local stakeholders prioritised five areas for change. Some of these changes would have considerable resources implications whilst others could be made within existing resources. The discussion focuses on implications for informing quality improvement interventions. Improvements will need to address health systems issues, such as supply of key drugs, as well as changes in professional practice to promote the rational use of drugs. Furthermore, the study considers the need to understand broader organizational factors and inter-professional relationships. The potential for greater integration of social science perspectives as part of currently increasing monitoring and evaluation activity around intrapartum care is highlighted. Author Affiliation: (a) LSE Health, London School of Economics and Political Science, London, UK (b) Division of Primary Care, Public and Occupational Health, University of Birmingham, Birmingham, UK (c) Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia (d) Department of Gastroenterology and Internal Medicine, Leicester Royal Infirmary, Leicester, UK (e) Department of Transplant Surgery, Leicester General Hospital, Leicester, UK

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2010.07.041 Byline: Sarah L. Krein (a)(b), Laura J. Damschroder (a), Christine P. Kowalski (a), Jane Forman (a), Timothy P. Hofer (a)(b), Sanjay Saint (a)(b) Abstract: Patient safety is a healthcare priority worldwide, with most hospitals engaging in activities to improve care quality, safety and outcomes. Despite these efforts, we have limited understanding of why quality improvement efforts are successful in some hospitals and not others. Using data collected as part of a multi-center study, we closely examined quality improvement efforts and the implementation of recommended practices to prevent central line-associated bloodstream infections (CLABSI) in U.S. hospitals. We compare and contrast the experiences among hospitals to better understand 'how' and 'why' certain hospitals were more successful with practice implementation when taking into consideration specific aspects of the organizational context. This study reveals that among a number of hospitals that focused on implementing practices to prevent CLABSI, the experience and outcomes varied considerably despite using similar implementation strategies. Moreover, our findings provide important insights about how and why different quality improvement strategies might perform across organizations with differing contextual characteristics. Author Affiliation: (a) VA Ann Arbor Healthcare System, HSR&D (11H), 2215 Fuller Road, Ann Arbor, MI 48105, United States (b) University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2010.04.010 Byline: Carol Lynn Pavlish (a), Sahra Noor (b), Joan Brandt (c) Abstract: The civil war in Somalia resulted in massive resettlement of Somali refugees. The largest diaspora of Somali refugees in the United States currently reside in Minnesota. Partnering with three community organizations in 2007-8, we implemented the Community Connections and Collaboration Project to address health disparities that Somali refugees experienced. Specifically, we examined factors that influenced Somali women's health experiences. Utilizing a socio-ecological perspective and a social action research design, we conducted six community-based focus groups with 57 Somali women and interviewed 11 key informants including Somali healthcare professionals. Inductively coding, sorting and reducing data into categories, we analyzed each category for specific patterns. The categorical findings on healthcare experiences are reported here. We found that Somali women's health beliefs related closely to situational factors and contrasted sharply with the biological model that drives Western medicine. These discordant health beliefs resulted in divergent expectations regarding treatment and healthcare interactions. Experiencing unmet expectations, Somali women and their healthcare providers reported multiple frustrations which often diminished perceived quality of health care. Moreover, silent worries about mental health and reproductive decision making surfaced. To provide high quality, transcultural health care, providers must encourage patients to voice their own health explanations, expectations, and worries. Author Affiliation: (a) School of Nursing, University of California, 4-238 Factor Building, 700 Tiverton Avenue Box 956918, Los Angeles, CA 90095-6918, United States (b) Fairview Health Services, 2450 Riverside Ave. So. Minneapolis, MN 55454, United States (c) Department of Nursing, Augsburg College, Minneapolis, MN 55454, United States

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.12.015 Byline: Katja Bjorklund (a)(d), Helina Hakkanen-Nyholm (a)(b), Teppo Huttunen (c), Kristina Kunttu (d) Abstract: The present study examined the prevalence of various forms of violence victimization among university students in Finland. Violence victimization was analyzed in relation to physical and mental health symptoms, and the use of student healthcare services. A cross-sectional Student Health Survey was performed as a national postal survey for Finnish university students in 2004. In the next phase of the study, an additional postal survey regarding violence victimization was sent to those who had answered the original survey, which resulted in a sample of 905 students. It was found that violence victimization and violence-related health issues were markedly prevalent among Finnish university students. The students reported multiple forms of violence and injury demonstrating the diversity of violence victimization. Male and female victims differed both in the amount and type of symptoms, and in their relationship to the abuser/offender. Violence victimization and gender had a significant main effect on specific symptoms, while no interaction effect was found. The data also showed that violence victimization is overrepresented among frequent healthcare users. These findings have implications for clinical practice and public policy. The present findings provide useful information for policy makers and healthcare professionals concerning the health effects of violence in accordance with the use of healthcare services. More specifically, this information should be taken into consideration when planning student healthcare and could serve as a guideline for student healthcare management. Author Affiliation: (a) Department of Psychology, University of Helsinki, P.O. Box 9, Helsinki 00014, Finland (b) Forensic Laboratory, National Bureau of Investigation, Vantaa, Finland (c) Biostatistician, 4Pharma, Ltd., Turku, Finland (d) Finnish Student Health Service, Helsinki, Finland

Most estimates of US deaths associated with influenza circulation have been similar despite the use of different approaches. However, a recently published estimate suggested that previous estimates substantially overestimated deaths associated with influenza, and concluded that substantial numbers of deaths during a future pandemic could be prevented because of improvements in medical care. We reviewed the data sources and methods used to estimate influenza-associated deaths. We suggest that discrepancies between the recent estimate and previous estimates of the number of influenza-associated deaths are attributable primarily to the use of different outcomes and methods. We also believe that secondary bacterial infections will likely result in substantial morbidity and mortality during a future influenza pandemic, despite medical progress. (Am J Public Health. 2009;99: $225-$230. doi: 10.2105/AJPH.2008.151944)

Persons coinfected with tuberculosis (TB) and HIV are at high risk of death, in part due to suboptimal utilization of HIV-specific health care. We sought to better understand HIV-associated health care utilization and mortality in a retrospective cohort of TB/HIV coinfected cases reported in North Carolina 1993-2003. In this cohort, HIV was newly diagnosed during TB presentation for 34.2% of coinfected patients. Patients had advanced HIV (median CD4 104 cells/[mm.sup.3]) at TB diagnosis. Of 260 patients previously known to be HIV positive, 32.3% had seen a physician for HIV care in the previous 6 months and only 18.5% were taking antiretrovirals when TB was diagnosed; 34.8% of patients started antiretrovirals during TB treatment. Twenty-seven (5%) patients died prior to starting TB treatment; of those who survived, 13.6% (70/515) died prior to completing TB treatment, and 42.7% (220/515) died during a median 1408 days of follow-up. CD4 count (relative risk [RR] 0.53 per 100 cell increase, 95% confidence interval [CI] 0.34, 1.02) and highly active antiretroviral therapy (HAART) use during TB therapy (RR 0.37, 95% CI 0.13,1.02) were independently associated with decreased mortality, while age greater than 45 (RR 2.18, 95% CI 1.11, 4.29) was independently associated with increased mortality during TB treatment. We conclude that TB/HIV coinfected patients had low utilization rates of HIV-specific care prior to TB diagnosis. Many did not receive potentially lifesaving HIV treatment while on TB therapy, and mortality was high as a result. Interventions to enhance utilization of HIV-related health care and integration of TB and HIV services should be studied to improve outcomes. DOI: 10.1089/apc.2009.0030

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.childyouth.2008.05.004 Byline: Richard Thompson Keywords: Mental health services; Outcomes; Externalizing; Trajectory; Early intervention Abstract: Although access to mental health services is frequently studied as an issue of health disparity, little is known about the long-term impact of such services on children. The current study examined the relationship between early mental health services (before the age of 4 years old) on the trajectory of externalizing behavioral problems between ages 4 and 10 years old in a sample of 245 low-income urban children. Early mental health services were associated with very high levels of externalizing behavioral problems at baseline (age 4) and with more rapid decline in such behavioral problems between ages 4 and 10. This effect held after controlling for child gender and caregiver use of psychological aggression. As currently administered, early mental health services appear to be associated with early problem behaviors and with improvement in these behaviors over time. Future research and policy efforts should focus on improving both access to mental health services and the quality and utility of these services for children. Author Affiliation: Juvenile Protective Association, United States Article History: Received 15 August 2007; Revised 23 April 2008; Accepted 11 May 2008 Article Note: (footnote) [star] This research was supported by grants from the Office of Child Abuse and Neglect to the Consortium of Longitudinal Studies on Child Abuse and Neglect (LONGSCAN). The assistance of Rochelle Jackson in project administration is gratefully acknowledged. This manuscript also benefited from the comments of Richard H. Calica.

As the HIV epidemic has evolved to become a chronic, treatable condition the focus of HIV care has shifted from the inpatient to the outpatient arena. The optimal structure of HIV care in the outpatient setting is unknown. Using the HIV Research Network (HIVRN), a federally sponsored consortium of 21 sites that provide care to HW-infected individuals, this study attempted to: (1) document key features of the organization of care in HIVRN adult clinics and (2) estimate variability among clinics in these parameters. A cross-sectional survey of adult clinic directors regarding patient volume, follow-up care, provider characteristics, acute patient care issues, wait times, patient safety procedures, and prophylaxis practices was conducted from July to December 2007. All 15 adult HIVRN clinic sites responded: 9 academic and 6 community-based. The results demonstrate variability in key practice parameters. Median (range) of selected practice characteristics were: (1) annual patient panel size, 1300 (355-5600); (2) appointment no-show rate, 28% (8%-40%); (3) annual loss to follow-up, 15% (5%-25%); (4) wait time for new appointments, 5 days (0.5-22.5), and follow-up appointment, 8 days (0-30). The majority of clinics had an internal mechanism to handle acute patient care issues and provide a number of onsite consultative services. Nurse practitioners and physician assistants were highly utilized. These data will facilitate improvements in chronic care management of persons living with HIV.

Amid increased concerns about the adverse consequences of low health literacy, it remains unclear how health literacy affects-health status and health service utilization. With a sample of 489 elderly Medicare patients in a Midwestern city in the USA, we explored the intermediate factors that may link health literacy to health status and utilization of health services such as hospitalization and emergency care. We expected to find that individuals with higher health literacy would have better health status and less frequent use of emergency room and hospital services due to (l) greater disease knowledge, (2) healthier behaviors, (3) greater use of preventive care, and (4) a higher degree of compliance with medication. Using path analysis, we found, however, that health literacy had direct effects on health outcomes and that none of these variables of interest was a significant intermediate factor through which health literacy affected use of hospital services. Our findings suggest that improving health literacy may be an effective strategy to improve health status and to reduce the use of expensive hospital and emergency room services among elderly patients. Keywords: Health literacy; Health; Health service utilization; Health status; USA; Elderly

Female-To-Male (FTM) transgender individuals were approached at a conference and several peer support groups in the United States and asked to complete a short questionnaire regarding their medical care. Results from the 122 completed questionnaires indicated that a high number of respondents were taking testosterone (n = 106) and had some gender-confirming surgery (n = 68). Seventy percent of respondents rated their overall quality of health care 'good' or 'excellent.' A surprising finding was the low number (7%) reporting diagnoses of polycystic ovarian syndrome-the incidence of which has been reported elsewhere as high as 50%. Also notable were the high levels of employment, insurance, knowledge of standards of care, and access to providers, contrasting with reports from studies involving predominantly MaleTo-Female (MTF) individuals. Finally, FTM's usage of transition-related medical resources can vary, but many within this study are foregoing genital surgery. KEYWORDS. Female-To-Male, FTM, transgender, transsexual, testosterone

Abstract Background: Rosacea is a chronic, relapsing dermatologic condition that affects an estimated 14 million people in the US. However, there is little data in the literature on the healthcare [...]

Access to health care is a major health and development issue. Most governments declare that their citizens should enjoy universal and equitable access to good quality care. However, even within [...]

Objectives. We examined the contribution of hospital type and quality of care to perinatal mortality rates in the city of Belo Horizonte, Brazil. Methods. We used a cohort study of all births (40953) and perinatal deaths (826) in Belo Horizonte in1999. After adjusting for maternal education and birthweight, we compared mortality rates according to hospital category--defined by a hospital's relation to the national Universal Public Health System (SUS)--and quality of care. We used the Wigglesworth Classification to examine perinatal deaths. Results. After we controlled for birthweight and maternal education, the highest perinatal death rates were observed in private and philanthropic SUS-contracted hospitals (relative to private, non-SUS-contracted hospitals). Hospital quality was also directly associated with perinatal death rates. Mortality rates were especially high for normal-birthweight babies born in private SUS-contracted hospitals. Intrapartum asphyxia was the leading cause of preventable death. Conclusions. In a class-segregated health care system, such as Brazil's, disparities in quality of care between SUS-contracted and non-SUS-contracted hospitals contribute to the unacceptably high rates of perinatal mortality.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jsat.2006.05.015 Byline: Anita Palepu (a), Debbie M. Cheng (b), Theresa Kim (c), David Nunes (d), John Vidaver (e), Julie Alperen (b), Richard Saitz (b)(f), Jeffrey H. Samet (b)(g) Keywords: Substance abuse; Hepatitis C virus; Liver specialty care; Substance abuse treatment Abstract: We examined the association of substance abuse treatment with access to liver specialty care among 231 persons coinfected with HIV and hepatitis C virus (HCV) with a history of alcohol problems who were recruited and followed up in the HIV-Longitudinal Interrelationships of Viruses and Ethanol cohort study from 2001 to 2004. Variables regarding demographics, substance use, health service use, clinical variables, and substance abuse treatment were from a standardized research questionnaire administered biannually. We defined substance abuse treatment services as any of the following in the previous 6 months: 12 weeks in a halfway house or residential facility, 12 visits to a substance abuse counselor or mental health professional, day treatment for at least 30 days, or any participation in a methadone maintenance program. Liver specialty care was defined as a visit to a liver doctor, a hepatologist, or a specialist in treating hepatitis C in the past 6 months. At study entry, most of the 231 subjects (89%, n = 205) had seen a primary care physician, 50% had been exposed to substance abuse treatment, and 50 subjects (22%) had received liver specialty care. An additional 33 subjects (14%) reported receiving liver specialty care during the follow-up period. In the multivariable model, we observed a clinically important although not statistically significant association between having been in substance abuse treatment and receiving liver specialty care (adjusted odds ratio = 1.38; 95% confidence interval = 0.9-2.11). Substance abuse treatment systems should give attention to the need of patients to receive care for prevalent treatable diseases such as HIV/HCV coinfection and facilitate its medical care to improve the quality of care for individuals with substance use disorders. The data illustrate the need for clinical care models that give explicit attention to the coordination of primary health care with addiction and hepatitis C specialty care while providing ongoing support to engage and retain these patients with complex health needs. Author Affiliation: (a) Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver, BC, Canada V6Z 1Y6 (b) Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA (c) Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA (d) Section of Gastroenterology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA (e) DM-STAT Inc., Malden, MA, USA (f) Youth Alcohol Prevention Center, and the Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA (g) Department of Social and Behavioral Sciences, Boston University School of Public Health, Boston, MA, USA Article History: Received 25 October 2005; Revised 4 May 2006; Accepted 16 May 2006

Byline: Nezihi Kucukarslan (1,5), Ata Kirilmaz (2), Yucesin Arslan (3), Yavuz Sanioglu (4), Ertugrul Ozal (1), Harun Tatar (1) Keywords: Muscle sparing; Thoracotomy; Morbidity; Pediatric age Abstract: Alternative approaches to the standard posterolateral incision for thoracotomy have been developed to minimize its postoperative pain and wound related side effects. Muscle-sparing (MS) thoracotomy has been a well-known substitution to the standard posterolateral thoracotomy for this purpose however it has not been studied in the pediatric age group in detail. We studied retrospectively the patients with thoracotomy for non-cardiac, thoracic surgical procedures. group 1 included the patients with standard posterolateral thoracotomy for the surgery. The patients with MS thoracotomy composed group 2. The related data were collected retrospectively. The early postoperative morbidities (time requiring for regaining shoulder girdle movement, extubation, intensive care unit stay, and hospital stay) and late musculoskeletal anomalies (scoliosis, elevation of the shoulder, winged scapula, asymmetry of the nipples) were compared between groups. A total of 90 patients were included in the study. Group 1 constituted 50 patients with an average age of 4.24 +- 2.91 years. Group 2 included 40 patients with an average age of 4.20 +- 2.92 years. Comparison of the demographics and the baseline characteristics of the patients were not different between groups. In comparison of operative characteristics, there was lesser morbidity in group 2 as re-exploration for bleeding, wound infection, wound healing and fewer intensive care unit and hospital stay days. Late follow-up revealed a significant increase in musculoskeletal deformities in group 1. We conclude that muscle-sparing incision should be preferred to the standard posterolateral thoracotomy in pediatric age. Author Affiliation: (1) Department of Cardiovascular Surgery, GATA Military Medical Faculty, Etlik, Ankara, Turkey (2) Department of Cardiology, GATA Haydarpasa Military Training Hospital, Kadikoy, Istanbul, Turkey (3) Department of Cardiovascular Surgery, GATA Haydarpasa Military Training Hospital, Kadikoy, Istanbul, Turkey (4) Department of Biostatistics, GATA Military Medical Faculty, Etlik, Ankara, Turkey (5) GATA Askeri Hastanesi Kalp ve Damar Cerrahisi ABD, 06018, Etlik, Ankara, Turkey Article History: Registration Date: 11/08/2006 Accepted Date: 11/08/2006 Online Date: 12/09/2006

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2006.04.011 Byline: Susan E. Robertson (a), Joseph J. Valadez (b) Keywords: Lot quality assurance sampling (LQAS); Survey methods; Monitoring and evaluation Abstract: We conducted a global review on the use of lot quality assurance sampling (LQAS) to assess health care services, health behaviors, and disease burden. Publications and reports on LQAS surveys were sought from Medline and five other electronic databases; the World Health Organization; the World Bank; governments, nongovernmental organizations, and individual scientists. We identified a total of 805 LQAS surveys conducted by different management groups during January 1984 through December 2004. There was a striking increase in the annual number of LQAS surveys conducted in 2000-2004 (128/year) compared with 1984-1999 (10/year). Surveys were conducted in 55 countries, and in 12 of these countries there were 10 or more LQAS surveys. Geographically, 317 surveys (39.4%) were conducted in Africa, 197 (28.5%) in the Americas, 115 (14.3%) in the Eastern Mediterranean, 114 (14.2%) in South-East Asia, 48 (6.0%) in Europe, and 14 (1.8%) in the Western Pacific. Health care parameters varied, and some surveys assessed more than one parameter. There were 320 surveys about risk factors for HIV/AIDS/sexually transmitted infections; 266 surveys on immunization coverage, 240 surveys post-disasters, 224 surveys on women's health, 142 surveys on growth and nutrition, 136 surveys on diarrheal disease control, and 88 surveys on quality management. LQAS surveys to assess disease burden included 23 neonatal tetanus mortality surveys and 12 surveys on other diseases. LQAS is a practical field method which increasingly is being applied in assessment of preventive and curative health services, and may offer new research opportunities to social scientists. When LQAS data are collected recurrently at multiple time points, they can be used to measure the spatial variation in behavior change. Such data provide insight into understanding relationships between various investments in social, human, and physical capital, and into the effectiveness of different public health strategies in achieving particular behavioral outcomes. Author Affiliation: (a) Department of Immunization, Vaccines and Biologicals, World Health Organization, 1211 Geneva 27, Switzerland (b) Malaria Implementation Resources Team, AFTHD, The World Bank, 1818 H Street, NW, Mail Stop J9-905, Washington DC 20433, USA

For more than two decades, prenatal care has been a cornerstone of our nation's strategy for improving pregnancy outcomes. In recent years, however, a growing recognition of the limits of prenatal care and the importance of maternal health before pregnancy has drawn increasing attention to preconception and internatal care. Internatal care refers to a package of healthcare and ancillary services provided to a woman and her family from the birth of one child to the birth of her next child. For healthy mothers, internatal care offers an opportunity for wellness promotion between pregnancies. For high-risk mothers, internatal care provides strategies for risk reduction before their next pregnancy. In this paper we begin to define the contents of internatal care. The core components of internatal care consist of risk assessment, health promotion, clinical and psychosocial interventions. We identified several priority areas, such as FINDS (family violence, infections, nutrition, depression, and stress) for risk assessment or BBEEFF (breastfeeding, back-to-sleep, exercise, exposures, family planning and folate) for health promotion. Women with chronic health conditions such as hypertension, diabetes, or weight problems should receive on-going care per clinical guidelines for their evaluation, treatment, and follow-up during the internatal period. For women with prior adverse outcomes such as preterm delivery, we propose an internatal care model based on known etiologic pathways, with the goal of preventing recurrence by addressing these biobehavioral pathways prior to the next pregnancy. We suggest enhancing service integration for women and families, including possibly care coordination and home visitation for selected high-risk women. The primary aim of this paper is to start a dialogue on the content of internatal care. Keywords Preconception care * Internatal care * Content * Preterm birth * Interpregnancy

BACKGROUND. There has been a gradual decrease in the proportion of children covered by private health insurance in Colorado and the United States with a commensurate increase in those with public insurance or having no insurance which may impact access to care and outcomes. OBJECTIVE. The purpose of this work was to determine whether children with public or no health insurance have differences in hospital admission rates, morbidity, mortality, and/or charges that might be improved if standards of primary care comparable to those of children with private insurance could be achieved. METHODS. We conducted a retrospective comparison of hospitalization-related outcomes for children RESULTS. Compared with those with private insurance, children in Colorado and the United States with public or no insurance have significantly higher rates of total hospital admission, as well as admission for chronic illness, asthma, diabetes, vaccine-preventable disease, psychiatric disease, and ruptured appendix. These children have higher mortality rates, higher severity of illness, are more likely to be admitted through the emergency department and have significantly higher hospital charges per insured child. Higher hospitalization rates occur in children who are nonwhite and/or Hispanic and those who are younger. If children with public or no health insurance in the United States in 2000 had the same hospitalization outcomes as children with private insurance, $5.3 billion in hospital charges could have been saved. CONCLUSIONS. There is an opportunity to achieve improved health outcomes and decreased hospitalization costs for children with public or no health insurance if private insurance standards of health care could be achieved for all US children. Key Words morbidity/mortality, cost-effectiveness outcomes analysis, health services, hospitalization Abbreviations SCHIP--State Children's Health Insurance Program CHA--Colorado Hospital Association APR-DRG all-patient refined diagnosis-related group MDC--major diagnostic category KID--Kids' Inpatient Database UFFS-- unassigned fee-for-service CI--confidence interval ICD-9--International Classification of Diseases--Ninth Revision, THE US CENSUS reports that 34.1% of children METHODS Data Sources This was a population-based analysis of hospitalization rates for children who were >28 days and A preliminary analysis of [...]

As part of a multisite initiative to evaluate outreach targeting underserved HIV-infected individuals, we describe baseline characteristics of unstably housed HIV-infected individuals from New York City, and their health care access and utilization patterns. Interviews with 150 HIV-infected single room occupancy (SRO) hotel residents on health care access and utilization, barriers to accessing health care, demographic characteristics, history of incarceration, severity of HIV disease, depressive symptoms, substance use, and exposure to violence were conducted. Most participants were 40 years of age or older, male, black or Latino, had public insurance, a history of substance use, depressive symptoms, and a CD[4.sup.+] count above 200 cells/[mm.sup.3]. Access to and utilization of care was high with 91% reporting having a regular provider, 95% identifying a non-emergency department (ED) clinic or office as their usual location of care, 89% reporting at least one ambulatory visit, and 82% reporting optimal ([greater than or equal to] 2) ambulatory visits during the previous 6 months. Additionally, 45% reported at least one ED visit, and 30% at least one hospitalization within the previous 6 months. Among black and Latino marginalized SRO hotel residents in New York City, this study found surprisingly high measures of access to and utilization of ambulatory care services, along with high use of acute care services. Understanding HIV-related health services access and utilization patterns among marginalized populations is essential to improve their HIV care. These patterns of high levels of access to and utilization of health care services contradict clinical experiences and other studies, and require further exploration.

Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.