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Disparities in care access for health conditions where physiotherapy can play a major role are abetting health inequities. Spatial analyses can contribute to illuminating inequities in health yet the geographic accessibility to physiotherapy care across New Zealand has not been examined. This population-based study evaluated the accessibility of the New Zealand physiotherapy workforce relative to the population at a local scale. The locations of 5,582 physiotherapists were geocoded and integrated with 2018 Census data to generate 'accessibility scores' for each Statistical Area 2 using the newer 3-step floating catchment area method. For examining the spatial distribution and mapping, accessibility scores were categorized into seven levels, centered around 0.5 SD above and below the mean. New Zealand has an above-average physiotherapy-to-population ratio compared with other OECD countries; however, this workforce is maldistributed. This study identified areas (and locations) where geographic accessibility to physiotherapy care is relatively low.

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Introduction: People with disabilities and those with non-English language preferences have worse health outcomes than their counterparts due to barriers to communication and poor continuity of care. As members of both groups, people who are Deaf users of American Sign Language have compounded health disparities. Provider discomfort with these specific demographics is a contributing factor, often stemming from insufficient training in medical programs. To help address these health disparities, we created a session on disability, language, and communication for undergraduate medical students. Methods: This 2-hour session was developed as a part of a 2020 curriculum shift for a total of 404 second-year medical student participants. We utilized a retrospective postsession survey to analyze learning objective achievement through a comparison of medians using the Wilcoxon signed rank test (α = .05) for the first 2 years of course implementation. Results: When assessing 158 students' self-perceived abilities to perform each of the learning objectives, students reported significantly higher confidence after the session compared to their retrospective presession confidence for all four learning objectives (ps < .001, respectively). Responses signifying learning objective achievement (scores of 4, probably yes, or 5, definitely yes), when averaged across the first 2 years of implementation, increased from 73% before the session to 98% after the session. Discussion: Our evaluation suggests medical students could benefit from increased educational initiatives on disability culture and health disparities caused by barriers to communication, to strengthen cultural humility, the delivery of health care, and, ultimately, health equity.

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In the context of implementing the strategy of "double carbon" and "healthy China," this paper firstly measures the level of green finance development and the comprehensive index of health care accessibility in each province by using the entropy weight method based on 30 provincial panel data from 2007 to 2021. A panel fixed effects model was also used to empirically analyze the effect of regional green finance development on the improvement of residents' health. In addition, a panel threshold model was constructed to empirically test the threshold effect of green finance on residents' health under the influence of four external environments: carbon intensity level, healthcare accessibility, residents' living standard and human capital level. The empirical results show that the regional green financial development in China significantly improves the health level of residents. And the impact has significant regional heterogeneity, as shown in the improvement effect is more significant for the provinces in the central and western regions. In addition, the impact of green financial development on the health level of residents in China is non-linearly influenced by external environmental factors. The improvement effect of green finance on residents' health level is more significant in the provinces with higher carbon intensity level, residents' living standard, human capital level and lower accessibility to medical services. In this regard, regional governments should continue to build and optimize a synergistic development ecosystem of green finance and public health, give full play to the advantages of financial leverage, promote green, low-carbon and high-quality economic and social development, and realize the beautiful vision of harmonious coexistence between human beings and nature.

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Introduction: The COVID-19 pandemic negatively impacted the global economy, disrupted essential health services, and distorted social determinants of health, reducing healthcare accessibility and increasing financial risk. Aim: we aimed to assess the impact of COVID-19 on healthcare accessibility and financial risk protection in Sri Lanka. Methodology: We conducted a cross-sectional study on a representative sample (multi-stage sampling process) of 3151 households in 105 clusters representing all the districts of Sri Lanka. The data collection was conducted using an interviewer-administered questionnaire in early November 2021. This was important to classify three periods of interest, namely: (1) the pre-lockdown period (2) the nationwide lockdown period, and (3) the new normal period. (After Oct 1 to early November 2021). Results: Among 11,463 household occupants, 12.6% reported having chronic diseases, with 76.5% diagnosed prior to six months. The majority had heart disease, high blood pressure, or diabetes. Of them, 53.7% have been followed up during the lockdown, increasing to 80.8% in the new normal period. Provincial variations in expenses were observed, with the highest food expenses in the Western Province. Catastrophic health expenditures affected 9.5% and 3.4% of households at 10% and 25%, respectively. Conclusions: A considerable proportion of those having heart disease, high blood pressure, high blood sugar or diabetes mellitus were not followed up in the lockdown period and the first month of the new normal period. Antenatal care and family planning were the least affected. Participants had incurred high out-of-pocket expenditures for healthcare during the entire period.

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Background Little is known about geographic variation in acute myocardial infarction (AMI) mortality within fast-developing megacities and whether changes in health care accessibility correspond to changes in AMI mortality at the small-area level. Methods and Results We included data of 94 106 AMI deaths during 2007 to 2018 from the Beijing Cardiovascular Disease Surveillance System in this ecological study. We estimated AMI mortality for 307 townships during consecutive 3-year periods with a Bayesian spatial model. Township-level health care accessibility was measured using an enhanced 2-step floating catchment area method. Linear regression models were used to examine the association between health care accessibility and AMI mortality. During 2007 to 2018, median AMI mortality in townships declined from 86.3 (95% CI, 34.2-173.8) to 49.4 (95% CI, 30.5-73.7) per 100 000 population. The decrease in AMI mortality was larger in townships where health care accessibility increased more rapidly. Geographic inequality, defined as the ratio of the 90th to 10th percentile of mortality in townships, increased from 3.4 to 3.8. In total, 86.3% (265/307) of townships had an increase in health care accessibility. Each 10% increase in health care accessibility was associated with a -0.71% (95% CI, -1.08% to -0.33%) change in AMI mortality. Conclusions Geographic disparities in AMI mortality among Beijing townships are large and increasing. A relative increase in township-level health care accessibility is associated with a relative decrease in AMI mortality. Targeted improvement of health care accessibility in areas with high AMI mortality may help reduce AMI burden and improve its geographic inequality in megacities.

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The implementation of a national suicide prevention hotline is imminent and will need to be supported by comprehensive crisis systems, which are currently rarely implemented in part due to their cost. In this Commentary paper we identify three core components of a high-functioning, integrated crisis service system. We identified regional crisis call centers, mobile response teams, and crisis receiving and stabilization centers as core components of an integrated crisis service system. We then outline how this approach has been used in Arizona. Building out these systems and sustainable funding models to support these systems is necessary to ensure that 988 implementation lives up to the promise of creating a lifeline to support services for individuals in crisis.

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Resumo Introdução Alterações neurológicas em crianças com síndrome congênita do vírus Zika (SCZ) repercutem em atrasos no desenvolvimento e deformidades, levando à necessidade da assistência aos serviços de reabilitação. Objetivo Analisar a acessibilidade geográfica de crianças com SCZ na Região Metropolitana do Recife (RMR) e compará-la com a otimizada (distância mais próxima entre a residência da criança e o serviço). Método Estudo descritivo, incluindo 51 crianças com SCZ que residiam na RMR. Utilizaram-se questionários semiestruturados com dados sociodemográficos, econômicos e informações dos serviços de reabilitação utilizados pela criança. Elaboraram-se mapas de distribuição espacial e fluxos pelo Sistema de Informação Geográfica QGis e análises descritivas do perfil da amostra, usando SPSS 20.0. Resultados A maioria era de crianças que viviam em locais de vulnerabilidade, considerando a renda como indicador. Quanto à acessibilidade, os serviços de reabilitação estavam concentrados na cidade do Recife, levando 37,3% das crianças a percorrer acima de 15 km até os serviços. Verificou-se que numa acessibilidade otimizada, 52,9% percorreriam entre 1 e 5 km. Conclusão Uma reorganização dos serviços para garantir maior facilidade de acessibilidade a essas crianças é necessária e imprescindível para garantia de melhor acompanhamento e assistência dessas famílias em longo prazo.

Abstract Background Neurological changes in children with congenital zika virus syndrome (CZS) have delays in development and deformities, leading to the need care for rehabilitation services Objective This study aims to analyze the geographical accessibility of children with CZS in the Metropolitan Region of Recife (RMR), and to compare such with the optimized (closest distance between the child's residence and the service). Method It is a descriptive study, including 51 CZS who resided in the RMR. The instruments used were semi structured questionnaire with sociodemographic data, economic and information from the centers attended by the child. Spatial distribution maps and flows were prepared by the Geographic Information System-QGis and descriptive analyzes of the sample profile, using SPSS 20.0. Results The majority were children who lived in locales of socioeconomic vulnerability. As for the accessibility, it was noted that the rehabilitation services which received these children were concentrated in the city of Recife, leading 37.3% of children to travel over 15 km to services. However, the optimal accessibility, 52,9% would be between 1 and 5 km. Conclusion A reorganization of these services to facilitate accessibility to these children, as well as a follow-up towards better tending to these families in the long term.

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BACKGROUND: Telemedicine has expanded access to high-quality, appropriate, and affordable health care for people with multiple sclerosis (MS). This study explored how the expansion of MS telemedicine is perceived and experienced by people with MS, health care providers (HCPs), and payers and policy experts (PYs). METHODS: Forty-five semistructured interviews with 20 individuals with MS, 15 HCPs, and 10 PYs were conducted between September 2020 and January 2021. The interviews were recorded on a televideo platform, transcribed, and analyzed for themes using qualitative data software. RESULTS: Interviews revealed the following 4 themes. Technology: Telemedicine increases access and convenience. Technical challenges were the most cited downside to telemedicine. Clinical encounters: Confidence in MS care via telemedicine varies. Virtual "house calls" have clinical benefits. Financing and infrastructure: Reimbursement parity is critical to utilization and expansion of telemedicine. Stakeholders are hopeful and fearful as infrastructure and business models begin to shift. Shifting expectations: The familiar structure of the office visit is currently absent in telemedicine. Telemedicine visits need more intentionality from both providers and patients. CONCLUSIONS: Telemedicine is an efficient, convenient way to deliver and receive many aspects of MS care. To expand telemedicine care, many HCPs need more training and experience, people with MS need guidance to optimize their care, and PYs in the United States need to pass legislation and adjust business models to incorporate benefits and reimbursement for telemedicine health in insurance plans. The future is promising for the ongoing use of telemedicine to improve MS care, and stakeholders should work to preserve and expand the policy changes made during the COVID-19 pandemic.

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BACKGROUND: Breast cancer is the most common cause of death, due to malignant neoplasms in women worldwide. The nature of the symptoms associated with breast cancer depends on the stage of the disease. In this case, any cancerous changes in the initial phase of the disease can only be detected during imaging tests. Participation in mammography screening can reduce breast cancer mortality by up to 40%, if only 70% of the eligible population participates in preventive programs. The purpose of the study was to assess the impact of accessibility to health care resources on breast cancer mortality. METHODS: Eurostat aggregated health care data was extracted. Hierarchical cluster analysis of average breast cancer mortality identified four groups of countries with similar mortality rates and trends. The data was then analyzed, in terms of access to health care. RESULTS: It was observed that the higher the financial expenditure on health care and the better the health care accessibility, the lower the mortality rates of breast cancer. CONCLUSIONS: There are examples indicating that the studied elements are not the only factors affecting the improvement of population health. The authors would like to emphasize the need to influence lifestyle factors, direct cancer risk, and introduce a multidisciplinary approach to breast cancer prevention.

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BACKGROUND: Studies on the effects of poverty on unmet medical needs are limited. Therefore, this study aimed to identify the impact of entering poverty on the unmet medical needs of South Korean adults. METHODS: This study used data from the Korea Health Panel Survey (2014-2018) and included 10,644 adults. Logistic regression was used to examine the impact of entering poverty on unmet medical needs (poverty status: no → no, yes → no, no → yes, yes → yes; unmet medical needs: no, yes). Poverty line was considered to be below 50% of the median income. RESULTS: When entering poverty, the proportion of unmet medical needs was 22.8% (adjusted odds ratio [AOR] 1.17, 95% confidence interval [CI] 1.01-1.36). Men (AOR 1.29, 95% CI 1.02-1.64), rural dwellers (AOR 1.24, 95% CI 1.01-1.50), and national health insurance (NHI) beneficiaries (AOR 1.21, 95% CI 1.04-1.42) were susceptible to unmet medical needs and entering poverty. Poverty line with below-median 40% had an AOR of 1.48 (95% CI 1.28-1.71). For the cause of unmet medical needs, the AORs were 1.50 for poverty (95% CI 1.16-1.94) and 1.08 for low accessibility to health care and information (95% CI 0.79-1.48). CONCLUSIONS: Entering poverty had the potential to adversely affect unmet medical needs. Men, rural dwellers, and NHI beneficiaries were vulnerable to unmet medical needs after entering poverty. Rigid definitions of poverty and inaccessibility to health care and information increase the likelihood of unmet medical needs and poverty. Society must alleviate unmet medical needs due to the increase in the population entering poverty.

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Background: This study evaluated the effectiveness of the reverse stethoscope technique in improving speech intelligibility. In this technique, a clinician places the earpieces of their stethoscope into the ears of a hearing-impaired patient and speaks into the chest piece. Methods: The International Speech Test Signal was presented to four Littman® stethoscope models and a Pocketalker® personal voice amplifier using an Audioscan® hearing instrument test box. The acoustic outputs of the stethoscopes and voice amplifier were measured across the frequency spectrum of speech. The Speech Intelligibility Index of the resulting speech was calculated for natural speech and for each device in relation to 10 standardized hearing losses representing the population of older adults. Results: For each of the 10 hearing losses, the speech signal emitted by the stethoscopes was quieter and yielded lower speech intelligibility scores than regular speech. In contrast, the voice amplifier provided mid- and high-frequency amplification and improved speech intelligibility scores for all but the mildest hearing losses. Conclusions: The reverse stethoscope technique worsens the clarity of speech and should not be used with older, hearing-impaired patients. Instead, clinicians should use regular speech or, preferably, personal voice amplifiers.

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Spatial accessibility to health care plays a vital role in the evaluation of medical resource equality. A widely used method of spatial accessibility is the Two-Step Floating Catchment Area (2SFCA) method. However, the 2SFCA model (and its later variants) implicitly assumes that each doctor has the same attraction (unlimited resources) to care seekers and each care seeker's need is the same; it does not consider insurance that doctors accept or patients' different needs by age and gender. In fact, patients usually choose doctors within their insurance network and seniors and females usually have higher health care needs/demands than others. Here we present an improvement to the 2SFCA method to address these shortcomings. On the supply side, we allocate each doctor's resource equally to the insurance plans that he/she accepts. On the demand side, we adjusted the population based on their health care needs by age and gender and estimated the population holding each insurance based on the insurance's market share (assuming each insurance's market share is a reasonable representation of the population using that insurance). Next we calculate the accessibility score of each insurance plan following the 2SFCA approach and sum them at each population location as the accessibility at that location. We call the new improved approach Supply-Demand Adjusted 2SFCA. The results indicate that the SDA-2SFCA model could better reflect the actual supply and demand situation of health care and thus provide a better measure of spatial accessibility to health care. The SDA-2SFCA model can help researchers and government agencies better allocate limited resources to the neediest areas.

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Background: Autistic adults have an elevated risk of many health problems compared with the general population, making health care access extra critical. Unfortunately, autistic people often find health care settings quite aversive, and many medical providers report feeling unsure about how to interact with autistic patients. We aimed at characterizing specific challenges regarding sensory experiences and communicative barriers in health care settings. Methods: We recruited adults to complete an anonymous online questionnaire on the topic of improving health care experiences for everyone. The questions covered demographics, sensory experiences in medical settings, and communication with health care providers. We quantified the associations between autism diagnosis and experiences of sensory discomfort and communication barriers in health care settings. We also did a qualitative analysis of text responses to questions on how to improve sensory environments and communication with providers. Results: Swedish adults (62 autistic and 36 nonautistic) participated in the study. The cohort was well educated, and autistic participants received their autism diagnosis late in life (median age 36 years, range 13-57). Compared with nonautistic participants, autistic participants reported greater discomfort with background sound levels in health care settings and felt more misunderstood by health care providers. Thematic analyses showed that auditory stimuli and proximity to other people were particularly bothersome for autistic participants, causing stress or avoidance and affecting the ability to interact with providers. Providers contributed to communication barriers by failing to recognize the need for individualized information, especially when respondents' difficulties were not visible or taken seriously. Participants requested greater clarity and supplementary written information. Providers also misunderstood autistic adults' body language or eye contact patterns, as they interpreted their clients through the lens of neurotypical expectations. Conclusions: Our results extend previous research by emphasizing sensory aspects of health care settings and suggesting specific and reasonable adaptations. The results also highlight how the provider's implicit expectations of nonverbal communication caused misinterpretations of autistic people who were socially skilled but did not use typical body language. Based on the data, we suggest specific adaptations, many of which may also benefit nonautistic people.

Why was this study done?: Health care needs of autistic adults are often unmet. This may contribute to poorer health outcomes in autistic compared with nonautistic adults. Autistic differences may not be obvious in this group because of behavioral compensation strategies. Health care providers may underestimate the support needs of autistic adults, leading to decreased quality of care. By analyzing autistic adults' own experiences, we may better understand barriers to effective health care. What was the purpose of this study?: We aimed at identifying patterns of sensory and communicative experiences that autistic adults find problematic in health care settings. What did the researchers do?: In an online questionnaire, we asked autistic and nonautistic adults how they experienced various medical settings. We focused on specific sensory inputs, such as light levels and background sounds, in waiting rooms and other medical contexts. We also asked questions about communication between patients and providers. Finally, we did a qualitative analysis on free-text responses about sensory environments for both groups, and about communication for the autistic group. What were the results of the study?: Ninety-eight people (62 autistic) participated. Most of the cohort was female or gender-diverse, middle-age, and well educated. Autistic participants identified auditory inputs as one of the greatest stressors in medical settings. They discussed the impact of light levels and other people's presence on their energy levels and ability to communicate. Health care providers often misunderstood their autistic patients, leading to a failure in transferring medical information. Participants described how providers underestimated their needs, even when they were aware of the autism diagnosis. Participants wanted to get information delivered at a slower pace and with a greater amount of detail, to be better able to process medical or procedural information. What do these findings add to what was already known?: The study contributes with information on specific sensory challenges and suggests that auditory noise is particularly problematic for autistic people. On the topic of communication, the findings point to a "double empathy" problem, whereby the provider's own limitations contribute significantly to communication barriers. This was apparent in accounts of nonverbal communication, where the provider's expectations of neurotypical body language caused misunderstandings that were difficult to overcome. What are the potential weaknesses in the study?: The sample was small and comprised an ethnically narrow demographic group. Thus, the results are not generalizable to other autistic populations, such as minimally verbal adults. We also did not measure health status beyond diagnosed conditions. How will these findings help autistic adults now or in the future?: The consequences of sensory and communicative barriers may go entirely unnoticed when autistic differences are not visible. Unsuccessful interactions with the health care system may have enormous effects on the health and quality of life of autistic people. Therefore, educators and providers may use the insightful information provided by autistic participants in this study to inform decisions on staff training or design of sensory environments.

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Objetivo: analisar a produção científica sobre a qualidade e o acesso aos serviços na Atenção Primária à Saúde (APS) na perspectiva de usuários, profissionais de saúde e gestores.Métodos: a análise foi realizada por meio da Bibliometria, um estudo quantitativo descritivo, utilizando o pacote R Bibliometrix, VOSviewer e Zotero, para avaliar os artigos de 2011 até 2020 na Scopus.Resultados: foram recuperados 791 documentos. O ano com mais publicações foi 2019 e o com mais citações,2015. Dos 461 periódicos, a BMC Health Services Research destacou-se com 28 artigos. Dos 4475 autores, Clare Liddy foi a autora de maior produção. Foram identificados 24 clusters, sendo que seis tinham participação destacada dos autores mais citados. A University of Californiafoi a instituição com mais autores filiados. Os países com mais publicações foram os Estados Unidos da América, Reino Unido e Canadá, respectivamente.Conclusões: essa análise permitiu mapear os centros de pesquisa e grupos de pesquisadores mais relevantes na temática e redes colaborativas, evidenciando potenciais parcerias para o desenvolvimento de pesquisa. Foram identificados poucos estudos em relação à perspectiva dos profissionais e, principalmente, dos gestores sobre o acesso e qualidade da APS.

Objectives: to analyze the scientific production about quality and access of Primary Health Care (PHC) services from the perspective of users, health professionals, and population health management. Methods: an analysis was performed using Bibliometrics, a descriptive qualitative study, using the R package Bibliometrix and VOSviewer and Zotero software, to evaluate articles retrieved from 2011 to 2020 in the Scopus database. Results: 791 documents were retrieved. The year with the most publications was 2019 and 2015 was the year with the most citations. BMC Health Services Research stood out with 28 articles from 461 journals. Of the 4475 authors, Clare Liddy was the highest-producing author. Twenty-four clusters were identified, six of which had the participation of the most cited authors. The University of California was the institution with the most affiliated authors. The countries with the most involvement in publications were the United States of America, the United Kingdom, and Canada, respectively. Conclusions: this analysis of scientific production mapped the most relevant research centers and research groups on the subject and collaborative networks, potential partnerships for research development. Few studies were also identified in relation to the perspective of professionals and, especially, managers on the access and quality of PHC.

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BACKGROUND: In rural communities, there are gaps in describing the design and effectiveness of technology interventions for treating diseases and addressing determinants of health. OBJECTIVE: The aim of this study is to evaluate literature on current applications, therapeutic areas, and outcomes of telehealth interventions in rural communities in the United States. METHODS: A narrative review of studies published on PubMed from January 2017 to December 2020 was conducted. Key search terms included telehealth, telemedicine, rural, and outcomes. RESULTS: Among 15 included studies, 9 studies analyzed telehealth interventions in patients, 3 in health care professionals, and 3 in both patients and health care professionals. The included studies reported positive outcomes and experiences of telehealth use in rural populations including acceptability and increased satisfaction; they also noted that technology is convenient and efficient. Other notable benefits included decreased direct and indirect costs to the patient (travel cost and time) and health care service provider (staffing), lower onsite health care resource utilization, improved physician recruitment and retention, improved access to care, and increased education and training of patients and health care professionals. CONCLUSIONS: Telehealth models were associated with positive outcomes for patients and health care professionals, suggesting these models are feasible and can be effective. Future telehealth interventions and studies examining these programs are warranted, especially in rural communities, and future research should evaluate the impact of increased telehealth use as a result of the COVID-19 pandemic.

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Background: Health inequities are among debatable and challenging aspects of health systems. Achieving equity through social determinants of health approach has been mentioned in most upstream national plans and acts in Iran. This paper reports the findings of a systematic review of the current synthesized evidence on health equity in Iran. Methods: This is a narrative systematic review. The relevant concepts and terminology in health equity was found through MeSH. We retrieved the relevant studies from PubMed/MedLine, Social Sciences Database, and Google Scholar in English, plus the Jihad University Database (SID), and Google Scholar in Farsi databases from 1979 until the end of January 2018. The retrieved evidence has been assessed primarily based on PICOS criteria and then Ottawa-Newcastle Scale, and CASP for qualitative studies. We used PRISMA flow diagram and a narrative approach for synthesizing the evidence. Results: We retrieved 172 455 studies. Following the primary and quality appraisal process, 114 studies were entered in the final phase of the analysis. The main part (approximately 95%) of the final phase included cross-sectional studies that had been analyzed through current descriptive inequality analysis indicators, analytical regression, or decomposition-based approaches. The studies were categorized within 3 main groups: health outcomes (40.3%), health utilization (32%), and health expenditures (27%). Conclusion: As a part of understanding the current situation of health equity in the policymakers' need to refer the retrieved evidence in this study, they need more inputs specially regarding the social determinants of health approach. It seems that health equity research plan in Iran needs to be redirected in new paths that give appropriate weights to biological, gene-based, environmental and contextbased, economic, social, and political aspects of health as well. We advocate addressing the aspects of Social Determinant of Health (SDH) in analyzing health inequalities.

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BACKGROUND: Veterans are more likely than other Canadians to have chronic health conditions, making access to health care an important issue. However, little research has addressed health care access and use among veterans. This paper examines access and use among veterans compared with other Canadians. DATA AND METHODS: Health care access and use indicators were examined for Regular Force veterans using the 2016 Life After Service Survey. Information for male and female veterans was compared with information on the Canadian general population from the 2015 and 2016 Canadian Community Health Survey, using age-adjusted rates and 95% confidence intervals. RESULTS: More than 80% of male and female veterans reported having a regular medical doctor in the 12 months before the survey. The majority of veterans (71% of males and 81% of females) had consulted a family doctor, while a minority had been hospitalized (8% of males and females). These rates were similar to those in the Canadian general population. However, veteran consultation rates for mental health care and with audiologists, speech therapists or occupational therapists among both sexes were double to triple those of the Canadian general population. Among veterans, males reported lower rates of unmet needs compared with females. DISCUSSION: Veterans had similar rates of access to a regular medical doctor and higher rates of use compared with other Canadians. However, these may be comparatively low, given previous findings on higher rates of disability and some chronic conditions among veterans. Noted differences between males and females highlight the importance of research and services that account for sex and gender. The extent to which health care needs explain health care use and barriers to care requires further research.

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Resumo Este artigo busca analisar o acesso e a continuidade do cuidado em trajetórias assistenciais de mulheres através da identificação dos principais pontos de apoio na rede de atenção à saúde. Trata-se de uma pesquisa qualitativa, realizada em uma região de saúde do Rio de Janeiro, a partir de entrevista semiestruturada com 21 mulheres para produção de suas trajetórias assistenciais. Os dados foram tratados por meio de análise de conteúdo e categorizados em quatro unidades temáticas: os agentes comunitários de saúde, identificados como o primeiro contato e facilitadores do acesso à rede; os profissionais de enfermagem, com quem se estabeleceram os mais fortes vínculos longitudinais e alguma possibilidade de continuidade do cuidado; o médico, que representava a expectativa de cura, mas onde os laços e a comunicação com as usuárias foram mais frágeis; e outros pontos de apoio, representados por atores intermediários (amigos, familiares, figuras políticas e outros) presentes ora como apoio, ora como facilitadores do acesso ao cuidado oportuno. O mosaico de trajetórias produzidas pelas mulheres na rede de atenção à saúde indicou fragilidades para garantia de acesso e continuidade do cuidado, mas também potências para a produção de intervenções e práticas que respondam a desejos e necessidades em saúde.

Abstract This article seeks to analyze the access and continuity of care in women's care trajectories through the identification of the main points of support in the health care network. This is a qualitative research, carried out in a health region of Rio de Janeiro, based on a semi-structured interview with 21 women to produce their care trajectories. The data were treated through content analysis and categorized into four thematic units: community health agents, identified as the first contact and facilitators of access to the network; nursing professionals, with whom the strongest longitudinal bonds and some possibility of continuity of care were established; the doctor, who represented the expectation of a cure, but where ties and communication with users were more fragile; and other points of support, represented by intermediate actors (friends, family, political figures and others) present at times as support, at times as facilitators of access to timely care. The mosaic of trajectories produced by women in the health care network indicated weaknesses to guarantee access and continuity of care, but also potencies to produce interventions and practices that respond to health wants and needs.

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The world health care system´s concern of inequalities in treatment of receiving the necessary medical care. The purpose of article to evaluate the availability of endovascular care (EVC) for patients at regional level in Russia and to develop a system for its improvement. As a result the low availability of EVC for the population at the regional level in Russia with coronary heart disease, atherosclerosis of the brachiocephalic arteries and critical lower limb ischemia (CLLI) was funded. The main reasons for the difficulties in obtaining EVC in the regions of Russia are the low frequency of diagnosing a critical stage of cardiovascular disease (CVD) requiring surgical treatment, the absence of cardiovascular surgeons and cardiologists in the medical care organizations, the failure in information to patients attending a regular doctor´s appointment about effectiveness and safety of endovascular treatment technology. More old-school traditional methods remain in place like bypass or endarterectomy surgery. Further obstacles are prolonged waiting list at the regional level for the provision of high-tech care in cardiovascular surgery, choice of conservative treatment methods or amputation of lower limbs for patients with CLLI 3 and 4 st. (p<0.05). In Conclusion the Clinical and organizational assessment of the endovascular care accessibility in CVD for the population in regions of Russia elaborated. One way to improve the situation is the introduction of the cardiovascular care clinical management. A dual-circuit clinical and organizational system was developed and proposed to increase endovascular care accessibility in regions.

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The short paper provides an overview on how geographic issues have become increasingly relevant to public health research and policy, particularly through the lens of geographic information systems (GIS). It covers six themes with an emphasis on methodological issues. (1) Our health-related behavior varies across geographic settings, so should public health policy. (2) Facilities (supply) and patients (demand) in a health care market interact with each other across geopolitical borders, and measures of health care accessibility need to capture that. (3) Our health outcome is the result of joint effects of individual attributes and neighborhood characteristics, and an adequate definition of neighborhood is critical for assessing neighborhood effect. (4) Disease rates in areas of small population are unreliable, and one effective way to mitigate the problem is to construct a larger, internally-homogenous and comparable area unit. (5) Defining a scientific geographic unit for health care market is critical for researchers, practitioners, and policy makers to evaluate health care delivery, and GIS enables us to define the unit (e.g., primary care service areas, hospital service areas, and cancer service areas) automatically, efficiently and optimally. (6) Aside from various optimization objectives around "efficiency", it is as important to plan the location and allocation of health care resources toward maximum equality in health care access. Case studies are cited to illustrate each theme.