The Oregon Health Insurance Experiment: Evidence from the First Year

In 2008, a group of uninsured low-income adults in Oregon was selected by lottery to be given the chance to apply for Medicaid. This lottery provides an opportunity to gauge the effects of expanding access to public health insurance on the health care use, financial strain, and health of low-income adults using a randomized controlled design. In the year after random assignment, the treatment group selected by the lottery was about 25 percentage points more likely to have insurance than the control group that was not selected. We find that in this first year, the treatment group had substantively and statistically significantly higher health care utilization (including primary and preventive care as well as hospitalizations), lower out-of-pocket medical expenditures and medical debt (including fewer bills sent to collection), and better self-reported physical and mental health than the control group.National Institutes of Health. Department of Health and Human ServicesCalifornia HealthCare FoundationJohn D. and Catherine T. MacArthur FoundationNational Institute on Aging (P30AG012810)National Institute on Aging (RC2AGO36631)National Institute on Aging (R01AG0345151)Robert Wood Johnson FoundationAlfred P. Sloan FoundationSmith Richardson FoundationUnited States. Social Security Administration (grant 5 RRC 08098400-03-00 to the National Bureau of Economic Research as part of the SSA Retirement Research Consortium)Centers for Medicare & Medicaid Services (U.S.

Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomised controlled trial

Background: Birth attendance by trained health workers is low in rural Nepal. Local participation in improving health services and increased interaction between health systems and communities may stimulate demand for health services. Significant increases in birth attendance by trained health workers may be affected through community mobilisation by local women's groups and health management committee strengthening. We will test the effect of community mobilisation through women's groups, and health management committee strengthening, on institutional deliveries and home deliveries attended by trained health workers in Makwanpur District. Design: Cluster randomised controlled trial involving 43 village development committee clusters. 21 clusters will receive the intervention and 22 clusters will serve as control areas. In intervention areas, Female Community Health Volunteers are supported in convening monthly women's groups. The groups work through an action research cycle in which they consider barriers to institutional delivery, plan and implement strategies to address these barriers with their communities, and evaluate their progress. Health management committees participate in three-day workshops that use appreciative inquiry methods to explore and plan ways to improve maternal and newborn health services. Follow-up meetings are conducted every three months to review progress. Primary outcomes are institutional deliveries and home deliveries conducted by trained health workers. Secondary outcome measures include uptake of antenatal and postnatal care, neonatal mortality and stillbirth rates, and maternal morbidity

Tracing shadows: How gendered power relations shape the impacts of maternal death on living children in Sub-Saharan Africa

Driven by the need to better understand the full and intergenerational toll of maternal mortality (MM), a mixed-methods study was conducted in four countries in sub-Saharan Africa to investigate the impacts of maternal death on families and children. The present analysis identifies gender as a fundamental driver not only of maternal, but also child health, through manifestations of gender inequity in house- hold decision making, labor and caregiving, and social norms dictating the status of women. Focus group discussions were conducted with community members, and in depth qualitative interviews with key- informants and stakeholders, in Tanzania, Ethiopia, Malawi, and South Africa between April 2012 and October 2013. Findings highlight that socially constructed gender roles, which define mothers as care- givers and fathers as wage earners, and which limit women's agency regarding childcare decisions, among other things, create considerable gaps when it comes to meeting child nutrition, education, and health care needs following a maternal death. Additionally, our findings show that maternal deaths have differential effects on boy and girl children, and exacerbate specific risks for girl children, including early marriage, early pregnancy, and school drop-out. To combat both MM, and to mitigate impacts on children, investment in health services interventions should be complemented by broader interventions regarding social protection, as well as aimed at shifting social norms and opportunity structures regarding gendered divisions of labor and power at household, community, and society levels.Web of Scienc

Child Psychosocial Adjustment and Parenting in Families Affected by Maternal HIV/AIDS

Child adjustment and parenting were examined in 23 9-through 16-year-old youth from families affected by maternal HIV infection and 20 same-age peers whose mothers were not infected. Children whose mothers were seropositive reported significantly more externalizing problems. Infected mothers reported less age-appropriate supervision/monitoring relative to non-infected mothers. Better mother-child relationship quality and less impairment in parental supervision/monitoring of age-appropriate youth behaviors were associated with fewer externalizing difficulties among the HIV-positive group only. Similarly, only among HIV-infected mothers was refraining from engaging in inconsistent disciplinary tactics associated with lower reports of internalizing and externalizing problems. These data highlight the promise of programs targeting parenting skills to prevent or ameliorate child difficulties

Enhanced invitation methods and uptake of health checks in primary care. Rapid randomised controlled trial using electronic health records

Background: A national programme of health checks to identify risk of cardiovascular disease is being rolled out but is encountering difficulties of low uptake. Objective: To evaluate the effectiveness of an enhanced invitation method using the Question-Behaviour Effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. Secondary objectives were to evaluate reasons for low uptake of invitations and to compare case-mix for invited and opportunistic health checks. Trial design: Three-arm randomised trial. Participants: All participants invited for health checks from 18 general practices. Randomisation: Individual participants were randomised. Interventions: i) standard health check invitation only, ii) QBE questionnaire followed by standard invitation; iii) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by standard invitation. Outcomes: The primary outcome was completion of health check within six months of randomisation. A P value of 0.0167 was used for significance. Case-mix was evaluated for invited and opportunistic health checks. Blinding: Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction. Results: There were 12,459 participants allocated and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was: standard invitation, 590 / 4,095 (14.4%); QBE questionnaire, 630 / 3,988 (15.8%); QBE questionnaire and financial incentive, 629 / 3,969 (15.9%). The increase in uptake associated with QBE questionnaire was 1.43% (95% confidence interval -0.12 to 2.97%, P=0.070) and for the QBE questionnaire and offer of financial incentive was 1.52% (-0.03 to 3.07%, P=0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was -0.01% (-1.59 to 1.58%, P=0.995). During the study, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received ‘opportunistic’ health checks had greater odds of ≥10% cardiovascular disease (CVD) risk; adjusted odds ratio 1.70, 95% confidence interval 1.45 to 1.99, P<0.001) compared with invited health checks. Conclusion: Uptake of health checks following an invitation letter is low and is not increased through an enhanced invitation method using the QBE, with or without an incentive. A high proportion of all health checks are performed opportunistically. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Trial registration: Current Controlled Trials ISRCTN42856343

Use of antenatal services and delivery care among women in rural western Kenya: a community based survey

BACKGROUND: Improving maternal health is one of the UN Millennium Development Goals. We assessed provision and use of antenatal services and delivery care among women in rural Kenya to determine whether women were receiving appropriate care. METHODS: Population-based cross-sectional survey among women who had recently delivered. RESULTS: Of 635 participants, 90% visited the antenatal clinic (ANC) at least once during their last pregnancy (median number of visits 4). Most women (64%) first visited the ANC in the third trimester; a perceived lack of quality in the ANC was associated with a late first ANC visit (Odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0–2.4). Women who did not visit an ANC were more likely to have < 8 years of education (adjusted OR [AOR] 3.0, 95% CI 1.5–6.0), and a low socio-economic status (SES) (AOR 2.8, 95% CI 1.5–5.3). The ANC provision of abdominal palpation, tetanus vaccination and weight measurement were high (>90%), but provision of other services was low, e.g. malaria prevention (21%), iron (53%) and folate (44%) supplementation, syphilis testing (19.4%) and health talks (14.4%). Eighty percent of women delivered outside a health facility; among these, traditional birth attendants assisted 42%, laypersons assisted 36%, while 22% received no assistance. Factors significantly associated with giving birth outside a health facility included: age ≥ 30 years, parity ≥ 5, low SES, < 8 years of education, and > 1 hour walking distance from the health facility. Women who delivered unassisted were more likely to be of parity ≥ 5 (AOR 5.7, 95% CI 2.8–11.6). CONCLUSION: In this rural area, usage of the ANC was high, but this opportunity to deliver important health services was not fully utilized. Use of professional delivery services was low, and almost 1 out of 5 women delivered unassisted. There is an urgent need to improve this dangerous situation

Evaluating a team-based approach to research capacity building using a matched-pairs study design

Background: There is a continuing need for research capacity building initiatives for primary health care professionals. Historically strategies have focused on interventions aimed at individuals but more recently theoretical frameworks have proposed team-based approaches. Few studies have evaluated these new approaches. This study aims to evaluate a team-based approach to research capacity building (RCB) in primary health using a validated quantitative measure of research capacity in individual, team and organisation domains

Please understand when I cry out in pain: women's accounts of maternity services during labour and delivery in Ghana

BACKGROUND: This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana. METHODS: Twenty-one individual in-depth interviews and two focus group discussions were conducted with women of reproductive age who had delivered in the past five years in the Greater Accra Region. The study investigated women's perceptions and experiences of care in terms of factors that influenced place of delivery, satisfaction with services, expectations of care and whether they would recommend services. RESULTS: One component of care which appeared to be of great importance to women was staff attitudes. This factor had considerable influence on acceptability and utilisation of services. Otherwise, a successful labour outcome and non-medical factors such as cost, perceived quality of care and proximity of services were important. Our findings indicate that women expect humane, professional and courteous treatment from health professionals and a reasonable standard of physical environment. Women will consciously change their place of delivery and recommendations to others if they experience degrading and unacceptable behaviour. CONCLUSION: The findings suggest that inter-personal aspects of care are key to women's expectations, which in turn govern satisfaction. Service improvements which address this aspect of care are likely to have an impact on health seeking behaviour and utilisation. Our findings suggest that user-views are important and warrant further investigation. The views of providers should also be investigated to identify channels by which service improvements, taking into account women's views, could be operationalised. We also recommend that interventions to improve delivery care should not only be directed to the health professional, but also to general health system improvements

Developing criteria for Cesarean Section using the RAND appropriateness method

<p>Abstract</p> <p>Background</p> <p>Cesarean section rates are increasing worldwide, and a rapid increase has been observed in Iran. Disagreement exists between clinicians about when to use cesarean section. We aimed to identify the appropriateness criteria for the use of cesarean section in Iran.</p> <p>Method</p> <p>A consensus development study using a modified version of the RAND Appropriateness Method (RAM). We generated scenarios from valid clinical guidelines and expert opinions. A panel of experts participated in consensus development: first round via mail (12 members), second round face-to-face (9 members). We followed the RAM recommendations for the development of the scenario lists, rating scales, and statistical analyses.</p> <p>Results</p> <p>294 scenarios relevant to cesarean section were identified. 191 scenarios were considered appropriate, of which 125 scenarios were agreed upon. The panel found cesarean inappropriate for 21% of scenarios, and 'equivocal' for 14% of scenarios.</p> <p>Conclusion</p> <p>RAM is useful for identifying stakeholder views in settings with limited resources. The participants' views on appropriateness of certain indications differed with available evidence. A large number of scenarios without agreement may partly explain why it has been difficult to curb the growth in cesarean section rate.</p