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1.  Understanding innovators' experiences of barriers and facilitators in implementation and diffusion of healthcare service innovations: a qualitative study 
Background
Healthcare service innovations are considered to play a pivotal role in improving organisational efficiency and responding effectively to healthcare needs. Nevertheless, healthcare organisations encounter major difficulties in sustaining and diffusing innovations, especially those which concern the organisation and delivery of healthcare services. The purpose of the present study was to explore how healthcare innovators of process-based initiatives perceived and made sense of factors that either facilitated or obstructed the innovation implementation and diffusion.
Methods
A qualitative study was designed. Fifteen primary and secondary healthcare organisations in the UK, which had received health service awards for successfully generating and implementing service innovations, were studied. In-depth, semi structured interviews were conducted with the organisational representatives who conceived and led the development process. The data were recorded, transcribed and thematically analysed.
Results
Four main themes were identified in the analysis of the data: the role of evidence, the function of inter-organisational partnerships, the influence of human-based resources, and the impact of contextual factors. "Hard" evidence operated as a proof of effectiveness, a means of dissemination and a pre-requisite for the initiation of innovation. Inter-organisational partnerships and people-based resources, such as champions, were considered an integral part of the process of developing, establishing and diffusing the innovations. Finally, contextual influences, both intra-organisational and extra-organisational were seen as critical in either impeding or facilitating innovators' efforts.
Conclusions
A range of factors of different combinations and co-occurrence were pointed out by the innovators as they were reflecting on their experiences of implementing, stabilising and diffusing novel service initiatives. Even though the innovations studied were of various contents and originated from diverse organisational contexts, innovators' accounts converged to the significant role of the evidential base of success, the inter-personal and inter-organisational networks, and the inner and outer context. The innovators, operating themselves as important champions and being often willing to lead constructive efforts of implementation to different contexts, can contribute to the promulgation and spread of the novelties significantly.
doi:10.1186/1472-6963-11-342
PMCID: PMC3265424  PMID: 22176739
2.  Mental Health Service Use by Older Adults: The Role of Chronic Pain 
Objective
Mental health disorders commonly co-occur in patients with chronic pain, but little is known about the role of chronic pain in mental health service use. In this study, we explored the role of chronic pain in mental health service use by adults according to age group.
Design
Cross-sectional analysis of survey data from the second wave of the Healthcare for Communities telephone survey, collected in 2000 to 2001.
Setting
Randomly selected U.S. households.
Participants
U.S. civilian adults (N=6629)
Measurements
Common mental disorders were assessed using the short-form versions of the World Health Organization's Composite International Diagnostic Interview (CIDI-SF). Chronic pain conditions and mental health services received were identified by self report. Physical and mental functioning were assessed using the Short Form-12.
Results
Adults older than age 60 had higher rates of chronic pain and lower rates of mental health service use compared to those age 18 to 60 years. In multiple logistic regression models, an interaction effect was found between age and chronic pain (OR 3.0 [1.1-8.0]), with chronic pain significantly increasing the odds of any mental health care in the past year in adults older than 60 years of age.
Conclusions
Chronic pain increases the likelihood of mental health service use among older adults. Chronic pain may facilitate the presentation of distress in medical settings for these adults.
doi:10.1097/JGP.0b013e31815a3ea9
PMCID: PMC2749707  PMID: 18192496
pain; mental health; health services; geriatrics
3.  Vertical equity of healthcare in Taiwan: health services were distributed according to need 
Introduction
To test the hypothesis that the distribution of healthcare services is according to health need can be achieved under a rather open access system.
Methods
The 2001 National Health Interview Survey of Taiwan and National Health Insurance claims data were linked in the study. Health need was defined by self-perceived health status. We used Concentration index to measure need-related inequality in healthcare utilization and expenditure.
Results
People with greater health need received more healthcare services, indicating a pro-need character of healthcare distribution, conforming to the meaning of vertical equity. For outpatient service, subjects with the highest health need had higher proportion of ever use in a year than those who had the least health need and consumed more outpatient visits and expenditures per person per year. Similar patterns were observed for emergency services and hospitalization. The concentration indices of utilization for outpatient, emergency services, and hospitalization suggest that the distribution of utilization was related to health need, whereas the preventive service was less related to need.
Conclusions
The universal coverage plus healthcare networking system makes it possible for healthcare to be utilized according to need. Taiwan’s experience can serve as a reference for health reform.
doi:10.1186/1475-9276-12-12
PMCID: PMC3570366  PMID: 23363855
4.  Patterns and predictors of health service utilization in adolescents with pain: comparison between a community and a clinical pain sample 
There is limited research describing the patterns of healthcare utilization in adolescents with chronic pain. This study describes healthcare utilization in a clinical chronic pain sample, and compares the patterns of service use of this group to a community sample with intermittent pain complaints. We also investigated demographic and clinical factors that predicted healthcare visits and medication use in the clinical sample. Data on 117 adolescents (aged 12-18; n=59 clinical pain sample, n=58 community) were collected. Caregivers and adolescents reported on sociodemographics, medical visits, current medications, pain, activity limitations, and depression. As hypothesized, the clinical pain sample had higher rates of healthcare consultation on all types of medical visits (general, specialty care, complementary medicine, mental health, OT/PT), and higher medication use compared to the community sample. Regression analyses revealed that higher annual income, greater pain frequency, and higher levels of caregiver reported activity limitations were associated with a greater number of healthcare visits for the total sample. Within the clinical pain sample, higher pain frequency and greater activity limitations (caregiver-report) predicted more specialty care visits. Additionally, higher income and greater levels of depressive symptoms predicted a higher number of prescribed medications.
Perspective
This study contributes to the limited available data on health service and medication use in a clinical chronic pain sample versus a community sample of adolescents. We also identify clinical factors (pain frequency, parent-reported activity limitations, depressive symptoms) and demographic factors (gender, income) associated with healthcare utilization.
doi:10.1016/j.jpain.2010.12.011
PMCID: PMC3130816  PMID: 21481647
adolescent; chronic pain; health service use; activity limitations
5.  Who should decide? Qualitative analysis of panel data from public, patients, healthcare professionals, and insurers on priorities in health care. 
BMJ : British Medical Journal  1997;315(7100):92-96.
OBJECTIVE: To explore the arguments underlying the choices of patients, the public, general practitioners, specialists, and health insurers regarding priorities in health care. DESIGN: A qualitative analysis of data gathered in a series of panels. Members were asked to economise on the publicly funded healthcare budget, exemplified by 10 services. RESULTS: From a medical point of view, both panels of healthcare professionals thought most services were necessary. The general practitioners tried to achieve the budget cuts by limiting access to services to those most in need of them or those who cannot afford to pay for them. The specialists emphasised the possibilities of reducing costs by increasing the efficiency within services and preventing inappropriate utilisation. The patients mainly economised by limiting universal access to preventive and acute services. The "public" panels excluded services that are relatively inexpensive for individual patients. Moreover, they emphasised the individual's own responsibility for health behaviour and the costs of health care, resulting in the choice for copayments. The health insurers emphasised the importance of including services that relate to a risk only, as well as feasibility aspects. CONCLUSIONS: There were substantial differences in the way the different groups approached the issue of what should be included in the basic package. Healthcare professionals seem to be most aware of the importance of maintaining equal access for everyone in need of health care.
PMCID: PMC2127072  PMID: 9240048
6.  A content analysis from a US statewide survey of memorable healthcare decisions for individuals with intellectual disability 
Background
Little is known about surrogate healthcare decision-making for individuals with intellectual disability (ID). This study examined healthcare decision-making by residential-agency directors to learn their process and the extent to which the individual is included.
Method
Content analysis of qualitative data from a mailed survey of residential-agency directors in a large US mid-Atlantic state.
Results
Narrative comments of 102 directors (65% of respondents) are reported. Three themes emerged: (a) Identifying someone else’s “best interest” is challenging; (b) Perceptions of the healthcare community, especially related to quality of life, can influence care provided; and (c) Surrogate decision-making is a team effort.
Conclusions
With knowledge of how decisions are made, the healthcare community can better interact with the complex array of service agencies and persons who determine care for this vulnerable population.
doi:10.1080/13668250903083332
PMCID: PMC2862000  PMID: 19681006
surrogate healthcare decision-making; intellectual disability; healthcare decision-making; qualitative methods; content analysis
7.  ‘Mind the gap’ - mapping services for young people with ADHD transitioning from child to adult mental health services 
BMC Psychiatry  2013;13:186.
Background
Once considered to be a disorder restricted to childhood, Attention Deficit/Hyperactivity Disorder (ADHD) is now recognised to persist into adult life. However, service provision for adults with ADHD is limited. Additionally, there is little guidance or research on how best to transition young people with ADHD from child to adult services.
Method
We report the findings of a survey of 96 healthcare professionals working in children’s (Child and Adolescent Mental Health Services and Community Paediatrics) and adult services across five NHS Trusts within the East Midlands region of England to gain a better understanding of the current provision of services for young people with ADHD transitioning into adult mental health services.
Results
Our findings indicate a lack of structured guidelines on transitioning and little communication between child and adult services. Child and adult services had differing opinions on what they felt adult services should provide for ADHD cases. Adult services reported feeling ill-prepared to deal with ADHD patients, with clinicians in these services citing a lack of specific knowledge of ADHD and a paucity of resources to deal with such cases.
Conclusions
We discuss suggestions for further research, including the need to map the national provision of services for adults with ADHD, and provide recommendations for commissioned adult ADHD services. We specifically advocate an increase in ADHD-specific training for clinicians in adult services, the development of specialist adult ADHD clinics and greater involvement of Primary Care to support the work of generic adult mental health services in adult ADHD management.
doi:10.1186/1471-244X-13-186
PMCID: PMC3717001  PMID: 23842080
Transition; Service mapping; ADHD; Adults
8.  Association of income with symptoms, morbidities and healthcare usage among Japanese adults 
Objectives
Socioeconomic inequalities in healthcare services are major public health and healthcare concerns. We have examined the association of income with symptoms, morbidities and healthcare usage in a national sample of the Japanese population.
Methods
For this study, data compiled on 21,929 men and 24,620 women from the Comprehensive Survey of the Living Conditions of People on Health and Welfare in 2007 were assessed. Among the survey respondents with symptoms, we compared the prevalences of symptoms and treatments and the number of respondents who received treatments for 16 groups of symptoms and disorders according to household income, from the highest to the lowest, using the relative index of inequalities (RII). The RIIs were computed by age groups [25–59 years (young group) and 60+ years (senior group)].
Results
People with lower incomes had higher prevalences of symptoms and treatments for most of the disorders examined. The RIIs of symptoms and treatments were 1.19 [95% confidence interval (CI) 1.09–1.31] and 1.04 (95% CI 0.93–1.16) for the young group and 1.69 (1.53–1.87) and 1.51 (1.36–1.67) for the senior group, respectively. In terms of treatment prevalence among those with symptoms, the RII was not significantly lower than 1.0 except for a few disorders in the young group.
Conclusions
Our results indicate that income inequalities can be related to the prevalences of various symptoms and morbidities in our Japanese sample population and that these inequalities were greater in the senior group than in the young group. Our results also suggest that lower income is not a substantial barrier to the use of healthcare services by older Japanese individuals, while it is related to lower healthcare usage by individuals of working age.
doi:10.1007/s12199-011-0254-6
PMCID: PMC3390568  PMID: 22180347
Health inequality; Socioeconomic factors; Income; Morbidity; Healthcare usage
9.  The use of CAM and conventional treatments among primary care consulters with chronic musculoskeletal pain 
BMC Family Practice  2007;8:26.
Background
Chronic musculoskeletal pain is the single most cited reason for use of complementary and alternative medicine (CAM). Primary care is the most frequent conventional medical service used by patients with pain in the UK. We are unaware, however, of a direct evidence of the extent of CAM use by primary care patients, and how successful they perceive it to be.
Methods
Aims and objectives
To determine CAM use among patients with chronic musculoskeletal pain who have consulted about their pain in primary care.
Study design
Face-to-face interview-based survey.
Setting
Three general practices in North Staffordshire.
Participants
Respondents to a population pain survey who had reported having musculoskeletal pain in the survey and who had consulted about their pain in primary care in the previous 12 months as well as consenting to further research and agreeing to an interview. Information was gathered about their pain and the use of all treatments for pain, including CAM, in the previous year.
Results
138 interviews were completed. 116 participants (84%) had used at least one CAM treatment for pain in the previous year. 65% were current users of CAM. The ratio of over-the-counter CAM use to care from a CAM provider was 3:2. 111 participants (80%) had used conventional treatment. 95 (69%) were using a combination of CAM and conventional treatment. Glucosamine and fish oil were the most commonly used CAM treatments (38%, 35% respectively). Most CAM treatments were scored on average as being helpful, and users indicated that they intended to use again 87% of the CAM treatments they had already used.
Conclusion
We provide direct evidence that most primary care consulters with chronic musculoskeletal pain have used CAM in the previous year, usually in combination with conventional treatments. The high prevalence and wide range of users experiences of benefit and harm from CAM strengthen the argument for more research into this type of medicine to quantify benefit and assess safety. The observation that most users of conventional medicine also used CAM suggests a continuing need for more investigation of effective pain management in primary care.
doi:10.1186/1471-2296-8-26
PMCID: PMC1878478  PMID: 17480212
10.  Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo – A Case study of Lubumbashi City 
Background
The use of maternal health services, known as an indirect indicator of perinatal death, is still unknown in Lubumbashi. The present study was therefore undertaken in order to determine the factors that influence the use of mother and child healthcare services in Lubumbashi, Democratic Republic of the Congo.
Methods
This was transversal study of women residing in Lubumbashi who had delivered between January and December 2009. In total, 1762 women were sampled from households using indicator cluster surveys in all health zones. Antenatal consultations (ANC), delivery assisted by qualified healthcare personnel (and delivery in a healthcare facility) as well as postnatal consultations (PNC) were dependent variables of study. The factors determining non-use of maternal healthcare services were researched via logistic regression with a 5% materiality threshold.
Results
The use of maternal healthcare services was variable; 92.6% of women had attended ANC at least once, 93.8% of women had delivered at a healthcare facility, 97.2% had delivered in the presence of qualified healthcare personnel, while the rate of caesarean section was 4.5%. Only 34.6% postnatal women had attended PNC by 42 days after delivery. During these ANC visits, only 60.6% received at least one dose of vaccine, while 38.1% received Mebendazole, 35.6% iron, 32.7% at least one dose of SulfadoxinePyrimethamine, 29.2% folic acid, 15.5% screening for HIV and 12.8% an insecticide treated net.
In comparison to women that had had two or three deliveries before, primiparous and grand multiparous women were twice as likely not to use ANC during their pregnancy. Women who had unplanned pregnancies were also more likely not to use ANC or PNC than those who had planned pregnancies alone or with their partner. The women who had not used ANC were also more likely not to use PNC. The women who had had a trouble-free delivery were more likely not to use PNC than those who had complications when delivering.
Conclusion
In Lubumbashi, a significant proportion of women continue not to make use of healthcare services during pregnancy, as well as during and after childbirth. Women giving birth for the first time, those who have already given birth many times, and women with an unwanted pregnancy, made less use of ANC. Moreover, women who had not gone for ANC rarely came back for postnatal consultations, even if they had given birth at a healthcare facility. Similarly, those who gave birth without complications, less frequently made use of postnatal consultations. As with ANCs, women with unwanted pregnancies rarely went for postnatal visits.
In addition to measures aimed at reinforcing women’s autonomy, efforts are also needed to reinforce and improve the information given to women of childbearing age, as well as communication between the healthcare system and the community, and participation from the community, since this will contribute to raising awareness of safe motherhood and the use of such services, including family planning.
doi:10.1186/1471-2393-12-66
PMCID: PMC3449182  PMID: 22780957
11.  Effect of Depression Treatment on Chronic Pain Outcomes 
Psychosomatic medicine  2009;72(1):61-67.
Objective
People with chronic pain and depression have worse health outcomes than those with chronic pain alone. Little is known about the effectiveness of depression treatment for this population. We examined the effect of depression treatment on medical and social outcomes for individuals with chronic pain and depression
Methods
Propensity score weighted analyses using both waves (1997-1998 and 2000-2001) of the National Survey of Alcohol, Drug, and Mental Health Problems were used to examine the effect of (1) any depression treatment and (2) minimally adequate depression treatment on persistence of depression symptoms, depression severity, pain severity, overall health, mental health status, physical health status, social functioning, employment status, and number of work days missed. Analyses were limited to those who met CIDI-SF criteria for major depressive disorder, reported having at least one chronic pain condition, and completed both interviews (n=553).
Results
Receiving any depression treatment was associated with higher scores on the mental component summary of the MOS SF-12, indicating better mental health (difference = 2.65 points, p=0.002) and less interference of pain on work (OR=0.57, p=0.02). Among those receiving treatment, minimal adequacy of treatment was not significantly associated with better outcomes.
Conclusions
Depression treatment improves mental health and reduces the effects of pain on work among those with chronic pain and depression. Understanding the effect of depression treatment on outcomes for this population is important for employers, healthcare providers treating this population, and policymakers working in this Decade of Pain Control and Research to improve care for chronic pain sufferers.
doi:10.1097/PSY.0b013e3181c2a7a8
PMCID: PMC3171143  PMID: 19875633
pain; depression; quality assessment; outcomes
12.  Age and sex interaction in reported help seeking in response to chest pain 
Background
There is a growing literature suggesting that access to cardiology services is affected by age. However, there is a dearth of studies that have considered age and sex in conjunction.
Aim
This study aims to examine the impact of age, and its interaction with sex, on reported healthcare seeking, based on responses to symptom vignettes, in an attempt to standardise symptomatology across all responders.
Design of study
A cross-sectional survey design was utilised.
Setting
Primary care.
Method
A random sample of 911 individuals, stratified by sex, was selected from one practice in the UK. Participants were invited to state how they would react in response to the chest pain symptoms presented. Patterns of response were examined, by age and sex, using χ2 and logistic regression models.
Results
This study identified differences by age and sex in a general practice population in the propensity to seek health care. In particular, men aged 60–69 years and women aged 70 years and over were more likely to report healthcare seeking than younger responders. For example, women aged 70 years and over had over three times greater odds of reporting contact with the GP compared to the reference category. Evidence for an interaction effect between age and sex was observed.
Conclusion
The results suggest that the inequity that has been demonstrated in access to cardiology services by age is not likely to be due to the patient's illness behaviour as, overall, older people are more likely than younger people to be willing to consult their doctors.
doi:10.3399/bjgp08X279670
PMCID: PMC2435666  PMID: 18482485
aged; gender identity; heart; patient acceptance of health care
13.  Chronic shoulder pain in the community: a syndrome of disability or distress? 
Annals of the Rheumatic Diseases  2002;61(2):128-131.
Objectives: To investigate two questions in a community based population of people with chronic shoulder pain. Firstly, does chronic pain lead to impaired psychological health over time? Secondly, how does restriction of daily activity influence pain perception and psychological health?
Methods: Two postal surveys, two years apart, were carried out to identify a group of subjects with chronic shoulder pain. The first survey was sent to a random sample of adults (n=40026) registered with a primary care practice, and included a pain manikin, demographic information, and the Hospital Anxiety and Depression scale (HAD). The second survey was sent to those subjects who reported unilateral shoulder region pain in the first survey and it included a shoulder-specific disability scale, pain severity score, and the HAD.
Results: 2606 (65.1%) people responded to the initial survey. Of these, 304 (11.7%) reported unilateral shoulder region pain at baseline. In the subsequent survey, there were 234 responders (83.3% adjusted response): 142 of these reported shoulder pain and formed our study group of "subjects with chronic shoulder pain". Within this group there was no significant change in psychological distress scores between baseline and follow up. Both the disability score and psychological distress scores correlated significantly with pain severity (disability v pain r=0.536, p<0.001; psychological distress v pain r=0.269, p=0.002). When the correlation between disability and pain severity was corrected for possible confounders, it remained significant (r=0.490, p<0.001). This was not the case for the correlation between psychological distress and pain (p>0.05). Disability was significantly correlated with psychological distress on univariate (r=0.445, p<0.001) and multivariate analysis (r=0.341, p=0.002).
Conclusion: In those with chronic shoulder pain the relation between pain and psychological health seems to be linked to disability. Psychological distress was not explained by persistent pain itself.
doi:10.1136/ard.61.2.128
PMCID: PMC1754001  PMID: 11796398
14.  Cross-sectional survey of users of Internet depression communities 
BMC Psychiatry  2003;3:19.
Background
Internet-based depression communities provide a forum for individuals to communicate and share information and ideas. There has been little research into the health status and other characteristics of users of these communities.
Methods
Online cross-sectional survey of Internet depression communities to identify depressive morbidity among users of Internet depression communities in six European countries; to investigate whether users were in contact with health services and receiving treatment; and to identify user perceived effects of the communities.
Results
Major depression was highly prevalent among respondents (varying by country from 40% to 64%). Forty-nine percent of users meeting criteria for major depression were not receiving treatment, and 35% had no consultation with health services in the previous year. Thirty-six percent of repeat community users who had consulted a health professional in the previous year felt that the Internet community had been an important factor in deciding to seek professional help.
Conclusions
There are high levels of untreated and undiagnosed depression in users of Internet depression communities. This group represents a target for intervention. Internet communities can provide information and support for stigmatizing conditions that inhibit more traditional modes of information seeking.
doi:10.1186/1471-244X-3-19
PMCID: PMC317315  PMID: 14664725
15.  Pain and health related functioning among employees 
Study objective
Although employees report high rates of pain, little is known about the effects of pain on health related functioning among them. This study examined the effects of pain on employees' health related functioning by bodily locations of pain, number of painful locations, and whether pain was acute or chronic.
Design
Cross sectional questionnaire survey. Data on pain and health related functioning as measured with the eight subscales of the short form 36 health survey (SF‐36) were obtained in the years 2001 and 2002.
Setting
Municipal employees of the City of Helsinki, Finland.
Participants
All employees who reached the age of 40, 45, 50, 55, and 60 years during each study year. Response rate was 66% (n = 5829).
Main results
Compared with those reporting no pain, those with pain had considerably poorer functioning on all SF‐36 subscales. The lowest scores for health related functioning were seen in the physical domain of health, whereas the mental domain was less affected. The association of pain with functioning was practically independent of the bodily location of pain. Whether pain was acute or chronic had only a modest effect on functioning. Widest variation in functioning was found by the number of painful locations.
Conclusions
Among employees pain complaints, irrespective of the location, are associated with a decreased level of functioning. The number of painful locations is likely to be the most useful measure to identify employees with a high risk of poor functioning.
doi:10.1136/jech.2005.043976
PMCID: PMC2566029  PMID: 16905725
bodily location of pain; number of painful locations; chronic pain; employees; SF‐36
16.  Chronic widespread pain in the population: a seven year follow up study 
Annals of the Rheumatic Diseases  2002;61(12):1071-1074.
Objectives: To document the natural course of chronic widespread pain (CWP) in a general population sample over a seven year period and to identify comorbidities which predict persistence.
Methods: A mailed survey questionnaire returned by 2334 adults registered with two general practices was used to obtain information on pain status (no pain, regional pain, or CWP) and other health and pain symptoms. Seven years later a second questionnaire was sent to responders who were still registered with the same general practice, asking about their current pain status.
Results: Information was obtained for 1386 adults (an adjusted response of 93%). The prevalence of CWP was similar for both surveys at 11% and 10% respectively. Of those with CWP initially, a third recorded CWP on the second survey and 15% were pain free. Only 2% of subjects with no initial pain had developed CWP at follow up. Of subjects with CWP on the initial survey who were aged over 50 years and reported dry eyes or mouth and daytime tiredness, 77% reported CWP seven years later. This contrasts with a persistence of only 9% for those aged under 50 and with neither symptom recorded at initial survey.
Conclusion: The proportion of subjects from a general population sample changing from CWP to no pain, or vice versa, over a seven year period was very low. This suggests that pain, once established, is likely to persist (or recur) especially if accompanied by other somatic symptoms and older age.
doi:10.1136/ard.61.12.1071
PMCID: PMC1753967  PMID: 12429537
17.  Determinants of Unacceptable Waiting Times for Specialized Services in Canada 
Healthcare Policy  2007;2(3):e140-e154.
Background:
Much of the current evidence regarding timely access to healthcare services focuses on the duration of the waiting time as the principal determinant of wait time acceptability. We conducted the first national-level analysis of wait time acceptability in Canada to identify the determinants of unacceptable waits for specialized healthcare services, including selected demographic and socio-economic variables.
Methods:
We analyzed data reported by respondents to a national survey on access to healthcare services who accessed specialized services (i.e., specialist visits, non-emergency surgery and selected diagnostic tests) during a 12-month period. We used univariate analyses and weighted logistic regression to examine the relation between wait time acceptability and selected demographic, socio-economic and health status factors for each specialized service.
Results:
Between 17% and 29% of patients who waited for a specialized service declared that their waiting time was unacceptable. Most individuals reported waiting less than 3 months for their services. Between 10% and 19% of those who waited indicated that waiting for care affected their lives. Results of the logistic regression analyses showed that longer waits and adverse experiences during the waiting period were significantly associated with higher odds of reporting an unacceptable waiting time for all three types of specialized services. The role of socio-economic and demographic factors on wait time acceptability was varied. Individuals with lower education were consistently less likely to consider their waiting times unacceptable. Patients less than 65 years of age were more likely to consider their waiting times unacceptable for specialist visits and diagnostic tests.
Interpretation:
Our study shows that the primary determinants of waiting time acceptability are the length of the waiting time and the effects of waiting on the patient’s life. In addition, some patient characteristics, such as age and education, may play a role, pointing to the potential role of patient expectations in determining the acceptability of waits for specialized services.
PMCID: PMC2585450  PMID: 19305710
18.  Assessment of Vulvodynia Symptoms in a Sample of U.S. Women: A Prevalence Survey with a Nested Case Control Study 
Objective
Vulvodynia is a chronic pain syndrome of unknown etiology with scant data on frequency. This study assessed the prevalence of vulvodynia symptoms in a sample of U.S. women and compared health characteristics of symptomatic and asymptomatic women.
Study Design
A phone survey contacted 2,127 U.S. households to identify 100 symptomatic women, who were matched on age and time-zone to 325 asymptomatic controls. Odds ratios and logistic regression were used to model associations between pain, medical conditions, and healthcare utilization variables.
Results
Current vulvar pain of at least 6 months duration was reported by 3.8% of respondents, with a 9.9% lifetime prevalence. Forty-five percent of women with pain reported an adverse effect on their sexual life and 27% an adverse effect on their life style. Cases more frequently reported repeated urinary tract infections (OR, 6.15; 95% CI, 3.51–10.77) and yeast infections (OR, 4.24; 95% CI, 2.47–7.28). Associations existed with chronic fatigue syndrome (OR, 2.78; 95% CI, 1.33–6.19), fibromyalgia (OR, 2.15; 95% CI, 1.06–4.36), depression (OR, 2.99; 95% CI, 1.87–4.80), and irritable bowel syndrome (OR, 1.86; 95% CI, 1.07–3.23).
Conclusions
Lifetime chronic vulvar pain was less prevalent in this national sample of women than previous data suggest and was correlated with several co-morbid chronic medical conditions and substantial reduction in self-reported quality of life.
doi:10.1016/j.ajog.2006.07.047
PMCID: PMC2746064  PMID: 17306651
Vulvodynia; chronic pain; vulvar pain; prevalence
19.  Satisfaction with Access to Health Services: The Perspective of Estonian Patients with Rheumatoid Arthritis 
The Scientific World Journal  2012;2012:257569.
In this cross-sectional study we explained the possible determinants of satisfaction with access to health services in patients with rheumatoid arthritis (RA). Of the 2000 randomly selected Estonian adult patients with RA, a total 1259 completed the survey. Regression analysis was used to analyse the predictors of patients' satisfaction with access to health services. Half of the respondents were satisfied with their access to health services. Factors that had a negative impact on satisfaction included pain intensity, longer waiting times to see the doctors, as well as low satisfaction with the doctors. Transportation costs to visit a rheumatologist and higher rehabilitation expenses also affected the degree of satisfaction. Patients who could choose the date and time at which they could visit the rheumatologist or who could visit their “own” doctor were more likely to be satisfied than patients whose appointment times were appointed by a healthcare provider.
doi:10.1100/2012/257569
PMCID: PMC3345532  PMID: 22593670
20.  Analysis of changes in the association of income and the utilization of curative health services in Mexico between 2000 and 2006 
BMC Public Health  2011;11:771.
Background
A common characteristic of health systems in most developing countries is unequal access to health services. As a result, members of the poorest population groups often do not receive formal attention for health services, because they cannot afford it. In 2001 in Mexico, to address income-related differences in the use of health services, the government launched a major healthcare reform, which includes a health insurance program called Seguro Popular, aimed at improving healthcare access among poor, uninsured residents. This paper analyzes the before and after changes in the demand for curative ambulatory health services focusing on the association of income-related characteristics and the utilization of formal healthcare providers vs. no healthcare service utilization.
Methods
By using two nationally representative health surveys (ENSA-2000 and ENSANUT-2006), we modeled an individual's decision when experiencing an illness to use services provided by the (1) Ministry of Health (MoH), (2) social security, (3) private entities, or (4) to not use formal services (no healthcare service utilization).
Results
Poorer individuals were more likely in 2006 than in 2000 to respond to an illness by using formal healthcare providers. Trends in provider selection differed, however. The probability of using public services from the MoH increased among the poorest population, while the findings indicated an increase in utilization of private health services among members of low- and middle-income groups. No significant change was seen among formal workers -covered by social security services-, regardless of socioeconomic status.
Conclusions
Overall, for 2006 the Mexican population appears less differentiated in using healthcare across economic groups than in 2000. This may be related, in part, to the implementation of Seguro Popular, which seems to be stimulating healthcare demand among the poorest and previously uninsured segment of the population. Still, public health authorities need to address the remaining income-related healthcare utilization differences, the differences in quality between public and private health services, and the general perception that MoH facilities offer inferior services.
doi:10.1186/1471-2458-11-771
PMCID: PMC3203078  PMID: 21978183
21.  The need for a clinical ethics service and its goals in a community healthcare service centre: a survey 
Journal of Medical Ethics  2006;32(10):564-566.
Objectives
To (1) assess whether according to healthcare providers, the creation of an ethics service responds to a need; (2) assess the importance of an ethics service for healthcare providers; (3) determine what ethics services should be offered and the preferred formats of delivery; and (4) identify key issues to be initially dealt with by the ethics service.
Design
A survey of healthcare providers in Québec's Centre Local de Services Communautaires (CLSC), healthcare institutions dedicated to community health and social services.
Findings
96 (95%) respondents agreed that an ethics service was needed, and on average the ethics service project was judged to be very important. Preferred formats for ethics consultation and education were identified, as well as key concerns such as the need of respect for the patient as a person, elder abuse and ethical issues in home care.
Conclusion
This survey is helping in the implementation of an ethics service and can guide others in similar healthcare institutions.
doi:10.1136/jme.2005.014589
PMCID: PMC2563304  PMID: 17012494
22.  Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation 
Annals of the Rheumatic Diseases  1998;57(11):649-655.
BACKGROUND—Epidemiologically-based rheumatology healthcare needs assessment requires an understanding of the incidence and prevalence of musculoskeletal disorders in the community, of the reasons why people consult in primary care, and of the proportion of people who would benefit from referral to secondary care and paramedical services. This paper reports the first phase of such a needs assessment exercise.
SPECIFIC OBJECTIVE—To estimate the relative frequency of musculoskeletal pain in different, and multiple, anatomical sites in the adult population.
SETTING—Three general practices in the former Tameside and Glossop Health Authority, Greater Manchester, UK, a predominantly urban area.
DESIGN—Population survey.
METHODS—An age and sex stratified sample of 6000 adults from the three practices was mailed a questionnaire that sought data on demographic factors, musculoskeletal symptoms (pain in the past month lasting for more than a week), and physical disability (using the modified Health Assessment Questionnaire- mHAQ). The areas of pain covered were neck, back, shoulder, elbow, hand, hip, knee, and multiple joints. The Carstairs index was used as a measure of social deprivation of the postcode sector in which the person lived.
RESULTS—The response rate after two reminders was 78.5%. Non-responders were more likely to live in areas of high social deprivation. People who lived in more deprived areas were also more likely to report musculoskeletal pain, especially backpain. After adjusting for social deprivation the rates of musculoskeletal pain did not differ between the practices and so their results were combined. After adjustment for social deprivation, the most common site of pain was back (23%; 95% CI 21, 25) followed by knee (19%; 95% CI 18, 21), and shoulder (16%; 95% CI 14, 17). The majority of subjects who reported pain had pain in more than one site. The prevalence of physical disability in the community rose with age. It was highest in those with multiple joint problems but was also high in those with isolated back or knee pain.
CONCLUSION—Musculoskeletal pain is common in the community. People who live in socially deprived areas have more musculoskeletal symptoms. Estimates of the overall burden of musculoskeletal pain that combine the results of site specific surveys will be too high, those that do not adjust for socioeconomic factors will be too low.

 Keywords: prevalence; pain; social deprivation
PMCID: PMC1752494  PMID: 9924205
23.  The role of uninsurance and race in healthcare utilization by rural minorities. 
Health Services Research  1998;33(3 Pt 1):597-610.
OBJECTIVE: To examine the independent effects of minority status, residence, insurance status, and income on physician utilization, controlling for general health status and the presence of acute or chronic health problems. Of special interest was the question of utilization differences among rural minority populations, as compared with urban non-Latino whites. DATA SOURCE: Data from the 1992 National Health Interview Survey (NHIS). STUDY DESIGN: Multivariate analyses used multiple logistic regression methods to detect independent effects of residence and minority status on whether or not individuals used physician services. DATA COLLECTION/EXTRACTION METHODS: Data were obtained from the National Health Interview Survey, 1992. The survey included information about the race/ethnicity of the respondent, health status, utilization of services, insurance status, and socioeconomic status. PRINCIPAL FINDINGS: The most salient determinant of utilization of healthcare services is insurance status, regardless of race/ethnicity or (rural or urban) place of residence. Racial and ethnic minorities were less likely than whites to use physician services, and use was generally lower for rural residents. The most striking differences were for rural Latinos and rural Asians/other persons. CONCLUSIONS: Although the results demonstrate a need to adjust policies designed to improve utilization by accounting for particular problems faced by minority populations, they also demonstrate the primacy of addressing financial access.
PMCID: PMC1070278  PMID: 9685124
24.  Evaluating the health and economic impact of osteoarthritis pain in the workforce: results from the National Health and Wellness Survey 
Background
There has been increasing recognition that osteoarthritis (OA) affects younger individuals who are still participants in the workforce, but there are only limited data on the contribution of OA pain to work productivity and other outcomes in an employed population. This study evaluated the impact of OA pain on healthcare resource utilization, productivity and costs in employed individuals.
Methods
Data were derived from the 2009 National Health and Wellness Survey. Univariable and multivariable analyses were used to characterize employed individuals (full-time, part-time, or self-employed) ≥20 years of age who were diagnosed with OA and had arthritis pain in the past month relative to employed individuals not diagnosed with OA or not experiencing arthritis pain in the past month. Work productivity was assessed using the Work Productivity and Activity Impairment (WPAI) questionnaire; health status was assessed using the physical (PCS) and mental component summary (MCS) scores from the SF-12v2 Health Survey and SF-6D health utilities; and healthcare utilization was evaluated by type and number of resources within the past 6 months. Direct and indirect costs were estimated and compared between the two cohorts.
Results
Individuals with OA pain were less likely to be employed. Relative to workers without OA pain (n = 37,599), the OA pain cohort (n = 2,173) was significantly older (mean age 52.1 ± 11.5 years vs 41.4 ± 13.2 years; P < 0.0001) and with a greater proportion of females (58.2% vs 45.9%; P < 0.0001). OA pain resulted in greater work impairment than among workers without OA pain (34.4% versus 17.8%; P < 0.0001), and was primarily due to presenteeism (impaired activity while at work). Health status, assessed both by the SF-12v2 and the SF-6D was significantly poorer among workers with OA pain (P < 0.0001), and healthcare resource utilization was significantly higher (P < 0.0001) than workers without OA pain. Total costs were higher in the OA pain cohort ($15,047 versus $8,175; P < 0.0001), driven by indirect costs that accounted for approximately 75% of total costs.
Conclusions
A substantial proportion of workers suffer from OA pain. After controlling for confounders, the impact of OA pain was significant, resulting in lower productivity and higher costs.
doi:10.1186/1471-2474-12-83
PMCID: PMC3110556  PMID: 21527024
25.  Antecedent Characteristics of Online Cancer Information Seeking Among Rural Breast Cancer Patients: An Application of the Cognitive-Social Health Information Processing (C-SHIP) Model 
Journal of health communication  2008;13(4):389-408.
Little research has examined the antecedent characteristics of patients most likely to seek online cancer information. This study employs the Cognitive-Social Health Information Processing (C-SHIP) model as a framework to understand what psychosocial characteristics precede online cancer-related information seeking among rural breast cancer patients who often have fewer healthcare providers and limited local support services. Examining 144 patients who were provided free computer hardware, Internet access and training for how to use an Interactive Cancer Communication System, pre-test survey scores indicating patients’ psychosocial status were correlated with specific online cancer information seeking behaviors. Each of the factors specified by the C-SHIP model had significant relationships with online cancer information seeking behaviors with the strongest findings emerging for cancer-relevant encodings and self-construals, cancer-relevant beliefs and expectancies and cancer-relevant self-regulatory competencies and skills. Specifically, patients with more negative appraisals in these domains were more likely to seek out online cancer information. Additionally, antecedent variables associated with the C-SHIP model had more frequent relationships with experiential information as compared to didactic information. This study supports the applicability of the model to discern why people afflicted with cancer may seek online information to cope with their disease.
doi:10.1080/10810730802063546
PMCID: PMC3632214  PMID: 18569368

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