Background: Several studies in wealthy countries suggest that utilization of GP and hospital services, after adjusting for health care need, is equitable or pro-poor, whereas specialist care tends to favour the better off. Horizontal equity in these studies has not been evaluated appropriately, since the use of healthcare services is analysed without distinguishing between public and private services. The purpose of this study is to estimate the relation between socioeconomic position and health services use to determine whether the findings are compatible with the attainment of horizontal equity: equal use of public healthcare services for equal need. Methods: Data from a sample of 18,837 Spanish subjects were analysed to calculate the percentage of use of public and private general practitioner (GP), specialist and hospital care according to three indicators of socioeconomic position: educational level, social class and income. The percentage ratio was used to estimate the magnitude of the relation between each measure of socioeconomic position and the use of each health service. Results: After adjusting for age, sex and number of chronic diseases, a gradient was observed in the magnitude of the percentage ratio for public GP visits and hospitalisation: persons in the lowest socioeconomic position were 61% to 88% more likely to visit public GPs and 39% to 57% more likely to use public hospitalisation than those in the highest socioeconomic position. In general, the percentage ratio did not show significant socioeconomic differences in the use of public sector specialists. The magnitude of the percentage ratio in the use of the three private services also showed a socioeconomic gradient, but in exactly the opposite direction of the gradient observed in the public services. Conclusion: These findings show inequity in GP visits and hospitalisations, favouring the lower socioeconomic groups, and equity in the use of the specialist physician. These inequities could represent an overuse of public healthcare services or could be due to the fact that persons in high socioeconomic positions choose to use private health services.

Background: Many patients with chronic illness receive health care in primary care settings, so a challenge is to provide well-structured chronic care in these settings. Our aim was to develop and test a Dutch version of the PACIC questionnaire, a measure for patient reported structured chronic care. Methods: Observational study in 165 patients with diabetes or COPD from four general practices (72% response rate). Patients completed a written questionnaire, which included instruments for assessing chronic illness care (PACIC), evaluations of general practice (Europep), enablement (PEI), and individual characteristics. Results The patients had a mean age of 68.0 years and 47% comprised of women. Twenty-two to 35% of responding patients did not provide answers to specific items in the PACIC. In 11 items the lowest answering category was used by 30% or more of the responders and in 6 items the highest answering category was used by this number of responders. Principal factor analysis identified the previously defined five domains reasonably well. Cronbach's alpha per domain varied from 0.71 to 0.83, and the intraclass coefficient from 0.66 to 0.91. Diabetes patients reported higher presence of structured chronic care for 14 out of the 20 PACIC items. The effect of patient evaluations of general practice on the PACIC score was positive (b=0.72, p<0.004), but the effect of patient enablement on the PACIC score was negative (b=-1.13, p<0.000). Conclusions: A translated and validated Dutch version of the PACIC questionnaire is now available. Further research on its validity is recommended.

Background: Quality Improvement Interventions require significant financial investments, and therefore demand careful consideration in their design in order to maximize potential benefits. In this correspondence we present the methodological approach of a multifaceted quality improvement intervention aiming to improve quality of care in primary care, properly tailored for a country such as Cyprus where general practice is currently seeking recognition. Methods: Our methodological approach was focused on the design of a community-based intervention controlled trial using all patients from two urban and two rural public primary care centers diagnosed with hypertension and type II diabetes mellitus. The design of our intervention was grounded on a strong theoretical framework that included the Unified Theory of Acceptance and Use of Technology, and the Chronic Care Model, which synthesize evidence-based system changes in accordance with the Theory of Planned Behavior and the Theory of Reasoned Action. The primary outcome measure was improvement in the quality of care for two chronic diseases evaluated through specific clinical indicators, as well as the patient satisfaction assessed by the EUROPEP questionnaire and additional personal interviews. Results: We designed a multifaceted quality improvement intervention model, supported by a varying degree of scientific evidence, tailored to local needs and specific country characteristics. Overall, the main components of the intervention were the development and adoption of an electronic medical record and the introduction of clinical guidelines for the management of the targeted chronic diseases facilitated by the necessary model of organizational changes. Conclusion: Health planners and policy makers need to be aware of the potential use of certain theoretical models and applied methodology as well as inexpensive tools that may be suitably tailored to the local needs, in order to effectively design quality improvement interventions in primary care settings.

Background: Redesigning care has been proposed as a lever for improving chronic illness care. Within primary care, diabetes care is the most widespread example of restructured integrated care. Our goal was to assess to what extent important aspects of restructured care such as multidisciplinary teamwork and different types of organizational culture are associated with high quality diabetes care in small office-based general practices. Methods: We conducted cross-sectional analyses of data from 83 health care professionals involved in diabetes care from 30 primary care practices in the Netherlands, with a total of 752 diabetes mellitus type II patients participating in an improvement study. We used self-reported measures of team climate (Team Climate Inventory) and organizational culture (Competing Values Framework), and measures of quality of diabetes care and clinical patient characteristics from medical records and self-report. We conducted multivariate analyses of the relationship between culture, climate and HbA1c, total cholesterol, systolic blood pressure and a sum score on process indicators for the quality of diabetes care, adjusting for potential patient- and practice level confounders and practice-level clustering. Results: A strong group culture was negatively associated to the quality of diabetes care provided to patients (beta=-0.04; p=0.04), whereas a more 'balanced culture' was positively associated to diabetes care quality (beta=5.97; p=0.03). No associations were found between organizational culture, team climate and clinical patient outcomes. Conclusions: Although some significant associations were found between high quality diabetes care in general practice and different organizational cultures, relations were rather marginal. Variation in clinical patient outcomes could not be attributed to organizational culture or teamwork. This study therefore contributes to the discussion about the legitimacy of the widespread idea that aspects of redesigning care such as teamwork and culture can contribute to higher quality of care. Future research should preferably combine quantitative and qualitative methods, focus on possible mediating or moderating factors and explore the use of instruments more sensitive to measure such complex constructs in small office-based practices.

Background: Improving quality of primary care is a key focus of international health policy. Current quality improvement efforts place a large focus on technical, clinical aspects of quality, but a comprehensive approach to quality improvement should also include interpersonal care. Two methods of improving the quality of interpersonal care in primary care have been proposed. One involves the feedback of patient assessments of interpersonal care to physicians, and the other involves brief training and education programmes. This study therefore reviewed the efficacy of (i) feedback of real patient assessments of interpersonal care skills, (ii) brief training focused on the improvement of interpersonal care and (iii) interventions combining both (i) and (ii) Methods: Systematic review of randomised controlled trials. Three electronic databases were searched (CENTRAL, Medline and Embase) and augmented by searches of the bibliographies of retrieved articles. The quality of studies was appraised and results summarised in narrative form. Results: Nine studies were included (two patient based feedback studies and seven brief training studies). Of the two feedback studies, one reported a significant positive effect. Only one training study reported a significant positive effect. Conclusions: There is limited evidence concerning the effects of patient based feedback. There is reasonable evidence that brief training as currently delivered is not effective, although the evidence is not definitive, due to the small number of trials and the variation in the training methods and goals. The lack of effectiveness of these methods may reflect a number of issues, such as differences in the effectiveness of the interventions in experienced practitioners and those in training, the lack of theory linking feedback to behaviour change, failure to provide sufficient training or to use a comprehensive range of behaviour change techniques. Further research into both feedback and brief training interventions is required before these interventions are routinely introduced to improve patient satisfaction with interpersonal care in primary care. The interventions to be tested in future research should consider using insights from the wider literature on communication outside primary care, might benefit from a clearer theoretical basis, and should examine the use of combined brief training and feedback.

Background: Knowledge of the extent to which patient characteristics are systematically associated with variation in patient evaluations will enable us to adjust for differences between practice populations and thereby compare GPs. Whether this is appropriate depends on the purpose for which the patient evaluation was conducted. Associations between evaluations and patient characteristics may reflect gaps in the quality of care or may be due to inherent characteristics of the patients. This study aimed to determine such associations in a setting with a comprehensive list system and gate-keeping. MethodA nationwide Danish patient evaluation survey among voluntarily participating GPs using the EUROPEP questionnaire, which produced 28,260 patient evaluations (response rate 77.3%) of 365 GPs. In our analyses we compared the prevalence of positive evaluations in groups of patients. Results: We found a positive GP assessment to be strongly associated with increasing patient age and increasing frequency of attendance. Patients reporting a chronic condition were more positive, whereas a low self-rated health was strongly associated with less positive scores also after adjustment. The association between patient gender and assessment was weak and inconsistent and depended on the focus. We found no association either with the patients' educational level or with the duration of listing with the GP even after adjusting for patient characteristics. Conclusion: Adjustment for patient differences may produce a more fair comparison between GPs, but may also blur the assessment of GPs' ability to meet the needs of the populations actually served. On the other hand, adjusted results will enable us to describe the significance of specific patient characteristics to patients' experience of care.

Background: Few studies have examined empowerment interventions as they actually unfold in home care in the context of chronic health problems. This study aims to document the empowerment process as it plays out in interventions with adults receiving home care services. Methods: The qualitative design chosen is a fourth generation evaluation combined with case studies. A home care team of a health and social services center situated in the Eastern Townships (Quebec, Canada) will be involved at every step in the study. A sample will be formed of 15 health care professionals and 30 of their home care clients and caregiver. Semi-structured interviews, observations of home care interventions and socio-demographic questionnaires will be used to collect the data. Nine instruments used by the team in prior studies will be adapted and reviewed. A personal log will document the observers' perspectives in order to foster objectivity and the focus on the intervention. The in-depth qualitative analysis of the data will illustrate profiles of enabling interventions and individual empowerment. DiscussionThe ongoing process to transform the health care and social services network creates a growing need to examine intervention practices of health care professionals working with clients receiving home care services. This study will provide the opportunity to examine how the intervention process plays out in real-life situations and how health care professionals, clients and caregivers experience it. The intervention process and individual empowerment examined in this study will enhance the growing body of knowledge about empowerment.

Background: The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) provide information on hospital risk-adjusted rates for potentially preventable adverse events. Although designed to work with routine administrative data, it is unknown whether the PSIs can accurately distinguish between complications and pre-existing conditions. The objective of this study is to examine whether the AHRQ PSIs accurately measure hospital complication rates, using the data with present-on-admission (POA) codes to distinguish between complications and pre-existing conditions Methods: Retrospective cohort study of patients undergoing isolated CABG surgery in California conducted using the 1998-2000 California State Inpatient Database. We calculated the positive predictive value of selected AHRQ PSIs using information from the POA as the gold standard, and the intra-class correlation coefficient to assess the level of agreement between the hospital risk-adjusted PSI rates with and without the information contained in the POA modifier. Results: The false positive error rate, defined as one minus the positive predictive value, was greater than or equal to 20% for four of the eight PSIs examined: decubitus ulcer, failure-to-rescue, postoperative physiologic and metabolic derangement, and postoperative pulmonary embolism or deep venous thrombosis. Pairwise comparison of the hospital risk-adjusted PSI rates, with and without POA information, demonstrated almost perfect agreement for five of the eight PSI's. For decubitus ulcer, failure-to-rescue, and postoperative pulmonary embolism or DVT, the intraclass-correlation coefficient ranged between 0.63 to 0.79. Conclusion: For some of the AHRQ Patient Safety Indicators, there are significant differences in the risk-adjusted rates of adverse events depending on whether the POA indicator is used to distinguish between pre-existing conditions and complications. The use of the POA indicator will increase the accuracy of the AHRQ PSIs as measures of adverse outcomes.

Background: This study investigated the costs and outcomes of implementing cognitive behavior therapy (CBT) for chronic fatigue syndrome (CFS) in a mental health center (MHC). CBT is an evidence-based treatment for CFS that was scarcely available until now. To investigate the possibilities for wider implementation, a pilot implementation project was set up. MethodCosts and effects were evaluated in a non-controlled before- and after study with an eight months time-horizon. Both the costs of performing the treatments and the costs of implementing the treatment program were included in the analysis. The implementation interventions included: informing general practitioners (GPs) and CFS patients, training therapists, and instructing the MHC employees. Given the non-controlled design, cost outcome ratio's (CORs) and their acceptability curves were analyzed. Analyses were done from a health care perspective and from a societal perspective. Bootstrap analyses were performed to estimate the uncertainty around the cost and outcome results. Results: 125 CFS patients were included in the study. After treatment 37% had recovered from CFS and the mean gained QALY was 0.03. Costs of patients' health care and productivity losses had decreased significantly. From the societal perspective the implementation led to cost savings and to higher health states for patients, indicating dominancy. From the health care perspective the implementation revealed overall costs of E5.320 per recovered patient, with an acceptability curve showing a 100% probability for a positive COR at a willingness to pay threshold of E6.500 per recovered patient. Conclusions: Implementing CBT for CFS in a MHC appeared to have a favorable cost outcome ratio (COR) from a societal perspective. From a health care perspective the COR depended on how much a recovered CFS patient is being valued. The strength of the evidence was limited by the non-controlled design. The outcomes of this study might facilitate health care providers when confronted with the decision whether or not to adopt CBT for CFS in their institution.

Background: Acute chest pain is responsible for approximately 700,000 patient attendances per year at emergency departments in England and Wales. A single centre study of selected patients suggested that chest pain unit (CPU) care could be less costly and more effective than routine care for these patients, although a more recent multi-centre study cast doubt on the generalisability of these findings. Methods: Our economic evaluation involved modelling data from the ESCAPE multi-centre trial along with data from other sources to estimate the comparative costs and effects of CPU versus routine care. Cost effectiveness ratios (cost per QALY) were generated from our model. Results: We found that CPU compared to routine care resulted in a non-significant increase in effectiveness of 0.0075 QALYs per patient and a non-significant cost decrease of GBP32 per patient and thus a negative incremental cost effectiveness ratio. If we are willing to pay GBP20,000 for an additional QALY then there is a 70% probability that CPU care will be considered cost-effective. Conclusions: Our analysis shows that CPU care is likely to be slightly more effective and less expensive than routine care, however, these estimates are surrounded by a substantial amount of uncertainty. We cannot reliably conclude that establishing CPU care will represent a cost-effective use of health service resources given the substantial amount of investment it would require

Background: Provision of complementary therapy services within the NHS is scarce and contested. However, their adoption may be more likely in a service model that is designed to the specifications of clinicians and Primary Care Trust (PCT) managers. Our objective was to identify the features of a 'NHS friendly' service to inform service designers who wish to develop NHS complementary therapy services. Methods: Using a case study approach, two sites offering complementary therapies on NHS premises were studied using interview and documentary data. We conducted interviews with 20 NHS professionals, including PCT managers and clinicians. We used descriptive content analysis to analyse interview data. We collected and analysed documentation, such as referral data, funding bids and evaluations, to compare reported and documented behaviour. Results: Ideally, a 'NHS friendly' complementary therapy service should offer a limited number of therapies for a specific condition for high priority patient populations (e.g. acupuncture for addictions). In this service model, the therapies should be perceived to have 'good' evidence for conditions where there are 'effectiveness gaps' (i.e. current treatments are limited). The service should be evaluated and regularly promoted. Inter-professional relationships would flourish through opportunities for informal contact and formal interactions, such as observations of consultations. However, the service should include gatekeeper mechanisms to control demand and avoid picking up 'unmet need' (i.e. individuals currently not accessing NHS services). The complementary therapy service should pay for itself and reduce NHS costs elsewhere, such as hospital admissions. Conclusions: The service design model identified in this study is problematic. For example, it is contradictory to provide specific interventions for specific conditions within a holistic healthcare framework. It is difficult to avoid providing for 'unmet need' while concurrently filling 'effectiveness gaps'. In addition, demonstrating the impact of a community service on reducing hospital admissions is challenging. Those seeking to establish a NHS complementary therapy service might be well-advised to meet as many of the criteria of a 'NHS friendly' model as possible, recognising that its full realisation may be impossible. However, during periods of innovation and financial security, some relaxation of expectations may occur.

Background: In quality improvement collaboratives (QICs) teams of practitioners from different health care organizations are brought together to systematically improve an aspect of patient care. Teams take part in a series of meetings to learn about relevant best practices, quality methods and change ideas, and share experiences in making changes in their own local setting. The purpose of this study was to develop an instrument for measuring team organization, external change agent support and support from the team's home institution in a Dutch national improvement and dissemination programme for hospital based on several QICs. Methods: The exploratory methodological design included two phases: a) content development and assessment, resulting in an instrument with 15 items, and b) field testing (N = 165). Internal consistency reliability was tested via Cronbach's alpha coefficient. Principal component analyses were used to identify underlying constructs. Tests of scaling assumptions according to the multi trait/multi-item matrix, were used to confirm the component structure. Results: Three components were revealed, explaining 65% of the variability. The components were labelled 'organizational support', 'team organization' and 'external change agent support'. One item not meeting item-scale criteria was removed. This resulted in a 14 item instrument. Scale reliability ranged from 0.77 to 0.91. Internal item consistency and divergent validity were satisfactory. Conclusion: On the whole, the instrument appears to be a promising tool for assessing team organization and internal and external support during QIC implementation. The psychometric properties were good and warrant application of the instrument for the evaluation of the national programme and similar improvement programmes.

Background: A comprehensive care and treatment program requires a well functioning laboratory services. We assessed satisfaction of medical personnel to the laboratory services to guide process of quality improvement of the services. Methodology: A cross-sectional survey in 24 randomly selected health facilities in Mainland Tanzania was conducted to assess the satisfaction of the medical personnel with the laboratory services. Results: Of 235 medical personnel interviewed, 196 were valid for analysis and about one quarter were dissatisfied with the laboratory services. Personnel dissatisfied with the services were 38.3% in timely test result, 24.5% in correct and accurate results and 22.4% in clear complete results. The personnel in public laboratories were more dissatisfied with timely test results (OR=3.6, 95% CI 1.8, 7.3), correct results (OR=4.1, 95% CI 1.6, 10.8) and clear complete results (OR=5.0 95% CI 1.6, 15.2). Personnel dissatisfied with the services in 15 laboratories sending specimens to referral laboratories, varied from 13% in availability of equipment to 57% in timely results feedback from the referral laboratories. Personnel dissatisfied with the services in 14 referral laboratories, varied from 28.6% in properly identified specimen to 42.9 % in clear, accurate test request and communication. Conclusion: About one quarter of medical personnel in sending or receiving laboratories were dissatisfied with the services. Comparing the personnel in public and private, the personnel in public laboratories were 4 times more dissatisfied with the timely test and correct results; and 5 times more dissatisfied with clear and complete test results. Key words: Dissatisfaction, laboratory services, public/private medical personnel.

Background: In 1995, Taiwan has launched a national health-care system (the National Health Insurance Program, NHI) covering the use of both Western medicine (WM) and Chinese medicine (CM). This population-based study was conducted to understand the role of CM in this dual medical system by determining the utilization patterns of CM and WM and to analyze the demographic characteristics and primary indications influencing the choice of the medical services for the development of strategies to enhance the appropriate use and reduce unnecessary use of CM. Methods: This study used the NHI sample files from 1997 to 2003 consisting of comprehensive utilization and enrolment information for a random sample of 200,432 NHI beneficiaries of the total enrolees from 1995 to 2000. A total of 136,720 subjects with valid and complete enrolment and utilization data were included in this study. The logistic regression method was employed to estimate the odds ratios (ORs) for utilization of CM and WM. The usage, frequency of services, and primary indications for CM and WM were evaluated. A significance level of alpha = 0.05 was selected. Results: Compared with WM, the odds of CM increased from 1997 to 2003. The odds of using CM (OR =1.48; 95% CI: 1.45-1.50; p< 0.001) and WM (OR =1.74; 95% CI: 1.72-1.77; p< 0.001) were higher in females and that of CM increased with age to a peak in the 45-54-year-group (OR =1.75; 95% CI: 1.68-1.82; p< 0.001) and WM (OR =1.09; 95% CI: 1.05-1.13; p< 0.001) in the elderly subjects ([greater than or equal to] 65 years). The odds of CM and WM were similar in all income groups. However, those of CM were higher in Central (OR =1.65; 95% CI: 1.56-1.74; p< 0.001) and Southern Taiwan (OR =1.18; 95% CI: 1.12-1.25; p< 0.001) and lower in the remote areas (OR =0.57; 95% CI: 0.52-0.63; p< 0.001). Most of the patients had one ambulatory visit of both medical services annually. However, the utilization of WM predominated over CM. Over 90% of CM service was provided by clinics, whereas over 60% of WM service by hospitals. Diseases of the respiratory system was the most frequent primary indication in CM and WM. Herbal medication was the most commonly used form of CM (68.4-72.7%). Conclusions: In recent years, there is an increasing trend in the utilization of CM in Taiwan. This increasing trend may be due to the covering of CM in the national health insurance system.

Background: People over the age of 70 carry the greatest burden of chronic disease, disability and health care use. Participation in physical activity is crucial for health, and walking accounts for much of the physical activity undertaken by sedentary individuals. Pedometers are a useful motivational tool to encourage increased walking and they are cheap and easy to use. The aim of this pilot study was to evaluate the feasibility of the use of pedometers plus a theory-based intervention to assist sedentary older women to accumulate increasing amounts of physical activity, mainly through walking. Methods: Female participants over the age of 70 were recruited from primary care and randomised to receive either pedometer plus a theory-based intervention or a theory-based intervention alone. The theory-based intervention consisted of motivational techniques, goal-setting, barrier identification and self-monitoring with pedometers and daily diaries. The pedometer group were further randomised to one of three target groups: a 10%, 15% or 20% monthly increase in step count to assess the achievability and acceptability of a range of targets. The primary outcome was change in daily activity levels measured by accelerometry. Secondary outcome measures were lower limb function, health related quality of life, anxiety and depression. Results: 54 participants were recruited into the study, with an average age of 76. There were 9 drop outs, 45 completing the study. All participants in the pedometer group found the pedometers easy to use and there was good compliance with diary keeping (96% in the pedometer group and 83% in the theory-based intervention alone group). There was a strong correlation (0.78) between accelerometry and pedometer step counts i.e. indicating that walking was the main physical activity amongst participants. There was a greater increase in activity (accelerometry) amongst those in the 20% target pedometer group compared to the other groups, although not reaching statistical significance (p = 0.192). Conclusions: We have demonstrated that it is feasible to use pedometers and provide theory-based advice to community dwelling sedentary older women to increase physical activity levels and a larger study is planned to investigate this further.

Background: Many patients are undernourished during hospitalisation. The clinical consequences include lassitude, an increased risk of complications and prolonged convalescence. The aim of the study is 1) to implement a new organisation with a focus on improving the quality of the nutritional care of medical inpatients at risk of undernutrition and 2) to investigate the effect of the intervention. Methods: Social and healthcare assistants are educated to nutritional and healthcare assistants to provide nutritional care in daily practice to undernourished medical inpatients. The effect of the intervention is investigated before and five months after the employment of the nutritional and healthcare assistants. Data from structured interviews with patients and staff, and amount of ordered and wasted food is collected. Results: Patients regard the work of the nutritional and healthcare assistant as very important for their recovery and weightgain: she takes care of the individual patient's nutritional requirements and wishes, and imparts knowledge to the patient about optimum nutrition. Staff members benefit from the knowledge and dedication of the nutritional and healthcare assistant and from her work; the staff are often too busy with other nursing tasks to make it a priority to ensure patients who are nibblers to get sufficient nutrition. The choices of food from the production kitchen are utilised to a higher degree, and more of the food is eaten by the patients; before the intervention a 20 per cent increase in ordered food in relation to the food budget is found. During the intervention a 20 per cent decrease in ordered food in relation to the food budget is found, and food wastage decreases from 55 per cent to 18 per cent due to the intervention. Conclusions: The job function of the nutritional and healthcare assistants on the medical wards is of great value to patients, nursing staff members and the production kitchen. The quality of the nutritional care of undernourished patients increases significantly, and a considerable optimisation of resources in the production and ordering of food take place. Hospitals can benefit from implementation of the present organisation model if they focus on improving the quality of the nutritional care of weak and elderly inpatients and optimisation of resources.

Background: Patient's satisfaction with both private and public laboratory services is important for the improvement of the health care delivery in any country. Methods: A cross-sectional survey was conducted in 24 randomly selected health facilities with laboratories that are conducting HIV related testing, in Mainland Tanzania. The study assessed patient's satisfaction with the laboratory services where by a total of 295 patients were interviewed. Results: Of data analyzed for a varying totals from 224 to 294 patients, the percentage of dissatisfaction with both public and private laboratory services, ranged from 4.3% to 34.8%, with most of variables being more than 15%. Patients who sought private laboratory services were less dissatisfied with the cleanness (3/72, 4.2%) and the privacy (10/72, 13.9%) than those sought public laboratory service for the same services of cleanness (41/222, 18.5%) and privacy (61/222, 27.5%), and proportional differences were statistically significant (X2 = 8.7, p =0.003 and X2 = 5.5, p =0.01, respectively). Patients with higher education were more likely to be dissatisfied with privacy (OR = 1.8, 95% CI: 1.1 -3.1) and waiting time (OR = 2.5, 95% CI: 1.5 - 4.2) in both private and public facilities. Patients with secondary education were more likely to be dissatisfied with the waiting time (OR = 5.2; 95%CI: 2.2-12.2) and result notification (OR = 5.1 95%CI (2.2-12.2) than those with lower education. Conclusion: About 15.0% to 34.8% of patients were not satisfied with waiting time, privacy, results notification cleanness and timely instructions. Patients visited private facilities were less dissatisfied with cleanness and privacy of laboratory services than those visited public facilities. Patients with higher education were more likely to be dissatisfied with privacy and waiting time in both private and public facilities.

Purpose: Mathematical modeling has been applied to a range of policy-level decisions on resource allocation for HIV care and treatment. We describe the application of classic operations research techniques to address logistical and resource management challenges in HIV treatment scale-up activities in resource-limited countries. Methods: We review and categorize several of the major logistical and operational problems encountered over the last decade in the global scale-up of HIV care and antiretroviral treatment for people with AIDS. While there are unique features of HIV care and treatment that pose significant challenges to effective modeling and service improvement, we identify several analogous OR-based solutions that have been developed in the service, industrial, and health sectors. Results: HIV treatment scale-up includes many processes that are amenable to mathematical and simulation modeling, including forecasting future demand for services; locating and sizing facilities for maximal efficiency; and determining optimal staffing levels at clinical centers. Optimization of clinical and logistical processes through modeling may improve outcomes, but successful OR-based interventions will require contextualization of response strategies, including appreciation of both existing health care systems and limitations in local health workforces. Conclusions: The modeling techniques developed in the engineering field of operations research have wide potential application to the variety of logistical problems encountered in HIV treatment scale-up in resource-limited settings. Increasing the number of cross-disciplinary collaborations between engineering and public health will help speed the appropriate development and application of these tools.

Background: Achieving the Millennium Development Goals for health requires a massive scaling-up of interventions in Sub Saharan Africa. Intermittent Preventive Treatment in infants (IPTi) is a promising new tool for malaria control. Although efficacy information is available for many interventions, there is a dearth of data on the resources required for scaling up of health interventions. MethodWe worked in partnership with the Ministry of Health and Social Welfare (MoHSW) to develop an IPTi strategy that could be implemented and managed by routine health services. We tracked health system and other costs of (1) developing the strategy and (2) maintaining routine implementation of the strategy in five districts in southern Tanzania. Financial costs were extracted and summarized from a costing template and semi-structured interviews were conducted with key informants to record time and resources spent on IPTi activities. Results: The estimated financial cost to start-up and run IPTi in the whole of Tanzania in 2005 was US$1,486,284. Start-up costs of US$36,363 were incurred at the national level, mainly on the development of Behaviour Change Communication (BCC) materials, stakeholders' meetings and other consultations. The annual running cost at national level for intervention management and monitoring and drug purchase was estimated at US$459,096. Start-up costs at the district level were US$7,885 per district, mainly expenditure on training. Annual running costs were US$170 per district, mainly for printing of BCC materials. There was no incremental financial expenditure needed to deliver the intervention in health facilities as supplies were delivered alongside routine vaccinations and available health workers performed the activities without working overtime. The economic cost was estimated at 23 US cents per IPTi dose delivered. Conclusion: The costs presented here show the order of magnitude of expenditures needed to initiate and to implement IPTi at national scale in settings with high Expanded Programme on Immunization (EPI) coverage. The IPTi intervention appears to be affordable even within the budget constraints of Ministries of Health of most sub-Saharan African countries.

Background: Despite certain contradictions, an association has been identified between adherence to drug treatment and the quality of life in patients with type 2 diabetes. The contradictions observed emphasize the importance of using different methods to measure treatment adherence, or the association of psychological precursors of adherence with quality of life. For this reason, we have used an indirect method to measure adherence (pill count), as well as two adherence behaviour precursors (attitude and knowledge), to assess the association between adherence and the quality of life in type 2 diabetes patients. Methods: A cross-sectional comparative study on a random sample of 238 type 2 diabetic patients was carried out over one year in four family medicine units of the Mexican Institute of Social Security (IMSS) in Aguascalientes, Mexico. Treatment adherence was measured using the indirect method of pill count to assess adherence behaviour, obtaining information at two home visits. In the first we recorded the medicine prescribed and in the second, we counted the medicine remaining to determine the proportion of the medicine taken. We also assessed two adherence behaviour precursors: the patients' knowledge regarding their medical prescription measured through a structured questionnaire; and attitudes to treatment adherence using a Likert scale. Quality of life was measured through the WHOQOL-100 (the WHO Quality of Life questionnaire). Information concerning both knowledge and attitude was obtained through interviews with the patients. A multiple linear regression model was constructed to establish the relationship between each quality of life domain and the variables related to adherence, controlling for covariates. Results: There was no association between quality of life and treatment adherence behaviour. However, the combination of strong knowledge and a positive attitude was associated with five of the six quality of life domains. Conclusions: The results suggest that it is important to explore psychological precursors of treatment adherence behaviour in type 2 diabetic patients. Indeed, we consider that it will be useful to carry out interventions that change negative attitudes towards treatment adherence and that promote medical prescription knowledge, which may help to improve the quality of life of such patients.