To describe the decision support needs of immigrant and refugee women from HIV endemic countries regarding decision-making about voluntary counseling and testing for HIV (VCT) in Canada; and the needs of practitioners who support these women in making this decision, in a culturally appropriate manner.
Adapted, semi-structured questionnaires, based on the Ottawa Decision Support Framework (ODSF), were used to interview practitioners and patients. Practitioners from diverse backgrounds were purposefully selected from centers providing VCT in Ottawa. Adult, English-speaking immigrant and refugee women from HIV endemic countries were recruited from a clinic specializing in immigrant health services. Responses were tabulated using descriptive statistics, and emerging themes coded to identify unique factors affecting decision-making.
Analysis revealed differences between practitioner and patient perceptions of the decision-making needs of women from HIV endemic countries regarding VCT. Practitioners identified women's lack of knowledge about HIV transmission and prevention as a primary need, while patients identified inadequate awareness of HIV screening and treatment services, and their benefits and harms. Patients also perceived that women would not be aware of the various VCT options, while few practitioners highlighted this concern. Both groups held similar viewpoints about counseling strategies that could improve decision-making.
Women were unaware of the options available to them for VCT. Both practitioners and patients highlighted the issue of stigma and negative outcomes associated with testing that created barriers or contributed to delays in women receiving testing. Women preferred anonymous testing, and recommended that information and decision support regarding HIV testing be provided via non-targeted strategies, and integrated within general health services or public education.
Decision support in the context of VCT can improve decision quality, empowering patients to make informed decisions based on personal values. Study findings can inform the development of clinical guidelines for the routine offering of VCT.
OBJECTIVE To determine the rate of cervical screening among HIV-positive women who received care at a tertiary care clinic, and to determine whether screening rates were influenced by having a primary care provider.DESIGN Retrospective chart review.SETTING Tertiary care outpatient clinic in Ottawa, Ont. PARTICIPANTS Women who were HIV-positive receiving care at the Ottawa Hospital General Campus Immuno deficiency Clinic between July 1, 2002, and June 30, 2005.MAIN OUTCOME MEASURES Whether patients had primary care providers and whether they received cervical screening. We recorded information on patient demographics, HIV status, primary care providers, and cervical screening, including date, results, and type of health care provider ordering the screening.RESULTS Fifty-eight percent (126 of 218) of the women had at least 1 cervical screening test during the 3-year period. Thirty-three percent (42 of 126) of the women who underwent cervical screening had at least 1 abnormal test result. The proportion of women who did not have any cervical tests performed was higher among women who did not have primary care providers (8 of 12 [67%] vs 84 of 206 [41%]; relative risk 1.6, 95%confidence interval 1.06 to 2.52, P
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Recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care poses a challenge because of differences in language and culture and because of specific stressors associated with migration and resettlement. We aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care.
We searched and compiled literature on prevalence and risk factors for common mental health problems related to migration, the effect of cultural influences on health and illness, and clinical strategies to improve mental health care for immigrants and refugees. Publications were selected on the basis of relevance, use of recent data and quality in consultation with experts in immigrant and refugee mental health.
The migration trajectory can be divided into three components: premigration, migration and postmigration resettlement. Each phase is associated with specific risks and exposures. The prevalence of specific types of mental health problems is influenced by the nature of the migration experience, in terms of adversity experienced before, during and after resettlement. Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. These issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations.
Systematic inquiry into patients' migration trajectory and subsequent follow-up on culturally appropriate indicators of social, vocational and family functioning over time will allow clinicians to recognize problems in adaptation and undertake mental health promotion, disease prevention or treatment interventions in a timely way.
As health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada.
Cross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity.
Low income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were overrepresented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For-Service model only.
Primary care service measures did not differ significantly across socio-economic status or primary care delivery models. In Ontario, capitation-based remuneration is age and sex adjusted only. Patients of low socio-economic status had fewer additional visits compared to those with high socio-economic status under the Capitation model. This raises the concern that Capitation may not support the provision of additional care for more vulnerable groups. Regions undertaking primary care model reforms need to consider the potential impact of the changes on the more vulnerable populations.
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This paper describes the integration of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach into their clinical preventive guideline development process by the new Canadian Task Force on Preventive Health Care.
The GRADE approach focused the analytic framework and key questions on patient-important benefits and harms related to screening that incorporated detection, treatment, and follow-up. It also led to an explicit consideration of values and preferences and resource implications on the basis of the recommendations.
There are challenges, however, in incorporating the GRADE approach to clinical prevention, as the randomized controlled trials in this field have needed to be very large and of long duration, given the rare occurrence of primary outcome events in asymptomatic individuals. We provide examples of how we met these challenges in relation to developing clinical guidelines for screening for breast cancer, cervical cancer, diabetes, hypertension, and depression in primary care settings.
The focus on the patient-important outcomes was helpful in estimating effectiveness of screening approaches and providing explicit detailing of the basis of our recommendations across subgroups.