BMC Health Services Research最新文献

Background: Older adults in rural India face persistent barriers to formal healthcare access, including financial constraints, transportation challenges, and limited geriatric-responsive services. In this context, self-medication often emerges as an informal strategy to manage symptoms and everyday health needs. Understanding the prevalence and correlates of self-medication among rural older adults is important for designing equitable, age-inclusive primary healthcare systems.

Methods: A community-based cross-sectional survey was conducted between May and August 2024 among adults aged ≥ 55 years in five rural villages of Chengalpattu district, Tamil Nadu, India. Data were collected on sociodemographic characteristics, chronic morbidity, recent injuries, joint pain, prescribed medication use, and perceived barriers to care. Self-medication was assessed as any self-medication episode in the past three months (yes/no). Associations were examined using Poisson regression with robust standard errors to estimate adjusted prevalence ratios (aPRs).

Results: Among 520 participants, 41.7% reported self-medication in the past three months. Although chronic morbidity was common, chronic illness burden was not independently associated with self-medication. In contrast, experiential health indicators-particularly recent injury (including fractures) and current joint pain-showed the strongest associations with self-medication in adjusted models. Adults aged ≥ 60 years and those currently married had a lower prevalence of self-medication compared with adults aged 55-59 years and those not currently married. Self-medication did not differ significantly by gender, caste, religion, or household income. Nearly one-third of participants reported irregular or no use of prescribed medications despite a high burden of chronic conditions.

Conclusion: Self-medication is common among rural older adults in Tamil Nadu and appears more strongly associated with injury- and pain-related discomfort than with chronic disease diagnosis. This pattern is consistent with a symptom-driven pathway whereby acute discomfort, combined with barriers to timely and continuous care, is associated with unsupervised medication use. These findings highlight gaps in pain management, injury follow-up, and medication continuity within primary care and underscore the need for geriatric-responsive, equity-oriented outreach through Health and Wellness Centres/Ayushman Arogya Mandirs.

Clinical trial registration: Not applicable.

Background: This study explores the "wave-off" mechanism in healthcare, in which physicians implicitly discourage patient revisits to manage high workloads. Understanding this mechanism is critical for balancing workload management and patient-centered care, as it highlights how physician discretion shapes patient behavior and operational efficiency.

Methods: We analyze 200,426 outpatient records from a cardiology department to investigate the relationship between physician workload and the likelihood of patient revisits. We introduce a novel metric, Sample Entropy, to quantify patient "stickiness," or the propensity to revisit. We examine physician behaviors-such as referrals for diagnostic examinations and medication prescribing-to identify strategies used to modulate patient flow. Statistical analyses assess the impact of workload on revisit patterns and the mechanisms driving the wave-off effect.

Results: Higher physician workloads are significantly associated with reduced short-term patient revisits. Physicians manage workload by prescribing more medications and referring fewer diagnostic examinations, laboratory tests, particularly for patients with higher stickiness as measured by Sample Entropy. These behaviors alleviate short-term workload pressure but risk long-term inefficiencies, potentially reflecting bounded rationality in clinical decision-making.

Conclusions: The wave-off mechanism illustrates a trade-off between immediate workload relief and long-term operational performance. While it helps physicians address short-term capacity constraints, it may undermine optimal long-term patient care and system efficiency. This study highlights the operational and behavioral implications of physician-driven demand modulation, including the subtle yet consequential phenomenon of physician-reduced demand, in which patients are implicitly discouraged from revisiting due to workload-driven adjustments in care delivery.

Background: Research on the cost-effectiveness of postnatal depression treatments is limited in developing countries and among ethnic minorities in developed nations. This study presents a health economic evaluation of an integrated parenting intervention, Learning Through Play Plus (LTP+), for postnatal depression and child development, compared to treatment as usual (TAU), alongside a randomised controlled trial in Pakistan.

Methods: Using data on 764 mothers from the ROSHNI-PK trial, we conducted an economic evaluation over a six-month time horizon to assess the cost-effectiveness of LTP+ from the perspective of health, social care and patient in Pakistan. Cost-utility was analysed using EQ-5D-3L instrument while cost-effectiveness was assessed using the Edinburgh Postnatal Depression Scale (EPDS) for mother and the Ages and Stages Questionnaires: Social-Emotional (ASQ: SE) for the child. Cost-utility analysis was conducted for mother-only and partially for mother-child dyad, as EQ-5D-3L data were collected for mother only, whereas cost-effectiveness was conducted for both dyad and mother-only. Incremental cost-effectiveness ratios (ICERs) were calculated from adjusted mean costs and outcomes.

Results: Delivering LTP+ cost US $68.7 per dyad. LTP+ increased maternal costs by $33 (95% CI: $24: $43) and gained 0.06 (CI: 0.05: 0.07) quality-adjusted life-years (QALYs) compared to TAU-only. For the dyad, costs increased by $15 (CI: $4: $25). The ICER per maternal QALY gained was $582 (CI: $404: $769) when only maternal costs were considered, and $258 (CI: $75: $442) when dyad costs were considered. Dyad recovery (normal EPDS and ASQ: SE scores) cost $29 (CI: $11: $49), while maternal recovery alone cost $80 (CI: $53: $111). Dyad analyses showed that LTP+ has a 100% likelihood of being more cost-effective than TAU-only at willingness-to-pay thresholds of $65 per recovery or $600 per QALY gain. Analyses with varying combinations of LTP+ and healthcare costs and outcomes confirmed that the cost per QALY gained from LTP+ consistently remained below Pakistan's annual per capita gross domestic product (GDP).

Conclusion: LTP+ combined with TAU resulted in higher QALYs and recovery rates but at higher costs than TAU alone. While not cost-saving, LTP+ has a very high likelihood of being more cost-effective than TAU alone if the willingness-to-pay per QALY is at least 25% of Pakistan's 2015 annual GDP per capita.

Trial: # NCT02047357; Pre participant trial enrolment, 21/01/2014.