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Background Ghana has developed two main community-based strategies that aim to increase access to quality treatment for malaria, diarrhoea and suspected pneumonia: the integrated community case management (iCCM) and the community-based health planning and services (CHPS). The aim of the study was to assess the cost-effectiveness of these strategies under programme conditions. Methods A cost-effectiveness analysis was conducted. Appropriate diagnosis and treatment given was the effectiveness measure used. Appropriate diagnosis and treatment data was obtained from a household survey conducted 2 and 8 years after implementation of iCCM in the Volta and Northern Regions of Ghana, respectively. The study population was carers of children under-5 years who had fever, diarrhoea and/or cough in the last 2 weeks prior to the interview. Costs data was obtained mainly from the National Malaria Control Programme (NMCP), the Ministry of Health, CHPS compounds and from a household survey. Results Appropriate diagnosis and treatment of malaria, diarrhoea and suspected pneumonia was more cost-effective under the iCCM than under CHPS in the Volta Region, even after adjusting for different discount rates, facility costs and iCCM and CHPS utilization, but not when iCCM appropriate treatment was reduced by 50%. Due to low numbers of carers visiting a CBA in the Northern Region it was not possible to conduct a cost-effectiveness analysis in this region. However, the cost analysis showed that iCCM in the Northern Region had higher cost per malaria, diarrhoea and suspected pneumonia case diagnosed and treated when compared to the Volta Region and to the CHPS strategy in the Northern Region. Conclusions Integrated community case management was more cost-effective than CHPS for the treatment of malaria, diarrhoea and suspected pneumonia when utilized by carers of children under-5 years in the Volta Region. A revision of the iCCM strategy in the Northern Region is needed to improve its cost-effectiveness. Long-term financing strategies should be explored including potential inclusion in the National Health Insurance Scheme (NHIS) benefit package. An acceptability study of including iCCM in the NHIS should be conducted.

Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue. This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability. Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability.

BackgroundSetting physical barriers, for example platform screen doors (PSDs), has been proven to be effective in preventing falls onto railway tracks, but its cost-effectiveness is not known. For economic evaluation of public health interventions, the importance of including non-health factors has been noted despite a lack of empirical studies. This study aimed to investigate the effectiveness and cost-effectiveness of PSDs, which are installed in part of the Hong Kong railway system, for preventing railway injuries.MethodsData on railway injuries from 1997 to 2007 were obtained from the railway operators. Poisson regression was used to examine the risk reduction. Two incremental cost-effectiveness ratios (ICER) were calculated to assess the cost-effectiveness based on (1) disability-adjusted life years (DALYs) only and (2) DALYs with potential fare revenue and passengers' waiting time lost due to railway circulation collapse.ResultsThe PSD installation has effectively reduced railway injuries (adjusted 5-year average percentage change: −68.8%, p<0.0001) with no apparent substitution effect to the other platforms observed. To be cost-effective, the cost of gaining a healthy life year (ICER) should not exceed three times the per capita GDP (US$74 700). The PSD installation would only be cost-effective if the loss of fare revenue and passengers' waiting time, in addition to DALY, were included (ICER: US$65 400), while the ICER based on DALY only would be US$77 900.ConclusionThe challenges of complexity for economic evaluation appear in many community-based health interventions. A more extensive perspective for exploring other outcome measurements and evaluation methods to reflect a fair and appropriate value of the intervention's cost-effectiveness is needed.

Key Points Dental practices in Merseyside took part in a programme to improve accessibility. Disability awareness training can help understanding of disabled people's needs and break down some barriers. Attitudes are just as important as physical premises in improving access. Disability audits highlighted some simple and inexpensive changes that practices could make to improve accessibility The paper gives examples of simple changes that practices can consider. Several Merseyside dental practices took part in disability access audits of practice premises and practice staff took part in disability awareness training. Grants were awarded to part-fund improvements to practice facilities in line with the recommendations in the audit reports. The dental teams reported that the awareness training was very valuable and many common issues arose from the audits. Access for disabled people needs to be considered in all practice developments to ensure that dental practices comply with Part III of the Disability Discrimination Act by 2004.

To develop recommendations for office-based physicians who wish to make their offices accessible to all patients. Include taking steps to make offices more accessible, or not; offices may be accessible to varying degrees. Outcomes of accessibility involve patient-care, economic, ethical and legal issues. Stakeholders in these outcomes include patients, physicians, government and society. Data were obtained from a series of searches of MEDLINE, CINAHL and Healthstar (previously Health) databases for articles on disability and family medicine, primary (health) care and family practice, and on access and offices, and health services accessibility, and from a telephone survey of 50 stakeholders. A high value was placed on services to persons with disabilities and on stakeholder input. Universal accessibility was valued as an overall goal; improved accessibility was also highly valued. Benefits to patients include improved access to care as guaranteed by the Canada Health Act and in keeping with provincial Human Rights Codes. Benefits to physicians include contact with a broader patient population and freedom from fear of litigation. Costs of improved accessibility vary depending on individual circumstances and on whether an office is being built or renovated; some improvement costs are minimal. All physicians should take measures to improve practice accessibility. Improved access should be considered in each of the following areas: transportation and entrance to the facility, entrance to the office, waiting rooms, rest rooms, examination rooms, general building features and other features. No similar guidelines exist. To assess the content validity of these guidelines, the authors had a draft document reviewed by 18 stakeholders. All specific recommendations met the minimum criterion of adherence to current legislation, including national and provincial building codes. The specific recommendations are endorsed by the Canadian Paraplegic Association (national and Ontario offices), the DisAbled Women's Network (Ontario) and the Centre for Independent Living (Toronto). Development of these guidelines was supported in part by the Department of Family and Community Medicine, Toronto Hospital, Toronto, Ont.

The guarantee of access for disabled persons to public accommodations is an historical cornerstone of civil-rights law that now extends to restaurants, hotels, national parks and fishing piers. Provisions under the Americans with Disabilities Act (ADA), standards, guidelines and costs are discussed.

An examination of some economic aspects of the employment provisions (Title 1) of the Americans with Disabilities Act (ADA). The extent to which the costs of reasonable accommodation may be expected to influence the employment opportunities of persons with disabilities is appraised. Also considered are data & research needed to determine whether the employment & economic status of persons with disabilities is changing over time, ie, whether Title I is achieving any degree of success. Analysis suggests that the average costs of accommodation should be expected to rise as more severely impaired persons enter the job market. As a result, policy tools beyond those encompassed by the ADA may be needed to ensure adequate employment opportunities for persons with disabilities. Modified AA

Study design: Pass-code protected web survey. Objectives: Defining exercise participation barrier prevalence and association with exercise participation status in adults with spinal cord injury (SCI). Setting: World-wide web. Methods: Individuals ≥18 years with ShCI in the United States completed a pass-code protected website survey ( N =180). Odds ratios (OR) and OR 95% confidence interval (95% CI) assessed association between barrier presence and exercise participation. Results: No differences existed between exercisers and non-exercisers with respect to age, gender, injury level, injury duration, education level, or employment status. A larger percentage of non-exercisers reported household annual incomes <$7,500. The five most prevalent barriers were not associated with participation status (all OR 95% CI included 1). Low prevalence (⩽13%) characterized four of the five barriers most strongly related to being a non-exerciser. Identifying too lazy, too difficult, or no interest as a barrier decreased odds of being an exerciser by 86%, 83%, and 71%, respectively. Not liking exercise decreased the odds of being an exerciser by 90%. Conclusion: Highly prevalent barriers were not associated with exercise participation status, whereas low prevalence barriers were strongly related to being a non-exerciser. Internal barriers had the strongest association with exercise participation status. The possible association between socioeconomic factors and exercise participation may be underappreciated. The most effective interventions to increase exercise participation may be multifocal approaches to enhance internal perceptions about and motivation to exercise, increase knowledge of how and where to exercise, while also reducing program and transportation financial costs.

Public transit, especially urban rail systems, plays a vital role in shaping commuting patterns. Compared with census data and survey data, large-scale and real-time big data can track the impacts of urban policy implementations at finer spatial and temporal scales. Therefore, this study proposed a multi-level analytical framework using transit smartcard data to examine urban commuting dynamics in response to rail transit upgrades. The study area was Shenzhen, one of the most highly urbanized and densely populated cities in China, which provides the opportunity to examine the effects of rail transit upgrades on commuting patterns in a rapidly developing urban context. Changes in commuting patterns were examined at three levels: city, region, and individual. At the city level, we considered the average commuting time, commuting speed, and commuting distance across the whole city. At the region level, we analyzed changes in the job accessibility of residential zones. Finally, this study evaluated the potential effects of rail transit upgrades on the jobs-housing relationship at the individual level. Difference-in-difference models were used for causal inference between rail transit upgrades and commuting patterns. In the very short term, the opening of new rail transit lines resulted in no significant changes in overall commuting patterns across the whole city; however, two effects of rail transit upgrades on commuting patterns were identified. First, rail transit upgrades enhanced regional connectivity between residential zones and employment centers, thus improving job accessibility. Second, rail transit improvement increased the commuting distances of individuals and contributed to the separation of workplaces and residences. This study provides meaningful insights into the effects of rail transit upgrades on commuting patterns.

Emergency department (ED)-initiated buprenorphine/naloxone has been shown to improve treatment retention and reduce illicit opioid use; however, its potential may be limited by a lack of accessible community-based facilities. This study compared one state's geographic distribution of EDs to outpatient treatment facilities that provide buprenorphine treatment and identified ED and geographic factors associated with treatment access. Treatment facility data were obtained from the SAMHSA 2018 National Directory of Drug and Alcohol Abuse Treatment Facilities, and ED data were obtained from the Michigan College of Emergency Physician's 2018 ED directory. Geospatial analysis compared EDs to buprenorphine treatment facilities using 5-, 10-, and 20-mile network buffers. Among 131 non-exclusively pediatric EDs in Michigan, 57 (43.5%) had a buprenorphine treatment facility within 5 miles, and 66 (50.4%) had a facility within 10 miles. EDs within 10 miles of a Medicaid-accepting, outpatient buprenorphine treatment facility had higher average numbers of beds (41 vs. 15; p < 0.0001) and annual patient volumes (58,616 vs. 17,484; p < 0.0001) compared to those without. Among Michigan counties with EDs, those with at least one buprenorphine facility had larger average populations (286,957 vs. 44,757; p = 0.005) and higher annual rates of opioid overdose deaths (mean 18.3 vs. 13.0 per 100,000; p = 0.02) but were similar in terms of opioid-related hospitalizations and socioeconomic distress. Only half of Michigan EDs are within 10 miles of a buprenorphine treatment facility. Given these limitations, expanding access to ED-initiated buprenorphine in states similar to Michigan may require developing alternative models of care.