Advancing Health Services Research to Eliminate Health Care Disparities

Pathways Linking School-Based Ethnic Discrimination to Latino/a Adolescents' Marijuana Approval and Use

Latino/a adolescents are a growing part of U.S. public high schools, and many experience stressors related to their ethnicity within their schools that can contribute to risky behaviors such as drug use. Marijuana remains the most common illicit drug that Latino/a adolescents use. Using a sample of 121 Latino/a 9th grade students, the current study examined pathways linking perceived peer- and educator-perpetrated ethnic discrimination with marijuana approval and use. Findings revealed that perceived peer-perpetrated ethnic discrimination was linked with lower school belonging (βapproval model = -.21, p = .031; βuse model = -.18, p = .013), and lower school belonging was related to higher marijuana approval (β =-.22, p = .030), but not use. Additionally, those students with lower school belonging were more likely to experience greater depressive symptoms (βapproval model = -.45, p < .001, β use model = -.50, p < .001) and had more close friends who smoked marijuana (βapproval model = -.28, p = .002, βuse model = -.35, p < .001). Higher depressive symptomology was associated with more marijuana use (β = .32, p = .008). Having more substance-using friends was linked with higher marijuana approval (β = .24, p = .010) and use (β = .44, p < .001). Educator-perpetrated ethnic discrimination was not associated with any of the constructs under study. Findings highlight both internalizing and externalizing pathways through which peer-perpetrated ethnic discrimination may contribute to Latino/a adolescents' marijuana approval and use. Results have the potential to inform intervention efforts aimed at curtailing Latino/a adolescents' marijuana use.

Association of State Medicaid Expansion With Racial/Ethnic Disparities in Liver Transplant Wait-listing in the United States

Importance

Millions of Americans gained insurance through the state expansion of Medicaid, but several states with large populations of racial/ethnic minorities did not expand their programs.

Objective

To investigate the implications of Medicaid expansion for liver transplant (LT) wait-listing trends for racial/ethnic minorities.

Design, Setting, and Participants

A cohort study was performed of adults wait-listed for LT using the United Network of Organ Sharing database between January 1, 2010, and December 31, 2017. Poisson regression and a controlled, interrupted time series analysis were used to model trends in wait-listing rates by race/ethnicity. The setting was LT centers in the United States.

Main Outcomes and Measures

(1) Wait-listing rates by race/ethnicity in states that expanded Medicaid (expansion states) compared with those that did not (nonexpansion states) and (2) actual vs predicted rates of LT wait-listing by race/ethnicity after Medicaid expansion.

Results

There were 75 748 patients (median age, 57.0 [interquartile range, 50.0-62.0] years; 48 566 [64.1%] male) wait-listed for LT during the study period. The cohort was 8.9% Black and 16.4% Hispanic. Black patients and Hispanic patients were statistically significantly more likely to be wait-listed in expansion states than in nonexpansion states (incidence rate ratio [IRR], 1.54 [95% CI, 1.44-1.64] for Black patients and 1.21 [95% CI, 1.15-1.28] for Hispanic patients). After Medicaid expansion, there was a decrease in the wait-listing rate of Black patients in expansion states (annual percentage change [APC], -4.4%; 95% CI, -8.2% to -0.6%) but not in nonexpansion states (APC, 0.5%; 95% CI, -4.0% to 5.2%). This decrease was not seen when Black patients with hepatitis C virus (HCV) were excluded from the analysis (APC, 3.1%; 95% CI, -2.4% to 8.9%), suggesting that they may be responsible for this expansion state trend. Hispanic Medicaid patients without HCV were statistically significantly more likely to be wait-listed in the post-Medicaid expansion era than would have been predicted without Medicaid expansion (APC, 13.2%; 95% CI, 4.0%-23.2%).

Conclusions and Relevance

This cohort study found that LT wait-listing rates have decreased for Black patients with HCV in states that expanded Medicaid. Conversely, wait-listing rates have increased for Hispanic patients without HCV. Black patients and Hispanic patients may have benefited differently from Medicaid expansion.

Use of the six core surgical indicators from the Lancet Commission on Global Surgery in Colombia: a situational analysis

BACKGROUND

Surgical, anaesthetic, and obstetric (SAO) health-care system strengthening is needed to address the emergency and essential surgical care that approximately 5 billion individuals lack globally. To our knowledge, a complete, non-modelled national situational analysis based on the Lancet Commission on Global Surgery surgical indicators has not been done. We aimed to undertake a complete situation analysis of SAO system preparedness, service delivery, and financial risk protection using the core surgical indicators proposed by the Commission in Colombia, an upper-middle-income country.

METHODS

Data to inform the six core surgical system indicators were abstracted from the Colombian national health information system and the most recent national health survey done in 2007. Geographical access to a Bellwether hospital (defined as a hospital capable of providing essential and emergency surgery) within 2 h was assessed by determining 2 h drive time boundaries around Bellwether facilities and the population within and outside these boundaries. Physical 2 h access to a Bellwether was determined by the presence of a motor vehicle suitable for individual transportation. The Department Administrativo Nacional de Estadística population projection for 2016 and 2018 was used to calculate the SAO provider density. Total operative volume was calculated for 2016 and expressed nationally per 100 000 population. The total number of postoperative deaths that occurred within 30 days of a procedure was divided by the total operative volume to calculate the all-cause, non-risk-adjusted postoperative mortality. The proportion of the population subject to impoverishing costs was calculated by subtracting the baseline number of impoverished individuals from those who fell below the poverty line once out-of-pocket payments were accounted for. Individuals who incurred out-of-pocket payments that were more than 10% of their annual household income were considered to have experienced catastrophic expenditure. Using GIS mapping, SAO system preparedness, service delivery, and cost protection were also contextualised by socioeconomic status.

FINDINGS

In 2016, at least 7·1 million people (15·1% of the population) in Colombia did not have geographical access to SAO services within a 2 h driving distance. SAO provider density falls short of the Commission's minimum target of 20 providers per 100 000 population, at an estimated density of 13·7 essential SAO health-care providers per 100 000 population in 2018. Lower socioeconomic status of a municipality, as indicated by proportion of people enrolled in the subsidised insurance regime, was associated with a smaller proportion of the population in the municipality being within 2 h of a Bellwether facility, and the most socioeconomically disadvantaged municipalities often had no SAO providers. Furthermore, Colombian providers appear to be working at or beyond capacity, doing 2690-3090 procedures per 100 000 population annually, but they have maintained a relatively low median postoperative mortality of 0·74% (IQR 0·48-0·84). Finally, out-of-pocket expenses for indirect health-care costs were a key barrier to accessing surgical care, prompting 3·1 million (6·4% of the population) individuals to become impoverished and 9·5 million (19·4% of the population) individuals to incur catastrophic expenditures in 2007.

INTERPRETATION

We did a non-modelled, indicator-based situation analysis of the Colombian SAO system, finding that it has not yet met, but is working towards achieving, the targets set by the Lancet Commission on Global Surgery. The observed interdependence of these indicators and correlation with socioeconomic status are consistent with well recognised factors and outcomes of social, health, and health-care inequity. The internal consistency observed in Colombia's situation analysis validates the use of the indicators and has now informed development of an early national SAO plan in Colombia, to set a data-informed stage for implementation and evaluation of timely, safe, and affordable SAO health care, within the National Public Health Decennial Plan, which is due in 2022.

FUNDING

Zoll Medical.

Design of Appropriate Technology-Assisted Urine Tester Enabling Remote and Long-Term Monitoring of Health Conditions

A novel design idea supported by affordable design processes can address unresolved social problems such as the imbalance of opportunity in healthcare services, owing to high costs and a lack of access. We designed an appropriate technology-assisted urine tester to provide healthcare services for the elderly and underprivileged in order to monitor their health conditions daily and remotely help them determine whether to visit hospitals/clinics for in-depth diagnoses. To minimize production costs, we used a charge-coupled device camera for colorimetric-type urine analysis in conjunction with commercially available urine test strips; all other electronic components were mass-produced. We calibrated this urine tester and compared it with a commercially available high-end tester; the results showed high accuracy for most urine compounds. We verified its major device functions by recruiting four participants who tested their urine over four weeks and provided self-surveys of their health conditions. The proposed tester demonstrates a low price-to-performance ratio with high reliability, while its production and maintenance costs are as low as 20 USD per set. We focused on a human-centered technological approach from a simple and innovative design point of view in order to serve people and healthcare providers in an affordable way. We believe that the tester can be widely distributed, exemplifying appropriate technological application for those who require, but cannot enjoy, proper medical services, thereby improving social healthcare sustainability.

Racial/Ethnic Disparities in Health Care Access Are Associated with Adverse Childhood Experiences

There is a growing body of research documenting racial/ethnic differences in the relationship between adverse childhood experiences (ACEs) and negative health outcomes in adulthood. However, few studies have examined racial/ethnic differences in the association between ACEs and health care access. Cross-sectional data collected from South Carolina's Behavioral Risk Factor Surveillance System (2014-2016; n = 15,436) was used to examine associations among ACEs, race/ethnicity, and health care access among South Carolina adults. Specifically, logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for three health care access outcomes: having a personal doctor, routine checkup in the last 2 years, and delay in seeking medical care due to cost. Without adjusting for any covariates, in the overall population, the odds of having no personal doctor, no checkup in the last 2 years, and delay in medical care due to cost was significantly higher among those with at least one ACE, compared with those with no ACEs; and health care access varied by race, with significant relationships detected among Whites and Blacks. Among White adults, the odds of having no checkup in the last 2 years and delay in medical care due to cost was significantly higher among those with at least one ACE, compared with those with no ACEs. Among Black adults, a delay in medical care due to cost was significantly higher among those who reported ACEs compared with their counterparts. The results from this study suggest that ACEs may be an underrecognized barrier to health care for adults. Investing in strategies to mitigate ACEs may help improve health care access among adults.

Determinants of access to eHealth services in regional Australia

BACKGROUND

Australia has a universal public healthcare system, but access to eHealth services (i.e. use of the Internet and related technologies for healthcare services) remains a remarkable challenge, particularly in regional, rural and remote communities. Similar to many other countries, Australia faces the challenges of an ageing population and chronic disease management as well as balancing the supply of and the demand for quality healthcare and advanced medical procedures. The prima facie case for inequality in accessing eHealth services across geographical settings is widely acknowledged. However, regional residents' perceptions on access to eHealth services lack empirical evidence. Therefore, this study empirically investigates the current state and predictors of eHealth service access in regional Australia.

METHODS

A cross-sectional questionnaire-based household survey was conducted within a total of 390 randomly selected adults from the Western Downs Region in Southeast Queensland, Australia. Bivariate analysis was conducted to examine the relationship between eHealth access and respondents' characteristics. A multivariate logistic regression model was also performed to identify the significant predictors of eHealth service access in regional Australia.

RESULTS

Approximately 78% of the households have access to eHealth services. However, access to eHealth services in socioeconomically disadvantaged households was lower (19%) than that of their advantaged counterparts (25%). Factors that significantly increased the likelihood of accessing eHealth services included middle age (odds ratio [OR] = 2.75, 95% confidence interval [CI]: 1.84, 8.66), household size (three to four members) (OR = 2.29, 95% CI: 1.19, 4.73), broadband Internet access (OR = 1.67, 95% CI: 1.15, 2.90) and digital literacy (OR = 2.39, 95% CI: 1.23, 4.59). Factors that negatively influenced access to eHealth services were low educational levels (OR = 0.28, 95% CI: 0.09, 0.61), low socioeconomic status (OR = 0.65, 95% CI: 0.28, 0.83) and remote locations (OR = 0.66, 95% CI: 0.23, 0.80).

CONCLUSION

Emerging universal eHealth access provides immense societal benefits in regional settings. The findings of this study could assist policy makers and healthcare practitioners in identifying factors that influence eHealth access and thereby formulate effective health policies to optimise healthcare utilisation in regional Australia.