Barriers to care questionnaire: reliability, validity, and responsiveness to change among parents of children with asthma

Models of care and the advanced practice nurse role in caring for children and adolescents with a cancer predisposition syndrome: a scoping review protocol

OBJECTIVE

This scoping review will examine the literature describing models of care, barriers and facilitators of care, and gaps in care delivery for children and adolescents with a cancer predisposition syndrome (CPS). It will also explore how advanced practice nurses contribute to the delivery of care for children and adolescents with a CPS.

INTRODUCTION

Cancer remains a leading cause of death in children and adolescents. Pediatric CPS clinics proactively aim for early diagnosis or prevention of cancer in children and adolescents with a CPS. Additionally, the holistic well-being of individuals requires a multidisciplinary team, including advanced practice nurses, to manage their complex health care needs.

INCLUSION CRITERIA

This review will consider both published and unpublished literature exploring aspects of models of care and the role of the nurse in pediatric CPS clinics. Literature published in English from 1991 onward will be considered.

METHODS

This scoping review will follow the JBI methodology for scoping reviews. The review will include searches in MEDLINE, Embase, and CINAHL Complete. Gray literature searches will be conducted in OAIster and Social Science Research Network, as well as websites of hospitals in the USA and the UK with large pediatric cancer centers. Two reviewers will screen titles, abstracts, and full-text articles. An extraction table will be used to extract relevant data from all included articles and facilitate data analysis. Results will be presented in narrative and tabular format.

REVIEW REGISTRATION

Open Science Framework osf.io/axkp7/.

Understanding constraints to adaptation using a community-centred toolkit

Worldwide, marginalized and low-income communities will disproportionately suffer climate change impacts while also retaining the least political power to mitigate their consequences. To adapt to environmental shocks, communities must balance intensifying natural resource consumption with the need to ensure the sustainability of ecosystem provisioning services. Thus, scientists have long been providing policy recommendations that seek to balance humanitarian needs with the best outcomes for the conservation of ecosystems and wildlife. However, many conservation and development practitioners from biological backgrounds receive minimal training in either social research methods or participatory project design. Without a clear understanding of the sociocultural factors shaping decision-making, their initiatives may fail to meet their goals, even when communities support proposed initiatives. This paper explores the underlying assumptions of a community's agency, or its ability to develop and enact preferred resilience-enhancing adaptations. We present a context-adaptable toolkit to assess community agency, identify barriers to adaptation, and survey perceptions of behaviour change around natural resource conservation and alternative food acquisition strategies. This tool draws on public health and ecology methods to facilitate conversations between community members, practitioners and scientists. We then provide insights from the toolkit's collaborative development and pilot testing with Vezo fishing communities in southwestern Madagascar. This article is part of the theme issue 'Climate change adaptation needs a science of culture'.

Understanding caregiver burden with accessing sickle cell care in the Midwest and their perspective on telemedicine

BACKGROUND

Survival for children with sickle cell disease (SCD) has improved significantly. However, patients with SCD still encounter several impediments to accessing adequate healthcare. Rural and medically underserved areas, such as parts of the Midwest, can exacerbate these barriers, separating children with SCD from subspecialists even further. Telemedicine has been a means to close these gaps in care for children with other special healthcare needs, but few studies have discussed how caregivers of children with SCD perceive its use.

METHODS

The objective of this study is to understand the experiences of caregivers of pediatric SCD patients in a geographically diverse area in the Midwest in accessing care, and their perspectives of telemedicine. Caregivers of children with SCD completed an 88-item survey via a secured REDCap link either in-person or via secure text. Descriptive statistics (means, medians, ranges, frequencies) were performed for all responses. Univariate chi square tests were performed to analyze associations, particularly with telemedicine responses.

RESULTS

The survey was completed by 101 caregivers. Nearly 20% of families traveled more than 1 hour to reach the comprehensive SCD center. Other than their SCD provider, caregivers reported their child having at least 2 other healthcare providers. Most barriers caregivers identified were financial or resource based. Almost a quarter of caregivers expressed feeling as though these barriers impacted their and/or their child's mental health. Ease of access to team members, as well as scheduling, were common facilitators of care cited by caregivers. The majority were willing to participate in telemedicine visits, regardless of how far they lived from the SCD center, though many noted aspects requiring adaptation.

CONCLUSION

This cross-sectional study describes barriers to care experienced by caregivers of children with SCD, regardless of proximity to an SCD center, as well as caregiver perceptions of the usefulness and acceptability of telemedicine for SCD care.

Diagnostic Delay in Paediatric Inflammatory Bowel Disease-A Systematic Investigation

Diagnostic delays (time from the first symptoms to diagnosis) are common in inflammatory bowel disease (IBD) and may lead to worse disease progression and treatment outcomes. This study aimed to determine the duration of diagnostic delays (DD) and to explore associated factors in a cohort of children with IBD in New Zealand. In this study, patients with IBD diagnosed as children and their parents/caregivers completed questionnaires on the patients’ medical history, diagnostic experience, and demographic characteristics. The parent/caregiver questionnaire also included the Barriers to Care Questionnaire (BCQ). Patients’ healthcare data was reviewed to summarise the history of clinical visits and determine symptoms. Total DD, healthcare DD, patient DD and parent DD were derived from the primary dataset. Factors associated with the different types of DD were explored with a series of simple linear and logistical ordinal regressions. A total of 36 patients (Crohn’s disease 25, ulcerative colitis 10; male 17) were included. They were diagnosed at a median age of 12 years (interquartile range (IQR) 10−15 years). Total healthcare delay (from first healthcare visit to formal diagnosis) was median (IQR) 15.4 (6.5−34.2) months. The median (IQR) specialist-associated delay was 4.5 (0−34) days. Higher household income was associated with shorter healthcare delay (p < 0.018), while lower overall BCQ scores (indicating more barriers experienced) were associated with longer total healthcare DD. Higher scores in each subscale of BCQ (Skills; Pragmatics; Expectations; Marginalization; Knowledge and Beliefs) were also significantly associated with shorter total healthcare delay (p < 0.04). This study found substantial diagnostic delays in paediatric patients with IBD and identified significant associations between longer total healthcare diagnostic delays and overall household income and higher self-reported barriers to accessing healthcare.

Impact of Seismic Activity on Access to Health Care in Hispanic/Latino Cancer Patients from Puerto Rico

On 7 January 2020, the southern region of Puerto Rico was struck by a 6.4 magnitude earthquake, followed by continual seismic activity. Our team performed secondary analyses to explore the relationship between exposure to seismic activity, protection (support) received, and barriers to health care access for cancer patients. Methods: The research team collected data from the database of a longitudinal case-control cohort parent study concerning the impact of Hurricane Maria in Puerto Rican cancer patients. The participants from the parent study were recruited in community clinics. The extracted data was collected from 51 cancer patients who completed the parent study’s interviews from January−July 2020 (seismic activity period). Barriers to health care were assessed using the Barrier to Care Questionaries (BCQ), which is composed of five subscales: skills, marginalization, knowledge and beliefs expectations, and pragmatics. Exposure to seismic activity and protection was assessed using their respective subscales from the Scale of Psychosocial Impact of Disasters. Results: The results showed a significant relationship between exposure to seismic activity and barriers to health care (p < 0.001) and its five subscales (p < 0.01). These results shed light on potential access to care barriers that could hinder cancer patient treatment in the event of a natural disaster.

Examining access to care in clinical genomic research and medicine: Experiences from the CSER Consortium

Introduction:

Ensuring equitable access to health care is a widely agreed-upon goal in medicine, yet access to care is a multidimensional concept that is difficult to measure. Although frameworks exist to evaluate access to care generally, the concept of “access to genomic medicine” is largely unexplored and a clear framework for studying and addressing major dimensions is lacking.

Methods:

Comprised of seven clinical genomic research projects, the Clinical Sequencing Evidence-Generating Research consortium (CSER) presented opportunities to examine access to genomic medicine across diverse contexts. CSER emphasized engaging historically underrepresented and/or underserved populations. We used descriptive analysis of CSER participant survey data and qualitative case studies to explore anticipated and encountered access barriers and interventions to address them.

Results:

CSER’s enrolled population was largely lower income and racially and ethnically diverse, with many Spanish-preferring individuals. In surveys, less than a fifth (18.7%) of participants reported experiencing barriers to care. However, CSER project case studies revealed a more nuanced picture that highlighted the blurred boundary between access to genomic research and clinical care. Drawing on insights from CSER, we build on an existing framework to characterize the concept and dimensions of access to genomic medicine along with associated measures and improvement strategies.

Conclusions:

Our findings support adopting a broad conceptualization of access to care encompassing multiple dimensions, using mixed methods to study access issues, and investing in innovative improvement strategies. This conceptualization may inform clinical translation of other cutting-edge technologies and contribute to the promotion of equitable, effective, and efficient access to genomic medicine.

Barriers to the access and utilization of healthcare for trafficked youth in the United States

BACKGROUND

Child trafficking is a pervasive public health problem in the United States, with significant health consequences for survivors. Previous studies demonstrated that survivors face barriers to healthcare, though much of the literature has not solely focused on domestic child trafficking.

OBJECTIVE

To identify barriers to healthcare faced by survivors of child trafficking in the United States, and to characterize the landscape of available trauma-informed medical services.

PARTICIPANTS

62 adult survivors of child trafficking (83% female, 10% male, 7% transgender; 90% sex trafficking, 25% labor trafficking; median age of entry 16) and 37 community agency professionals who work with trafficked children.

SETTING

The United States of America.

METHODS

The Barriers to Care Questionnaire (BCQ) was adapted, piloted with a focus group, and disseminated to participants.

RESULTS

A statistically significant increase in survivors seeking healthcare after compared to before trafficking was demonstrated (p < 0.05). Eighteen consequential barriers to healthcare were identified. The marginalization domain, representing the individual's perception of negative experiences with the healthcare system, had the highest number of consequential barriers. The majority of survivor and agency participants felt the physical and mental health needs of survivors are not being met, but would seek out trauma-informed healthcare if it were available in their community.

CONCLUSIONS

Survivors of child trafficking in the U.S. experience a wide range of barriers to healthcare, and a lack of available trauma-informed healthcare. This study identified barriers to healthcare that can be considered by providers hoping to provide accessible and truama-informed services to trafficked children.

Disparities in Access to Pediatric Otolaryngology Care During the COVID-19 Pandemic

OBJECTIVE

Racial/ethnic minority pediatric otolaryngology patients experience health disparities, including barriers to accessing health care. Our hypothesis for this study is that Hispanic or economically disadvantaged patients would represent a larger percentage of missed appointments and report more barriers to receiving care during the COVID-19 pandemic.

METHODS

A cross-sectional survey utilizing a modified version of the Barriers to Care Questionnaire was administered via telephone to no-show patients, and median income by zip code was collected. Chi-squared, logistic regression, and Student's t-tests were used to investigate any differences in those who did and did not keep their appointments as well as any differences in mean questionnaire scores.

RESULTS

No-show patients were more likely to be Hispanic than not (OR 2.3, 95% CI: 1.3, 3.9, P = .002) and to live in a zip code that had a median income less than 200% of the federal poverty level (OR 1.7, 95% CI: 1.2, 2.4, P = .004). Respondents with a high school degree tended to report more barriers to care compared to those with less education.

CONCLUSION

In our study, we identified ethnic, financial, and logistic concerns that may contribute to patients failing to keep their appointments with the otolaryngology clinic. Future studies are needed to assess the efficacy of measures aimed to reduce these barriers to care such as preventive plans to assist new patients and expanding telehealth services.

Psychometric Evaluation of a Barriers to Mental Health Treatment Questionnaire for Latina/o/x Caregivers of Children and Adolescents

Background

Knowledge regarding barriers faced by Latina/o/x caregivers in accessing youth mental health services (MHS) have largely depended on resource intensive interview-based assessments.

Objective

We evaluated a questionnaire for Latina/o/x caregivers of youths that presents a briefer and more feasible alternative.

Method

We conducted a psychometric evaluation of the Barriers to Treatment Questionnaire - Latina/o/x Caregivers (BTQ-LC) with a sample of 598 Latina/o/x caregivers from across the United States. Descriptive statistics and confirmatory factor analyses were used to identify common barriers to services, confirm the factor structure of the scale, and establish construct validity.

Results

Descriptive statistics suggest that not knowing where and how to access services, and normalization of youth psychopathology were the most frequently reported barriers among caregivers of youth with clinically elevated problems on the CBCL. Confirmatory factor analysis suggests that the BTQ-LC was best represented by a three-factor structure: (1) structural, (2) perceptions regarding mental health problems, and (3) services. Our finding suggest that the BTQ-LC could also be used as a single factor as fit indices ranged from acceptable to poor. BTQ-LC scales were all negatively correlated with the utilization of common youth MHS (i.e., psychological counseling, medical doctors, school professionals).

Conclusions

The BTQ-LC represents an important step towards improving our understanding and assessment of barriers to services contributing to mental health disparities among Latina/o/x youths.

Modeling Risk Factors for Sleep- and Adiposity-Related Cardiometabolic Disease: Protocol for the Short Sleep Undermines Cardiometabolic Health (SLUMBRx) Observational Study

Background

Obesity and short sleep duration are significant public health issues. Current evidence suggests that these conditions are associated with cardiovascular disease, metabolic syndrome, inflammation, and premature mortality. Increased interest in the potential link between obesity and short sleep duration, and its health consequences, has been driven by the apparent parallel increase in the prevalence of both conditions in recent decades, their overlapping association with cardiometabolic outcomes, and the potential causal connection between the two health issues. The SLUMBRx (Short Sleep Undermines Cardiometabolic Health) study seeks to contribute to the development of a comprehensive adiposity-sleep model while laying the groundwork for a future research program that will be designed to prevent and treat adiposity- and sleep-related cardiometabolic disease risk factors.

Objective

This SLUMBRx study aims to address 4 topics pertinent to the adiposity-sleep hypothesis: the relationship between adiposity and sleep duration; sex-based differences in the relationship between adiposity and sleep duration; the influence of adiposity indices and sleep duration on cardiometabolic outcomes; and the role of socioecological factors as effect modifiers in the relationship between adiposity indices, sleep, and cardiometabolic outcomes.

Methods

SLUMBRx will employ a large-scale survey (n=1000), recruiting 159 participants (53 normal weight, 53 overweight, and 53 obese) to be assessed in 2 phases.

Results

SLUMBRx was funded by the National Institutes of Health, Heart, Lung, and Blood Institute through a K01 grant award mechanism (1K01HL145128-01A1) on July 23, 2019. Institutional Review Board (IRB) approval for the research project was sought and obtained on July 10, 2019. Phase 1 of SLUMBRx, the laboratory-based component of the study, will gather objective adiposity indices (air displacement plethysmography and anthropometrics) and cardiometabolic data (blood pressure, pulse wave velocity and pulse wave analysis, and a blood-based biomarker). Phase 2 of SLUMBRx, a 1-week, home-based component of the study, will gather sleep-related data (home sleep testing or sleep apnea, actigraphy, and sleep diaries). During phase 2, detailed demographic and socioecological data will be collected to contextualize hypothesized adiposity and sleep-associated cardiometabolic disease risk factors. Collection and analyses of these data will yield information necessary to customize future observational and intervention research.

Conclusions

Precise implementation of the SLUMBRx protocol promises to provide objective and empirical data on the interaction between body composition and sleep duration. The hypotheses that will be tested by SLUMBRx are important for understanding the pathogenesis of cardiometabolic disease and for developing future public health interventions to prevent its conception and treat its consequences.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27139

The Short Barriers Questionnaire (SBQ): Validity, factor structure and correlates in an out-of-treatment sample of people dependent on methamphetamine

INTRODUCTION AND AIMS

We validate a brief questionnaire to assess barriers to help-seeking for illicit substance use, and explore the factor structure and correlates of scale scores, among people dependent on methamphetamine.

DESIGN AND METHODS

We administered a modified version of 27 items from the Barriers Questionnaire to 145 adults who had used methamphetamine in the past month and who screened positive for methamphetamine dependence on the Mini International Neuropsychiatric Interview. We used an exploratory factor analysis to identify the scale's dimensions. We examined correlates of the scale scores, their internal consistency, and their concurrent validity against help-seeking intentions on the General Help Seeking Questionnaire (GHSQ).

RESULTS

A three factor model (χ² = 308.6 _df=168; RMSEA 0.08 [95% CI 0.06-0.09]; comparative fit index = 0.92) identified low perceived need for treatment (9 items), stigma (6 items), and apprehension about treatment (7 items) with Eigenvalues of 5.7, 3.8 and 2.3 respectively. The final 22-item scale had good internal consistency (Cronbach's alpha 0.83) and correlated negatively with help-seeking intentions on the GHSQ (r_s = -0.24 p < .001) and positively with the GHSQ item, "I would not seek help from anyone" (r_s = 0.38 p < .001). The scale dimensions of low perceived need, stigma, and apprehension had adequate to good internal consistency (Cronbach's alpha of 0.83, 0.79 and 0.69 respectively) but only low perceived need for treatment correlated significantly with the GHSQ scores. Low perceived need was also related to less severe methamphetamine dependence, not having children, and not having received professional help for methamphetamine use. Stigma was associated with specific demographics (being employed, having children), polysubstance use, and having attended sessions with a counselor or psychologist. Apprehension was associated with poor mental health, more severe substance use, being a woman, and having received help from an ambulance.

DISCUSSION AND CONCLUSIONS

This short version of the Barriers Questionnaire (the Short Barriers Questionnaire; SBQ) is an internally consistent and valid scale for assessing low perceived need for treatment among people who use methamphetamine. Further work is needed to capture and validate other barriers to help-seeking for this population.

Impact of a natural disaster on access to care and biopsychosocial outcomes among Hispanic/Latino cancer survivors

Cancer is the leading cause of death in Puerto Rico (PR). Hurricane Maria (HM) and its aftermath lead to widespread devastation on the island, including the collapse of the healthcare system. Medically fragile populations, such as cancer survivors, were significantly affected. The goal of this study was to assess the impact of HM on barriers to care, emotional distress, and inflammatory biomarkers among cancer survivors in PR. This exploratory longitudinal study was conducted in health care facilities and community support groups from PR. Cancer survivors (n = 50) and non-cancer participants (n = 50) completed psychosocial questionnaires and provided blood samples that were used to assess inflammatory cytokines levels. Among this cohort, we identified 41 matched cancer survivors/non-cancer participants pairs. Data were analyzed through descriptive, frequencies, correlational, and regression analyses. Cancer survivors that were affected by HM reported increased barriers in accessing medical care, which were directly associated with anxiety, perceived stress, and post-traumatic symptomatology. Moreover, being a cancer survivor, predicted more barriers to receiving health care, especially in the first six weeks after the event, after which the effect was attenuated. Several inflammatory cytokines, such as CD31, BDNF, TFF3, Serpin E-1, VCAM-1, Vitamin D BP, and PDGF-AA, were significantly upregulated in cancer survivors while MMP9 and Osteopontin both had significant positive correlations with barriers to care. HM significantly impacted Puerto Ricans psychosocial well-being. Cancer survivors had significant barriers to care and showed increased serum inflammatory cytokines but did not show differences in anxiety, stress, and post-traumatic symptoms compared to non-cancer participants.

A study protocol for a randomized controlled trial of family-partnered delirium prevention, detection, and management in critically ill adults: the ACTIVATE study

Background

Delirium is very common in critically ill patients admitted to the intensive care unit (ICU) and results in negative long-term outcomes. Family members are also at risk of long-term complications, including depression and anxiety. Family members are frequently at the bedside and want to be engaged; they know the patient best and may notice subtle changes prior to the care team. By engaging family members in delirium care, we may be able to improve both patient and family outcomes by identifying delirium sooner and capacitating family members in care.

Methods

The primary aim of this study is to determine the effect of family-administered delirium prevention, detection, and management in critically ill patients on family member symptoms of depression and anxiety, compared to usual care. One-hundred and ninety-eight patient-family dyads will be recruited from four medical-surgical ICUs in Calgary, Canada. Dyads will be randomized 1:1 to the intervention or control group. The intervention consists of family-partnered delirium prevention, detection, and management, while the control group will receive usual care. Delirium, depression, and anxiety will be measured using validated tools, and participants will be followed for 1- and 3-months post-ICU discharge. All analyses will be intention-to-treat and adjusted for pre-identified covariates. Ethical approval has been granted by the University of Calgary Conjoint Health Research Ethics Board (REB19–1000) and the trial registered. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

Discussion

Critically ill patients are frequently unable to participate in their own care, and partnering with their family members is particularly important for improving experiences and outcomes of care for both patients and families.

Trial registration

Registered September 23, 2019 on Clinicaltrials.gov NCT04099472.

Identifying Modifiable Health Care Barriers to Improve Health Equity for Hospitalized Children

BACKGROUND

Children from socially disadvantaged families experience worse hospital outcomes compared with other children. We sought to identify modifiable barriers to care to target for intervention.

METHODS

We conducted a prospective cohort study of hospitalized children over 15 months. Caregivers completed a survey within 3 days of admission and 2 to 8 weeks after discharge to assess 10 reported barriers to care related to their interactions within the health care system (eg, not feeling like they have sufficient skills to navigate the system and experiencing marginalization). Associations between barriers and outcomes (30-day readmissions and length of stay) were assessed by using multivariable regression. Barriers associated with worse outcomes were then tested for associations with a cumulative social disadvantage score based on 5 family sociodemographic characteristics (eg, low income).

RESULTS

Of eligible families, 61% (n = 3651) completed the admission survey; of those, 48% (n = 1734) completed follow-up. Nine of 10 barriers were associated with at least 1 worse hospital outcome. Of those, 4 were also positively associated with cumulative social disadvantage: perceiving the system as a barrier (adjusted β = 1.66; 95% confidence interval [CI] 1.02 to 2.30), skill barriers (β = 3.82; 95% CI 3.22 to 4.43), cultural distance (β = 1.75; 95% CI 1.36 to 2.15), and marginalization (β = .71; 95% CI 0.30 to 1.11). Low income had the most consistently strong association with reported barriers.

CONCLUSIONS

System barriers, skill barriers, cultural distance, and marginalization were significantly associated with both worse hospital outcomes and social disadvantage, suggesting these are promising targets for intervention to decrease disparities for hospitalized children.

Factors associated with using alternative sources of primary care: a cross-sectional study

BACKGROUND

Mobile (MHCs), Community (CHCs), and School-based health clinics (SBHCs) are understudied alternative sources of health care delivery used to provide more accessible primary care to disenfranchised populations. However, providing access does not guarantee utilization. This study explored the utilization of these alternative sources of health care and assessed factors associated with residential segregation that may influence their utilization.

METHODS

A cross-sectional study design assessed the associations between travel distance, perceived quality of care, satisfaction-adjusted distance (SAD) and patient utilization of alternative health care clinics. Adults (n = 165), child caregivers (n = 124), and adult caregivers (n = 7) residing in New Orleans, Louisiana between 2014 and 2015 were conveniently sampled. Data were obtained via face-to face interviews using standardized questionnaires and geospatial data geocoded using GIS mapping tools. Multivariate regression models were used to predict alternative care utilization.

RESULTS

Overall 49.4% of respondents reported ever using a MCH, CHC, or SBHC. Travel distance was not significantly associated with using either MCH, CHC, or SBHC (OR = 0.91, 0.74-1.11 p > .05). Controlling for covariates, higher perceived quality of care (OR = 1.02, 1.01-1.04 p < .01) and lower SAD (OR = 0.81, 0.73-0.91 p < .01) were significantly associated with utilization.

CONCLUSIONS

Provision of primary care via alternative health clinics may overcome some barriers to care but have yet to be fully integrated as regular sources of care. Perceived quality and mixed-methods measures are useful indicators of access to care. Future health delivery research is needed to understand the multiple mechanisms by which residential segregation influences health-seeking behavior.

Parents' reports of barriers to care for pediatric otolaryngology patients

OBJECTIVE

To understand parent perceptions of types and severity of barriers to care within the pediatric otolaryngology patient population in WV.

STUDY DESIGN

Descriptive survey.

SETTING

University pediatric otolaryngology clinic, Morgantown, WV.

SUBJECTS AND METHODS

Subjects were caretakers of pediatric patients in clinic. Subjects were asked to complete the modified validated Barriers to Care Questionnaire (BCQ) and to provide some demographic details.Each BCQ question response was reported as a Mean Total Score (MTS), ranging from 0 (complete barrier) to 100 (no barrier) and they were grouped into 5 BTC subscales. Demographic question responses were used to establish subgroups. Data for subscale groups was compared across the demographic subgroups using non-parametric methods.

RESULTS

301 parents provided responses. The overall mean BTC was 91.59 (95% CI 90.12-93.05). The Expectations and Pragmatics subscales were the two greatest barriers at 88.56 and 90.80, respectively. 26.7% reported no barriers to care. No statistically significant association was found among subscale scores and demographic subgroups.

CONCLUSIONS

Parents of pediatric otolaryngology patients in WV demonstrate low expectations of the healthcare system. There are concerns about pragmatics that could create barriers. Our hope is to spur scientific interest in this understudied healthcare topic. Future studies should be conducted to identify association/causation and help establish a framework for addressing potential barriers to care in the pediatric population.

Family Caregiver Marginalization is Associated With Decreased Primary and Subspecialty Asthma Care in Head Start Children

BACKGROUND

Urban minority children are at risk for poor asthma outcomes and might not receive appropriate primary or subspecialty care. We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma.

METHODS

The Barriers to Care Questionnaire (BCQ) is used to measure expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control using the Test for Respiratory and Asthma Control in Kids and these outcomes: PCP visits for asthma in the past 6 months, subspecialty care (allergist or pulmonologist) in the past 2 years, and ED visits in the past 3 months.

RESULTS

Three hundred ninety-five caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent (n = 236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (odds ratio [OR], 0.95; P = .014) and subspecialty visits (OR, 0.92; P = .019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR, 0.98; P = .027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes.

CONCLUSIONS

Among low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the health care system (marginalization). Clinicians who serve at-risk populations should be sensitive to families' past experiences and should consider designing interventions to target the most commonly reported barriers.

Barriers to pediatric cochlear implantation: A parental survey

OBJECTIVE

This study aims to (1) determine barriers in the pediatric cochlear implantation process specific to publicly insured patients, wherein delayed implantation has been reported, and (2) compare the perceived barriers between publicly and privately insured patients.

SETTING

Tertiary care cochlear implantation center at academic pediatric hospital.

STUDY DESIGN

Cross-sectional survey, retrospective chart review.

METHODS

The validated, 39 item Barriers to Care Questionnaire was administered to the parents of 80 recipients of cochlear implantation by two surgeons between 2013 and 2016. Survey results and diagnosis to implant interval were compared based on public or private insurance status. Two-tailed Mann-Whitney and Fisher's exact test was used for statistical analysis.

RESULTS

Of 110 cochlear implants, 27 of 80 (34%) English-speaking parents completed the survey. 15 were privately insured and 12 were publicly insured. 23 of 27 respondents received cochlear implantation for pre-lingual sensorineural hearing loss. Publicly insured patients had significantly longer median time from diagnosis to implant than privately insured (19 vs. 8 mo, p = 0.01). The three worst scoring barrier categories for privately insured families in order were Pragmatics, Expectations, and Marginalization, whereas for publicly insured families it was Pragmatics, Skills, and Expectations. The worst scoring question for privately insured patients was "Having to take time off work". For the publicly insured, it was "Lack of communication."

CONCLUSION

Privately insured patients reported more barriers on the Barriers to Care Questionnaire than publicly insured patients did. Although pragmatics was the worst-scoring barrier category for both groups, difficulties found on the survey ranked differently for each group. This information can help providers address disparities and access barriers for vulnerable patients.

Place Matters in Non-Traditional Migration Areas: Exploring Barriers to Healthcare for Latino Immigrants by Region, Neighborhood, and Community Health Center

This paper identifies differences in adult Latino immigrant barriers to healthcare in the Cincinnati area in Hamilton County, OH, on three levels: by region, by neighborhood, and by community health center. Secondary data analysis was performed on 439 surveys. Respondents were aggregated by the geographic regions and neighborhoods where they live and by two community health centers where they receive care. Outcome measures included pragmatic and skill barrier indices adapted from the Barriers to Care Questionnaire (BCQ); the pragmatics index consists logistical barriers, including transportation and cost; the skills index is made up of items related to navigating the healthcare system, including communicating with physicians and completing paperwork. The results indicate that immigrant Latinos living in western Cincinnati and northern Hamilton County face significantly higher pragmatic barriers to care, while Latino immigrants going to a community health center in western Cincinnati have significantly fewer pragmatic and skill barriers than immigrants utilizing a nearby community health center. Because healthcare options for undocumented immigrants do not improve with the Affordable Care Act, community health centers will continue to serve as their primary source of care. This is particularly true in non-traditional migration areas, where immigrants tend to be isolated and lack resources. Efforts to improve access to healthcare for immigrant Latinos require place-based approaches that allow for targeted resources to improve care in these locations. This study helps to fill that need by identifying variation in barriers to care on multiple levels and offering strategies to alleviate these barriers.

Oral health-related quality of life in youth receiving cleft-related surgery: self-report and proxy ratings

PURPOSE

This paper evaluated the impact of cleft-related surgery on the oral health-related quality of life (OHRQoL) of youth with cleft over time.

METHODS

Data were derived from a 5-year, multi-center, prospective, longitudinal study of 1196 youth with cleft lip and/or palate and their caregivers. Eligible youth were between 7.5 and 18.5 years old, spoke English or Spanish, and were non-syndromic. During each observational period, which included baseline, and 1- and 2-year post-baseline follow-up visits, youths and their caregivers completed the Child Oral Health Impact Profile, a validated measure of OHRQoL. Multilevel mixed-effects models were used to analyze the effects of receipt of craniofacial surgery on OHRQoL over time.

RESULTS

During the course of this study a total of 516 patients (43 %) received at least one surgery. Youth in the surgery recommendation group had lower self- (β = -2.18, p < 0.05) and proxy-rated (β = -2.92, p < 0.02) OHRQoL when compared to non-surgical self- and proxy-rated OHRQoL at baseline. Both surgical and non-surgical youth (β = 3.73, p < 0.001) and caregiver (β = 1.91, p < 0.05) ratings of OHRQoL improved over time. There was significant incremental improvement (time × surgery interaction) in self-reported OHRQoL for youth postsurgery (β = 1.04, p < 0.05), but this postsurgery increment was not seen in the caregiver proxy ratings.

CONCLUSIONS

Surgical intervention impacts OHRQoL among youth with cleft. Youth who were surgical candidates had lower baseline self- and caregiver-rated OHRQoL when compared to non-surgical youth. Youth who underwent cleft-related surgery had significant incremental improvements in self-rated but not caregiver (proxy)-rated OHRQoL after surgery.

Demographic Characteristics Associated With Barriers to Health Care Among Mexican and Guatemalan Immigrants in a Nontraditional Destination Area

The purpose of this study was to examine demographic factors associated with health care barriers among Mexican (n = 258) and Guatemalan (n = 143) immigrants in Cincinnati, a nontraditional destination (new migration area). Three primary results emerged: length of US residence was not associated with fewer health care barriers, Mexican women and younger Guatemalans endorsed fewer skills-related barriers, and childless Guatemalans reported more barriers to care the longer they reside in the United States, when compared with Guatemalans with children. Our study highlights the importance of disaggregating data to create more tailored interventions to eliminate health disparities for Latinos.

Theoretical domains framework to assess barriers to change for planning health care quality interventions: a systematic literature review

BACKGROUND

Theoretical domains framework (TDF) provides an integrative model for assessing barriers to behavioral changes in order to suggest interventions for improvement in behavior and ultimately outcomes. However, there are other tools that are used to assess barriers.

OBJECTIVE

The objective of this study is to determine the degree of concordance between domains and constructs identified in two versions of the TDF including original (2005) and refined version (2012) and independent studies of other tools.

METHODS

We searched six databases for articles that studied barriers to health-related behavior changes of health care professionals or the general public. We reviewed quantitative papers published in English which included their questionnaires in the article. A table including the TDF domains of both original and refined versions and related constructs was developed to serve as a reference to describe the barriers assessed in the independent studies; descriptive statistics were used to express the results.

RESULTS

Out of 552 papers retrieved, 50 were eligible to review. The barrier domains explored in these articles belonged to two to eleven domains of the refined TDF. Eighteen articles (36%) used constructs outside of the refined version. The spectrum of barrier constructs of the original TDF was broader and could meet the domains studied in 48 studies (96%). Barriers in domains of "environmental context and resources", "beliefs about consequences", and "social influences" were the most frequently explored in 42 (84%), 37 (74%), and 33 (66%) of the 50 articles, respectively.

CONCLUSION

Both refined and original TDFs cataloged barriers measured by the other studies that did not use TDF as their framework. However, the original version of TDF explored a broader spectrum of barriers than the refined version. From this perspective, the original version of the TDF seems to be a more comprehensive tool for assessing barriers in practice.

Resiliency and socioemotional functioning in youth receiving surgery for orofacial anomalies

OBJECTIVES

Restorative interventions for cleft lip and palate involve annual evaluations, adjunct treatment, and multiple surgeries. The purpose of this study was to investigate the longitudinal impact of cleft surgery on psychosocial functioning among youth with cleft.

METHODS

Data were derived from a 5-year, multicenter, prospective longitudinal study of children with cleft (N = 1196). Children completed psychological inventories for self-concept, anxiety, depression, mastery, and relatedness. Multilevel mixed-effects models were used to analyze the effects of craniofacial surgery for cleft on psychosocial outcomes over time.

RESULTS

There were 1196 participants at baseline, of whom 258 (27.5%) received a surgical intervention prior to their 1st follow-up visit. Approximately 78% of participants had cleft lip and palate, and 22% had cleft palate only. Surgery receipt was significantly associated with lower relatedness (β = -1.48, 95% CI = -2.91, -0.05) and mastery (β = -1.32, 95% CI = -2.49, -0.15) scores, although overall scores appeared to increase over time. Surgery was not related to anxiety (β = -0.15, 95% CI = -1.08, 0.79), depression (β = 0.18, 95% CI = -0.65, 1.01), and self-concept (β = -0.84, 95% CI = -1.83, 0.15). The treatment-time interaction was not significant. Significant differences in psychosocial functioning were found across sex, race/ethnicity, and age groups.

CONCLUSIONS

Surgery may have negative short-term impacts on psychosocial functioning, although effects may diminish over time. Given the limited postsurgical follow-up period, long-term change in psychological well-being and the moderating effects of surgery may not be fully realized. Further follow-up of children with cleft through adulthood to explore developmental trajectories of psychosocial functioning in more detail is recommended.

Patient perspectives on fluticasone-vilanterol versus other corticosteroid combination products for the treatment of asthma

OBJECTIVE

Fluticasone furoate (FF), an inhaled corticosteroid (ICS), and vilanterol (VI), a long-acting beta2 receptor agonist (LABA), is a new combination used in an Ellipta(®) device. This article compares FF-VI to other ICS-LABA combinations available, particularly emphasizing product selection from the patient perspective.

DATA SOURCES

A PubMED and EMBASE search completed in October 2015 identified trials using the MeSH terms "fluticasone", "vilanterol", and "asthma". Additional information was gathered from references cited in the identified publications, the manufacturer, package insert, and ClinicalTrials.gov registry.

STUDY SELECTION/DATA EXTRACTION

Preference was given to randomized controlled clinical trials. Animal trials, trials for COPD, and non-English sources were excluded.

DATA SYNTHESIS

Seven efficacy trials of FF-VI in asthma were identified. Only one (24 weeks) trial compared FF-VI to another ICS-LABA combination (fluticasone propionate-salmeterol). Primary outcomes (usually lung function) and secondary outcomes (eg, quality of life and symptom scores) were comparable. In three FF-VI safety trials, the type and frequency of common adverse reactions (ie, thrush and dysphonia) were similar to those in clinical trials. Over 90% of subjects rated the Ellipta(®) device as "easy to use" and demonstrated correct device technique initially and at 4 weeks.

CONCLUSION

Individuals may have drug- and device-specific preferences that should be incorporated into therapeutic decision making. Limited data indicate that clinical and patient-oriented efficacy/safety outcomes of FF-VI are likely comparable to other available combinations for adults with asthma. Patient-friendly features include once-daily dosing, flexibility of dose timing, and design/ease of the use of the device. Additional larger and long-term comparative studies are needed to determine whether these features translate into greater efficacy, safety, patient preference, or adherence versus other ICS-LABA combinations. In the next few years, the availability of less expensive generic ICS-LABA products may strongly influence patient preference.

Barriers to care and quality of primary care services in children with sickle cell disease

AIMS

The aims of this study were: to (1) identify barriers to care in children with sickle cell disease; (2) examine the quality of primary care services received by these children and (3) examine the relationship between barriers to care and quality of primary care services in children with sickle cell disease.

BACKGROUND

Effective management in children with sickle cell disease requires early access to a comprehensive range of preventive screenings, urgent care treatments for vaso-occlusive pain crisis and ongoing prophylactic treatments.

DESIGN

A cross-sectional survey of parents of children with sickle cell disease was conducted between April-September 2011.

METHODS

Parents of children with sickle cell disease completed the Barriers to Care Questionnaire and Parent's Perceptions of Primary Care.

RESULTS

Parents of children with sickle cell disease (n = 38) reported health system barriers such as inability to contact doctors or clinics, extended wait times and inconvenient clinic hours. Some barriers were reported more frequently among children with concurrent sickle cell disease and asthma, compared with those children without a concurrent asthma condition. Parents who reported more barriers were least likely to perceive their care as accessible, comprehensive and coordinated.

CONCLUSIONS

Minimizing healthcare barriers may improve the quality of primary care services received by children with sickle cell disease and consequently prevent complications associated with sickle cell disease.

IMPLICATIONS FOR NURSING PRACTICE

Nurses and other care providers need to identify healthcare barriers, so that access, coordination, comprehensiveness and overall quality of primary care services may be improved in children with sickle cell disease.

Interventions to Improve Asthma Management of the School-Age Child

Improvement of medication adherence in the school-age child can lead to improvement in quality of life, decreased morbidity, and a potential decreased risk of deferred academic, social, and emotional development. The objective of this article is to review barriers to asthma medication adherence and identify evidence-based techniques that improve medication management of the asthmatic child 5 to 12 years of age. A literature review was performed and articles were obtained through database searches within Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PubMed. Research indicates that barriers to the adherence of medication regimens required for asthmatic children include poor understanding of the medication regimen, substandard education on symptom recognition and environmental triggers, rejection of the diagnosis, and a lack of support or understanding within the community. Researched techniques aimed to improve medication management in 5- to 12-year-olds include: computer-based education; workshops for parents, teachers, and children; incorporation of asthma education into classroom lessons; use of case managers; the introduction of a nurse practitioner in the school to provide care, including medication prescriptions for the asthmatic child; and assessment and evaluation of environmental and emotional triggers in the home and school. Collaboration of current data may help lead to a successful interventional model that can improve asthma management in this population.

Families referred to a Child Assessment Team: the Campbelltown experience

AIM

To study the socio-demographic and psychosocial risk factors of families presenting with their children for a diagnostic developmental assessment.

METHODS

Socio-demographic details of children who had a multidisciplinary developmental assessment with the Child Assessment Team at Campbelltown Hospital between January 2009 and December 2010 were collated and compared with census data.

RESULTS

In 2009 and 2010, 277 families were seen by the Child Assessment Team. A detailed socio-demographic profile was available for 251 (91%) families. Parents seen in the clinic were more likely to be younger, single, born overseas, have less post-school education, identify as Aboriginal and/or live in public housing compared with the district rates.

CONCLUSIONS

Families presenting to the developmental clinic have more socio-economic disadvantage compared with the referring district. This has implications for service delivery and clinical presentation, and highlights the importance of the social worker's role in a developmental diagnostic team.

Adherence-related issues in adolescents and young adults with hematological disorders

Nonadherence to medical recommendations is a widespread problem well documented in a multitude of clinical settings. Nonadherence may adversely affect clinical outcomes such as survival and quality of life and increase health-care-related costs. An understanding of the factors driving nonadherence is key to developing effective adherence-enhancing interventions (AEIs). There are ongoing attempts in contemporary adherence research to better define the various components of adherence, to find optimal measures of adherence and correlations with clinical outcomes, and to create a classification system for AEIs. Nonadherence is also widely prevalent among adolescents and young adults (AYAs) with chronic hematological diseases, affecting up to 50% of patients and increasing with age. Combined use of objective (i.e. electronic monitoring, EM) and subjective (i.e. self-report) measures of adherence may be the preferred approach to assess adherence. The unique physical, social and emotional aspects of the AYA life stage are closely related to intricate causes of nonadherence in AYAs such as problems in transition to adult care. Until proven otherwise, the empirical target in AYAs with hematological disorders should be perfect adherence. Multilevel AEIs, EM feedback and behavioral interventions are among the most effective types of AEIs. Despite the magnitude of the problem, only a handful of AEIs have been evaluated among AYAs with hematological disorders. Thus, this is a field with unmet needs warranting high-quality trials using standardized and well-specified assessment methods and interventions. This review discusses the prevalence, definition, causes and clinical implications of nonadherence among AYAs with hematological disorders, along with strategies to measure and improve adherence.

Barriers to care for children with orofacial clefts in North Carolina

BACKGROUND

Little is known about the barriers faced by families of children with birth defects in obtaining healthcare. We examined reported perceived barriers to care and satisfaction with care among mothers of children with orofacial clefts.

METHODS

In 2006, a validated barriers to care mail/phone survey was administered in North Carolina to all resident mothers of children with orofacial clefts born between 2001 and 2004. Potential participants were identified using the North Carolina Birth Defects Monitoring Program, an active, state-wide, population-based birth defects registry. Five barriers to care subscales were examined: pragmatics, skills, marginalization, expectations, and knowledge/beliefs. Descriptive and bivariate analyses were conducted using chi-square and Fisher's exact tests. Results were stratified by cleft type and presence of other birth defects.

RESULTS

Of 475 eligible participants, 51.6% (n = 245) responded. The six most commonly reported perceived barriers to care were all part of the pragmatics subscale: having to take time off work (45.3%); long waits in the waiting rooms (37.6%); taking care of household responsibilities (29.7%); meeting other family members' needs (29.5%); waiting too many days for appointments (27.0%); and cost (25.0%). Most respondents (72.3%, 175/242) felt "very satisfied" with their child's cleft care.

CONCLUSION

Although most participants reported being satisfied with their child's care, many perceived barriers to care were identified. Due to the limited understanding and paucity of research on barriers to care for children with birth defects, including orofacial clefts, additional research on barriers to care and factors associated with them are needed.

A patient navigation intervention for drug-involved former prison inmates

BACKGROUND

Former prison inmates experience high rates of hospitalizations and death during the transition from prison to the community, particularly from drug-related causes and early after release. The authors designed a randomized controlled trial (RCT) of patient navigation to reduce barriers to health care and hospitalizations for former prison inmates.

METHODS

Forty former prison inmates with a history of drug involvement were recruited and randomized within 15 days after prison release. Participants were randomized to receive 3 months of patient navigation (PN) with facilitated enrollment into an indigent care discount program (intervention) or facilitated enrollment into an indigent care discount program alone (control). Structured interviews were conducted at baseline, 3 months, and 6 months. Outcomes were measured as a change in self-reported barriers to care and as the rate of health service use per 100 person-days.

RESULTS

The mean number of reported barriers to care was reduced at 3 and 6 months in both groups. At 6 months, the rate of emergency department/urgent care visits per 100 person-days since baseline was 1.1 among intervention participants and 0.5 among control participants (P = .04), whereas the rate of hospitalizations per 100 person-days was 0.2 in intervention participants and 0.6 in control participants (P = .04).

CONCLUSIONS

Recruitment of former inmates into an RCT of patient navigation was highly feasible, but follow-up was limited by rearrests. Results suggest a significantly lower rate of hospitalizations among navigation participants, although the rate of emergency department/urgent care visits was not improved. Patient navigation is a promising, pragmatic intervention that may be effective at reducing high-cost health care utilization in former prison inmates.

Perceived barriers to care in a pediatric medical home: the moderating role of caregiver minority status

OBJECTIVE

To examine the association of minority status to perceived barriers to care and health-related quality of life in families presenting to a Medical Home.

METHOD

Fifty-three caregivers were classified as minority or nonminority caregivers based on self-reported race/ethnicity. Caregivers completed a measure of perceived barriers to care and child health-related quality of life.

RESULTS

Minority caregivers reported more perceived barriers to care with regard to the pragmatics of obtaining health care. The association between perceived barriers to care and child health-related quality of life was moderated by minority status. Perceived barriers to care were only related to child health-related quality of life among minority caregivers.

CONCLUSION

Minority families may have difficulties with the cost of health care or logistics of obtaining health care for their child. Perceived health care barriers may still exist within pediatric Medical Homes for minority caregivers and affect child health-related quality of life.

Medical home quality and readmission risk for children hospitalized with asthma exacerbations

OBJECTIVE

The medical home likely has a positive effect on outpatient outcomes for children with asthma. However, no information is available regarding the impact of medical home quality on health care utilization after hospitalizations. We sought to explore the relationship between medical home quality and readmission risk in children hospitalized for asthma exacerbations.

METHODS

We enrolled 601 children, aged 1 to 16 years, hospitalized for an acute asthma exacerbation at a single pediatric facility that captures >85% of all asthma admissions in an 8-county area. Caregivers completed the Parent's Perception of Primary Care (P3C), a Likert-based, validated survey. The P3C yields a total score of medical home quality and 6 subscale scores assessing continuity, access, contextual knowledge, comprehensiveness, communication, and coordination. Asthma readmission events were prospectively collected via billing data. Hazards of readmission were calculated by using Cox proportional hazards adjusting for chronic asthma severity and key measures of socioeconomic status.

RESULTS

Overall P3C score was not associated with readmission. Among the subscale comparisons, only children with lowest access had a statistically increased readmission risk compared with children with the best access. Subgroup analysis revealed that children with private insurance and good access had the lowest rates of readmission within a year compared with other combinations of insurance and access.

CONCLUSIONS

Among measured aspects of medical home in a cohort of hospitalized children with asthma, having poor access to a medical home was the only measure associated with increased readmission. Improving physician access for children with asthma may lower hospital readmission.

Barriers to mental health care: perceived delivery system differences

Treatment barriers have prompted the development of new models of care. Distance delivery systems bridge the access gap, increasing service availability. Understanding differences between systems can inform system improvements. Sixty participants from the Strongest Families telephone intervention for child behavior difficulties participated. Participants completed a questionnaire to explore differences in perceived treatment barriers (Treatment Barriers Index-TBI) and therapeutic processes (eg, therapeutic alliance, self-disclosure, health outcome) between face-to-face versus distance treatment. The TBI scale has strong internal reliability (Cronbach α: 0.95 [face-to-face]; 0.90 [distance]). Statistically significant differences were found between delivery system TBI mean scores, indicating fewer barriers with distance treatment. Therapeutic process differences between delivery modes suggest enhanced therapeutic alliance and self-disclosure scores with distance treatment. Increased access, convenience, and sense of privacy (visual anonymity) offered by a distance delivery system may provide an enhanced experience for some individuals.

Modifiable factors associated with severe asthma exacerbations in urban patients

BACKGROUND

Rates of asthma morbidity, mortality, and resource use are highest among African American individuals residing in inner-city locations, yet factors associated with adverse outcomes are not well established.

OBJECTIVE

To identify modifiable factors associated with asthma exacerbations.

METHODS

A total of 104 adult patients who presented to an inner-city hospital or emergency department (ED) with an asthma exacerbation from October 1, 2009, through June 31, 2010, completed surveys of clinical status, acute events, sociodemographic characteristics, current asthma knowledge, self-efficacy, attitudes toward asthma self-management, and perceived barriers to asthma care questionnaires. Associations with asthma hospitalizations and ED visits were assessed.

RESULTS

The mean age of the patients was 42 years, 91% were African American, 33% were insured, 57% were taking a controller medication, and 63% had an income level below the federal poverty line. On bivariate analysis, males, years of asthma, history of smoking, self-classification of asthma severity, history of admission to intensive care unit or intubation, use of peak flow meter or asthma action plan, controller medication use, and history of oral corticosteroid bursts were positively associated, whereas self-efficacy was negatively associated with number of ED visits or hospitalizations. No association was found for asthma knowledge, perceived barriers to care, or attitudes toward asthma management. On multivariate analysis, low self-efficacy remained associated with both asthma hospitalizations and ED visits.

CONCLUSION

Short-term use of health services for asthma is negatively associated with asthma self-efficacy. Self-management programs that enhance self-efficacy, rather than those that focus on knowledge or attitudes, may be effective in reducing adverse asthma outcomes for inner-city, predominantly African American populations.

Integrating interactive web-based technology to assess adherence and clinical outcomes in pediatric sickle cell disease

Research indicates that the quality of the adherence assessment is one of the best predictors for improving clinical outcomes. Newer technologies represent an opportunity for developing high quality standardized assessments to assess clinical outcomes such as patient experience of care but have not been tested systematically in pediatric sickle cell disease (SCD). The goal of the current study was to pilot an interactive web-based tool, the Take-Charge Program, to assess adherence to clinic visits and hydroxyurea (HU), barriers to adherence, solutions to overcome these barriers, and clinical outcomes in 43 patients with SCD age 6–21 years. Results indicate that the web-based tool was successfully integrated into the clinical setting while maintaining high patient satisfaction (>90%). The tool provided data consistent with the medical record, staff report, and/or clinical lab data. Participants reported that forgetting and transportation were major barriers for adherence to both clinic attendance and HU. A greater number of self-reported barriers (P < .01) and older age (P < .05) were associated with poorer clinic attendance and HU adherence. In summary, the tool represents an innovative approach to integrate newer technology to assess adherence and clinical outcomes for pediatric patients with SCD.

Maternal Perspectives: Qualitative Responses about Perceived Barriers to Care among Children with Orofacial Clefts in North Carolina

Objective

To examine maternal perceptions of barriers to care of children with orofacial clefts (OFC) in a population-based survey that solicited open-ended qualitative responses.

Design and Setting

In 2006, a combination mail/phone survey was sent to all mothers of children with OFC. The questionnaire included 76 items. A final open-ended question was included for additional information about cleft-related care. The analysis included responses to the open-ended question and sociodemographic characteristics of the respondents. Qualitative responses were transcribed and entered into a qualitative software package for analysis, and common themes were elucidated.

Participants/Patients

The North Carolina Birth Defects Monitoring Program was used to identify all resident infants born with OFC from 2001 to 2004. Of 478 eligible mothers, 52.9% (n = 248) responded to the survey, and 39.5% (n = 98) responded to the final open-ended question.

Main Outcome Measures

Percentage reporting problems accessing care, frequency of positive and negative comments, and indicators of financial, personal, and structural barriers to care.

Results

Of the 98 respondents, the majority (n = 95, 96.99%) were the biological mother. Almost 40% of mothers indicated that accessing primary craniofacial care was a problem. Of those citing perceived barriers to care, the major issues cited were financial, structural, and personal barriers.

Conclusions

Collaborative efforts between craniofacial centers and teams, health care systems, and birth defects registries are warranted to reduce perceived barriers to care among families of children with OFC. Further exploration of the themes and factors associated with barriers to care and services is needed.

Perceived barriers to care and attitudes towards shared decision-making among low socioeconomic status parents: role of health literacy

OBJECTIVE

Although low parent health literacy (HL) has been linked to poor child health outcomes, it is not known whether differences in perceptions related to access to care and provider-parent partnership in care are potential contributing factors. We sought to assess whether parent HL is associated with differences in perceived barriers to care and attitudes regarding participatory decision-making with the provider.

METHODS

This was a cross-sectional analysis of data collected from parents presenting with their child to an urban public hospital pediatric clinic in New York City. Dependent variables were caregiver-reported barriers to care (ability to reach provider at night/on weekends, difficult travel to clinic) and attitudes towards participatory decision-making (feeling like a partner, relying on doctor's knowledge, leaving decisions up to the doctor, being given choices/asked opinion). The primary independent variable was caregiver HL (Short Test of Functional Health Literacy in Adults [S-TOHFLA]).

RESULTS

A total of 823 parents were assessed; 1 in 4 (27.0%) categorized as having low HL. Parents with low HL were more likely to report barriers to care than those with adequate HL: trouble reaching provider nights/weekends, 64.9% vs. 49.6%, (p < 0.001, adjusted odds ratio [AOR] 1.7, 95% confidence interval [95% CI] 1.2-2.4); difficult travel, 15.3% vs. 8.0%, (p = 0.004, AOR 1.8, 95% CI 1.1-3.0). Low HL was also associated with not feeling like a partner (28.8% vs. 17.1%; AOR 2.0; 95% CI 1.4-3.0), preference for relying on the doctor's knowledge (68.9% vs. 52.2%; AOR 1.7; 95% CI 1.2-2.4), and preference for leaving decisions up to the doctor (57.7% vs. 33.3%; AOR 2.2; 95% CI 1.6-3.1).

CONCLUSIONS

Addressing issues of parent HL may be helpful in ameliorating barriers to care and promoting provider-parent partnership in care.

The Breathmobile program: a good investment for underserved children with asthma

BACKGROUND

The Breathmobile, a specialty-based mobile asthma clinic, provides free care to underserved children. The cost of symptom-free day (SFD) improvement in this population has not been previously reported.

OBJECTIVE

To examine the clinical impact and cost-effectiveness of the Baltimore Breathmobile.

METHODS

Existing computerized data were analyzed for Breathmobile patient visits between 2002 and 2007. All SFDs were calculated, and direct medical cost savings attributable to decreased emergency department visits and hospitalizations (after program utilization vs the previous year) were compared with annual operating costs. Incremental cost-effectiveness ratios were determined by calculating the incremental costs of Breathmobile care per additional SFD gained per child per year.

RESULTS

The analysis included 255 patients enrolled in the program for at least 1 year. Most participants were black (93.3%), and 54.9% were male. At baseline, patients reported a mean (SD) of 199 (118) SFDs in the year before enrollment. After 1 year in the program, patients had a mean (SD) improvement of 44 (9) SFDs. The program resulted in overall cost savings of $79.43 per SFD gained, with greater cost savings for children aged 5 to 11 years (-$116.84 per SFD gained) and those with intermittent asthma (-$126.71 per SFD gained).

CONCLUSIONS

The Baltimore Breathmobile program has demonstrated significant improvement in SFDs, with direct medical cost savings of the program outweighing the operational costs. These data support the need to continue to sustain and expand Breathmobile programs for children at high risk for asthma exacerbations and to conduct a randomized clinical trial to estimate the cost-effectiveness of the Breathmobile.