Identifying and intervening on barriers to healthcare access among members of a small Korean community in the southern USA

The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review

BACKGROUND

Multimorbidity, the presence of more than one condition in a single individual, is a global health issue in primary care. Multimorbid patients tend to have a poor quality of life and suffer from a complicated care process. Clinical decision support systems (CDSSs) and telemedicine are the common information and communication technologies that have been used to reduce the complexity of patient management. However, each element of telemedicine and CDSSs is often examined separately and with great variability. Telemedicine has been used for simple patient education as well as more complex consultations and case management. For CDSSs, there is variability in data inputs, intended users, and outputs. Thus, there are several gaps in knowledge about how to integrate CDSSs into telemedicine and to what extent these integrated technological interventions can help improve patient outcomes for those with multimorbidity.

OBJECTIVE

Our aims were to (1) broadly review system designs for CDSSs that have been integrated into each function of telemedicine for multimorbid patients in primary care, (2) summarize the effectiveness of the interventions, and (3) identify gaps in the literature.

METHODS

An online search for literature was conducted up to November 2021 on PubMed, Embase, CINAHL, and Cochrane. Searching from the reference lists was done to find additional potential studies. The eligibility criterion was that the study focused on the use of CDSSs in telemedicine for patients with multimorbidity in primary care. The system design for the CDSS was extracted based on its software and hardware, source of input, input, tasks, output, and users. Each component was grouped by telemedicine functions: telemonitoring, teleconsultation, tele-case management, and tele-education.

RESULTS

Seven experimental studies were included in this review: 3 randomized controlled trials (RCTs) and 4 non-RCTs. The interventions were designed to manage patients with diabetes mellitus, hypertension, polypharmacy, and gestational diabetes mellitus. CDSSs can be used for various telemedicine functions: telemonitoring (eg, feedback), teleconsultation (eg, guideline suggestions, advisory material provisions, and responses to simple queries), tele-case management (eg, sharing information across facilities and teams), and tele-education (eg, patient self-management). However, the structure of CDSSs, such as data input, tasks, output, and intended users or decision-makers, varied. With limited studies examining varying clinical outcomes, there was inconsistent evidence of the clinical effectiveness of the interventions.

CONCLUSIONS

Telemedicine and CDSSs have a role in supporting patients with multimorbidity. CDSSs can likely be integrated into telehealth services to improve the quality and accessibility of care. However, issues surrounding such interventions need to be further explored. These issues include expanding the spectrum of medical conditions examined; examining tasks of CDSSs, particularly for screening and diagnosis of multiple conditions; and exploring the role of the patient as the direct user of the CDSS.

Knowledge of legal rights as a factor of refugee and asylum seekers' health status: a qualitative study

OBJECTIVES

To examine health behaviours of refugees and asylum seekers, in relation to their knowledge of public benefits and legal rights.

DESIGN

Qualitative study, utilising an open-ended, semi-structured interview guide to ensure information-rich data collection. Thematic content was analysed using qualitative research software.

SETTING

Participants were drawn from the Weill Cornell Center for Human Rights (WCCHR) in New York City, a single-center, human rights clinic with a globally representative patient population. All interviews were conducted at the Weill Cornell Medicine Clinical and Translational Science Center, a multidisciplinary space within an urban academic medical center.

PARTICIPANTS

Twenty-four refugees and asylum seekers currently living in the greater New York City area. Eligible participants were 18 years of age or older and had previously sought services from the WCCHR. The recruitment rate was 55%.

PRIMARY AND SECONDARY OUTCOME MEASURES

Themes and concepts in participants' health, knowledge, perceptions of and experiences with accessing healthcare and public benefits programmes.

RESULTS

Twenty-four participants represented 18 countries of origin and 11 primary languages. Several impediments to accessing healthcare and public benefits were identified, including pragmatic barriers (such as prohibitive costs or lack of insurance), knowledge gaps and mistrust of healthcare systems.

CONCLUSIONS

There is low health engagement by refugees and asylum seekers, as a result of multiple, complex factors impeding the ability of refugee and asylum seekers to access healthcare and other public benefits for which they are eligible-with resultant detrimental health effects. However, there is an opportunity to utilise novel approaches, such as digital technologies, to communicate relevant information regarding legal rights and public benefits to advance the health of vulnerable individuals such as refugees and asylum seekers.

Evaluation of Access to Care Barriers and Their Effect on General Health Status Among Native Hawaiian and Pacific Islander Adults

There is a paucity of information on access to care barriers faced by Native Hawaiian and Pacific Islander (NHPI) community. This study utilized the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey (NHPI NHIS) data to evaluate access to care barriers among NHPI population and their effect on general health status. Access to care barriers were categorized as financial barrier (affordability) and non-financial barriers (availability, accommodation, acceptability, and accessibility). Overall, 13.7% reported of the fair/poor general health and over 30% reported at least one access to care barrier. Logistic regression model was used to evaluate how financial and non-financial barriers affect general health status, adjusting for socio-demographic variables such as age, poverty threshold, and marital status and health-related variables such as smoking status and chronic health conditions. Those who reported financial barrier (21.2%) were more likely to be in fair/poor general health (odds ratio 2.25, 95% confidence interval 1.43-3.56). Non-financial barrier, reported by 20.0% of the study population, was found to be not associated with general health status after adjusting for socio-demographic and health-related variables. Improving access to care among NHPI community could be achieved by identifying and addressing the barriers, which in turn could lead to improvement in the general health status among NHPI community.

Finding Dr. Kim: Information Sources of Korean Immigrants' Search for a Doctor in the U.S

Korean immigrants in the United States (U.S.) are known for their preference for, and dependence on, co-ethnic doctors due to various barriers to the U.S. healthcare system. Recent immigrants tend to face more barriers than their non-recent counterparts. However, there is little information on how they find their doctors in the U.S. This study includes a self-administrated survey of Korean immigrants aged 18 and above who lived in the New York-New Jersey Metropolitan area in 2013-2014 (n = 440). Descriptive analysis was conducted to understand the most common information sources and the number of sources based on the duration of stay in the U.S. More recent Korean immigrants were female, had no family doctor, uninsured, younger, and more educated than their non-recent counterparts. Regardless of the duration of stay in the U.S., family members and friends were the most frequently sought-after sources for Korean immigrants in their search for doctors. In addition to family members and friends, non-recent Korean immigrants also used other methods (e.g., Korean business directories), whereas recent immigrants used both U.S. and Korean websites. More recent Korean immigrants used multiple sources compared to non-recent Korean immigrants, often combined with a Korean website. Our study suggests policy implications to improve recent immigrants' accessibility to health information in a timely manner.

"Worrying About Getting Sick in the Future": Lived Experience of Health Seeking and Healthcare Utilization Among Korean Immigrant Nail Salon Workers

To understand the health and safety concerns of Korean immigrant women nail salon workers in the Greater New York City area and their experiences of health seeking and health service utilization, 20 semi-structured interviews were conducted and analyzed using interpretive hermeneutic phenomenology. Most worried about working in nail salons and experienced work-related health symptoms. However, they were disinclined toward personal protective device use because of discomfort and inconvenience. Major barriers to healthcare utilization limited their healthcare use to times when they had intolerable symptoms, preventing opportunities for regular screening tests. To overcome these limitations, workers actively sought available resources and health-related information online and through personal networks, the latter facilitated by living in a Korean community. Despite efforts to maintain their health and manage their symptoms, Korean nail salon workers worried about getting sick as they got older due to prolonged occupational chemical exposure and limited healthcare access. Appropriate education and intervention should aim to resolve current barriers to personal protective device use and healthcare use and provide a source of care for uninsured workers.

Factors Influencing Health Service Utilization Among Asian Immigrant Nail Salon Workers in the Greater New York City Area

Most nail salon workers in the greater New York City area are Asian immigrant women. They are exposed daily to potentially toxic chemicals and hazards in their workplace, making them more vulnerable for possible health problems. The study's primary purpose was to identify factors influencing past year healthcare utilization among Asian immigrant women working in nail salons. A cross-sectional study was conducted based on a modification of Andersen's behavioral model of healthcare utilization in which 148 Korean and Chinese immigrant women currently working in nail salons were surveyed. The questionnaire included: (1) individual health determinants, (2) health service utilization in the past year, and (3) work environment, work-related health concerns, and work-related health problems. Descriptive statistics and multivariate logistic regression models assessed factors related to past year healthcare utilization. Women who had health insurance (p < .01), a usual source of care (p < .01), low educational attainment (p < .05), and more work-related health symptoms (p < .05) were more likely to visit a primary care provider. Women who had health insurance (p < .01), a usual source of care (p < .05), and low educational attainment (p < .05), were also more likely to visit a woman's health provider. Korean (rather than Chinese) women (p < .05) and women who perceived themselves to be in fair/poor health (p < .05) were more likely to see a traditional provider of Eastern medicine. Asian immigrant women who work in nail salons have workplace health and safety concerns. They generally use Western rather than traditional medicine, with different factors related to these two types of medicine.

Preliminary Impact of the weCare Social Media Intervention to Support Health for Young Men Who Have Sex with Men and Transgender Women with HIV

Young racial/ethnic minority men who have sex with men (MSM) and transgender women with HIV often have poor health outcomes. They also utilize a wide array of social media. Accordingly, we developed and implemented weCare, a social media intervention utilizing Facebook, texting, and GPS-based mobile social and sexual networking applications to improve HIV-related care engagement and health outcomes. We compared viral load suppression and clinic appointment attendance among 91 participants during the 12-month period before and after weCare implementation. McNemar's chi-square test analyses were conducted comparing the pre- and postintervention difference using paired data. Since February 2016, intervention staff and 91 intervention participants (79.1% African American and 13.2% Latino, mean age = 25) exchanged 13,830 messages during 3,758 conversations (average: 41.3 conversations per participant) across a variety of topics, including appointment reminders, medication adherence, problem solving, and reducing barriers. There were significant reductions in missed HIV care appointments (68.0% vs. 53.3%, p = 0.04) and increases in viral load suppression (61.3% vs. 88.8%, p < 0.0001) 12 months postimplementation. Our results highlight the initial success of weCare in improving care engagement and viral suppression. Social media is an important tool, especially for young MSM and transgender women, to support individual- (e.g., viral suppression) and community- (e.g., reduced transmission efficiency) level health. It may also be a useful tool for improving engagement with biomedical HIV prevention tools (e.g., PrEP use).

Access to health care for uninsured Latina immigrants in South Carolina

Background

South Carolina is considered a “new destination” state for Latino immigrants. Language barriers, transportation difficulties, low socioeconomic status, inflexible work schedules, different cultural norms, and anxiety and fear related to the current anti-immigrant political climate all negatively impact Latino immigrants’ frequency of contact with the health care system, and consequently they suffer poor health outcomes. The study objective was to explore uninsured Latina immigrant women’s access to health care and alternative treatment strategies in coastal South Carolina.

Methods

The study design was a qualitative interview design. Thirty women participated in semi-structured interviews in community sites. Thematic analysis identified salient categories of topics across interview participants.

Results

The themes were organized into four primary categories including: 1) Barriers and Facilitators to Healthcare, 2) Health Behaviors and Coping Mechanisms, 3) Disease Management Strategies, and 4) Cultural Factors. Participants demonstrated determination for accessing care but reported that their primary health care access barriers included the high cost of services, lack of health insurance, family and work responsibilities, and language barriers. Coping mechanisms included activating their social networks, visiting family and friends and assisting one another with navigating life challenges.

Conclusion

Participants overcame obstacles to obtain healthcare for themselves and their family members despite the multiple barriers presented. Social networks were leveraged to protect against some of the negative effects of financial barriers to health care access.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3138-2) contains supplementary material, which is available to authorized users.

A qualitative study into the perceived barriers of accessing healthcare among a vulnerable population involved with a community centre in Romania

Background

Minority vulnerable communities, such as the European Roma, often face numerous barriers to accessing healthcare services, resulting in negative health outcomes. Both these barriers and outcomes have been reported extensively in the literature. However, reports on barriers faced by European non-Roma native communities are limited. The “Health Care Access Barriers” (HCAB) model identifies pertinent financial, structural and cognitive barriers that can be measured and potentially modified. The present study thus aims to explore the barriers to accessing healthcare for a vulnerable population of mixed ethnicity from a charity community centre in Romania, as perceived by the centre’s family users and staff members, and assess whether these reflect the barriers identified from the HCAB model.

Methods

Eleven community members whose children attend the centre and seven staff members working at the centre participated in face-to-face semi-structured interviews, exploring personal experiences and views on accessing healthcare. The interviews were transcribed and analysed using an initial deductive and secondary inductive approach to identify HCAB themes and other emerging themes and subthemes.

Results

Identified themes from both groups aligned with HCAB’s themes of financial, structural and cognitive barriers and emergent subthemes important to the specific population were identified. Specifically, financial barriers related mostly to health insurance and bribery issues, structural barriers related mostly to service availability and accessibility, and cognitive barriers related mostly to healthcare professionals’ attitudes and discrimination and the vulnerable population’s lack of education and health literacy. A unique theme of psychological barriers emerged from both groups with associated subthemes of mistrust, hopelessness, fear and anxiety of this vulnerable population.

Conclusion

The current study highlights healthcare access barriers to a vulnerable non-Roma native population involved with a charity community centre in Romania. The “Healthcare Access Barriers for Vulnerable Populations” (HABVP) model is proposed as an adaption to the existing HCAB model to account for the unique perceived barriers to healthcare for this population. Recommendations for future resolution of these identified barriers are proposed.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0753-9) contains supplementary material, which is available to authorized users.

Determinants of Transgender Individuals' Well-Being, Mental Health, and Suicidality in a Rural State

This project utilized a Community-Based Participatory Research (CBPR) approach to conduct qualitative interviews with 30 transgender adults living in a rural state. Participants' identities spanned from trans women and men to non-binary and Two-Spirit. The aim of this study was to better understand the experiences, needs, and priorities of the participants as well as to examine possible determinants of mental health, well-being, and suicidality for transgender individuals in Montana. These factors were investigated at individual, interpersonal, community, and societal levels using an ecological framework. Qualitative results indicate that participants experienced discrimination at all levels. Participants noted that discrimination contributed to mental health challenges and limited access to adequate general and transgender-specific healthcare services, both of which impacted overall well-being. This is reflected most notably in the elevated rate of past suicidal ideation attempts among the sample. Participants reported that the ability to transition, as well as other protective factors, played a role in reducing suicidality and improving mental and physical health. Our findings highlight the need to address transgender mental health through implementing changes at multiple ecological levels.

Breast Cancer Screening Among Korean Americans: A Systematic Review

Cancer is the leading cause of death for Korean Americans (KAs). Breast cancer (BC) is the most commonly occurring cancer among KA women, and its rate has been rapidly increasing. Low BC screening rates for KAs puts them at greater risk for late-stage breast cancer. We conducted a systematic review of the published literature on cancer screening among KAs, and identified 38 eligible studies. Despite significant increases in mammogram utilization over the past two decades, KAs have consistently lower rates of mammogram screening than other American populations. KA women also report lower rates of clinical breast examination and breast self-examination. Screening rates are higher among adults with higher socioeconomic status, greater acculturation to the United States, more cancer knowledge, higher perceived susceptibility to BC, more social support, and better access to health services. However, fear of finding something wrong, fear of embarrassment or lack of modesty, not knowing where to go for screening, believing that mammography is only necessary when symptoms are present, and perceived time and cost difficulties in accessing mammography were reported as barriers to mammogram screening. Coordinated efforts from clinicians, public health workers, KA cultural and religious organizations, and the broader breast cancer advocacy and awareness community are necessary for improving BC screening among KAs.

Promoting Community and Population Health in Public Health and Medicine: A Stepwise Guide to Initiating and Conducting Community-engaged Research

Various methods, approaches, and strategies designed to understand and reduce health disparities, increase health equity, and promote community and population health have emerged within public health and medicine. One such approach is community-engaged research. While the literature describing the theory, principles, and rationale underlying community engagement is broad, few models or frameworks exist to guide its implementation. We abstracted, analyzed, and interpreted data from existing project documentation including proposal documents, project-specific logic models, research team and partnership meeting notes, and other materials from 24 funded community-engaged research projects conducted over the past 17 years. We developed a 15-step process designed to guide the community-engaged research process. The process includes steps such as: networking and partnership establishment and expansion; building and maintaining trust; identifying health priorities; conducting background research, prioritizing "what to take on"; building consensus, identifying research goals, and developing research questions; developing a conceptual model; formulating a study design; developing an analysis plan; implementing the study; collecting and analyzing data; reviewing and interpreting results; and disseminating and translating findings broadly through multiple channels. Here, we outline and describe each of these steps.

Engaged for Change: A Community-Engaged Process for Developing Interventions to Reduce Health Disparities

The science underlying the development of individual, community, system, and policy interventions designed to reduce health disparities has lagged behind other innovations. Few models, theoretical frameworks, or processes exist to guide intervention development. Our community-engaged research partnership has been developing, implementing, and evaluating efficacious interventions to reduce HIV disparities for over 15 years. Based on our intervention research experiences, we propose a novel 13-step process designed to demystify and guide intervention development. Our intervention development process includes steps such as establishing an intervention team to manage the details of intervention development; assessing community needs, priorities, and assets; generating intervention priorities; evaluating and incorporating theory; developing a conceptual or logic model; crafting activities; honing materials; administering a pilot, noting its process, and gathering feedback from all those involved; and editing the intervention based on what was learned. Here, we outline and describe each of these 13 steps.

Using the socioecological model to explore factors affecting health-seeking behaviours of older Korean immigrants

AIMS AND OBJECTIVES

The purpose of this study was to explore multilevel factors affecting older Korean immigrants' health-seeking behaviours.

BACKGROUND

Although studies have documented significant issues related to healthcare access and utilisation issues among older immigrants, a noted limitation of current research is its failure to explore multiple factors related to their health-seeking behaviours.

DESIGN

A qualitative study using interview data from two previous studies.

METHODS

We performed a qualitative analysis of focus groups and individual interviews using inductive coding methods. The socioecological model provided a useful framework to guide this study. The sample included 17 community-dwelling older Korean immigrants aged ≥65 years living in the metropolitan area of Seattle, WA, USA.

RESULTS

Findings revealed various factors at the individual (e.g., perception of health and illness, mistrust, cultural values and norms, length of residency in the United States, language barriers and ageing experiences), interpersonal (e.g., peers, family and primary care physicians), community (e.g., ethnic community centres and organisations, home care helpers and interpretation services) and policy (e.g., lack of affordability and health benefits coverage) levels. Each of these factors played a role as either a barrier to or facilitator of older Korean immigrants' health-seeking behaviours. Several factors, such as language barriers and lack of available information, were intertwined.

CONCLUSIONS

Findings indicate the importance of considering four major areas when designing culturally appropriate, community-based interventions for older immigrants. Also, utilising peers or trusted human resources in the community is critical to the design and implementation of health promotion interventions for older immigrants.

IMPLICATIONS FOR PRACTICE

Examining intrapersonal, interpersonal, community, and policy level factors that affect older immigrants' health-seeking behaviours informs the design of community-based health promotion interventions for older immigrants.

Health Care Access, Utilization, and Management in Adult Chinese, Koreans, and Vietnamese with Cardiovascular Disease and Hypertension

BACKGROUND

Asians are often pooled together when evaluating disparities in health care indicators (access, utilization, and management), though substantial variation may exist across different Asian ethnicities.

OBJECTIVE

The aim of this study was to compare health care indicators among Chinese, Korean, Vietnamese, and non-Hispanic white (NHW) adults with cardiovascular disease and hypertension (CVD/HTN).

METHODS

We analyzed health care indicators using multivariable logistic regression in a sample of Asians and NHWs with CVD/HTN from the 2011-2012 California Health Interview Survey (CHIS).

RESULTS

Koreans had the lowest utilization of emergency room (ER) or inpatient hospital services; Vietnamese had the lowest access to a personal doctor; Chinese had the lowest adjusted odds of having seen a doctor in the prior 12 months; and all Asians received fewer written heart disease care plans compared to NHWs. Even when utilization of ER for heart disease appeared to be similar, lack of access to a doctor was a more common reason noted by Asians versus NHWs. However, a lower proportion of Asians reported delays in receiving prescription or care. Accounting for differences across groups did not diminish these disparities.

CONCLUSION

Health care indicators varied by race and across Asian ethnicities even after controlling for sociodemographic factors, insurance coverage, and health status. Future studies should consider oversampling other Asian ethnicities and assessing more in depth the potential impact of ethnicity-related factors on disparities in health care indicators.