Use of preventive care by the working poor in the United States

The Association of Persistent Poverty and Outcomes Among Patients Undergoing Cardiac Surgery

INTRODUCTION

We sought to evaluate the association of county-level poverty duration and cardiac surgical outcomes.

METHODS

Patients who underwent coronary artery bypass graft, surgical aortic valve replacement, and mitral valve repair and replacement between 2016 and 2020 were identified using the Medicare Standard Analytical Files Database. County-level poverty data were acquired from the American Community Survey and US Department of Agriculture (1980-2015). High poverty was defined as ≥19.5% of residents in poverty. Patients were stratified into never-high poverty (NHP), intermittent low poverty, intermittent high poverty, and persistent poverty (PP). A mixed-effect hierarchical generalized linear model and Cox regression models that adjusted for patient-level covariates were used to evaluate outcomes.

RESULTS

Among 237,230 patients, 190,659 lived in NHP counties, while 10,273 resided in PP counties. Compared with NHP patients, PP patients were more likely to present at a younger median age (NHP: 75 y versus PP: 74 y), be non-Hispanic Black (5388, 2.9% versus PP: 1030, 10.1%), and live in the south (NHP: 66,012, 34.6% versus PP: 87,815, 76.1%) (all P < 0.001). PP patients also had more nonelective surgical operations (NHP: 58,490, 30.8% versus 3645, 35.6%, P < 0.001). Notably, PP patients had increased odds of 30-d mortality (odds ratio 1.13, 95% confidence interval [CI] 1.02-1.26), 90-d mortality (odds ratio 1.14, 95% CI 1.05-1.24), and risk of long-term mortality (hazard ratio 1.13, 95% CI 1.09-1.19) compared with patients in NHP counties (all P < 0.05).

CONCLUSIONS

County-level poverty was associated with a greater risk of short- and long-term mortality among cardiac surgical patients.

Corporate influenced state preemption and health: A legal mapping analysis of workers' rights preemption bills in the US south

Work is a structural determinant of health. As local governments have taken the lead on implementing workers' rights policies, state governments have increasingly been using preemption to block local them. These policies would improve work and employment conditions, particularly for Black, Brown, immigrant, and low-wage workers. Thus, preemption of workers' right policies is an important health equity issue. Legal epidemiology methods were used to analyze and quantify worker's rights preemption bills introduced in southern state legislatures between 2009 and 2019. Between 2009 and 2019, over 100 workers' rights preemption bills were introduced in southern state legislatures, and there was significant variation between states. Preemption of local paid leave and minimum wage ordinances were the most common. Textual analysis of the bills revealed that states prioritize the perspectives of employers instead of workers. State labor policies are prioritizing the perspectives of businesses over workers resulting in a labor environment that creates structural advantages for employers and is hostile to the well-being of workers. Preemption is part of the political and social context that is shaping the association between work and health in and is likely re (creating) racial and economic inequities.

Income Inequality, Race/Ethnicity, and Obesity in U.S. Men 20 Years and Older: 1999 to 2016

Obesity is a significant public health problem globally and within the United States. It varies by multiple factors, including but not limited to income. The literature indicates little evidence of the association between income and obesity. We examined the association between income and obesity in U.S. adult men ages 20 years and older and tested racial and ethnic differences. We used data from the 1999 to 2016 National Health and Nutrition Examination Surveys for analyses. Obesity was determined using body mass index ≥30 kg/m². We used poverty income ratio (PIR) as a proxy for income and calculated the Gini coefficient (GC) to measure income inequality. We then categorized low-, medium-, and high PIR to examine the relationship between income inequality and obesity. We used Modified Poisson regression in a sample of 17,238 adult men, including 9,511 White Non-Hispanic White (NHW), 4,166 Non-Hispanic Black (NHB), and 3,561 Mexican Americans (MA). We controlled the models for age category, racial and ethnic groups, marital status, education, health behaviors, health insurance coverage, self-reported health, comorbidity, and household structure. Results of our adjusted models suggested a positive and significant association between PIR and obesity among NHWs and NHBs in medium and high PIR; this association was not significant in MAs. Results of our analyses using GC in obese men indicate that compared with NHWs (GC: 0.306, SE: 0.004), MAs (GC: 0.368, SE: 0.005), and NHBs (GC: 0.328, SE: 0.005) had experienced higher-income inequality. In treating obesity, policymakers should consider race/ethnicity strategies to reduce inequality in income.

Equity in the usage of biologics for psoriasis in the working poor

Biologic therapy often produces excellent outcomes for psoriasis; however, their high cost may create a barrier to appropriate usage, especially in the working poor population. This study defines working poor as income below 150% of the federal poverty level and holding or seeking work at least half a year. Our study aims to identify gaps in access to biologic therapy for psoriasis based on working poor status. This retrospective cross-sectional study was conducted utilizing data from the Medical Expenditure Panel Survey (MEPS) from 2007 to 2018. Patients were stratified into working poor (57,091), non-working poor (43,421), and non-poor (693,841) groups for analysis. In univariate analysis, WP (4.0%, ph p = 0.003) and NWP (2.8%, ph p = 0.006) were less likely to use biologics than NP (15.8%) (X² p < 0.001). A binary logistic regression showed that WP vs. NP status (OR 0.27, p = 0.05), female vs. male sex (OR 0.55, p = 0.05), Black vs. White race (OR 0.14, p = 0.02), and Medicare vs. private insurance (OR 0.09, p = 0.03) had lower odds of using biologics. After correcting for age, sex, race, and insurance, WP confers an independent risk factor to lower biologic prescriptions. The high cost of biologics in the setting of financial barriers for some patients should be considered by physicians prescribing biologic therapy for psoriasis.

The Impact of Dependency Burden on Urban Household Health Expenditure and Its Regional Heterogeneity in China: Based on Quantile Regression Method

Background

The aging population has led to a growing health expenditure burden. According to the National Bureau of Statistics of China, the old-age dependency ratio rose from 10.7% in 2003 to 17.8% in 2019, and health expenditure increased from 658.410 billion yuan in 2003 to 5812.191 billion yuan in 2019 in China.

Methods

This paper utilizes the quantile regression method to discuss the influencing factors of health expenditure in urban China based on the China Household Finance Survey (CHFS), especially dependency burden. Moreover, its regional heterogeneity is also compared.

Results

The old-age dependency ratio, age, family size, self-rated health status, and income significantly impact the health expenditure of urban families in the quantile regression of the national sample. Dependency burden and other variables on urban household health expenditure have great regional heterogeneity. The relationship between urban health expenditure and residential areas in western China is more stable than that in eastern and central China.

Discussion

Government should improve the healthcare system suitable for the older adult population as soon as possible. The government of western China should pay more attention to the introduction of professional medical talents and the configuration of precision medical equipment to improve the health system in western China.

Empirical Analysis of Health Assessment Objective and Subjective Methods on the Determinants of Health

Background

There are several methods for assessing health status. The aims of this study were to investigate the empirical differences between health assessment objective and subjective methods, to identify a possible long-term relationship between methods and health determinants and the influence of these methods on the perceived level of risk according to health determinants.

Methods

Using data from 1970 to 2018 in the United States, health status was assessed by perception of health, absence from work due to self-reported illness, life expectancy at birth and mortality rate. Health determinants were tobacco and alcohol consumptions, number of physicians per 1,000 persons, stay in hospitalization unit, curative care, release of greenhouse gases, per capita gross domestic product (GDP) and urbanization. The differences between health objective and subjective assessment methods were investigated through a Generalized linear model, a structural break date of health methods was investigated by Chow test and the long-term relationship between health assessment methods and health determinants by Engle and Granger cointegration test.

Results

Tobacco consumption was associated with a decrease of life expectancy while no long-term causal relationship was found between them. There was a positive correlation between alcohol consumption and perception of good health with a long-term causal relationship. Although per capita GDP positively influenced life expectancy, there was no cointegration between them. The release of greenhouse gases was positively correlated with both the absence from work due to self-reported illness and the perception of good health. Finally, curative care was associated with a decrease of mortality and absence from work due to self-reported illness and an increase of life expectancy and perception of good health while hospitalization is positively correlated with mortality and negatively correlated with life expectancy with a long-term causal relationship. Finally, the number of physicians per 1,000 persons was not correlated with health assessment methods used.

Conclusion

Our results highlight the influence of health assessment methods on the determinants of health and the fact that the perceived risk of health determinants changes according to the method used. Thus, the impact of health assessment methods must be considered in order to prioritize the determinants of health.

Association Between Body Mass Index and Cancer Screening Adherence Among Latinas in the United States and Puerto Rico

Background

Research on the role of body size on cancer screening is mixed with few studies among Latinas in the United States. We evaluated the association between body size and cancer screening adherence among Latinas living in Puerto Rico and the rest of the United States.

Methods

We conducted a cross-sectional study using 2012-2018 Behavioral Risk Factor Surveillance System data among Latinas 50-64 years of age (n = 16,410). Breast, cervical, and colorectal cancer screening (guideline adherent: yes/no), height and weight were self-reported. Prevalence ratios (PRs) derived from Poisson models were estimated for each cancer screening utilization for Puerto Rico versus rest of the United States by body mass index (BMI) category.

Results

Nearly a quarter of women lacked adherence with breast and cervical cancer screening and 43.6% were nonadherent to colorectal cancer screening. Latinas with BMI ≥40.0 kg/m² in both groups were more likely to lack adherence to cervical cancer screening than women with BMI 18.5-24.9 kg/m². For those with BMI ≥40.0 kg/m², Latinas in Puerto Rico were more likely to lack adherence to colorectal cancer screening recommendations than Latinas living in the rest of the United States (adjusted PR: 1.38; 95% confidence interval = 1.12-1.70).

Conclusions

The role of body size in cancer screening utilization among Latinas differs in women living in Puerto Rico versus in the rest of the United States and varies by cancer type. Understanding Latinas' experience can inform culturally adapted interventions to promote cancer screening.

Relation of the Dietary Approaches to Stop Hypertension Dietary Pattern to Heart Failure Risk and Socioeconomic Status (from the Southern Community Cohort Study)

The Dietary Approaches to Stop Hypertension (DASH) dietary pattern has been associated with a lower risk of incident heart failure (HF); however, previous studies were conducted in mostly middle-income White populations. The association between DASH and incident HF risk in lower income and Black individuals is less well understood. We analyzed 25,300 White and Black adults without a history of HF at enrollment (2002 to 2009) in the Southern Community Cohort Study receiving Centers for Medicare and Medicaid Services. Alignment with DASH was assessed at enrollment using a validated food frequency questionnaire. Incident HF was ascertained from Centers for Medicare and Medicaid Services claims through 2016. The association between DASH diet alignment and incident HF was examined in multivariable-adjusted Cox proportional hazards regression models, including an interaction term testing effect modification by income. The cohort was predominantly middle-aged (median 54 years), Black (68%), female (63%), and low-income (88% <$25,000/year/household). Socioeconomic factors, including education and annual income, were larger contributors to the variance in DASH score than were cardiovascular co-morbidities. The association between DASH dietary alignment and HF risk was not significant overall (hazard ratio [HR] 1.00; 95% confidence interval [CI] 0.96 to 1.04) or in race-sex groups. However, the association between alignment with the DASH diet and HF risk significantly varied by income (interaction p = 0.030), with neutral and inverse associations in lower (<$25,000/year) and higher ($≥25,000) income participants, respectively. In conclusion, income modified the association between healthier dietary patterns and risk of incident HF. In lower income participants, greater alignment with the DASH diet was not associated with lower HF risk.

Demographic and socioeconomic correlates of suicide deaths and nonfatal self-injury related hospital visits: An analysis of counties in New York State

For many years, suicide rates in U.S. general and veteran populations have steadily increased, stimulating research into suicide and nonfatal self-injury (NFSI). However, little research has examined community correlates of suicide and NFSI. This study used county data from New York State to identify community correlates of veteran and general population suicide deaths and general population NFSI-related hospitalization. In bivariate analyses, both suicide and NFSI-related hospitalization were associated with measures of social disintegration (i.e., smaller population size, larger male and/or White population) and socioeconomic disadvantage (i.e., higher disability rates disability, lower household incomes, more limited-English speaking households). In regression analyses, general-population suicide was independently associated with higher disability and veteran-suicide rates, whereas NFSI-related hospitalization was independently associated with lower household income. Findings attest the importance of low-cost, accessible, outpatient services and highlight social disintegration and socioeconomic disadvantage as salient, community risk factors for suicide and NFSI.

Measuring the effectiveness of a car seat program in an urban, level one pediatric trauma center

Background

Motor vehicle collisions (MVCs) are a significant safety issue in the United States. Young children are disproportionally impacted by car accidents and suffer high rates of injuries and mortality. When used properly, car seats have been found to reduce the severity of injuries. However, individuals from low-income areas often do not have access to education or car seats compared to those in suburban or higher income areas. Therefore, the goal of the present study was to measure the effectiveness of a car seat program in an urban, Level I Pediatric Trauma Center on caregiver car seat knowledge.

Methods

Caregivers (N = 200) attended a single, one-hour car seat educational program with a Child Passenger Safety Technician (CPST). The sessions included educational and hands-on components, where caregivers were asked to complete a seven-item pre-post knowledge assessment. For completion of the course, caregivers received a car seat for their child.

Results

A paired t-test revealed that the workshop significantly increased caregiver knowledge from pre-post: t (199) = − 12.56, p < .001; d = 1.27. McNemar’s Chi-Square analyses displayed that caregivers increased in all knowledge categories (p < .001).

Conclusions

While caregivers in urban areas or in low-income areas may have less access to resources, hospital-led car seat courses can increase knowledge of proper car seat usage in these communities. These findings should be used to establish programs in hospitals in areas where these resources are not readily available to caregivers.

Ambulatory care, insurance, and avoidable emergency department utilization in North Carolina

OBJECTIVE

To examine whether and how avoidable emergency department (ED) utilization is associated with ambulatory or primary care (APC) utilization, insurance, and interaction effects.

DESIGN AND SAMPLE

A cross-sectional analysis of electronic health records from 70,870 adults residing in Mecklenburg County, North Carolina, who visited an ED within a large integrated healthcare system in 2017.

METHODS

APC utilization was measured as total visits, categorized as: 0, 1, and > 1. Insurance was defined as the method of payment for the ED visit as: Medicaid, Medicare, private, or uninsured. Avoidable ED utilization was quantified as a score (aED), calculated as the sum of New York University Algorithm probabilities multiplied by 100. Quantile regression models were used to predict the 25th, 50th, 75th, 95th, and 99th percentiles of avoidable ED scores with APC visits and insurance as predictors (Model 1) and with an interaction term (Model 2).

RESULTS

Having >1 APC visit was negatively associated with aED at the lower percentiles and positively associated at higher percentiles. A higher aED was associated with having Medicaid insurance and a lower aED was associated with having private insurance, compared to being uninsured. In stratified models, having >1 APC visit was negatively associated with aED at the 25th percentile for the uninsured and privately insured, but positively associated with aED at higher percentiles among the uninsured, Medicaid-insured, and privately insured.

CONCLUSIONS

The association between APC utilization and avoidable ED utilization varied based on segments of the distribution of ED score and differed significantly by insurance type.

Colorectal cancer screening among Hispanics in the United States: Disparities, modalities, predictors, and regional variation

Hispanics represent the largest and one of the fastest growing minority populations in the U.S. and have lower survival from colorectal cancer (CRC) than non-Hispanic Whites (NHW). We aimed to examine screening modalities, predictors, and regional disparities among Hispanics and NHW in the U.S. by conducting a cross-sectional analysis of Hispanic participants age 50 to 75 from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey. The primary outcome was self-reported CRC screening status. We used the Rao-Scott Chi-square test to compare screening rates and modalities in NHWs and Hispanics. We also used univariable and multivariable logistic regression to determine predictors of screening among Hispanics and calculated Hispanic-NHW screening rate differences for each U.S. state/territory as a measure of regional screening disparities. The screening rate was 53.4% for Hispanics (N = 12,395), compared to 70.4% for NHWs (N = 186,331) (p < 0.001). Among Hispanics, colonoscopy was most common (75.9%). Uninsured status (aOR = 0.51; 95% CI = 0.38-0.70) and limited access to medical care (aOR = 0.38; 95% CI = 0.29-0.49) predicted lack of screening. States/territories with the largest screening disparities were North Carolina (33.9%), Texas (28.3%), California (25.1%), and Nebraska (25.6%). Disparities were smallest in New York (2.6%), Indiana (3.1%), and Delaware (4.0%). In Ohio and Guam, Hispanics had higher screening rates than NHWs. In conclusion, Hispanics have lower CRC screening rates than NHWs across most U.S. states/territories; however, the disparity varies by region. Future efforts must address multi-level barriers to screening among Hispanics and target regions with low rates to improve CRC outcomes in this growing population.

Employee wellness on the frontline: an interactional psychology perspective

Purpose

Employee wellness is vital to creating high-quality employee–customer interactions, yet frontline service workers (FLSWs) do not typically engage in, or benefit from, wellness initiatives. This paper aims to conceptually model the interactive influences of organizational and employee factors in influencing FLSW involvement in wellness programs and provides suggestions on how service organizations can enhance wellness behaviors and outcomes.

Design/methodology/approach

This paper builds upon classical and contemporary management theories to identify important gaps in knowledge about how employees and firms engage with wellness. Interactive psychology, emphasizing multidirectional interaction between person (employee) and situation (organization) wellness orientation, is introduced.

Findings

The paper develops a model that can be used to assess organizational wellness program effectiveness by emphasizing the interaction of employee and organizational wellness orientation. The model illustrates that wellness effectiveness relies equally on employee agency through an active wellness orientation matched with the organizational wellness orientation.

Originality/value

This paper questions the dominant approaches to assessing the effectiveness of workplace wellness initiatives, arguing for a more humanistic and agentic perspective rather than traditional organizationally centered fiscal measures.

Effects of the Training About Prostate Cancer and Screening Methods on Knowledge Level

This quasi-experimental study aims to identify the effects of the training about prostate cancer and screening methods given to men aged 40 and over on their knowledge level. It was found that there were no differences between the experimental and control groups in terms of the perceived susceptibility, perceived seriousness, health motivation, perceived barriers, and perceived benefits subscale mean scores, but the posttest data revealed that the perceived susceptibility, health motivation, and perceived benefits subscale mean scores of the experimental group were higher and their perceived barriers mean score was lower; the differences between the mean scores were statistically significant (p < .05, p < .01, p < .001). An analysis of the Health Belief Model after the training about prostate cancer and screening methods showed that the training was effective. Actually, the authors recommended that especially male nurses can play an effective role in training about prostate cancer and screening methods for men in Turkey.

Professionals' Perceptions: "Why is Lead Poisoning Prevalent in Lancaster County?"

Background: The prevalence of lead poisoning in children under the age of six years living in Lancaster County, Pennsylvania continues to be greater than the state-wide prevalence for this age group. This study aims to determine the factors that contribute to the high lead poisoning rates. Methods: For this qualitative study, the researchers recruited a convenience sample of professionals providing healthcare and social welfare services in the county. Researchers conducted in-depth interviews with participants. The research team audio recorded, transcribed verbatim, and analyzed each interview using NVivo 12 software. Results: The 16 interviewed participants identified factors that contribute to high lead poisoning rates including knowledge levels, housing status, and competing interests. Specifically, low knowledge levels, renting as opposed to home ownership, and having competing interests seemed to minimize the attention directed towards preventing lead poisoning. The experts offered recommendations to address the high lead poisoning rates including increasing lead knowledge levels of both community members and landlords, through creating and distributing health promotion material, enacting policies to empower renters, and systematically collaborating to streamline lead poisoning related information and services. Conclusions: Findings provide insights to factors that Lancaster can address to achieve a decrease in lead poisoning rates. This study provides information that can be utilized by public health professionals to develop appropriate interventions.

Low use of routine medical care among African Americans with high CKD risk: the Jackson Heart Study

Background

Use of routine medical care (RMC) is advocated to address ethnic/racial disparities in chronic kidney disease (CKD) risks, but use is less frequent among African Americans. Factors associated with low RMC use among African Americans at risk of renal outcomes have not been well studied.

Methods

We examined sociodemographic, comorbidity, healthcare access, and psychosocial (discrimination, anger, stress, trust) factors associated with low RMC use in a cross-sectional study. Low RMC use was defined as lack of a physical exam within one year among participants with CKD (estimated glomerular filtration rate < 60 mL/min/1.73m² or urine albumin-to-creatinine ratio > 30 mg/g) or CKD risk factors (diabetes or hypertension). We used multivariable logistic regression to estimate the odds of low RMC use at baseline (2000–2004) for several risk factors.

Results

Among 3191 participants with CKD, diabetes, or hypertension, 2024 (63.4%) were ≥ 55 years of age, and 700 (21.9%) reported low RMC use. After multivariable adjustment, age < 55 years (OR 1.61 95% CI 1.31–1.98), male sex (OR 1.71; 1.41–2.07), <high school diploma (OR 1.31; 1.07–1.62), absence of hypertension (OR 1.74; 1.27–2.39) or diabetes (OR 1.34; 1.09–1.65), and tobacco use (OR 1.43; 1.18–1.72) were associated with low RMC use. Low trust in providers (OR 2.16; 1.42–3.27), high stress (OR 1.41; 1.09–1.82), high daily discrimination (OR 1.30; 1.01–1.67) and low burden of lifetime discrimination (OR 1.52; 1.18–1.94), were also associated with low RMC use.

Conclusions

High-risk African Americans who were younger, male, less-educated, and with low trust in providers were more likely to report low RMC use. Efforts to improve RMC use by targeting these populations could mitigate African Americans’ disparities in CKD risks.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1190-0) contains supplementary material, which is available to authorized users.

Worksite Health Promotion for Low-Wage Workers: A Scoping Literature Review

OBJECTIVE

To determine: (1) What research has been done on health promotion interventions for low-wage workers and (2) what factors are associated with effective low-wage workers' health promotion programs.

DATA SOURCE

This review includes articles from PubMed and PsychINFO published in or before July 2016. Study Inclusion/Exclusion Criteria: The search yielded 130 unique articles, 35 met the inclusion criteria: (1) being conducted in the United States, (2) including an intervention or empirical data around health promotion among adult low-wage workers, and (3) measuring changes in low-wage worker health.

DATA EXTRACTION

Central features of the selected studies were extracted, including the theoretical foundation; study design; health promotion intervention content and delivery format; intervention-targeted outcomes; sample characteristics; and work, occupational, and industry characteristics.

DATA ANALYSIS

Consistent with a scoping review, we used a descriptive, content analysis approach to analyze extracted data. All authors agreed upon emergent themes and 2 authors independently coded data extracted from each article.

RESULTS

The results suggest that the research on low-wage workers' health promotion is limited, but increasing, and that low-wage workers have limited access to and utilization of worksite health promotion programs.

CONCLUSION

Workplace health promotion programs could have a positive effect on low-wage workers, but more work is needed to understand how to expand access, what drives participation, and which delivery mechanisms are most effective.

Access to Employee Wellness Programs and Use of Preventive Care Services Among U.S. Adults

INTRODUCTION

There is little research at the national level on access to employee wellness programs and the use of preventive care services. This study examined the use of seven preventive care services among U.S working adults with access to employee wellness programs.

METHODS

The study population comprised 17,699 working adults aged ≥18 years, obtained from the 2015 National Health Interview Survey. Multivariate logistic regression models examined the relationship between access to employee wellness programs and use of seven preventive care services: influenza vaccination, blood pressure check, diabetes check, cholesterol check, Pap smear test, mammogram, and colon cancer screening. Data analysis began in Fall 2016.

RESULTS

Overall, 46.6% of working adults reported having access to employee wellness programs in 2015. Working adults with access to employee wellness programs had higher odds of receiving influenza vaccination (OR=1.57, 95% CI=1.43, 1.72, p<0.001), blood pressure check (OR=2.46, 95% CI=2.17, 2.78, p<0.001), diabetes check (OR=1.30, 95% CI=1.12, 1.50, p<0.001), cholesterol check (OR=1.48, 95% CI=1.33, 1.67, p<0.001), and mammogram (OR=1.57, 95% CI=1.24, 1.98, p<0.001). However, there was no significant difference between access to employee wellness programs and the use of Pap smear test and colon cancer screening services.

CONCLUSIONS

Using a nationally representative sample of individuals, this study found a positive association between access to employee wellness programs and the use of preventive care services. The results support favorable policies to encourage implementing wellness programs in all worksites, especially those with <50 employees.

Urban-rural disparity in utilization of preventive care services in China

Preventive care service is considered pivotal on the background of demographic ageing and a rise in chronic diseases in China. The disparity in utilization of preventive care services between urban and rural in China is a serious issue. In this paper, we explored factors associated with urban-rural disparity in utilization of preventive care services in China, and determined how much of the urban-rural disparity was attributable to each determinant of utilization in preventive care services. Using representative sample data from China Health and Nutrition Survey in 2011 (N = 12,976), the present study performed multilevel logistic model to examine the factors that affected utilization of preventive care services in last 4 weeks. Blinder-Oaxaca decomposition method was applied to divide the utilization of preventive care disparity between urban and rural residents into a part that can be explained by differences in observed covariates and unobserved part. The percentage of rural residents utilizing preventive care service in last 4 weeks was lower than that of urban residents (5.1% vs 9.3%). Female, the aged, residents with higher education level and household income, residents reporting self-perceived illness in last 4 weeks and physician-diagnosed chronic disease had higher likelihood of utilizing preventive care services. Household income was the most important factor accounting for 26.6% of urban-rural disparities in utilization of preventive care services, followed by education (21.5%), self-perceived illness in last 4 weeks (7.8%), hypertension (4.4%), diabetes (3.3%), other chronic diseases (0.8%), and health insurance (-1.0%). Efforts to reduce financial barriers for low-income individuals who cannot afford preventive services, increasing awareness of the importance of obtaining preventive health services and providing more preventive health services covered by health insurance, may help to reduce the gap of preventive care services utilization between urban and rural.

Prostate cancer screening in Switzerland: 20-year trends and socioeconomic disparities

BACKGROUND

Despite important controversy in its efficacy, prostate cancer (PCa) screening has become widespread. Important socioeconomic screening disparities have been reported. However, trends in PCa screening and social disparities have not been investigated in Switzerland, a high risk country for PCa. We used data from five waves (from 1992-2012) of the population-based Swiss Health Interview Survey to evaluate trends in PCa screening and its association with socioeconomic indicators.

METHODS

We used multivariable Poisson regression to estimate prevalence ratios (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status, and use of healthcare.

RESULTS

The study included 12,034 men aged ≥50 years (mean age: 63.9). Between 1992 and 2012, ever use of PCa screening increased from 55.3% to 70.0% and its use within the last two years from 32.6% to 42.4% (p-value <0.05). Income, education, and occupational class were independently associated with PCa screening. PCa screening within the last two years was greater in men with the highest (>$6,000/month) vs. lowest income (≤$2,000) (46.5% vs. 38.7% in 2012, PR for overall period =1.29, 95%CI: 1.13-1.48). These socioeconomic disparities did not significantly change over time.

CONCLUSIONS

This study shows that about half of Swiss men had performed at least one PCa screening. Men belonging to high socioeconomic status are clearly more frequently screened than those less favored. Given the uncertainty of the usefulness of PCa screening, men, including those with high socioeconomic status, should be clearly informed about benefits and harms of PCa screening, in particular, the adverse effect of over-diagnosis and of associated over-treatment.

The effectiveness of preventive care at reducing curative care risk for the Taiwanese elderly under National Health Insurance

Whether provision of free preventive care for the elderly under National Health Insurance has reduced the risk for curative care use raises much concern in Taiwan. This study analyzes the relationship by examining the impact of health examination utilization on the utilizations of outpatient care and inpatient care. Data come from the 2005 National Health Interview Survey and National Health Insurance Research Database. A two-stage method is used in the estimation. We found a negative relationship between the utilization of preventive care and hospitalization care in terms of length of stay and medical expenditures. On average, the elderly people who used preventive care tended to have 16 shorter hospitalization stays and NTD64,220 lower hospitalization expenditures than their counterparts. In order to improve the health of the elderly and reduce the escalation of medical expenditures due to aging, including preventive care in the health insurance is a very effective strategy.

Spillover effects of an uninsured population

A lack of health insurance has long been associated with negative effects on individual and family health due to access barriers. However, we know little about how a lack of health insurance affects wider communities beyond health care. Based on in-depth interviews in two Los Angeles communities, we report how a lack of health insurance affects the functioning of religious institutions and schools from kindergarten to 12th grade. We find a negative spillover effect at the individual and institutional levels for schools experiencing greater absenteeism due to health insurance problems of pupils. However, we find that religious organizations are little affected by a lack of health insurance of adherents. Instead, churches offer health programs as a means to engage their communities. Besides documenting a negative and a positive spillover effect, we offer a conceptual framework for the qualitative study of health spillover effects and examine the policy implications of our findings.

Clarifying the positive association between education and prostate cancer: a Monte Carlo simulation approach

Using the 1993-2011 data from the Wisconsin Longitudinal Study (N = 5,218), we examine prostate cancer screening, mortality after the diagnosis, and health behaviors as potential mechanisms explaining the paradoxical association between men's higher education and higher prostate cancer risk. Our study combines within-cohort longitudinal hazard models predicting a prostate cancer diagnosis with Monte Carlo simulations estimating the joint effects of socioeconomic differences in prostate cancer screening and mortality after the diagnosis. Our findings strongly suggest that higher utilization of prostate cancer screening and lower mortality after the diagnosis are important explanations for higher prostate rates among more educated men. In addition to applying an innovative method to the issues of prostate cancer incidence and survival, our results have potentially important implications for the current debate about the utility of prostate cancer screening as well as for accurate predictions of future mortality and morbidity trends in the expanding older population.

Screening for cardiovascular disease risk factors in an urban low-income setting at baseline and post intervention: a prospective intervention study

BACKGROUND

Not all segments of society might have equal access to screening. We determined predictors for regular cardiovascular health screening at baseline amongst those of low socioeconomic status (SES) and evaluated the effectiveness of a 6-month intervention on screening in this group compared to a high-SES group.

METHODS

The study population involved all residents aged ≥ 40 years in two housing estates comprising owner-occupied housing (high SES) and rental flats (low SES) in Singapore. From 2009 to 2011, residents not being screened regularly at baseline for hypertension, diabetes, and dyslipidaemia were offered free and convenient blood pressure, fasting blood glucose, and lipid testing over 6 months. Chi-squared and multi-level logistic regression identified predictors of regular screening at baseline; likelihood ratio and Cox regression analysis identified predictors of screening participation post intervention.

RESULTS

Participation was 78.2% (1081/1383). At baseline, in the low-SES group, 41.7% (150/360), 38.8% (177/456), and 30.8% (128/416) had gone for regular hypertension, diabetes, and dyslipidaemia screening, respectively; compared with higher numbers in the high-SES group. Sociodemographic factors predicting regular screening in the low-SES community included being married and not smoking. Post intervention, screening rates rose significantly (p < 0.001) by similar proportions in both communities. Staying in a lower-SES community (adjusted relative risk (aRR) 0.61, 95% CI 0.37-0.99, p = 0.048) and having hypertension (aRR 0.45, 95% CI 0.18-0.98, p = 0.049) was associated with lower take-up; Chinese ethnicity (aRR 1.84, 95% CI 1.00-3.43, p = 0.050) and employment associated with higher take-up (aRR 1.57, 95% CI 1.03-2.60, p = 0.040).

CONCLUSION

Participation in cardiovascular health screening was poor amongst those of low SES; a 6-month intervention programme improved participation in this population.

The emergency department as a potential intervention recruitment venue among vulnerable rural residents

Meeting the health care needs of rural residents is complicated by their substantial medical burdens that frequently outstrip patient and community resources. Nowhere is this more evident than in central Appalachia. Preventive procedures are often sacrificed as patients and providers attend to more pressing medical issues. We report the results of a pilot study designed to explore the need for and appropriateness of a potential intervention placed in an emergency department (ED), with the eventual goal of using the ED to link traditionally underserved patients to preventive services. We used a convenience sample of 49 ED patients to explore their characteristics and health needs and compare them with a sample of 120 case management clients participating in the Kentucky Homeplace Program (KHP), and a general sample of 3,165 Appalachian Kentuckians. The recruited ED patients had low socio-economic status, numerous health conditions, and several unmet health needs, including need for colorectal, cervical, and breast cancer screening. Compared to their KHP counterparts, more ED patients were uninsured. Participants in the ED and KHP groups had particularly low income, were less educated, and had less insurance coverage than an average Appalachian resident. Although case management services, including the KHP have been successful in increasing access to health care by those in need, certain segments of the population remain underserved and continue to be missed by such programs. Our study suggests the need for and appropriateness of reaching out to such underserved populations in the ED and involving them into potential interventions designed to enhance preventive health services.

Disability and health behavior change

OBJECTIVE/HYPOTHESIS

We conducted a review of four health behavior change (HBC) theories (Health Belief, Theory of Planned Behavior, Social Cognitive, and Transtheoretical) to consider how these theories conceptually apply to people with disabilities.

METHODS

We identified five common constructs across HBC theories and examined how these commonalities fit within the International Classification of Function (ICF).

RESULTS

Four of the HBC constructs appear to be Personal Factors within the ICF, while the fifth represents Environmental Factors.

CONCLUSIONS

Using the ICF framework to understand disability and HBC, we propose that including a sense of meaning as another personal factor will further develop HBC theories that lead to more effective HBC interventions for people with disabilities.

Iowa certified nursing assistants study: self-reported ratings of the nursing home work environment

Certified nursing assistants (CNAs) are the principal bedside caregivers in nursing homes, yet little is known about their perceptions of the work environment. This population-based, cross-sectional study used a mailed questionnaire to a random sample of Iowa CNAs (N=584), representing 166 nursing homes. Of the respondents, 88.5% (n=517) were currently employed in long-term care settings; however, 11.5% (n=67) indicated they had left their jobs. When CNA responses were compared with those of other occupational groups, general workers reported higher scores on involvement, coworker cohesion, work pressure, and supervisor support. Those who left their CNA jobs rated their work environment as characteristic of excessive managerial control and task orientation. Results of this study emphasize the importance of the relationship between CNAs and their supervisors, CNAs' need for greater autonomy and innovation, and the need for the work environment to change dramatically in the area of human resource management.

Influence of number of children on cancer screening among adults in the United States

OBJECTIVE

To investigate the influence of children in the household on the likelihood of reporting cancer screening among adult men and women living in the United States.

METHODS

2004-2006 Medical Expenditure Panel Surveys (MEPS) were used to calculate the probability of self-reported cancer screening by number of children for adult men and women with adjustment for age, sex, marital status, race, education, current smoking status, obesity status, health insurance and having a usual health-care provider.

RESULTS

The largest percentage of persons who had cancer screening was among respondents with no children in the household. In multivariate results, the probability of endoscopy was lower for persons with one child (24%) and two or more children (21%) in comparison with persons with no children living in the household (30%). Prostate-specific antigen (PSA) testing was lower among men with one child (17%) and two or more children (14%) in comparison with no children (22%). Pap smears were lower for women with two or more children (50%) but not different for women with one child (55%) in comparison with no children (56%). Mammograms were lower for women with one child (48%) and two or more children (42%) in comparison with no children in the household (55%).

CONCLUSION

Across several different cancer screening modalities, the probability of screening is lower as the number of children in the household increases. Children may be an additional barrier to screening beyond factors such as socioeconomic status and access to care.

Building the Case for Delivering Health Promotion Services Within the Vocational Rehabilitation System

Research studies report a negative relationship between employment and secondary conditions. Access to health promotion programs to manage secondary conditions, however, is limited for people with disabilities due to employment, financial, and insurance barriers. Vocational rehabilitation (VR) is one possible delivery point to overcome these barriers and improve access. To build the case for VR delivery, this article compares VR clients to Living Well health promotion program participants, who successfully reduced their secondary conditions. At baseline,VR ( n = 162) and Living Well ( n = 188) participants reported similar health promoting lifestyle behavior ratings and similar severity ratings across many secondary conditions. In addition, the VR group experienced similar rates of limitation from secondary conditions over time, indicating that their health was not improving in the absence of a health promotion intervention. Because health promotion programs can reduce secondary conditions, this research supports continued exploration of health promotion delivery within the VR system.

Prostate cancer severity among low income, uninsured men

PURPOSE

The proportion of American men with organ confined, low risk prostate cancer has increased significantly during the last 2 decades. Whether this trend also applies to men at the extremes of socioeconomic disadvantage remains unknown. Therefore, we evaluated trends in prostate cancer severity in an ethnically diverse cohort of low income, uninsured men served by a state funded public health program in California.

MATERIALS AND METHODS

We performed a retrospective cohort study of 570 disadvantaged men enrolled in the California program from 2001 through 2006. Using routinely collected clinical variables we defined 2 measures of cancer severity as 1) the proportion of enrollees with metastases at diagnosis and 2) the proportions of men with nonmetastatic tumors whose cancers had low, intermediate or high risk features at diagnosis. We performed bivariate analyses to assess time trends in cancer severity.

RESULTS

Prostate specific antigen levels at diagnosis exceeded 10 ng/ml for 51% of enrollees, 50% had a Gleason score 7 or greater and 43% had clinical T stage T2 or greater. Of disadvantaged men 19% had metastatic cancer at diagnosis and this proportion remained stable over time (p = 0.66). Among men with nonmetastatic cancers 24% had tumors with low risk features and the proportion of low risk cancers did not increase over time (p = 0.34).

CONCLUSIONS

Unlike the broader United States population the proportion of disadvantaged men with organ confined, low risk prostate cancer has not been increasing. Thus, while much attention focuses on potential overdiagnosis and overtreatment of men with screen detected prostate cancer, our findings suggest that for low income, uninsured men, underdetection and undertreatment remain significant concerns.