The role of federally funded health centers in serving the rural population

Job satisfaction of village doctors in a rural-oriented tuition-waived medical education program in China

INTRODUCTION

To address health inequity and relieve shortage of rural doctors, China initiated Rural-oriented Tuition-waived Medical Education (RTME) to train doctors in rural areas for free since 2010. Little is known about job satisfaction of this particular group of rural doctors.

METHODS

Job Satisfaction Questionnaires for Village Doctors were distributed to 240 village doctors with RTME program in China, and 40 received in-depth semi-structured interviews. Descriptive analysis, chi-square test, univariate and multivariate logistic regressions in SPSS23.0 were conducted, and thematic analysis was applied to interviews.

RESULTS

Job satisfaction rate of village doctors with RTME program was 56.50%. Full understanding of RTME policy, recognition of rural medical work, relevance of RTME curriculum with present job, education background, rural origin and renumeration were positively correlated with job satisfaction. Preferential policies of RTME program, relaxing working atmosphere, more promotion opportunity, and easier access to higher technical titles were the key factors to retain rural doctors.

CONCLUSION

Our findings may interest healthcare authorities, medical colleges and primary healthcare establishments. Studying the job satisfaction of village doctors in China may also be beneficial in developing community and rural health services, and provide valuable insights into the training and retention of primary healthcare providers in other countries.

Geographic access to federally qualified health centers before and after the affordable care act

Background

The Affordable Care Act (ACA) increased funding for Federally Qualified Health Centers (FQHCs). We defined FQHC service areas based on patient use and examined the characteristics of areas that gained FQHC access post-ACA.

Methods

We defined FQHC service areas using total patient counts by ZIP code from the Uniform Data System (UDS) and compared this approach with existing methods. We then compared the characteristics of ZIP codes included in Medically Underserved Areas/Populations (MUA/Ps) that gained access vs. MUA/P ZIP codes that did not gain access to FQHCs between 2011–15.

Results

FQHC service areas based on UDS data vs. Primary Care Service Areas or counties included a higher percentage of each FQHC’s patients (86% vs. 49% and 71%) and ZIP codes with greater use of FQHCs among low-income residents (29% vs. 22% and 22%), on average. MUA/Ps that gained FQHC access 2011–2015 included more poor, uninsured, publicly insured, and foreign-born residents than underserved areas that did not gain access, but were less likely to be rural (p < .05).

Conclusions

Measures of actual patient use provide a promising method of assessing FQHC service areas and access. Post-ACA funding, the FQHC program expanded access into areas that were more likely to have higher rates of poverty and uninsurance, which could help address disparities in access to care. Rural areas were less likely to gain access to FQHCs, underscoring the persistent challenges of providing care in these areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07685-0.

Trends in access to care among rural patients served at HRSA-funded health centers

PURPOSE

Nearly one-fifth of Americans live in rural areas and experience multiple socioeconomic and health disparities. Health Resources and Services Administration (HRSA)-funded health centers (HCs) provide comprehensive primary care in rural communities. However, no prior research has examined trends in access to care in rural HC patients. We examined the change in access to care among patients served at rural HRSA-funded HCs in the United States between 2009 and 2014.

METHODS

We compared patients by year to examine measures of access using multilevel generalized structural equation logistic regression models with random effects. We used the 2009 and 2014 cross-sectional Health Center Patient Surveys and identified 2,625 adult rural HC patients. Dependent variables were subjective (unmet need/delay in medical care, mental health, dental care, and prescription medications) and objective measures (preventive care and other health care utilization) in access to care. Our independent variable of interest was time, comparing access in 2009 and 2014.

RESULTS

Rural HC patients reported higher predicted probability of influenza vaccine receipt (37% vs 51%), and lower unmet (25% vs 14%) and delayed medical care (36% vs 18%) between 2009 and 2014. Any emergency department visits in the last year increased (32% vs 46%) and mammogram (70% vs 55%) and Pap test (83% vs 72%) screening rates decreased.

CONCLUSIONS

Observed increases in access to care among rural HC patients are positive developments but the challenges to access care still persist. Remote services, such as telehealth, could be cost-effective means of improving access to care among rural patients with limited provider supply.

Spatial variation in access to the health care safety net for Hispanic immigrants, 1970-2017

Hispanic immigrants have long faced barriers to accessing health care in the U.S., as they are largely excluded from federal programs like Medicaid. Since the 1960s, the federal government has operated a nationwide network of Community Health Centers (CHCs) that serve anyone, regardless of ability to pay or citizenship status. To what extent has this widespread, immigrant-inclusive institution been accessible to Hispanic immigrants? Using novel administrative data joined with Census and American Community Survey data from 1970 to 2017, this study documents spatial variation in population-level proximity to CHCs in relation to changing Hispanic migration patterns. Findings show that health centers, both historically and contemporarily, have been far more spatially proximate to poor and foreign-born Hispanics than to poor whites. In 2017, 56% of poor and foreign-born Hispanics in the U.S. lived within two miles of a CHC compared to 30% of poor whites. While access to CHCs has been consistently greater in established gateways, regardless of urbanicity, growth in new destination safety net infrastructure has increased at a faster rate. The CHC program has been substantially more accessible to the foreign-born than U.S.-born Hispanic and uninsured populations, showing the geographic potential for CHCs to provide care to underserved immigrant communities. This study provides the first descriptive evidence of the programmatic reach of this safety net institution across time and space, highlighting a crucial yet underexplored factor in understanding the health of Hispanic immigrants.

Assessing clinical quality performance and staffing capacity differences between urban and rural Health Resources and Services Administration-funded health centers in the United States: A cross sectional study

BACKGROUND

In the United States, there are nearly 1,400 Health Resources and Services Administration-funded health centers (HCs) serving low-income and underserved populations and more than 600 of these HCs are located in rural areas. Disparities in quality of medical care in urban vs. rural areas exist but data on such differences between urban and rural HCs is limited in the literature. We examined whether urban and rural HCs differed in their performance on clinical quality measures before and after controlling for patient, organizational, and contextual characteristics.

METHODS AND FINDINGS

We used the 2017 Uniform Data System to examine performance on clinical quality measures between urban and rural HCs (n = 1,373). We used generalized linear regression models with the logit link function and binomial distribution, controlling for confounding factors. After adjusting for potential confounders, we found on par performance between urban and rural HCs in all but one clinical quality measure. Rural HCs had lower rates of linking patients newly diagnosed with HIV to care (74% [95% CI: 69%, 80%] vs. 83% [95% CI: 80%, 86%]). We identified control variables that systematically accounted for eliminating urban vs. rural differences in performance on clinical quality measures. We also found that both urban and rural HCs had some clinical quality performance measures that were lower than available national benchmarks. Main limitations included potential discrepancy of urban or rural designation across all HC sites within a HC organization.

CONCLUSIONS

Findings highlight HCs' contributions in addressing rural disparities in quality of care and identify opportunities for improvement. Performance in both rural and urban HCs may be improved by supporting programs that increase the availability of providers, training, and provision of technical resources.

Can Health Disparity Be Eliminated? The Role of Family Doctor Played in Shanghai, China

Background: Globally, the elimination of health disparity is a significant policy target. Primary health care has been implemented as a strategy to achieve this target in China for almost 10 years. This study examined whether family doctor (FD) policy in Shanghai contributed to eliminating health disparity as expected. Methods: System dynamics modeling was performed to construct and simulate a system of health disparity formation (business-as-usual (BAU) scenario, without any interventions), a system with FD intervention (FD scenario), and three other systems with supporting policies (Policy 1/Policy 2/Policy hybrid scenario) from 2013 to 2050. Health disparities were simulated in different scenarios, making it possible to compare the BAU results with those of FD intervention and with other policy interventions. Findings: System dynamics models showed that the FD policy would play a positive role in reducing health disparities in the initial stage, and medical price control—rather than health management—was the dominant mechanism. However, in this model, the health gap was projected to expand again around 2039. The model examined the introduction of two intervention policies, with findings showing that the policy focused on socioeconomic status improvement would be more effective in reducing health disparities, suggesting that socioeconomic status is the fundamental cause of these disparities. Conclusions: The results indicate that health disparities could be optimized, but not eliminated, as long as differences in socioeconomic status persists.

Rapid Growth of Mental Health Services at Community Health Centers

Community Health Centers (CHCs) target medically underserved communities and expanded by 70% in the last decade. We know little, however, about mental health services at CHCs. We analyzed data from 2006 to 2015 and determined county-level drivers of these services. Mental health patients at CHCs fall from 2006 to 2007 but then rise consistently from 2007 to 2015. Counties with fewer physicians, greater percent insured and greater percent white population show faster growth in mental health services. Increases in mental health services at CHCs outpace general CHC growth and reflect federal efforts to integrate behavioral health care into primary care.

Operational efficiency, patient composition and regional context of U.S. health centers: Associations with access to early prenatal care and low birth weight

Community health centers (CHCs) provide comprehensive medical services to medically under-served Americans, helping to reduce health disparities. This study aimed to identify the unique compositions and contexts of CHCs to better understand variation in access to early prenatal care and rates of low birth weights (LBW). Data include CHC-level data from the Uniform Data System, and regional-level data from the US Census American Community Survey and Behavioral Risk Factor Surveillance System. First, latent class analysis was conducted to identify unobserved subgroups of CHCs. Second, data envelopment analysis was performed to evaluate the operational efficiency of CHCs. Third, we used generalized linear models to examine the associations between the CHC subgroups, efficiency, and perinatal outcomes. Seven classes of CHCs were identified, including two rural classes, one suburban, one with large centers serving poor minorities in low poverty areas, and three urban classes. Many of these classes were characterized by the racial compositions of their patients. Findings indicate that CHCs serving white patients in rural areas have greater access to early prenatal care. Health centers with greater efficiency have lower rates of LBW, as do those who serve largely white patient populations in rural areas. CHCs serving poor racial minorities living in low-poverty areas had particularly low levels of access to early prenatal care and high rates of LBW. Findings highlight that significant diversity exists in the sociodemographic composition and regional context of US health centers, in ways that are associated with their operations, delivery of care, and health outcomes. Results from this study highlight that while the provision of early prenatal care and the efficiency with which a health center operates may improve the health of the women served by CHCs and their babies, the underlying social and economic conditions facing patients ultimately have a larger association with their health.

Primary care and survival among American Indian patients with diabetes in the Southwest United States: Evaluation of a cohort study at Gallup Indian Medical Center, 2009-2016

OBJECTIVES

To evaluate the role of primary care healthcare delivery on survival for American Indian patients with diabetes in the southwest United States.

METHODS

Data from patients with diabetes admitted to Gallup Indian Medical Center between 2009 and 2016 were analyzed using a log-rank test and Cox Proportional Hazards analyses.

RESULTS

Of the 2661 patients included in analysis, 286 patients died during the study period. Having visited a primary care provider in the year prior to first admission of the study period was protective against all-cause mortality in unadjusted analysis (HR (95% CI)=0.47 (0.31, 0.73)), and after adjustment. The log-rank test indicated there is a significant difference in overall survival by primary care engagement history prior to admission (p<0.001). The median survival time for patients who had seen a primary care provider was 2322days versus 2158days for those who had not seen a primary care provider.

CONCLUSIONS

Compared with those who did not see a primary care provider in the year prior to admission, having seen a primary care provider was associated with improved survival after admission.

Differences in Human Papillomavirus Vaccination Among Adolescent Girls in Metropolitan Versus Non-metropolitan Areas: Considering the Moderating Roles of Maternal Socioeconomic Status and Health Care Access

OBJECTIVES

This study is among the first to examine metropolitan status differences in human papillomavirus (HPV) vaccine initiation and completion among United States adolescent girls and is unique in its focus on how maternal socioeconomic status and health care access moderate metropolitan status differences in HPV vaccination.

METHODS

Using cross-sectional data from 3573 girls aged 12-17 in the U.S. from the 2008-2010 Behavioral Risk Factor Surveillance System, we estimate main and interaction effects from binary logistic regression models to identify subgroups of girls for which there are metropolitan versus non-metropolitan differences in HPV vaccination.

RESULTS

Overall 34 % of girls initiated vaccination, and 19 % completed all three shots. On average, there were no metropolitan status differences in vaccination odds. However, there were important subgroup differences. Among low-income girls and girls whose mothers did not complete high school, those in non-metropolitan areas had significantly higher probability of vaccine initiation than those in metropolitan areas. Among high-income girls and girls whose mothers completed college, those in metropolitan areas had significantly higher odds of vaccine initiation than those in non-metropolitan areas. Moreover, among girls whose mothers experienced a medical cost barrier, non-metropolitan girls were less likely to initiate vaccination compared to metropolitan girls.

CONCLUSIONS

Mothers remain essential targets for public health efforts to increase HPV vaccination and combat cervical cancer. Public health experts who study barriers to HPV vaccination and physicians who come into contact with mothers should be aware of group-specific barriers to vaccination and employ more tailored efforts to increase vaccination.

Changes in the Supply of US Rural Health Centers, 2000-2011: Implications for Rural Minority Communities

PURPOSE

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) provide primary care in rural areas with a shortage of providers. This paper examines whether racial and ethnic minority composition was related to changes in the supply of RHCs and FQHCs in rural counties from 2000 to 2011.

METHODS

We conducted a retrospective cohort study of rural counties using the Area Health Resource File 2012-2013. We examined rural counties defined as non-Core-Based Statistical Areas, with complete data on county characteristics for the study period (N = 1,349). Logistic regression analyses estimated associations between percentage of minority residents, and net gains and losses of RHCs and FQHCs, adjusting for total population, percentage of elderly residents, infant mortality rate, poverty rate, and physician, hospital, and clinic supply. Model estimates were used to calculate the predicted probability of outcomes across a range of minority percentage, from the 10th (≤1.6%) to 90th (≥46%) percentile of rural counties.

FINDINGS

In high-minority counties, the predicted probability of a net gain in any type of clinic was 28.6% (95% CI: 21.3-35.8), versus 46.4% (95% CI: 40.0-52.8) for low-minority counties. High-minority counties were also more likely to experience a net decline in RHCs.

CONCLUSIONS

During a period of substantial growth in both programs, the percentage of minority residents was negatively associated with gaining new clinics of either type. Policy makers may need to consider targeting rural minority communities for additional primary care workforce support.

Disentangling the Linkage of Primary Care Features to Patient Outcomes: A Review of Current Literature, Data Sources, and Measurement Needs

Primary care plays a central role in the provision of health care, and is an organizing feature for health care delivery systems in most Western industrialized democracies. For a variety of reasons, however, the practice of primary care has been in decline in the U.S. This paper reviews key primary care concepts and their definitions, notes the increasingly complex interplay between primary care and the broader health care system, and offers research priorities to support future measurement, delivery and understanding of the role of primary care features on health care costs and quality.

Urban and rural safety net health care system clinics: no disparity in HPV4 vaccine completion rates

OBJECTIVE

Safety net health care centers in the US serve vulnerable and underinsured females. The primary aim of this work was to determine if HPV4 dosing compliance differs between females who receive doses at rural vs. urban core safety net health care locations.

METHODS

Females exclusively receiving health care in the Truman Medical Center (TMC) safety net system at the urban core and rural locations were identified by their HPV4 vaccine records. Dates and number of HPV4 doses as well as age, gravidity, parity and race/ethnicity were recorded from the electronic medical record (EMR). Appropriate HPV4 dosing intervals were referenced from the literature.

RESULTS

1259 females, 10-26 years of age, received HPV4 vaccination at either the rural (23%) or urban core location (77%). At the rural location, 23% received three doses on time, equal to the 24% at the urban core. Females seen in the urban core were more likely to receive on-time doublet dosing than on-time triplet dosing (82% vs. 67%, p<0.001). Mistimed doses occurred equally often among females receiving only two doses, as well as those receiving three doses.

CONCLUSIONS

Compliance with on-time HPV4 triplet dose completion was low at rural and urban core safety net health clinics, but did not differ by location.

Health care utilization and receipt of preventive care for patients seen at federally funded health centers compared to other sites of primary care

OBJECTIVE

To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings.

DATA SOURCES

A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004-2008).

STUDY DESIGN

HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non-HC patients.

PRINCIPAL FINDINGS

Compared to non-HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p < .001). HC patients were more likely to receive breast cancer screening than non-HC patients (adjusted odds ratio [aOR] 2.78, p < .01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non-HC patients.

CONCLUSIONS

Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.

Primary health care service use among women who have recently left an abusive partner: income and racialization, unmet need, fits of services, and health

Primary health care (PHC) can improve the health of women who have experienced intimate partner violence; yet, access to and fit of PHC services may be shaped by income and racialization. We examined whether income and racialization were associated with differences in PHC service use, unmet needs, fit with needs, and mental and physical health in a sample of 286 women who had separated from an abusive partner. Mothers, unemployed women, and those with lower incomes used more PHC services and reported a poorer fit of services. Poorer fit of services was related to poorer mental and physical health.

Clinical quality performance in U.S. health centers

OBJECTIVE

To describe current clinical quality among the nation's community health centers and to examine health center characteristics associated with performance excellence.

DATA SOURCES

National data from the 2009 Uniform Data System.

DATA COLLECTION/EXTRACTION METHODS

Health centers reviewed patient records and reported aggregate data to the Uniform Data System.

STUDY DESIGN

Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance.

PRINCIPAL FINDINGS

Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.

CONCLUSIONS

Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.

Case-mix adjustment and the comparison of community health center performance on patient experience measures

OBJECTIVE

To assess the effect of case-mix adjustment on community health center (CHC) performance on patient experience measures.

DATA SOURCES

A Medicaid-managed care plan in Washington State collected patient survey data from 33 CHCs over three fiscal quarters during 2007-2008. The survey included three composite patient experience measures (6-month reports) and two overall ratings of care. The analytic sample includes 2,247 adult patients and 2,859 adults reporting for child patients.

STUDY DESIGN

We compared the relative importance of patient case-mix adjusters by calculating each adjuster's predictive power and variability across CHCs. We then evaluated the impact of case-mix adjustment on the relative ranking of CHCs.

PRINCIPAL FINDINGS

Important case-mix adjusters included adult self-reported health status or parent-reported child health status, adult age, and educational attainment. The effects of case-mix adjustment on patient reports and ratings were different in the adult and child samples. Adjusting for race/ethnicity and language had a greater impact on parent reports than adult reports, but it impacted ratings similarly across the samples. The impact of adjustment on composites and ratings was modest, but it affected the relative ranking of CHCs.

CONCLUSIONS

To ensure equitable comparison of CHC performance on patient experience measures, reports and ratings should be adjusted for adult self-reported health status or parent-reported child health status, adult age, education, race/ethnicity, and survey language. Because of the differential impact of case-mix adjusters for child and adult surveys, initiatives should consider measuring and reporting adult and child scores separately.

Presence of a community health center and uninsured emergency department visit rates in rural counties

CONTEXT

Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities.

PURPOSE

We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence.

METHODS

We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits.

FINDINGS

Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22).

CONCLUSIONS

The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.

Trends in mental health and substance abuse services at the nation's community health centers: 1998-2003

OBJECTIVE

We examined trends in delivery of mental health and substance abuse services at the nation's community health centers.

METHODS

Analyses used data from the Health Resources and Services Administration (HRSA), Bureau of Primary Care's (BPHC) 1998 and 2003 Uniform Data System, merged with county-level data.

RESULTS

Between 1998 and 2003, the number of patients diagnosed with a mental health/substance abuse disorder in community health centers increased from 210,000 to 800,000. There was an increase in the number of patients per specialty mental health/substance abuse treatment provider and a decline in the mean number of patient visits, from 7.3 visits per patient to 3.5 by 2003. Although most community health centers had some on-site mental health/substance abuse services, centers without on-site services were more likely to be located in counties with fewer mental health/substance abuse clinicians, psychiatric emergency rooms, and inpatient hospitals.

CONCLUSIONS

Community health centers are playing an increasingly central role in providing mental health/substance abuse treatment services in the United States. It is critical both to ensure that these centers have adequate resources for providing mental health/substance abuse care and that they develop effective linkages with mental health/substance abuse clinicians in the communities they serve.

Women's preventive screening in rural health clinics

CONTEXT

Despite the strong interest in health care quality, little is known about the quality of preventive care among women in rural primary care settings.

PURPOSE

We sought to assess the quality of screening practices in Rural Health Clinics (RHCs) as measured by the rates at which female patients received screening within national guidelines.

METHODS

A cross-sectional, retrospective chart review of 480 charts of female patients in 12 randomly selected RHCs was conducted. Data were collected on screening activities documented in >3,800 patient visits. Chart data was extracted by trained, standardized chart auditors using the Women's Primary Care Screening Form for patient data and the Revised National Rural Health Clinic Survey for RHC background data. The rates of receipt of 5 preventive screenings received by female patients in RHCs were determined using a standardized and reproducible method, and patient and clinic characteristics associated with women's receipt of these screenings were identified.

FINDINGS

Demographic characteristics of patients were similar to that of national rural comparisons. Screening rates for Pap tests (66%) and mammograms (55%) were lower than Healthy People 2010 estimates, but similar to other record audit data; screening rates for cholesterol with comorbidity (66%) were near the Healthy People 2010 estimate, and screening rates for cholesterol without comorbidity (61%) exceeded it; and rates of blood pressure screening (99%) exceeded Healthy People 2010 estimates of national rates. Screening rates for depression showed that 35% had received a formal or informal screening.

CONCLUSIONS

Rates of screenings for insured and uninsured female RHC patients in this retrospective chart review were not significantly different. Methods to improve pap and mammogram screening rates are needed.

Trends in Mental Health and Substance Abuse Services at the Nation's Community Health Centers: 1998-2003

OBJECTIVE

We examined trends in delivery of mental health and substance abuse services at the nation's community health centers.

METHODS

Analyses used data from the Health Resources and Services Administration (HRSA), Bureau of Primary Care's (BPHC) 1998 and 2003 Uniform Data System, merged with county-level data.

RESULTS

Between 1998 and 2003, the number of patients diagnosed with a mental health/substance abuse disorder in community health centers increased from 210,000 to 800,000. There was an increase in the number of patients per specialty mental health/substance abuse treatment provider and a decline in the mean number of patient visits, from 7.3 visits per patient to 3.5 by 2003. Although most community health centers had some on-site mental health/substance abuse services, centers without on-site services were more likely to be located in counties with fewer mental health/substance abuse clinicians, psychiatric emergency rooms, and inpatient hospitals.

CONCLUSIONS

Community health centers are playing an increasingly central role in providing mental health/substance abuse treatment services in the United States. It is critical both to ensure that these centers have adequate resources for providing mental health/substance abuse care and that they develop effective linkages with mental health/substance abuse clinicians in the communities they serve.

The United States health centers initiative: a state by state status report

In 2001, the United States federal government began a 5-year initiative to expand services offered by health centers to people who live in area designated "underserved" because there are insufficient primary care medical practitioners. There were national targets for expansion. How the Health Resources and Services Administration (HRSA) reviewed and monitored State plans to expand health centers is presented. These early results suggest that collectively the States would meet the target. Several States would require major efforts to move toward the national average and they were examined more closely.

Testing the Theory of Planned Behavior to Predict Mammography Intention

BACKGROUND

Louisiana ranks 50th as the least healthy state in the United States. Although limited healthcare access may explain part of the health disparity related to mammography utilization, there is no research to elucidate mammography intention among rural Southeastern Louisiana women.

OBJECTIVE

To test the Theory of Planned Behavior to predict mammography intention among rural women in Southeastern Louisiana.

METHODS

A correlation study design with multiple regression and path analysis was used. The sample consisted of 302 women, between the ages of 40-74 who were without a prior history of breast cancer, able to read English, and able to respond to a written questionnaire.

RESULTS

Path analysis confirmed the direct and indirect relationships of mammography intention (chi2 = 26.2, p > .10, Comparative Fit Index =.968). Regression analysis computed the model path coefficients ranging from beta .176 to .640. Overall, the Theory of Planned Behavior explained 24% of the variance.

DISCUSSION

Perceived behavioral control was the strongest predictor of mammography intention. A woman's attitude towards mammography and referent motivation needs further explanation prior to the development of an intervention to increase mammography intention and use.

High prevalence of overweight among pediatric users of community health centers

OBJECTIVE

With the increasing prevalence of pediatric obesity, it is important to identify high-risk populations of children to direct limited resources for prevention and treatment to those who are most vulnerable. The objectives of this study were to determine the prevalence of overweight in children who are clients of community health centers in medically underserved areas of the Health Resources and Service Administration regions II and III (Mid-Atlantic and Puerto Rico), compare this prevalence to nationally representative data, and contrast prevalence data between geographic areas and racial/ethnic groups.

METHODS

The charts from a representative sample of 2474 children using 30 community health centers in 2001 were abstracted to collect clinically measured weight and height. Overweight was defined as a body mass index of > or =95th percentile of a reference population. To generate an unbiased estimate of overweight, multiple imputations were used for missing data. These data were compared with the 1999-2002 National Health and Nutrition Examination Survey.

RESULTS

The prevalence of overweight was elevated in this sample of children aged 2 to 5 years (21.8%; 95% confidence interval [CI]: 19.1-24.8) and 6 to 11 years (23.8%; 95% CI: 16.9-27.7) compared with the 1999-2002 National Health and Nutrition Examination Survey (10.3% and 15.8%, respectively). No significant differences in prevalence were observed between Asian American (18.2%; 95% CI: 11.2-28.3), Hispanic (24.6%; 95% CI: 21.3-28.2), non-Hispanic black (25.6%; 95% CI: 20.8-30.9), and non-Hispanic white (22.8%; 95% CI: 19.0-27.0) children. Furthermore, no differences in prevalence were observed between children using community health centers in continental urban (23.7%; 95% CI: 20.6-27.2), suburban (24.0%; 95% CI: 20.0-28.5), or rural (22.9%; 95% CI: 19.3-26.9) areas.

CONCLUSIONS

The present study identified a population of children at particularly high risk for obesity based on the type of health care delivery system they use regardless of race/ethnicity or geographic characteristics. Because community health centers are experienced in prevention and serve >4.7 million children in the United States, they may be a particularly promising point of access and setting for pediatric obesity prevention.

Health center trends, 1994-2001: what do they portend for the federal growth initiative?

The Federal Health Center Growth Initiative aims to increase community health centers' (CHCs') capacity by 60 percent from 2002 to 2006. This study investigates how primary care delivery changed and sustained its growth during 1994-2001. Findings reveal a rise in the number of patients and maintenance of their visit rate. People ages 41-64 accounted for the highest percentage of visits in 2001, and continuity of care improved. There were no disparities in visit-based preventive services delivery by race/ethnicity or insurance status. Continued growth under the initiative is likely to help reduce health disparities and improve care for the underserved.

Contribution of primary care to health systems and health

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

America's Health Centers: reducing racial and ethnic disparities in perinatal care and birth outcomes

OBJECTIVE

To examine whether community health centers (CHCs) reduce racial/ethnic disparities in perinatal care and birth outcomes, and to identify CHC characteristics associated with better outcomes.

BACKGROUND

Despite great national wealth, the U.S. continues to rank poorly relative to other industrialized nations on infant mortality and other birth outcomes, and with wide inequities by race/ethnicity. Disparities in primary care (including perinatal care) may contribute to disparities in birth outcomes, which may be addressed by CHCs that provide safety-net medical services to vulnerable populations.

METHODS

Data are from annual Uniform Data System reports submitted to the Bureau of Primary Health Care over six years (1996-2001) by about 700 CHCs each year.

RESULTS

Across all years, about 60% of CHC mothers received first-trimester prenatal care and more than 70% received postpartum and newborn care. In 2001, Asian mothers were the most likely to receive both postpartum and newborn care (81.7% and 80.3%), followed by Hispanics (75.0% and 76.3%), blacks (70.8% and 69.9%), and whites (70.7% and 66.7%). In 2001, blacks had higher rates of low birth weight (LBW) babies (10.4%), but the disparity in rates for blacks and whites was smaller in CHCs (3.3 percentage points) compared to national disparities for low-socioeconomic status mothers (5.8 percentage points) and the total population (6.2 percentage points). In CHCs, greater perinatal care capacity was associated with higher rates of first-trimester prenatal care, which was associated with a lower LBW rate.

CONCLUSION

Racial/ethnic disparities in certain prenatal services and birth outcomes may be lower in CHCs compared to the general population, despite serving higher-risk groups. Within CHCs, increasing first-trimester prenatal care use through perinatal care capacity may lead to further improvement in birth outcomes for the underserved.

Disparities in access to care among rural working-age adults

CONTEXT

Nationally, minority population disparities in health and in the receipt of health services are well documented but are infrequently examined within rural populations.

PURPOSE

The purpose of this study is to provide a national picture of health insurance coverage and access to care among rural minorities.

METHODS

A cross-sectional analysis using the 1999-2000 National Health Interview Surveys examined insurance status and receipt of ambulatory care during the past year. Multiple logistic regression was used to measure factors influencing the odds of insurance coverage and a provider visit.

FINDINGS

Among rural minority adults, 32% of blacks, 35% of "other" race persons, and 45% of Hispanics were uninsured compared to 18% of whites. Differences in insurance status were not significant for rural blacks and Hispanics after resources such as education, income, and employment were held constant. Examining use, 37% of rural Hispanics and 27% of blacks, versus 20% of whites and 19% of persons of other race, had not made a health care visit in the past year. When resources were held constant, blacks and persons of other race/ethnicity no longer differed from whites, but differences among Hispanics persisted.

CONCLUSIONS

A comprehensive approach to the health needs of rural working age adults must consider the unique characteristics of rural communities and populations, requiring cultural as well as financial creativity in the design of health delivery systems. The importance of resources such as education and employment points to the need to link health problems to area-specific rural economic development.