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Tabler J, Mykyta L. Forgoing Care in Southernmost Texas: Compounding Hardship and Health Among Latinx Immigrant Border Residents. FAMILY & COMMUNITY HEALTH 2021; 44:171-183. [PMID: 32841999 DOI: 10.1097/fch.0000000000000269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This study examines how material hardship and perceived discrimination are associated with health care access and self-rated health among lower Rio Grande Valley residents. Of respondents to surveys administered at 2 clinic systems (N = 546), approximately 67% reported forgoing medical care in the past 12 months. Regression results suggested that perceived discrimination (odds ratio [OR] = 1.05, P < .05) and material hardship (OR = 1.63, P < .001) increased the odds of forgoing care. Also, discrimination (OR = 1.04, P < .01) and material hardship (OR = 1.24, P < .001) were independently associated with worse self-rated health. Service providers should consider screening for hardship experiences to target resources to address these stressors on patient health.
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Affiliation(s)
- Jennifer Tabler
- Department of Criminal Justice and Sociology, University of Wyoming, Laramie (Dr Tabler); and Department of Sociology and Anthropology, The University of Texas Rio Grande Valley, Edinburg (Dr Mykyta)
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2
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Do financial barriers to access to primary health care increase the risk of poor health? Longitudinal evidence from New Zealand. Soc Sci Med 2020; 288:113255. [PMID: 32819742 DOI: 10.1016/j.socscimed.2020.113255] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/26/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
Primary health care policies in New Zealand, as in many countries, have focused on reducing barriers to access. Financial barriers to obtaining timely health care, while not the only important barriers, are amongst the most important, and are amenable to policy reforms. There is little robust empirical evidence about the extent to which cost related barriers are associated with adverse health outcomes. Past evidence is limited to cross-sectional studies of selected groups, selected primary health care services, and to cross-sectional studies that are susceptible to unmeasured confounding bias. Using fixed effects regression modelling and data from 17,363 participants with at least two observations in three waves (2004-05, 2006-07, 2008-09) of the SoFIE-Health panel data, this study examines the impact of financial barriers to access to primary health care (general practitioner and dentist) on health status using a longitudinal national panel study of adult New Zealanders. Self-rated health (SRH), physical health (PCS) and mental health summary scores (MCS) were the health measures. The two exposures were: not seeing 1) the doctor and 2) the dentist because of cost at least once during the preceding 12 months. We also tested for interactions between the exposure (deferral of care) and age, gender, ethnicity and three health outcomes. For all outcomes, after adjusting for time-varying confounders, health deteriorated as the number of waves increased in which a non-visit was reported. Moreover, the effect size for any health deterioration was greater for deferring a dentist visit than for deferring a physician visit. Except gender and age (for MCS and doctor visits), and gender and ethnicity (for SRH and dentist visits) we did not find any evidence of interactions. These results support policy responses focussed on decreasing financial barriers to access. In the New Zealand context this finding is particularly important for dental care.
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Gibson G, Clair L. O brother how art thou: Propensity to report self-assessed unmet need. Soc Sci Med 2019; 243:112632. [PMID: 31683115 DOI: 10.1016/j.socscimed.2019.112632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 11/29/2022]
Abstract
Research investigating self-assessed unmet need (SUN) has taken the reports from surveys as given and subsequently attempted to discover patterns in inequality of access to healthcare. This requires the yet untested assumption that, given a certain level of care and demand, the likelihood of reporting unmet need does not vary across socioeconomic/demographic status (SEDS), be satisfied. Using an administrative dataset spanning 2001 to 2011 comprised of sufferers of a set of conditions that suggest unmet need (n = 3300) we evaluate the proposition that, given health status and care received, the propensity to report unmet need does not vary along SEDS. The results are further validated using the Canadian Community Health Surveys between 2001 and 2013 (n = 237,483). We find that the assumption of independence between reporting SUN and SEDS is not satisfied. Many of the groups found to have less access in previous studies may simply be more prone to interpret/answer the survey questions about unmet need in a certain way. The results of this research suggest that, in its present incarnation, survey data on self-assessed unmet need does not accurately measure what much of the academic literature has assumed it does.
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Affiliation(s)
- Grant Gibson
- McMaster University Department of Economics, Wilson Hall rm. 3024, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada.
| | - Luc Clair
- University of Winnipeg, Department of Economics - University of Winnipeg, 515 Portage Avenue, Winnipeg, Manitoba, R3B 2E9, Canada.
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Gibson G, Grignon M, Hurley J, Wang L. Here comes the SUN: Self-assessed unmet need, worsening health outcomes, and health care inequity. HEALTH ECONOMICS 2019; 28:727-735. [PMID: 31020778 DOI: 10.1002/hec.3877] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 02/04/2019] [Accepted: 02/18/2019] [Indexed: 06/09/2023]
Abstract
Utilization-based approaches have predominated the measurement of socioeconomic-related inequity in health care. This approach, however, can be misleading when preferences over health and health care are correlated with socioeconomic status, especially when the underlying focus is on equity of access. We examine the potential usefulness of an alternative approach to assessing inequity of access using a direct measure of possible barriers to access-self-reported unmet need (SUN)-which is documented to vary with socioeconomic status and is commonly asked in health surveys. Specifically, as part of an assessment of its external validity, we use Canadian longitudinal health data to test whether self-reported unmet need in one period is associated with a subsequent deterioration in health status in a future period, and find that it is. This suggests that SUN does reflect in part reduced access to needed health care, and therefore may have a role in assessing health system equity as a complement to utilization-based approaches.
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Affiliation(s)
- Grant Gibson
- Economics, McMaster University, Hamilton, Ontario, Canada
| | - Michel Grignon
- Economics, McMaster University, Hamilton, Ontario, Canada
- CHEPA, McMaster University, Hamilton, Ontario, Canada
| | - Jeremiah Hurley
- Economics, McMaster University, Hamilton, Ontario, Canada
- CHEPA, McMaster University, Hamilton, Ontario, Canada
| | - Li Wang
- CHEPA, McMaster University, Hamilton, Ontario, Canada
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Detollenaere J, Boeckxstaens P, Willems S. Association between person-centredness and financially driven postponement of care in European primary care: a cross-sectional multicountry study. CMAJ Open 2018; 6:E176-E183. [PMID: 29669737 PMCID: PMC7869660 DOI: 10.9778/cmajo.20170082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous research has shown that person-centred care has beneficial effects on several health-related outcomes. We investigated the association between a general practitioner's person-centred attitude and financially driven postponement of care in European countries. METHODS In this cross-sectional study, data were collected within the Quality and Costs of Primary Care in Europe study, which included 69 201 patients and 7183 general practitioners from 31 European countries (all 27 European Union member states, 2 candidate states [former Yugoslav Republic of Macedonia and Turkey], Norway and Switzerland). Financially driven postponement of care was measured by asking patients whether they had postponed care for financial reasons in the previous 12 months. We constructed a variable for person-centredness using a previously published conceptual framework: 1) exploring both the disease and the illness experience, 2) understanding the whole person, 3) finding common ground and 4) enhancing the patient-physician relationship. We analyzed the data using multilevel logistic regression modelling, adjusting for the strength of a country's primary care system. RESULTS Having a low income was associated with higher financially driven postponement of care. General practitioners with a person-centred attitude were associated with lower rates of financially driven postponement among their patients. An increase in general practitioners' person-centredness with 1 standard deviation was associated with a decreased likelihood of postponement of care for financial reasons (odds ratio 0.923, 95% confidence interval 0.869-0.981). INTERPRETATION Person-centred care by general practitioners in Europe was associated with lower financially driven postponement of care, irrespective of the strength of a country's primary care system.
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Affiliation(s)
- Jens Detollenaere
- Affiliation: Faculty of Medicine and Health Sciences, Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium
| | - Pauline Boeckxstaens
- Affiliation: Faculty of Medicine and Health Sciences, Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium
| | - Sara Willems
- Affiliation: Faculty of Medicine and Health Sciences, Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium
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Schokkaert E, Steel J, Van de Voorde C. Out-of-Pocket Payments and Subjective Unmet Need of Healthcare. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:545-555. [PMID: 28432643 DOI: 10.1007/s40258-017-0331-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We present a critical review of the literature that discusses the link between the level of out-of-pocket payments in developed countries and the share of people in these countries reporting that they postpone or forgo healthcare for financial reasons. We discuss the pros and cons of measuring access problems with this subjective variable. Whereas the quantitative findings in terms of numbers of people postponing care must be interpreted with utmost caution, the picture for the vulnerable groups in society is reasonably robust and unsurprising: people with low incomes and high morbidity and incomplete (or non-existent) insurance coverage are most likely to postpone or forgo healthcare for financial reasons. It is more surprising that people with high incomes and generous insurance coverage also report that they postpone care. We focus on some policy-relevant issues that call for further research: the subtle interactions between financial and non-financial factors, the possibility of differentiation of out-of-pocket payments between patients and between healthcare services, and the normative debate around accessibility and affordability.
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Affiliation(s)
- Erik Schokkaert
- Department of Economics, KU Leuven and CORE, Université catholique de Louvain, Louvain-la-Neuve, Belgium.
| | - Jonas Steel
- Department of Economics, KU Leuven, Louvain, Belgium
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Detollenaere J, Van Pottelberge A, Hanssens L, Pauwels L, van Loenen T, Willems S. Postponing a General Practitioner Visit: Describing Social Differences in Thirty-One European Countries. Health Serv Res 2017; 52:2099-2120. [PMID: 28217969 DOI: 10.1111/1475-6773.12669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To describe social differences in postponing a general practitioner visit in 31 European countries and to explore whether primary care strength is associated with postponement rates. DATA SOURCES Between October 2011 and December 2013, the multicountry QUALICOPC study collected data on 61,931 patients and 7,183 general practitioners throughout Europe. STUDY DESIGN Access to primary care was measured by asking the patients whether they postponed a general practitioner visit in the past year. Social differences were described according to patients' self-rated household income, education, ethnicity, and gender. DATA COLLECTION/EXTRACTION METHODS Data were analyzed using multivariable and multilevel binomial logistic regression analyses. PRINCIPAL FINDINGS According to the variance-decomposition in the multilevel analysis, most of the variance can be explained by patient characteristics. Postponement of general practitioner care is higher for patients with a low self-rated household income, a low education level, and a migration background. In addition, although the point estimates are consistent with a substantial effect, no statistically significant association between primary care strength and postponement in the 31 countries is determined. CONCLUSIONS Despite the universal and egalitarian goals of health care systems, access to general practitioner care in Europe is still determined by patients' socioeconomic status (self-rated household income and education) and migration background.
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Affiliation(s)
- Jens Detollenaere
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | | | - Lise Hanssens
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Lieven Pauwels
- Department of Criminology, Criminal Law and Social Law, Ghent University, Ghent, Belgium
| | - Tessa van Loenen
- Netherlands Center for Social Care Research, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Sara Willems
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
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Immigrant-Native Disparities in Perceived and Actual Met/Unmet Need for Medical Care. J Immigr Minor Health 2017; 17:1337-46. [PMID: 25204623 DOI: 10.1007/s10903-014-0092-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study compares the unmet medical needs of foreign-born and U.S.-born adults. Both subjective and objective unmet medical needs are considered, and the roles of duration of U.S. residence, English language proficiency, and state-level destination type in explaining immigrants' unmet need are assessed. Multivariate analyses of the 2007-2009 Medical Expenditure Panel Survey reveal that immigrants reported less subjective unmet need and equal or greater objective unmet need vis-à-vis natives. Among immigrants only, living less than 5 years in the U.S. and in a new or traditional, high-skill destination state versus a traditional, low-skill state is significantly associated with greater objective, but not subjective, unmet need. While this study reinforces the importance of stable health insurance and, to a lesser extent, income for gaining entry to the formal healthcare system for both immigrants and natives, it also highlights the need to identify factors that influence immigrants' positive health-related perceptions, including characteristics of the healthcare system in origin countries.
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Detollenaere J, Hanssens L, Vyncke V, De Maeseneer J, Willems S. Do We Reap What We Sow? Exploring the Association between the Strength of European Primary Healthcare Systems and Inequity in Unmet Need. PLoS One 2017; 12:e0169274. [PMID: 28046051 PMCID: PMC5207486 DOI: 10.1371/journal.pone.0169274] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 12/14/2016] [Indexed: 12/16/2022] Open
Abstract
Access to healthcare is inequitably distributed across different socioeconomic groups. Several vulnerable groups experience barriers in accessing healthcare, compared to their more wealthier counterparts. In response to this, many countries use resources to strengthen their primary care (PC) system, because in many European countries PC is the first entry-point to the healthcare system and plays a central role in the coordination of patients through the healthcare system. However it is unclear whether this strengthening of PC leads to less inequity in access to the whole healthcare system. This study investigates the association between strength indicators of PC and inequity in unmet need by merging data from the European Union Statistics on Income and Living Conditions database (2013) and the Primary Healthcare Activity Monitor for Europe (2010). The analyses reveal a significant association between the Gini coefficient for income inequality and inequity in unmet need. When the Gini coefficient of a country is one SD higher, the social inequity in unmet need in that particular country will be 4.960 higher. Furthermore, the accessibility and the workforce development of a country's PC system is inverse associated with the social inequity of unmet need. More specifically, when the access- and workforce development indicator of a country PC system are one standard deviation higher, the inequity in unmet healthcare needs are respectively 2.200 and 4.951 lower. Therefore, policymakers should focus on reducing income inequality to tackle inequity in access, and strengthen PC (by increasing accessibility and better-developing its workforce) as this can influence inequity in unmet need.
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Affiliation(s)
- Jens Detollenaere
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
- * E-mail:
| | - Lise Hanssens
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Veerle Vyncke
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Jan De Maeseneer
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Sara Willems
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
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Detollenaere J, Van Pottelberge A, Hanssens L, Boerma W, Greß S, Willems S. Patients' Financially Driven Delay of GP Visits: Is It Less Likely to Occur in Stronger Primary Care Systems? Med Care Res Rev 2016; 75:292-311. [PMID: 27927838 DOI: 10.1177/1077558716682170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Available evidence has suggested that strong primary care (PC) systems are associated with better outcomes. This study aims to investigate whether PC strength is specifically related to the prevalence of patients' financially driven postponement of general practitioner (GP) care. Therefore, data from a cross-sectional multicountry study in 33 countries among GPs and their patients were analyzed using multilevel logistic regression modelling. According to the results, the variation between countries in the levels of patients' postponement of seeking GP care for financial reasons was large. More than one third of these cross-country differences could be explained by characteristics of the health care system and the GP practices. In particular, PC systems with good accessibility and those systems that offer comprehensive care were associated with lower levels of financially driven delay. Consequently, we can conclude that well-organized PC systems can compensate for the negative influence of individual characteristics (socioeconomic position) on the care-seeking behaviors of patients.
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Affiliation(s)
| | | | | | - Wienke Boerma
- 2 Netherlands Institute for Health Services Research, Utrecht, Netherlands
| | - Stefan Greß
- 3 Hochschule Fulda-University of Applied Sciences, Fulda, Germany
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Spigner C. African Americans, Democracy, and Biomedical and Behavioral Research: Contradictions or Consensus in Community-Based Participatory Research? INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2016; 19:259-84. [PMID: 16021781 DOI: 10.2190/xbwt-g9rf-4b35-kbnm] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Individualism, in both its political and attitudinal senses, reinforces societal and institutional racism in the United States. Because of individualism's dominant focus on self-interest and self-reliance, any application of “participatory democracy” in community-based biomedical and behavioral research is fraught with dilemmas similar to those that Gunnar Myrdal observed between American racism and democracy. The research establishment is overwhelmed by well-meaning non-minorities who recognize racism and its consequences on health, but only greater representation of people-of-color in the health establishment can ameliorate the inherent contradictions of “participatory democracy” which is so fundamental to the process of community-based participatory research.
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Affiliation(s)
- C Spigner
- Department of Health Services, Box 357660, School of Public Health and Community Medicine, University of Washington, Seattle, WA 98195, USA
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Choi JW, Park EC, Chun SY, Han KT, Han E, Kim TH. Health care utilization and costs among medical-aid enrollees, the poor not enrolled in medical-aid, and the near poor in South Korea. Int J Equity Health 2015; 14:128. [PMID: 26572490 PMCID: PMC4647799 DOI: 10.1186/s12939-015-0257-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 10/23/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although government has implemented medical-aid policy that provides assistance to the poor with almost free medical services, there are low-income people who do not receive necessary medical services in Korea. The aim of this study is to highlight the characteristics of Medical-Aid enrollees, the poor not enrolled in Medical-Aid, and the near poor and their utilization and costs for health care. METHODS This study draws on the 2012 Korea Welfare Panel Study (KOWEPS), a nationally representative dataset. We divided people with income less than 120% of the minimum cost of living (MCL) into three groups (n = 2,784): the poor enrolled in Medical-Aid, the poor not enrolled in Medical-Aid (at or below 100% of MCL), and the near poor (100-120% of MCL). Using a cross-sectional design, this study provides an overview of health care utilization and costs of these three groups. RESULTS The findings of the study suggest that significantly lower health care utilization was observed for the poor not enrolled in Medical-Aid compared to those enrolled in Medical-Aid. On the other hand, two groups (the poor not enrolled in Medical-Aid, the near poor) had higher health care costs, percentage of medical expenses to income compared to Medical-Aid. CONCLUSION Given the particularly low rate of the population enrolled in Medical-Aid, similarly economically vulnerable groups are more likely to face barriers to needed health services. Meeting the health needs of these groups is an important consideration.
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Affiliation(s)
- Jae Woo Choi
- Department of Public Health, Graduate School, Yonsei University, Seoul, Korea. .,Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea.
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea. .,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Sung-Youn Chun
- Department of Public Health, Graduate School, Yonsei University, Seoul, Korea. .,Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea.
| | - Kyu-Tae Han
- Department of Public Health, Graduate School, Yonsei University, Seoul, Korea. .,Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea.
| | - Euna Han
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Korea.
| | - Tae Hyun Kim
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea. .,Department of Hospital Administration, Graduate School of Public Health, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
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Brittin J, Elijah-Barnwell S, Nam Y, Araz O, Friedow B, Jameton A, Drummond W, Huang TTK. Community-Engaged Public Health Research to Inform Hospital Campus Planning in a Low Socioeconomic Status Urban Neighborhood. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2015; 8:12-24. [DOI: 10.1177/1937586715575908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To compare sociodemographic and motivational factors for healthcare use and identify desirable health-promoting resources among groups in a low socioeconomic status (SES) community in Chicago, IL. Background: Disparities in health services and outcomes are well established in low SES urban neighborhoods in the United States and many factors beyond service availability and quality impact community health. Yet there is no clear process for engaging communities in building resources to improve population-level health in such locales. Methods: A hospital building project led to a partnership of public health researchers, architects, and planners who conducted community-engaged research. We collected resident data and compared factors for healthcare use and choice and likelihood of engaging new health-promoting services. Results: Neighborhood areas were strongly associated with ethnic groupings, and there were differences between groups in healthcare choice and service needs, such as, proximity to home was more important to Latinos than African Americans in choice of healthcare facility ( padj = .001). Latinos expressed higher likelihood to use a fitness facility ( padj = .001). Despite differences in vehicle ownership, >75% of all respondents indicated that nearby public transportation was important in choosing healthcare. Conclusion: Knowledge of community needs and heterogeneity is essential to decision makers of facility and community development plans. Partnerships between public health, urban planning, architecture, and local constituents should be cultivated toward focus on reducing health disparities. Further work to integrate community perspectives through the planning and design process and to evaluate the long-term impact of such efforts is needed.
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Affiliation(s)
- Jeri Brittin
- Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
- HDR Architecture, Omaha, NE, USA
| | | | - Yunwoo Nam
- Community and Regional Planning, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Ozgur Araz
- Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
| | | | - Andrew Jameton
- Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
| | - Wayne Drummond
- College of Architecture, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Terry T.-K. Huang
- Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
- School of Public Health, City University of New York, New York, NY, USA
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Wilkin HA, Tannebaum MA, Cohen EL, Leslie T, Williams N, Haley LL. How community members and health professionals conceptualize medical emergencies: implications for primary care promotion. HEALTH EDUCATION RESEARCH 2012; 27:1031-1042. [PMID: 22907536 DOI: 10.1093/her/cys090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Access to continuous care through a primary care provider is associated with improved health outcomes, but many communities rely on emergency departments (EDs) for both emergent and non-emergent health problems. This article describes one portion of a community-based participatory research project and investigates the type of education that might be needed as part of a larger intervention to encourage use of a local primary care clinic. In this article we examine how people who live in a low-income urban community and the healthcare workers who serve them conceptualize 'emergency medical condition'. We conducted forum and focus group discussions with 52 community members and individual interviews with 32 healthcare workers. Our findings indicate that while community members share a common general definition of what constitutes a medical emergency, they also desire better guidelines for how to assess health problems as requiring emergency versus primary care. Pain, uncertainty and anxiety tend to influence their choice to use EDs rather than availability of primary care. Implications for increasing primary care use are discussed.
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Affiliation(s)
- Holley A Wilkin
- Department of Communication, Georgia State University, Atlanta, GA 30302-4000, USA.
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Cannoodt L, Mock C, Bucagu M. Identifying barriers to emergency care services. Int J Health Plann Manage 2012; 27:e104-20. [PMID: 22674816 DOI: 10.1002/hpm.1098] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE This paper aims to present a review of published evidence of barriers to emergency care, with attention towards both financial and other barriers. METHOD With the keywords (financial) accessibility, barriers and emergency care services, citations in PubMed were searched and further selected in the context of the objective of this article. RESULTS Forty articles, published over a period of 15 years, showed evidence of significant barriers to emergency care. These barriers often tend to persist, despite the fact that the evidence was published many years ago. Several publications stressed the importance of the financial barriers in foregoing or delaying potentially life-saving emergency services, both in poor and rich countries. Other publications report non-financial barriers that prevent patients in need of emergency care (pre-hospital and in-patient care) from seeking care, from arriving in the proper emergency department without undue delay or from receiving proper treatment when they do arrive in these departments. CONCLUSION It is clear that timely access to life-saving and disability-preventing emergency care is problematic in many settings. Yet, low-cost measures can likely be taken to significantly reduce these barriers. It is time to make an inventory of these measures and to implement the most cost-effective ones worldwide.
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Affiliation(s)
- Luk Cannoodt
- General Direction Department, University Hospitals K.U. Leuven, Leuven, Belgium.
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Woo JM, Gibbons RD, Rogers CA, Qin P, Kim JB, Roberts DW, Noh ES, Mann JJ, Postolache TT. Pollen counts and suicide rates. Association not replicated. Acta Psychiatr Scand 2012; 125:168-75. [PMID: 22176539 PMCID: PMC6452436 DOI: 10.1111/j.1600-0447.2011.01813.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To replicate a previously reported association between pollen counts and county suicide rates in the continental United States, across space and time. METHOD The authors evaluated the relationship between airborne pollen counts and suicide rates in 42 counties of the continental United States, containing a pollen-counting station participating in the Aeroallergen Monitoring Network in the United States (N = 120,076 suicides), considering years' quarter, age group, sex, race, rural/urban location, number of local psychiatrists, and median household income, from 1999 to 2002. The county-level effects were broken into between-county and within-county. RESULTS No within-county effects were found. Between-county effects for grass and ragweed pollen on suicide rates lost statistical significance after adjustment for median income, number of psychiatrists, and urban vs. rural location. CONCLUSION Future research is necessary to reappraise the previously reported relationship between pollen levels and suicide rates that may have been driven by socioeconomic confounders.
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Affiliation(s)
- J. M. Woo
- Mood and Anxiety Program (MAP), Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA,Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine,Stress Research Institute, Inje University, Seoul, Korea
| | - R. D. Gibbons
- Center for Health Statistics, University of Chicago, Chicago, IL
| | - C. A. Rogers
- Environmental Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - P. Qin
- National Centre for Register-Based Research, University of Aarhus, Aarhus C, Denmark
| | - J. B. Kim
- Center for Health Statistics, University of Chicago, Chicago, IL
| | | | - E. S. Noh
- Stress Research Institute, Inje University, Seoul, Korea
| | - J. J. Mann
- Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute and Columbia University, New York, NY, USA
| | - T. T. Postolache
- Mood and Anxiety Program (MAP), Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA,National Center for the Treatment of Phobias, Anxiety and Depression, Washington, DC, USA
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Parikh PB, Gruberg L, Jeremias A, Chen JJ, Naidu SS, Shlofmitz RA, Brener SJ, Pappas T, Marzo KP, Brown DL. Association of health insurance status with presentation and outcomes of coronary artery disease among nonelderly adults undergoing percutaneous coronary intervention. Am Heart J 2011; 162:512-7. [PMID: 21884869 DOI: 10.1016/j.ahj.2011.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 06/06/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine if insurance status is associated with adverse outcomes in patients with coronary artery disease. METHODS A cohort of 13,456 patients who underwent percutaneous coronary intervention (PCI) between January 1, 2004, and December 31, 2007, at 4 New York State teaching hospitals was retrospectively studied. The primary outcome of interest was in-hospital mortality from any cause. RESULTS Of the 13,456 patients studied, 11,927 (88.6%) were insured by private carriers, 1,036 (7.7%) patients were covered by Medicaid, and 493 (3.7%) were uninsured. Uninsured and Medicaid patients tended to be younger and more often nonwhite and Hispanic. They had a higher prevalence of congestive heart failure and worse left ventricular function. Compared with privately insured patients, uninsured and Medicaid patients had increased all-cause mortality (1.2% and 0.9%, respectively, vs 0.3%; P < .001). For all patients, lack of insurance (OR 3.02, 95% CI 1.10-8.28) and Medicaid (OR 4.39, 95% CI 1.93-9.99) were independently associated with mortality. Lack of insurance (OR 5.02, 95% CI 1.58-15.93) and Medicaid (OR 4.55, 95% CI 1.19-17.45) were also independently associated with increased mortality in patients undergoing emergent PCI. CONCLUSION Lack of insurance and Medicaid insurance are both independently associated with an increased risk of in-hospital mortality after PCI for coronary artery disease.
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Health care disparities in the acute management of venous thromboembolism based on insurance status in the U.S. J Thromb Thrombolysis 2011; 32:393-8. [DOI: 10.1007/s11239-011-0632-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Baggett TP, O'Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a national study. Am J Public Health 2010; 100:1326-33. [PMID: 20466953 DOI: 10.2105/ajph.2009.180109] [Citation(s) in RCA: 301] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the prevalence and predictors of past-year unmet needs for 5 types of health care services in a national sample of homeless adults. METHODS We analyzed data from 966 adult respondents to the 2003 Health Care for the Homeless User Survey, a sample representing more than 436,000 individuals nationally. Using multivariable logistic regression, we determined the independent predictors of each type of unmet need. RESULTS Seventy-three percent of the respondents reported at least one unmet health need, including an inability to obtain needed medical or surgical care (32%), prescription medications (36%), mental health care (21%), eyeglasses (41%), and dental care (41%). In multivariable analyses, significant predictors of unmet needs included food insufficiency, out-of-home placement as a minor, vision impairment, and lack of health insurance. Individuals who had been employed in the past year were more likely than those who had not to be uninsured and to have unmet needs for medical care and prescription medications. CONCLUSIONS This national sample of homeless adults reported substantial unmet needs for multiple types of health care. Expansion of health insurance may improve health care access for homeless adults, but addressing the unique challenges inherent to homelessness will also be required.
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Affiliation(s)
- Travis P Baggett
- General Medicine Division, Massachusetts General Hospital, Boston, MA 02114, USA.
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Subjective unmet need and utilization of health care services in Canada: what are the equity implications? Soc Sci Med 2009; 70:465-472. [PMID: 19914759 DOI: 10.1016/j.socscimed.2009.10.027] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Indexed: 11/23/2022]
Abstract
This study aimed to evaluate whether subjective assessments of unmet need may complement conventional methods of measuring socioeconomic inequity in health care utilization. This study draws on the 2003 Canadian Community Health Survey to develop a conceptual framework for understanding how unmet need arises, to empirically assess the association between utilization and the different types of unmet need (due to waiting times, barriers and personal reasons), and to investigate the effect of adjusting for unmet need on estimates of income-related inequity. The study's findings suggest that a disaggregated approach to analyzing unmet need is required, since the three different subgroups of unmet need that we identify in Canada have different associations with utilization, along with different equity implications. People who report unmet need due to waiting times use more health services than would be expected based on their observable characteristics. However, there is no consistent pattern of utilization among people who report unmet need due to access barriers, or for reasons related to personal choice. Estimates of inequity remain unchanged when we incorporate information on unmet need in the analysis. Subjective assessments of unmet need, namely those that relate to barriers to access, provide additional policy-relevant information that can be used to complement conventional methods of measuring inequity, to better understand inequity, and to guide policy action.
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Jatrana S, Crampton P. Primary health care in New Zealand: Who has access? Health Policy 2009; 93:1-10. [DOI: 10.1016/j.healthpol.2009.05.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 04/22/2009] [Accepted: 05/06/2009] [Indexed: 11/30/2022]
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Abstract
This study identified the underlying demographic and socioeconomic factors associated with insurance status among nonelderly Americans (age 19-64), as well as compared health care utilization between insured and uninsured. Data from the Community Tracking Study 1996-1997 Household Survey were analyzed. Approximately 74 percent of uninsured Americans are nonelderly Americans. Among the nonelderly Americans, about 17 percent are uninsured. Our findings show that insurance status varies significantly by region, age, race, gender, marital status, income, education, employment status, and health status. Also, the insured nonelderly Americans were found to have better access to health care than the uninsured nonelderly.
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de Silveira ASA, da Silva BMF, Peres EC, Meneghin P. [Immunization control and student registration at the city of São Paulo's Municipal Schools of Infantile Education]. Rev Esc Enferm USP 2007; 41:299-305. [PMID: 17722398 DOI: 10.1590/s0080-62342007000200018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
The presentation of the vaccination passbook is mandatory for student registration at the city of São Paulo's Municipal Schools of Infantile Education, as a form of stimulating parents to keep their children's immunizations calendar updated. However, attendants do not verify periodically if the vaccinations are correct. In order to overcome this problem, a project with the aim of facilitating the immunization control through a software that controls immunizations was tested at a Municipal School of Infantile Education. Of the 286 pupils registered in the system, 236 (82.5%) were notified that their vaccines were incomplete. Of these, 21.2% updated their vaccinations, 2.5% returned their passbooks unchanged, and the remainders were still in the process of updating. The program identified the imperfections and encouraged immunization, thus helping to prevent the propagation of transmissible diseases in the school environment.
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Geyman JP. Moral hazard and consumer-driven health care: a fundamentally flawed concept. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2007; 37:333-51. [PMID: 17665727 DOI: 10.2190/j354-150m-ng76-7340] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
For more than 30 years, most health care economists in the United States have accepted a conventional theory of health insurance based on the concept of moral hazard: an assumption is made that insured people overuse health care services because they have insurance. The recent trend toward "consumer-driven health care" (CDHC) is advocated by its supporters based on this same premise, assuming that imprudent choices by patients can be avoided if they are held more financially responsible for their health care choices through larger co-payments and deductibles and other restrictions. This article examines how moral hazard-based CDHC plays out in both private plans and public programs. The author identifies seven ways in which this concept fails the public interest, while also failing to control health care costs. Uninsured and underinsured people, now including many in the middle class, underuse essential health care services, resulting in increased morbidity and more preventable hospitalizations and deaths among these groups than their more affluent counterparts. A case is made to reject moral hazard as an organizing rationale for health care, and the author offers some alternative approaches.
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Affiliation(s)
- John P Geyman
- Department of Family Medicine, University of Washington School of Medicine, Seattle 98195, USA.
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McAlearney AS, Reeves KW, Tatum C, Paskett ED. Cost as a barrier to screening mammography among underserved women. ETHNICITY & HEALTH 2007; 12:189-203. [PMID: 17364901 PMCID: PMC4465254 DOI: 10.1080/13557850601002387] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Breast cancer is a troublesome health problem, particularly among underserved and minority women. Early detection through screening mammography can reduce the impact of this disease, yet it remains underused. Objective. We examined cost as a barrier to screening mammography and studied the accuracy of women's perceptions of the cost of a mammogram among a rural, low-income, tri-racial (white, Native American and African American) population in need of a mammogram. DESIGN We interviewed 897 women age 40 and older, asking about cost as a barrier to mammography and perceptions about the actual costs of a screening mammogram. Face-to-face interviews were conducted between 1998 and 2000 among women participating in a randomized, controlled study to evaluate a health education intervention to improve mammography screening rates in an underserved population. All data used in these analyses were from the baseline interviews. RESULTS Cost acted as a barrier to screening mammography for a majority of the participants (53%). More than half of these women (52%), however, overestimated the cost of a screening mammogram, and overestimation of the cost was significantly related to mentioning cost as a barrier (OR 1.56, 95% CI 1.04-2.33). Higher estimates of out-of-pocket costs were associated with reporting cost as a barrier to mammography (OR 2.25, 95% CI 1.43-3.52 for $1-50 and OR 12.64, 95% CI 6.61-24.17 for >$50). Factors such as race, income and employment status were not related to reporting cost as a barrier to screening mammography. CONCLUSIONS Among a group of tri-racial, low-income, rural women who were in need of a mammogram, cost was a common barrier. Overestimating the cost, however, was significantly and positively associated with reporting cost as a barrier. Providing information about the actual cost women have to pay for mammograms may lessen the role of cost as a barrier to mammography screening, especially for underserved women, potentially improving utilization rates.
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Affiliation(s)
- Ann Scheck McAlearney
- Division of Health Services, Management and Policy, College of Public Health, The Ohio State University, Columbus, OH 43210, USA.
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Kennedy J, Morgan S. Health care access in three nations: Canada, insured America, and uninsured America. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2007; 36:697-717. [PMID: 17175842 DOI: 10.2190/ec30-kp22-ra84-ral4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This analysis provides new statistics for one of the oldest and fiercest debates in American health policy: whose residents have better access to health care, the United States' or Canada's? Data from the 2002-2003 Joint Canada U.S. Survey of Health show that, despite major differences in their health systems, most Canadians and Americans get the care they need. However, one group of Americans is much more likely to report serious access barriers--the uninsured. About one-third of currently or recently uninsured Americans, aged 18 to 64, said they could not get needed health care (over three times the rate of insured Americans or Canadians). Compared with Canadians and insured Americans, the uninsured are less likely to use hospital or physician services, and those who do are less satisfied with the care they receive. They are also less likely to purchase prescribed medications, due to cost. From a consumer perspective, the most salient feature of the Canadian system is its universality. In contrast, insured Americans under age 65 are at risk of losing their insurance and facing substantial access barriers.
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Affiliation(s)
- Jae Kennedy
- Department of Health Policy and Adminstration, Washington State University, Spokane 99210, USA.
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Malat JR, van Ryn M, Purcell D. Race, socioeconomic status, and the perceived importance of positive self-presentation in health care. Soc Sci Med 2006; 62:2479-88. [PMID: 16368178 DOI: 10.1016/j.socscimed.2005.11.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Indexed: 11/16/2022]
Abstract
Hundreds of studies have documented disparities in medical treatment in the USA. These findings have generated research and initiatives intended to understand and ameliorate such disparities. Many articles examine disadvantaged patients' beliefs and attitudes toward health care, but generally limit their investigation to how these beliefs and attitudes influence adherence and utilization. Thus, this approach fails to consider whether patients use particular strategies to overcome providers' potentially negative perceptions of them and/or obtain quality medical care. In this paper, we examine positive self-presentation as a strategy that may be used by disadvantaged groups to improve their medical treatment. Analysis of survey data (the 2004 Greater Cincinnati Survey) suggests that both African Americans and lower socioeconomic status persons are more likely than whites or higher socioeconomic status persons to report that positive self-presentation is important for their getting the best medical care. Based on these findings, we suggest several routes for future research that will advance our understanding of patients' everyday strategies for getting the best health care.
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Boucher F, Schenker MB. Cervical cancer among Hispanic women: assessing the impact on farmworkers. ACTA ACUST UNITED AC 2006; 4:159-65. [PMID: 16228759 DOI: 10.1023/a:1015603018296] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The purpose of this paper was to review the literature on Hispanic populations to outline: 1) demographics; 2) general health status; 3) cervical cancer incidence and mortality; 4) Pap smear screening rates; and 5) barriers to preventive care services. The methods: MEDLINE, Med66, Med75, and Med85 files, from 1966 to 1999, were searched for key words Hispanic health, cervical cancer and Hispanics, cervical cancer and Mexico, migrants and health, agricultural occupational health, farmworkers and cancer, and farmworker health. AGRICOLA (1982-98) was searched for key words farmworker health, agricultural workers and health, and agriculture and cancer. The results show that Hispanic immigrant women may have cervical cancer incidence rates ranging between the California rates for 1991-93 (19.8/100,000) and for Mexico in 1990 (115-220 per 100,000). Mortality rates for the same periods were 3.9/100,000 and 16.11/100,000 respectively. While survey results report Hispanic Pap smear rates above 70%, these surveys count urban women who do not share the barriers to care experienced by poor rural Hispanics. Since validated self-reports of survey responses are 20-50% lower than reported lower rates and Pap smear screening persist in Hispanic Pap evaluations and are reflected in higher morbidity and mortality from cervical cancer. That targeted community interventions have been successful in raising Pap smear rates among poor Spanish-speaking women. Such interventions should be a priority for preventive health care policy and practice.
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Affiliation(s)
- Faith Boucher
- Department of Epidemiology and Preventive Medicine, University of California at Davis, Davis, California 95616, USA.
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Slater JS, Henly GA, Ha CN, Malone ME, Nyman JA, Diaz S, McGovern PG. Effect of direct mail as a population-based strategy to increase mammography use among low-income underinsured women ages 40 to 64 years. Cancer Epidemiol Biomarkers Prev 2005; 14:2346-52. [PMID: 16214915 DOI: 10.1158/1055-9965.epi-05-0034] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Women with inadequate health insurance have lower mammography rates than the general population. Finding successful strategies to enroll eligible women is an ongoing challenge for the National Breast and Cervical Cancer Early Detection Program. To test the effectiveness of a population-based strategy to increase mammography utilization among low-income underinsured women ages 40 to 64 years, a randomized trial was conducted to assess the effect of two mailed interventions on mammography utilization through Sage, the National Breast and Cervical Cancer Early Detection Program in Minnesota. Women (N = 145,467) ages 40 to 63 years [mean (SD), 49.7 (6.8)] with estimated household incomes below 50,000 US dollars (47.9% were < 35,000 US dollars) from a commercial database were randomized to three groups: Mail, Mail Plus Incentive, or Control. Both the Mail and the Mail Plus Incentive groups received two simple mailings prompting them to call a toll-free number to access free mammography services. The Mail Plus Incentive intervention offered a small monetary incentive for a completed mammogram. After 1 year, both intervention groups had significantly higher Sage mammography rates than the Controls, and the Mail Plus Incentive group had a significantly higher rate than the Mail group. The Mail and Mail Plus Incentive interventions were estimated to produce increases in Sage screening rates of 0.23% and 0.75%, respectively, beyond the composite Control rate of 0.83%. Direct mail is an effective strategy for increasing mammography use through Sage. Coupling direct mail with an incentive significantly enhances the intervention's effectiveness. Direct mail should be considered as a strategy to increase mammography use among low-income, medically underserved women.
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Affiliation(s)
- Jonathan S Slater
- Cancer Control Section, Minnesota Department of Health, 717 Delaware Street Southeast, P.O. Box 9441, Minneapolis, MN 55440-9441, USA.
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Flores G, Abreu M, Chaisson CE, Meyers A, Sachdeva RC, Fernandez H, Francisco P, Diaz B, Diaz AM, Santos-Guerrero I. A randomized, controlled trial of the effectiveness of community-based case management in insuring uninsured Latino children. Pediatrics 2005; 116:1433-41. [PMID: 16322168 DOI: 10.1542/peds.2005-0786] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Lack of health insurance adversely affects children's health. Eight million US children are uninsured, with Latinos being the racial/ethnic group at greatest risk for being uninsured. A randomized, controlled trial comparing the effectiveness of various public insurance strategies for insuring uninsured children has never been conducted. OBJECTIVE To evaluate whether case managers are more effective than traditional methods in insuring uninsured Latino children. DESIGN Randomized, controlled trial conducted from May 2002 to August 2004. SETTING AND PARTICIPANTS A total of 275 uninsured Latino children and their parents were recruited from urban community sites in Boston. INTERVENTION Uninsured children were assigned randomly to an intervention group with trained case managers or a control group that received traditional Medicaid and State Children's Health Insurance Program (SCHIP) outreach and enrollment. Case managers provided information on program eligibility, helped families complete insurance applications, acted as a family liaison with Medicaid/SCHIP, and assisted in maintaining coverage. MAIN OUTCOME MEASURES Obtaining health insurance, coverage continuity, the time to obtain coverage, and parental satisfaction with the process of obtaining insurance for children were assessed. Subjects were contacted monthly for 1 year to monitor outcomes by a researcher blinded with respect to group assignment. RESULTS One hundred thirty-nine subjects were assigned randomly to the intervention group and 136 to the control group. Intervention group children were significantly more likely to obtain health insurance (96% vs 57%) and had approximately 8 times the adjusted odds (odds ratio: 7.78; 95% confidence interval: 5.20-11.64) of obtaining insurance. Seventy-eight percent of intervention group children were insured continuously, compared with 30% of control group children. Intervention group children obtained insurance significantly faster (mean: 87.5 vs 134.8 days), and their parents were significantly more satisfied with the process of obtaining insurance. CONCLUSIONS Community-based case managers are more effective than traditional Medicaid/SCHIP outreach and enrollment in insuring uninsured Latino children. Case management may be a useful mechanism to reduce the number of uninsured children, especially among high-risk populations.
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Affiliation(s)
- Glenn Flores
- Center for the Advancement of Underserved Children, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Greene J, Blustein J, Remler D. The impact of Medicaid managed care on primary care physician participation in Medicaid. Med Care 2005; 43:911-20. [PMID: 16116356 DOI: 10.1097/01.mlr.0000173598.85217.7f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Medicaid managed care has been touted as an important vehicle for increasing physician participation in Medicaid. Although there is anecdotal evidence that the opportunity to participate in Medicaid via managed care increases physician participation, no empirical study has validated the claim. This study explores the relationship between Medicaid managed care penetration at the county-level and the likelihood that a physician practicing in that county will participate in Medicaid. RESEARCH DESIGN We used 3 waves of a large, nationally representative sample of primary care physicians from the Community Tracking Study followed across time (1996-2001) to estimate the impact of changing Medicaid managed care penetration levels on physician participation in the program. County-level Medicaid managed care penetration rates were collected directly from state Medicaid agencies for the study. FINDINGS In cross-sectional bivariate and multivariate analyses, Medicaid managed care penetration is significantly associated with physician participation in Medicaid; however, the relationship is nonmonotonic, of small magnitude and generally not in the anticipated direction. Our analyses indicate that a 10 percentage point increase in managed care penetration would reduce the likelihood that physicians participate in Medicaid on average by 2.9 percentage points. Although commercial MCO penetration exhibited a small positive, linear relationship with physician participation, this was not sufficient to offset the effects of Medicaid-dominant MCO penetration. Panel data analysis supported these findings. CONCLUSIONS This study failed to find that increases in Medicaid managed care lead to increased primary care physician participation in Medicaid during the period 1996-2001.
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Affiliation(s)
- Jessica Greene
- Department of Planning, Public Policy and Management, University of Oregon, Eugene, OR 97403, USA.
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Shone LP, Dick AW, Klein JD, Zwanziger J, Szilagyi PG. Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program. Pediatrics 2005; 115:e697-705. [PMID: 15930198 DOI: 10.1542/peds.2004-1726] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Racial/ethnic disparities are associated with lack of health insurance. Although the State Children's Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll. OBJECTIVES The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors. METHODS Pre/post-parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York State's SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP. RESULTS Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured > or =12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period. CONCLUSIONS Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.
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Affiliation(s)
- Laura P Shone
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642, USA.
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Breast and cervical cancer screening: impact of health insurance status, ethnicity, and nativity of Latinas. Ann Fam Med 2005; 3:235-41. [PMID: 15928227 PMCID: PMC1466881 DOI: 10.1370/afm.291] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Although rates of cancer screening for Latinas are lower than for non-Latina whites, little is known about how insurance status, ethnicity, and nativity interact to influence these disparities. Using a large statewide database, our study examined the relationship between breast and cervical cancer screening rates and socioeconomic and health insurance status among foreign-born Latinas, US-born Latinas, and non-Latina whites in California. METHODS Data from the1998 California Women's Health Survey (CWHS) were analyzed (n = 3,340) using multiple logistic regression models. Utilization rates of mammography, clinical breast examinations, and Papanicolaou (Pap) smear screening among foreign-born Latinas, US-born Latinas, and non-Latina whites were the outcome measures. RESULTS Foreign-born Latinas had the highest rates of never receiving mammography, clinical breast examinations, and Pap smears (21%, 24%, 9%, respectively) compared with US-born Latinas (12%, 11%, 7%, respectively) and non-Latina whites (9%, 5%, 2%, respectively). After controlling for socioeconomic factors, foreign-born Latinas were more likely to report mammography use in the previous 2 years and Pap smear in the previous 3 years than non-Latina whites. Lack of health insurance coverage was the strongest independent predictor of low utilization rates for mammography (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.53-2.76), clinical breast examinations (OR = 2.29; 95% CI, 1.80-2.90) and Pap smears (OR = 2.89; 95% CI, 2.17-3.85.) CONCLUSIONS Breast and cervical cancer screening rates vary by ethnicity and nativity, with foreign-born Latinas experiencing the highest rates of never being screened. After accounting for socioeconomic factors, differences by ethnicity and nativity are reversed or eliminated. Lack of health insurance coverage remains the strongest predictor of cancer screening underutilization.
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Abstract
OBJECTIVE To provide an assessment of how well the Medicaid program is working at improving access to and use of health care for low-income mothers. DATA SOURCE/STUDY SETTING The 1997 and 1999 National Survey of America's Families, with state and county information drawn from the Area Resource File and other sources. STUDY DESIGN Estimate the effects of Medicaid on access and use relative to private coverage and being uninsured, using instrumental variables methods to control for selection into insurance status. DATA COLLECTION/EXTRACTION METHOD This study combines data from 1997 and 1999 for mothers in families with incomes below 200 percent of the federal poverty level. PRINCIPAL FINDINGS We find that Medicaid beneficiaries' access and use are significantly better than those obtained by the uninsured. Analysis that controls for insurance selection shows that the benefits of having Medicaid coverage versus being uninsured are substantially larger than what is estimated when selection is not accounted for. Our results also indicate that Medicaid beneficiaries' access and use are comparable to that of the low-income privately insured. Once insurance selection is controlled for, access and use under Medicaid is not significantly different from access and use under private insurance. Without controls for insurance selection, access and use for Medicaid beneficiaries is found to be significantly worse than for the low-income privately insured. CONCLUSIONS Our results show that the Medicaid program improved access to care relative to uninsurance for low-income mothers, achieving access and use levels comparable to those of the privately insured. Our results also indicate that prior research, which generally has not controlled for selection into insurance coverage, has likely understated the gains of Medicaid relative to uninsurance and overstated the gains of private coverage relative to Medicaid.
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Affiliation(s)
- Sharon K Long
- Health Policy Center, The Urban Institute, Washington, DC 20037, USA
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Gifford EJ, Weech-Maldonado R, Short PF. Low-income children's preventive services use: implications of parents' Medicaid status. HEALTH CARE FINANCING REVIEW 2005; 26:81-94. [PMID: 17288070 PMCID: PMC4194911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This article examines the effect of parents' Medicaid status on the use of preventive health services by young children. Using data from the 1996 Medical Expenditure Panel Survey (MEPS), we analyzed a logit model for receipt of any well-child visits (WCVs) that compared three groups of low-income children. The three groups, defined by the joint insurance status of children and their parents, involved Medicaid pairs (both the child and the parent had Medicaid throughout the year), mixed pairs (the child had Medicaid and the parent was uninsured), and uninsured pairs (both child and parent were uninsured). Medicaid coverage for children was positively associated with receipt of any WCVs. However, the utilization effect of Medicaid coverage for children was significantly larger when the parent was also on Medicaid instead of being uninsured. Considering uninsured children with uninsured parents in 1996, enrolling only the children in Medicaid would have increased the percentage with WCVs from 29 to 43 percent according to simulations with the logit model. If the parents were enrolled in Medicaid as well, the percentage of children with any WCVs would have increased to 67 percent.
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Selassie AW, Pickelsimer EE, Frazier L, Ferguson PL. The effect of insurance status, race, and gender on ED disposition of persons with traumatic brain injury. Am J Emerg Med 2004; 22:465-73. [PMID: 15520941 DOI: 10.1016/j.ajem.2004.07.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The objective of this study was to assess the effect of insurance status and demographic characteristics on ED disposition among patients with traumatic brain injury (TBI). Statewide hospital discharge and ED datasets in South Carolina, 1996-2001, were analyzed by primary or secondary diagnosis of TBI in a multivariable logistic regression model. Of 70,671 unduplicated patients with TBI evaluated in the ED, 76% were treated and released; 26% had no insurance. The strongest predictors of hospital admission were TBI severity and preexisting health conditions. However, the uninsured and black females were less likely to be hospitalized after adjusting for demographic, clinical, and hospital characteristics (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.48-0.55 and OR, 0.79; CI, 0.72-0.87, respectively). Although this study does not infer causality, insurance status, race, and gender were significant predictors of hospital admission. These results suggest that inpatient resources are not equitably used.
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Affiliation(s)
- Anbesaw Wolde Selassie
- Department of Biometry and Epidemiology, Medical University of South Carolina, Charleston 29425, USA.
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Fisher DA, Martin C, Galanko J, Sandler RS, Noble MD, Provenzale D. Risk factors for advanced disease in colorectal cancer. Am J Gastroenterol 2004; 99:2019-24. [PMID: 15447766 DOI: 10.1111/j.1572-0241.2004.40010.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The goal of this study was to identify predictors of presenting with late-stage colorectal cancer with a focus on potentially modifiable factors. METHODS This was a multicenter, case-based study of patients with colorectal cancer. Detailed information about the cancer was abstracted from the tumor registries, pathology reports, and medical records. The remaining information was obtained by telephone interview. Inclusion criteria were age 40-85 yr with a first diagnosis of histologically proven colorectal cancer between July 1, 1997 and January 1, 2001. Simple contingency table methods were used to examine the relationship between potential risk factors for early versus advanced-stage disease. Logistic regression was performed to simultaneously control for potential confounding factors. RESULTS There was complete information for 549 respondents. Approximately, 43% of the sample presented with late-stage colorectal cancer. In univariate analysis, lacking a usual source of health care (doctor's office or clinic), no participation in any colorectal cancer screening test in the prior 10 yr, symptoms of blood in stool, and unexplained weight loss were associated with late-stage colorectal cancer. In the logistic regression model, only lacking a usual source of healthcare and unexplained weight loss were associated with late-stage colorectal cancer with odds ratios (95% confidence intervals) of 0.4 (0.2-0.6) and 1.9 (1.2-3.0), respectively. CONCLUSIONS These results suggest that system changes in the VA health-care system that increase access to and improve utilization of primary care may reduce presentation with late-stage colorectal cancer and thus, reduce mortality from colorectal cancer in veterans.
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Affiliation(s)
- Deborah A Fisher
- Institute for Clinical and Epidemiological Research, Durham VAMC (Veterans Affairs Medical Center), Durham, NC 27705, USA
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Diamant AL, Hays RD, Morales LS, Ford W, Calmes D, Asch S, Duan N, Fielder E, Kim S, Fielding J, Sumner G, Shapiro MF, Hayes-Bautista D, Gelberg L. Delays and unmet need for health care among adult primary care patients in a restructured urban public health system. Am J Public Health 2004; 94:783-9. [PMID: 15117701 PMCID: PMC1448338 DOI: 10.2105/ajph.94.5.783] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We estimated the prevalence and determinants of delayed and unmet needs for medical care among patients in a restructured public health system. METHODS We conducted a stratified cross-sectional probability sample of primary care patients in the Los Angeles County Department of Health Services. Face-to-face interviews were conducted with 1819 adult patients in 6 languages. The response rate was 80%. The study sample was racially/ethnically diverse. RESULTS Thirty-three percent reported delaying needed medical care during the preceding 12 months; 25% reported an unmet need for care because of competing priorities; and 46% had either delayed or gone without care. CONCLUSIONS Barriers to needed health care continue to exist among patients receiving care through a large safety net system. Competing priorities for basic necessities and lack of insurance contribute importantly to unmet health care needs.
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Affiliation(s)
- Allison L Diamant
- Division of General Internal Medicine and Health Services Research, University of California-Los Angeles, 911 Broxton Avenue, Los Angeles, CA 90095-1736, USA.
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Szilagyi PG, Dick AW, Klein JD, Shone LP, Zwanziger J, McInerny T. Improved access and quality of care after enrollment in the New York State Children's Health Insurance Program (SCHIP). Pediatrics 2004; 113:e395-404. [PMID: 15121980 DOI: 10.1542/peds.113.5.e395] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although many studies have noted that uninsured children have poorer access and quality of health care than do insured children, few studies have been able to demonstrate the direct benefits of providing health insurance to previously uninsured children. The State Children's Health Insurance Program (SCHIP), enacted as Title XXI of the Social Security Act, was intended to improve insurance coverage and access to health care for low-income, uninsured children. With limited state and federal resources for health care, continued funding of SCHIP requires demonstration of success of the program. As yet, little is known about the effectiveness of SCHIP on improving access and quality of care to enrollees. OBJECTIVES To measure the impact of the New York State (NYS) SCHIP on access, utilization, and quality of health services for enrolled children. DESIGN SETTING NYS, stratified into 4 regions. The NYS SCHIP is modeled on commercial insurance (32 managed care plans) and at the time of the study had 18% of SCHIP enrollees nationwide. STUDY DESIGN For the study group, the design used pre/poststudy telephone interviews of parents of children enrolling in the NYS SCHIP, with baseline interviews soon after enrollment and follow-up interviews 1 year after enrollment. Baseline interviews reflected the child's experience during the 1-year period before enrollment in SCHIP. The follow-up interviews reflected the 1-year period after enrollment in SCHIP. For the comparison group, the design used baseline interviews of a comparison group enrolled 1 year after the study group to test for secular trends; these interviews reflected the 1-year period before enrollment in SCHIP. SUBJECTS Children (n = 2644) 0 to 18 years of age who enrolled in the NYS SCHIP for the first time (November 2000 to March 2001), stratified by age (0-5, 6-11, and 12-18 years), race/ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic; others excluded), and region of NYS. The comparison group consisted of 400 children. Telephone interviews were conducted in English or Spanish throughout the day and evening, 7 days per week, to obtain measures. MAIN OUTCOME MEASURES Demographic and health measures (child and family characteristics, health status, presence of a special health care need, and prior health insurance), access (usual source of care [USC] and unmet needs for health care), utilization (visits for specific health services), and quality (continuity with USC and measures of primary care interactions). Analyses included bivariate tests, comparing the pre-SCHIP period to the 1-year period after enrollment in SCHIP. Multivariate models were computed to generate standardized populations comprised of key characteristics of the sample to test for differences in measures (after SCHIP versus before SCHIP), controlling for demographic characteristics. RESULTS Of the 2644 study-group children who completed the initial interview, 2290 (87%) completed the follow-up interview. Key measures for the pre-SCHIP period and short-term "postenrollment" measures for the study group were not statistically different from measures for the comparison group, suggesting no major secular trends. Participants were non-Hispanic white (25%), non-Hispanic black (31%), and Hispanic (45%). Fifty-one percent of the parents were single, and 61% had a high school education or less; 81% of families had income <160% of the federal poverty level. Sixty-two percent of the children were uninsured > or = 12 months before the NYS SCHIP; of those insured, 43% previously had Medicaid. The proportion of children who had a USC increased after enrollment in the NYS SCHIP (86% to 97%). Two measures of accessibility (difficulty getting a medical person by telephone and difficulty getting an appointment) improved after enrollment in SCHIP. The proportion of children with any unmet health care needs decreased (31% to 19%). Specific types of unmet need also were reduced after enrollment; for example, among SCHIP enrollees who had a need for specific type of care, unmet needs wds were significantly lower postenrollment versus pre-SCHIP for specialty care (-15.5% in unmet need), acute care (-10.1%), preventive care (-9.6%), dental care (-13.0%%), and vision care (-13.2%). Emergency and total ambulatory visits did not change, but the proportion of children with a preventive care visit increased (74% to 82%). The proportion of children who used their USC for most or all visits increased (47% to 89%), demonstrating increased continuity of care. Several indicators of health care quality improved, including an overall rating of quality, the 4 indicators of physician-patient interaction used by the Consumer Assessment of Health Plans Survey, and a measure of parental worry about their child's health. Improvements were noted among major subgroups of children, with the greatest improvements for those with the lowest baseline levels. For example, at baseline, a lower percentage of children living at <160% of the federal poverty level had a presence of a USC or continuity with their USC than children living in families at >160% of the federal poverty level, and these poorer children experienced the greatest gains in having a USC or having continuity with their USC after enrollment in SCHIP. CONCLUSIONS Enrollment in the NYS SCHIP was associated with 1) improved access, continuity, and quality of care and 2) a change in the pattern of health care, with a greater proportion of care taking place within the usual source of primary care.
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Affiliation(s)
- Peter G Szilagyi
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
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Pandey SK, Cantor JC. The changing profile of the urban uninsured: exploring implications of rise in the number of moderate-income uninsureds. J Urban Health 2004; 81:135-49. [PMID: 15047792 PMCID: PMC3456142 DOI: 10.1093/jurban/jth090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Access to care is a major problem in urban America that increasingly affects new segments of the population. Although the demographic profile of the uninsured has changed, recording large increases in numbers of moderate-income uninsured persons, it has not been accompanied by changes in health care safety net programs or increased availability of private insurance products tailored to these groups. Any such changes, however, need to be based on a good understanding of the similarities and differences between low-income and moderate-income uninsured. Based on a telephone survey of the uninsured in three northern New Jersey counties, this study presents a systematic comparison of low-income (below 150% of federal poverty level) and moderate-income (150% to 350% federal poverty level) uninsured on attitudes to health care, perceptions regarding access to care, health status, and health care utilization. We discuss the implications of this comparison for expanding health care access and design of safety net programs and institutions.
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Affiliation(s)
- Sanjay K Pandey
- Dept. of Public Policy and Administration, Rutgers University, 401 Cooper Street, Camden, NJ 08102-1521, USA.
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Abstract
Four clinical nurse specialists (CNSs) were funded for a project to increase breast cancer (BC) screening practices and the knowledge of BC risk factors for women in 4 medically underserved rural counties. The goal was to implement a program to increase knowledge of breast health practices, increase access to mammography, establish linkages among CNSs and community organizations, and increase resources for breast health education and screening. Phase I: A training program (focusing on breast health, breast cancer, and screening) was presented to public health nurses from each of the 4 counties. Phase II: Project and public health nurses teamed to provide an education and screening program for rural area women. The program involved making mammograms available at no cost through a mobile mammography unit that was brought to each county. Mammograms and educational programs were provided to 141 women. The project team was clearly able to function as both clinical experts and clinical leaders. The spheres of influence for these 4 CNSs included patient/client (rural women), nursing personnel (county health department nurses), and organization/network (state health department and governmental bodies). This project, based on the Logic Model, can serve as a framework for delivering care in underserved, rural populations.
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Affiliation(s)
- Adrianne Lane
- University of Cincinnati College of Nursing, Cincinnati, Ohio 45221, USA
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Kessler TA, Alverson E. Health concerns and learning styles of underserved and uninsured clients at a nurse managed center. J Community Health Nurs 2003; 20:81-92. [PMID: 12738575 DOI: 10.1207/s15327655jchn2002_02] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The medically underserved and uninsured often seek care for immediate health concerns rather than use health promotion activities. To facilitate health promotion activities, it is important to understand the health concerns and learning styles of these underserved clients. The purpose of this descriptive study was to assess specific health concerns and identify learning styles of clients seeking care at a nurse managed center. Eighty-two participants completed the Hilltop Health Questionnaire, a self-report instrument developed by the research team. Top reasons for seeking care included upper respiratory infections (17%), routine physical (17%), medication refill (12%), and low back pain (11%). Preference for learning style included hands-on instruction (82%), reading (63%), and listening (59%). These data were used to obtain or customize teaching modules based on the clients' health concerns and preferred style of learning. Continued emphasis should be placed on health education that engages the underserved and uninsured in their care and health promotion activities.
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Affiliation(s)
- Theresa A Kessler
- College of Nursing, Valparaiso University, 836 LaPorte Avenue, Valparaiso, IN 46383, USA.
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Abstract
BACKGROUND Medicaid insurance promotes screening for early stage cancers. However, previous research suggests that Medicaid recipients are at risk for late stage disease. OBJECTIVE To identify differences in stage of diagnosis between cancer patients enrolled in Medicaid before versus after their disease was identified, as well as differences in diagnostic stage between Medicaid enrollees and other patients. DESIGN Analyses of a linked database including information from the 1996 and 1997 Michigan Cancer Registry and Medicaid enrollment files. PATIENTS All persons ages 25 to 64 diagnosed with incident cases of breast, cervical, colorectal, or lung cancer (n = 5852). Patients enrolled in Medicaid before their cancer diagnosis and those enrolled in the same month or after their diagnosis were identified. MAIN OUTCOME MEASURE Early (in situ, local) versus late (regional, distant, invasive/unknown) cancer stage at diagnosis was modeled using multivariate logistic regression. RESULTS In each site of disease with the exception of breast, persons who enrolled in Medicaid after a cancer diagnosis were approximately 2 to 3 times more likely to have late stage disease compared with persons who were enrolled in Medicaid before the month of diagnosis. Odds ratios (OR) and 95% confidence intervals (C.I.) were: 1.28 (95% C.I. = 0.95, 1.67) for breast cancer, 2.96 (95% C.I. = 1.85, 4.75) for cervical cancer, 2.08 (95% C.I. = 1.30, 3.33) for colorectal cancer, and 3.40 (95% C.I. = 2.13, 5.43) for lung cancer. Relative to non-Medicaid enrollees, Medicaid enrollees were 2 to 5 times more likely to be diagnosed with late stage disease. CONCLUSIONS Cancer patients enrolled in Medicaid after their diagnosis were disproportionately likely to have late stage disease relative to patients previously enrolled in Medicaid or non-Medicaid enrollees.
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Affiliation(s)
- Cathy J Bradley
- Department of Medicine, Michigan State University, East Lansing 48824, USA.
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Schulz MA, Ludwick R, Cukr PL, Kelly D. Outcomes of a community-based three-year breast and cervical cancer screening program for medically underserved, low income women. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2002; 14:219-24. [PMID: 12051146 DOI: 10.1111/j.1745-7599.2002.tb00117.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate a community level three-year breast and cervical cancer screening program for medically underserved, low income women. DATA SOURCES Descriptive data on 128 women gathered from five semiannual screening programs held between 1995 and 1997 were analyzed. CONCLUSIONS Poor and medically under served women often face barriers that may discourage or prevent screening activity and measures for early detection of breast and cervical cancer. Besides success in recruiting women to the program, community collaborative partnerships were established that continue to sustain this program. IMPLICATIONS FOR PRACTICE The results from this project provide an example of how advance practice nurses (APNs) can demonstrate meaningful and competitive health care services for underserved women and how APNs can actively evaluate programs they offer that affect the health practices of communities in need.
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Abstract
OBJECTIVE We compared quality of care for uninsured patients with diabetes in private physician offices and community/migrant health centers (C/MHCs). RESEARCH DESIGN AND METHODS We conducted a cross-sectional medical record review in a convenience sample of eight physician offices and three C/MHC sites in rural North Carolina. Billing systems generated lists of self-pay patients with diabetes. Abstraction of the medical records (n = 142) yielded data on process and intermediate outcome measures of diabetes care, which were derived from the Diabetes Quality Improvement Project. RESULTS Medical records of patients in C/MHCs demonstrated higher rates on four of six process measures of quality of care, including measurement of HbA(1c) (98 vs. 75%; P < 0.001), cholesterol (82 vs. 51%; P < 0.001), and urine protein (90 vs. 25%; P < 0.001). Nonsignificant trends in documented eye examinations and the intermediate outcome of blood pressure control were found in medical records of C/MHC patients. No differences were seen in the intermediate outcomes of glucose or lipid control. Notable differences in provider type, time since training, and use of flow sheets were found. CONCLUSIONS In our sample, uninsured patients with diabetes in C/MHCs had higher quality of care as suggested by higher rates of processes of care. Outcomes were similar in the two settings and well below targets. Further work is required to replicate these findings and to understand which features of C/MHCs may facilitate quality care for the uninsured and are replicable in other settings.
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Affiliation(s)
- Deborah S Porterfield
- Diabetes Control Branch, North Carolina Division of Public Health, Mail Center 1915, Raleigh, NC 27699, USA.
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Dykewicz CA, Kruszon-Moran D, McQuillan GM, Williams WW, Van Loon FP, Cossen C, Forghani B, Hadler SC. Rubella seropositivity in the United States, 1988-1994. Clin Infect Dis 2001; 33:1279-86. [PMID: 11565065 DOI: 10.1086/322651] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2000] [Revised: 02/06/2001] [Indexed: 11/03/2022] Open
Abstract
Data obtained in the third National Health and Nutrition Examination Survey (NHANES III), conducted during 1988-1994, were analyzed to determine the epidemiology of rubella seropositivity in the United States, including risk factors for low rubella seropositivity. Serological samples obtained from NHANES III study participants > or =6 years of age were tested for rubella IgG antibodies. "Rubella seropositivity" was defined as serum rubella IgG antibody level > or =10 IU by enzyme immunoassay. Overall, rubella seropositivity rates in the United States were 92% in persons aged 6-11 years, 83% in persons aged 12-19 years, 85% in persons aged 20-29 years, 89% in persons aged 30-39 years, and >or =93% in persons aged > or =40 years. The lowest rate (78%) of any United States birth cohort of the 20th century occurred among persons born from 1970-1974. Eliminating rubella and chronic rubella syndrome in the United States will require international efforts, including vaccination of preschool- and school-age children and all susceptible young adults.
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Affiliation(s)
- C A Dykewicz
- National Immunization Program, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Jackson S, Camacho D, Freund KM, Bigby J, Walcott-McQuigg J, Hughes E, Nunez A, Dillard W, Weiner C, Weitz T, Zerr A. Women's health centers and minority women: addressing barriers to care. The National Centers of Excellence in Women's Health. JOURNAL OF WOMEN'S HEALTH & GENDER-BASED MEDICINE 2001; 10:551-9. [PMID: 11559452 DOI: 10.1089/15246090152543139] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
New models of care delivery have been developed to better coordinate and integrate healthcare for women. In the United States, one of the challenges is to incorporate the needs of racial and ethnic minority populations into these newer care paradigms. This paper begins with a brief historical review of the experience of racial and ethnic minorities in the American healthcare system to provide a context for discussing barriers and limitations of more traditional models of women's healthcare. Specific approaches used by National Centers of Excellence in Women's Health are presented as examples of strategies that may be implemented by other communities to address these barriers.
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Affiliation(s)
- S Jackson
- Department of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
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Bair YA, García JA, Romano PS, Siefkin AD, Kravitz RL. Does "mainstreaming" guarantee access to care for medicaid recipients with asthma? J Gen Intern Med 2001; 16:475-81. [PMID: 11520386 PMCID: PMC1495233 DOI: 10.1046/j.1525-1497.2001.016007475.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated. DESIGN Cross-sectional survey. SETTING/PARTICIPANTS A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group. MEASUREMENTS AND MAIN RESULTS We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction. CONCLUSIONS Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves.
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Affiliation(s)
- Y A Bair
- Graduate Group in Epidemiology and the Center for Health Services Research in Primary Care, University of California, Davis, USA
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Carrasquillo O, Lantigua RA, Shea S. Preventive services among Medicare beneficiaries with supplemental coverage versus HMO enrollees, medicaid recipients, and elders with no additional coverage. Med Care 2001; 39:616-26. [PMID: 11404644 DOI: 10.1097/00005650-200106000-00009] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies conducted when Medicare began to cover preventive services, found that beneficiaries with supplemental insurance were much more likely to have such services than those without additional coverage. OBJECTIVE To examine preventive services among Medicare beneficiaries with supplemental insurance, Medicaid, health maintenance organization (HMO) enrollees, and those without additional insurance. RESEARCH DESIGN Analysis of the 1996 Medical Expenditure Panel Survey, a nationally representative multistage survey. SUBJECTS 2,251 persons aged 65 and older with Medicare coverage. MEASURES Self-reported preventive services, specifically, blood pressure measurement, cholesterol testing, influenza vaccination, mammography, Papanicolau (Pap) testing, and breast and prostate examinations. Multivariate modeling was used to adjust for age, education, race/ethnicity, and functional status. RESULTS Elders without additional coverage were approximately 10% points less likely to have influenza vaccination, cholesterol testing, mammography, or Pap smears than those with supplemental coverage (P < 0.05). Multivariate adjustment attenuated some of these differences with age and education being the most important predictors of having preventive services. HMO enrollees were more likely to have mammograms than those with supplemental coverage (P < 0.05). CONCLUSIONS Several years after Medicare extended coverage to include preventive services, differences in utilization of such services among elders with and without supplemental insurance have narrowed substantially.
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Affiliation(s)
- O Carrasquillo
- Division of General Medicine and the Center for Active Life of Minority Elders, Columbia Presbyterian Medical Center, New York, New York, USA.
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