'It wasn't the strategies on their own': Exploring caregivers' experiences of accessing services in the development of interventions for autistic people with intellectual disability

LAY ABSTRACT

Many autistic individuals with intellectual disability experience anxiety, and for those who use few or no words, anxiety may present as behaviour that challenges, such as self-injury and avoiding anxiety-provoking situations. Families report difficulty accessing support from services for autistic individuals experiencing anxiety. Moreover, once receiving support, effective interventions for autistic people with intellectual disability are limited. We completed individual and group discussions with 16 caregivers of autistic people with intellectual disability, to (a) explore their experiences of accessing services for anxiety and/or behaviour that challenges for their child; and (b) understand what matters to caregivers when developing interventions that have been designed for them and the autistic individual with intellectual disability that they support. Caregivers reported that services, in their experience, did not deliver the support that they expected, and that they often needed to 'fight' for support. Caregivers considered services and families working together, the inclusion of peer support, and families being offered interventions that are flexible to individual circumstances to be important. These considerations are valuable for clinicians and researchers developing interventions and aiming to improve outcomes for autistic people with intellectual disability and their families.

Top Ten Tips Palliative Clinicians Should Know About Rural Palliative Care in the United States

Palliative care improves outcomes, yet rural residents often lack adequate and equitable access. This study provides practical tips to address palliative care (PC)-related challenges in rural communities. Strategies include engaging trusted community partners, addressing cultural factors, improving pediatric care, utilizing telehealth, networking with rural teams including caregivers, and expanding roles for nurses and advanced practice providers. Despite complex barriers to access, providers can tailor PC to be patient-centered, respect local values, and bridge gaps. The "Top 10" format emphasizes the relevant issues to enable clinicians to provide optimal care for people from rural areas.

"…in the middle of nowhere…" Access to, and quality of, services for autistic adults from parents' perspectives: a qualitative study

Introduction

Adequate education, employment, and services for autistic individuals contribute significantly to their and their parents' quality of life. Services and support for adults are dramatically more limited than those for children. The main purpose of this study was to explore how parents perceive factors supporting/hindering access to services, and how they assess the quality of services.

Methods

Qualitative data provided by 12 parents via a semi-structured interview with a broader focus on parental quality of life and its factors were analyzed. Their autistic children were between 20 and 34 years of age. A thematic analysis was performed on parts of the narratives on their adult periods of life.

Results

A complex pattern of parental perception of supportive and hampering factors influencing access to services unfolded. The sparsity of services/activities and reliable information on them made the space for autonomous decisions on service take highly limited. Parents have modest expectations on quality of services, evaluating them along two key aspects: a safe, positive atmosphere, and communication between parents and professionals. Other aspects of individualized autism-specific support were not or just rarely mentioned.

Discussion

Parents perceive themselves as investing a lot of effort and resources in getting some form of regular service and/or activity for their adult child. However, these parental efforts often fail, their child becoming inactive, and dependent on their presence. This suggests system-level problems with services for autistic adults in Hungary, with literature showing it is not specific to this country.

Child Maltreatment Prevention Service Cases are Significantly Reduced During the COVID-19 Pandemic: A Longitudinal Investigation Into Unintended Consequences of Quarantine

Unprecedented financial and emotional stress, paired with measures to slow the spread of COVID-19 (e.g., school closures), place youth at risk for experiencing increased rates of abuse. We analyzed data from New York City's Administration for Children's Services to investigate the frequency of child maltreatment prevention service case openings during this time. Longitudinal counts of case openings were compiled for January through June of the years 2014-2020. An independent samples Kruskal-Wallis H-test suggested that pre-quarantine case openings were significantly larger than case openings during quarantine. To account for the possible influence of other historical events impacting data, a secondary Kruskal-Wallis H-test was conducted comparing only the 4 months of quarantine data available to the 4 months immediately preceding quarantine orders. The second independent samples Kruskal-Wallis H-test again suggested that pre-quarantine case openings were significantly larger than case openings during quarantine. A Poisson regression model further supported these findings, estimating that the odds of opening a new child maltreatment prevention case during quarantine declined by 49.17%. These findings highlight the severity of COVID-19 impacts on child maltreatment services and the gap between demand for services and service accessibility. We conclude with recommendations for local governments, community members, and practitioners.

Child Maltreatment Prevention Service Cases are Significantly Reduced During the COVID-19 Pandemic: A Longitudinal Investigation Into Unintended Consequences of Quarantine

Unprecedented financial and emotional stress, paired with measures to slow the spread of COVID-19 (e.g., school closures), place youth at risk for experiencing increased rates of abuse. We analyzed data from New York City's Administration for Children's Services to investigate the frequency of child maltreatment prevention service case openings during this time. Longitudinal counts of case openings were compiled for January through June of the years 2014-2020. An independent samples Kruskal-Wallis H-test suggested that pre-quarantine case openings were significantly larger than case openings during quarantine. To account for the possible influence of other historical events impacting data, a secondary Kruskal-Wallis H-test was conducted comparing only the 4 months of quarantine data available to the 4 months immediately preceding quarantine orders. The second independent samples Kruskal-Wallis H-test again suggested that pre-quarantine case openings were significantly larger than case openings during quarantine. A Poisson regression model further supported these findings, estimating that the odds of opening a new child maltreatment prevention case during quarantine declined by 49.17%. These findings highlight the severity of COVID-19 impacts on child maltreatment services and the gap between demand for services and service accessibility. We conclude with recommendations for local governments, community members, and practitioners.

Post-Gender-Based Violence Services Utilization Among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

Little is known about service utilization among female entertainment workers (FEWs) after experiencing gender-based violence (GBV). This study explored factors associated with post-GBV service utilization among FEWs in Cambodia. We included 299 FEWs, who experienced any forms of GBV in the past 12 months. This study highlights low access (14.05%) to post-GBV services among FEWs. Factors associated with post-GBV services utilization were marital status, living conditions, mental health, and types of entertainment venues. To improve post-GBV services utilization, ensuring quality, and availability of services are required. Further research is needed to develop pathways toward a supportive environment for FEWs to access these services.

Access to Health and Disability Services for New Zealanders With Impaired Vision During the COVID-19 Pandemic 2020-2022

Introduction: The COVID-19 pandemic has affected access to health and social services globally, leading to delays in accessing appropriate care. However, while there is a growing base of research into service access for the general population, there remains scarce information on the implications of the pandemic on disabled people. This article describes issues with health and disability support access for people with impaired vision in Aotearoa New Zealand (Aotearoa). Methods: Applying an Interpretive Description methodology, 62 interviews were conducted with disabled people; 10 of these individuals identified as having impaired vision. Findings were analyzed thematically for the entire group of 62, representing varied impairment groups, and then for the 10 who had impaired vision. Results: Five key themes arose from the interviews, including transportation difficulties, mental distress, loss of community, loss of physical contact and signals, and general loss of support. Participants identified that this loss of support occurred at multiple levels, meaning that the disability and healthcare system as a whole was ill-equipped to manage their needs. Participants reported a lag-time in accessing care, meaning that the effects of the pandemic are still felt due to a lack of available support and resources. Discussion: This article remains one of a few studies to look at the implications of the pandemic on access to health and disability services for those with impaired vision. It highlights that despite Aotearoa's good track record in managing the pandemic, groups were forgotten and marginalized by the collective response to managing COVID-19. Implications for Practitioners: Blindness professionals must be aware of the possible disadvantages and impacts of pandemics and other disasters on people with impaired vision and their access to health and disability services. Policymakers must include disabled people at the decision-making table so that the diverse needs of these populations are managed.

Access, utilization, and awareness for clinical genetic testing in autism spectrum disorder in Sweden: A survey study

Clinical genetic testing is recommended for individuals diagnosed with autism spectrum disorder. There are only a few reports of how these recommendations are followed and especially missing for European countries. We aimed to analyze the rate of access, utilization, and awareness of clinical genetic testing among autistic individuals in Sweden through online surveys targeting parents with at least one autistic child and autistic adolescents (from 15 years) and adults. In total, 868 parents of autistic children and 213 autistic adolescents or adults completed the survey. Only 9.1% (n = 79) of parents and 2.8% (n = 6) of autistic adolescents/adults reported having received a referral for clinical genetic testing after autism spectrum disorder diagnosis. The autistic children offered a referral were younger at diagnosis (p < 0.001) and more likely to have an additional neurodevelopmental diagnosis (p < 0.01), including intellectual disability (p < 0.001) or a language disorder (p < 0.001). Genetic counseling was provided to less than half of the families that were referred for clinical genetic testing. Finally, we report that both respondent groups preferred to be informed by written text and an expert in genetics about clinical genetic testing. This study highlights a lack of awareness and access to clinical genetic testing after autism spectrum disorder diagnosis in Sweden and demonstrates the need for additional studies on how clinical guidelines for genetic testing are followed in different countries.

A Multiple Streams Framework Approach to Access to Domestic Violence Services in an Indigenous Community

This article focuses on access to domestic violence services within Belize. Using data from community asset mapping, interviews with key informants, and focus groups with community members, the multiple streams framework was used to identify potential areas for intervention to improve access and ameliorate the effects of family violence in Belize. Identified challenges to accessing limited domestic violence resources were mainly confidentiality concerns and mistrust. Existing laws and regulations, organizational structures, and policies and plans also influenced access. Women's groups, nongovernmental organizations, and the health department can play a crucial role in improving access to domestic violence services.

Factors Associated with Contraceptive Use in Sub-Saharan Africa

Background:

Globally 10% of women have an unmet need for contraception, with higher rates in sub-Saharan Africa. Programs to improve family planning (FP) outcomes require data on how service characteristics (e.g., geographic access, quality) and women's characteristics are associated with contraceptive use.

Materials and Methods:

We combined data from health facility assessments (2018 and 2019) and a population-based regional household survey (2018) of married and in-union women ages 15–49 in the Kigoma Region of Tanzania. We assessed the associations between contraceptive use and service (i.e., distance, methods available, personnel) and women's (e.g., demographic characteristics, fertility experiences and intentions, attitudes toward FP) characteristics.

Results:

In this largely rural sample (n = 4,372), 21.7% of women used modern reversible contraceptive methods. Most variables were associated with contraceptive use in bivariate analyses. In multivariate analyses, access to services located <2 km of one's home that offered five methods (adjusted odds ratio [aOR] = 1.57, confidence interval [CI] = 1.18–2.10) and had basic amenities (aOR = 1.66, CI = 1.24–2.2) increased the odds of contraceptive use. Among individual variables, believing that FP benefits the family (aOR = 3.65, CI = 2.18–6.11) and believing that contraception is safe (aOR = 2.48, CI = 1.92–3.20) and effective (aOR = 3.59, CI = 2.63–4.90) had strong associations with contraceptive use.

Conclusions:

Both service and individual characteristics were associated with contraceptive use, suggesting the importance of coordination between efforts to improve access to services and social and behavior change interventions that address motivations, knowledge, and attitudes toward FP.

Delivering Interventions Via Telehealth: Functional Communication Training with a Child with Autism as a Case Example

In this article, we provide a case example of how telehealth can be used by care providers in their homes to access empirically validated procedures such as functional communication training. As shown in the case example, complex assessment and intervention procedures were implemented successfully by care providers in their homes while receiving real-time coaching by behavior analysts who were located in a hospital in a different city. This case example is representative of the results we obtained thus far; substantial improvements in challenging and adaptive behavior occurred. Given these results obtained to date with telehealth, in terms of both outcomes of interventions and rated acceptability of the procedures by care providers, further and more widespread application of telehealth is warranted.

Adequate Utilization of Emergency Services in Germany: Is There a Differential by Migration Background?

Background: The role of emergency services (ES) is to provide round-the-clock acute care. In recent years, inadequate use of ES has been internationally thematised because of overcrowding and the associated cost. Evidence shows that migrant populations tend to use more ES than non-migrant but it remains to show if there is a differential in inadequacy.

Method: Quantitative data from consecutive patients visiting three ES in Berlin (hospital-based outpatient clinics for internal medicine or gynecology) from July 2017 to July 2018 were obtained. Utilization was defined as adequate if the patient was admitted to hospital and/or if all of the three following criteria were fulfilled: reported to have been sent by medical staff; reported strong pain; and reported a high urgency (both ≥7, scale from 0 to 10). Differences between migrants (1st generation), their offspring (2nd generation), and non-migrants were evaluated using logistic regression.

Results: Of the 2,327 patients included, 901 had a migration background. Adjusting for gender, age, gynecological hospital-based outpatient clinic, and the number of chronic diseases, 1st generation migrant patients (n = 633) had significantly lower odds than non-migrants to have an adequate utilization of services [OR 0.78, 95% confidence interval (0.62, 0.99), p-value 0.046]. For 2nd generation patients (n = 268), no statistically significant difference was found [OR 0.80, 95% confidence interval (0.56, 1.15), p-value 0.231]. Only adjusting for gynecological hospital-based outpatient clinic did weaken the association between migration status on adequacy but interactions between type of hospital-based outpatient clinic and migration were not significant.

Discussion: First generation migrants show lower odds of adequate ES use compared to non-migrants. Only visiting a gynecological hospital-based outpatient clinic as opposed to internal medicine could partly explain the lower odds of adequate use among immigrants. This indicates a need for structural changes in the healthcare system: The threshold of access to general practices needs to be lowered, considering the needs of diverse subgroups of migrant patients.

A picture of medically assisted reproduction activities during the COVID-19 pandemic in Europe

STUDY QUESTION

How did coronavirus disease 2019 (COVID-19) impact on medically assisted reproduction (MAR) services in Europe during the COVID-19 pandemic (March to May 2020)?

SUMMARY ANSWER

MAR services, and hence treatments for infertile couples, were stopped in most European countries for a mean of 7 weeks.

WHAT IS KNOWN ALREADY

With the outbreak of COVID-19 in Europe, non-urgent medical care was reduced by local authorities to preserve health resources and maintain social distancing. Furthermore, ESHRE and other societies recommended to postpone ART pregnancies as of 14 March 2020.

STUDY DESIGN, SIZE, DURATION

A structured questionnaire was distributed in April among the ESHRE Committee of National Representatives, followed by further information collection through email.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The information was collected through the questionnaire and afterwards summarised and aligned with data from the European Centre for Disease Control on the number of COVID-19 cases per country.

MAIN RESULTS AND THE ROLE OF CHANCE

By aligning the data for each country with respective epidemiological data, we show a large variation in the time and the phase in the epidemic in the curve when MAR/ART treatments were suspended and restarted. Similarly, the duration of interruption varied. Fertility preservation treatments and patient supportive care for patients remained available during the pandemic.

LARGE SCALE DATA

N/A

LIMITATIONS, REASONS FOR CAUTION

Data collection was prone to misinterpretation of the questions and replies, and required further follow-up to check the accuracy. Some representatives reported that they, themselves, were not always aware of the situation throughout the country or reported difficulties with providing single generalised replies, for instance when there were regional differences within their country.

WIDER IMPLICATIONS OF THE FINDINGS

The current article provides a basis for further research of the different strategies developed in response to the COVID-19 crisis. Such conclusions will be invaluable for health authorities and healthcare professionals with respect to future similar situations.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for the study, apart from technical support from ESHRE. The authors had no COI to disclose.

Experiences of Unmet Need and Access to Supportive Care for Men Receiving Androgen Deprivation Therapy for Prostate Cancer: A Bi-national Study

OBJECTIVE

The number of men affected by incurable prostate cancer is expected to increase worldwide. Research is needed to enable men to share their experiences of unmet supportive care needs in current care delivery. We aimed to identify the most frequently reported domains of unmet supportive care needs, levels of anxiety, depression, distress, health-related quality of life, and to identify any perceived barriers to receiving supportive care.

DATA SOURCES

Men diagnosed with prostate cancer who had received a minimum of 6 months of ADT were recruited into a cross-sectional study. Participants completed standardised questionnaires; clinical and demographic data was also collected.

CONCLUSION

Two hundred seventy-two patients were invited, and 102 participated. No statistically significant differences were found between participant scores from Australia and UK in relation to anxiety and depression, exercise, health-related quality of life, or distress scores. Perceived barriers include service delivery related to information provision and difficulties in the navigation of complex care systems.

IMPLICATIONS FOR NURSING PRACTICE

Men affected by prostate cancer receiving ADT reported unmet supportive care needs, specifically related to sexual, informational, and psychological aspects of care. Mapping future trajectories of needs and identifying men at high risk can significantly improve timely and tailored interventions.

Barriers in seeking support: Perspectives of service providers who are survivors of sexual violence

Research with survivors of sexual violence suggests that most do not seek supportive services from community organizations. The purpose of this study is to understand the unique barriers that service providers, who are also survivors of sexual violence, may experience and how it informs their work with survivors. We conducted semi-structured interviews with 19 female, trans, and nonbinary survivors of sexual violence who are also employed as domestic violence or sexual assault advocates, community organizers, therapists, health care providers, educators, or substance abuse counselors, and had worked with survivors of sexual violence in their current positions. We coded the data using a multistep strategy derived from grounded theory. Participants indicated sensitivity to community-level barriers including where services are offered, perceived cost of services, and taking time off of work. Internalized blame, shame, minimization of their experiences, and trauma were also mentioned as significant barriers for themselves and impacted their work with survivors. Our findings suggest a need for trauma-informed intervention in community practice and policy.

To be young, unmarried, rural, and female: intersections of sexual and reproductive health and rights in the Maldives

This paper explores sexual and reproductive health and rights (SRHR) among young people, identifying intersecting factors that create inequities in access to services, health-seeking behaviour, and ultimately health outcomes. Based on qualitative interviews with young people in the Maldives, it demonstrates how these intersectional experiences are contrary to what is often assumed in official data, policies, and services. Three factors were found to shape young people's experiences: marital status, gender, and urban/rural differences. Non-marital sexual activity is illegal in the Maldives, but it is somewhat expected of unmarried men, while unmarried women are stigmatised for being sexually active. Although access to SRH services is restricted for all unmarried people, young women face additional difficulties, as the risk of being exposed is much greater in small island communities. Maldivian island communities are extremely small and characterised by an inward-looking culture that exerts considerable social pressure, particularly on unmarried women. For an unmarried woman, being known to be sexually active, or worse, pregnant outside of marriage, has severe social consequences including stigma and isolation from the community, and their own family. This concern is more prevalent among rural young women, as they live in smaller communities where stigma is inescapable. The need to avoid public scrutiny and humiliation contributes to making unsafe abortion a common solution for many unintended pregnancies. Failure to acknowledge these intersecting factors in SRHR experience and access has led to inequities among an already overlooked population, shaping their experiences, knowledge, health-seeking behaviour, and health outcomes.

"They're always in a hurry" - Older people´s perceptions of access and recognition in health and social care services

The article examines older people's perceptions of quality of life from the perspective of access and use of health and social care services. The data include focus group discussions with older people living alone. The data were analysed using thematic analysis focusing on the older people's collective views on health and social care services as supportive or restrictive factors for their quality of life. Two central themes were present in all the focus group discussions: the importance of accessing services and information regarding the services, and need for recognition within the services/by the professionals. Both themes were connected to the older people's desire to maintain autonomy in their everyday life despite increasing functional disabilities, which was seen as an important factor of quality of life. The older people felt that accessing and finding information about the services was difficult, and dependent on the professional's good will and the older person's own financial resources. Within the services, older people experienced a lack of recognition of their own personhood and individual needs. The participants felt that they were easily bypassed and left out of negotiations regarding their own care. The article highlights the importance of developing health and social care services and practices towards a more holistic approach recognising older people's individual needs.

Who is willing to come back? College students' willingness to seek help after using campus mental health services

OBJECTIVE

To examine characteristics of college students who have previously received mental health (MH) services on campus and are willing to seek help again in the future.

PARTICIPANTS

Spring 2015 ACHA-NCHA II (N = 12,501) undergraduate respondents who had previously used MH services on their current campus.

METHODS

Binary logistic regression with willingness to seek MH services in the future as the dependent variable.

RESULTS

Among students who had already utilized campus MH services, significant predictors for future help-seeking were: female, white, gay/lesbian, those not working for pay, having the college/university health insurance plan, and not currently/previously serving in the military (p < .05).

CONCLUSIONS

The predictors for willingness to use services in the future were consistent with the existing literature related to initial use. Colleges and universities need to consider factors that influence openness to MH services after a previous experience in addition to initiating care. Implications for college MH professionals are provided.

Factors Associated With Caregivers' Use of Support Services and Caregivers' Nonuse of Services Sought

Informal caregivers may face barriers accessing services like respite care, training, and support groups. Using multinomial logistic regression, I modeled caregivers' probability of using all services sought ("all services used") and nonuse of any services sought ("any unused services") as a function of caregiver and care-recipient characteristics. Care-recipient health and function, especially dementia and need for medical task assistance, were associated with all services used and any unused services, and any unused services were more likely among adult children caring for their parents, caregivers of Black and Hispanic older adults, caregivers providing intensive care, caregivers living in metropolitan areas, and residents of states that spend more on increasing access to caregiver services under the National Family Caregiver Support Program. Regularly scheduled caregiving was associated with higher likelihood of all services used, but not with any unused services. Steps should be taken to increase access for caregivers who provide intensive care, care to dementia patients, or assistance with medical tasks and for Hispanic families.

A snapshot of intellectual disabilities in Lao PDR: Challenges for the development of services

Lao People's Democratic Republic (PDR) has experienced significant economic growth in the last two decades. While access to education, health, and employment for people with disabilities has also improved markedly, people with intellectual disabilities are still among the most vulnerable in society. This article presents findings from a screening survey of 2469 participants, a focus group discussion with key stakeholders in intellectual disabilities, and a case study of the Association for Autism. The screening survey suggests 1.9% of working age participants (18-59) and 0.7% of children (6-17) have intellectual disabilities. The qualitative data illustrate poor understanding and stigmatization of people with intellectual disabilities, lack of services, and development of a parent association to improve the life prospects for children with autism and intellectual disabilities. People with intellectual disabilities in Lao PDR remain particularly vulnerable. Parents and other disability advocates are raising awareness and demonstrating the effectiveness of specialized services.

Support networks for Chinese older immigrants accessing English health and social care services: the concept of Bridge People

As Chinese immigrants in the United Kingdom age, they experience an increasing need to access health and care services. It has, however, been reported that older Chinese immigrants have difficulties in accessing these services. This study explored the experiences of this population in using health and care services and the strategies that they adopted to address their difficulties. A grounded theory method with a two-staged research design was used. Stage 1 explored the participants' experiences of ageing and use of health and social care services through focus group interviews. Stage 2 investigated the strategies individuals used to support access to and use of services through individual interviews. Forty-four older Chinese people and 15 supporters participated in interviews during August 2011 and May 2013. These older Chinese immigrants were challenged in knowing about and in accessing services. Their difficulties were attributed to language barriers, lack of information and instrumental support, and emotional and cultural issues regarding use of health and care services. Their supporters facilitated access to services and acted as a bridge between the service and the user; therefore, they were given the title 'Bridge People'. Bridge People have different backgrounds: family and friends, public sector workers and staff from community-based Chinese organisations. The defining attributes of these supporters were: bilinguality, bicultural, multifunctionality and accessibility. There is no charge for this support; and the relationship between the Bridge Person and recipient involves trust and influence over decisions regarding use of health and care services. Bridge People should be recognised and identified by health, social care and housing services to promote engagement and use of services by older immigrant Chinese people.

Using 'candidacy' as a framework for understanding access to mainstream psychological treatment for people with intellectual disabilities and common mental health problems within the English Improving Access to Psychological Therapies service

BACKGROUND

The Improving Access to Psychological Therapies (IAPT) service was established to address common mental health problems among the English population in a timely manner in order to counter the social and economic disadvantage accompanying such difficulties. Using the concept of candidacy, we examined how the legitimacy of claims by people with intellectual disabilities to use this service is facilitated or impeded.

METHOD

We used a sequential mixed methods design. We completed 21 interviews with a range of stakeholders, including people with intellectual disabilities and their carers. Themes from the interviews were used to design an online survey questionnaire that was returned by 452 staff from IAPT and specialist intellectual disability services.

RESULTS

Using the candidacy framework, we noted that eligibility and access to IAPT were achieved through dynamic and iterative processes of negotiation involving people with intellectual disabilities and their supporters on one side and IAPT staff and service structures on the other. Barriers and facilitators were apparent throughout the seven dimensions of candidacy (identification, navigation, permeability of services, appearances, adjudications, offers and resistance and operating conditions) and were linked to discourses relating to the character and purpose of IAPT and specialist intellectual disability services.

CONCLUSIONS

Opportunities exist for some people with intellectual disabilities to assert their candidacy for IAPT input, although there are barriers at individual, professional, organisational and structural levels. More attention needs to be paid to how principles of inclusiveness are operationalised within IAPT teams and to the mental health facilitation role of specialist intellectual disability staff.

Climbing Back Up the Mountain: Reflections From an Exploration of End-of-Life Needs of Persons Living With HIV/AIDS in Appalachian Tennessee

Little is known about the health access and end-of-life (EOL) concerns of persons living with HIV/AIDS (PLWHA) in Appalachia, where religious and cultural values are largely traditional. A qualitative, descriptive study with 9 participants was undertaken to assess EOL care needs among those from South Central Appalachian PLWHA. The focus of the study was to examine subjective data regarding EOL needs assessment related to advanced care planning. Five men and 4 women self-acknowledged a diagnosis of HIV/AIDS and completed a 2-hour face-to-face interview with the nurse researcher. Data were analyzed using qualitative descriptive content analysis methods, including data coding for emergent themes and metaphors. A common metaphor tied content to both struggle and triumph as well as the beauty and ruggedness of the Appalachian region: "Climbing Back up the Mountain." Rich descriptions of the significance of the metaphor match with stigma as the greatest hurdle to overcome in planning and interacting with others, including health care providers and significant others, about EOL care needs and advanced planning preferences. Further, the metaphor was derived directly from quotes offered by participants. Sources of stigma were often intersecting: the disease itself, associations with "promiscuity," sexual minority status, illicit drug use, and so on. Strong spiritual images were contrasted with a common avoidance and disdain of organized religion. Findings were used in refining plans for a larger study of EOL care needs and concerns on the population of PLWHA in 2 Southern Appalachian states. Comparison with other research and insights for providers is included.

Perceived self-efficacy in parents of adolescents and adults with autism spectrum disorder

Many parents of adolescents and adults with autism spectrum disorder experience difficulty accessing appropriate services for their children, and may report low levels of parent self-efficacy. In an effort to identify the factors that contribute to the difficulties these families face, this study examined the role of demographic, systemic, and clinical need variables as they relate to parents' experience of self-efficacy. Participants included 324 parents of individuals with autism spectrum disorder, 12-25 years of age. Results suggest that parent self-efficacy is related to a number of variables and not simply a child's clinical situation, including child age, parent immigrant status, barriers to service access, and caregiver burden. Given the crucial role that parents often play in the lives of individuals with autism spectrum disorder across the lifespan, it is important that service providers support the efforts of parents who provide and access care for their children.

An evaluation of equitable access to a community-based maternal and newborn health program in rural Ethiopia

INTRODUCTION

The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) aimed to promote equitable access to safe childbirth and postnatal care through a community-based educational intervention. This study evaluates the extent to which MaNHEP reached women who are socially and materially disadvantaged and, thus, at high risk for inadequate access to care.

METHODS

The data used in this analysis are from MaNHEP's cross-sectional 2010 baseline and 2012 endline surveys of women who gave birth in the prior year. A logistic regression model was fit to examine the effects of sociodemographic characteristics on participation in the MaNHEP program. Descriptive statistics of select characteristics by birth and postnatal care provider were also calculated to explore trends in services use.

RESULTS

Using data from the endline survey (N = 1019), the regression model showed that age, parity, education, and geographic residence were not significantly associated with MaNHEP exposure. However, women who were materially disadvantaged were still less likely to have participated in the program than their better-off counterparts. From the baseline survey (N = 1027) to the endline survey, women's use of skilled and semiskilled providers for birth care and postnatal care increased substantially, while use of untrained providers or no provider decreased. These shifts were greater for women with less personal wealth than for women with more personal wealth.

DISCUSSION

MaNHEP appears to have succeeded in meeting its equity goals to a degree. However, this study also supports the intractable relationship between wealth inequality and access to maternal and newborn health services. Strategies targeting the poor in diverse contexts may eventually prove consistently effective in equitable services delivery. Until that time, a critical step that all maternal and newborn health programs can take is to monitor and evaluate to what extent they are reaching disadvantaged groups within the populations they serve.

Uterine cancer: exploring access to services in the public health system

BACKGROUND

Māori are the indigenous peoples of New Zealand and experience higher rates of uterine cancer and poorer survival rates. Postmenopausal bleeding (PMB) is the most common presenting symptom for uterine cancer. Prompt investigation is essential with 28 days being viewed as an appropriate time from first medical contact (FMC) to first specialist appointment (FSA).

AIMS

To compare access to services for the investigation of PMB between Māori and non-Māori women.

MATERIALS AND METHODS

The time interval between FMC to FSA was obtained from medical records for women presenting to gynaecology clinics for PMB. Dates of first bleeding symptoms, knowledge and access issues were collected in a nurse-administered questionnaire.

RESULTS

A total of 154 women (n = 27 Māori and 127 non-Māori) participated in the study. 23% of women had their FSA from FMC within 28 days and 67% waited more than six weeks. The 75th percentile was approximately two weeks longer for Māori women. 25% (n = 37) of women were not aware that they needed to see a doctor about PMB, and this was significantly more common for Māori women (44%; 95% CI 25-65) than non-Māori women (20%; 95% CI 13-28; P = 0.011).

CONCLUSIONS

The majority of women were not seen for FSA within 28 days of their FMC. Māori women were more likely to experience lengthy delays and to report that they did not know they should see a doctor about PMB. Further investigation into reasons for delays and initiatives to improve access to services and health information appears warranted.

Empirically derived model of social outcomes and predictors for adults with ASD

This study used data from the National Core Indicators (NCI) Survey to derive an empirically validated measurement model for social outcomes and associated constructs for both individuals with Autism Spectrum Disorder (ASD) and individuals with other disabilities. Items consistent with the survey structure of the NCI were selected as initial indicators of the latent constructs Social Relationships, Community Inclusion, and Opportunity for Choice in factor analyses. Results yielded a novel factor structure that is different from the original NCI survey structure. Three factors emerged as a result of these analyses: Personal Control, Social Determination, and Social Participation and Relationships. The factor structure of each of these constructs was consistent although not identical across individuals with ASD and individuals with developmental disabilities other than ASD.

Rationale for a New Direction in Foster Youth Substance Use Disorder Prevention

BACKGROUND

Of the 463,000 children residing in United States foster care, 29,000 annually exit the system because they have "aged out," are thus dropped from supportive services, and become responsible for their own housing, finances, and health needs. Given histories of maltreatment, housing instability, and parental substance use, youth preparing to exit care are at substantial risk of developing substance use disorders. Unfortunately, access to services is often limited, both before and after exit from care.

METHODS

With the goal of developing a relevant substance use intervention for these youth, focus groups were conducted with foster care staff, administrators, and parents to assess the feasibility of potential approaches.

RESULTS

Participants identified several population-specific barriers to delivering adapted intervention models developed for normative populations. They expressed concerns about foster youth developing, then quickly ending, relationships with interventionists, as well as admitting to substance use, given foster care program sanctions for such behavior. Group members stressed the importance of tailoring interventions, using creative, motivational procedures.

CONCLUSIONS

Foster youth seem to encounter unique barriers to receiving adequate care. In light of these results, a novel, engaging approach to overcoming these barriers is also presented.

Negotiating candidacy: ethnic minority seniors' access to care

The 'Barriers to Access to Care for Ethnic Minority Seniors ' (BACEMS) study in Vancouver, British Columbia, found that immigrant families torn between changing values and the economic realities that accompany immigration cannot always provide optimal care for their elders. Ethnic minority seniors further identified language barriers, immigration status, and limited awareness of the roles of the health authority and of specific service providers as barriers to health care. The configuration and delivery of health services, and health-care providers' limited knowledge of the seniors' needs and confounded these problems. To explore the barriers to access, the BACEMS study relied primarily on focus group data collected from ethnic minority seniors and their families and from health and multicultural service providers. The applicability of the recently developed model of 'candidacy', which emphasises the dynamic, multi-dimensional and contingent character of health-care access to ethnic minority seniors, was assessed. The candidacy framework increased sensitivity to ethnic minority seniors' issues and enabled organisation of the data into manageable conceptual units, which facilitated translation into recommendations for action, and revealed gaps that pose questions for future research. It has the potential to make Canadian research on the topic more co-ordinated.