Showing papers in "Journal of Health Care for the Poor and Underserved in 2014"

Health Outcomes and Retention in Care Following Release from Prison for Patients of an Urban Post-incarceration Transitions Clinic

Abstract: Chronic health conditions are overrepresented among prisoners who often face barriers to medical care following release. Transitions clinics seek to provide timely access to medical care following release. This retrospective cohort study investigated care delivery and health outcomes for recently released prisoners receiving care at the Bronx Transitions Clinic. Among 135 recently released prisoners, median time from release to initial medical visit was 10 days (IQ Range: 5-31). Six-month retention in care was high for HIV-infection (86%), but lower for opioid dependence (33%), hypertension (45%) and diabetes (43%). At six months, 54% of HIV-patients had a suppressed viral load, but fewer buprenorphine-treated patients reduced opioid use (19%), and fewer hypertensive and diabetic patients reached respective blood pressure (35%) and hemoglobin A1c (14%) goals. Access to medical care is necessary but not sufficient to control chronic health conditions. Additional interventions are necessary for formerly incarcerated people to achieve optimal health outcomes.

Women as health care decision-makers: implications for health care coverage in the United States.

Abstract: Women in the United States make approximately 80% of the health care decisions for their families, yet often go without health care coverage themselves. The implementation of the Affordable Care Act provides an historical opportunity for women to gain health care coverage for themselves and their families. The focus of this commentary is on women's leadership roles in the context of health care decision- making and Affordable Care Act education and outreach, and implications for reaching broader health and social goals.

An Integrated Chronic Disease Management Model: A Diagonal Approach to Health System Strengthening in South Africa

Abstract: The integrated chronic disease management model provides a systematic framework for creating a fundamental change in the orientation of the health system. This model adopts a diagonal approach to health system strengthening by establishing a service-linked base to training, supervision, and the opportunity to try out, assess, and implement integrated interventions.

Challenges and Opportunities for Integrating Preventive Substance-Use-Care Services in Primary Care through the Affordable Care Act

Abstract: Undertreated or untreated substance use disorders (SUD) remain a pervasive, medically-harmful public health problem in the United States, particularly in medically underserved and low-income populations lacking access to appropriate treatment. The need for greater access to SUD treatment was expressed as policy in the Final Rule on standards related to essential health benefits, required to be covered through the 2010 Affordable Care Act (ACA) health insurance exchanges. SUD treatment services have been included as an essential health benefit, in a manner that complies with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Consequently, with the ACA, a vast expansion of SUD-care services in primary care is looming. This commentary discusses challenges and opportunities under the ACA for equipping health care professionals with appropriate workforce training, infrastructure, and resources to support and guide science-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) for SUD in primary care.

The Effect of Involvement in a Student-run Free Clinic Project on Attitudes toward the Underserved and Interest in Primary Care

Abstract: Methods. The authors designed a survey instrument to examine the effect of involvement in a student- run free clinic project (SRFCP) on medical student self- reported attitudes toward the underserved and interest in primary care. From 2001- 2010, first- and second- year medical students in an introductory service- learning elective course rated each of 15 statements on a seven- point Likert scale pre/ post survey. Wilcoxon's signed rank test was performed on all matched pairs and an intent- to-treat analysis included unmatched pairs. Results. The response rate was 97.9%, with 914 of 934 students enrolled participating. Significant increases were seen in each of the 15 items in matched pre/ post survey pairs, N = 433 (47.4%), or with an intent- to-treat analysis, N = 914 (p ≤ .002 for all). Conclu- sions. This study found that medical student involvement in a SRFCP improved student knowledge, skills, attitudes and self- efficacy with the underserved, interest in work with the underserved after graduation, and interest in primary care.

Factors Influencing Health Care Access Perceptions and Care-seeking Behaviors of Immigrant Latino Sexual Minority Men and Transgender Individuals: Baseline Findings from the HOLA Intervention Study

Abstract: Little is known about immigrant Latino sexual minorities' health seeking behaviors. This study examined factors associated with perceptions of access and actual care behaviors among this population in North Carolina. Methods. A community- based participatory research partnership recruited 180 Latino sexual minority men and transgender individuals within preexisting social networks to participate in a sexual health intervention. Mixed- effects logistic regression models and GIS mapping examined factors influencing health care access perceptions and use of services (HIV testing and routine check- ups). Results. Results indicate that perceptions of access and actual care behaviors are low and affected by individual and structural factors, including: years living in NC, reported poor general health, perceptions of discrimination, micro-, meso-, and macro- level barriers, and resi- dence in a Medically Underserved Area. Discussion. To improve Latino sexual minority health, focus must be placed on multiple levels, including: individual characteristics (e.g., demographics), clinic factors (e.g., provider competence and clinic environment), and structural factors (e.g., discrimination).

Adverse childhood events: incarceration of household members and health-related quality of life in adulthood.

Abstract: Background . Incarceration of a household member has been associated with adverse outcomes for child well-being. Methods . We assessed the association between childhood exposure to the incarceration of a household member and adult health-related quality of life (HRQOL) in the 2009/2010 Behavioral Risk Factor Surveillance System controlling for age, race/ethnicity, education, and additional adverse childhood experiences. Results . Adults who lived in childhood with an incarcerated household member had higher risk of poor HRQOL compared with adults who had not (adjusted relative risk [ARR] 1.18; 95% CI 1.07, 1.31). Among Black adults the association was strongest with the physical health component of HRQOL (ARR 1.58 [95% CI 1.18, 2.12]); among White adults, the association was strongest with the mental health component of HRQOL (ARR 1.29, [95% CI 1.07–1.54]). Conclusions . Living with an incarcerated household member during childhood is associated with higher risk of poor HRQOL during adulthood, suggesting that the collateral damages of incarceration for children are long-term.

Do Our Patients Have Enough to Eat?: Food Insecurity among Urban Low-income Cancer Patients

Abstract: This study assessed the prevalence and predictors of food insecurity among a cohort of underserved oncology patients at New York City cancer clinics. A demographic survey and the U.S. Household Food Security Survey Module were administered. A multivariate General Linear Model Analysis of Covariance was used to evaluate predictors of food insecurity. Four hundred and four (404) completed the surveys. Nearly one-fifth (18%) had very low, 38% low, 17% marginal, and 27% high food security. The Analysis of Covariance was statistically significant (F[7, 370] = 19.08; p

The development of the DSM-5 Cultural Formulation Interview-Fidelity Instrument (CFI-FI): a pilot study.

Abstract: This paper reports on the development of the Cultural Formulation Interview-Fidelity Instrument (CFI-FI) which assesses clinician fidelity to the DSM-5 Cultural Formulation Interview (CFI). The CFI consists of a manualized set of standard questions that can precede every psychiatric evaluation. It is based on the DSM-IV Outline for Cultural Formulation, the cross-cultural assessment with the most evidence in psychiatric training. Using the New York sample of the DSM-5 CFI field trial, two independent raters created and finalized items for the CFI-FI based on six audio-taped and transcribed interviews. The raters then used the final CFI-FI to rate the remaining 23 interviews. Inter-rater reliability ranged from .73 to 1 for adherence items and .52 to 1 for competence items. The development of the CFI-FI can help researchers and administrators determine whether the CFI has been implemented with fidelity, permitting future intervention research.

Low socioeconomic status is associated with increased risk for hypoglycemia in diabetes patients: the Diabetes Study of Northern California (DISTANCE).

Abstract: Background . Social risk factors for hypoglycemia are not well understood. Methods . Cross-sectional analysis from the DISTANCE study, a multi-language, ethnically-stratified random sample of adults in the Kaiser Permanente Northern California diabetes registry, conducted in 2005–2006 (response rate 62%). Exposures were income and educational attainment; outcome was patient report of severe hypoglycemia. To test the association, we used multivariable logistic regression to adjust for demographic and clinical factors. Results . 14,357 patients were included. Reports of severe hypoglycemia were common (11%), and higher in low-income vs . high-income (16% vs . 8.8) and low-education vs . high-education (11.9% vs . 8.9%) groups. In multivariable analysis, incomes of less than $15,000 (OR 1.51 95%CI 1.19–1.91), $15,000–$24,999 (OR 1.57 95%CI 1.27–1.94), and high school or less education (OR 1.42, 95% CI 1.24–1.63) were associated with increased hypoglycemia, similar to insulin use (OR 1.44 95%CI 1.19–1.74). Conclusions . Low income and educational attainment are important risk factors for hypoglycemia.

Reducing barriers to hepatitis C treatment among drug users: an integrated hepatitis C peer education and support program.

Abstract: This report describes an innovative HCV Peer Educator Program that facilitates education, support, and engagement in HCV treatment among patients in an opioid treatment program. Integrating peer educators in a collaborative manner with close supervision holds promise as a model to reduce barriers to HCV treatment among drug users.

Religious Beliefs and Cancer Screening Behaviors among Catholic Latinos: Implications for Faith-based Interventions

Abstract: Although most U.S. Latinos identify as Catholic, few studies have focused on the influence of this religious tradition on health beliefs among this population. This study explores the role of Catholic religious teachings, practices, and ministry on cancer screening knowledge, attitudes, and behaviors among Latinos. Eight focus groups were conducted with 67 Catholic Latino parishioners in Massachusetts. Qualitative analysis provided evi- dence of strong reliance on faith, God, and parish leaders for health concerns. Parishes were described as vital sources of health and social support, playing a central role in the community's health. Participants emphasized that their religious beliefs promote positive health behaviors and health care utilization, including the use of cancer screening services. In addition, they expressed willingness to participate in cancer education programs located at their parishes and provided practical recommendations for implementing health programs in parishes. Implications for culturally appropriate health communication and faith- based interventions are discussed.

Community Health Workers and the Patient Protection and Affordable Care Act: An Opportunity for a Research, Advocacy, and Policy Agenda

Abstract: Community health workers (CHWs), who have been shown to be effective in multiple roles in the provision of culturally appropriate health care in a variety of settings, have the potential to be important members of an interdisciplinary health care team. Recent efforts have started to explore how best to integrate CHWs into the health system. However, to date, there has been limited policy guidance, support, or evidence on how best to achieve this on a larger scale. The Patient Protection and Affordable Care Act (ACA), through several provisions, provides a unique opportunity to create a unified framework for workforce integration and wider utilization of CHWs. This review identifies four major opportunities to further the research, advocacy, and policy agenda for CHWs.

Race and Socioeconomic Differences in Obesity and Depression among Black and Non-Hispanic White Americans

Abstract: Obesity and depression often co-occur; however, the association between these conditions is poorly understood, especially among racial/ethnic minority groups. Using multinomial logistic regression and data from the National Survey of American Life, the relationships between race, ethnicity, and sociodemographic factors to the joint classification of body mass index categories and depression among African Americans, Caribbean Blacks, and non-Hispanic Whites were examined. Differential risk for the combination of obesity and depression by sociodemographic status was found. Being African American, female, young, married, or having low income or education increases the risk for obesity without depression. Risk factors for obesity with depression include being female, young, married and having a low income. Race was not a significant predictor of obesity with depression relative to normal weight without depression status. However, racial differences were observed among the non-depressed. Non-depressed African Americans were more likely than non-depressed Whites or Caribbean Blacks to be obese.

"The Stress Will Kill You": Prisoner Reentry as Experienced by Family Members and the Urgent Need for Support Services

Abstract: The role of incarceration and community reentry after incarceration has been studied extensively for individual and community health; however, little attention has been given to the experiences of individuals who provide support to those in reentry. Through a community-academic partnership, seven focus groups were conducted with 39 individuals supporting a family member in reentry in the summer of 2012. The primary objectives of the focus groups were to explore community experiences and perspectives regarding providing support during a family member's reentry from a period of incarceration and any desired support for themselves during this time. Five themes emerged under a metatheme of stress, indicating that family members experience acute stress as a result of family reentry that adds to the chronic stress they already endure. Programs that acknowledge the difficult role of family members as supporters during an individual's reentry and provide support to them are desperately needed.

Perceived Social Stress, Pregnancy-Related Anxiety, Depression and Subjective Social Status among Pregnant Mexican and Mexican American Women in South Texas

Abstract: Purpose . The purpose of this study was to determine differences in subjective social status, perceived social stress, depressive symptoms, and pregnancy-related anxiety between pregnant Mexican American and Mexican immigrant women. Methods . Three hundred pregnant Mexican immigrant and Mexican American women in South Texas were surveyed for pregnancy-related anxiety, perceived social stress, depressive symptoms, and subjective social status. Results . Pregnant Mexican immigrant women had higher levels of pregnancy-related anxiety and lower levels of depression and perceived social stress than pregnant Mexican American women. Change in these variables among Mexican immigrant women was relatively linear as time of residence in the United States increased. Mexican immigrant and Mexican American women had significantly different correlations between subjective social status, self-esteem and perceived social stress. Conclusions . Results indicate that subjective social status is an important psychosocial variable among pregnant Hispanic women. Results contribute to ongoing efforts to provide culturally responsive prenatal psychosocial support services.

Health Literacy from the Perspective of African Immigrant Youth and Elderly: A PhotoVoice Project

Abstract: Background. This project examines the views of African immigrants on health, access to health resources in the U.S., and perceived barriers to a healthy wellbeing faced by the elderly immigrants in the community. Methods. PhotoVoice methodology was used to evaluate the views of African immigrant youths and elderly drawn from a convenience sample. Participants were trained on the use of cameras and guided by research questions while taking photographs. The photographs were analyzed, coded into themes and presented to community resource representatives at a photo exhibit. Results. Emergent themes were: 1) nutrition, obesity and physical activity; 2) occupational regulation and educational opportunities; 3) feeling of security and public safety; 4) ethno- racial diversity and the health care system; 5) religiosity and social well- being. Discussion. These results have implications for health care professionals and community agencies serving immigrant populations. A deeper look into the health issues affecting this population is essential.

A qualitative study of pregnancy intention and the use of contraception among homeless women with children.

Abstract: We undertook a qualitative analysis informed by grounded theory to explore pregnancy intention and the barriers to contraceptive use as perceived by homeless women with children. Semi-structured interviews (n = 22) were performed in English and in Spanish. The dominant theme emerging from the interviews was a strong desire to avoid pregnancy while homeless. However, few women in our sample used contraception or accessed reproductive health care consistently. There were multiple barriers to using contraception and to accessing reproductive health care services that homeless women reported: (1) inability to prioritize health due to competing demands, (2) shelter-related obstacles and restrictive provider practices that impede access to reproductive health care services and the use of contraception, and (3) change in the power dynamics of sexual relationships while homeless, making women more vulnerable to sexual exploitation. Findings suggest a multifactorial approach is needed to help homeless women use contraception and access reproductive health services.

Emergency Department Charges for Asthma-Related Outpatient Visits by Insurance Status

Abstract: Though Americans make 1.8 million asthma-related outpatient visits to the emergency department (ED) annually, little is known about the episodic charges for asthma care in the ED. We therefore sought to assess the bills patients could face for acute asthma incidents by examining hospital charges for asthma-related outpatient ED visits. We performed a nationwide, cross-sectional study of 2.9 million weighted asthma-related outpatient ED visits from 2006–2008 using data from the Medical Expenditure Panel Survey. We found that the average charge for an outpatient ED visit was $1,502 (95% CI $1,493–$1,511). The charges did not vary significantly by insurance group but did increase significantly with age. Our results indicate that the financial burden of ED care for asthma may take a severe toll on low-income populations who have limited ability to pay, especially patients who must pay undiscounted charges, including the uninsured and those on high-deductible health plans.

Barriers to HIV Testing in Black Immigrants to the U.S.

Abstract: Background. Late HIV testing is common among immigrants from sub Saharan Africa and the Caribbean. Since 2010, HIV testing is no longer a required component of immigrant screening examinations or mandatory for immigrants seeking long term resi- dence in the US. Thus, barriers to HIV testing must be addressed. Methods. Five hundred and fifty- five (555) immigrants completed a barriers- to- HIV testing scale. Univariate and multivariate linear regression were performed to examine predictors of barriers. Results. In multivariate analysis, primary language other than English (β=2.9, p=.04), lower educa- tion (β=5.8, p=.03), low income (= below $20K/year) (β=4.6, p=.01), no regular provider (β=5.2, p=.002) and recent immigration (β=5.7, p=.0008) were independently associated with greater barriers. Barriers due to health care access, privacy, fatalism, and anticipated stigma were greater for recent versus longer term immigrants. Discussion. Immigrants from sub- Saharan Africa and the Caribbean face significant barriers to HIV testing. Interventions to improve access and timely entry into care are needed.

A Systematic Review of Innovative Diabetes Care Models in Low-and Middle-Income Countries (LMICs)

Abstract: Background . Over 70% of the world’s patients with diabetes reside in low-and middle-income countries (LMICs), where adequate infrastructure and resources for diabetes care are often lacking. Therefore, academic institutions, health care organizations, and governments from Western nations and LMICs have worked together to develop a variety of effective diabetes care models for resource-poor settings. Methods . A focused search of PubMed was conducted with the goal of identifying reports that addressed the implementation of diabetes care models or initiatives to improve clinical and/or biochemical outcomes in patients with diabetes mellitus. Results . A total of 15 published manuscripts comprising nine diabetes care models in 16 locations in sub-Saharan Africa, Latin America, and Asia identified by the above approach were systematically reviewed. The reviewed models shared a number of principles including collaboration, education, standardization, resource optimization, and technological innovation. The most comprehensive models used a number of these principles, which contributed to their success. Conclusions . Reviewing the principles shared by these successful programs may help guide the development of effective future models for diabetes care in low-income settings.

Stigma and Difficulty Accessing Medical Care in a Sample of Adults with Serious Mental Illness

Abstract: Introduction . Wellness of people with mental illness is increasingly a public health priority. This study examined factors associated with difficulties receiving medical care in adults with mental illness. Methods . In a sample of 1,670 adults with mental illness, we assessed difficulties in accessing medical care and stigma. Results . A total of 465 (28%) participants reported difficulties in accessing medical care; 211 (13%) attributed difficulties in access to stigma. Lack of comprehensive medical care coverage and mental health symptoms were associated with increased odds of perceived difficulties in accessing medical care; personal empowerment was negatively associated with perceived difficulties attributed to stigma; education was positively associated. Discussion . The findings highlight unmet need for medical care in this population and the need to recognize stigma as a barrier medical care. Interventions to empower patients and educate medical providers about wellness for people with serious mental illness could help to reduce barriers.

Journal of Health Care for the Poor and Underserved: 25 Years of Service

Abstract: Th ere was a continuing disparity in the burden of death and illness experienced by Black and other minority Americans, as compared with our nation as a whole. Th at disparity has existed ever since accurate Federal recordkeeping began more than a generation ago, and although our health charts do itemize steady gains in the health of minority Americans, the stubborn disparity remains . . . an aff ront to both our ideals and to the ongoing genius of American medicine.1

From Admission to Discharge: Patterns of Interpreter Use among Resident Physicians Caring for Hospitalized Patients with Limited English Proficiency

Abstract: Resident physicians' use of professional interpreters drives communication with hospitalized patients with limited English proficiency (LEP). We surveyed residents from three specialties across two hospitals affiliated with one academic medical institution about their communication with their last hospitalized LEP patient. Among 149 respondents (73% response rate), 71% reported using professional interpreters for fewer than 60% of hospital encounters. Most (91%) perceived their quality of communication with hospitalized LEP patients as worse than with English-speaking patients. Professional interpreter use varied substantially by resident and by hospital encounter, with more reporting use of ad hoc interpreters, their own language skills, or not talking to the patient due to time constraints during pre-rounds (39%), team rounds (49%), or check-ins (40%) than during procedural consents (9%) or family meetings (17%). The reported variation suggests targets for quality improvement efforts and the need for clear enforceable guidelines on resident communication with hospitalized LEP patients.

Access to Mental Health Services Among Patients at Health Centers and Factors Associated with Unmet Needs

Abstract: Cross-sectional 2009 Health Center Patient Survey data describe the mental health status of health center patients, utilization of mental health services, and factors associated with unmet need for mental health treatment. One in five health center patients accessed mental health services in the past year, and over half of the patients who received counseling received this treatment at a health center. Patients who were unable to access mental health care cited affordability as a concern. Unmet need for mental health treatment was reported by one in three patients. Multivariate analysis found that the odds of reporting unmet need were higher for patients who lacked a usual source of care and patients with serious mental illness.

Prevalence and correlates of depressive symptoms and resiliency among African American women in a community-based primary health care center.

Abstract: The purpose of this cross-sectional pilot study was to determine the prevalence and correlates of depressive symptoms and resiliency among 290 African American women (AAW) in a community-based primary health care center. Descriptive statistics, Pearson product-moment correlation, and logistic regression analyses were conducted. Findings indicate that depressive symptoms are experienced by 49% of the participants, while 10% indicated a history of suicidal ideation. Participants had moderately high resiliency scores that had a statistically significant inverse relationship with depressive symptoms. This suggests that resiliency is potentially a protective factor for depressive symptoms. Depressive symptoms were positively correlated with participants’ diagnosis of at least one chronic disease. The strongest predictors of depressive symptoms were previous diagnoses of a mental health condition and unemployment. This study identifies risk and potential protective factors for depression among a clinic sample of AAW.

A systematic review of factors affecting migrant attitudes towards seeking psychological help

Abstract: Research indicates that service utilization rates in migrant groups are low, although levels of distress appear high when compared with host populations. This paper systematically reviews quantitative and qualitative literature on factors associated with attitudes toward seeking psychological help among working age migrants. Data were extracted from MEDLINE, EMBASE, PsycINFO, Science Direct and SAGE databases. Eight quantitative studies and 16 qualitative studies met the inclusion and exclusion criteria. The majority of studies were conducted in North America (67%). Although results of quantitative studies were heterogeneous, stronger identification with host than heritage culture, fluency in host country language, psychological attributions of distress, higher educational levels, higher socioeconomic status, female gender, and older age were associated with more favourable attitudes toward help-seeking in some migrant groups. Three major themes emerged from the qualitative literature: logistical barriers, cultural mismatch between service providers and participants, and preferences for other sources of assistance.

Exploring Protective Factors among Homeless Youth: The Role of Natural Mentors

Abstract: This study explored the presence and characteristics of natural mentors among 197 homeless youth and the association between natural mentoring relationships and youth functioning. Few studies have explored protective factors in the lives of homeless youth and how these may buffer against poor health outcomes. Relationships with natural mentors have been shown to have protective effects on adolescent functioning among the general adolescent population, and, thus, warrant further investigation with homeless youth. Results from this study revealed that 73.6% of homeless youth have natural mentoring relationships, split between kin and non-kin relationships. Having a natural mentor was associated with higher satisfaction with social support and fewer risky sexual behaviors. Findings suggest that natural mentors may play a protective role in the lives of homeless youth and should be considered an important source of social support that may enhance youth resilience.

A Community-Based Pilot Study of a Diabetes Pharmacist Intervention in Latinos: Impact on Weight and Hemoglobin A1c

Abstract: Type 2 diabetes disproportionately affects Latinos increasing their risk of diabetes-related complications. This study used a randomized controlled design with a community-based approach to evaluate the impact of a culturally tailored pharmacist intervention on clinical outcomes in Latino diabetics. The intervention included a focused discussion and two individual pharmacist counseling sessions on medication, nutrition, exercise, and self-care to promote behavior changes. Sessions were culturally adapted for language, diet, family participation, and cultural beliefs. Clinical outcomes were measured at baseline and three months. Nineteen intervention and 24 control participants completed the study. Mean BMI reduction was greater for intervention than for control group participants (-0.73 ± 0.07 kg/m2 versus + 0.37 ± 0.02 kg/m2 p<.009 respectively). Hemoglobin A1c was significantly reduced by 0.93 ± 0.45% in the intervention group only. There was no significant difference in blood glucose, blood pressure, or lipid levels. An innovative culturally-sensitive pharmacist intervention improved selected clinical outcomes among Latino diabetics.

The Effects of a Culturally Sensitive, Empowerment-Focused, Community-Based Health Promotion Program on Health Outcomes of Adults with Type 2 Diabetes

Abstract: The purpose of the present study was to test the effects of a culturally sensitive, health empowerment-focused, community-based health promotion program tailored to adult patients with type 2 diabetes on these patients' body mass index (BMI), blood pressure, and self-reported blood glucose levels, treatment adherence, and stress levels. Study participants (N = 130) consisted mostly of African Americans (70%) and Hispanic/Latinos (22.3%) who were divided almost evenly between an intervention group and wait-list control group. The tested health promotion program is informed by Health Self-Empowerment Theory. At post-test, program participants in the intervention group as compared to those in the control group demonstrated significantly lower levels of BMI, diastolic blood pressure, and physical stress. Implications of these study findings for future similar programs and research are discussed.