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The update also summarizes recent journal articles and other research developments in the field and features a data slide from a relevant Kaiser Family Foundation publication. 1. Puerto Ricans Have Highest Rates of Asthma in Nation DISPARITIES IN RESEARCH
9. Racial Disparities in In-Hospital Death and Hospice Use among Nursing Home Residents at the End of Life 14. Unintended Pregnancy in the United States: Incidence and Disparities, 2006 15. Access to Care for Women Veterans: Delayed Healthcare and Unmet Need 17. Understanding Prenatal Health Care for American Indian Women in a Northern Plains Tribe DISPARITIES DATA SPOTLIGHT Health Insurance Coverage for the Nonelderly by Citizenship Status, 2010 DISPARITIES IN THE NEWS 1. Puerto Ricans Have Highest Rates of Asthma in Nation A recent article published in the Orlando Sentinel discussed the findings of a report from the American Lung Association which found that Puerto Ricans living in the mainland United States have disproportionately higher asthma rates than other Hispanic ethnicities and higher rates than many racial populations. Asthma is a chronic lung disease that constricts the muscles around a person’s airways, and makes it difficult for them to breathe. According to the report by the American Lung Association, approximately 25 million people across the United States are affected by asthma. However, Puerto Ricans experience rates that are higher than many other racial and ethnic populations. The prevalence rate among Puerto Ricans is more than double the rate of whites, and as Dr. Josè R. Arias Jr., an allergy and asthma specialist and an associate professor at the UCF College of Medicine, noted “Puerto Ricans also have the highest mortality rate from asthma, and they average the highest number of emergency room visits.” María Barbot, a Puerto Rican resident of Orlando, says she has “little control in planning her daily life” because she never knows when her asthma is going to “flare up.” Orlando has the second largest concentration of Puerto Ricans, behind New York City, with over 300,000 Puerto Ricans. Like Barbot, Arleen Pedraza witnessed her toddler son, Paul, experience the challenges of asthma and the road to being diagnosed. “I’d tell them [doctors] that asthma runs in my family, that I had seen those symptoms before, and they would tell me that it was anything from the flu to allergies,” Pedraza said. Little research has explored why Puerto Ricans have such high rates of asthma, however, Janelle Middents, regional director of the American Lung Association, said there are ways to improve the situation. “There is a great need to educate not just doctors, nurses and respiratory therapists bust also people who work in schools and the Hispanic community itself” (Rivera-Lyles, 11/14). 2. Where You Live Can Help Determine Your Health, Studies Say A recent article in The Baltimore Sun highlighted the findings from several studies that showed a strong link between a person’s neighborhood and their health. As the article points out, “Sociologists and public health offices have long thought a ZIP code is at least as important as race, age and genetics in determining a person’s health.” This idea has been bolstered by the findings of several studies. In one study by researchers at Johns Hopkins Bloomberg School of Public Health, racial disparities in diabetes, obesity and hypertension decreased after accounting for geographic location. In another study started by the Department of Housing and Urban Development, families who moved out of high-poverty neighborhoods had lower risks for diabetes and extreme obesity compared to families who stayed. Sabrina Oliver experienced the results first-hand when she moved from West Baltimore to the suburbs and discovered that her health dramatically improved. Previously unable to work as a result of chronic depression, she is no longer taking antidepressants, and working. “I feel transformed. I feel like I moved to a whole other world,” she said. Ms. Oliver was able to move because of a federal program that helped low-income families of Baltimore move to a suburban neighborhood. This program, administered by the American Civil Liberties Union (ACLU) of Maryland, provided funding for more than 1,500 families relocate from a neighborhood with a median household income of $24,182 to a neighborhood with a median household income of $48,318. While the exact path by which a person’s neighborhood may not be known, the article noted that the findings from prior research suggest that neighborhood characteristics such as housing stock, violence, the availability of healthy foods, access to good jobs, and access to health care may be important. According to Dr. Michelle Gourdine, a Maryland physician and consultant, there are policy changes that can be made that will help make communities better, such as requiring new developments to have walking paths and parks (Walker, 11/14). 3. Education Helps Low-Income Families Make Better Health Choices, Advocates Say The Network for a Healthy California, a partnering program by federal, state, and local agencies, established programs that help many of Santa Ana’s low-income population change their eating and exercise habits Healthy Cal reports. The 2009 Pediatric Nutrition Surveillance data from the California Department of Public Health found that roughly 21 percent of the population in Orange County’s between the ages of 5 and 20 years, and 17 percent of children between the ages of 2 and 5 years were obese. The Network for a Healthy California works with Santa Ana’s low-income population, including those receiving Cal Fresh—the federal Supplemental Nutrition Assistance Program (SNAP)—to make sustained life-style changes. The Network created a number of initiatives that have helped many of Santa Ana’s low-income population access healthy foods. Additionally, the Network is trying to improve awareness of living a healthy lifestyle by providing community and school-based educational programs to local residents. “We are educating them from many different angles, whether it’s in the classroom, at a parent meeting or at a monthly board meeting,” said Jennifer Chavez, Program Coordinator for Network within the Santa Ana Unified School District. Parents and children from over 30 schools in the district are participating in the program and are taking it upon themselves to improve the health of their children. “Parents want to provide healthy items to their children and once they have learned what healthy means, they make the necessary changes,” said Chavez. Many of the schools in the district have also made efforts to help the children’s health, such as changing the lunch menus and removing many of the vending machines that contributed to the bad eating habits. Chavez signaled that these changes have made improvements in the children’s health. “Physical activity is up, as in consumption of milk, fruit and water,” she said. While some of the issues facing this population are food choices, others include cultural and awareness barriers. “They’re not aware they’re not healthy,” said Maridet Ibanez, Administrative Manager at the Orange County Health Care Agency. “I was at a [health] screening, and some don’t know their numbers put them at risk for diabetes and high blood pressure. Our intervention creates that awareness,” Ibanez said (Afrasiabi, 11/08). 4. The New Poor: Elderly Hit Hard on Health Costs A recent article in The Fiscal Times reported on the change in the percentage of the elderly living in poverty that resulted from a potential update in the way the Census Bureau measures poverty. An official poverty rate was first calculated when President Johnson began the War on Poverty, and while it has been revised repeatedly, a 1995 report from the National Academy of Sciences criticized the measure for its failure to account for ‘in-kind benefits, the changed family structure, necessary expenses like taxes and health care, and the geographic price differentials between regions.’ The new draft measure from the Census Bureau includes a number of the recommendations from the report, and resulted in an increase in the poverty rate for all Americans from 15.1 percent using the official calculation, to 16 percent with the draft measure. According to the article, the number of children living in poverty decreased would have decreased by 4.3 percentage points to 18.2 percent, while the poverty rate among the elderly would have increased nearly 7 percentage points to 15.9 percent. The article noted that the increase in poverty among the elderly is largely the result of out-of-pocket expenses because low-income seniors tend not to have supplemental insurance for Medicare. This is in contrast to low-income children who tend to have better access to in-kind benefits such as the Children’s Health Insurance Program and supplemental nutrition programs. The article concluded by noting that despite the changes, the new measure is not likely to be approved by Congress in determining benefit eligibility because as Timothy Smeeding, director of the Institute for Research said, “It would redistribute the money from rural areas, the Midwest and South to more expensive areas. If I’m a senator from one of those states, my constituents are going to lose money.” (Goozner, 11/08). 5. Drug Use Highest Among American Indian Teens, Lower Among Blacks A recent article published in California Watch discussed the high rate of drug-related disorders among Native American adolescents, and the challenges associated with trying to provide adequate care to Native American youth in California. According to the article, a national study found the highest rates of drug-related disorders are among Native American, white, Latino and mixed-race teens. California has a very racially and ethnically diverse population, and Native American youth in California face significant disparities and public health challenges. For example, the resources needed to address many of the health issues that this population faces are either inadequate or limited. “I don’t know anyone who works with (Native American) youth with these types of problems who think there are enough resources dedicated to substance abuse prevention and treatment,” said David Sprenger, chief medical officer for the California Area Indian Health Service. According to the article, the California Area Indian Health Service estimates that 5,000 Native American teens need residential care, yet there are no treatment facilities for Native American youth in the California. “You would think that there are a lot of programs funded locally or statewide for these adolescents, and there are not,” said Dr. Jeffery Wilkins, president of the California Society of Addiction Medicine and medical director of addiction medicine at Cedars-Sinai Medical Center in Los Angeles. A lot of the challenges that this population faces are complex and largely stem from the lack of funding coupled with genetics and history. Dr. Sprenger noted that the psychosocial stress due to the loss of culture may be another potential cause for the high rate of drug-related disorders among this population. “In general, Native Americans or Indians come from a history of trauma,” he said. The study’s results are consistent with prior research, and as Dan Blazer, co-author of the study said, “the study should underscore the importance of early intervention with youth, which is crucial for successful addiction prevention and treatment” (Yeung, 11/07). 6. Mobile Mammography Unit Will Help Uninsured Women in Cancer Fight A recent article in the Orlando Sentinel detailed the challenges many low-income women face obtaining screenings and care for breast cancer, and highlighted a new program in Orange County, Florida that will provide free mammograms to low-income residents. According to the article, there are roughly 40,000 women in Orange County ages 40 and over who do not have health insurance, and it is believed that many of are not getting regular mammograms. For some of these women, the consequences are dire. Dr. Jennie Yoon, medical director of women’s imaging services for Florida Hospital, and founder of the Jennie Yoon Buchanan M.D. Breast Cancer Fund, has seen first-hand the impact breast cancer can have, and vowed to do something about it. With support from Florida Hospital and various community partners, Dr. Yoon has been working to make it easier for uninsured women to get the screening and care they need. For some women, these programs can mean the difference between life and death. Jen Radloff, a 50-year-old Orlando resident may have experienced the unfortunate outcome from breast cancer if she did not get a mammogram screening when she went to go for a regular checkup at Grace Medical Home. “My husband and I fall into that huge abyss of people that make too much money to qualify for Medicaid but can’t afford private health insurance,” said Radloff. “If it were not for Grace Medical Home and Libby’s Legacy [another nonprofit group that paid for the screening] and MD Anderson [Cancer Center, which also provided her treatment at no cost], I could very well be dead.” “I never asked for money,” said Yoon. However, after providing over 100 mammograms and saving seven lives, she says “Now every time I see someone, it’s like: ‘Please donate!’” (Santich, 11/07). 7. Survey Finds Houstonian Health Worse than National Average The Houston Chronicle published an article that discussed the findings of a recent survey by researchers at the University of Texas, that found Houstonians fare far worse in cardiovascular disease, high blood pressure, diabetes, obesity, and asthma than the national average and found that Hispanic Houstonians experience significant health disparities. Stephen Linder, a professor at the University of Texas of Public Health in Houston, was lead author of the study that was “the first to map Houston health by neighborhood and race or ethnic group.” The survey found that Hispanics in the Houston area have the highest uninsured rate. This even held constant after removing the illegal population. Additionally, the number of people reporting psychiatric distress and lack of dental insurance among Houstonians is almost twice the national average. “In many areas, Houston health is worse than I would have thought,” said Linder. There were also some surprising findings among the Vietnamese population. Thirty-six percent of Vietnamese Houstonians reported their health as fair or poor compared to 15 percent of whites, 24 percent of blacks, and 25 percent of Hispanics. However, rates of fair or poor health for all racial and ethnic groups in Houston were higher than the national average, which is 10 percent. The article noted that “not all the news was bad.” Childhood obesity rate in Houston is better than the national average (11 percent versus 12 percent) and the state average (11 percent versus 14 percent). “This scorecard shows that we’re still not where we need to be,” said Linder. Linder hopes to obtain funding to do the survey periodically and that groups will create strategies to address these disparities (Ackerman, 11/07). 8. Thyroid Cancer Hits Filipinos Hardest According to an article recently published in cancer the Honolulu Star-Advertiser thyroid cancer disproportionately affects the Filipino population in Hawaii and a study by a research team at Queen’s Medical Center found a genetic mutation in a greater share of Filipino thyroid cancer patients as compared with other thyroid cancer patients. According to the article, thyroid cancer has more than doubled in the past decade in the United States and between 1998 and 2008, the number nearly doubled in Hawaii. In Hawaii, Filipinos have the highest prevalence of the disease. A research team at Queen’s Medical Center found that almost 85 percent of Filipino patients with thyroid cancer had the BRAF genetic mutation, a mutation that “is associated with aggressive tumor behavior, a higher chance of treatment failure, increased recurrence, and a worse outcome.” Although the gene is associated with more aggressive tumor behavior, it is not routinely screened for in every thyroid cancer patient according to the article. Shane Morita, the study leader and assistant professor at the University of Hawaii John A. Burns School of Medicine, suggested that for some groups, such as Filipinos, screening for the gene should be routine. “The end goal is to improve patient care and to understand a little bit more about the ethnic disparities we see in Hawaii.” Dr. Morita noted that a drug recently approved by the Food and Drug Administration to fight against the BRAF gene in connection with melanoma, is now being tested for use in thyroid cancer patients. Morita hopes further research will investigate why inequalities in outcomes exist in select minority groups. “We hope that this research in thyroid cancer will advance knowledge of the disease, especially how it affects particular groups in Hawaii’s diverse population,” he said (Consillio, 11/07). DISPARITIES IN RESEARCH 9. Racial Disparities in In-Hospital Death and Hospice Use Among Nursing Home Residents at the End of Life A recent study published in Medical Care found race alone did not explain why black long-term care residents in New York experience higher rates of in-hospital deaths, more aggressive end-of-life care, and have lower rates of hospice use than whites. According to the authors, a patient’s risk of death for care at the end-of-life (EOL) is higher when they are a patient in a hospital rather than a nursing home. Exploring racial disparities in hospice use and in-hospital deaths at EOL was the purpose of this study. The study’s sample included 49,048 decedents from 555 nursing homes in the state of New York. This sample was pulled from four sources of data: The Medicare beneficiary file, The Minimum Data Set (MDS), and the Medicare inpatient and hospice claims. To account for the in-hospital death rate and hospice use among decedents in New York, MDS was connected with the data from the Medicare inpatient and hospice claims. The two key independent variables were individual-level race which was dichotomized into black and white and facility-level race-mix which was calculated proportion of black residents in each facility over a 3-year period. Facilities with a black population more than 90 percent or less than 10 percent of the total nursing home population were excluded. The results showed that blacks tended to have a higher in-hospital death rate and experienced more aggressive EOL care than whites. Additionally, blacks tended to have a higher usage of feeding tubes (31.12% vs. 10.08%) and signed fewer DNR and/or DNH orders than whites. However, after controlling for nursing home characteristics, racial disparities between black and whites in hospice care and in-hospital deaths disappeared. The authors explained that race alone could not explain why this disparity persisted. They point out that blacks being less likely to sign a DNR and/or DNH order and being more likely to use feeding tubes could be a stronger predictor for these disparities. This finding, blacks being less likely to sign a DNR and/or DNH order, is consistent with previous literature. Despite these findings, variation for EOL care across-facilities, especially in facilities with higher black populations, emerged in the study. Future research will need to explore the overall quality of care in predominantly black nursing home facilities according to the authors. (Zheng NT, Mukamel DB, Caprio T, et al. Racial disparities in in-hospital death and hospice use among nursing home residents at the end of life. Medical Care. 2011 Nov; 49(11): 992-998). 10. Racial and Ethnic Variations in Temporal Changes in Fetal Deaths and First Day Infant Deaths A recent study published in the Maternal and Child Health Journal found that while there was an overall improvement in infant and fetal mortality rates between the years 1990 to 2002, the improvements were not shared equally. Moreover, the disparity between black and white fetal mortality rates increased. The authors of the study wanted to explore if there were any changes in fetal and infant mortality rates from 1990 to 2002. The authors also wanted to account for any potential differences across racial and ethnic groups. The study included data from the National Center for Health Statistics for live singleton births and deaths between 1990—1991 and 2001—2002 , and analyses were limited to deliveries at 20 weeks’ gestation and beyond. The results indicated solid improvements in fetal mortality rates for white and Hispanic mothers. The fetal morality rate, the first day mortality rate, and the combined fetal-first day mortality rate for Hispanics each improved by more than 12 percentage points. While the first day mortality rate and the combined fetal-first day mortality rate decreased for blacks, rates still remained higher than either white or Hispanic women, and the black fetal mortality rate increased by 4.06 percent. Furthermore, the first day infant mortality rate for black mothers was almost triple the rate of that of white mothers (4.18 per 1,000 live births vs. 1.53 per 1,000 live births). The study also found an increase in early gestational fetal and combined fetal-fist day deaths at early gestational ages for all racial and ethnic groups. In light of the recent findings, the authors argue that more advanced and targeted public health interventions—such as the use of steroids, surfactant therapies, and intrapartum antibiotics—may help close the disparity in fetal and infant mortality rates within black populations. (Wingate MS and Barfield WD. Racial and ethnic variations in temporal changes in fetal deaths and first day infant deaths. Maternal and Child Health Journal. 2011 Nov; 15(8): 1135-1142). 11. Missed Opportunities for HIV Testing in Health Care Settings Among Young African American Men Who Have Sex with Men: Implications for the HIV Epidemic A recent study published in AIDS Patient Care and STDs found that black men in Jackson, Mississippi had an increased probability of being infected with HIV if they do not have a primary care provider and did not disclose their sexual behaviors during a doctor visit. The HIV epidemic in the United States has disproportionately affected young black men. This is especially true for young black men who have sex with men (MSM) in the south. Between 2004—2005 and 2006—2007, the number of new HIV diagnoses among young black men in the metropolitan area of Jackson, Mississippi increased by 45 percent. The authors determine the relationship between access to care and HIV prevention and HIV infection rates, and to identify ways to improve HIV prevention and testing in the clinical setting for black MSM in the Jackson area. From February – April 2008, a case-control study of three counties in Jackson, Mississippi was done. Black men who received a diagnosis of HIV between January 2006 and April 2008 and were identified by the HIV/AIDS Reporting System (HARS) were categorized as cases in the study. Black men who have had anal sex with another man within a 6-month period prior to the interview, tested negative for HIV and lived within one of the three counties were eligible for the control group. Both groups were between the ages 16 – 25 years and self-reported as MSM. Demographic, socioeconomic, behavioral, and health care-related data were collected for both groups for the recall period. Of the 86 potential cases, 40 were interviewed, and 30 were eligible. A total of 95 controls were eligible and enrolled. The findings showed men in both groups had similar rates of visits to a health care provider within the recall period and no statistical difference was apparent in the type of insurance a participant had in either group. However, the findings did show cases were more likely than controls to be uninsured and to not have a primary health care provider. Furthermore, cases were seven times more likely not to disclose their sexual identity to their health care provider. Ultimately, the study discovered those who did not have a primary care provider, did not disclose their sexual identity during a doctor visit, engaged in unprotected anal intercourse, and had an older male partner were at a significantly higher risk of HIV transmission. The authors suggested that the findings ultimately indicate the best opportunity to diagnose an individual and prevent HIV transmission among this population occurs during a doctor visit. The conclude that policies should promote discussions between a doctor and patient about sexual behavior in addition to providing routine HIV screening. (Dorell, CG, Sutton, MY, Oster AM, et al. Missed opportunities for HIV testing in health care settings among young African American men who have sex with men: implications for the HIV Epidemic. AIDS Patient Care and STDs. 2011 Nov; 25(11): 657-663). 12. Health Disparities in Medication Adherence Between African-Americans and Caucasians with Epilepsy The medication possession ratio (MPR), the index that defines the number of days between prescription refills, for blacks with epilepsy is poorer than it is for whites according to a recent study in Epilepsy & Behavior. The authors of the study wanted to explore if there were any racial disparities in adherence to antiepileptic drugs (AED) among patients with epilepsy. The authors reviewed the Shands-Jacksonville pharmacy prescription and refill information from January 1, 2006 to December 31, 2010. The authors specifically reviewed the information of patients with epilepsy enrolled in the First Care Program who treats seizures with AEDs. Eligible participants included individuals who were enrolled in First Care, were a resident of Duval County in Jacksonville, Florida, had an annual income less than or equal to 200% of the federal poverty level, and had been diagnosed with epilepsy by a neurologist from the University of Florida Health Sciences Center/Jacksonville. The MPR was used to measure medication adherence among those who were diagnosed with epilepsy. The results showed the MPR for whites was .872 and .796 for blacks, which corresponds to a 2.3 day difference between white and black patients when filling a 30-day prescription, and suggests that white patients had a better medication adherence than blacks. These findings are consistent with prior research that found blacks tend to have poorer medication adherence than whites. According to the authors, possible explanations for the inequalities in medication adherence between whites and blacks may be attributable to blacks with epilepsy having higher levels of mistrust of their health care providers. The results of the study, the authors argue, promote the need of cultural awareness and sensitivity being incorporated to strategies that seek to improve medication adherence among individuals with epilepsy. (Bautista RD, Graham C, Mukardamwala S. Health disparities in medication adherence between African-Americans and Caucasians with epilepsy. Epilepsy & Behavior. 2011 Nov; 22(3): 495-498). 13. Reproductive Health Screening Disparities and Sexual Orientation in a Cohort Study of U.S. Adolescent and Young Adult Females According to a recent study in the Journal of Adolescent Health, sexual minority adolescents have a lower odds of having a Pap test or a screening for a sexually transmitted infection (STI) in the past year compared to heterosexual adolescents. The authors in this study wanted to explore sexual orientation disparities in the Papanicolaou (Pap) and sexually transmitted infection (STI)/human papillomavirus (HPV) tests. Specifically, they wanted to explore disparities among adolescent and young adult women, ages 17-25. The 2005 reproductive health and sexual risk behavior questions from The Growing Up Today Study, a longitudinal cohort study of U.S adolescents, were used in this study. The sample of female participants was broken down by completely heterosexual, mostly heterosexual, bisexual, mostly homosexual, completely homosexual (lesbian). They were asked if they had ever had any sexual contact with a man, had a Pap test, or been tested for an STI. The results demonstrated heterosexual adolescent and young adult women had higher rates of Pap and STI screenings than lesbian adolescent and young adult women. Additionally, mostly heterosexual and bisexual adolescent women had almost 40% higher odds of being diagnosed with an STI than completely heterosexuals and lesbians. Lesbian adolescent and lesbian young adult women had the lowest rate of Pap and STI screening out of every group. These disparities persisted even after controlling for sociodemographic characteristics and sexual history. Prior studies have demonstrated that sexual minority youth have lower social support from family than their heterosexual peers, which may explain the lower rates of Pap and STI screenings for this population. The authors recommend that providers and clinicians should be aware of these disparities and barriers so they can better provider appropriate care to this population. They went on to suggest that all young females need regular Pap tests and STI screenings, regardless of sexual orientation. 14. Unintended Pregnancy in the United States: Incidence and Disparities, 2006 Although some progress was made between 2001 and 2006, almost half of the pregnancies in the United States in 2006 were unintended, and according to results of a recent study in Contraception women who are black, less educated, poor, cohabiting, or younger than 20 years old, experience higher rates. Unintended pregnancy is associated with poorer maternal health behaviors and worse child health outcomes, and while the unintended pregnancy rate decreased between the late 1980s and 1990s, it became stagnant by 2001. Using data from the National Center for Health Statistics (NCHS), the National Survey of Family Growth (NSFG), and data that was extrapolated from two Abortion Patient Surveys, the authors examined differences in unintended pregnancy rates between 2001 and 2006 and differences in pregnancy outcomes across various demographic populations. Unintended pregnancies were identified by either mistimed or unwanted. Mistimed was understood to mean a pregnancy occurred not at the time the woman planned, although she wanted to be pregnant at some point in the future. A pregnancy was defined as unwanted when the woman did not want to be pregnant at that time or in the future. The authors also examined the abortion rate among the women who had unintended pregnancies. The results showed that there were 3.2 million unintended pregnancies in the United States, a number that was slightly higher than the 3.1 million unintended pregnancies in 2001, and representing nearly half (49%) of the total number of pregnancies in 2006 (6.7 million). By age, the highest rate of unintended pregnancies was among 20-24 women. Women with the fewest years of educational attainment also had the highest rate of unintended pregnancies. The unintended rate among poor and low-income women was almost five times higher than women in the highest income brackets. There were also differences in unintended pregnancy rates by race, with higher rates being observed in black women. Roughly 43 percent of unintended pregnancies ended in abortion. The abortion rate was highest among women ages 15-17, women with some college education but no degree, black women, and women who live in higher-income brackets. Overall however, the abortion rate decreased during this time. In order to reduce the number of unintended pregnancies in the United States, the authors recommend increasing and improving contraceptive use among women and couples. According to The American Congress of Obstetricians and Gynecologists, intrauterine device (IUD) paired with condom usage should be the “first-line” of choices for young women and couples who do not want to have an unintended pregnancy. (Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011 Nov; 84(5): 478-485). 15. Access to Care for Women Veterans: Delayed Healthcare and Unmet Need According to the results of a recent study published in the Journal of General Internal Medicine,roughly 1 in 5 women veterans delayed or went without needed care at some point during the previous 12 month period, and rates varied by age, coverage status, military service, and perceptions about care at the Department of Veterans Affairs. In 2010, the Department of Veterans Affairs (VA) established a plan to expand healthcare access to women veterans, a population that has experienced disparities in access to care. The authors sought to better understand the barriers women veterans face when accessing care. The authors conducted the National Survey of Women Veterans (NSWV) in 2008-2009. The NSWV is a cross-sectional national telephone survey of a population-based, stratified a random sample of women veterans. They examined the association between self-reported delays in care and foregoing needed care in the past 12 months and general access factors such as age, race and ethnicity, and insurance status and the association with VA and veterans-related factors like length of service, perceptions of VA care, and knowledge of available VA services. The results demonstrated that 18.9% of women veterans reported delaying or not getting needed care in the prior 12 month period. Rates were higher for uninsured women veterans, women between the ages of 18 and 34 years, women of color, and those with less than a college education. The reasons women delayed or went without needed care differed by age group, but regardless of age, the number one reason women veterans reported was affordability of care (41 percent). In multivariate analyses, being uninsured, less than 35 years old, not knowing what services are available through the VA, perceiving the VA and insensitive to gender, and having a history of military sexual assault were predictive of delaying or foregoing needed care. Although the VA is an equal access care system, yet the study demonstrated that many women veterans are delaying or foregoing needed care. The authors note that many of the barriers identified in the study can be ameliorated through an expansion of VA health care and services. They suggest that “after-hours care should be considered, as should expanded VA transportation services and tele-medicine” to reduce barriers to care for women veterans. (Washington DL, Bean-Mayberry B, Riopelle D, et al. Access to care for women veterans: delayed healthcare and unmet need. Journal of General Internal Medicine. 2011 Nov; 26 (Suppl. 2): 655-661). 16. Do Medical Homes Reduce Disparities in Receipt of Preventive Services Between Children Living in Immigrant and Non-immigrant Families? A recent study found in the Journal of Immigrant Minority Health found that immigrant children were less likely than non-immigrant children to receive care in a medical home, and among those who have a medical home, less likely to receive preventive care. One mechanism that has the potential to reduce healthcare disparities among children of immigrant families is the patient-centered medical home model (PCMHM) according to the authors. The authors used data from the National Survey of Children’s Health, 2007 (NSCH) to determine whether receipt of preventive services differed among children using the PCMHM by immigration status. The survey response rate was 55.3 percent out of 91,642 respondents. The NSCH defines a medical home using five components: 1) personal doctor or nurse, 2) usual source of sick or well care, 3) family-centered care, 4) problems getting needed referral and 5) coordinated care. Immigrant status was dichotomized to include children living in immigrant families (i.e. children born outside the U.S. or those born in the U.S., but have at least on non-U.S.-born parent) and non-immigrant children (i.e. children born of two U.S.-born parents). The results found that children living in immigrant families were less likely to meet the medical home criteria (59.7 percent) than children in non-immigrant families (40.3 percent). Black and Hispanic children were less likely that white children and children living below 400% of the federal poverty level (FPL) were less likely than children living above 400% FPL to meet the medical home criteria. The study also found that children without medical homes were less likely to receive preventive care services in the previous 12 months and tend to have more chronic conditions. The disparities persisted even after controlling for factors like a parents education, employment, and insurance status. Children living in immigrant families, were more likely to be uninsured, less likely to meet any aspect of the medical home criteria, and less likely to have received preventive services in the past 12 months. Finally, among children with a medical home, the odds of receiving preventive services in the past 12 months was higher for non-immigrant children (OR = 1.61, CI: 1.41-2.30). These findings are consistent with prior research that found similar results for children with specific illnesses and special needs. Because medical homes have the potential to reduce disparities in preventive care, the authors suggest possible culturally competent policies should be used or introduced in health care settings. (BeLue R, Degboe AN, Miranda PY, et al. Do medical homes reduce disparities in receipt of preventive services between children living in immigrant and non-immigrant families? Journal of Immigrant Minority Health. 2011 Nov; DOI: 10.1007/s10903-011-9540-z). 17. Understanding Prenatal Health Care for American Indian Women in a Northern Plains Tribe A recent study published in the Journal of Transcultural Nursing found that the lack of trust of certain physicians, long waiting periods for doctor checkups, and transportation issues are specific barriers that help explain why the women of American Indian ancestry in a Northern tribe are less likely to obtain prenatal care. Prior studies have found that the health of a mother and baby are dependent upon receiving early and regular prenatal care. Unfortunately, studies have also found that American Indians are less likely to obtain prenatal care. The purpose of this study was to explore what were some of the reasons why this population is less likely to receive prenatal care. The population that the authors focused on was American Indian women from one tribe in the Northern Plains region. A total of 58 women were interviewed about their experiences using prenatal care. The questions they used were from previous research that covered current prenatal practices, views on pregnancy, the benefits and drawbacks of prenatal care, and opinions about current models of prenatal care. The interviews were taped-recorded and were coded for themes using Atlas.ti, a software program created specifically for qualitative data analysis. Three themes emerged from the interviews that may help explain why this population is less likely to obtain prenatal care. They are: 1) communication barriers, 2) institutional barriers, and 3) other barriers. The communication barriers included concerns that the doctor was not that interested in their needs, which in turned created a lack of trust in physicians. Institutional barriers included concerns about the long waiting periods for short appointments, which can be as long as 2 hours for a 15-minute visit, having to sit in a waiting room with sick people, and having a different physician for each visit. The findings for this theme further demonstrated a desire for female physicians and nurse mid-wives. According to the findings, many of the women felt embarrassed about discussing their pregnancies with a male doctor. Finally, other barriers included transportation problems and work schedule conflicts, and interpersonal problems like poverty, sexual or physical abuse, and substance use. Solutions to these barriers include implementing culturally competent training programs for doctors, having women only see one doctor for the entire pregnancy, specifically a female doctor. According to the author, this study is a first step towards understanding why this population is less likely to obtain prenatal care, and she suggests that future research should explore the barriers faced by American Indians in different tribes and in different regions. (Hanson JD. Understanding prenatal health care for American Indian women in a northern plains tribe. Journal of Transcultural Nursing. 2011 Nov; DOI: 10.1177/1043659611423826).
NOTES: Medicaid/Other Public also includes CHIP, other state programs, Medicare, and military-related coverage. Data may not total 100% due to rounding. In 2010, there were 21 million non-citizens residing in the United States. Regardless of how they became citizens, U.S. citizens have significantly higher coverage rates than non-citizens. Despite similar employment rates, nearly 40 percent of non-citizens have employer sponsored or other private coverage as compared to nearly 64 percent of both native and naturalized citizens, and almost 50 percent of non-citizens are uninsured. The Affordable Care Act will help make coverage more accessible to lawfully residing immigrants through the expansion of Medicaid and the creation of Health Insurance Exchanges. However, many immigrants currently eligible for coverage face significant barriers when attempting to enroll in Medicaid and CHIP, including fear, onerous application processes, and language and literacy issues. These are just some of the barriers that emerged from focus groups with outreach and enrollment workers who serve immigrant communities, and it will be important to address these and other barriers to coverage and access if immigrant families are to benefit from the coverage expansions. To learn more about the health coverage of immigrants, some of the barriers they face when enrolling in coverage and accessing needed care, and some of the strategies successful in overcoming these barriers, please read Connecting Eligible Immigrant Families to Health Coverage and Care: Key Lessons from Outreach and Enrollment Workers. |
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