A Qualitative Study of Provider Perspectives of Structural Barriers to Cervical Cancer Screening Among First Nations Women

ObjectiveIn Canada, opportunistic screening programs have successfully reduced mortality from cervical cancer; however, minority or disadvantaged groups, as well as women in northern and rural areas, are inadequately recruited by this approach. Hence, we set out to examine the structural barriers that prevent First Nations women's participation in cervical cancer screening.MethodsUsing a participatory action research approach and semistructured interview guides, we conducted in-depth interviews with 18 experienced health care professionals, 12 of whom were also community members. These individuals included nurses, nurse practitioners, community health representatives, social workers and physicians who provide care to women in our First Nations partner communities. In the current report, we explored perceived barriers to cervical cancer screening through the lens of service providers.ResultsStructural barriers to cervical cancer screening for First Nations women included shortage of appropriate health care providers, lack of a recall-based screening system, geographic and transportation barriers; health literacy and socioeconomic inequalities, generational effects, and the colonial legacy.ConclusionExisting, opportunistic cervical cancer screening programs do not perform well for First Nations women who experience significant screening-related health inequalities that are largely influenced by structural barriers. Sustainable screening interventions in First Nations communities require approaches that resolve these structural barriers, explore new ways of screening, and provide education for both women and health care providers. Many of the structural barriers are rooted in colonial history. Given the negative impact of the consequences of colonization on indigenous women worldwide, many of our findings strongly resonate with marginalized populations in other countries.     

Improving access to health care in Latino communities.

Public debate about health care reform often focuses on the need for health insurance coverage, but in Latino communities many other barriers also inhibit access to medical care. In addition, basic public health services often go underfunded or ignored. Thus, health care reform efforts, nationally and in each State, must embrace a broader view of the issues if the needs of Latino communities are to be served. This report reviews and summarizes information about the mounting problems Latino communities face in gaining access to medical care. Access to appropriate medical care is reduced by numerous financial, structural, and institutional barriers. Financial barriers include the lack of health insurance coverage and low family incomes common in Latino communities. More than 7 million Latinos (39 percent) go without health insurance coverage. Latinos without health insurance receive about half as much medical care as those who are insured. Structurally, the delivery system organization rarely reflects the cultural or social concerns of the communities where they are located. Therefore, providers and patients fail to communicate their concerns adequately. These communication problems are exacerbated by the extreme shortage of Latino health care professionals and other resources available. Institutional barriers often reflect the failure to consider what it means to provide good service as well as high-quality medical care. Reducing these barriers to medical care requires modifying governmental and institutional policies, expanding the supply of competent providers, restructuring delivery system incentives to ensure primary care and public health services, and enhancing service and satisfaction with care.     

Understanding Factors that Influence Health Care Utilization Among Mixtec and Zapotec Women in a Farmworker Community in California

This paper examines health care utilization among indigenous immigrants from Oaxaca, Mexico, who have settled in a farmworker community in southern California. In 2016, two trained Spanish-Mixteco and Spanish-Zapoteco bi-lingual interviewers conducted in-depth interviews with 44 indigenous women residing in Oxnard, California on issues that affect health care utilization. Interviews were conducted in Mixteco, Zapoteco and Spanish and were coded to identify structural, cultural, and provider-related barriers to health care utilization. Five bi-lingual Spanish-Mixteco indigenous interpreters employed at local clinics were also interviewed. Many women reported lack of health insurance, inability to pay, language barriers, long waiting times, rushed encounters with providers, and seeking western medical care only after home remedies did not work. However, several women were able to access routine health care services, often with support from indigenous interpreters employed at clinics. Interviews with five interpreters found that they provided assistance with interpretation during medical encounters and appointment making. They also educated patients about upcoming exams, identified low-cost services and insurance programs available to patients, assisted with paperwork and occasionally educated physicians on behalf of their patients. In addition to addressing barriers to health care access our findings suggest the importance of identifying and leveraging community assets, such as indigenous navigators, when developing programs for such underserved communities. Our findings can inform best practice in settings that provide health care to indigenous populations and may also apply to settings that provide health care to other immigrant communities that have very limited familiarity and contact with western health care.     

Cultural Perceptions and Negotiations Surrounding Sexual and Reproductive Health Among Migrant and Non-migrant Indigenous Mexican Women from Yucatán,Mexico

Information regarding sexual and reproductive health of indigenous women from Mexican sending and US receiving communities is limited. This research aims to explore the perceptions of indigenous women from US migrant receiving and Mexican migrant sending communities regarding their sexual health experiences and reproductive health practices. From January to March 2012, two key informant interviews and 31 in-depth, semi-structured interviews were conducted among women ages 18–55 in Tunkás, Yucatán and Anaheim and Inglewood, California. Women reported challenges to obtaining routine reproductive clinical care, including access to care barriers and lack of perceived power over their own sexual health. This was further compounded by migration processes and deficiencies in health care delivery systems. Socio-cultural beliefs and gendered power dynamics influence sexual and reproductive health decisions and behaviors of migrant and non-migrant women. Findings underscore existing gender-based reproductive health norms and serve to inform future transnational research and public health education to improve the health of indigenous migrant and non-migrant women in the US and Mexico.     

Structural barriers to ART adherence in Southern Africa: Challenges and potential ways forward

Abstract

Structural barriers to antiretroviral therapy (ART) adherence are economic, institutional, political and cultural factors, that collectively influence the extent to which persons living with HIV follow their medication regimens. We identify three sets of structural barriers to ART adherence that are salient in Southern Africa: poverty-related, institutional, and political and cultural. Examples of poverty-related barriers are competing demands in the context of resource-constrained settings, the lack of transport infrastructure, food insecurity, the role of disability grants and poor social support. Examples of institutional factors are logistical barriers, overburdened health care facilities, limited access to mental health services and difficulties in ensuring adequate counselling. Examples of political and cultural barriers are controversies in the provision of treatment for AIDS, migration, traditional beliefs about HIV and AIDS, poor health literacy and gender inequalities. In forging a way forward, we identify ways in which individuals, communities and health care systems may overcome some of these structural barriers. Finally, we make recommendations for further research on structural barriers to ART adherence. In all likelihood, enhancing adherence to ART requires the efforts of a variety of disciplines, including public health, psychology, anthropology, sociology and medicine.     

Issues in health policy for indigenous peoples in Canada

This paper provides a preliminary report on the work of the Canadian Royal Commission on Aboriginal Peoples. This commission has spent the past four years undertaking a comprehensive review of all matters pertaining to indigenous people in Canada, and will publish a final report in late 1995 or early 1996. The paper provides an overview of health policy issues examined by the commission. The author was employed by the commission in various capacities to contribute to this analysis of indigenous people's health policy concerns. A disproportionate burden of illness has been suffered by indigenous peoples in Canada. Past policy has systematically undermined the capacity of indigenous communities to develop their own health care systems. Current concerns about health problems and services, as expressed by indigenous people at the commission's community hearings, describe a need for a community-controlled and culturally appropriate approach to healing in indigenous communities. The commission's framework for developing an indigenous people's health strategy is intended to ensure that indigenous people have the capacity, the resources and the appropriate political environment in which to implement community healing. Its relevance to the Australian context may best be seen through a careful review of the commission's final report.     

Access to health care in an age of austerity: disabled people’s unmet needs in Greece

Since late 2009, Greece has been dealing with the effects of a debt crisis. The neoliberal principles embedded in the three structural adjustment programmes that the country accepted have required radical cuts in health care funding, which in turn have led to widening inequalities in health. This article focuses on access to health care for people with disabilities in Greece in the context of these structural adjustments. We investigate possible differences in unmet health care needs between people with and without disabilities, using de-identified cross-sectional data from the European Health Interview Survey. The sample included 5400 community-dwelling men and women aged 15 years and over. The results of the logistic regressions showed that people with disabilities report higher unmet health care needs, with cost, transportation, and long waiting lists being significant barriers; experience of all barriers was positively associated with low socio-economic status. These findings suggest that a section of the population who may have higher health care needs face greater barriers in accessing services. Austerity policies impact on access to health care in both direct and indirect ways, producing long-term disadvantage for disabled people. Social policies and comprehensive anti-discrimination legislation might help to address some of the barriers this population faces.     

Understanding wellness and barriers to care among Iraqi refugee women in the United States

Iraqi refugees in the US experience a high prevalence of non‐communicable diseases. In this article, we explore how cultural and structural realities intersect to influence utilisation of preventative healthcare and cancer screening with the aim of understanding health disparities in this population. We conducted three focus group discussions with a total of 14 Iraqi refugee women living in a northeastern US city in 2016 and analysed the qualitative data using a thematic analysis. Eight themes emerged from our data: (a) ‘prevention is better than cure:' Iraqi refugee women maintain wellness; (b) physical and mental health are interrelated in causing and curing ill‐health; (c) Iraqi refugee women embrace both biomedical and other healing practices; (d) God contributes to healing; (e) cancer is caused by dangerous environments. Three of the eight themes related to barriers to care; (f) multi‐level problems within hospitals and clinics prevent the delivery of care; (g) financial barriers prevent access to care and good health; (h) competing priorities are a barrier to good health. We argue that understanding refugee health requires critical analysis of both culturally informed understandings of health and illness as well as the structural aspects of health disparities that result in limited access to life opportunities, racism and inequality for refugees and their communities.     

Exploring loss to follow-up among women living with HIV in Prevention of Mother to Child Transmission programmes in Côte d'Ivoire

The expansion of Prevention of Mother to Child Transmission (PMTCT) services globally has been accompanied by significant rates of loss to follow-up (LTFU). This study explored barriers and facilitators to participation in PMTCT programmes for pregnant and post-partum women living with HIV who had been LTFU at public sector antenatal care facilities in the Vallée du Bandama region of Côte d'Ivoire, West Africa. Three types of interviews were conducted at seven health sites: (1) individual or small group interviews with health staff; (2) one focus group with women actively enrolled in PMTCT services; and (3) individual interviews with women who had been LTFU from PMTCT services. Ten main themes emerged and were classified within a modified social ecological model. The individual level barriers included discouragement and internalised stigma, while hope for self/child's health was a facilitator. The family/community level barriers were fear of stigma and gender inequities. The health system level barriers were unclear information and poor post-test counselling, while staff advice and support groups were facilitators. The structural level barrier was associated costs. Factors on all four levels of the social ecological model must be addressed in order to maximise adherence to PMTCT services.     

Institutional Barriers and Strategies to Health Promotion: Perspectives and Experiences of Cape Verdean Women Health Promoters

Background Health promoters are critical resources in improving health care access and in providing culturally-responsive health education and interventions to members of medically underserved communities. Little is known about the barriers that impede their health-promoting practices and the strategies used to overcome these barriers. Methods In-depth, semi-structured interviews were conducted with nine Cape Verdean women health promoters to examine their perspectives on barriers and strategies to health promotion. Results Findings revealed how their health promotion practice is influenced by a host of institutional barriers, including insufficient program funding, restrictive institutional policies, and a lack of culturally and linguistically appropriate health resources. Adaptive and resistant strategies used to counterbalance these barriers included forming supportive internal and external alliances, having a good mentor, and “making noise.” Discussion A complete and effective model of health promotion must embrace not only individual-level factors, but also macro-level factors, thus emphasizing the need for institutional change to enhance health-promoting practices.     

Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability

STUDY OBJECTIVE: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability. DESIGN: A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients. SETTING: The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care. PARTICIPANTS: Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities. MAIN RESULTS: The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation. CONCLUSIONS: In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.     

“People are struggling in this area:” a qualitative study of women’s perspectives of telehealth in rural South Carolina

ABSTRACT

Rural communities face disparities and barriers to health care access that may be addressed through telehealth programs; yet little research is available detailing rural women’s attitudes toward telehealth. Researchers partnered with a women’s reproductive health organization to conduct formative audience research to understand rural women’s perspectives of telehealth in their communities. Qualitative research was conducted to improve understandings of women’s perceptions of telehealth in rural South Carolina. In-depth interviews with 52 women aged 18–44 years were conducted in five rural counties in South Carolina during June – August 2015. Analytical techniques from grounded theory methodology were used throughout data collection and analysis. Participants believed a telehealth intervention would benefit the community by addressing reproductive health barriers, such as cost, transportation, and long wait times at local health care facilities. Participants’ concerns included issues of confidentiality in a small town, discomfort with mediated communication, privacy, and the importance of relationship-centered care, including patient-provider communication and approachability of health care providers. Findings provide insight to design and implement telehealth interventions to improve women’s health in rural communities.     

Addressing health system barriers to access to and use of skilled delivery services: perspectives from Ghana

Poor access to and use of skilled delivery services have been identified as a major contributory factor to poor maternal and newborn health in sub‐Saharan African countries, including Ghana. However, many previous studies that examine norms of childbirth and care‐seeking behaviours have focused on identifying the norms of non‐use of services, rather than factors, that can promote service use. Based on primary qualitative research with a total of 185 expectant and lactating mothers, and 20 healthcare providers in six communities in Ghana, this paper reports on strategies that can be used to overcome health system barriers to the use of skilled delivery services. The strategies identified include expansion and redistribution of existing maternal health resources and infrastructure, training of more skilled maternity caregivers, instituting special programmes to target women most in need, improving the quality of maternity care services provided, improving doctor–patient relationships in maternity wards, promotion of choice, protecting privacy and patient dignity in maternity wards and building partnerships with traditional birth attendants and other non‐state actors. The findings suggest the need for structural changes to maternity clinics and routine nursing practices, including an emphasis on those doctor–patient relational practices that positively influence women's healthcare‐seeking behaviours. Copyright © 2015 John Wiley & Sons, Ltd.     

A qualitative exploration of barriers to HIV prevention,treatment and support: Perspectives of transgender women and service providers

Transgender (trans) women experience barriers to access to HIV care, which result in their lower engagement in HIV prevention, treatment and support relative to cisgender people living with HIV. Studies of trans women's barriers to HIV care have predominantly focused on perspectives of trans women, while barriers are most often described at provider, organisation and/or systems levels. Comparing perspectives of trans women and service providers may promote a shared vision for achieving health equity. Thus, this qualitative study utilised focus groups and semi-structured interviews conducted 2018–2019 to understand barriers and facilitators to HIV care from the perspectives of trans women (n = 26) and service providers (n = 10). Barriers endorsed by both groups included: (a) anticipated and enacted stigma and discrimination in the provision of direct care, (b) lack of provider knowledge of HIV care needs for trans women, (c) absence of trans-specific services/organisations and (d) cisnormativity in sexual healthcare. Facilitators included: (a) provision of trans-positive trauma-informed care, (b) autonomy and choice for trans women in selecting sexual health services and (c) models for trans-affirming systems change. Each theme had significant overlap, yet nuanced perspective, between trans women and service providers. Specific recommendations to improve HIV care access for trans women are discussed. These recommendations can be used by administrators and service providers alike to work collaboratively with trans women to reduce barriers and facilitators to HIV care and ultimately to achieve health equity for trans women.     

Aboriginal mothering,FASD prevention and the contestations of neoliberal citizenship

Over the past 25 years, Aboriginal leaders, community advocates, children's and women's health specialists and Canadian government agencies have drawn increasing attention to the perceived need to undertake targeted initiatives to prevent fetal alcohol spectrum disorder (FASD) in indigenous communities. In pursuit of this goal, a range of prevention campaigns have been undertaken – generally with funding from the State – urging pregnant women to abstain from alcohol. Because both risk and protective factors for FASD are intimately connected to the social conditions in which women become pregnant, give birth to and mother their children, FASD prevention campaigns targeting Aboriginal communities suggest possibilities that are both provocative and problematic for advancing movements for social justice, decolonisation and improved maternal and child health. In this essay, I consider how the gendered and racialised legacies of colonisation emerge alongside concerns for improved health and well-being of indigenous children to inform contemporary, state-funded efforts to prevent FASD. In so doing, I examine the ways that neoliberal economic and political trajectories of Canadian state formation intersect with some aspects of decolonisation movements to raise important questions about when, how and under what conditions colonial states support FASD prevention efforts among indigenous peoples.     

WORK LIFE AND PSYCHOLOGICAL HEALTH: THE EXPERIENCES OF THAI WOMEN IN DEPRIVED COMMUNITIES

I discuss women's work life and the psychological health of women in low-income communities in Northeast Thailand. Previous research has shown that low-income women are part of a disadvantaged group who struggle against several problems in their everyday life, and who work hard to survive. These women worked as either manual laborers in agriculture or factories or as self-employed vendors, and were busy Ha Yoo Ha Kin (working and earning a living). The women's way of life was complex and involved being responsible for their children, husband, extended family, work, and themselves. Understanding women's beliefs and practice relating to work life and health is essential in designing effective intervention programmes to promote the health and well-being of low-income women in Thailand.     

Community-based health care for indigenous women in Mexico: a qualitative evaluation

Introduction

Indigenous women in Mexico represent a vulnerable population in which three kinds of discrimination converge (ethnicity, gender and class), having direct repercussions on health status. The discrimination and inequity in health care settings brought this population to the fore as a priority group for institutional action. The objective of this study was to evaluate the processes and performance of the “Casa de la Mujer Indígena”, a community based project for culturally and linguistically appropriate service delivery for indigenous women. The evaluation summarizes perspectives from diverse stakeholders involved in the implementation of the model, including users, local authorities, and institutional representatives.

Methods

The study covered five Casas implementation sites located in four Mexican states. A qualitative process evaluation focused on systematically analyzing the Casas project processes and performance was conducted using archival information and semi-structured interviews. Sixty-two interviews were conducted, and grounded theory approach was applied for data analysis.

Results

Few similarities were observed between the proposed model of service delivery and its implementation in diverse locations, signaling discordant operating processes. Evidence gathered from Casas personnel highlighted their ability to detect obstetric emergencies and domestic violence cases, as well as contribute to the empowerment of women in the indigenous communities served by the project. These themes directly translated to increases in the reporting of abuse and referrals for obstetric emergencies.

Conclusions

The model’s cultural and linguistic competency, and contributions to increased referrals for obstetric emergencies and abuse are notable successes. The flexibility and community-based nature of the model has allowed it to be adapted to the particularities of diverse indigenous contexts. Local, culturally appropriate implementation has been facilitated by the fact that the Casas have been implemented with local leadership and local women have taken ownership. Users express overall satisfaction with service delivery, while providing constructive feedback for the improvement of existing Casas, as well as more cost-effective implementation of the model in new sites. Integration of user’s input obtained from this process evaluation into future planning will undoubtedly increase buy-in. The Casas model is pertinent and viable to other contexts where indigenous women experience disparities in care.     

The health of Romanian Gypsy women in Serbia

Indigenous people are over-represented among the world's disadvantaged; their health is influenced by lack of access to critical resources including health care and by their cultural practices. We report on the health and the health practices of one group of indigenous women, the Roma/Gypsies of northern Serbia who live in poverty, reside in sub-standardized housing in segregated communities, and are poorly educated and stigmatized. We describe the environment in which they live, their health history, and the cultural practices that influence their health and health behaviors, including their sporadic utilization of health services that are provided by the state. We also present evidence supporting that, in the face of adversity, cultural practices, including those related to kinship and social support, can have significant benefits in shaping health status.