Hospital- versus community-based syringe exchange: a randomized controlled trial.

This study examined the effect of syringe exchange program setting on the injection practices, health status, and health service utilization patterns of injection drug users (IDUs) recruited from a public urban hospital. One hundred sixty-six participants were randomized to either community- or hospital-based syringe exchange services. Poisson regression models were used to compare service utilization between groups. In both conditions, risky drug use practices decreased, and physical health functioning improved over time. Hospital-based syringe exchange program (SEP) attendees had 83% more inpatient admissions (p < .0001) and 22% more ambulatory care visits (p < .0001) than those assigned to the community-based SEP condition. Syringe exchange services that are integrated into public hospital settings may serve as a valuable strategy to engage hard to reach IDU populations in behavioral interventions designed to reduce HIV risk transmission behaviors and increase access to, or engagement in, the use of secondary and tertiary preventive medical care.     

HIV health care access issues for women living with HIV, mental illness, and substance abuse

Nurses at the Well-Being Institute, a community-based nursing outreach clinic in Detroit, Michigan, located 75 women living with HIV, mental illness, and substance abuse who were lost to follow-up at their HIV medical clinic as part of a nursing research study. Women who had been scheduled for an appointment in the last 4 months but who had missed that appointment were considered "lost to follow-up" in the HIV clinic. The purpose of the research was to study factors related to health care access in women not participating in regular health care for their HIV infection. Women were randomly assigned to two study groups. Women assigned to "care as usual" study group (n = 37) received no additional services beyond study interviews for 1 year. Women assigned to the "nursing intervention" group (n = 38) were provided with nursing services designed to facilitate their return to and continued connection with their HIV clinic. Findings showed that factors related to the women's vulnerability, such as mental illness and drug use, were more related to their use of expensive health care services such as hospital emergency departments or hospital inpatient admissions than was assignment to either the "nursing intervention" or "care as usual" study groups. Two case studies describing the cost of care for 2 of the multiply diagnosed women in the study is presented. The women differed on whether they had stable housing and were accessing care for their mental illness.     

Theoretical and methodological issues in conducting research related to health care utilization among individuals with HIV infection

Although empirical information on resource use during HIV infection is vital to improving quality of care, the issues involved in conducting research on resource use have received little attention in the medical literature. The purpose of this paper is to review the theoretical and methodological issues of conducting research on health care utilization patterns among persons with HIV/AIDS. Conceptual definitions of utilization are compared and contrasted. Three theoretical frameworks, the Andersen Behavioral Model, the Health Belief Model, and the Biopsychosocial Model are described to illustrate their applicability in future research studies. Research designs, measurement considerations, sampling approaches, and existing data sources on utilization are reviewed. Recommendations for health care utilization research are summarized and highlight the importance of designing studies and generating data for investigation of the factors facilitating patients' use of an optimal array of services including prevention, long-term, and rehabilitation care.     

“I have it just like you do”: voices of HIV-negative partners in serodifferent relationships receiving primary care at a public clinic in San Francisco

HIV transmission among serodifferent couples has a significant impact on incidence of HIV worldwide. Antiretroviral interventions (i.e., preexposure prophylaxis, post-exposure prophylaxis, and treatment as prevention) are important aspects of comprehensive prevention and care for serodifferent couples. In this study, HIV-negative members of serodifferent couples were interviewed using open-ended questions to explore their health-care needs, perceptions of clinic-based prevention services, and experience of having an HIV-infected partner. Analysis of interviews with 10 HIV-negative partners revealed the following themes: (1) health needs during joint medical visits; (2) sexual risk reduction strategies; (3) relationship dynamics; and (4) strategies for coping. This study elucidated relationship, health and health care factors that might affect development and implementation of clinic-based prevention interventions for HIV serodifferent couples. The findings point to possible relationship-centered recommendations for health-care providers who serve HIV-affected couples in clinical settings.     

Health care access and utilization patterns in unstably housed HIV-infected individuals in New York City

As part of a multisite initiative to evaluate outreach targeting underserved HIV-infected individuals, we describe baseline characteristics of unstably housed HIV-infected individuals from New York City, and their health care access and utilization patterns. Interviews with 150 HIV-infected single room occupancy (SRO) hotel residents on health care access and utilization, barriers to accessing health care, demographic characteristics, history of incarceration, severity of HIV disease, depressive symptoms, substance use, and exposure to violence were conducted. Most participants were 40 years of age or older, male, black or Latino, had public insurance, a history of substance use, depressive symptoms, and a CD4(+) count above 200 cells/mm(3). Access to and utilization of care was high with 91% reporting having a regular provider, 95% identifying a non-emergency department (ED) clinic or office as their usual location of care, 89% reporting at least one ambulatory visit, and 82% reporting optimal (>/=2) ambulatory visits during the previous 6 months. Additionally, 45% reported at least one ED visit, and 30% at least one hospitalization within the previous 6 months. Among black and Latino marginalized SRO hotel residents in New York City, this study found surprisingly high measures of access to and utilization of ambulatory care services, along with high use of acute care services. Understanding HIV-related health services access and utilization patterns among marginalized populations is essential to improve their HIV care. These patterns of high levels of access to and utilization of health care services contradict clinical experiences and other studies, and require further exploration.     

Use of health services in later life: the influence of health beliefs

This study examined the influence of health beliefs on the use of various health services by elderly individuals, employing Andersen-Newman's framework of predisposing, enabling, and need factors. Data are from a random sample of 743 individuals aged 60 and over living in Winnipeg, Canada. Need factors emerge as the strongest correlates of physician visits, hospitalization, and overall service use. The degree of medical skepticism appears to exert some influence on utilization, particularly in regard to physician visits. A stronger belief in the value of health maintenance activities is associated with the use of a greater number of services overall, suggesting that preventive health beliefs may promote use of the health care system. Generally health locus of control appears to be unrelated to health service utilization. Implications for further research are discussed.     

Correlates of health care utilization among HIV-seropositive injection drug users

This study sought to identify correlates of poor health care utilization among HIV-positive injection drug users (IDUs) using Andersen's behavioural health model. We used baseline data from INSPIRE, a study of HIV-positive IDUs (n=1161) to identify predisposing, enabling, and need factors related to poor utilization (defined as fewer than two outpatient visits in the past six months, or identification of emergency room (ER) as the usual place for care). Using bivariate and multivariate models, we found a number of enabling factors that could facilitate the use of health care services such as having health insurance, having seen a case manager, and better engagement with health care providers. These enabling factors could be modified through interventions targeting HIV-positive IDUs. In addition, health insurance and case management appear to be important factors to address because they contributed in making other factors (e.g. lower education, lack of stable housing) non-significant barriers to outpatient care utilization. In the future, these findings may be used to inform the development of interventions that maximize use of scarce HIV resources and improve health care utilization among HIV-positive IDUs.     

A package of primary health care services for comprehensive family-centred HIV/AIDS care and treatment programs in low-income settings

Particularly in resource-limited settings, HIV/AIDS is a family concern. Separate services for children and adults may make accessing care more difficult for families than services where family members can be cared for together. Implicit in comprehensive, family-centred approaches to care are the broader notions of longitudinal primary care and linkages to other services, including those based in communities. As highly-active antiretroviral therapy becomes more available, and the direct burden of HIV-associated morbidity diminishes, HIV-infected individuals require primary care that goes beyond exclusive management of HIV and related conditions, including preventive services and the management of common medical issues. The prevention of tuberculosis, diarrhoea, and, in endemic regions, malaria; the addressing of debilitating depression; cervical screening; and the management of chronic cardiovascular disease and its risk factors are all of benefit to patients accessing HIV/AIDS care. Packaging such services is an effective means both of standardizing care within a program and of ensuring patients receives a full roster of available interventions. As family-centred care models develop in resource-limited settings, the availability of evidence-based service packages such as presented here will help program designers prioritize available human and materiel resources toward those interventions that improve patients' global health and well being.     

Caregiving and institutionalization of cognitively impaired older people: utilizing dynamic predictors of change

PURPOSE: The purpose of this study was to identify reliable predictors of nursing home entry over a 3-year period in a sample of 3,944 persons with dementia who resided in a home setting at baseline. Strengths of the analysis include a multiregional recruitment strategy, incorporation of salient caregiver characteristics, and a 3-year prospective design that allows for the modeling of change in important variables (e.g., care recipient functional status or caregiving indicators) when time to institutionalization is predicted. DESIGN AND METHODS: Data were derived from the control sample of the Medicare Alzheimer's Disease Demonstration Evaluation (MADDE). A Cox proportional hazards model was used to predict time to institutionalization among individuals with dementia (baseline was enrollment into MADDE). Predictors included care recipient demographics, caregiver demographics, and time-varying measurements of care recipient functional status, caregiving indicators, and service utilization. Indicators of change were also incorporated to capitalize on the prospective data available. RESULTS: Although several results were consistent with prior findings, caregiving indicators (i.e., burden and self-rated health) and community-based service use were significant predictors of earlier placement. Change in caregiver instrumental activities of daily living and care recipient activities of daily living were also related to expedited institutionalization. IMPLICATIONS: The findings emphasize the importance of incorporating both care recipient and caregiver function and service use patterns when targeting programs designed to prevent or delay institutionalization for people with dementia.     

“Health Is on the Back Burner:” Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs

BackgroundThe estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs.ObjectiveThe objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis.DesignParticipants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns.ParticipantsWe recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island.ApproachThematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels.Key ResultsAmong 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine–trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction.ConclusionsFindings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06201-6) contains supplementary material, which is available to authorized users.KEY WORDS: substance-related disorders, preventive health services, primary health care, social stigma, patient acceptance of health care, quality of health care     

More than wisdom

This paper assesses whether the same factors are predictive of health service utilization among this ethnic group as is true of the general population of seniors. The data suggest that the health of Chinese elders is just as bad as other seniors, and their utilization is very similar. They have a strong preference for Western over Chinese medicine and for Western trained doctors over Chinese practitioners, and use services with Chinese staff, probably because of language. Similarly, the predictors of service use are strikingly similar to predictors revealed in utilization studies throughout the industrialized world. Ability to speak English, immigration history, and country of origin are unrelated to the use of these services. However, approximately half of Chinese seniors also engage in traditional Chinese care. Religious beliefs and a preference for traditional Chinese medicine are strongly predictive of the use of traditional care. It would appear that distinctive culture is related to the use of traditional care, but not the use of the western health care system.     

Male patient perceptions of HIV stigma in health care contexts

Individuals living with HIV may have a heightened sensitivity to the behaviors of others that may signal bias or discrimination. Identifying and avoiding these potentially problematic behaviors may be especially important for service providers, such as health care personnel, who regularly interact with HIV-positive clientele. This study examines the experiences of 50 male American military veterans living with HIV and their perceptions of HIV stigma within health care contexts. Participants described a variety of behaviors performed by health care personnel that they perceived to be indicative of HIV stigma, ranging from ambiguous nonverbal cues (e.g., minimal eye contact) to blatant discrimination (e.g., physical abuse of HIV-positive patients). These findings extend previous research on HIV stigma in health care settings by (1) focusing on health care personnel's actual behaviors rather than their attitudes and beliefs about HIV-positive patients, (2) including patients' perceptions regarding the behaviors of both clinical and nonclinical health care personnel, and (3) identifying behaviors patients perceive as stigmatizing that are unique to health care contexts. Combined, these findings provide health care personnel a tangible list of behaviors that should either be avoided or further explained to HIV-positive patients, as they may be interpreted as stigmatizing.     

Utilization of health care services in hard-to-reach marginalized HIV-infected individuals

To benefit from HIV treatment advances individuals must utilize ambulatory primary care services. Few studies focus on marginalized populations, which tend to have poor health care utilization patterns. This study examined factors associated with health care utilization in hard-to-reach marginalized HIV-infected individuals. As part of a multisite initiative evaluating outreach programs that target underserved HIV-infected individuals, 610 participants were interviewed about their HIV disease, health services utilization, substance use, mental health, and case management. Primary outcomes included ambulatory, emergency department, and inpatient visits. Generalized estimating equations were used in logistic regression analyses. On regression analyses ambulatory visits were associated with having insurance (adjusted odds ratio [AOR] = 2.46), mental health medications (AOR = 7.46), and case management (AOR = 4.81). Emergency department visits were associated with having insurance (AOR = 1.74), homelessness (AOR = 2.23), poor health status (AOR = 2.02), length of HIV infection (AOR = 2.02), mental health care (AOR = 1.47), mental health medications (AOR = 1.59), and heavy alcohol intake (AOR = 1.46). Hospitalizations were associated with high school education (AOR = 1.57), having insurance (AOR = 10.45), homelessness (AOR = 2.18), poor health status (AOR = 2.64), length of HIV infection (AOR = 2.03), and mental health medications (AOR = 1.87). In hard-to-reach marginalized HIV-infected individuals, having insurance, case management and mental health care were associated with increased ambulatory visits. These findings support HIV multidisciplinary care with marginalized populations. Understanding factors associated with health care utilization is essential for outreach programs to facilitate engagement in HIV care.     

Predictors of Preventive Health Care Use Among Middle-aged and Older Adults in Mexico: The Role of Religion

Research has shown that religion is associated with a wide range of health behaviors among adults of all ages. Although there is strong support for religion’s influence on behaviors such as drinking and smoking, less is known about the possible relationship between religion and the use of preventive health services. This relationship may be particularly important in Mexico, a country with high levels of religiousness and low levels of preventive service utilization. The current study uses a nationally representative sample of middle-aged and older adults in Mexico (n = 9,890) to test the association between three facets of religion and three preventive services aimed at detecting chronic conditions or underlying risk factors. The findings show that religious salience is significantly related to the use of blood pressure and cholesterol screenings, even after controlling for a variety of social, demographic, and health-related factors. In addition, attending religious services and participating in religious activities are both positively associated with blood pressure and diabetes screening. This type of research adds to our knowledge of the determinants of preventive service utilization, as well as to the burgeoning literature on religion and health. Furthermore, because the vast majority of research in this field takes place in more developed and Westernized countries, such as the US and Western Europe, analyzing this relationship in a sample of older Mexicans is critical for providing the field with a more comparative orientation.     

Home care and health reform: changes in home care utilization in one Canadian province, 1990-2000

PURPOSE: This study examines population-based trends in home care service utilization, alone and in conjunction with hospitalizations, during a period of health reform in Canada. It focuses on the extent to which observed trends suggest enhanced community-based care relative to three competing hypotheses: cost-cutting, medicalization, and profitization. DESIGN AND METHODS: Analyses drew on administrative health data from the province of British Columbia for the period from 1990 through 2000. Annual trends in age- and gender-adjusted utilization rates are examined by use of joinpoint regression; multivariate analyses draw on generalized linear modeling. RESULTS: Home support claims decreased significantly during the study period. There was less evidence of decline with regard to home nursing care claims and the extent of both home support and home nursing care. Intensity of care increased for home support services but decreased somewhat for home nursing care. Multivariate analyses revealed a decline in joint use of home support and hospital care and little change in joint use of home nursing and hospital care. Similarities as well as differences in trends are evident across age groups. IMPLICATIONS: The findings suggest a reduction and reallocation of health services in general rather than a shift of focus toward community-based care. In this way, they appear more consistent with a cost-reduction hypothesis than with expectations of enhanced community-based care that are generated by recent health reform initiatives.     

Structure and quality of outpatient care for people living with an HIV infection

Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.     

Differences in HIV risk behavior of injection drug users in New York City by health care setting

The purpose of this study is to examine the HIV risk behaviors and demographic characteristics of injection drug users (IDUs) by type of health care setting, which can inform development of tailored structural interventions to increase access to HIV prevention and medical treatment services. IDU syringe customers were recruited from pharmacies as part of the “Pharmacist As Resources Making Links to Community Services” (PHARM-Link) study, a randomized community-based intervention in New York City (NYC) aimed at connecting IDUs to HIV prevention, medical, and social services. An ACASI survey ascertained demographics, risk behavior, health-care utilization, and location where health care services were received in the past year. Data were analyzed using logistic regression. Of 602 participants, 34% reported receiving health care at a community clinic, 46% a private medical office, 15% a mobile medical unit, and 59% an emergency room (ER). After adjustment, participants who attended a community clinic were significantly more likely to have health insurance, report syringe sharing, and be HIV positive. Whites, nondaily injectors, insured, and higher income IDUs were more likely to attend a private medical office. Participants who recently used a case manager and had multiple sexual partners were more likely to use a mobile medical unit. ER attendees were more likely to be homeless and report recent drug treatment use. These findings show that IDU demographics and risk behaviors differ by health care setting, suggesting that risk reduction interventions should be tailored to health care settings. Specifically, these data suggest that community clinics and mobile medical units serve high-risk IDUs, highlighting the need for more research to develop and test innovative prevention and care programs within these settings.     

Predictors of Late Presentation for HIV Diagnosis: A Literature Review and Suggested Way Forward

Early commencement of antiretroviral treatment can be beneficial and economical in the long run. Despite global advances in access to care, a significant proportion of adults presenting at HIV/AIDS care facilities present with advanced HIV disease. Understanding factors associated with late presentation for HIV/AIDS services is critical to the development of effective programs and treatment strategies. Literature on factors associated with late presentation for an HIV diagnosis is reviewed. Highlighted is the current emphasis on socio-demographic factors, the limited exploration of psychosocial correlates, and inconsistencies in the definition of late presentation that make it difficult to compare findings across different studies. Perspectives based on experiences from resource limited settings are underreported. Greater exploration of psychosocial predictors of late HIV diagnosis is advocated for, to guide future intervention research and to inform public policy and practice targeted at ‘difficult to reach’ populations.     

An Agenda for Advancing the Science of Implementation of Evidence-Based HIV Prevention Interventions

In the past 25 years, a tremendous amount of time and resources have been committed to developing evidence-based HIV prevention interventions. More recently, there have been noteworthy efforts to develop an infrastructure and related policies to promote the dissemination (i.e., “the targeted distribution of information and intervention materials to a specific public health or clinical practice audience”) of evidence-based interventions. Despite these advances, however, we have had comparatively little success in the effective implementation (i.e., “the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings”) of such interventions in everyday practice or community settings. The objective of the current paper is to highlight select and initial areas of research that are critically needed to advance the state-of-the-science of implementation of HIV prevention interventions in our broader efforts to curb the epidemic worldwide.