The Impact of School-Based Health Centers on the Health Outcomes of Middle School and High School Students

Objectives. We studied the direct and indirect effects of school-based health centers (SBHCs) on the health and health behaviors of middle and high school students.Methods. We used a prospective cohort design to measure health outcomes annually over 2 consecutive years by student self-report. Cohorts of middle school and high school students were recruited from matched schools with and without SBHCs. Data were obtained from 744 students in both year 1 and year 2 of the study. We used 2-level hierarchical linear models to estimate the effects of the presence of SBHCs at the school level and of SBHC use at the student level.Results. At year 2, users of SBHCs experienced greater satisfaction with their health, more physical activity, and greater consumption of healthy food than did nonusers of SBHCs.Conclusions. Students who used SBHCs were more satisfied with their health and engaged in a greater number of health-promoting behaviors than did students who did not use SBHCs. These findings indicate that SBHCs are achieving their goal of promoting children''s health.At school-based health centers (SBHCs), multidisciplinary teams of providers, including physicians, nurse practitioners, registered nurses, physician assistants, and social workers provide a comprehensive range of primary care, preventive care, and early intervention services to children from elementary school through high school. SBHCs located in medically underserved areas have helped increase access to and utilization of primary care services among a wide variety of students, including low-income,¹ urban,^1–3 rural,^2,4,5 female,⁵ and African American⁵ students. SBHC utilization rates are highest among children with public insurance or no insurance.⁵ Thus, SBHCs serve as an important health care safety net for disadvantaged and medically underserved youth.Most students who use SBHCs do so infrequently, averaging slightly more than 1 visit per year. An analysis of the diagnostic categories associated with SBHC visits paints a portrait of the typical SBHC user as a student who occasionally visits the SBHC for the treatment of an acute illness or to receive a physical examination.⁶ In addition to providing direct health care services, SBHC staff members engage in a wide range of other activities to promote student health. A recent study found that 20% of all clinical activity in a sample of SBHCs was devoted to patient, classroom, and group education activities and to contacts with parents and school staff.⁷ Such activities hold the promise of spreading the effects of SBHCs to students who do not directly receive SBHC health care services.The strongest evidence for the impact of SBHCs on the health of the children they serve is found among children with chronic diseases. For children with asthma, SBHC use is associated with fewer hospitalizations,^8,9 fewer visits to emergency rooms,^8,10 and better school attendance.⁹ The evidence for the health benefits of SBHCs for children in the general population is less compelling. A study sponsored by the Robert Wood Johnson Foundation''s School-Based Adolescent Health Care Program¹¹ compared the health status and health outcomes of 9th- and 10th-grade students in schools with SBHCs to a national random sample of 9th- and 10th-grade students attending schools without SBHCs. The presence of SBHCs in schools had no significant effect on the overall health status or health outcomes of students. A second study,^2,5 funded by the Health Foundation of Greater Cincinnati, compared the health-related quality of life of students in 4 elementary schools with SBHCs to students in 4 comparison schools without SBHCs. SBHC users reported significant improvement in student-reported quality of life over 3 years when compared with students in non-SBHC schools.It is worth noting that, whereas the Robert Wood Johnson Foundation–funded study compared all students in schools with SBHCs to a national random sample of students in schools without SBHCs, the Health Foundation of Greater Cincinnati–funded study involved a comparison among 3 groups of students: students in schools without SBHCs, students in schools with SBHCs who used their school''s SBHC, and students in schools with SBHCs who did not use their school''s SBHC. Distinguishing between SBHC users and nonusers within the same school is critical because it allows for analysis of the direct effects of SBHC services on users.The purpose of this study was to extend understanding of the effects of SBHCs on the general population of school-aged children by analyzing the impact of SBHCs on a range of health and health behavior outcomes among middle and high school students over a 2-year period. In particular, we sought to answer the following research questions: (1) What is the direct impact of SBHC use on middle and high school students'' health and health behaviors? (2) What is the indirect impact of having an SBHC in a school on the health and health behaviors of students in that school, regardless of whether students use SBHC services? To answer these questions we used multilevel modeling to model school-level (i.e., SBHC status) and individual-level (i.e., student use of SBHCs) predictors of health separately.     

School-Based Health Centers: Cost�CBenefit Analysis and Impact on Health Care Disparities

Objectives. We evaluated the impact of school-based health centers—which provide essential health care for students by aiming to eliminate many access barriers—on health care access disparities and conducted a cost–benefit analysis.Methods. We employed a longitudinal quasi-experimental repeated-measures design. Primary data sources included the Ohio Medicaid claims, enrollment file with race/ethnicity, and survey reports from parents. We used hierarchical linear modeling to control unbalanced data because of student attrition. We assessed quarterly total Medicaid reimbursement costs for 5056 students in the SBHC and non-SBHC groups from 1997 to 2003. We calculated net social benefit to compare the cost of the SBHC programs with the value that SBHCs might save or create.Results. With SBHCs, the gap of lower health care cost for African Americans was closed. The net social benefits of the SBHC program in 4 school districts were estimated as $1 352 087 over 3 years. We estimated that the SBHCs could have saved Medicaid about $35 per student per year.Conclusions. SBHCs are cost beneficial to both the Medicaid system and society, and may close health care disparity gaps.Racial or ethnic health care disparities are a social phenomenon that reveals differences in utilization and quality of health care because of accessibility, operation of health care systems, cultural or socioeconomic status, and discrimination at the individual and patient–provider level.^1–5 Recent literature has documented ethnic and racial disparities in the health care system across a wide range of diseases. According to the Centers for Disease Control and Prevention,⁶ African Americans had higher prevalence rates across many chronic diseases, including perinatal diseases, diabetes mellitus, hypertension, and obesity. Health care disparities can lead to decreased quality of life, loss of economic opportunities, and perceptions of injustice.⁷ Twenty-two percent of African American children and adolescents were classified as overweight or obese and 68% were fully vaccinated, compared with White children and adolescents, who were less likely to be overweight or obese (12%) and more likely to be fully vaccinated (78%).^6,8For some illnesses, health care disparities are manifested through the underuse of treatments and procedures.^9–11 School-aged children and adolescents have high prevalence rates of some chronic diseases, including asthma (estimated at 7%) and attention deficit/hyperactivity disorder (estimated at between 3% and 6%).^7,12,13 However, African American children and adolescents with asthma had more hospitalizations, disability, and a higher mortality rate compared with that of White children and adolescents with asthma.^14,15 Moreover, African American children and adolescents were also less likely to access mental health services.^16–19School-based health centers (SBHCs) are thought to be 1 solution to reduce these health status and health care disparities across groups. SBHCs provide essential primary care (e.g., mental health treatment, dental care, well-child checkups) for students. SBHCs, by their location in schools, are designed to overcome many health care access barriers, including transportation, lack of providers, lack of insurance coverage, and inconvenient appointment times because of parents working. By 2008, more than 1980 SBHCs nationwide had been established with partial support from the federal government, foundations, Medicaid, health insurance companies, and other programs such as “Healthy Schools Healthy Communities.”^20–22 In many SBHCs, the majority of enrolled students are uninsured or low income, ranging from 50% to 90% of the patient load.Numerous studies have documented that SBHCs can effectively reduce health care access barriers and emergency room visits in children and adolescents.^23–31 These in-school services can also alleviate barriers such as nonadherence and inadequate access to mental health services for youths.^23,32–34 With the SBHC, students received more mental health care services,²³ less hospitalization,^24,26 fewer urgent or emergency visits,^25–28 and fewer transportation and pharmacy costs.²⁶Although SBHCs have demonstrated their value to school-aged children and adolescents, their impact on addressing health care disparities has not been evaluated. Moreover, it is unclear whether the SBHC is cost-beneficial. With these considerations in mind, we sought to measure the impact of SBHCs on addressing health care disparities among students in schools with SBHCs compared with students in comparable schools without SBHCs. The central hypotheses were that increased accessibility to primary care services with SBHCs would reduce the gaps of health care disparities over time by increasing needed primary care. Second, by providing timely and essential primary care, the SBHC program would have a positive net social benefit to the population.     

Universal Health Insurance and Health Care Access for Homeless Persons

Objectives. We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system.Methods. We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs.Results. Unmet health care needs were reported by 17% of participants. Compared with Toronto''s general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey.Conclusions. Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.Homeless people are among the most marginalized groups in society, and large numbers of homeless individuals are found in the United States, Canada, and throughout the world.^1,2 Although the majority of homeless people are men, women and parents with children represent substantial segments of the homeless population.³ Homeless people suffer from many serious threats to their health, including an increased risk of all-cause mortality.⁴ Common medical conditions in this population include epilepsy, chronic obstructive pulmonary disease, hypertension, diabetes, and musculoskeletal disorders.⁵ Substance abuse, mental illness, and related comorbidities are also highly prevalent.⁵Despite high levels of morbidity and mortality, homeless people face numerous financial and nonfinancial barriers to obtaining needed health services.^6,7 A 1996 nationwide survey of homeless people across the United States found that 57% were uninsured, and lack of health insurance was associated with significantly lower odds of using ambulatory health care.⁷ Nonfinancial barriers have also been described. Competing priorities such as securing adequate food and shelter may lead to delays in seeking health care.⁸ Lack of transportation to health visits, long waiting times in clinics, and feelings of being stigmatized by health care professionals are also obstacles frequently reported by homeless people.^6,9 Lack of appropriate health care for homeless people may contribute to deterioration in health status, prolonged homelessness, and even death.^10,11Most studies of unmet needs for care among homeless individuals have been conducted in the United States.^6,7,12 Unmet needs for medical care in the past year were reported by 25% of respondents in a nationwide survey of homeless people in the United States and were somewhat more common among homeless families than among single homeless persons (27% vs 24%, respectively).^7,13 Studies conducted in various US urban centers have found even higher rates of unmet needs for care. Among homeless people living in urban encampments in Los Angeles, California, 41% felt there was a time in the past 6 months when they had needed to go to a doctor but did not.¹² A study of homeless women in Los Angeles County in 1997 found that 37% of participants had unmet needs for health care in the past 60 days.⁶ In a survey of low-income adults in Baltimore, Maryland, 57% of whom were homeless, 51% reported having difficulty accessing health care services.¹⁴ A recent study conducted in Birmingham, Alabama, found that the prevalence of unmet needs for care among homeless people rose from 32% in 1995 to 54% in 2005.¹⁵ This overall pattern suggests inadequacy of the US health care safety net for low-income and uninsured individuals.¹⁵Canada has a publicly funded system of universal health insurance that consists of single-payer plans administered by each province. All medically necessary physician services and hospital-based care are fully covered with no copayments. However, the extent to which such a system meets the needs of severely disadvantaged individuals has not been well defined.^16,17 Our objectives were to determine the prevalence of unmet needs for health care among homeless single men, single women, and women with dependent children within Canada''s universal health insurance system and to identify individual characteristics associated with having unmet needs.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

The Relationship Between Living Arrangement and Preventive Care Use Among Community-Dwelling Elderly Persons

Objectives. We sought to examine the relationship between living arrangements and obtaining preventive care among the elderly population.Methods. We obtained data on 13 038 community-dwelling elderly persons from the 2002 to 2005 Medical Expenditure Panel Survey and used multivariate logistic regression models to estimate the likelihood of preventive care use among elderly persons in 4 living arrangements: living alone (38%), living with one''s spouse only (52%), living with one''s spouse and with one''s adult offspring (5%), and living with one''s adult offspring only (5%). Preventive care services included influenza vaccination, physical and dental checkup, and screenings for hypertension, cholesterol, and colorectal cancer.Results. After we controlled for age, gender, race, education, income, health insurance, comorbidities, self-reported health, physical function status, and residence location, we found that elderly persons living with a spouse only were more likely than were those living alone to obtain all preventive care services, except for hypertension screening. However, those living with their adult offspring were not more likely to obtain recommended preventive care compared with those living alone. These results did not change when the employment status and functional status of adult offspring were considered.Conclusions. Interventions to improve preventive care use should target not only those elderly persons who live alone but also those living with adult offspring.Ensuring the timely use of preventive care services among adults who are 65 years and older is a public health priority as the elderly population in the United States continues to grow. Strong evidence indicates that annual influenza vaccination and early detection of certain conditions such as hypertension, hypercholesterolemia, heart disease, and many forms of cancers are effective in reducing mortality and associated disability among elderly men and women.^1,2 Based on the strength of scientific evidence and the net benefit assessment of various preventive health services, the United States Preventive Services Tasks Force (USPSTF) has developed recommendations on clinical preventive care that include screening tests, counseling, and preventive medications for adults 65 years and older.³ Unfortunately, adherence to USPSTF recommendations is below expectation, and the available research documents wide variation in preventive service use. Prior studies have documented variation in preventive care use by sociodemographic characteristics such as race/ethnicity, education, and income,^4,5 as well as health-related factors including health status, psychological distress, and health beliefs.^6,7 Other studies have examined community characteristics including urban versus rural status, racial/ethnic composition, and median income level.^8,9One important factor that has not been studied but may influence preventive care use among the elderly population is living arrangement—cohabitation with other individuals in a household unit. The United Nations has identified living arrangements of older persons as one of the most pressing concerns of the aging population.¹⁰ About 1 in 3 community-dwelling elderly persons 65 years or older, and 1 in 2 aged 80 years and older, live alone in the United States.¹¹ Previous studies found that elderly persons living alone are more likely to use publicly subsidized home care services to meet instrumental activities of daily living (IADL).¹²In addition, some evidence suggests that with all else being equal, living arrangement may be better than marital status at predicting health services use, including physician office visits.¹³ Given these findings, it is reasonable to expect that living arrangements may be related to elderly persons'' use of preventive care according to USPSTF recommendations. Because elderly persons'' living arrangement can be considered a proxy measure of family-related resources for accessing preventive services, we hypothesized that even after we controlled for health and other characteristics, community-dwelling elderly men and women who live alone would be less likely to adhere to recommended preventive care than would elderly men and women who live with their spouse, children, or both.     

Effect of health care system distrust on breast and cervical cancer screening in Philadelphia, Pennsylvania

Objectives. We investigated whether health care system distrust is a barrier to breast and cervical cancer screening and whether different dimensions of distrust—values and competence—have different impacts on cancer screening.Methods. We utilized data on 5268 women aged 18 years and older living in Philadelphia, Pennsylvania, and analyzed their use of screening services via logistic and multinomial logistic regression.Results. High levels of health care system distrust were associated with lower utilization of breast and cervical cancer screening services. The associations differed by dimensions of distrust. Specifically, a high level of competence distrust was associated with a reduced likelihood of having Papanicolaou tests, and women with high levels of values distrust were less likely to have breast examinations within the recommended time period. Independent of other covariates, individual health care resources and health status were associated with utilization of cancer screening.Conclusions. Health care system distrust is a barrier to breast and cervical cancer screening even after control for demographic and socioeconomic determinants. Rebuilding confidence in the health care system may improve personal and public health by increasing the utilization of preventive health services.Cancer is a leading cause of death in the United States. Approximately 1.5 million Americans are diagnosed with cancer per year and 1 in 4 deaths are attributed to cancer.¹ Among women, an estimated 192 000 breast and 11 000 cervical cancer cases are detected each year, and in 2009 more than 40 000 women died of breast cancer and approximately 4000 of cervical cancer.¹ To effectively reduce the morbidity and mortality resulting from breast and cervical cancer, efforts need to be made to increase the proportion of women who comply with screening recommendations²; according to a recent report, a third of women are not in compliance with screening guidelines for breast cancer, and more than a fifth are not in compliance for cervical cancer.³ Our goal was to investigate whether health care system distrust (hereafter referred to as distrust) is a barrier to breast and cervical cancer screening.The late 20th century saw many changes in the theoretical underpinnings of research on health in general and women''s health in particular. The prevailing biomedical model was criticized for ignoring social determinants of health, such as social class, gender roles, and poverty,⁴ and health determinants models that incorporated multiple social, economic, and demographic dimensions were embraced.^5–7 The multiple determinants of health perspective emphasizes the relationships between socioeconomic factors and health outcomes,⁴ but the role of psychological factors (i.e., depression and distrust) in cancer screening has only recently been recognized.^8–11 Relatively little is known about whether distrust affects health outcomes, and specifically whether it influences cancer screening behaviors among women.¹¹Americans’ overall confidence in their health care system has declined markedly in recent decades. In 2010, only 34% of adults reported “a great deal” of confidence in the health system, down from over 70% in 1966.¹² More than 80% of Americans, however, held high levels of trust in their personal physicians or providers,¹³ a paradox that has been widely documented in the literature.^14–17 Previous studies suggest that trust in physicians is associated with seeking timely medical care, maintaining appropriate health care, and adhering to medical advice,^18–20 but it is unclear whether trust or its converse, distrust, affects the adoption of preventive health services among women.¹¹The emerging distrust research in health care shows that distrust is a multidimensional concept.^21–23 For example, Shea et al. used focus groups, pilot testing, and a telephone survey to develop a highly reliable 9-item distrust scale that includes 2 subscales: competence distrust and values distrust.²² Competence distrust is expected to be high when the quality of service fails to meet patient expectations and does not improve health. Values distrust is expected to be high when the integrity of the health care system is questioned (e.g., ethical issues, financial priorities, transparency of care). Although dimensions of distrust may influence the use of preventive health services in different ways, little research has addressed this issue explicitly.A range of individual characteristics has been found to be associated with the use of breast and cervical cancer screening, including age,^5,24 race/ethnicity,^11,25 socioeconomic factors,^5,24 marital status,^5,11,24 and availability and utilization of health care resources.^11,24 Access to insurance and health care providers is associated with higher likelihood of interaction with the health care system and has been hypothesized to be related to levels of distrust and to individuals’ health-related behaviors.²⁶ Personal health status has been found to be related to levels of distrust,²⁷ although the underlying causal mechanisms have not been well documented. Evidence concerning the association of health status with use of preventive health services is inconclusive.¹¹ An important contribution of our study is the investigation of the association of distinct aspects of distrust—values distrust and competence distrust—with receipt of 2 preventive health services for adult women: the Papanicolaou (Pap) test for cervical cancer and clinical breast examination to screen for breast cancer. We tested the following 2 hypotheses: after we controlled for individual socioeconomic and demographic characteristics, (1) high levels of distrust are associated with low utilization of cancer screening services and (2) the negative relationship between distrust and cancer screening utilization holds for the values and competence dimensions of distrust.     

Trust in the health care system and the use of preventive health services by older black and white adults

Objectives. We sought to find racial differences in the effects of trust in the health care system on preventive health service use among older adults.Methods. We conducted a telephone survey with 1681 Black and White older adults. Survey questions explored respondents'' trust in physicians, medical research, and health information sources. We used logistic regression and controlled for covariates to assess effects of race and trust on the use of preventive health services.Results. We identified 4 types of trust through factor analysis: trust in one''s own personal physician, trust in the competence of physicians'' care, and trust in formal and informal health information sources. Blacks had significantly less trust in their own physicians and greater trust in informal health information sources than did Whites. Greater trust in one''s own physician was associated with utilization of routine checkups, prostate-specific antigen tests, and mammograms, but not with flu shots. Greater trust in informal information sources was associated with utilization of mammograms.Conclusions. Trust in one''s own personal physician is associated with utilization of preventive health services. Blacks'' relatively high distrust of their physicians likely contributes to health disparities by causing reduced utilization of preventive services. Health information disseminated to Blacks through informal means is likely to increase Blacks'' utilization of preventive health services.There is strong empirical evidence of health care disparities between Black and White Americans. Blacks are less likely than are Whites to receive many needed services, including routine preventive care.^1–5 The causes of disparities in health care are complex and have been the subject of considerable research; socioeconomic differences and structural characteristics (such as lack of access to care) are important sources of care disparities, and there is significant evidence that racial bias in the health care system is also a major factor in disparities in care between Blacks and Whites.¹Blacks'' distrust of physicians and the health care system may also contribute to health care disparities. Studies have demonstrated that Blacks exhibit less trust in the health care system.^6–9 There are a variety of mechanisms through which this distrust may occur, including Blacks'' personal experiences with racism, their knowledge of a history of racism in the health care system—including circumstances in which Blacks were victimized, such as the Tuskegee Syphilis Study^10–12—and social and cultural distance between Black patients and White physicians.¹³ Taken together, these individual experiences constitute a broader cultural memory of abuse that may contribute to belief in conspiracy theories among Blacks.^14,15 Goertzel reported that belief in conspiracies was correlated with lack of interpersonal trust and that Blacks were more likely to believe in conspiracy theories than were Whites.¹⁶Trust plays a central role in all medical relationships and is an important contributor to positive therapeutic outcomes.^17–20 Lack of patient trust is associated with less doctor–patient interaction, poor clinical relationships that exhibit less continuity, reduced adherence to recommendations, worse self-reported health, and reduced utilization of health care services^17–22; thus, Blacks'' relatively lower trust in the health care system puts them at greater risk of all these negative outcomes. When O''Malley et al.²² evaluated respondents'' answers to a global question assessing overall trust in personal physicians, they found that greater trust was associated with higher overall use of a number of preventive services among low-income Black women 41 years and older.However, little is known about whether distrust affects use of specific preventive services differently. Because trust in the health care system is conceived as consisting of a number of types and dimensions,^17,19,20 it is also possible that different aspects of trust may affect service use differently, thus warranting more detailed study of how the dimensions of trust may affect use of preventive services among various populations. Because of its likely origins in racial bias, Blacks'' health care–related distrust may have somewhat different effects from that of Whites, perhaps manifesting as institutional distrust as opposed to interpersonal distrust.We explored these issues by examining the association of different aspects of health care–related trust with receipt of preventive health services among older Blacks and Whites. We focused on older adults because preventive services such as immunizations, routine physical examinations, and screening for cancer and other diseases can greatly reduce premature mortality and morbidity among this population and are critical to sustaining older adults'' health.²³ Thus, disparities in receipt of preventive services are an especially strong contributor to disparities in health outcomes for older adults.     

Investing in Preventive Dental Care for the Medicare Population: A Preliminary Analysis

Objectives. We estimated the use of preventive dental care services by the US Medicare population, and we assessed whether money spent on preventive dental care resulted in less money being spent on expensive nonpreventive procedures.Methods. We used data from the 2002 Medicare Current Beneficiary Survey to estimate a multinomial logistic model to analyze the influence of predisposing, enabling, and need variables in identifying those beneficiaries who used preventive dental care, only nonpreventive dental care, or no dental care in a multiple-variable context. We used regression models with similar controls to estimate the influence of preventive care on the utilization and cost of nonpreventive dental care and all dental care.Results. Our analyses showed that beneficiaries who used preventive dental care had more dental visits but fewer visits for expensive nonpreventive procedures and lower dental expenses than beneficiaries who saw the dentist only for treatment of oral problems.Conclusions. Adding dental coverage for preventive care to Medicare could pay off in terms of both improving the oral health of the elderly population and limiting the costs of expensive nonpreventive dental care for the dentate beneficiary population.For many retirees, paying for dental care treatment can be difficult.^1–3 According to the 2006 Health and Retirement Study, out-of-pocket dental expenditures over the previous 2-year period for persons aged 51 years and older averaged $776 for those with insurance coverage and $1126 for those without insurance coverage, among those with a dental visit during that period.⁴ These amounts are not trivial, especially for those who live on a fixed income. Seventy percent of persons aged 65 years and older in 2004 were not covered by any dental insurance.⁵ Without assistance, older Americans who are poorer may choose to delay or forgo dental care, but postponing dental care may lead to expensive complications.^6,7 As recently reported in the New York Times, “Left unchecked, a small cavity that would cost about $100 to fill can easily turn into a $1000 root canal. Skip those $80 cleanings each year, and you may be looking at $2000 worth of gum disease.”⁸Studies of the impact of preventive dental care visits have primarily focused on younger populations.^9–11 Insufficient attention has been paid to the possibility that preventive dental care may limit expensive nonpreventive dental care procedures among an older population. Previous research on preventive dental care has either not focused strictly on the elderly¹² or has not used nationally representative data.¹³To fill these gaps in the literature, we sought to identify the characteristics of older adults who used preventive and nonpreventive dental care as well as those who used no dental care at all. Previous studies have found patterns of increasing dental care use over the life span,¹⁴ as well as differences in racial/ethnic background, education, and income levels in the use of dental care among elderly populations.^15,16 Data from the 1996 Medical Expenditure Panel Survey show similar differences in the use of preventive services over the entire community-based population.¹⁷We then assessed dental care use and costs for beneficiaries who received preventive care during the year, and we compared those figures with dental care use and costs for those who did not receive preventive care to determine whether investing in preventive care can affect costs related to more expensive nonpreventive procedures.     

Innovative Primary Care Training: The Cambridge Health Alliance Oral Physician Program

We evaluated the Oral Physician Program, a dental residency sponsored by Harvard Medical School, Harvard School of Dental Medicine, and the Cambridge Health Alliance that offers an innovative model for training dentists to provide limited primary care. The didactic and clinical experiences increased residents'' medical knowledge and interviewing skills, and faculty assessments supported their role as oral physicians. Oral physicians could increase patients''—especially patients from underserved groups—access to integrated oral and primary care services.Static and fragmented curricula are failing to prepare graduates of health professional schools for current population health challenges, including the growing burden of chronic diseases.1 Primary care must be a pillar of clinical training,1,2 and dentists, as oral physicians, should be trained to provide limited preventive primary care and disease prevention.3 During their predoctorate clinical training years, dentists learn about the oral manifestations of more than 100 genetic and systemic disorders,4 including developmental and eating disorders, cardiovascular disease, diabetes, osteoporosis, and cancers, as well as substance and child abuse.5 Thus, dentists should be well positioned to identify numerous systemic conditions in addition to oral diseases, often at an early stage, through oral manifestations.Advanced oral physician training following dental school can provide skill strengthening and the practice necessary to adapt to the changing health needs of today’s most vulnerable populations by increasing early disease detection and referral. Dentists practice as oral physicians, for example, when providing or overseeing complete dental care and aspects of primary care,6 such as taking vital signs, screening for diabetes and other major health problems, and administering vaccines.7 By providing a range of preventive health care services, dentists can help increase access to care and improve the health of the community as part of the primary care prevention and referral system.8 The training model of the oral physician decompartmentalizes oral and general health and meets the primary care training objective of “interprofessional and transprofessional education that breaks down professional silos.”1^(p1924)     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

Reducing the Impact of the Health Care Access Crisis Through Volunteerism: A Means, Not an End

In the absence of meaningful health reform, Florida implemented a volunteer health care program to strengthen the existing safety net. Since program implementation in 1992, over $1 billion of services have been provided to uninsured and underserved populations. Currently, over 20 000 volunteers participate statewide. Key incentives for provider participation have been an organized framework for volunteering and liability protection through state-sponsored sovereign immunity. Volunteerism, although not a solution to the health care crisis, serves as a valuable adjunct pending full-scale health care reform.AS THE NUMBER OF uninsured persons continues to increase, patients are relying more on uncompensated care from medical providers through safety nets and volunteer programs to receive needed care.^1,2 State and local governments spend an estimated $17.2 billion on care for the uninsured, and physicians donate roughly $7.8 billion in services.³ In communities with higher social capital and in which physicians provide charity care, the uninsured report having less difficulty obtaining needed care.^4,5 The Florida Department of Health''s Volunteer Health Services Program (VHSP) is a unique safety net program that has been able to leverage public and private resources to obtain health care access for thousands of Floridians while providing substantial return on resources invested.⁶ We highlight the implementation and successes of the program.     

Requiring Influenza Vaccination for Health Care Workers

Annual influenza vaccination for health care workers has the potential to benefit health care professionals, their patients, and their families by reducing the transmission of influenza in the health care setting. Furthermore, staff vaccination programs are cost-effective for health care institutions because of reduced staff illness and absenteeism.Despite international recommendations and strong ethical arguments for annual influenza immunization for health care professionals, staff utilization of vaccination remains low. We have analyzed the ethical implications of a variety of efforts to increase vaccination rates, including mandatory influenza vaccination.A program of incentives and sanctions may increase health care worker compliance with fewer ethical impediments than mandatory vaccination.IT IS GENERALLY ACCEPTED that vaccinating health care workers against influenza reduces the transmission of the virus in health care settings, decreases staff illness and absenteeism, and indirectly benefits patients by decreasing their chance of being infected.¹ There are also very few risks associated with influenza vaccination, with the most frequently reported side effect being mild pain or swelling at the injection site. The results of a randomized double-blind controlled trial conducted over three consecutive years showed that localized pain or swelling following influenza vaccination was generally rare and that there were no absences from work because of vaccine-adverse events in the study population.² Influenza vaccination programs for health care workers are cost-effective in both direct medical costs and indirect costs of staff absenteeism.² Vaccinating employees and reducing absenteeism can save employers US $2.58 for every dollar invested in an influenza vaccination program.³ The influenza vaccine is approximately 80% effective in healthy adults, with the effectiveness being even higher when there is a close match between the vaccine and the circulating strain of the virus.⁴Evidence on whether vaccinating health care workers against influenza is beneficial for patients has been surprisingly inconclusive. For example, a recent systematic review had equivocal findings on the effect of staff vaccination on the rates of influenza among elderly patients.⁵ There have been a number of smaller, recent studies that have shown some improvement in patient outcomes when staff were immunized against influenza.^6,7 In all studies, the quality of evidence is undermined by relatively low levels of vaccination among health care workers, even in intervention groups. For example, Carman et al.''s study in long-term-care geriatric hospitals across west and central Scotland found that the vaccination rate for health care workers was only 50.9% compared with 4.9% when it was not explicitly offered.⁶There is evidence that vaccinating healthy people younger than 60 years (which includes health care workers) results in decreases of influenza cases among those groups.⁵ Reduction in virus transmission may be particularly important in institutions and wards caring for young children, immunocompromised individuals, or the elderly. The vaccine is only 60% to 70% effective for individuals 65 years and older; despite approximately 80% of this population being immunized against influenza,⁸ they remain susceptible to infection if exposed to the virus. In elder-care settings, influenza among staff precedes illness among residents, suggesting that health care workers introduce the virus into the setting.⁹These findings highlight the fact that, despite the value of vaccination, health care workers are notoriously noncompliant with vaccination regimes. International guidelines recommend annual vaccination for all health care workers with patient contact,¹⁰ but worldwide, rates of influenza immunization among health care workers range between 2% and 60%,¹¹ well below the 83% to 94% required for the whole population to be resistant to spread of an influenza virus.¹²Health care institutions have used a variety of methods to increase immunization rates among employees, including education, reminder notices, small incentives, easy access to free vaccination, active promotion within the workplace, and compulsory vaccination as a condition of employment.^13–19 Most of these programs have achieved only small increases in vaccination rates, apart from employment-related mandatory vaccination.¹⁹ For example, a program in Australian Capital Territory elder-care facilities included the provision of reminders and information about the importance and benefits of influenza vaccination, but resulted in only 28% of staff obtaining vaccination.¹⁸ Similarly, in a tertiary Australian hospital in which an influenza vaccination promotion program had been in place since 2001, only 24% of staff reported being fully vaccinated despite 96% of staff indicating that they were willing to update their vaccination status.¹⁷ In the United States, surveyed health care institutions have reported staff influenza vaccination rates ranging from 15% to 40%, despite national recommendations that health care workers receive vaccinations annually.¹⁴ A study conducted in neonatal intensive care units in the United States found that influenza immunization compliance rates among staff ranged between 15% and 20% and that 76% of staff continued to care for patients despite reporting flu-like symptoms.²⁰ In the United Kingdom, less than 25% of health care workers are vaccinated against influenza each year despite being aware of the potential benefits of vaccination.¹⁶Many reasons for this low level of acceptance have been proposed; however, it seems most likely that continued resistance to accepting vaccination is largely because of attitudinal barriers.²¹ Most health care workers believe that they are healthy and thus will derive no benefit from vaccination or that the risk of adverse events following immunization outweighs the benefits. Alternatively, they are simply unaware of the recommendations for annual influenza immunization.²⁰ It is possible that some health care workers may be conscientious objectors to vaccination; however, active refusals are unlikely to be a significant contributor to the low levels of vaccination among health care workers.Health care workers vary considerably in their health care knowledge, educational level, primary work environment, race, and culture. These factors affect the use of vaccination. For example, health care workers 50 years and older, of higher socioeconomic status, and with greater duration of employment at the same institution are more likely to accept vaccination than are those of lower socioeconomic status and shorter duration of employment, suggesting they are more familiar with influenza vaccination recommendations or possible risks and benefits to health care workers and patients.²² To be effective, interventions to raise immunization rates need to identify specific barriers and concerns expressed by health care workers about influenza immunization and then target themthrough the implementation of policies, education programs, and improved access to vaccination.¹⁴Programs that actively target previously identified barriers have had a greater impact than have generic programs on staff vaccination rates. Increases in acceptance rates and reduced staff illness and absenteeism have been achieved by improving access to vaccination with a mobile unit, addressing common misconceptions through staff education, making vaccination free of charge, and offering small incentives to staff members who participated in the program.^13,23 Targeting previously identified barriers resulted in increases in vaccination rates from 42% to 77% over a period of three years in one setting and from 4.9% to 50.9% in another.^13,16 A US program that combined free vaccination with an educational component increased influenza vaccination coverage rates from 5% to 44% in one year.²⁴ These rates, however, remain significantly below the 83% to 94% levels required to achieve herd immunity.Despite considerable evidence that the vaccination of health care workers benefits workers, their patients, their families, and their institutions, few health care professionals take advantage of vaccination programs unless these programs are actively promoted or required as a condition of employment. Even when programs are actively promoted, the increases in vaccination rates generally remain below levels required to achieve herd immunity and, therefore, are unlikely to secure the potential benefits from high rates of vaccination.     

Pregnancy as a Window of Opportunity for HIV Prevention: Effects of an HIV Intervention Delivered Within Prenatal Care

Objectives. We sought to determine whether an HIV prevention program bundled with group prenatal care reduced sexually transmitted infection (STI) incidence, repeat pregnancy, sexual risk behavior, and psychosocial risks.Methods. We conducted a randomized controlled trial at 2 prenatal clinics. We assigned pregnant women aged 14 to 25 years (N = 1047) to individual care, attention-matched group care, and group care with an integrated HIV component. We conducted structured interviews at baseline (second trimester), third trimester, and 6 and 12 months postpartum.Results. Mean age of participants was 20.4 years; 80% were African American. According to intent-to-treat analyses, women assigned to the HIV-prevention group intervention were significantly less likely to have repeat pregnancy at 6 months postpartum than individual-care and attention-matched controls; they demonstrated increased condom use and decreased unprotected sexual intercourse compared with individual-care and attention-matched controls. Subanalyses showed that being in the HIV-prevention group reduced STI incidence among the subgroup of adolescents.Conclusion. HIV prevention integrated with prenatal care resulted in reduced biological, behavioral, and psychosocial risks for HIV.Young pregnant women are at high risk for HIV and sexually transmitted infections (STIs).¹ In a systematic review of sexual risk behavior among pregnant or mothering adolescents, 19% to 39% had an STI during pregnancy, and 14% to 39% had an STI 6 to 10 months postpartum. Furthermore, young pregnant women were 5 times less likely to use condoms compared with nulliparous women.²Despite the risks of STI and HIV infection among women of reproductive age, few HIV interventions have specifically targeted pregnant women. The Children''s Health and Responsible Mothering project (Project CHARM), a school-based intervention of pregnant and mothering adolescents, found increases in condom-use intentions, but no difference in number of unprotected acts of sexual intercourse compared with a general health promotion control group.³ Another study found that pregnant women given a 4-session HIV intervention had moderate increases in knowledge and safer sexual behaviors that were sustained 6 months after the intervention.⁴Although few studies of HIV and STI interventions have targeted pregnant women, some have focused on women attending primary care clinics.^5–8 Interventions for STI clinic patients documented significant declines in STI incidence.^8,9 However, most HIV interventions are limited because they do not integrate HIV prevention with the provision of other services,^10,11 and are not theory based.^12–14Pregnancy offers a unique opportunity for intervention as it is a time when women engage in high-risk behaviors, make behavioral changes, and have frequent contact with health care professionals.^15–18 Finally, interventions integrated with existing care systems (e.g., prenatal care) can be sustained because care is reimbursable by insurance.¹⁹The bundling of HIV prevention with existing systems can increase the accessibility of HIV prevention by providing opportunities to reach individuals who may not have the motivation or time to attend stand-alone HIV prevention sessions.¹⁹ HIV and STI prevention programs have been successfully integrated in care settings such as psychiatric, drug treatment, and palliative medicine.^20–22 We developed an HIV intervention that was integrated with a model of prenatal care.CenteringPregnancy group prenatal care^23,24 has been shown to reduce preterm birth and increase prenatal care satisfaction.^23,25 We created a modified program, CenteringPregnancy Plus, by integrating HIV prevention with the group prenatal care model. The purpose of this study was to evaluate the effects of this integrated HIV prevention program on biological outcomes (STI, repeat pregnancy), sexual risk behaviors (condom use, unprotected sexual intercourse), and psychosocial variables (communication, perceived risk, self-efficacy).     

Effects of Different Types of Antismoking Ads on Reducing Disparities in Smoking Cessation Among Socioeconomic Subgroups

Objectives. We assessed which types of mass media messages might reduce disparities in smoking prevalence among disadvantaged population subgroups.Methods. We followed 1491 adult smokers over 24 months and related quitting status at follow-up to exposure to antismoking ads in the 2 years prior to the baseline assessment.Results. On average, smokers were exposed to more than 200 antismoking ads during the 2-year period, as estimated by televised gross ratings points (GRPs). The odds of having quit at follow-up increased by 11% with each 10 additional potential ad exposures (per 1000 points, odds ratio [OR] = 1.11; 95% confidence interval [CI] = 1.00, 1.23; P < .05). Greater exposure to ads that contained highly emotional elements or personal stories drove this effect (OR = 1.14; 95% CI 1.02, 1.29; P < .05), which was greater among respondents with low and mid-socioeconomic status than among high–socioeconomic status groups.Conclusions. Emotionally evocative ads and ads that contain personalized stories about the effects of smoking and quitting hold promise for efforts to promote smoking cessation and reduce socioeconomic disparities in smoking.Tobacco use inflicts the greatest burden of illness on those least able to afford it.^1,2 An enormous challenge for tobacco control is how to tackle the consistently higher levels of smoking prevalence found among disadvantaged groups,^3–5 especially because these gaps may be widening.^6,7 Televised antismoking campaigns provide an effective population-wide method of preventing smoking uptake,^8,9 promoting adult smoking cessation,¹⁰ and reducing adult smoking prevalence,¹¹ and research indicates that some types of ads may be more effective than others. Antismoking messages that produce strong emotional arousal, particularly personal stories or graphic portrayals of the health effects of smoking, tend to perform well¹²; they are perceived to be more effective than others, are more memorable, and generate more thought and discussion.^13–16 However, it is unclear whether different types of messages might maintain, increase, or mitigate the disparities in smoking prevalence across population subgroups.Research on subgroup differences in responses to a range of anti-tobacco ads has not found systematic differences by gender, race/ethnicity, or nationality.^13,17–19 A review of the literature on the use of mass media concluded that in comparison with their effects on other populations, campaigns have often been less effective, sometimes equally effective, but rarely more effective in promoting cessation among socioeconomically disadvantaged populations.²⁰ However, many of the less effective general-audience campaigns were hampered by minimal reach to smokers of low socioeconomic status (SES) because they were low-cost campaigns unable to afford extensive media exposure.²⁰Most research examining longer-term quit rates in the context of large-scale, well-funded antismoking campaigns found comparable quit rates or reductions in smoking prevalence in low- and high-SES groups.^21–28 However, to our knowledge, no population-based research has examined the relationship between the degree of exposure to different types of antismoking messages and quit rates between low- and high-SES groups.A variety of theories^29–38 provide guidance about which styles of ads may best encourage quitting, especially among members of lower socioeconomic groups. Consistent with these theories, reviews of the effects of antismoking advertising have concluded that advertisements that evoke strong emotional responses through negative visceral imagery or personal stories about the health effects of smoking can increase attention, generate greater recall and appeal, and influence smoking beliefs and intentions.^12,39,40 Recent research indicates that self-relevant emotional reactions (i.e., emotional reflections about one''s life, body, or behavior that are triggered by the ad⁴¹) may be especially persuasive, because they affect perceptions of future risk of becoming ill,⁴² which in turn have been linked with reduced cigarette consumption, increased intentions to quit, and quit attempts.⁴³Antismoking ads that use strong graphic imagery of the health effects of smoking are likely to be predominately associated with high negative emotional arousal, but personal stories of the consequences of smoking may evoke high or low levels of emotion depending on the particular story and the degree to which smokers relate to the characters.³⁸ However, less emotional personal testimonials may still be more effective than other types of less emotional ads because there is no explicit persuasive intent against which smokers may react^38,44 and because health information is presented in a story-based format, which people learn to process naturally from an early age.⁴⁵Because lower-SES groups tend to have a greater degree of resistance to messages from the health care sector,⁴⁶ lower health literacy levels,^47,48 greater likelihood of belief in myths about cancer risks and prevention,⁴⁹ and less perception that smoking increases a person''s chance of getting cancer,⁴⁸ we proposed that emotional messages and personal stories might be especially influential. Presenting antismoking messages in an emotional or personal testimonial format may convey health information to these smokers in a way that is difficult to discount, natural and easy to process, and likely to arouse emotions that lead to increased perceptions of susceptibility to smoking-related diseases and motivation to quit.^38,42,44Drawing on the only previous study to examine the effect on adult quitting of the degree of exposure to antismoking ads,¹⁰ we first hypothesized that when all types of advertisements were considered together, greater exposure to these antismoking ads would be associated with greater likelihood of quitting by follow-up. Our second hypothesis was that particular types of antismoking ads (those containing highly emotional elements or personal testimonials about the effects of smoking) would be associated with a greater chance of successful quitting by follow-up than would exposure to ads without these elements. Finally, we hypothesized that highly emotional or personal testimonial ads would be especially effective among lower-SES groups.     

Participatory Design of Mass Health Communication in Three Languages for Seniors and People With Disabilities on Medicaid

Objectives. We used participatory design methods to develop and test guidebooks about health care choices intended for 600 000 English-, Spanish-, and Chinese-speaking seniors and people with disabilities receiving Medicaid in California.Methods. Design and testing processes were conducted with consumers and professionals; they included 24 advisory group interviews, 36 usability tests, 18 focus groups (105 participants), 51 key informant interviews, guidebook readability and suitability testing, linguistic adaptation, and iterative revisions of 4 prototypes.Results. Participatory design processes identified preferences of intended audiences for guidebook content, linguistic adaptation, and format; guidebook readability was scored at the sixth- to eighth-grade level and suitability at 95%. These findings informed the design of a separate efficacy study that showed high guidebook usage and satisfaction, and better gains in knowledge, confidence, and intended behaviors among intervention participants than among control participants.Conclusions. Participatory design can be used effectively in mass communication to inform vulnerable audiences of health care choices. The techniques described can be adapted for a broad range of health communication interventions.Reaching vulnerable populations and communicating effectively with them is a critical public health challenge. The estimated 55.6 million Medicaid beneficiaries¹ are one of the most vulnerable US populations and face serious communication barriers related to limited literacy, language, culture, and disability.^2,3 Of this population, the most at-risk subgroups are the more than 13.5 million seniors and people with disabilities.¹ Their communication barriers are even greater: many have limited health literacy skills (difficulty accessing, understanding, and acting on health information), limited English proficiency,^2,4 or physical or cognitive conditions that impede access to information.With the rapid proliferation of “consumer choice models” in many states, millions of Medicaid beneficiaries are now required to make complex decisions about health plan options and effectively using health care.³ These decisions have important implications for the targeted beneficiaries regarding access to needed preventive, curative, and supportive services.^3,5–9 However, studies show that these populations have difficulty making such decisions—in part because of the poor quality of information they receive.^3–6,8,9 For example, in studies in which seniors on Medicaid used printed materials about health care choices, only 32% of those in Florida³ and 25% of those in California¹⁰ could understand the information. This is not surprising, as more than 250 studies indicate that printed materials related to health are written at reading levels greatly exceeding the average literacy skills of adults in the United States.¹¹Theoretical guidance from socio-ecological,¹² social cognitive,¹³ and transtheoretical models,¹⁴ as well as 40 years of empirical research, suggest that health communication is more effective when it is relevant to people''s personal and social contexts.^15–29 For this reason, interpersonal and tailored computer-mediated communication, which can be personalized, typically show better results than materials-based mass communication.^{18,22,24,25,30–32} However, Medicaid programs primarily communicate with seniors and people with disabilities through printed materials, given the need for low-cost mass distribution and this population''s limited access to both in-person advice and the Internet. Is there a way to reach these highly vulnerable groups effectively and affordably?Research from the past 20 years shows that using strategies to adapt printed mass communication resources more closely to the needs of population subgroups can improve outcomes.^15–29 These design principles include matching readability more closely to users'' literacy levels and using “clear communication” formatting criteria,^33–35 incorporating culturally relevant concepts and graphics,^{4,17,19,23,36–40} and adapting rather than literally translating material into other languages.^{4,19,23,39,41}Such design principles are invaluable, but they can only approximate how real audiences use and react to health communication. For this reason, increasing emphasis is being placed on “participatory” or “user-centered” design—a structured approach that employs varied formative research methods to involve intended consumer and professional audiences as codevelopers of communication.^{4,19,25,42–45}Guidelines from the US Department of Health and Human Services and its centers, including the Centers for Disease Control and Prevention and the National Cancer Institute, recommend participatory design as a primary strategy to develop health communication.^{33–35,43,46} For the past 20 years, our center (Health Research for Action, www.uchealthaction.org) has leveraged such guidance to create large-scale mass communication materials by and for diverse populations.Two decades of studies confirm that when users participate in designing and testing communication, outcomes are more successful, including those for vulnerable groups.^{4,25,28,42,44,47–51} However, limited research is available about the detailed, iterative methods and steps involved in developing user-centered, materials-based mass communication—especially about how to adapt it for specific situations.In California, the Department of Health Care Services (DHCS) was concerned that fewer than 25% of Medicaid beneficiaries who were seniors or people with disabilities made active choices about health plans. By default, many beneficiaries could have plans ill suited for their health care needs. In 2006, the DHCS commissioned our center to use participatory processes to develop and test a guidebook about choosing and navigating health plans, intended for approximately 600 000 statewide Medicaid beneficiaries who were seniors and people with disabilities, in multiple language versions. Our objectives were to determine the (1) importance of participatory design in improving mass communication for diverse and vulnerable audiences, (2) methods to engage consumers and professionals in communication design and testing, (3) processes and outcomes of a project to create a user-designed guidebook for Medicaid beneficiaries, and (4) implications for health communication researchers and practitioners.     

Demonstrating the Importance and Feasibility of Including Sexual Orientation in Public Health Surveys: Health Disparities in the Pacific Northwest

Objectives. We identified health disparities for a statewide population of lesbian, gay, and bisexual (LGB) men and women compared with their heterosexual counterparts.Methods. We used data from the 2003–2006 Washington State Behavioral Risk Factor Surveillance System to examine associations between sexual orientation and chronic health conditions, health risk behaviors, access to care, and preventive services.Results. Lesbian and bisexual women were more likely than were heterosexual women to have poor physical and mental health, asthma, and diabetes (bisexuals only), to be overweight, to smoke, and to drink excess alcohol. They were also less likely to have access to care and to use preventive services. Gay and bisexual men were more likely than were heterosexual men to have poor mental health, poor health-limited activities, and to smoke. Bisexuals of both genders had the greatest number and magnitude of disparities compared with heterosexuals.Conclusions. Important health disparities exist for LGB adults. Sexual orientation can be effectively included as a standard demographic variable in public health surveillance systems to provide data that support planning interventions and progress toward improving LGB health.A limited number of studies have described chronic disease health risks among lesbian, gay, and bisexual (LGB) adults. Few of these studies have been population based, and those were often conducted in limited geographic areas or did not include a heterosexual comparison group. Most have relied on convenience samples or other targeted study designs and studied only specific health issues such as smoking or HIV risk factors.The patchwork of available studies indicates that LGB adults have important health disparities. Compared with heterosexual women, lesbian and bisexual women have been shown to have poorer overall health and mental health^1–3; higher rates of smoking,^4–11 alcohol consumption,^8,11–13 asthma,^3,13 and obesity²; and less access to health care,¹² including routine preventive screenings such as Papanicolaou (Pap) tests or mammograms,^14–16 although they were more likely to have had HIV tests.¹⁵ Gay and bisexual men have reported higher rates of smoking^4–6,9 and alcohol use⁸ and poorer general health and mental health^1,3 compared with heterosexual men. An LGB companion document to the Healthy People 2010 initiative identified 29 specific objectives that prioritized sexual minorities, but data by sexual orientation were not available in public health surveillance systems to track most of those objectives.¹⁷ In a recent review of sexual and gender minority health issues, Mayer et al.¹⁸ called for more inclusion of sexual minority identifiers in national data sets as a necessary next step in elimination of health disparities.In 2003, Washington began to include a question about sexual orientation in its Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a telephone-based survey of adults that is sponsored by the Centers for Disease Control and Prevention (CDC) and implemented throughout the United States.¹⁹For previous analyses, we combined data from 2 states (Washington and Oregon) collecting LGB information in BRFSS since 2003 into a single data set to gain sufficient numbers to describe LGB smoking behaviors.⁶ After 4 years of data collection, we now have enough LGB respondents from Washington alone to examine a variety of indicators. The purpose of this study was to describe a variety of health indicators for a statewide population of LGB men and women compared with their heterosexual counterparts. By demonstrating the feasibility and relevance of collecting information on sexual orientation in the BRFSS, we provide justification for public health surveillance systems to progress beyond “don''t ask, don''t tell” policies.     

Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data

Objectives. We sought to determine the magnitude, direction, and statistical significance of the relationship between active travel and rates of physical activity, obesity, and diabetes.Methods. We examined aggregate cross-sectional health and travel data for 14 countries, all 50 US states, and 47 of the 50 largest US cities through graphical, correlation, and bivariate regression analysis on the country, state, and city levels.Results. At all 3 geographic levels, we found statistically significant negative relationships between active travel and self-reported obesity. At the state and city levels, we found statistically significant positive relationships between active travel and physical activity and statistically significant negative relationships between active travel and diabetes.Conclusions. Together with many other studies, our analysis provides evidence of the population-level health benefits of active travel. Policies on transport, land-use, and urban development should be designed to encourage walking and cycling for daily travel.Many nations throughout the world have experienced large increases in obesity rates over the past 30 years.^1,2 The World Health Organization estimates that more than 300 million adults are obese,³ putting them at increased risk for diseases such as diabetes, hypertension, cardiovascular disease, gout, gallstones, fatty liver, and some cancers.^4,5 Several studies have linked the increase in obesity rates to physical inactivity^6–8 and to widespread availability of inexpensive, calorie-dense foods and beverages.^1,9The importance of physical activity for public health is well established. A US Surgeon General''s report in 1996, Physical Activity and Health,¹⁰ summarized evidence from cross-sectional studies; prospective, longitudinal studies; and clinical investigations. The report concluded that physical inactivity contributes to increased risk of many chronic diseases and health conditions. Furthermore, the research suggested that even 30 minutes per day of moderate-intensity physical activity, if performed regularly, provides significant health benefits. Subsequent reports have supported these conclusions.^11–13The role of physical activity in prevention of weight gain is well documented.¹⁴ Strong evidence from cross-sectional studies has established an inverse relationship between physical activity and body mass index.^15,16 In addition, longitudinal studies have shown that exercisers gain less weight than do their sedentary counterparts.^6,8 Thus, the obesity epidemic may be explained partly by declining levels of physical activity.^1,17,18A growing body of evidence suggests that differences in the built environment for physical activity (e.g., infrastructure for walking and cycling, availability of public transit, street connectivity, housing density, and mixed land use) influence the likelihood that people will use active transport for their daily travel.^19,20 People who live in areas that are more conducive to walking and cycling are more likely to engage in these forms of active transport.^21–25 Walking and cycling can provide valuable daily physical activity.^26–30 Such activities increase rates of caloric expenditure,³¹ and they generally fall into the moderate-intensity range that provides health benefits.^32–35 Thus, travel behavior could have a major influence on health and longevity.^29,30,36,37Over the past decade, researchers have begun to identify linkages between active travel and public health.^38–40 Cross-sectional studies indicate that walking and cycling for transport are linked to better health. The degree of reliance on walking and cycling for daily travel differs greatly among countries.^39,41 European countries with high rates of walking and cycling have less obesity than do Australia and countries in North America that are highly car dependent.²⁶ In addition, walking and cycling for transport are directly related to improved health in older adults.⁴² The Coronary Artery Risk Development in Young Adults Study found that active commuting was positively associated with aerobic fitness among men and women and inversely associated with body mass index, obesity, triglyceride levels, resting blood pressure, and fasting insulin among men.^26,39,41,43Further evidence of the link between active commuting and health comes from prospective, longitudinal studies.⁴⁴ Matthews et al. examined more than 67 000 Chinese women in the Shanghai women''s health study and followed them for an average of 5.7 years.³⁷ Women who walked (P < .07) and cycled (P < .05) for transport had lower rates of all-cause mortality than did those who did not engage in such behaviors. Similarly, Andersen et al. observed that cycling to work decreased mortality rates by 40% among Danish men and women.³⁶ A recent analysis of a multifaceted cycling demonstration project in Odense, Denmark, reported a 20% increase in cycling levels from 1996 to 2002 and a 5-month increase in life expectancy for males.⁴⁵We analyzed recent evidence from a variety of data sources that supports the crucial relationship between active travel, physical activity, obesity, and diabetes. We used city- and state-level data from the United States and national aggregate data for 14 countries to determine the magnitude, direction, and statistical significance of each relationship.     

Integrating Public Health and Personal Care in a Reformed US Health Care System

Compared with other developed countries, the United States has an inefficient and expensive health care system with poor outcomes and many citizens who are denied access.Inefficiency is increased by the lack of an integrated system that could promote an optimal mix of personal medical care and population health measures. We advocate a health trust system to provide core medical benefits to every American, while improving efficiency and reducing redundancy.The major innovation of this plan would be to incorporate existing private health insurance plans in a national system that rebalances health care spending between personal and population health services and directs spending to investments with the greatest long-run returns.THE UNITED STATES HAS THE most technologically intensive medical practice in the world.¹ It also spends more than any other nation on medical care,² but health outcomes in the United States are inferior to those in most other developed nations.^3–7 This inefficiency—spending more with poorer results—stems partly from failure to provide effective access to medical care to a substantial share of the population.^8,9 Lack of access leads to wider disparities in health in the United States than are experienced by the populations of other developed nations. The fragmented delivery system also leads to cost shifting (insurers'' attempts to transfer costs to other payers), administrative waste, and an imbalance between spending on medical care and spending on population health initiatives.There is general agreement that the US health care system should be more efficient as well as more equitable.^10,11 Most comprehensive proposals for reforming the system recognize the need for universal coverage that is independent of employment status, disability status, or age, although some would continue to rely on employers to collect health insurance payments.¹² Although universal insurance is important, it is not the only urgent issue. A reformed system should integrate personal preventive and therapeutic care with public health and should include population-wide health initiatives. Coordinating personal medical care with population health will require a more structured system than has ever existed in the United States.We argue that a reformed health care system not only should provide health insurance coverage for all but should also be organized and funded to take advantage of new knowledge about medical and nonmedical determinants of health. This health trust system (HTS) would (1) assess the cost of health insurance equitably, (2) promote efficiency by reducing fragmentation and relying on competitive markets, (3) allow coordination of spending on population health and personal medical care, (4) accommodate heterogeneous preferences, and (5) build on existing American health insurance and provider institutions, informed by international experience.