Barriers to Care and Comorbidities Along the U.S.-Mexico Border

Objective

While limited access to care is associated with adverse health conditions, little research has investigated the association between barriers to care and having multiple health conditions (comorbidities). We compared the financial, structural, and cognitive barriers to care between Mexican-American border residents with and without comorbidities.

Methods

We conducted a stratified, two-stage, randomized, cross-sectional health survey in 2009–2010 among 1,002 Mexican-American households. Measures included demographic characteristics; financial, structural, and cognitive barriers to health care; and prevalence of health conditions.

Results

Comorbidities, most frequently cardiovascular and metabolic conditions, were reported by 37.7% of participants. Controlling for demographics, income, and health insurance, six financial barriers, including direct measures of inability to pay for medical costs, were associated with having comorbidities (odds ratios [ORs] ranged from 1.7 to 4.1, p<0.05). The structural barrier of transportation (OR=3.65, 95% confidence interval [CI] 1.91, 6.97, p<0.001) was also associated with higher odds of comorbidities, as were cognitive barriers of difficulty understanding medical information (OR=1.71, 95% CI 1.10, 2.66, p=0.017), being confused about arrangements (OR=1.82, 95% CI 1.04, 3.21, p=0.037), and not being treated with respect in medical settings (OR=1.63, 95% CI 1.05, 2.53, p=0.028). When restricting analyses to participants with at least one health condition (comparing one condition vs. having ≥2 comorbid conditions), associations were maintained for financial and transportation barriers but not for cognitive barriers.

Conclusion

A substantial proportion of adults reported comorbidities. Given the greater burden of barriers to medical care among people with comorbidities, interventions addressing these barriers present an important avenue for research and practice among Mexican-American border residents.Limited access to health care has been associated with a wide range of adverse health consequences including premature mortality^1,2 and increased risk for many common chronic conditions.^3–5 Despite prior research documenting associations between sustained lack of access and many health conditions independently,^6,7 very little research has described whether people with more than one health condition (i.e., comorbidities) experience greater barriers to obtaining health care.Prior research based on information from the Medical Expenditure Panel Survey has further indicated that people with multiple chronic conditions incur far greater health-care costs (up to seven times as many) as patients with only one chronic condition.⁸ It is essential, therefore, to understand the barriers to care that are disproportionately faced by people with comorbidities who need ongoing care, particularly among populations at high risk for developing comorbidities.Populations at high risk for having multiple health conditions include most minority populations in the U.S. and, in particular, Hispanic people, the largest and most rapidly growing minority group in the U.S.⁹ For example, the largest subgroup of Hispanic people, Mexican-Americans, has been found to have the highest incidence (an estimated 33.2%) of metabolic syndrome,¹⁰ a cluster of risk factors placing people at higher risk for heart disease, type 2 diabetes, and stroke.¹¹ Although there is substantial variability among Hispanic subgroups, based on information from the National Health Interview Survey, Mexican-American populations have the poorest access to care and the lowest use of health services of all Hispanic subgroups.^12,13 An estimated 32% of Hispanic people in the U.S. do not have health insurance compared with 15% of non-Hispanic white people.¹⁴ Besides economic limitations, Hispanic populations often face additional barriers to accessing health services. Factors that have been reported to impede Hispanic populations from obtaining medical care include, but are not limited to, language and literacy barriers,^15–17 lack of transportation and geographic inaccessibility,^15,17 the perception of being treated without respect in medical settings, and the perception that they would have received better quality care if they belonged to a difference racial/ethnic group.¹⁸A valuable guiding framework for the current study that provides a comprehensive overview of modifiable factors associated with access to health care is the recently developed Health Care Access Barriers model, an evidence-based analytical framework developed by Carillo and colleagues.¹⁹ This model describes the assessment of three categories of barriers to health care (financial, structural, and cognitive) that have been shown to be associated with poor health outcomes.Given the limited access to health care and high risk for comorbidities, gaining insight into which financial, structural, and cognitive barriers to care are associated with comorbidities among Mexican-Americans can provide valuable information for preventive efforts. Therefore, based on information from a randomized household survey conducted in a large city along the U.S.-Mexico border, the primary aim of the current study was to compare barriers to health care of participants with and without comorbidities. We hypothesized that people reporting comorbidities would be disproportionately affected by financial, cognitive, and structural barriers to care.     

Substance Use by Immigrant Generation in a U.S.-Mexico Border City

Immigrant generation status has an impact on substance use, with lower use rates for recent immigrants. Substance use surveillance data are reported at the national and state levels; however, no systematic collection of data exists at the city level for the general population. In particular, rates of substance use have not been published for El Paso, Texas. The aims of this study are to estimate the prevalence of substance use among Hispanics in El Paso and to determine the association between substance use and immigrant generation. Hispanic residents of El Paso (N = 837) were interviewed. Demographic, immigration, and substance use data were collected. Bivariate analysis indicated that substance use increased as immigrant generation increased, while perceived problems with substance use decreased. In comparison to Texas and national data, our data showed that the rates of tobacco, marijuana, and illicit drug use were lower among young adults in El Paso.     

First Trimester Prenatal Care Initiation Among Hispanic Women Along the U.S.-Mexico Border

Background First trimester prenatal care (FTPNC) is associated with improved birth outcomes. U.S.-Mexico border Hispanic women have lower FTPNC than non-border or non-Hispanic women. This study aimed to identify (1) what demographic, knowledge and care-seeking factors influence FTPNC among Hispanic women in border counties served by five Healthy Start sites, and (2) what FTPNC barriers may be unique to this target population. Healthy Starts work to eliminate disparities in perinatal health in areas with high poverty and poor birth outcomes. Methods 403 Hispanic women of reproductive age in border communities of California, Arizona, New Mexico and Texas were surveyed on knowledge and behaviors related to prenatal care (PNC) and basic demographic information. Chi square analyses and logistic regressions were used to identify important relationships. Results Chi square analyses revealed that primiparous women were significantly less likely to start FTPNC than multiparous women (χ² = 6.8372, p = 0.0089). Women with accurate knowledge about FTPNC were more likely to obtain FTPNC (χ² = 29.280, p < .001) and more likely to have seen a doctor within the past year (χ² = 5.550, p = .018). Logistic regression confirmed that multiparity was associated with FTPNC and also that living in Texas was negatively associated with FTPNC (R² = 0.066, F(9,340) = 2.662, p = .005). Among 27 women with non-FTPNC, barriers included late pregnancy recognition (n = 19) and no medical insurance (n = 5). Conclusions This study supports research that first time pregnancies have lower FTPNC, and demonstrated a strong association between delayed PNC and late pregnancy recognition. Strengthened investments in preconception planning could improve FTPNC in this population.

     

Healthcare Access and Utilization Among Women 40 and Older at the U.S.-Mexico Border: Predictors of a Routine Check-Up

Mexican Americans are more likely to experience barriers to access and utilization of healthcare services than any other U.S. Hispanic group. In Mexico, where the majority of the population has access to care, the pressing issue is the underutilization of preventive services among adults. This study was conducted to assess access and utilization barriers among a U.S.-Mexico border population. A cross-sectional, population-based survey was conducted during 1999–2000 in a pair of contiguous U.S.-Mexico border communities. Household surveys were administered to U.S. and Mexican women, 40 years of age and older, to assess healthcare access and utilization, participation in chronic disease screenings, orientation toward prevention and personal history of chronic disease. Analysis indicates few statistically significant differences (p < 0.05) among access and utilization variables by country. Mexican participants were more likely to have a regular source of care and to have had a blood sugar test within the past 12 months. U.S. participants more often reported having had a Pap smear and mammogram during the previous year. Factors independently positively associated with having had a routine check-up during the past 12 months included age and having a regular provider or place to go when sick. Only going to the doctor when ill was independently inversely associated with routine check-ups in the past 12 months. Findings suggest that U.S. and Mexican border populations are similar with regard to healthcare access and utilization characteristics. Efforts to increase utilization of preventive health screenings among women are needed at the U.S.-Mexico border.     

Insider/Outsiders,Reproductive (In)justice,and the U.S.-Mexico Border

ABSTRACT

In this article, we combine narrative and visual elements – our experiences as scholars in reproductive justice, health communication, and border studies coupled with photos from reproductive justice activist marches we attended in El Paso and Houston – to advocate for a stronger coalition between health communication scholars and Latina/o communication scholars in responding to and resisting reproductive injustices and gendered violence currently occurring at the U.S.-Mexico border.     

Access to Transportation and Health Care Utilization in a Rural Region

CONTEXT: Access to transportation to transverse the large distances between residences and health services in rural settings is a necessity. However, little research has examined directly access to transportation in analyses of rural health care utilization. PURPOSE: This analysis addresses the association of transportation and health care utilization in a rural region. METHODS: Using survey data from a sample of 1,059 households located in 12 western North Carolina counties, this analysis tests the relationship of different transportation measures to health care utilization while adjusting for the effects of personal characteristics, health characteristics, and distance. FINDINGS: Those who had a driver's license had 2.29 times more health care visits for chronic care and 1.92 times more visits for regular checkup care than those who did not. Respondents who had family or friends who could provide transportation had 1.58 times more visits for chronic care than those who did not. While not significant in the multivariate analysis, the small number who used public transportation had 4 more chronic care visits per year than those who did not. Age and lower health status were also associated with increased health care visits. The transportation variables that were significantly associated with health care visits suggest that the underlying conceptual frameworks, the Health Behavior Model and Hagerstrand's time geography, are useful for understanding transportation behavior. CONCLUSIONS: Further research must address the transportation behavior related to health care and the factors that influence this behavior. This information will inform policy alternatives to address geographic barriers to health care in rural communities.     

Access to and use of ambulatory health care by a vulnerable Mexican American population on the U.S.-Mexico border.

The objective of this study was to determine if health care access is equitable and effective for Mexican Americans at the U.S.-Mexico border. The design was a cross-sectional telephone and door-to-door survey using the Behavioral Risk Factor Surveillance System, and the subjects were 1,409 El Paso County residents, ages 18 to 64 years. After controlling for other predisposing, enabling, and need characteristics, the presence of health insurance was significantly associated with health care use in the past year, both for a checkup (odds ratio [OR] = 2.48; 95 percent confidence interval [CI] = 1.83, 3.38) and a visit for any reason (OR = 2.20; 95 percent CI = 1.60, 3.04). Findings were similar for a regular source of care. Those who reported a checkup in the past year were significantly more likely to receive clinical preventive services. The lack of health insurance and a regular source of care for Mexican Americans on the U.S.-Mexico border creates significant inequalities in access to care.     

Assessment of respiratory symptoms and asthma prevalence in a U.S.-Mexico border region

The authors studied children who were 10-12 yr of age and who resided in sister cities in a U.S.-Mexico border region to determine the prevalence of asthma and respiratory symptoms. The relationship of symptoms to ambient levels of particulate matter less than 10 microm in diameter (PM10), and to several indoor environmental conditions, was assessed. The study was conducted in the border cities of Ambos Nogales (Nogales, Arizona [United States], and Nogales, Sonora [Mexico]). At the beginning of the 11-wk study, during the autumn of 1996, 631 students and their parents completed baseline questionnaires. While in school, the children completed daily symptom diaries and daily peak expiratory flow maneuvers. PM10 values and daily temperatures were also measured. The authors found that the prevalence of self-reported asthma among 5th-grade students was comparable on both sides of the border (i.e., 7.6% on the Arizona side and 6.9% on the Sonora side). Wheezing was a frequent complaint (29.5-35.6%), as was cough (16.8-29.6%). Smoking in the home was common on both sides of the border, and it was associated with a greater occurrence of self-reported asthma and respiratory complaints. Increased respiratory symptoms were also associated with increased ambient PM10 levels. The prevalence of respiratory symptoms such as wheezing and frequent cough among all children in this study, combined with the limitations inherent in self-reporting, suggest that asthma may actually be more prevalent than has been previously reported.     

Transitioning to Person-Centered Care: a Qualitative Study of Provider Perspectives

The Journal of Behavioral Health Services & Research -     

Community Demographics and Access to Health Care among U.S. Hispanics

Objective. To explore the influence of the communities in which Hispanics live on their access to health care.
Data. 1996–2002 Medical Expenditure Panel Survey data, linked to secondary data sources and including 14,504 observations from 8,371 Mexican American respondents living in metropolitan areas.
Study Design. We use multivariate probit regression models, stratified by individuals' insurance status, for analyses of four dependent variables measuring access to health care. We measure community characteristics at the zip code tabulation area level, and key independent variables of interest are the percentage of the population that speaks Spanish and percentage of the population that is immigrant Hispanic. Each of these measures is interacted with individual-level measures of nativity and length of U.S. residency.
Principal Findings. For Mexican American immigrants, living in an area populated by relatively more Spanish speakers or more Hispanic immigrants is associated with better access to care. The associations are generally stronger for more recent immigrants compared with those who are better established. Among U.S.-born Mexican Americans who are uninsured, living in areas more heavily populated with Spanish-speaking immigrants is negatively associated with access to care.
Conclusions. The results suggest that characteristics of the local population, including language and nativity, play an important role in access to health care among U.S. Hispanics, and point to the need for further study, including analyses of other racial and ethnic groups, using different geographic constructs for describing the local population, and, to the extent possible, more specific exploration of the mechanisms through which these characteristics may influence access to care.     

Helicobacter pylori infection in pregnant women from a U.S.-Mexico border population

Helicobacter pylori infection causes chronic digestive diseases that disproportionately affect Hispanics and other immigrant groups in the United States. Information on the epidemiology of H. pylori infection in pregnant women who reside along the U.S.-Mexico border is critical to understanding the dynamics of current H. pylori transmission patterns within families along the border. We describe the epidemiology of H. pylori infection in pregnant women recruited from Women, Infants, and Children (WIC) clinics in El Paso, Texas, and Mexican Social Security Institute maternal-child clinics in Ciudad Juarez, Mexico, from April 1998 to October 2000. We interviewed participants regarding environmental factors and tested their serum for IgG antibodies. We used logistic regression to estimate associations between environmental exposures and the odds of H. pylori prevalence. Definitive serological tests were available from 751 women. Seroprevalence was 74% in Juarez women and 56% in El Paso women. Prevalence increased with age, crowding, poor sanitation, and residence in Mexico, decreased with education, and was not associated with the woman's number of living children. In the U.S.-Mexico border region, women of reproductive age have a high prevalence of H. pylori infection, apparently related to poor socioeconomic conditions.     

Immigrant Health in Rural Maryland: A Qualitative Study of Major Barriers to Health Care Access

Immigration to rural areas in new receiving communities like Maryland’s Eastern Shore is growing. Despite a rapid rise in immigration and diminishing health system resources, little attention has been focused on barriers to health care access in this region for immigrants. A total of 33 in-depth key informant interviews with providers and immigrants were conducted. Qualitative analysis employing a constant comparison approach was used to explore emergent themes related to barriers to health care access for a growing immigrant population. Participants perceived limited health care resources, lack of health insurance coverage, high health expenditures, language barriers, and non-citizenship status as barriers to immigrants’ access of health care. Findings imply that immigrants living and working on the rural Eastern Shore face serious barriers to health care access. Additional work on immigrant health in rural areas and the impacts of immigration to rural health systems are needed.     

Patient Perspectives of Living with Coeliac Disease and Accessing Dietetic Services in Rural Australia: A Qualitative Study

Adapting to living with coeliac disease requires individuals to learn about and follow a strict gluten-free diet. Utilising a qualitative inductive approach, this study aimed to explore the perspectives of adults diagnosed with coeliac disease who have accessed dietetic services in a rural outpatient setting. A purposive sample of adults with coeliac disease who had accessed dietetic services from two rural dietetic outpatient clinics were recruited. Semi-structured interviews were conducted by telephone. Data were thematically analysed. Six participants were recruited and interviewed. Three key themes emerged: (i) optimising individualised support and services, (ii) adapting to a gluten-free diet in a rural context, and (iii) managing a gluten-free diet within the context of interpersonal relationships. Key issues identified in the rural context were access to specialist services and the increased cost of gluten-free food in more remote areas. The findings of this study have highlighted the difficulties associated with coeliac disease management and how dietetic consultation has the potential to influence confidence in management and improve lifestyle outcomes. Further qualitative research is required to expand on the findings of this study and inform future dietetic practice that meets the expectations and individual needs of people with coeliac disease in rural settings.     

Continuity and Trust in Primary Care: A Qualitative Study Informed by Game Theory

PURPOSE The relationship between continuity of care and patient trust in primary care is not fully understood. We report an empirical investigation, informed by game theory, of patients’ accounts of their trust in general practitioners (GPs).METHODS We conducted an analysis based on the constant comparative method of 20 semistructured interviews with patients about trust in GPs in the United Kingdom.RESULTS People use institutional trust, derived from expectations of medicine as an institution and doctors as professionals, as a starting point for their transactions with unfamiliar doctors. This expectation may be enough to allow patients the minimum of what they want from doctors and is often sufficient for single-episode encounters, where patients have specific goals. Repeated interactions with the same doctor can allow patients to develop more secure expectations, based on a history of other interactions and anticipation of future interactions. Secure trust can develop over time, especially if patients are convinced that the doctor has their interests at heart.CONCLUSIONS This work identifies dynamics inherent in repeated interactions that enable secure trust to develop. These findings have important implications for the design of services, which in the United Kingdom and elsewhere are increasingly focused on enhancing access rather than continuity. They suggest that patients do not see GPs as interchangeable and that the move toward organizing services around single encounters may disrupt the development of secure trust.     

Patient Experiences of Continuity of Cancer Care: Development of a New Medical Care Questionnaire (MCQ) for Oncology Outpatients

Objectives:  To adapt the Components of Primary Care Index (CPCI) to be applicable to oncology outpatients and to assess the reliability and validity of the adapted instrument (renamed the Medical Care Questionnaire [MCQ]).
Methods:  The development and validation of the MCQ took place in four phases. Phase 1 reviewed the literature and examined existing measures. In Phase 2, the selected instrument (CPCI) was reviewed by a panel of experts using a stepwise consensus procedure. In Phase 3, the adapted 21-item MCQ was administered to 200 outpatients attending oncology appointments. The instrument was refined to 15 items and in Phase 4, it was completed by 477 oncology outpatients. The psychometric properties of the new instrument were assessed using exploratory factor analysis (EFA), confirmatory factor analysis, multitrait scaling analysis, and by comparing MCQ scores between known groups.
Results:  EFA of the 15-item MCQ suggested three subscales with acceptable to good reliability: "Communication"α = 0.69; "Coordination"α = 0.84; and "Preferences"α = 0.75. Comparing known groups showed that patients who saw fewer doctors during their clinic visits reported stronger "Preferences" to see their usual doctor and rated "Communication" with their doctors as better than patients who saw more doctors during their clinic visits.
Conclusion:  The MCQ demonstrates good psychometric properties in the target population. It is a brief and simple-to-use instrument, which provides a valid perspective on patients' experiences of communicating with doctors and their perceptions of the continuity and coordination of their cancer care.