Shaping access to health care for refugees on the local level in Germany – Mixed-methods analysis of official statistics and perspectives of gatekeepers

BackgroundAnalyses of refugee reception in European countries are increasingly focusing on the local level. We analyzed how gatekeepers can shape access to health care on a local level, taking as an example the federal state of North Rhine-Westphalia (NRW), Germany, where municipalities have implemented different local access models for newly arrived refugees.MethodsWe assessed the details of and the rationale for the implementation of local access models (implementation analysis), and the potential access to health care for refugees in municipalities (local policy analysis). We covered three municipalities with a health care voucher model and three with an electronic health card model. We combined data from official reports and semi-structured interviews (N = 21) with gatekeepers.ResultsLarger municipalities are more likely to implement the eHC. Gatekeepers report that costs, workload and control are the major aspects underlying the choice of a model in municipalities. Access plays only a minor role – even though some of the gatekeepers claim that the eHC can facilitate access. Regardless of the implemented model, gatekeepers on the local level can contribute to facilitating the access to health care for refugees.ConclusionPotential access of newly arrived refugees is – among others – determined by the gatekeepers’ support and the implementation of the access models. Within the legal framework, municipalities implement the models differently.     

Oral health and access to dental care services in relation to the Health Necessities Index: São Paulo, Brazil, 2008

The Health Department of S?o Paulo, Brazil, has developed a Health Necessities Index (HNI) to identify priority areas for providing health assistance. In 2008, a survey of the status of oral health was conducted. The objective of this ecological study was to analyze the status of oral health in relation to the HNI. The variables, stratified by the age of 5, 12 and 15 years old were: percentage of individuals with difficulty of access to dental care services; DMFT and DMFS; prevalence of the need for tooth extraction and treatment of dental caries. Data were analyzed for the 25 Health Technical Supervision Units (HTS). The Statistical Covariance Test was used as well as the Pearson correlation coefficient and linear regression model. A positive correlation was observed between high scores of the HNI and difficulty of access to services. In the HTS with high scores of HNI a higher incidence of dental caries was observed, a greater need for tooth extractions and low caries-free incidence. In order to improve health conditions of the population it is mandatory to prioritize actions in areas of social deprivation.     

Is health a right for all? An umbrella review of the barriers to health care access faced by migrants

Objective. To synthesise the scientific evidence concerning barriers to health care access faced by migrants. We sought to critically analyse this evidence with a view to guiding policies.

Design. A systematic review methodology was used to identify systematic and scoping reviews which quantitatively or qualitatively analysed data from primary studies. The main variables analysed were structural and contextual barriers (health system organisation) as well as individual (patients and providers). The quality of evidence from the systematic reviews was critically appraised. From 2674 reviews, 79 were retained for further scrutiny, and finally 9 met the inclusion criteria.

Results. The structural barriers identified were the lack of health insurance and the high cost of drugs (non-universal health system) and organisational aspects of health system (social insurance system and national health system). The individual barriers were linguistic and cultural. None of the reviews provided a quality appraisal of the studies.

Conclusions. Barriers to health care for migrants range from entitlement in non-universal health systems to accessibility in universal ones, and determinants of access to the respective health services should be analysed within the corresponding national context. Generate social and institutional changes that eliminate barriers to access to health services is essential to ensure health for all.     

Inequalities in access to health care services and utilization for the elderly in São Paulo, Brazil

OBJECTIVE: To describe factors associated to inequalities in access to health care services and utilization for the elderly. METHODS: Study part of the Health, Well-being and Aging in Latin America and the Caribbean ("SABE") Survey that included 2,143 elderly individuals aged 60 or older in the city of S?o Paulo, southeastern Brazil, in 2000. A two-step sampling procedure with probability proportional to size was carried out using census tracts with replacement. To achieve the desired number of respondents aged 75 or older, additional households close to the selected census tracts were sampled. Access to health services and utilization were measured for outpatient and hospital services during a 4-month period prior to the interview, and correlated to factors related to ability, need and predisposition (total income, schooling, health insurance, reported medical condition, self-perception, gender and age).Multivariate logistic regression was performed in the analysis. RESULTS: Of all respondents, 4.7% reported being hospitalized and 64.4% seeking outpatient care in the four months prior to the study. As for public outpatient care provided, 24.7% were in hospital clinics and 24.1% in other public outpatient services. As for private care, 14.5% received care in hospitals and 33.7% in health clinics. The multivariate analysis showed an association between health service utilization and sex, medical condition, self-perceived health, income, schooling, and health insurance. However, an inverse effect was found for the variable "schooling". CONCLUSIONS: The study results show inequalities in access to health services and utilization as well as a deficient health care system. Public policies should take into account the specific needs of the elderly population to facilitate access to health care services and reduce inequalities.     

Information and access to health care: is there a role for trust?

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure.     

Quality of life of Turkish type 2 diabetics in Germany and Turkey – a comparison between Hamburg and Istanbul

Objectives. The analyses address the following research questions: (1) Do Turkish diabetics in Germany and Turkey differ in terms of quality of life? (2) If yes, can these differences (in part) be explained by social factors (age, gender, education, household size), functional limitations and availability of support? (3) Are social factors, functional limitations and availability of support differently associated with quality of life among Turkish diabetics in Germany and Turkey?

Design. For this comparative cross-sectional study, 111 patients with type 2 diabetes were personally interviewed in Istanbul (Turkey) and 294 Turkish patients in Hamburg (Germany). For quality of life measurement we have used the Turkish version of the WHOQOL-Bref-26. Sociodemographics included age, sex, education and household-size. Health related functional limitations were assessed on the basis of an index of (instrumental) activities of daily living including the availability of help. Statistical analyses were conducted on group comparisons with Chi-square- and T-tests as well as linear regressions.

Results. There are no significant differences between Turkish diabetics in Germany and Turkey in the physical and the psychological dimensions of the WHOQOL-Bref. However, in the WHOQOL-domains ‘social QoL’ and ‘environmental QoL’ Turkish diabetics living in Hamburg have a significantly better quality of life than their counterparts in Istanbul. These differences cannot be explained by individual sociodemographic factors, functional limitations and availability of support. Furthermore, we found much stronger positive associations between education and quality of life in Istanbul than in Hamburg.

Conclusion. Beyond strong similarities between the two samples in sociodemographics, physical and mental health the social and environmental quality of life was significantly assessed better by the Turkish diabetics living in Hamburg. This is most likely an effect of public investment in social security, infrastructure and health care which is also influencing the decision as to where to spend life in retirement.     

Inequalities in out-of-pocket payments for health care services among elderly Germans – results of a population-based cross-sectional study

Introduction

In order to limit rising publicly-financed health expenditure, out-of-pocket payments for health care services (OOPP) have been raised in many industrialized countries. However, higher health-related OOPP may burden social subgroups unequally. In Germany, inequalities in OOPP have rarely been analyzed. The aim of this study was to examine OOPP of the German elderly population in the different sectors of the health care system. Socio-economic and morbidity-related determinants of inequalities in OOPP were analyzed.

Methods

This cross-sectional analysis used data of N?=?3,124 subjects aged 57 to 84 years from a population-based prospective cohort study (ESTHER study) collected in the Saarland, Germany, from 2008 to 2010. Subjects passed a geriatric assessment, including a questionnaire for health care utilization and OOPP covering a period of three months in the following sectors: inpatient care, outpatient physician and non-physician services, medical supplies, pharmaceuticals, dental prostheses and nursing care. Determinants of OOPP were analyzed by a two-part model. The financial burden of OOPP for certain social subgroups (measured by the OOPP-income-ratio) was investigated by a generalized linear model for the binomial family.

Results

Mean OOPP during three months amounted to €119, with 34% for medical supplies, 22% for dental prostheses, 21% for pharmaceuticals, 17% for outpatient physician and non-physician services, 5% for inpatient care and 1% for nursing care. The two-part model showed a significant positive association between income (square root equivalence scale) and total OOPP. Increasing morbidity was associated with significantly higher total OOPP, and in particular with higher OOPP for pharmaceuticals. Total OOPP amounted to about 3% of disposable income. The generalized linear model for the binomial family showed a significantly lower financial burden for the wealthiest quintile as compared to the poorest one.

Conclusions

This is the first study providing evidence of inequalities in OOPP in the German elderly population. Socio-economic and morbidity-related inequalities in OOPP and the resulting financial burden could be identified. The results of this study may contribute to the discussion about the mechanisms causing the observed inequalities and can thus help decision makers to consider them when adapting future regulations on OOPP.     

Has public health insurance for older children reduced disparities in access to care and health outcomes?

This paper investigates the effects of expanding public health insurance eligibility for older children. Using data from the National Health Interview Surveys from 1986 to 2005, we first show that although income continues to be an important predictor of children's health status, the importance of income for predicting health has fallen for children 9-17 in recent years. We then investigate the extent to which the dramatic expansions in public health insurance coverage for these children in the past decade are responsible for the decline in the importance of income. We find that while eligibility for public health insurance unambiguously improves current utilization of preventive care, it has little effect on current health status. However, we find some evidence that Medicaid eligibility in early childhood has positive effects on future health. This may indicate that adequate medical care early on puts children on a better health trajectory, resulting in better health as they grow.     

Promoting access to dental care in South London: adult patients’ perspectives

Objective

To evaluate patients’ views on health service initiatives established to improve uptake of NHS primary dental care amongst adult patients in a socially deprived area, comparing practices with extended and regular contract capacity.

Study design

Service evaluation and cross-sectional survey.

Method

Questionnaire survey of patients attending a random sample of dental practices in three inner-metropolitan boroughs of south London following initiatives to improve access to dental care (across dental practices delivering regular and extended contracts for services) exploring attendance patterns and the influence and awareness of local initiatives to promote access.

Results

Four hundred fifty adults across 12 dental practices completed questionnaires: 79% reported attending for routine and 21% for urgent care. Patients were most aware of banners outside practices, followed by dental advertisements in newspapers. Vouchers for free treatments were considered of the highest possible influence, followed by vouchers for reduced treatment costs and an emergency out-of-hours helpline. Awareness and influence were not aligned, and there was no evidence of difference by practice contract type whilst there were differences by age and type of attendance.

Conclusion

The findings suggest that financial incentives and emergency services are considered the most influential initiatives for adult patients whose attendance patterns appear to be related to personal circumstances rather than merely being influenced by the provision of information.

     

Do transgender men have equal access to health care and engagement in preventive health behaviors compared to cisgender adults?

ABSTRACT

Using 2015 Behavioral Risk Factor Surveillance System data, this study investigates whether transgender men have equal access to health care and engagement in preventive health behaviors compared to cisgender adults in the U.S. and whether race/ethnicity, socioeconomic status, and rural residence moderate these relationships. Once controlling for sociodemographic factors, we do not find differences for transgender men. Rural transgender men were less likely to have a personal doctor or receive a blood cholesterol screening than their urban peers; transgender men with less education were more likely to have a cholesterol screening. We detail implications for social workers within health care.     

Mental health literacy and attitudes in a Swedish community sample – Investigating the role of personal experience of mental health care

Background

The role of social and family environments in the development of mental health problems among children and youth has been widely investigated. However, the degree to which parental working conditions may impact on developmental psychopathology has not been thoroughly studied.

Methods

We conducted a case-control study of several mental health outcomes of 19,833 children of sawmill workers and their association with parental work stress, parental socio-demographic characteristics, and paternal mental health.

Results

Multivariate analysis conducted with four distinct age groups (children, adolescents, young adults, and adults) revealed that anxiety based and depressive disorders were associated with paternal work stress in all age groups and that work stress was more strongly associated with alcohol and drug related disorders in adulthood than it was in adolescence and young adulthood.

Conclusion

This study provides support to the tenet that being exposed to paternal work stress during childhood can have long lasting effects on the mental health of individuals.     

The recognition of access to health care as a human right in South Africa: is it enough?

A right of access to health care services is among the economic and social rights guaranteed by the Constitution of South Africa. Given the jurisprudential novelty of such a right and its dependence on economic resources, however, its realization is likely to be difficult to secure. The article discusses the scope and limitations of the right of access to health care in South Africa. Though the country's courts have yet to develop clear principles for interpreting a right of access to health care services, the more significant obstacles to the full enjoyment of this right are the country's pervasive poverty, gross income disparities, and extremely high burden of disease.     

Integrated health and social care in England – Progress and prospects

This paper reviews recent policy initiatives in England to achieve the closer integration of health and social care. This has been a policy goal of successive UK governments for over 40 years but overall progress has been patchy and limited. The coalition government has a new national framework for integrated care and variety of new policy initiatives including the ‘pioneer’ programme, the introduction of a new pooled budget – the ‘Better Care Fund’ – and a new programme of personal commissioning. Further change is likely as the NHS begins to develop new models of care delivery. There are significant tensions between these very different policy levers and styles of implementation. It is too early to assess their combined impact. Expectations that integration will achieve substantial financial savings are not supported by evidence. Local effort alone will be insufficient to overcome the fundamental differences in entitlement, funding and delivery between the NHS and the social care system.With a national election set to take place in May 2015, all political parties are committed to the integration of health and social care but clear evidence about the best means to achieve it is likely to remain as elusive as ever.