Structural vulnerability and access to medical care among migrant street-based male sex workers in Germany

This article discusses health concerns of migrant street-based male sex workers (SMSW) in Germany, a population that remains underexplored by health and social scientists. It is based on five months of ethnographic research in 2011/2012, including 46 semi-structured interviews with physicians, social workers, health department staff, and SMSW from Romania and Bulgaria. This is supplemented with annual reports by organizations providing assistance to this population in eight cities. The article contributes, first, an analysis of the increase in migrant SMSW as a response to economic opportunities (freedom of movement across European Union borders) and constraints (transitional measures restricting access to the labor market). It seeks to move beyond the myopic association between sex work and HIV to contextualize health risks as resultant of macro-level processes associated with migration. Second, the article contributes a summary of primary health concerns for this population. Especially troubling is their lack of access to regular medical services, reflecting a socio-legal position that often resembles that of unauthorized migrants rather than European Union citizens.     

The association between primary source of ambulatory care and access to and outcomes of treatment among AIDS patients.

OBJECTIVES: To examine the relationship between having a primary source of ambulatory care (PSAC), access to AIDS treatment and prophylaxis for opportunistic infection, and hospital and mortality outcomes among heterosexual men and women with AIDS. METHODS: Using a linked AIDS Registry-Medicaid database, 366 adults were identified (1989-1991) with at least 1 year of continuous Medicaid enrollment before AIDS diagnosis, who survived 2 weeks after diagnosis, and with no antiretroviral use or Pneumocystis carinii pneumonia (PCP) prophylaxis during the pre-diagnosis year. Outcomes included times to zidovudine treatment, PCP prophylaxis, hospitalization and death following diagnosis. Multivariate proportional hazards models were used to estimate the effects of patients' PSAC status in the 12-month post-diagnosis period on outcomes, controlling for demographic and case-mix variables. RESULTS: Study criteria preferentially included females, non-whites and enrollees eligible on the basis of aid to families with dependent children. A total of 49% of the patients had no PSAC. Patients with a PSAC were more likely to have received zidovudine [relative risk (RR) = 1.75, 95% confidence interval (CI) = 1.2, 2.2] or PCP prophylaxis (RR = 2.22, 95% CI = 1.5, 3.3). Regression models simultaneously examining association of the propensity to use zidovudine and PCP prophylaxis agents with death indicated that zidovudine-treated and PCP-prophylaxed patients were 64% and 51% less likely to die, respectively (RRdeath,zidovudine = (.36, 95% CI = 0.2, 0.4; RRdeath, PCP prophylaxis = 0.49, 95% CI = 0.3, 0.8). CONCLUSIONS: Patients' underuse of zidovudine and PCP prophylaxis was systematically associated with not having a PSAC. Lack of PSAC, in turn, predicted shorter survival but not increased hospitalization. Female gender, injecting drug use, non-white race and earlier diagnosis year also predicted poorer outcomes.     

Racial and ethnic differences in access to medical care in managed care plans

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.     

Specialty differences in the association between health care climate and patient trust

Medical Education 2011: 45 : 905–912 CONTEXT Previous studies have suggested that there is a positive correlation between doctors’ emotional intelligence (EI) and patients’ trust in their attending physicians; however, there is only limited evidence of specialty differences between internists and surgeons for such an association. OBJECTIVES This study examined the association of nursing director assessments of doctors’ EI, outside observer assessments of doctors’ health care climate (HCC) in the examining room and patient‐rated trust in internists and surgeons. Health care climate refers to a key component in communication and reflects the extent to which patients perceive their health care providers as supporting patient autonomy rather than controlling the provision of treatment. METHODS In this observational study, 2702 patients seen by 110 internists and 2642 patients seen by 101 surgeons were surveyed in face‐to‐face interviews by trained nurses in two teaching hospitals in Taiwan. Using hierarchical linear modelling, we examined the association between EI and HCC as well as patient trust in doctors working in the specialties of internal medicine and surgery. RESULTS We found a significantly positive correlation between doctor EI and patient trust for all patients (p < 0.01). In addition, although HCC was positively associated with patient trust for internists (p < 0.01), it was not so for surgeons. CONCLUSIONS We conclude that doctors might benefit from training programmes aimed at improving EI and that differences in patient expectations might be considered when hospitals attempt to evaluate doctors in different specialties.     

Territorial differences in access to prenatal care and health at birth

We assess the impact of prenatal care on health at birth using birth certificates from the Czech Republic. We use a predictive machine learning algorithm to identify the observables affecting birth health outcomes. We control for those observables in our empirical analysis, which indicates that a more intense use of prenatal care is positively correlated with better health outcomes at birth. Exploiting the Czech adhesion to the EU in 2004, we construct an instrument to capture the geographical heterogeneous access to prenatal care across districts. Differently from the OLS results, the IV results do not capture any significant effect of prenatal care, leaving room for the hidden role of unobservable mothers’ characteristics when it comes to health behaviors during pregnancy.     

Associations between older adults' spoken interactive health literacy and selected health care and health communication outcomes

Recent trends in the conceptualization of health literacy lead toward expansive notions of health literacy as social practice, rather than as a narrower cognitive capacity to understand health-related texts and materials. These expansive and complex constructions of health literacy demand tools for assessing individuals' propensities to actively seek information in their interactions with health care professionals and other health information sources. This study proposes a measure of this information-exchange component of health literacy and examines its capacity to predict outcomes and processes such as satisfaction with health care and comprehension of spoken health messages. Results for this sample ( n = 334) of low socioeconomic status older adults (mean age = 74.70 years) reveal that indices derived from the Measure of Interactive Health Literacy (MIHL) do contribute unique variance-apart from document-based health-literacy--on several criterion measures such as satisfaction with health care services. Comprehension checking improved health message listening comprehension, but for White participants only. These findings invite further investigations of interactive health literacy involving different populations, message topics, and elicitation methods.     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.     

A study of attitudes toward medical care and health behaviors among older adults

In order to understand the attitudes of older adults toward medical care, we interviewed 480 persons living in Yokohama, and 180 persons living in Aikawa, Kanagawa, aged 45 to 84 years old. The following results were obtained; 1) Attitudes toward medical care can be classified into four types; self-determined medical care, self treatment attitudes, high dependence on the medical care system, and distrust of medical care. Those interviewees who had high self-determination in medical care and self treatment attitudes showed strong distrust of medical care. 2) There were two groups with trend toward low compliance to the advice of a physician for a physician diagnosed illness: the group that had strong self-determination in medical care, and the group that had high distrust of medical care. The interviewees who had a strong tendency to see a physician for potentially serious illness had high self treatment attitudes, but disease prevention behaviors was not associated with all of four types. 3) In both communities, those interviewees who were younger and with higher educational levels showed strong distrust of medical care and had more self-determination attitudes. Those interviewees who had actually experienced problems in medical treatment showed less dependence on medical care and more distrust of medical care compared to those who had not. In Yokohama, distrust of medical care appeared to be higher among those interviewees who did not have a family doctor than those who had. 4) Distrust of medical care and self-determination in medical care was significantly higher in Yokohama than in Aikawa. The differences in the distribution of educational level and family doctors were a part of the reason for area differences in attitudes of distrust of medical care.     

中学生健康素养与遭受欺凌的关联及其性别差异

目的 探讨中学生健康素养和遭受欺凌的关联及其性别间的差异,为改善青少年遭受欺凌提供依据.方法 2017年11月至2018年1月采用多阶段整群抽样方法,在安徽省合肥市、辽宁省沈阳市、广东省阳江市和重庆市抽取18 900名中学生进行问卷调查.采用自填式问卷调查研究对象的基本特征、健康素养水平和遭受欺凌情况,比较不同特征中学...     

Barriers to health care access among the elderly and who perceives them

OBJECTIVES: We evaluated self-perceived access to health care in a cohort of Medicare beneficiaries. METHODS: We identified patterns of use and barriers to health care from self-administered questionnaires collected during the 1993-1994 annual examination of the Cardiovascular Health Study. RESULTS: The questionnaires were completed by 4889 (91.1%) participants, with a mean age of 76.0 years. The most common barriers to seeing a physician were the doctor's lack of responsiveness to patient concerns, medical bills, transportation, and street safety. Low income, no supplemental insurance, older age, and female gender were independently related to perceptions of barriers. Race was not significant after adjustment for other factors. CONCLUSIONS: Psychological and physical barriers affect access to care among the elderly; these may be influenced by poverty more than by race.     

Socioeconomic differences in health among older adults in Mexico

Although the relationship between socioeconomic status (SES) and health is well-established in Western industrialized countries, few studies have examined this association in developing countries, particularly among older cohorts. We use the Mexican Health and Aging Study (MHAS), a nationally representative survey of Mexicans age 50 and older, to investigate the linkages between three indicators of SES (education, income, and wealth) and a set of health outcomes and behaviors in more and less urban areas of Mexico. We consider three measures of current health (self-rated health and two measures of physical functioning) and three behavioral indicators (obesity, smoking, and alcohol consumption). In urban areas, we find patterns similar to those in industrialized countries: higher SES individuals are more likely to report better health than their lower SES counterparts, regardless of the SES measure considered. In contrast, we find few significant SES-health associations in less urban areas. The results for health behaviors are generally similar between the two areas of residence. One exception is the education-obesity relationship. Our results suggest that education is a protective factor for obesity in urban areas and a risk factor in less urban areas. Contrary to patterns in the industrialized world, income is associated with higher rates of obesity, smoking, and excessive alcohol consumption. We also evaluate age and sex differences in the SES-health relationship among older Mexicans. The results suggest that further economic development in Mexico may lead to a widening of socioeconomic inequalities in health. The study also provides insight into why socioeconomic gradients in health are weak among Mexican-Americans and underscores the importance of understanding health inequalities in Latin America for research on Hispanic health patterns in the US.     

Religious involvement and health outcomes among older persons in Taiwan

We use data from a nationally representative, longitudinal survey of older Taiwanese to examine the relationship between religious involvement-including religious affiliation, religious attendance, beliefs, and religious practices-and self-reported measures of overall health status, mobility limitations, depressive symptoms, and cognitive function; clinical measures of systolic and diastolic blood pressure, serum interleukin-6, and 12-h urinary cortisol; and 4-year mortality. Frequency of religious attendance shows the strongest, most consistent association with health outcomes. But, with only one exception, this relationship disappears in the presence of controls for health behaviors, social networks, and prior health status. Religious attendance remains significantly associated with lower mortality even after controlling for prior self-assessed health status, but the coefficient is substantially reduced. Other aspects of religiosity are only sporadically associated with health and, in all cases, private religious practices and stronger beliefs are associated with worse health; again, this relationship disappears after controlling for prior health status. These results suggest that reverse causality may partly account for both the positive and negative correlations between religiosity and health. We find no significant associations between religious involvement and biological markers. Notably, even after controlling for prior health, participation in social activities has a more robust effect on health than religious attendance. Consequently, we question whether the purported health benefits are attributable to religion or to social activity in general.     

Improving access to health care among New Zealand's Maori population

The health status of indigenous peoples worldwide varies according to their unique historical, political, and social circumstances. Disparities in health between Maoris and non-Maoris have been evident for all of the colonial history of New Zealand. Explanations for these differences involve a complex mix of components associated with socioeconomic and lifestyle factors, availability of health care, and discrimination. Improving access to care is critical to addressing health disparities, and increasing evidence suggests that Maoris and non-Maoris differ in terms of access to primary and secondary health care services. We use 2 approaches to health service development to demonstrate how Maori-led initiatives are seeking to improve access to and quality of health care for Maoris.     

Language spoken and differences in health status, access to care, and receipt of preventive services among US Hispanics

Objectives. We examined self-reported health status, health behaviors, access to care, and use of preventive services of the US Hispanic adult population to identify language-associated disparities.Methods. We analyzed 2003 to 2005 Behavioral Risk Factor Surveillance System data from 45 076 Hispanic adults in 23 states, who represented 90% of the US Hispanic population, and compared 25 health indicators between Spanish-speaking Hispanics and English-speaking Hispanics.Results. Physical activity and rates of chronic disease, obesity, and smoking were significantly lower among Spanish-speaking Hispanics than among English-speaking Hispanics. Spanish-speaking Hispanics reported far worse health status and access to care than did English-speaking Hispanics (39% vs 17% in fair or poor health, 55% vs 23% uninsured, and 58% vs 29% without a personal doctor) and received less preventive care. Adjustment for demographic and socioeconomic factors did not mitigate the influence of language on these health indicators.Conclusions. Spanish-language preference marks a particularly vulnerable subpopulation of US Hispanics who have less access to care and use of preventive services. Priority areas for Spanish-speaking adults include maintenance of healthy behaviors, promotion of physical activity and preventive health care, and increased access to care.More than 1 in 10 US residents now speak Spanish at home, and approximately half of these persons report an ability to speak English less than “very well.”¹ Language preference and English language proficiency have previously been associated with health-related behaviors, disease prevalence, and receipt of health care services among Hispanics,^2–6 but lack of sufficient individual-level population-based data on ethnicity, socioeconomic position, acculturation, and language has limited our ability to document the extent of language-associated disparities or to understand their component causes.⁷The utility of national surveys in monitoring health disparities and informing public health interventions relies upon methodologic adaptation to the increasing diversity of the US population.⁸ One of the most important sources of national data for identifying emerging health problems, developing public health policies and targeted prevention programs, and tracking progress toward meeting the Healthy People 2010 objectives is the Behavioral Risk Factor Surveillance System (BRFSS) sponsored by the Centers for Disease Control and Prevention.⁹ The BRFSS has included an optional Spanish-language survey instrument since 1987, but until recently, few states conducted Spanish-language interviews. Spanish-language survey data are now available from 23 states, which together represent approximately 90% of the total US Hispanic population. Thus, it is newly possible to describe rates of common population health indicators for a nationally representative sample of Spanish-speaking adults and to broadly examine language-associated disparities within the US Hispanic population.We sought to (1) provide a broad, national overview of the current US Spanish-speaking population, examining chronic disease prevalence, risk factors, self-reported health status, access to care, and receipt of preventive health services; (2) assess the extent to which language is associated with these health indicators among US Hispanics; and (3) examine regional variation in these health indicators among Spanish-speaking Hispanics. Comparative indicators for English-speaking Hispanic respondents are given to provide a context for evaluating and responding to the health risks and health care needs of the Spanish-speaking population.     

Economic class and differential access to care: comparisons among health care systems.

This paper presents a new technique for describing inequality of access to medical care. Access is described by the empirical relationship between need and the probability of entering the health care system for treatment. The need-entry probability relationship for one population group is compared with that for another population group to determine the extent of access differentials (differences in entry probabilities) at varying levels of need. As an illustrative application, the technique is employed to describe access differentials by economic class in six different geographic areas located in five different countries (Canada, England, Finland, Poland, United States) with differently structured health care systems. Although the findings for adults varied considerably from area to area, the access differentials among children were surprisingly consistent and unrelated to health care system structure. In particular, it appears that higher family income is associated with greater access to medical care among children at all levels of need. The paper concludes with suggestions for further applications of the proposed technique to problems of monitoring and evaluating the effectiveness of policies aimed at reducing the extent of access inequality.     

The association between health risk status and health care costs among the membership of an Australian health plan

Health promotion in Australia has developed into an accepted strategy for solving public health problems and promoting the health of its citizens. However, there are few evidence-based research studies in Australia that measure health risk status or track health changes over time with defined cost outcome measures. Those individuals with more high-risk lifestyle behaviors have been associated with higher costs compared with those with low-risk behaviors. Although intuitively it was believed that the health promotion programs had a positive impact on health behaviors and consequently on health care costs, the relationship between health risk status and health care costs had yet to be tested in the Australian population. Consequently, a verification study was initiated by the Australian Health Management Group (AHMG) to confirm that those relationships between health risks and medical costs that had been published would also hold in the Australian population using Australian private health care costs as the outcome measure. Eight health risks were defined using a Health Risk Appraisal (HRA) to determine the health risk status of participants. Consistent with previous studies, low-risk participants were associated with the lowest health care costs (377 Australian dollars) compared with medium- (484 Australian dollars) or high-risk (661 Australian dollars) participants and non-participants (438 Australian dollars). If the health care costs of those at low risk were considered as the baseline costs, excess health care costs associated with excess health risks in this population were calculated at 13.5% of total expenditures. Health risk reduction and low-risk maintenance can provide important strategies for improving/maintaining the health and well-being of the membership and for potential savings in health care costs.