Changes in How Health Plans Provide Behavioral Health Services

Health plans appear to be moving toward less stringent management, but it is not known whether behavioral health care arrangements mirror the overall trend. To improve access to and quality of behavioral health services, it is critical to track plans’ delivery of these services. This study examined plans’ behavioral health care arrangements and changes over time using a nationally representative health plan survey regarding alcohol, drug abuse, and mental health services in 1999 (N = 434, 92% response) and 2003 (N = 368, 83% response). Findings indicate health plans’ behavioral health service provision changed significantly since 1999, including a large increase in contracting with managed behavioral health care organizations. Some evidence of loosening administrative controls such as prior authorization implies easier access to services. However, increased prevalence of higher levels of cost sharing suggests financial barriers have grown. These changes have important implications for enrollees seeking care and for providers working to meet patients’ needs. This study was supported by the National Institute of Drug Abuse grant #R01DA10915 and the National Institute on Alcohol Abuse and Alcoholism grant # R01AA10869. The 1999 round was also supported by the Substance Abuse and Mental Health Services Administration contract #98M-0028601.     

Health and Mental Health Care Utilization by Clients of Resources for Homeless Persons in Quebec City and Montreal,Canada: A 5-Year Follow-Up Study

The objective of this cohort study is to describe the service utilization by clients of homeless resources in Quebec and Montreal (Canada) over a 5-year period. Participants (N = 426) were recruited from a survey conducted in 1999 about clients’ utilization of resources intended for homeless people in Montreal and Quebec. Data analyzed in this study were also drawn from three administrative databanks managed by the Quebec health care system. Results revealed that: (1) in general, mental health services are less used than physical health services; (2) generally, women, older persons, nonhomeless persons, and persons with mental health problems utilized proportionately more health services; and (3) participants involved in this study tend to continue using services over years in a system where health services are free. These findings are discussed in terms of long-term service utilization by clients of homeless resources.     

Physical health literacy of student–athletes

Student–athletes are a vulnerable population who face many unique stressors and often engage in risky physical behaviours. Understanding that high levels of health literacy (HL) can lead to improved health knowledge and decreased negative health outcomes, the purpose of this study was to assess the HL of both student–athletes and their non-athlete peers attending NCAA Division I, II and III institutions. Specifically, guided by Nutbeam's (2000) framework of HL, we assessed functional, communicative and critical HL in 205 student–athletes and 205 non-athlete students using the All Aspects of Health Literacy Scale. Compared to non-athletes, student–athletes had lower functional HL (b = 0.20; p < .001; d = 0.21), lower communicative HL (b = 0.12; p < .01; d = 0.13) and higher critical HL (b = 0.11; p < .05; d = 0.11). These findings suggest that additional interventions may be needed to increase the self-sufficiency of student–athletes to care for personal physical health. As social work in sport is an emerging subspecialty of the profession, social workers may consider increased involvement in advocating for this group by working with individuals, coaches and teams to decrease stigma in requesting health services, attending to the complexity of interacting systems and stressors in student–athletes' lives in therapeutic interventions, and connecting them to empowering health education resources.     

Urban homelessness and poverty during economic prosperity and welfare reform: Changes in self-reported comorbidities,insurance, and sources for usual care, 1995–1997

Little is known of how homeless and other urban poor populations have fared during the robust economy and within structural changes in health care delivery and entitlement programs of the 1990s. This is important in determining the need for population-specific services during a vigorous economy with low unemployment and increasing Medicaid managed-care penetration. This study compared health insurance status and availability of a source for usual medical care, psychiatric and substance abuse comorbidities, and perceived causes of homelessness in homeless adults surveyed in 1995 and 1997. Cross-sectional, community-based surveys were conducted in 1995 and 1997 at sites frequented by urban homeless adults residing in Pittsburgh, Pennsylvania. Self-reported medical, mental health, and substance abuse comorbidities, health insurance, and source for usual care were measured. Compared to the 388 individuals surveyed in 1995, the 267 homeless adults surveyed in 1997 had more medical comorbidity (56.6% vs. 30.2%, P<.001) and mental health comorbidity (44.9% vs. 36.9%, P=.04) and required more chronic medication (52.1% vs. 30.3%, P<.001). More respondents in 1997 than 1995 reported having no health insurance (41.4% vs. 29.4%, P<.001). While there was no difference in the overall proportion reporting a source for usual care (78.3% in 1997 vs. 80.2% in 1995, P=.55), fewer persons reported use of the emergency department and more persons reported using a shelter-based clinic for usual care in 1997 compared with 1995. These findings suggest more need for medical care among homeless and urban poor persons in 1997 compared with 1995 and support the continued need for outreach and support services despite a vigorous economy.     

Predictors of Health Care System and Physician Distrust in Hospitalized Cardiac Patients

Trusting relationships among patients, physicians, and the health care system is important in encouraging self-care behaviors in cardiovascular patients. This study aimed to assess the prevalence of health care system and physician distrust in this population, compare the 2 forms of distrust, and describe the demographic, socioeconomic, and psychosocial predictors of high distrust. A total of 1,232 hospitalized adults with acute coronary syndrome or heart failure were enrolled in a prospective, observational study assessing health care system distrust and physician distrust. High health care system distrust (35%) was observed across the population, with lower levels of interpersonal physician distrust (16%). In a multivariate analysis, poor social support and coping skills were strong predictors of both health care system (p = .026, p = .003) and physician distrust (p < .001, p = .006). Individuals with low or marginal health literacy had a higher likelihood of physician distrust (p < .001), but no relation was found between health literacy and health care system distrust. In conclusion, distrust is common among acutely ill cardiac patients. Those with low social support and low coping skills are more distrusting of physicians and the health care system.     

中国3个直辖市育龄流动人口接受生殖健康服务情况及其特征的相关分析

目的 了解北京、上海和重庆3个直辖市育龄流动人口接受生殖健康服务情况及其相关因素。方法 采用多阶段整群随机抽样,于2014年8月至2015年8月在3个直辖市开展横断面调查。采用绝对数和构成比描述计数资料,非线性典型相关分别分析基本人口特征、流动特征与生殖健康服务获得状况的相关性。结果 共调查育龄流动人口6 545人,其中41.76%在最近1年内接受过生殖健康服务。非线性典型相关发现育龄流动人口接受生殖健康服务情况分别与基本人口特征（r₁^a=0.28,P<0.000 1）和流动特征（r₁^b=0.21,P<0.000 1）存在正相关关系。基本人口特征指标的第一典型变量L₁主要受地区、职业和最高学历影响,生殖健康服务获得状况指标的第一典型变量M₁主要受避孕药具领取、避孕/生殖健康知识宣教和查孕/孕期保健影响;人口流动特征指标的第一典型变量U₁主要受流动目的、现居住地的主要居住方式和平均每年在现居住地居住月数影响,生殖健康服务获得状况指标的第一典型变量V₁主要受避孕药具领取、生殖道感染检查、避孕/生殖健康知识宣教和查孕/孕期保健的影响。结论 育龄流动人口生殖健康公共服务使用率较低,卫生计生部门应从相关基本人口特征和流动特征入手,使该人群重视生殖保健。     

Association between Having a Regular Health Provider and Access to Services Linked to Electronic Health Records

Objective: A regular care provider is an important measure of access to health services, but little is known about the association between having a regular provider and patients’ access to services associated with electronic health records (EHR). Furthermore, the composition of the additional electronic services made available to patients is not well studied.

Methods: We analyzed the most recent data from the Health Information National Trends Survey (HINTS5-Cycle1, 2017, n?=?3,285). We estimated a weighted multivariable logistic regression model to assess the association between having a regular provider (65.3%) and access to EHR (29%). Control variables were selected based on Andersen’s Behavioral Model.

Results: In the adjusted model, participants with a regular provider had significantly greater access to an EHR (aOR 2.91, p < .001) compared to participants without a regular provider. Participants were more likely to have access to an EHR if they were females (aOR 1.56, p < .01), had a tablet computer (aOR 1.55, p < .05), smartphone (aOR 2.27, p < .01), a former smoker (aOR 1.67, p < .05) or had two or more chronic medical conditions (aOR 1.79, p < .01).

Discussion: Individuals who have a regular provider are roughly three times as likely to have access to services linked to an EHR. Access to an EHR enhances both potential and realized access to many healthcare services.

Conclusion: The availability of a regular care provider impacts the “digital divide.” The expansion of electronic health services intensifies the importance of a regular care provider.     

Residents' preferences and preparation for caring for underserved populations

Access to care by low-income persons and residents of rural and poor innercity areas is a persistent problem, yet physicians tend to be maldistributed relative to need. The objectives were to describe prefernces of resident physicians to locate in underserved areas and to assess their preparedness to provide service to low-income populations. A national survey was made of residents completing their training in eight specialties at 162 USacademic health center hospitals in 1998, with 2,626 residents responding. (Of 4,832 sampled, 813 had invalid addresses or were no longer in the residency program. Among the valid sample of 4,019, the response rate was 65%). The percentage of residents ranking public hospitals, rural areas, and poor inner-city areas as desirable employment locations and the percentage feeling prepared to provide specified services associated with indigent populations were ascertained. Logistic regressions were used to calculate adjusted percentages, controlling for sex, race/ethnicity, international medical graduate (IMG) status, plans to subspecialize, ownership of hospital, specialty, and exposure to underserved patients during residency. Only one third of residents rated public hospitals as desirable settings, although there were large variations by specialty. Desirability was not associated with having trained in a public hospital or having greater exposure to underserved populations. Only about one quarter of respondents ranked rural (26%) or poor inner-city (25%) areas as desirable. Men (29%. P<.01) and noncitizen IMGs (43%, P<.01) were more likely than others to prefer rural settings. Residents who were more likely to rate poor innercity settings as desirable included women (28%, P=.03), noncitizen IMGs (35%, P=.01), and especially underrepresented minorities (52%, P<.01). Whereas about 90% or more of residents felt prepared to treat common clinical conditions, only 67% of residents in four primary care specialties felt prepared to counsel patients about domestic violence or to care for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or substance abuse patients (all 67%). Women were more likely than men to feel prepared to counsel patients about domestic violence (70% vs. 63%, P=.002) and depression (83% vs. 75%, P<.01). Underrepresented minority residents were more likely than other residents to feel prepared to counsel patients about domestic violence (P<.01) and compliance with care (P=.04). Residents with greater exposure to underserved groups were more prepared to counsel patients about domestic violence (P=.01), substance abuse (P=.01), and to treat patients with HIV/AIDS (P=.01) or with substance abuse problems (P<.01). This study demonstrates the need to expose graduate trainees to underserved populations and suggests a contininuing role of minorities, women, and noncitizen physicians in caring for low-income populations.     

Screening and brief intervention for hazardous drinking in an HMO: Effects on medical care utilization

This study examined whether a brief intervention to reduce hazardous alcohol consumption among primary care patients reduced use of medical care. In a parent, randomized controlled trial, at-risk drinkers identified in HMO outpatient waiting rooms were randomly assigned to receive usual care or brief clinician advice plus a 15-minute motivational counseling session. The current study (n=514) examined the groups' use of outpatient and inpatient medical services during two years after intervention. Although the intervention reduced alcohol consumption at six-month follow-up, intervention and control groups made similar numbers of outpatient visits (M=17.7 vs. 18.3, respectively;p=.47), were equally likely to be hospitalized (21.2% vs. 22.0%;p=.81), and, among those hospitalized, had similar lengths of stay (4.7 vs. 6.6 days;p=.37). Although brief interventions to reduce hazardous drinking may potentially reduce medical care utilization, more evidence is needed to substantiate their practicality and cost-effectiveness.     

Health Status,Quality of Life,Residential Stability,Substance Use,and Health Care Utilization among Adults Applying to a Supportive Housing Program

Supportive housing, defined as subsidized housing in conjunction with site-based social services, may help improve the health and residential stability of highly disadvantaged individuals. This study examined changes in health status, quality of life, substance use, health care utilization, and residential stability among 112 homeless and vulnerably housed individuals who applied to a supportive housing program in Toronto, Canada, from December 2005 to June 2007. Follow-up interviews were conducted every 6 months for 18 months. Comparisons were made between individuals who were accepted into the program (intervention) and those who were wait-listed (usual care) using repeated-measures analyses. Individuals who were accepted into the housing program experienced significantly greater improvements in satisfaction with living situation compared with individuals in the usual care group (time, F _3,3,261 = 47.68, p < 0.01; group × time, F _3,3,261 = 14.60, p < 0.01). There were no significant differences in other quality of life measures, health status, health care utilization, or substance use between the two groups over time. Significant improvement in residential stability occurred over time, independent of assigned housing group (time, F _3,3,261 = 9.96, p < 0.01; group × time, F _3,3,261 = 1.74, p = 0.17). The ability to examine the effects of supportive housing on homeless individuals was limited by the small number of participants who were literally homeless at baseline and by the large number of participants who gained stable housing during the study period regardless of their assigned housing status. Nonetheless, this study shows that highly disadvantaged individuals with a high prevalence of poor physical and mental health and substance use can achieve stable housing.     

Health expenditure and catastrophic spending among older adults living with HIV

Introduction: The burden of HIV is increasing among adults aged over 50, who generally experience increased risk of cormorbid illnesses and poorer financial protection. We compared patterns of health utilisation and expenditure among HIV-positive and HIV-negative adults over 50. Methods: Data were drawn from the Study on global AGEing and adult health in South Africa with analysis focusing on individual and household-level data of 147 HIV-positive and 2725 HIV-negative respondents. Results: HIV-positive respondents reported lower utilisation of private health-care facilities (11.8%) than HIV-negative respondents (25.0%) (p?=?.03) and generally had more negative attitudes towards health system responsiveness than HIV-negative counterparts. Less than 10% of HIV-positive and HIV-negative respondents experienced catastrophic health expenditure (CHE). Women (OR 1.8; p?p?Conclusions: These findings suggest that although HIV-positive and HIV-negative older adults in South Africa are protected to some extent from CHE, inequalities still exist in access to and quality of care available at health-care services – which can inform South Africa’s development of a national health insurance scheme.     

“They Don't See Our Feelings.” The Health Care Experiences of HIV-Positive Transgendered Persons

Objective: To support longer survival, it is necessary to reach an understanding of the knowledge and experience of the HIV-positive transgendered population of current HIV antiretroviral therapies and mainstream health care. Methods: This qualitative study utilized a grounded theory analysis with data collection occurring through two peer-facilitated focus groups. The study participants were 10 male-to-female HIV+ transgendered persons who were street-involved injection drug users or recovering addicts. A short questionnaire was used to complete a demographic profile of the group. Focus group sessions elicited information on participants' experiences with (a) health care delivery and (b) primary care services. Audiotapes from the sessions were transcribed verbatim. Major themes were generated and subthemes explored via hierarchical branching schema. Results: Primary care providers emerged in the text as dominant figures on which the participants were completely dependent for a variety of care needs. Text data revealed many barriers to the mainstream health care system. Specifically, poor coordination and/or lack of services prevented transgendered persons from accessing HIV care. Findings illustrated a failure in professional skill, poor practice, and a lack of cultural competence in existing health care agencies. Conclusions: Health providers must coordinate care with sensitivity and skill with respect to issues of gender, addiction, and HIV for transgendered persons. Adherence to antiretroviral therapy is more effective when addiction is addressed with methadone and/or recovery programs at the same time. The need for hormone therapy creates an important entry point to care, and represents a pragmatic reference point to which to affix HIV prevention and care programs effectively.     

A Wake-up Call for Burnout in Portuguese Physicians During the COVID-19 Outbreak: National Survey Study

BackgroundThe COVID-19 outbreak has imposed physical and psychological pressure on health care professionals, including frontline physicians. Hence, evaluating the mental health status of physicians during the current pandemic is important to define future preventive guidelines among health care stakeholders.ObjectiveIn this study, we intended to study alterations in the mental health status of Portuguese physicians working at the frontline during the COVID-19 pandemic and potential sociodemographic factors influencing their mental health status.MethodsA nationwide survey was conducted during May 4-25, 2020, to infer differences in mental health status (depression, anxiety, stress, and obsessive compulsive symptoms) between Portuguese physicians working at the frontline during the COVID-19 pandemic and other nonfrontline physicians. A representative sample of 420 participants stratified by age, sex, and the geographic region was analyzed (200 frontline and 220 nonfrontline participants). Moreover, we explored the influence of several sociodemographic factors on mental health variables including age, sex, living conditions, and household composition.ResultsOur results show that being female (β=1.1; t=2.5; P=.01) and working at the frontline (β=1.4; t=2.9; P=.004) are potential risk factors for stress. In contrast, having a house with green space was a potentially beneficial factor for stress (β=–1.5; t=–2.5; P=.01) and anxiety (β=–1.1; t=–2.4; P=.02).ConclusionsIt is important to apply protective mental health measures for physicians to avoid the long-term effects of stress, such as burnout.     

Racial and Ethnic Discrimination,Medical Mistrust,and Satisfaction with Birth Control Services among Young Adult Latinas

Background

Racial/ethnic discrimination and medical mistrust contribute to disparities in use of and satisfaction with health care services. Previous work examining the influence of discrimination and medical mistrust on health care experiences has focused primarily on African Americans. Despite the finding that Latinas report lower rates of contraceptive use than White women, little is known about the influence of these factors on health care satisfaction, specifically satisfaction with contraceptive services, among Latina women.

Receipt of Preventive Health Services in Young Adults

PurposeTo examine self-reported rates and disparities in delivery of preventive services to young adults.MethodsA population-based cross-sectional analysis, of 3,670 and 3,621 young adults aged 18–26 years who responded to California Health Interview Survey (CHIS) in 2005 and CHIS 2007, respectively. The main outcome measures were self-reported receipt of flu vaccination, sexually transmitted disease (STD) screening, cholesterol screening, diet counseling, exercise counseling, and emotional health screening. Multivariate logistic regression was used to examine how age, gender, race/ethnicity, income, insurance, and usual source of care influence the receipt of preventive services.ResultsDelivery rates ranged from 16.7% (flu vaccine) to 50.6% (cholesterol screening). Being female and having a usual source of care significantly increased receipt of services, with female participants more likely to receive STD screening (p < .001), cholesterol screening (p < .01), emotional health screening (p < .001), diet counseling (p < .01), and exercise counseling (p < .05) than male participants after controlling for age, race/ethnicity, income, insurance, and usual source of care. Young adults with a usual source of care were more likely to receive a flu vaccine (p < .05), STD screening (p < .01), cholesterol screening (p < .001), diet counseling (p < .05), and exercise counseling (p < .05) than those without a usual source of care after adjusting for age, race/ethnicity, income, and insurance.ConclusionsRates of preventive services delivery are generally low. Greater efforts are needed to develop guidelines for young adults to increase the delivery of preventive care to this age-group, and to address the gender and ethnic/racial disparities in preventive services delivery.     

Correction to: Randomized Controlled Trial of Doula-Home-Visiting Services: Impact on Maternal and Infant Health

Introduction Although home-visiting programs typically engage families during pregnancy, few studies have examined maternal and child health outcomes during the antenatal and newborn period and fewer have demonstrated intervention impacts. Illinois has developed an innovative model in which programs utilizing evidence-based home-visiting models incorporate community doulas who focus on childbirth education, breastfeeding, pregnancy health, and newborn care. This randomized controlled trial (RCT) examines the impact of doula-home-visiting on birth outcomes, postpartum maternal and infant health, and newborn care practices. Methods 312 young (M = 18.4 years), pregnant women across four communities were randomly assigned to receive doula-home-visiting services or case management. Women were African American (45%), Latina (38%), white (8%), and multiracial/other (9%). They were interviewed during pregnancy and at 3-weeks and 3-months postpartum. Results Intervention-group mothers were more likely to attend childbirth-preparation classes (50 vs. 10%, OR = 9.82, p < .01), but there were no differences on Caesarean delivery, birthweight, prematurity, or postpartum depression. Intervention-group mothers were less likely to use epidural/pain medication during labor (72 vs. 83%; OR = 0.49, p < .01) and more likely to initiate breastfeeding (81 vs. 74%; OR = 1.72, p < .05), although the breastfeeding impact was not sustained over time. Intervention-group mothers were more likely to put infants on their backs to sleep (70 vs. 61%; OR = 1.64, p < .05) and utilize car-seats at three weeks (97 vs. 93%; OR = 3.16, p < .05). Conclusions for practices The doula-home-visiting intervention was associated with positive infant-care behaviors. Since few evidence-based home-visiting programs have shown health impacts in the postpartum months after birth, incorporating doula services may confer additional health benefits to families.

     

Characteristics of Genomic Test Consumers Who Spontaneously Share Results With Their Health Care Provider

The purpose of this study was to evaluate the characteristics of direct-to-consumer (DTC) genomic test consumers who spontaneously shared their test results with their health care provider. Utilizing data from the Scripps Genomic Health Initiative, we compared demographic, behavioral, and attitudinal characteristics of DTC genomic test consumers who shared their results with their physician or health care provider versus those who did not share. We also compared genomic risk estimates between the two groups. Of 2,024 individuals assessed at approximately 6 months post testing, 540 individuals (26.5%) reported sharing their results with their physician or health care provider. Those who shared were older (p < .001), had a higher income (p = .01), were more likely to be married (p = .005), and were more likely to identify with a religion (p = .004). As assessed prior to undergoing testing, sharers also reported higher levels of exercise (p = .003), lower fat intake (p = .02), fewer overall concerns about testing (p = .001), and fewer concerns related to the privacy of their genomic information (p = .03). The genomic disease risk estimates disclosed were not associated with sharing. Thus, in a DTC genomic testing context, physicians and other health care providers may be more likely to encounter patients who are more health conscious and have fewer concerns about the privacy of their genomic information. Genomic risk itself does not appear to be a primary determinant of sharing behavior among consumers.     

Demographic and socio-cultural correlates of medical mistrust in two Australian States: Victoria and South Australia

Studies on medical mistrust have mainly focused on depicting the association between medical mistrust and access/utilization of healthcare services. The effect of broader socio-demographic and psycho-social factors on medical mistrust remains poorly documented. The study examined the effect of broader socio-demographic factors, acculturation, and discrimination on medical mistrust among 425 African migrants living in Victoria and South Australia, Australia. After adjusting for socio-demographic factors, low medical mistrust scores (i.e., more trusting of the system) were associated with refugee (β=−4.27, p<0.01) and family reunion (β=−4.01, p<0.01) migration statuses, being Christian (β=−2.21, p<0.001), and living in rural or village areas prior to migration (β=−2.09, p<0.05). Medical mistrust did not vary by the type of acculturation, but was positively related to perceived personal (β=0.43, p<0.001) and societal (β=0.38, p<0.001) discrimination. In order to reduce inequalities in healthcare access and utilisation and health outcomes, programs to enhance trust in the medical system among African migrants and to address discrimination within the community are needed.     

Risk factors of underutilization of childhood immunizations in ultraorthodox Jewish communities in Israel despite high access to health care services

Background

The risk factors of underutilization of childhood vaccines in populations with high access to health services are not fully understood.

Objectives

To determine vaccination coverage and factors associated with underutilization of childhood vaccines in a population with sub-optimal vaccination compliance, despite a high health care access.

Methods

The study was conducted among 430 children from ultraorthodox Jewish communities in the Bnei Brak city and Jerusalem district. Data on immunization status, socio-demographic factors and on parents’ attitudes regarding vaccines were obtained from medical records and through parents’ interviews.

Results

The proportion of fully vaccinated children was 65% in 2- to 5-year-old ultraorthodox children from Jerusalem district, and 86% in 2.5-year-old children from Bnei Brak city. The factors that were significantly associated with vaccines underutilization in Bnei Brak were having >6 siblings, maternal academic education, parental religious beliefs against vaccination, perceived risk of vaccine preventable diseases as low, and mistrust in the Ministry of Health (MOH). Similarly, in Jerusalem, religious beliefs against vaccination, and the perceived low risk of vaccine preventable diseases significantly increased the likelihood of under-immunization, while having a complementary health insurance was inversely related with vaccines underutilization.

Conclusions

The risk factors of under-immunization are in part modifiable, by means of health education on the risks of vaccine preventable diseases and by improving the trust in the MOH. The leaders of the ultraorthodox communities could play an important role in such interventions.