“Automatic assumption of your gender,sexuality and sexual practices is also discrimination”: Exploring sexual healthcare experiences and recommendations among sexually and gender diverse persons in Arctic Canada

Sexual and mental health disparities are reported in Arctic Canada as in other Arctic regions that experience shared challenges of insufficient healthcare resources, limited transportation, and a scarcity of healthcare research. Lesbian, gay, bisexual, transgender, and queer persons (LGBTQ+) report sexual and mental health disparities in comparison with their heterosexual and cisgender counterparts, and these disparities may be exacerbated in rural versus urban settings. Yet limited research has explored sexual healthcare experiences among LGBTQ+ persons in the Arctic who are at the juncture of Arctic and LGBTQ+ health disparities. We conducted a qualitative study from May 2015 to October 2015 with LGBTQ+ persons in the Northwest Territories, Canada that involved in‐depth individual interviews with LGBTQ+ youth (n = 16), LGBTQ+ adults (n = 21), and key informants (e.g. coaches, teachers, nurses, social workers, and healthcare providers) (n = 14). We conducted thematic analysis, a theoretically flexible approach that integrates deductive and inductive approaches, to identify and map themes in the data. Findings reveal geographical, social, and healthcare factors converge to shape healthcare access. Specifically, the interplay between heterosexism and cisnormativity, intersectional forms of stigma, and place limited LGBTQ+ persons’ sexual healthcare access and produced negative experiences in sexual healthcare. Limited healthcare facilities in small communities resulted in confidentiality concerns. Heteronormativity and cisnormativity constrained the ability to access appropriate sexual healthcare. LGBTQ+ persons experienced LGBTQ+, HIV, and sexually transmitted infections stigma in healthcare. Participants also discussed healthcare provider recommendations to better serve LGBTQ+ persons: non‐judgment, knowledge of LGBTQ+ health issues, and gender inclusivity. Findings can inform multi‐level strategies to reduce intersecting stigma in communities and healthcare, transform healthcare education, and build LGBTQ+ persons’ healthcare navigation skills.     

Unmet Need and Problems Accessing Specialty Medical and Related Services Among Children with Special Health Care Needs

OBJECTIVES: To extend what is known about parent reports of their child's need for specialty medical and related services, unmet need, and specific types of access problems among children with special health care needs (CSHCN). METHODS: Using data from a 1998-1999 20-state survey of families of CSHCN, we examined differences in parent report of need for services by child characteristics, investigated parent report of unmet need and access problems by service area and number of services needed, and estimated the likelihood of four access problems and unmet need by child, family, and health insurance characteristics. RESULTS: Overall, the sample children had numerous service needs, although the prevalence of need varied by service type and child characteristics. Reports of unmet need were greater for older children and for children with multiple service needs, unstable health care needs or a behavioral health condition, parents who were in poor health or had more than a high school education, and families whose insurance coverage was inconsistent or lacked a secondary plan. Reports of access problems were greatest for mental health and home health services. The two most prevalent access problems were finding a skilled provider and getting enough visits. CONCLUSIONS: The results underscore the importance of finding new ways to link children with behavioral health problems to mental health services, implementing coordinated care and the other core dimensions of the medical home concept, increasing the number of specialty pediatricians and home health providers, and expanding coverage for a wider range of mental health services.     

“It’s kind of hard to go to the doctor’s office if you’re hated there.” A call for gender‐affirming care from transgender and gender diverse adolescents in the United States

Research has identified discrimination and a lack of knowledgeable providers as major barriers for transgender and gender diverse (TGD) individuals seeking care, which contributes to greater stress and significant health disparities affecting this population. However, research involving TGD youth is limited. The aim of this study, therefore, was to describe TGD adolescents’ experiences, concerns and needs in healthcare settings, including their feedback on themes previously identified by healthcare providers (i.e. discomfort with gender‐related topics, reasons for not asking patients about gender and previous training regarding gender diversity). The authors conducted semi‐structured interviews with 12 TGD‐identified adolescents aged 14–17, living in Minnesota, USA in 2017–2018. Inductive thematic analysis was used to summarise participant comments into themes and subthemes. Two main themes were directly relevant to concerns and needs of TGD youth in healthcare settings and their views on healthcare providers’ concerns: (a) asking about gender and pronouns and (b) training for healthcare providers. Findings suggest the need for revisions to clinic materials, infrastructure and protocols. Adding training to all general medical and nursing education to increase knowledge, comfort and competence around gender identity would further improve care and ultimately reduce healthcare disparities affecting TGD youth.     

On the game: women and sex work

Latinos living with HIV residing in the US-Mexico border region frequently seek care on both sides of the border. Given this fact, a border health perspective to understanding barriers to care is imperative to improve patient health outcomes. This qualitative study describes and compares experiences and perceptions of Mexican and US HIV care providers regarding barriers to HIV care access for Latino patients living in the US-Mexico border region. In 2010, we conducted in-depth qualitative interviews with HIV care providers in Tijuana (n = 10) and San Diego (n = 9). We identified important similarities and differences between Mexican and US healthcare provider perspectives on HIV care access and barriers to service utilisation. Similarities included the fact that HIV-positive Latino patients struggle with access to ART medication, mental health illness, substance abuse and HIV-related stigma. Differences included Mexican provider perceptions of medication shortages and US providers feeling that insurance gaps influenced medication access. Differences and similarities have important implications for cross-border efforts to coordinate health services for patients who seek care in both countries.     

Recently released with HIV/AIDS: primary care treatment needs and experiences

The research objectives of this study are to describe the re-entry experiences of people recently released from jail who were living with HIV/AIDS, and to identify factors that influence their access to primary care and adherence to a treatment regimen. The research used a mixed-method, qualitative and quantitative research design. The findings indicate that the overall instability in the lives of many of the former inmates studied hampered their ability to attend to their HIV/AIDS-related health care needs. Most former inmates returned to the community with co-occurring problems related to housing and substance abuse. Complicating their access to health care were fragmented health care and correctional systems. The study highlights the need for coordination and collaboration between correctional facilities and community-based health care and human service providers that leads to a deliberative and planned transition from jail to service systems in the community.     

Providers’ perceptions of Aboriginal palliative care in British Columbia’s rural interior

Aboriginal Canadians experience a disproportionate burden of ill‐health and have endured a history of racism in accessing and using health care. Meanwhile, this population is rapidly growing, resulting in an urgent need to facilitate better quality of living and dying in many ways, including through enhancing (cultural) access to palliative care. In this article, we report the findings from a qualitative case study undertaken in rural British Columbia, Canada through exploring the perceptions of Aboriginal palliative care in a region identified as lacking in formal palliative care services and having only a limited Aboriginal population. Using interview data collected from 31 formal and informal palliative care providers (May–September 2008), we thematically explore not only the existing challenges and contradictions associated with the prioritisation and provision of Aboriginal palliative care in the region in terms of (in)visibility but also identify the elements necessary to enhance such care in the future. The implications for service providers in rural regions are such that consideration of the presence of small, and not always ‘visible’, populations is necessary; while rural care providers are known for their resilience and resourcefulness, increased opportunities for meaningful two‐way knowledge exchange with peers and consultation with experts cannot be overlooked. Doing so will serve to enhance culturally accessible palliative care in the region in general and for Aboriginal peoples specifically. This analysis thus contributes to a substantial gap in the palliative care literature concerning service providers’ perceptions surrounding Aboriginal palliative care as well as Aboriginal peoples’ experiences with receiving such care. Given the growing Aboriginal population and continued health inequities, this study serves to not only increase awareness but also create better living and dying conditions in small but incremental ways.     

Impact of Medical Home on Health Care of Children With and Without Special Health Care Needs: Update from the 2016 National Survey of Children’s Health

Objective The medical home has been promoted as an optimal model of health care delivery for children. The purpose of this study was to examine the association between having access to a medical home and the health care experiences of children with and without special health care needs (SHCN) in the United States. Methods We analyzed data from the 2016 National Survey of Children’s Health. We modeled logistic regressions to assess associations of having access to a medical home with health care experiences for 11,392 CSHCN and 38,820 non-CSHCN. Results We found that not having access to a medical home was negatively associated with preventive medical and dental care visits, greater unmet medical and dental needs, and hospital emergency room visits. Additionally, not having access to a medical home was negatively associated with the physical and oral health among CSHCN and oral health among non-CSHCN. However, we found no significant association between improved physical health status and having access to a medical home among non-CSHCN. Conclusions Results from our analysis suggest that having access to a medical home remains key determinant of improved health care experiences by CSHCN and non-CSHCN in the United States. Our findings underscore the need to develop policies and implement a more concerted program to increase access to health care delivered under the medical home model for CSHCN and non-CSHCN. Policymakers, health care administrators and physician groups can use these findings to inform future policy decisions and service delivery reforms.

     

The impact of payor/provider type on health care use and expenditures among the frail elderly.

OBJECTIVES: This study examined whether health care expenditures and usage by the frail elderly differ under three payor/provider types: Medicare fee for service, Medicare health maintenance organization (HMO), and dual Medicare-Medicaid enrollment. METHODS: In-home interviews were conducted among 450 frail elderly patients of a San Diego, Calif, health care system. Cost and use data were collected from providers. RESULTS: Analyses revealed no difference in total expenditures between fee-for-service and HMO enrollees, but Medicare-Medicaid beneficiaries' expenditures were 46.8% higher than those for HMO enrollees and 52.2% higher than those for the fee-for-service group. Fee-for-service participants were less than half as likely as HMO enrollees to have two or more hospital admissions, but hospital usage rates between those two payor/provider groups did not differ. Not were there payor/provider differences in access to home health care, but HMO home health care users received significantly fewer services than the others. CONCLUSIONS: The care provided to these HMO beneficiaries resulted in a combination of restricted home health use and higher multiple hospitalizations. This raises compelling questions for future research. For the dually enrolled, stronger cost containment may be required.     

Capacity of AIDS service organisations in Connecticut to respond to intimate partner violence

Although intimate partner violence (IPV) is prevalent among women living with HIV and negatively impacts their health, few studies have examined the ability of AIDS service organisations (ASOs) to address IPV. This study used a qualitative approach to identify facilitators of and barriers to addressing IPV in female clients of ASOs in the United States. In‐depth interviews were conducted between March and August 2011 with 20 ASO staff members and 19 female clients who reported a current or past history of IPV. Interviews were audio recorded, transcribed and analysed using the constant comparative method. These data identify barriers to addressing IPV at the organisation, provider and client levels, and include suggestions from both clients and providers about improving access to care. Client and provider suggestions differed in some areas. While providers emphasised structural changes such as increased training on IPV provided by their organisation, clients highlighted the importance of trusting personal relationships with staff to increase client disclosure of IPV experiences. Given the differing opinions of clients and staff, ASOs should consider involving women with histories of IPV in the process of programme and policy development. ASOs have the unique opportunity to provide comprehensive and holistic care by addressing IPV. The extent to which ASOs are able to recognise and address IPV and strategies for increasing this ability warrant greater attention from funders, ASO administrators and researchers.     

Access and acceptability of community‐based services for older Greek migrants in Australia: user and provider perspectives

In most developed nations, ageing migrants represent a growing proportion of the older population. Policies that emphasise care in the community depend on older migrants having access to formal services along with informal support, yet little is known about how older migrants experience community‐based formal services. By examining the views of both Greek elders in Australia and those of formal service providers, this research fills an important gap in the literature around access to and acceptability of formal community‐based services for older migrants. A research team including two Greek background researchers used existing social groups and a snowball sampling method to conduct face‐to‐face interviews and focus groups with seventy older Greeks in Adelaide, Australia. In addition, 22 community‐based service providers were interviewed over the telephone. Results from users and providers showed that while many older Greeks experience service access issues, they also relied heavily on family for support and assistance at home. Reliance on family was both in preference to formal services or where formal services were used, to locate, negotiate and monitor such services. Common barriers identified by both groups included cost, transport and availability, but additional challenges were posed by language, literacy and cultural attitudes. Demographic changes including greater employment mobility and female workforce participation among adult children will have implications for both formal and informal care providers. Formal service providers need to ensure that services are promoted and delivered to take account of the important role of family in informal support while also addressing the access challenges posed by language and literacy. Research conducted by researchers from the same cultural background in the respondent’s native language can further advance knowledge in this area.     

Health Training and Information Needs of Child Day Care Providers

This study sought to determine day care providers (day care center directors and family day care home providers) knowledge of the health status of children in their care, the availability of first and and emergency procedures, the management of acute conditions and illness, and provider interest in training and information on child health Although both types of providers need additional training, the needs of family day care home providers seem greater There was limited interest in topics that have become increasingly important, e g, care of children with disabilities or with chronic conditions To meet these health training and informational needs of day care providers, community-based health professionals and health agencies should become more involved as advocates, consultants, and resources for health promotion and disease prevention practices in day care settings.     

Switching HMO providers. Dissatisfaction with emergency access cited as the primary reason for disenrollment

The reasons consumers choose one service provider over another are not necessarily the same as the reasons for changing service providers. The distinctions may be even more important when the service in question is health care, specifically the decision to reenroll or switch HMO providers. The authors undertook a consumer survey to gauge the importance of 41 variables in the decision process. Using logistic regression analysis, they concluded that variables associated with access to emergency care services had the greatest impact on decisions to switch. This is contrary to other studies, which have ranked emergency care access much lower, and additional research is recommended.     

Child Care Provider Perspectives on the Role of Education and Training for Quality Caregiving

This study describes child care providers' reports of the types of training necessary for quality caregiving and their beliefs about the level of training and education required for child care workers. 70 providers (25 center directors, 19 center providers, and 26 home providers) participated in 8 focus groups that were conducted as part of a larger statewide assessment of child care provider training needs. Providers most frequently listed 1) Health, Safety, and Nutrition, 2) Child Development; and 3) Developmentally Appropriate Practices and Learning Environments as important topics for child care training. When asked to identify a level of training and education for child care workers, providers endorsed 3 different types of preparation: education, life experience (e.g., parenting), and personal attributes (e.g., patience). Center providers were more likely than home providers to identify education and providers with child-care relevant education were more likely than providers with no post-high school preparation to endorse education. Results are discussed in terms of providers' perceptions of professional worth and the design of educational and professional development initiatives.     

Association between Women Veterans' Experiences with VA Outpatient Health Care and Designation as a Women's Health Provider in Primary Care Clinics

BackgroundWomen veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers.MethodsSecondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs.FindingsOf the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01–1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs.ConclusionsThe main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics.     

Local access to care programs (LACPs): new developments in the access to care for the uninsured

Context: New, locally based health care access programs are emerging in response to the growing number of uninsured, providing an alternative to health insurance and traditional safety net providers. Although these programs have been largely overlooked in health services research and health policy, they are becoming an important local supplement to the historically overburdened safety net. Methods: This article is based on a literature review, Internet search, and key actor interviews to document programs in the United States, using a typology to classify the programs and document key characteristics. Findings: Local access to care programs (LACPs) fall outside traditional private and publicly subsidized insurance programs. They have a formal enrollment process, eligibility determination, and enrollment fees that give enrollees access to a network of providers that have agreed to offer free or reduced‐price health care services. The forty‐seven LACPs documented in this article were categorized into four general models: three‐share programs, national‐provider networks, county‐based indigent care, and local provider–based programs. Conclusions: New, locally based health access programs are being developed to meet the health care needs of the growing number of uninsured adults. These programs offer an alternative to traditional health insurance and build on the tradition of county‐based care for the indigent. It is important that these locally based, alternative paths to health care services be documented and monitored, as the number of uninsured adults is continuing to grow and these programs are becoming a larger component of the U.S. health care safety net.     

Language and regional differences in evaluations of Medicare managed care by Hispanics

OBJECTIVES: This study uses the Consumer Assessments of Healthcare Providers and Systems (CAHPS((R))) survey to examine the experiences of Hispanics enrolled in Medicare managed care. Evaluations of care are examined in relationship to primary language (English or Spanish) and region of the country. DATA SOURCES: CAHPS 3.0 Medicare managed care survey data collected in 2002. STUDY DESIGN: The dependent variables consist of five CAHPS multi-item scales measuring timeliness of care, provider communication, office staff helpfulness, getting needed care, and health plan customer service. The main independent variables are Hispanic primary language (English or Spanish) and region (California, Florida, New York/New Jersey, and other states). Ordinary least squares regression is used to model the effect of Hispanic primary language and region on CAHPS scales, controlling for age, gender, education, and self-rated health. DATA COLLECTION/EXTRACTION METHODS: The analytic sample consists of 125,369 respondents (82 percent response rate) enrolled in 181 Medicare managed care plans across the U.S. Of the 125,369 respondents, 8,463 (7 percent) were self-identified as Hispanic. The survey was made available in English and Spanish, and 1,353 Hispanics completed one in Spanish. PRINCIPAL FINDINGS: Hispanic English speakers had less favorable reports of care than whites for all dimensions of care except provider communication. Hispanic Spanish speakers reported more negative experiences than whites with timeliness of care, provider communication, and office staff helpfulness, but better reports of care for getting needed care. Spanish speakers in all regions except Florida had less favorable scores than English-speaking Hispanics for provider communication and office staff helpfulness, but more positive assessments for getting needed care. There were greater regional variations in CAHPS scores among Hispanic Spanish speakers than among Hispanic English speakers. Spanish speakers in Florida had more positive experiences than Spanish speakers in other regions for most dimensions of care. CONCLUSIONS: Hispanics in Medicare managed care face barriers to care; however, their experiences with care vary by language and region. Spanish speakers (except FL) have less favorable experiences with provider communication and office staff helpfulness than their English-speaking counterparts, suggesting language barriers in the clinical encounter. On the other hand, Spanish speakers reported more favorable experiences than their English-speaking counterparts with the managed care aspects of their care (getting needed care and plan customer service). Medicare managed care plans need to address the observed disparities in patient experiences among Hispanics as part of their quality improvement efforts. Plans can work with their network providers to address issues related to timeliness of care and office staff helpfulness. In addition, plans can provide incentives for language services, which have the potential to improve communication with providers and staff among Spanish speakers. Finally, health plans can reduce the access barriers faced by Hispanics, especially among English speakers.     

Reproductive Health Care Priorities and Barriers to Effective Care for LGBTQ People Assigned Female at Birth: A Qualitative Study

Background

Little research documents the self-identified reproductive health priorities and health care experiences of lesbian, gay, bisexual, transgender, queer (LGBTQ)-identified individuals who may be in need of services.