Exploring the 'fit' between people and providers: refugee health needs and health care services in Mt Roskill, Auckland, New Zealand

The needs of refugees and the struggles on the part of service providers to address this diverse population have received limited attention within the academic literature. This paper profiles Hauora o Puketapapa/Roskill Union and Community Health Centre (HoP), which is a non-profit, community owned and operated health clinic designed to deliver accessible, affordable and appropriate primary health care services to low-income groups in the Mt Roskill area of Auckland, New Zealand. The clinic's locality has undergone considerable demographic change over recent years with the arrival of refugees from diverse backgrounds. This situation has resulted in new sets of health needs and expectations which need to be addressed. The study took place in 2002-2003 and employed qualitative methods. In-depth interviews with community representatives, clinic users and health service staff members revealed that refugees face considerable barriers in accessing and utilising health services. Similarly, we found that health practitioners face the daunting task of endeavouring to meet these needs in an effective and culturally appropriate manner within a limited funding environment. We conclude that, despite these challenges, HoP has successfully established itself as a well-regarded place of primary health care. In so doing, it has strengthened the capacity of the local community to respond to the changing policy environment. However, long-term sustainability issues remain unless resourcing issues are adequately addressed.     

Lack of immunization documentation in Minnesota refugees: challenges for refugee preventive health care

Children and adults immigrating to the United States without documentation of vaccinations or evidence of immunity should receive age-appropriate immunizations. To learn how often immunization documentation is lacking, we reviewed medical screening records of 1,389 primary refugees over 18 months of age who came Minnesota during 1998. Restricting our analysis to those age groups for whom specific immunizations are recommended, 81.1% of refugees lacked documentation of receiving three doses of diphtheria and tetanus vaccines; 78.8% lacked documentation of one dose of measles vaccine, and 63.8% lacked documentation of three doses of polio vaccine. Of refugees without a known positive test for hepatitis B antigen or antibody, 99.5% lacked documentation of receiving three doses of hepatitis B vaccine. Documentation rates decreased with increasing age, and were lowest for refugees from sub-Saharan Africa (p < 0.001). Refugees and other immigrants may face a number of barriers to receiving necessary immunizations. Health care providers seeing these new arrivals need to ensure that they do fail to receive recommended vaccinations and other preventive health care.     

Access to health care, reproductive health and disability: a large scale survey in Sierra Leone

This is the first study to compare health status and access to health care services between disabled and non-disabled men and women in urban and peri-urban areas of Sierra Leone. It pays particular attention to access to reproductive health care services and maternal health care for disabled women. A cross-sectional study was conducted in 2009 in 5 districts of Sierra Leone, randomly selecting 17 clusters for a total sample of 425 households. All adults who were identified as being disabled, as well as a control group of randomly selected non-disabled adults, were interviewed about health and reproductive health. As expected, we showed that people with severe disabilities had less access to public health care services than non-disabled people after adjustment for other socioeconomic characteristics (bivariate modelling). However, there were no significant differences in reporting use of contraception between disabled and non-disabled people; contrary to expectations, women with disabilities were as likely to report access to maternal health care services as did non-disabled women. Rather than disability, it is socioeconomic inequality that governs access to such services. We also found that disabled women were as likely as non-disabled women to report having children and to desiring another child: they are not only sexually active, but also need access to reproductive health services. We conclude that disparity in access to government-supported health care facilities constitutes a major and persisting health inequity between persons with and without disabilities in Sierra Leone. Ensuring equal access will require further strengthening of the country's health care system. Furthermore, because the morbidity and mortality rates of pregnant women are persistently high in Sierra Leone, assessing the quality of services received is an important priority for future research.     

Management of human resources in health care: the Canadian experience.

Each of Canada's ten provinces has a publicly administered system of health insurance, funded by provincial and federal taxes, that is accessible to all citizens and covers all medically necessary services provided by physicians and hospitals. Canadians spend an estimated 9.2 percent of their gross national product on health care (about 2.8 percentage points below US spending), of which three quarters is public-sector spending. According to the Organization for Economic Cooperation and Development, Canada's health status is equal to or better than that of the United States, despite lower per capita health spending. About seven percent of the Canadian labour force works in health care, and attempts to introduce coordinated planning of human resources in health care have not as yet proceeded far. The predominant policy issue here is the supply and the role of physicians. It has been argued that entrenching within the system the fee-for-service method of paying physicians has created a disincentive to the delegation of responsibility to health personnel other than doctors. It is also argued that introduction of government-run health insurance provided the opportunity for human resource planning, but that the decision by governments to act only as the payer resulted in ad-hoc planning approaches. However, governments' concern over health care costs has led to a more direct role by them in the planning of the human resources in health. They are re-examining the autonomy and jurisdictional rights of the professions that deliver health care to Canadians.     

Forces for reforming the U.S. health care system: a review of the cost and access issues.

In recent years, a spate of health care reform proposals have emerged on the American agenda. Although the elements of the reform proposals often vary substantially, most of the initiatives are fuelled by two common concerns: rising health care expenditures and a growing uninsured population. National health spending, for example, commands an increasing share of U.S. gross national product despite numerous cost-containment efforts initiated by public and private payers throughout the 1980s. And the uninsured population continues to grow--by an estimated 30 percent between 1978 and 1989. To facilitate understanding of the public policy options being considered to address these concerns, the article examines U.S. health care expenditure data and some of the causes of rising health care costs. The article also discusses the demographic characteristics of the uninsured population, the reasons why they lack health coverage, and the health consequences associated with being uninsured.     

'Race' matters: racialization and egalitarian discourses involving Aboriginal people in the Canadian health care context

The major purpose of this paper is to examine how 'race' and racialization operate in health care. To do so, we draw upon data from an ethnographic study that examines the complex issues surrounding health care access for Aboriginal people in an urban center in Canada. In our analysis, we strategically locate our critical examination of racialization in the 'tension of difference' between two emerging themes, namely the health care rhetoric of 'treating everyone the same,' and the perception among many Aboriginal patients that they were 'being treated differently' by health care providers because of their identity as Aboriginal people, and because of their low socio-economic status. Contrary to the prevailing discourse of egalitarianism that paints health care and other major institutions as discrimination-free, we argue that 'race' matters in health care as it intersects with other social categories including class, substance use, and history to organize inequitable access to health and health care for marginalized populations. Specifically, we illustrate how the ideological process of racialization can shape the ways that health care providers 'read' and interact with Aboriginal patients, and how some Aboriginal patients avoid seeking health care based on their expectation of being treated differently. We conclude by urging those of us in positions of influence in health care, including doctors and nurses, to critically reflect upon our own positionality and how we might be complicit in perpetuating social inequities by avoiding a critical discussion of racialization.     

Regional primary health care organisations and migrant and refugee health: the importance of prioritisation,funding, collaboration and engagement

Objective : This paper examines whether Australian regional primary health care organisations – in this case, Medicare Locals (MLs) and Primary Health Networks (PHNs) – have engaged with migrant and refugee health, and what factors encourage work in this area. Methods: The study used mixed methods with surveys of ML (N=210) and PHN staff (N=66), interviews with ML (N=50) and PHN (N=55) staff, national consultations with migrant and refugee organisations (N=8 groups with 62 participants), and analysis of ML and PHN documents. Results : Needs assessment documents identified migrant and refugee health issues in 46% of MLs and 74% of PHNs. However, 48% of MLs and 55% of PHNs did not report any activities on migrant health, and 78% and 62% did not report any activities for refugees, respectively. Key factors identified by participants as associated with whether ML and PHN focus on migrant and refugee health were the determination of local priority areas, policy context and funding, collaboration with migrant and refugee organisations and communities, and mechanisms for engagement. Conclusions : Despite the importance of primary health care for migrants and refugees, there was relatively little attention paid to these population groups in MLs and PHNs, with a small number of notable exceptions. Implications for public health : The paper concludes with a range of recommendations for improving regional primary health care organisation engagement with migrant and refugee health.     

Proposals to reform the U.S. health care system: a critical review.

The objective is to provide an overview and analysis of the current discussion of ways to reform the U.S. health care system. A common analytic framework is needed to evaluate the alternative approaches that are being advocated. Such a framework, organized around seven general questions, is developed and discussed. The analytic framework is then applied to five specific reform proposals, selected to be representative of the range of options being considered. The results are used to identify the basic choices that are inherent in the current discussion of health system reform. A discussion of the political realities of the health system reform movement in the U.S. concludes that an incremental reform measure will be implemented at the federal level in the near future and that the reform measure will give the federal government increased control over the health care sector. However, the pressure for more fundamental reform will continue to grow.     

Changes in health insurance coverage,access to care,and health services utilization by sexual minority status in the United States, 2013‐2018

ObjectiveTo examine the changes in health insurance coverage, access to care, and health services utilization among nonelderly sexual minority and heterosexual adults between pooled years 2013‐2014 and 2017‐2018.Data SourcesData on 3223 sexual minorities (lesbians, gay men, bisexual individuals, and other nonheterosexual populations) and 86 181 heterosexuals aged 18‐64 years were obtained from the 2013, 2014, 2017, and 2018 National Health Interview Surveys.Study DesignUnadjusted and regression‐adjusted estimates compared changes in health insurance status, access to care, and health services utilization for nonelderly adults by sexual minority status. Regression‐adjusted changes were obtained from logistic regression models controlling for demographic and socioeconomic characteristics.Principal FindingsUninsurance declined for both sexual minority adults (5 percentage points, P < .05) and heterosexual adults (2.5 percentage points, P < .001) between 2013‐2014 and 2017‐2018. Reductions in uninsurance for sexual minority and heterosexual adults were associated with increases in Medicaid coverage. Sexual minority and heterosexual adults were also less likely to report unmet medical care in 2017‐2018 compared with 2013‐2014. Low‐income adults (regardless of sexual minority status) experienced relatively large increases in Medicaid coverage and substantial improvements in access to care over the study period. The gains in coverage and access to care across the study period were generally similar for heterosexual and sexual minority adults.ConclusionsSexual minority and heterosexual adults have experienced improvements in health insurance coverage and access to care in recent years. Ongoing health equity research and public health initiatives should continue to monitor health care access and the potential benefits of recent health insurance expansions by sexual orientation and sexual minority status when possible.     

Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches

BackgroundIt has been widely acknowledged that refugees are at risk of poorer health outcomes, spanning mental health and general well‐being. A common point of access to health care for the migrant population is via the primary health care network in the country of resettlement. This review aims to synthesize the evidence of primary health care interventions to improve the quality of health care provided to refugees and asylum seekers.MethodsA systematic review was undertaken, and 55 articles were included in the final review. The Preferred Reporting Items for Systematic Reviews was used to guide the reporting of the review, and articles were managed using a reference‐management software (Covidence). The findings were analysed using a narrative empirical synthesis. A quality assessment was conducted for all the studies included.ResultsThe interventions within the broad primary care setting could be organized into four categories, that is, those that focused on developing the skills of individual refugees/asylum seekers and their families; skills of primary health care workers; system and/or service integration models and structures; and lastly, interventions enhancing communication services. Promoting effective health care delivery for refugees, asylum seekers and their families is a complex challenge faced by primary care professionals, the patients themselves and the communication between them.ConclusionThis review highlights the innovative interventions in primary care promoting refugee health. Primary care interventions mostly focused on upskilling doctors, with a paucity of research exploring the involvement of other health care members. Further research can explore the involvement of interprofessional team members in providing effective refugee/migrant health.Patient or Public ContributionPatient and public involvement was explored in terms of interventions designed to improve health care delivery for the humanitarian migrant population, that is, specifically refugees and asylum seekers.     

Health and health care status of African-born residents of Metropolitan Washington, DC

This study examines health status, health behaviors, and health care access and utilization among African-born residents of the metropolitan Washington, DC area. A telephone survey was administered to a random sample of 525 African-born adults. Results are compared to those for the general local and regional population. Twenty-nine percent of respondents were uninsured; 24% lacked a usual, appropriate source of primary care. Among female respondents, 44% and 34% reported never having had a mammogram or pap smear, respectively. Most health status indicators demonstrated relatively good health, but 15% of respondents reported one of the infectious diseases we investigated. Consumption of alcohol and tobacco was relatively low. African-born residents are generally at risk regarding access to health care, and certain segments (the uninsured, recent arrivals) face critical access barriers. Infectious diseases are a notable feature of health status, and use of some preventive and dental services is considerably lower than for the general population.     

Primary health care for refugees and asylum seekers: a review of the literature and a framework for services

OBJECTIVES: This paper aims to provide a framework for primary health care services to meet the recognized health needs of refugees and asylum seekers that can be used in planning and evaluating services for this group. REVIEW: Primary care services for refugees and asylum seekers are reviewed and presented in terms of a tripartite framework of gateway, core and ancillary services. Gateway services facilitate entry into primary care by identifying unregistered patients and carrying out health assessments. They are typically undertaken by nurse-led outreach services and specialist health visitors. Core services provide full registration and may be provided by dedicated practices or by mainstream practices, with or without additional support. Ancillary services are those that supplement and support core services' ability to meet the additional health needs of this group. They include language and information services, close links with community-based organizations, specialist mental health services and services for survivors of torture and organized violence, as well as targeted health promotion and training of health workers. CONCLUSIONS: The framework can be used for education and training, planning and commissioning, and to provide criteria for comparison and evaluation. The paper suggests that a lack of published evaluations and reports about interventions for refugees and asylum seekers constrains further policy development that could build on the strengths of such interventions. It also stresses the importance of ancillary services to successful mainstream provision.     

Do health care reforms in Turkey have a significant effect in equal access to maternal and child health services in Turkey: An evidence from 20 years

This study aimed to investigate whether there was an improvement in the equitable access to maternal and child health care services by examining the effects of socioeconomic and individual factors in Turkey from 1993 to 2013 and determine the effectiveness of health care reforms implemented mainly under the Health Transformation Program since 2003 on equitable access t;o maternal and child health care services in terms of years. The study used nationally representative 5 Turkey Demographic and Health Surveys (1993, 1998, 2003, 2008, and 2013). Prenatal care utilization rate increased from 67.0% in 1993 to 96.2% in 2013 while the rate of women giving birth at health care facilities increased from 63.8% to 98.1% in 2013. Prenatal care utilization and giving birth at health care facilities were higher among women who were under health insurance coverage, first time mothers, those staying in the western region and urban areas, and those with the highest level of wealth. The findings suggest that the issue of equity in the utilization of maternal and child health care services exists in Turkey, and the latest health care reforms under HTP are not effective in diminishing the effect of wealth.     

Here comes the SUN: Self‐assessed unmet need,worsening health outcomes,and health care inequity

Utilization‐based approaches have predominated the measurement of socioeconomic‐related inequity in health care. This approach, however, can be misleading when preferences over health and health care are correlated with socioeconomic status, especially when the underlying focus is on equity of access. We examine the potential usefulness of an alternative approach to assessing inequity of access using a direct measure of possible barriers to access—self‐reported unmet need (SUN)—which is documented to vary with socioeconomic status and is commonly asked in health surveys. Specifically, as part of an assessment of its external validity, we use Canadian longitudinal health data to test whether self‐reported unmet need in one period is associated with a subsequent deterioration in health status in a future period, and find that it is. This suggests that SUN does reflect in part reduced access to needed health care, and therefore may have a role in assessing health system equity as a complement to utilization‐based approaches.     

Optimising Hepatitis C care in an urban Aboriginal and Torres Strait Islander primary health care clinic

Objective: Describe the sociodemographic and clinical characteristics of patients with Hepatitis C Virus (HCV) attending an urban Indigenous primary health clinic (IPHC) in Brisbane, Australia. Methods: A retrospective chart review of sociodemographic characteristics, presence of liver disease and treatments, lifestyle behaviours and comorbidities in patients with a HCV infection was conducted between October 2015 and March 2016. Results: One hundred and thirteen patients with confirmed HCV infection were aged between seven and 63 years; 66% were male, and 84% were Indigenous. Sixty‐nine per cent had been incarcerated; 41% had experienced conflict or domestic violence; 47% were injecting drugs; 72% had depression; and 61% had anxiety. Cirrhosis was present in 7/95 patients with adequate data and associated with age (p=0.02). Eleven patients had commenced direct acting antiviral (DAA) therapy in the 18 months that it had been available. Conclusions: The study highlights the opportunities for enhancing treatment of patients with HCV infection. Opportunities to improve treatment rates in an Indigenous primary healthcare include optimising diagnostic pathways, improving patient engagement, and general practitioner and peer worker participation. Implications for public health: HCV poses a serious threat to public health in Australia and IPHCs are key sites to addressing this for Indigenous people. Optimising care of patients with HCV attending IPHC requires recognition of the complex health needs and social context, to reduce the incidence and consequences of HCV infection.     

Karenni refugees living in Thai-Burmese border camps: traumatic experiences, mental health outcomes, and social functioning

In June 2001, we assessed mental health problems among Karenni refugees residing in camps in Mae Hong Son, Thailand, to determine the prevalence of mental illness, identify risk factors, and develop a culturally appropriate intervention program. A systematic random sample was used with stratification for the three camps; 495 people aged 15 years or older from 317 households participated. We constructed a questionnaire that included demographic characteristics, culture-specific symptoms of mental illness, the Hopkins Symptoms Checklist-25, the Harvard Trauma Questionnaire, and selected questions from the SF-36 Health Survey. Mental health outcome scores indicated elevated levels of depression and anxiety symptoms; post-traumatic stress disorder (PTSD) scores were comparable to scores in other communities affected by war and persecution. Psychosocial risk factors for poorer mental health and social functioning outcomes were insufficient food, higher number of trauma events, previous mental illness, and landmine injuries. Modifications in refugee policy may improve social functioning, and innovative mental health and psychosocial programs need to be implemented, monitored, and evaluated for efficacy.     

Rebuilding a health care system: war, reconstruction and health care reforms in Kosovo

This article explores the complexity of a health care system reforms in a post-conflict situation. It describes how the health care system was revamped immediately after the war, and then reorganized with Primary Health Care (PHC) as the fulcrum for change. It highlights the coordination problems, typical of a post-war situation when un-coordinated humanitarian assistance pours in. From the vantage points of Ministry of Health officials, the article details how the change process has gone over the years, the directions it has taken and the lessons learnt. It notes that reforms are often so fast that they outstrip the absorption capacity of the potential change agents because of their inadequate preparation for the new roles and responsibilities. This in turn threatens to undermine and weaken the very system that the reforms seek to strengthen. Several options adopted for change in Kosovo's health care system are at varying levels of implementation today. Some commentators have questioned if the policy for the new health care system has failed. We contend that there have been major organizational successes. But there are also shortcomings. There is also a potential danger that the health care system could partly revert to the old system. While some of the successes and shortcomings may be specific to Kosovo, many lessons learnt from Kosovo apply to health care reforms elsewhere.     

国内外卫生服务整合评价方法概述

卫生服务整合理念越来越受到国内外学者和政策制定者的关注。在实践的同时进行有效的评价研究可以进一步深入实践的开展。本文概述国内外卫生服务整合的研究内容,详细介绍国内外评价卫生服务整合的方法,分析中国卫生服务整合研究存在的不足,为中国相关研究的深入和实践的开展提供方法学基础。