E-health and the Universitas 21 organization: 4. Professional portability

Professional portability is the ease with which health-care professionals can move in person or virtually across barriers, and among and between jurisdictions, to transfer their knowledge, skills and care. As part of the Universitas 21 (U21) project on e-health, professional portability was examined using a SWOT analysis (strengths, weaknesses, opportunities and threats). The analysis showed that many factors hamper the development of global professional portability; on the other hand, the potential exists to substantially improve access to health care and its quality around the world. The study suggests that professional portability can be advanced in a number of ways. These include exploring policy, technology and medical training. The field of professional portability, while of considerable relevance to health and other professions, is undeveloped and is clearly an area that would benefit from discussion, research and global collaboration.     

E-health and the Universitas 21 organization: 3. Global policy

There is an urgent need to develop global e-health policy in order both to facilitate and to manage the potential of e-health. As part of the Universitas 21 (U21) project in e-health, an evaluation of the status of global e-health policy was performed using a SWOT analysis (strengths, weaknesses, opportunities and threats). The analysis showed that the greatest threat to global e-health policy is the autonomous nature of domestic health-care systems. The greatest opportunity may be the prospect for nations and individuals to work together in establishing mechanisms necessary to offer health-care access through global e-health--a new 'global public good'. Full integration of e-health into existing health-care systems could be achieved in both a practical and a policy sense through global e-health policy initiatives that facilitate integration across jurisdictions. There is a pressing need to resolve a range of e-health policy issues, and a concomitant need for research that will inform and support the process. A process that adopts a global approach is recommended.     

E-health and the Universitas 21 organization: 1. Global e-health through synergy

The Universitas 21 (U21) organization funded a one-year project to examine global e-health. An e-health steering committee surveyed the opinions of e-health researchers at U21 member schools and conducted a literature review. Information about key themes was analysed and the findings were summarized. The steering committee recommended an eight-step strategy to establish a sustainable endeavour in global e-health. This included implementing a dissemination strategy within the U21 organization to engage a progressively larger community of faculty members and others, and translating e-health knowledge into global practice in those areas in which the U21 has special expertise. While the recommendations in the discussion paper are specific to the U21 organization, the e-health steering committee believes they can be generalized and applied to any globally minded educational or research institutions seeking to contribute to e-health.     

Lead abatement training for underserved populations: lessons learned

An environmental-justice (equity) grant program was used to make accessible an existing lead-training program to minority persons and residents of low-income communities. The purpose of the program was to enhance the knowledge base within the communities concerning lead hazards and intervention strategies and expand possibilities for employment in the lead abatement industry. Barriers to attendance were anticipated and addressed, and included transportation, meals, license application fees, reminders of course date and location, and day care. The program was evaluated through measures of recruitment rates, pre- and post-testing scores, and change in perception of confidence at pre-test, post-test, and at four-month follow-up. Fee-paying registrants over the same time period were used as a comparison group. First day attendance rates for individuals recruited into the equity-grant was 59 percent, of these 94 percent completed all days. Equity and fee-paying groups had similar scores on the pre-test (p = .209), while mean scores on the final exam differed significantly (p < .001) between the groups and were 77 percent and 85 percent, respectively. After adjusting for demographic and course type attended, perceptions of self-efficacy (benefit) and outcome-effectiveness (confidence) increased significantly from pre- to post-tests for both groups and remained at post-course levels at four months follow-up. Lessons learned include: (1) Lead abatement and other related activities can be successfully taught through traditional training methods; (2) A necessary element for delivery of educational services to minority groups is forming workable ties with local community groups, but eligibility requirements must be maintained; (3) Once barriers to first-day attendance are overcome, the information necessary to perform specific work skills can be taught; (4) Positive changes in belief are not dependent on minority status, income, or education levels; (5) Training and education increased confidence in ability to perform learned skills, and belief that there will be a beneficial outcome when performed for themselves, their families, and communities; and, (6) A consensus regarding applicability of regulations must be achieved among federal, state, and local communities.     

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.     

Emergency care with lay responders in underserved populations: a systematic review

ObjectiveTo assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide.MethodsWe systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format.FindingsOf 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies).ConclusionFirst aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.     

Designating places and populations as medically underserved: a proposal for a new approach

This article describes the development of a theory-based, data-driven replacement for the Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA) designation systems. Data describing utilization of primary medical care and the distribution of practitioners were used to develop estimates of the effects of demographic and community characteristics on use of primary medical care. A scoring system was developed that estimates each community's effective access to primary care. This approach was reviewed and contributed to by stakeholder groups. The proposed formula would designate over 90% of current geographic and low-income population HPSA designations. The scalability of the method allows for adjustment for local variations in need and was considered acceptable by stakeholder groups. A data-driven, theory-based metric to calculate relative need for geographic areas and geographically-bounded special populations can be developed and used. Its use, however, requires careful explanation to and support from affected groups.     

E-health: the changing model of healthcare

E-health--any electronic exchange of healthcare data or information across organizations--reflects an industry in transition. Even as its form and structure continue to emerge, e-health is being used to change business and medical practices, affecting every facet of the American health experience. Business, medical, social, and technological factors are converging to make wide-scale, continuum-based care functionally achievable perhaps for the first time. The Internet clearly drives the development and adoption of e-health applications; standing alone, it has the reach, the infrastructure, and the acceptance to achieve widespread change. As the public grows increasingly Internet-enabled, healthcare organizations have an opportunity to cost-effectively reach a large part of the U.S. population. The sheer breadth of e-health, the many options available to healthcare organizations, and the relative immaturity of the applications in most areas make navigating the spectrum of possibilities a clear healthcare management challenge. Deciding how to incorporate the demand for e-health has extensive technological, organizational, managerial, and ethical implications.     

The relationship between the race/ethnicity of generalist physicians and their care for underserved populations.

OBJECTIVES: The purpose of this study was to examine empirically the relationship between physicians' race or ethnicity and their care for medically underserved populations. METHODS: Generalist physicians who received the MD degree in 1983 or 1984 (n = 1581) were surveyed. The personal and background characteristics of four racial/ethnic groups of physicians were compared with the characteristics of their patients. RESULTS: When the potentially confounding variables of gender, childhood family income, childhood residence, and National Health Services Corps financial aid obligations were controlled, generalist physicians from underrepresented minorities were more likely than their nonminority counterparts to care for medically underserved populations. CONCLUSIONS: Physicians from underrepresented minorities are more likely than others to care for medically underserved populations.     

State funding of comprehensive primary medical care service programs for medically underserved populations.

OBJECTIVES: This study examined the availability of state funding for comprehensive primary care programs and the need for primary care subsidies for medically underserved communities. METHODS: A brief questionnaire was used to ask health agencies in all 50 states whether their state funded a program that met our definition of comprehensive primary medical care practice programs. An in-depth written survey instrument was then administered to the states with programs. RESULTS: Almost half of all states provide some funds for the development and/or operation of comprehensive primary medical care practices. Expenditures in most states were found to be relatively modest in comparison with both federal funding and the total level of unmet need for primary care. States that subsidize primary care practices tend to follow the model established under the federal health centers program. CONCLUSIONS: The findings suggest the continued viability of the health center model of care, as well as the presence of some state support for such a program. However, in light of limited state resources for the development and operation of comprehensive practices, a continued and significant federal effort is imperative.     

Factors influencing participation in worksite wellness programs among minority and underserved populations

In the United States, employers and employees are increasingly paying a larger portion of the nation's healthcare bill. Preventive measures are being employed by businesses in an effort to contain the escalating costs of employee healthcare. The work site is an ideal setting for health promotion because 130 million Americans are employed and spend one third of their time at work. However, unhealthy workers tend to be the least likely to participate in health promotion activities. Worksite Wellness Programs must be designed to engage segments of the work force with the greatest health needs. Culturally sensitive and appropriate programs must be developed to engage economically challenged minority and other underserved populations.