Access to health care among children in the U.S.: Use of health inequalities measures to evaluate progress in reduction of disparities from 1997 to 2005

Much of the literature on disparities in access to health care among children has focused on measuring absolute and relative differences experienced by race/ethnic groups and, to a lesser extent, socioeconomic groups. However, it is not clear from existing literature how disparities in access to care may have changed over time for children, especially following implementation of the State Children’s Health Insurance Program (SCHIP). The primary objective of this research was to determine if there has been a decrease in disparities in access to care for children across two socioeconomic groups and race/ethnicity groups after SCHIP implementation. Methods commonly used to measure ‘health inequalities’ were used to measure disparities in access to care including population-attributable risk (PAR) and the relative index of inequality (RII). Using these measures there is evidence of a substantial decrease in socioeconomic disparities in health insurance coverage and to a lesser extent in having a usual source of care since the SCHIP program began. There is also evidence of a considerable decrease in non-Hispanic Black disparities in access to care. However, there appears to be a slight increase in disparities in access to care among Hispanic compared to non-Hispanic White children. While there were great improvements in disparities in access to care with the introduction of the SCHIP program, continuing progress in disparities may depend on continuation of the SCHIP program or similar targeted health policy programs. ^

A program manual to assist with implementation of a volunteer health and wellness program

Based on the success of a community health and wellness program, Wellness in the City, delivered in Dallas County by trained volunteers, Texas Cooperative Extension (TCE) decided to pilot the program in 16 counties in North and East Texas. Before implementing the program, TCE wanted the Dallas County program to be reviewed and revised as needed to meet the diverse community needs in the pilot counties. TCE also asked for an implementation manual to be developed for the county agents to utilize. ^ To achieve these objectives, I first reviewed literature on other volunteer-implemented health interventions in the U.S. to see how they were planned, disseminated, implemented, and evaluated. Next, I reviewed the Wellness in the City program and materials. I applied all the information I gathered up to that point to the program development committee meetings (committee included seven TCE county agents, a TCE regional program director, and me). The program structure and training materials were revised based on our research and program implementation experience. These changes were made to ensure adequate training for the volunteers and to create a program that is applicable in the communities it will be piloted in. ^ With the program structure and training presentations developed, next I focused on compiling the implementation manual, which includes program details and volunteer recruitment, training, and management materials. The goal was to create a manual with everything the county agents will need to implement the program, so they can focus their efforts on putting the manual to use and recruiting and managing the volunteers. The final step was developing a program evaluation form for the agents to complete. It includes questions to assess the agents' thoughts about the training content, the feasibility of implementing the program using the manual, and the challenges of the program. ^

A descriptive study on Hurricanes Katrina and Rita evacuees participating in the Harris County Housing Authority Disaster Housing Assistance Program

Natural disasters occur in various forms such as hurricanes, tsunamis, earthquakes, outbreaks, etc. The most unsettling aspect of a natural disaster is that it can strike at any moment. Over the past decade, our society has experienced an alarming increase of natural disasters. How to expeditiously respond and recover from natural disasters has become a precedent question for public health officials. To date, the most recent natural disaster was the January 12, 2010 earthquake in Haiti; however the most memorable was that of Hurricane Katrina (“Haiti Earthquake”, 2010). ^ This study provides insight on the need to develop a National Disaster Response and Recovery Program which effectively responds to natural disasters. The specific aims of this paper were to (1) observe the government’s role on federal, state and local levels in assisting Hurricanes Katrina and Rita evacuees, (2) assess the prevalence of needs among Hurricanes Katrina and Rita families participating in the Disaster Housing Assistance Program (DHAP) and (3) describe the level of progress towards “self sufficiency” for the DHAP families receiving case management social services. ^ Secondary data from a cross-sectional “Needs Assessment” questionnaire were analyzed. The questionnaire was administered initially and again six months later (follow-up) by H.A.U.L. case managers. The “Needs Assessment” questionnaire collected data regarding participants’ education, employment, transportation, child care, health resources, income, permanent housing and disability needs. Case managers determined the appropriate level of social services required for each family based on the data collected from the “Needs Assessment” questionnaire. ^ Secondary data provided by the H.A.U.L. were analyzed to determine the prevalence of needs among the DHAP families. In addition, differences measured between the initial and follow-up (at six months) questionnaires were analyzed to determine statistical significance between case management services provided and prevalence of needs among the DHAP families from initial to 6 months later at follow-up. The data analyzed describe the level of progress made by these families to achieve program “self sufficiency” (see Appendix A). Disaster assistance programs which first address basic human needs; then socioeconomic needs may offer an essential tool in aiding disaster affected communities quickly recover from natural disasters. ^

A review of economic analysis in the vaccination program; decision making and governance: Adivisory Committee on Immunization Practices (ACIP)

The Advisory Committee on Immunization Practices (ACIP) develops written recommendations for the routine administration of vaccines to children and adults in the U.S. civilian population. The ACIP is the only entity in the federal government that makes such recommendations. ACIP elaborates on selection of its members and rules out concerns regarding its integrity, but fails to provide information about the importance of economic analysis in vaccine selection. ACIP recommendations can have large health and economic consequences. Emphasis on economic evaluation in health is a likely response to severe pressures of the federal and state health budget. This study describes the economic aspects considered by the ACIP while sanctioning a vaccine, and reviews the economic evaluations (our economic data) provided for vaccine deliberations. A five year study period from 2004 to 2009 is adopted. Publicly available data from ACIP web database is used. Drummond et al. (2005) checklist serves as a guide to assess the quality of economic evaluations presented. Drummond et al.'s checklist is a comprehensive hence it is unrealistic to expect every ACIP deliberation to meet all of their criteria. For practical purposes we have selected seven criteria that we judge to be significant criteria provided by Drummond et al. Twenty-four data points were obtained in a five year period. Our results show that out of the total twenty-four data point‘s (economic evaluations) only five data points received a score of six; that is six items on the list of seven were met. None of the data points received a perfect score of seven. Seven of the twenty-four data points received a score of five. A minimum of a two score was received by only one of the economic analyses. The type of economic evaluation along with the model criteria and ICER/QALY criteria met at 0.875 (87.5%). These three criteria were met at the highest rate among the seven criteria studied. Our study findings demonstrate that the perspective criteria met at 0.583 (58.3%) followed by source and sensitivity analysis criteria both tied at 0.541 (54.1%). The discount factor was met at 0.250 (25.0%).^ Economic analysis is not a novel concept to the ACIP. It has been practiced and presented at these meetings on a regular basis for more than five years. ACIP‘s stated goal is to utilize good quality epidemiologic, clinical and economic analyses to help policy makers choose among alternatives presented and thus achieve a better informed decision. As seen in our study the economic analyses over the years are inconsistent. The large variability coupled with lack of a standardized format may compromise the utility of the economic information for decision-making. While making recommendations, the ACIP takes into account all available information about a vaccine. Thus it is vital that standardized high quality economic information is provided at the ACIP meetings. Our study may provide a call for the ACIP to further investigate deficiencies within the system and thereby to improve economic evaluation data presented. ^

Planning and implementation efficacy as a determinant of health risk communication outcomes: Case studies of the U.S. Public Health Service (PHS)

This study was conducted under the auspices of the Subcommittee on Risk Communication and Education of the Committee to Coordinate Environmental Health and Related Programs (CCEHRP) to determine how Public Health Service (PHS) agencies are communicating information about health risk, what factors contributed to effective communication efforts, and what specific principles, strategies, and practices best promote more effective health risk communication outcomes.^ Member agencies of the Subcommittee submitted examples of health risk communication activities or decisions they perceived to be effective and some examples of cases they thought had not been as effective as desired. Of the 10 case studies received, 7 were submitted as examples of effective health risk communication, and 3, as examples of less effective communication.^ Information contained in the 10 case studies describing the respective agencies' health risk communication strategies and practices was compared with EPA's Seven Cardinal Rules of Risk Communication, since similar rules were not found in any PHS agency. EPA's rules are: (1) Accept and involve the public as a legitimate partner. (2) Plan carefully and evaluate your efforts. (3) Listen to the public's specific concerns. (4) Be honest, frank, and open. (5) Coordinate and collaborate with other credible sources. (6) Meet the needs of the media. (7) Speak clearly and with compassion.^ On the basis of case studies analysis, the Subcommittee, in their attempts to design and implement effective health risk communication campaigns, identified a number of areas for improvement among the agencies. First, PHS agencies should consider developing a focus specific to health risk communication (i.e., office or specialty resource). Second, create a set of generally accepted practices and guidelines for effective implementation and evaluation of PHS health risk communication activities and products. Third, organize interagency initiatives aimed at increasing awareness and visibility of health risk communication issues and trends within and between PHS agencies.^ PHS agencies identified some specific implementation strategies the CCEHRP might consider pursuing to address the major recommendations. Implementation strategies common to PHS agencies emerged in the following five areas: (1) program development, (2) building partnerships, (3) developing training, (4) expanding information technologies, and (5) conducting research and evaluation. ^

The impact of communication and cultural diversity in utilizing dental services among Saudi Arabian students in U.S.A.

Objectives: The purpose of this study is to understand the perceived effects of patient-dental staff communication and cultural diversity on the utilization of dental services in the U.S. by Saudi Arabian students who live in the U.S. and enrolled into the King Abdullah Scholarship program. Methods: The study design was an analytical cross-sectional study. Data for this study was obtained from the Saudi Dental Servicers Utilization Survey, a voluntary internet survey available online for one month through Facebook. Ordered logistic regression analyses and multinomial logistic regression analyses were used to measure the relationships between patient-dental staff communication and cultural diversity on the utilization of dental services. Results: Eight hundred and forty-seven responses were analyzed for this study. Overall, the majority of Saudi students reported having excellent communication experience with dental providers in the U.S. More than 58% of respondents reported at least one regular dental visit last year. Factors that influenced the use of regular dental care were: dentist's explanation of treatment plan, response of dental staff to patient's needs, respectful and polite dental staff, dental staff kindness, availability of up-to-date equipment, and overall communication with dentist. However, the utilization of emergency dental care was not associated with any measurement of patient-dental provider communication. Overall future utilization of dental care is associated with all aspects of patient-dental staff communication measured in this survey. Furthermore, more utilization of regular dental care was related to respondent's perception of the importance of trustworthiness dental staff and the importance of a dentist's reputation was only marginally associated. Respondent's perception of dentist's reputation was associated with more use of emergency dental services. Respondents are more likely to anticipate using dental care in the future if they perceived trustworthiness dental staff, and the dentist's reputation as influencing factors to their usage of dental services. Conclusions: Patient-dental staff communication was partially associated with utilization of regular dental care, not associated with utilization of emergency dental care, and broadly associated with anticipated future utilization of dental care. In addition, trustworthy dental staff, and a dentist's reputation were considered to be strong influencing factors towards utilization of dental services.^

Planning, implementation, and evaluation of an HIV -screening program for pregnant women

The purpose of this study was to evaluate the effectiveness of an HIV-screening program at a private health-care institution where the providers were trained to counsel pregnant women about the HIV-antibody test according to the latest recommendations made by the U.S. Public Health Service (PHS) and the Texas legislature. A before-and-after study design was selected for the study. The participants were OB/GYN nurses who attended an educational program and the patients they counseled about the HIV test. Training improved the nurses' overall knowledge about the content of the program and nurses were more likely to offer the HIV test to all pregnant women regardless of their risk of infection. Still, contrary to what was predicted, the nurses did not give more information to increase the knowledge pregnant women had about HIV infection, transmission, and available treatments. Consequently, many women were not given the chance to correctly assess their risk during the counseling session and there was no evidence that knowledge would reduce the propensity of many women to deny being at risk for HIV. On the other hand, pregnant women who received prenatal care after the implementation of the HIV-screening program were more likely to be tested than women who received prenatal care before its implementation (96% vs. 48%); in turn, the likelihood that more high-risk women would be tested for HIV also increased (94% vs. 60%). There was no evidence that mandatory testing with right of refusal would deter women from being tested for HIV. When the moment comes for a woman to make her decision, other concerns are more important to her than whether the option to be tested is mandatory or not. The majority of pregnant women indicated that their main reasons for being tested were: (a) the recommendation of their health-care provider; and (b) concern about the risks to their babies. Recommending that all pregnant women be tested regardless of their risk of infection, together with making the HIV test readily available to all women, are probably the two best ways of increasing the patients' participation in an HIV-screening program for pregnant women. ^